Investigating sexual health after breast cancer by longitudinal assessment of patient-reported outcomes

BACKGROUND

Sexual concerns are a major unaddressed need among survivors of breast cancer (BC) with significant negative effects on quality of life. We longitudinally analyzed sexual health over time, using patient-reported outcomes.

METHODS

Patients with stage I-III BC prospectively included from the CANcer TOxicity cohort (CANTO) provided data at diagnosis, then 1, 2, and 4 years afterward. Sexual concerns outcomes included poor body image (score ≤91/100), poor sexual functioning (≤16/100), poor sexual enjoyment (≤66/100), and sexual inactivity (EORTC QLQ-B23). Multivariate generalized estimating equation models assessed associations with sexual concerns after diagnosis, adjusting for age, sociodemographic, tumor, treatment, and clinical characteristics.

RESULTS

Nearly 78.1% among 7895 patients reported at least one sexual concern between diagnosis and 4 years' follow-up. Over time, the proportion of patients reporting sexual concerns either increased or remained constant with diagnosis. Less than half (46%, range 11.4-57) of the patients with sexual concerns reported the use of supportive care strategies, including gynecological or psychological consultations (range 11.4-57.4). Factors consistently associated with sexual concerns up to 4 years after diagnosis included already reporting the same concern at diagnosis [odds ratio (OR)poor body image 3.48 [95% confidence interval (CI) 3.11-3.89]; ORsexual inactivity 9.94 (95% CI 8.84-11.18), ORpoor sexual function 9.75 (95% CI 8.67-10.95), ORpoorsexual enjoyment 3.96 (95% CI 3.34-4.69)], endocrine therapy use [ORpoor body image 1.15 (95% CI 1.01-1.31); ORsexual inactivity 1.19 (95% CI 1.02-1.39), ORpoor sexual function 1.17 (95% CI 1.01-1.37), ORpoor sexual enjoyment 1.23 (95% CI 1.00-1.53)], and depression [ORpoor body image 2.00 (95% CI 1.72-2.34); ORsexual inactivity 1.66 (95% CI 1.40-1.97), ORpoor sexual function 1.69 (95% CI 1.43-2.00), ORpoor sexual enjoyment 1.94 (95% CI 1.50-2.51)]. Outcome-specific associations were also identified.

CONCLUSIONS

Sexual concerns seem frequent, persistent, and insufficiently addressed. Pretreatment concerns, endocrine therapy, and emotional distress are commonly associated factors. A proactive evaluation of sexual health across the care continuum is needed, to promptly identify patients suitable for multidisciplinary counseling, referral, and supportive interventions.

Implementing a PROACTive Care Pathway to Empower and Support Survivors of Breast Cancer

PURPOSE

Optimal comprehensive survivorship care is insufficiently delivered. To increase patient empowerment and maximize the uptake of multidisciplinary supportive care strategies to serve all survivorship needs, we implemented a proactive survivorship care pathway for patients with early breast cancer at the end of primary treatment phase.

METHODS

Pathway components included (1) a personalized survivorship care plan (SCP), (2) face-to-face survivorship education seminars and personalized consultation for supportive care referrals (Transition Day), (3) a mobile app delivering personalized education and self-management advice, and (4) decision aids for physicians focused on supportive care needs. A mixed-methods process evaluation was performed according to the Reach, Effectiveness, Adoption, Implementation and Maintenance framework including administrative data review, pathway experience survey (patient, physician, and organization), and focus group. The primary objective was patient-perceived satisfaction with the pathway (predefined progression criteria for pathway continuation ≥70%).

RESULTS

Over 6 months, 321 patients were eligible for the pathway and received a SCP and 98 (30%) attended the Transition Day. Among 126 patients surveyed, 77 (66.1%) responded. 70.1% received the SCP, 51.9% attended the Transition Day, and 59.7% accessed the mobile app. 96.1% of patients were very or completely satisfied with the overall pathway, whereas perceived usefulness was 64.8% for the SCP, 90% for the Transition Day, and 65.2% for the mobile app. Pathway implementation seemed to be positively experienced by physicians and the organization.

CONCLUSION

Patients were satisfied with a proactive survivorship care pathway, and the majority reported that its components were useful in supporting their needs. This study can inform the implementation of survivorship care pathways in other centers.

The Future of Breast Cancer Research in the Survivorship Field

Prevalence of survivors of breast cancer has been steadily increasing in the last 20 years. Currently, more than 90% of women diagnosed with early-stage breast cancer are expected to be alive at 5 years from diagnosis thanks to early detection and breakthrough innovations in multimodal treatment strategies. Alongside this advancement in clinical outcomes, survivors of breast cancer might experience several specific challenges and present with unique needs. Survivorship trajectories after diagnosis and treatment of breast cancer can be significantly impacted by long-lasting and severe treatment-related side effects, including physical problems, psychological distress, fertility issues in young women, and impaired social and work reintegration, which add up to patients' individual risk of cancer recurrence and second primary malignancies. Alongside cancer-specific sequelae, survivors still present with general health needs, including management of chronic preexisting or ensuing conditions. Survivorship care should implement high-quality, evidence-based strategies to promptly screen, identify, and address survivors' needs in a comprehensive way and minimize the impact of severe treatment sequelae, preexisting comorbidities, unhealthy lifestyles, and risk of recurrence on quality of life. This narrative review focuses on core areas of survivorship care and discuss the state of the art and future research perspectives in key domains including selected long-term side effects, surveillance for recurrences and second cancers, well-being promotion, and specific survivors' needs.

Approaches to Fertility Preservation for Young Women With Breast Cancer

In patients with early breast cancer, the combination of different systemic treatment strategies, including chemotherapy, endocrine therapy, targeted therapy, and more recently also immunotherapy has demonstrated to significantly improve their survival outcomes. However, this gain is often obtained at the cost of higher toxicity calling for the need of increased attention toward survivorship-related issues, including fertility preservation in young women. According to available guidelines, health care providers should offer oncofertility counseling to all patients with cancer diagnosed at reproductive age. Counselling should focus on the risk of gonadotoxicity of anticancer treatments and on the access to fertility preservation techniques. However, several surveys have demonstrated suboptimal implementation of these recommendations. This review aims at summarizing the available evidence on oncofertility to guide health care providers involved in the management of young women with breast cancer. Available and effective options for fertility preservation include oocyte/embryo cryopreservation or ovarian tissue cryopreservation. Patient, disease, and treatment characteristics should be carefully considered when offering these strategies. Ovarian function preservation with gonadotrophin-releasing hormone agonists during chemotherapy should be discussed and offered to every premenopausal woman concerned about developing premature ovarian insufficiency and independently of her wish to preserve fertility. Current available data confirm that pregnancy occurring after proper treatment for breast cancer is safe, both in terms of long-term clinical outcomes and for the babies. Fertility preservation and pregnancy desire should be pivotal components of the multimodal management of breast cancer in young women, and require a multidisciplinary approach based on close collaborations between oncologists and fertility specialists.

Second-line treatment outcomes after progression from first-line chemotherapy plus immunotherapy in patients with advanced non-small cell lung cancer

INTRODUCTION

Chemotherapy plus immunotherapy is the standard of care for patients with metastatic NSCLC. No study has evaluated the outcomes of second-line chemotherapy treatments after progression following first-line chemo-immunotherapy.

METHOD

This multicenter retrospective study evaluated the efficacy of second line (2L) chemotherapies after progression under first-line (1L) chemo-immunotherapy, measured by overall survival (2L-OS) and progression free survival (2L-PFS).

RESULTS

A total of 124 patients were included. The mean age was 63.1 years, 30.6 % of the patients were female, 72.6 % had an adenocarcinoma and 43.5 % had a poor ECOG-performance status prior to 2L initiation. Sixty-four (52.0 %) patients were considered resistant to first line chemo-immunotherapy. (1L-PFS < 6 months). In 2L treatments, 57 (46.0 %) patients received taxane monotherapy, 25 (20.1 %) taxane plus anti-angiogenic, 12 (9.7 %) platinum-based chemotherapy and 30 (24.2 %) other chemotherapy. At a median follow-up of 8.3 months (95 %CI: 7.2-10.2), post initiation of 2L treatment, the median 2L-OS was 8.1 months (95 % CI: 6.4-12.7) and the median 2L-PFS was 2.9 months (95 %CI: 2.4-3.3). Overall, the 2L-objective response and 2L-disease control rates were 16.0 %, and 42.5 %, respectively. Taxane plus anti-angiogenic and platinum rechallenge achieved longest median 2L-OS: not reached (95 %CI: 5.8-NR) and 17.6 months (95 %CI 11.6-NR), respectively (p = 0.05). Patients resistant to the 1L treatment had inferior outcomes (2L-OS 5.1 months, 2L-PFS 2.3 months) compared with 1L responders (2L-OS 12.7 months, 2L-PFS 3.2 months).

CONCLUSION

In this real-life cohort, 2L chemotherapy achieved modest activity following progression under chemo-immunotherapy. 1L-resistant patients remained a refractory population, highlighting a need for new 2L strategies.

PROACT: Implementing a PROACTive care pathway to empower and support breast cancer (BC) survivors

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Background: Optimal comprehensive survivorship care, beyond screening of recurrences and new cancers, and including health promotion, management of physical as well as psychosocial needs and chronic conditions is insufficiently delivered. To increase patient (pt) empowerment and maximize the uptake of multidisciplinary strategies serving all survivorship needs, we implemented a proactive survivorship care pathway offered for pts with early BC at the end of their primary treatment phase (surgery, chemotherapy, radiotherapy). Methods: The pathway consisted of the following components: 1) receipt of a personalized survivorship care plan (SCP), 2) invitation to attend face-to-face group seminars focused on specific themes and a comprehensive survivorship consultation for multidisciplinary referrals (”the transition day”) 3) access to a mobile application (app) delivering personalized education according to symptoms reported and 4) decision aids for helping physicians to manage prevalent symptoms and side effects related to BC treatment. Administrative data were collected. A pre-specified post-experience survey was sent to all pts four weeks post pathway delivery to inform program implementation with a minimum requirement of 50 responses. BC physicians and members of the multidisciplinary implementation team (MIT) answered a dedicated survey. For the overall pathway and each of its components we descriptively evaluated the following domains: satisfaction (primary outcome), uptake, perceived usefulness, barriers for delivery, and suggestions for improvement. A 70% satisfaction rate would define a positive experience. Results: From October 2021 to April 2022, 241 SCP were delivered, and 98 pts attended the “transition day”. 62 pts replied to the survey, 42 (67%) had received the SCP, 34 (55%) attended the “transition day”, 36 (57%) accessed the app. Only 21 pts (34%) who answered the survey received the full pathway, 81% of whom were very or completely satisfied with it. Perceived usefulness of individual components and for pts that received the full pathway were, respectively: 64% and 90% for the SCP, 91% and 95% for the “transition day”, 72% and 90% for the app. Among 14 BC physicians, agreement regarding the usefulness of the components was: 93% for the SCP, 86% for the decision aids, 93% for the “transition day”, and 86% for the app. The MIT (n = 13) reported high engagement and satisfaction (100%). Main actionable points for improvement included: automated screening and SCP preparation, virtual “transition day”, increase physicians’ awareness. Conclusions: In this pilot phase, pts were satisfied with receiving a proactive survivorship care pathway and the majority reported that the components were useful for supporting their needs. This study informed improvements on program penetration. Evolution towards sustainability phase is ongoing including dissemination to other cancers and centers.

Coffee and tea consumption, patient-reported, and clinical outcomes in a longitudinal study of patients with breast cancer

Background

Higher consumption of coffee and tea has been associated with improved health outcomes in the general population and improved breast cancer (BC) prognosis. This study investigated patterns of coffee and tea consumption and association with patient‐reported outcomes (PROs) and clinical outcomes among survivors of BC.

Methods

The authors included survivors of stage I–III BC enrolled in the CANTO cohort (NCT01993498) that provided post‐treatment assessment of coffee and tea consumption from years 1 to 4 after diagnosis. Group‐based trajectory modeling clustered patients according to daily consumption of coffee and tea. Multivariable mixed models and Cox models examined associations between consumption, PROs and clinical outcomes.

Results

Among 3788 patients, the authors identified four stable patterns of consumption: “Low” (25.8%), “Moderate” (37.6%), “High” (25.3%), and “Very high” (11.3%), corresponding to <1, 2, 3, and ≥ 4 cups of coffee and/or tea per day. Patients in the “Very high” group (vs. “Low”), were more likely to be younger, smokers, with higher monthly income and education. PROs and survival outcomes were similar across the four groups.

Conclusions

Over one in three survivors of BC reported high or very high consumption of coffee and/or tea. The authors found no association between higher consumption of coffee and/or tea, worse PROs and clinical outcomes.

More than 30% of survivors of breast cancer report high post‐diagnostic consumption of coffee and tea. In this study, the authors did not find any detrimental association between higher consumption of coffee and tea and patient‐reported or clinical outcomes.

Factors associated with enrolment in clinical trials among women with early-stage breast cancer

Background

Clinical trials allow development of innovative treatments and ameliorate the quality of clinical care in oncology. Data show that only a minority of patients are enrolled in clinical trials. We assessed enrolment in clinical trials and its correlates among women with early breast cancer.

Methods

We included 9516 patients with stage I-III breast cancer from the multicenter, prospective CANTO study (NCT01993498), followed-up until year 4 (Y4) post-diagnosis. We assessed factors associated with enrolment using multivariable logistic regression. In exploratory, propensity score matched analyses, we used multiple linear regression to evaluate the relationship of enrolment in clinical trials with the European Organisation for Research and Treatment of Cancer Quality Of Life (QoL) questionnaire (EORTC QLQ-C30) Summary Score and described clinical outcomes (distant disease event, invasive disease event, and death by any cause) according to enrolment.

Results

Overall, 1716 patients (18%) were enrolled in a clinical trial until Y4 post-diagnosis of breast cancer. Socioeconomic factors were not associated with enrolment. Centres of intermediate volume were most likely to enrol patients in clinical trials [versus low volume, odds ratio 1.45 (95% confidence interval (CI) 1.08-1.95), P = 0.0124]. Among 2118 propensity score matched patients, enrolment was associated with better QoL at Y4 (adjusted mean difference versus not enrolled 1.37, 95% CI 0.03-2.71, P = 0.0458), and clinical outcomes (enrolled versus not enrolled, distant disease event 7.3% versus 10.1%, P = 0.0206; invasive disease event 8.2% versus 10.5%, P = 0.0732; death by any cause 2.8% versus 3.7%, P = 0.2707).

Conclusions

In this large study, one in five patients enrolled on a clinical trial until Y4 after diagnosis of early breast cancer. Geographical and centre-related factors were significantly associated with enrolment in clinical trials. Inclusion in clinical trials seemed associated with improved QoL and clinical outcomes. Access to innovation for early-stage breast cancer patients should be encouraged and facilitated by overcoming organizational and geographical barriers to recruitment.

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The proportion of patients who access innovation through participation in clinical trials is generally limited.

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Rate of enrolment in clinical trials among women with early breast cancer exceeded what previously found in other settings.

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Clinical and geographical factors were associated to access to innovation in clinical trials.

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Enrolment in clinical trials is associated with better quality of life and clinical outcomes.

18F-FDG PET–derived parameter total lesion glycolisis (TLG) as a tool to stratify patients (pts) with advanced non–small cell lung cancer (aNSCLC) treated with immunotherapy

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Background: Upfront Immune Checkpoint Blockers (ICB) alone or in combination with chemotherapy (CT) have become the backbone treatment of non-oncogene addicted aNSCLC. PD-L1 remains the only predictive biomarker, but additional biomarkers are mandatory to better discriminate the population more suitable for the combination approach (CT-ICB). We hypothesized that TLG, a parameter that measure tumor burden and metabolic activity, may help to select the optimal first-line regimen. Methods: We performed a multicentric (n = 5) retrospective study including pts treated either with ICB alone, CT-ICB or CT alone. Overall survival (OS) and progression-free survival (PFS) were estimated with Kaplan-Meier analysis. Hazard ratios (HR) were calculated using multivariate Cox proportional Hazard models adjusting for relevant covariates (neutrophil/lymphocyte ratio, ECOG PS, liver, bone metastases). TLG was calculated on PET scans as the product of metabolic tumor volume (with a threshold of 42% of SUV max) and SUV mean. Results: 250 pts with aNSCLC initiated first-line treatment (94 ICB, 102 CT-ICB and an hystorical control group of 54 CT) within 42 days from PET. Median follow up was 22 months for ICB, 16 for CT-ICB and 47 for CT. 170 pts were male (68%), 210 had non-squamous histology (84%), 110 (44%)and 38 (15%) had bone and liver metastasis, respectively. On the 194 pts with PD-L1 status available: 20%, 29% and 50% had PD-L1 < 1%, 1-49% and > 50%, respectively. No correlation was seen between PD-L1 and TLG. Presence of liver metastases (13% vs 2%) and ECOG PS > 1 (16% vs 3%) were associated with elevated TLG. PFS correlated with TLG, with longer median PFS in the lower quartile (TLG < 380) either with ICB (12.4 vs 4.7 months, HR 1.9, 95% CI1.1 – 3.35, p 0.025) and CT-ICB (17.9 vs 7.3, HR 1.9, 95% CI1.1 – 3.7, p 0.032) but not with CT (4.2 vs 3.5, p 0.986), whereas OS was correlated with TLG < 380 in all 3 groups. The risk of progression under ICB was lower in tumors with TLG < 380 (15% vs.29%, p = 0.02), but no difference was seen in other 2 groups. In PD-L1 ≥50% pts with elevated TLG, treatment with CT-ICB (n = 20) increased the PFS respect with ICB (n = 55) (10.7 vs 3.9, HR 0.54, 95% CI 0.29 – 0.99, p = 0.048).The analysis was underpowered to find a difference in OS (HR 0.49, 95% CI 0.21 - 1.12, p = 0.092). Conclusions: TLG retains a prognostic validity in aNSCLC identifying pts with an increased rate of early progression on ICB, who may benefit from CT-ICB. Further analyses are required to compare CT-ICB and ICB in PD-L1 ≥50% according to TLG. Enrollement from other centers is ongoing, an update will be presented.

Long-Term Longitudinal Patterns of Patient-Reported Fatigue After Breast Cancer: A Group-Based Trajectory Analysis

PURPOSE

Fatigue is recognized as one of the most burdensome and long-lasting adverse effects of cancer and cancer treatment. We aimed to characterize long-term fatigue trajectories among breast cancer survivors.

METHODS

We performed a detailed longitudinal analysis of fatigue using a large ongoing national prospective clinical study (CANcer TOxicity, ClinicalTrials.gov identifier: NCT01993498) of patients with stage I-III breast cancer treated from 2012 to 2015. Fatigue was assessed at diagnosis and year 1, 2, and 4 postdiagnosis. Baseline clinical, sociodemographic, behavioral, tumor-related, and treatment-related characteristics were available. Trajectories of fatigue and risk factors of trajectory-group membership were identified by iterative estimates of group-based trajectory models.

RESULTS

Three trajectory groups were identified for severe global fatigue (n = 4,173). Twenty-one percent of patients were in the high-risk group, having risk estimates of severe global fatigue of 94.8% (95% CI, 86.6 to 100.0) at diagnosis and 64.6% (95% CI, 59.2 to 70.1) at year 4; 19% of patients clustered in the deteriorating group with risk estimates of severe global fatigue of 13.8% (95% CI, 6.7 to 20.9) at diagnosis and 64.5% (95% CI, 57.3 to 71.8) at year 4; 60% were in the low-risk group with risk estimates of 3.6% (95% CI, 2.5 to 4.7) at diagnosis and 9.6% (95% CI, 7.5 to 11.7) at year 4. The distinct dimensions of fatigue clustered in different trajectory groups than those identified by severe global fatigue, being differentially affected by sociodemographic, clinical, and treatment-related factors.

CONCLUSION

Our findings highlight the multidimensional nature of cancer-related fatigue and the complexity of its risk factors. This study helps to identify patients with increased risk of severe fatigue and to inform personalized interventions to ameliorate this problem.

Prognostic effect of body mass index in patients with advanced NSCLC treated with chemoimmunotherapy combinations

Introduction

It has been recognized that increasing body mass index (BMI) is associated with improved outcome from immune checkpoint inhibitors (ICIs) in patients with various malignancies including non-small cell lung cancer (NSCLC). However, it is unclear whether baseline BMI may influence outcomes from first-line chemoimmunotherapy combinations.

Methods

In this international multicenter study, we evaluated the association between baseline BMI, progression-free survival (PFS) and overall survival (OS) in a cohort of patients with stage IV NSCLC consecutively treated with first-line chemoimmunotherapy combinations. BMI was categorized according to WHO criteria.

Results

Among the 853 included patients, 5.3% were underweight; 46.4% were of normal weight; 33.8% were overweight; and 14.5% were obese. Overweight and obese patients were more likely aged ≥70 years (p=0.00085), never smokers (p<0.0001), with better baseline Eastern Cooperative Oncology Group—Performance Status (p=0.0127), and had lower prevalence of central nervous system (p=0.0002) and liver metastases (p=0.0395). Univariable analyses showed a significant difference in the median OS across underweight (15.5 months), normal weight (14.6 months), overweight (20.9 months), and obese (16.8 months) patients (log-rank: p=0.045, log rank test for trend: p=0.131), while no difference was found with respect to the median PFS (log-rank for trend: p=0.510). Neither OS nor PFS was significantly associated with baseline BMI on multivariable analysis.

Conclusions

In contrast to what was observed in the context of chemotherapy-free ICI-based regimens, baseline BMI does not affect clinical outcomes from chemoimmunotherapy combinations in patients with advanced NSCLC.

Abstract P4-11-01: Development of a clinico-bio-behavioral model for cancer-related fatigue (CRF) incorporating inflammatory biomarkers and proteomic data

Background: We previously developed a clinico-behavioral model of CRF and reported an increased risk of severe CRF among survivors of breast cancer (BC) receiving adjuvant hormonal therapy (HT) (Di Meglio A, ASCO 2021). We now aim to comprehensively explore the contribution of relevant serum proteins in explaining CRF. We adopted a multimodal approach, both (1) hypothesis-driven, based on the rationale that deregulation of systemic inflammatory processes and mediators of immunologic or neuroendocrine activation are associated with vulnerability to CRF, and (2) discovery-driven, based on proteomic analyses. Methods: Women with stage I-III HR+/HER2- tumors receiving HT (N=1153) were included from the multicenter, prospective CANTO cohort (NCT01993498). The primary outcome of interest was severe post-treatment global CRF at year-2 (Y2) after diagnosis (score ≥ 40/100, EORTC QLQ-C30). Secondary outcomes included CRF dimensions (physical, emotional, cognitive; EORTC QLQ-FA12). For the hypothesis-driven analyses, pre-treatment blood samples were profiled (Randox Laboratories Limited, UK) at diagnosis of BC, using a multi-biomarker panel assessing IL6, TNFα, IL1RA, CRP, IL2, IL1β, IFNγ, IL10, IL1A, IL4, and IL8. Pre-specified pre-treatment clinico-behavioral covariates (age, BMI, smoking status, psychological, and pre-treatment symptom burden, based on previously developed models) were forced into a multivariable logistic regression. Biomarkers were retained by Augmented Backwards Elimination (p&lt;0.05) only if significantly associated with CRF. For the discovery approach, we used hyper-reaction monitoring mass spectrometry for the unbiased quantification of all detectable peptides and proteins in human plasma samples at diagnosis (Biognosys, CH), among a discovery subset (N=462). We then aimed to identify a proteomic signature associated with severe CRF at Y2. Log-transformed protein intensities were analyzed in terms of differential expression. The proteins that were identified to be significantly different among the patients reporting and not reporting severe CRF were then used to train a logistic regression model. Results: Prevalence of severe global CRF increased from 21.6% at diagnosis to 34.8% at Y2. In the final model, higher pre-treatment levels of IL6 and lower levels of IFNγ and IL10 were significant predictors of severe global CRF at Y2 (Table). The AUC of this clinico-bio-behavioral model was 0.78 (95%CI 0.75 - 0.82) and was suggestive of an improved performance as compared to clinico-behavioral models. Among CRF dimensions, a significant association emerged only between CRP and severe cognitive CRF (outcome prevalence at Y2 14.2%; adjusted OR per CRP log-unit increase 1.40 [95%CI 1.01-1.93]).

In the discovery subset, several proteins were identified as differentially regulated (p&lt;0.05) among patients reporting and not reporting severe CRF at Y2. Most of these were related to coagulation pathways (including C4BPA, C4BPB, HABP2, PLF4, PROS). However, models incorporating proteomic data did not seem to augment the predictive ability compared to clinico-behavioral models. Conclusions: Using clinical and biological pre-treatment measurements, it may be possible to identify a subset of BC patients at high risk for increased post-treatment CRF while on HT. This provides the possibility of testing dedicated preventive interventions.

Table. Clinico-bio-behavioral model of pre-treatment predictors of severe global CRF at Y2, incorporating circulating inflammatory biomarkers.Adjusted OR§ (95% CI)Age, per additional 1 year0.98 (0.96-0.99)BMI, per additional unit1.02 (0.99-1.06)Current smoker, vs never2.27 (1.47-3.51)Former smoker, vs never0.97 (0.64-1.46)Anxiety case*, vs normal1.13 (0.75-1.70)Doubtful anxiety*, vs normal1.11 (0.73-1.68)Pre-treatment Insomnia**, per additional 10 points1.09 (1.04-1.15)Pre-treatment Pain**, per additional 10 points1.10 (1.01-1.18)Severe pre-treatment CRF**, vs no4.70 (3.13-7.05)IL6***1.72 (1.25-2.36)IL1RA***1.24 (0.85-1.81)IL2***1.43 (0.99-2.08)IFNγ***0.54 (0.30-0.95)IL10***0.40 (0.18-0.87)IL4***1.47 (0.67-3.20)IL8***1.15 (0.83-1.60)OR= Odds Ratio; CI= Confidence Interval; §by all factors in Table; *HADS; **QLQ-C30; ***per log-unit increase

Citation Format: Antonio Di Meglio, Stergios Christodoulidis, Davide Soldato, Antonin Della Noce, Daniele Presti, Julie Havas, Florine Dubuisson, Barbara Pistilli, Valerie Camara-Clayette, Cecile Charles, Patricia A Ganz, Julienne Bower, Ann H Partridge, Alexandra Jacquet, Sibille Everhard, Sandrine Boyault, Fabrice André, Paul-Henry Cournede, Stefan Michiels, Caroline Pradon, Ines Vaz-Luis. Development of a clinico-bio-behavioral model for cancer-related fatigue (CRF) incorporating inflammatory biomarkers and proteomic data [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-01.

Abstract P4-11-34: An integrated clinical, behavioral and biological model to predict the risk of weight gain among breast cancer survivors (BCS)

Background: Weight management is an integral part of survivorship care. Excess weight in BCS is associated with worse clinical outcomes and quality of life. Early identification of BCS at risk of gaining substantial weight could lead to prompt and tailored interventions. We aimed at developing a predictive model of weight gain that integrates clinical, behavioral and biological data. Methods: We included patients with stage I-III BC from the CANTO cohort (NCT01993498). CANTO collects longitudinal data, including objective anthropometric measures, at diagnosis (dx), 1 (T1), 2 (T2) and 4 (T3) years after dx. In addition, profiling of blood samples obtained at dx was performed for two sub-cohorts with HR+/HER2- BC for quantification of: (1) inflammatory and metabolic biomarkers (IL6, TNFα, IL1RA, CRP, IL2, IL1β, IFNγ, IL10, IL1A, IL4, IL8, ADPN, LEPT, INS, RETN) and (2) detectable proteins using hyper reaction mass spectrometry (Biognosys). Our outcome of interest was weight gain (increase ≥ 5%) compared to dx. First, multivariable logistic regression with bootstrapped Augmented Backwards Elimination (ABE) retained associations between weight gain and clinico-behavioral covariates. To assess contribution of biologic data, ABE retained associations between weight gain and biomarkers, correcting for significant covariates. Models were validated using internal cross-validation and overoptimism-correction. For proteomics, proteins relative intensity was calculated, and a bootstrapped differential protein expression analysis identified proteins associated with weight gain that were then included in logistic regression. Models performance was assessed in terms of Area Under the Curve (AUC). Results: In the overall cohort (N=9541) mean age was 56.8 (SD 11.4), mean BMI was 25.9 Kg/m2 (SD 5.4), 48.9% of pts were overweight or obese, and 52.9% received chemotherapy (CT). Overall, 16.9% (T1), 23.4% (T2), and 27.2% (T3) BCS gained weight (absolute mean change (95% CI): 6.1 kg (5.9-6.2), 6.7 kg (6.5-6.9) and 7.2 kg (6.9-7.3) at T1, T2, T3, respectively). In clinico-behavioral models, younger age, current smoking, lower income and education, receipt of CT and radiotherapy were associated with increased risk of weight gain (Table). Among 1261 BCS with biomarkers data, higher levels of IL1α (OR for 1-unit log increase [95%CI] 0.11 [0.02 - 0.65]) and of ADPN (1.36 [1.01 - 1.85]) were associated with lower and higher risk of weight gain at T2 and T3, respectively. Performance of models integrating these biomarkers was similar to clinico-behavioral models. Among 462 BCS with proteomic profiling, preliminary data showed that higher relative abundance of IgG Fc Binding Protein (OR 0.44, p&lt;.05) and Tubulin-1 (OR 0.73, p&lt;.05) was associated with lower risk of weight gain at T1. AUC of model integrating clinical and proteomics data was 0.74 (0.58-0.90). Conclusions: Over one-in-four BCS in the CANTO cohort experienced meaningful weight gain 4 years after dx. This large, multidimensional study confirms the role of clinico-behavioral risk factors for weight gain. However, the predictive ability of clinico-behavioral models seems suboptimal. The exploitation of additional data dimensions, including serum proteins and proteomic data, may help improve predictive ability and inform underlying biological processes implicated in weight gain after BC. Further studies will aim at improving model stability, particularly for proteomics analyses.

Table. Models of weight gain in the overall cohort.T1 (N= 8397)T2 (N= 7663)T3 (N= 5802)Clinical predictors OR* (95% CI)OR* (95% CI)OR* (95% CI)Age, 1-year increase0.96 (0.94 - 0.97)0.96 (0.95 - 0.97)0.96 (0.95 - 0.97)BMI, 1-unit increaseNRNS0.97 (0.94 - 0.99)Education, primary vs collegeNS1.57 (1.04 - 2.39)NREducation, high school vs college1.38 (1.04 - 1.83)1.54 (1.21 - 1.98)NRIncome, ≥ 1500 and &lt;3000 vs &gt;3000NRNR1.29 (1.00 - 1.66)Smoke, current vs never1.70 (1.24 - 2.33)NR1.53 (1.12 - 2.08)Chemotherapy, yes vs no1.40 (1.07 - 1.82)1.31 (1.01 - 1.69)NRRadiotherapy, yes vs no2.10 (1.10 - 3.99)NR1.83 (1.08 - 3.12)AUC (95% CI) - clinical models0.65 (0.63 - 0.68)0.64 (0.61 - 0.67)0.65 (0.63 - 0.68)AUC (95% CI) - clinical + inflammatory and metabolic biomarkers models, [N]0.65 (0.60 - 0.70), [1179]0.66 (0.62 - 0.70), [948]0.67 (0.63 - 0.71), [1017]AUC (95% CI) - clinical and proteomics models, [N]0.74 (0.58 - 0.90), [462]0.65 (0.50 - 0.81), [462]NEOR= Odds Ratio, CI= Confidence Interval, NR= Not Retained, NS= Not significant, NE= Not evaluated *Adjusted by age, menopause, smoke, socioeconomic, psychological, tumor and treatments **Significant covariates from previous models were forced and ABE selected significant variables among all circulating biomarkers.

Citation Format: Davide Soldato, Antonio Di Meglio, Caroline Pradon, Antonin Della Noce, Daniele Presti, Julie Havas, Florine Dubuisson, Barbara Pistilli, Valerie Camara-Clayette, Fabrice André, Alexandra Jacquet, Sibille Everhard, Sandrine Boyault, Paul-Henry Cournede, Stefan Michiels, Ines Vaz-Luis, Stergios Christodoulidis. An integrated clinical, behavioral and biological model to predict the risk of weight gain among breast cancer survivors (BCS) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-34.

Abstract P4-11-27: A multimodal and personalized digital companion to help survivors of breast cancer (BC) manage side effects of adjuvant endocrine therapy (ET): A qualitative exploration

Background: Mobile health (mHealth) applications (app) and remote monitoring demonstrated tangible value in terms of improving dose delivery, quality of life and mitigating the severity of acute treatment-related side effects, both in the metastatic setting and during the active phase of treatment in patients (pts) with early-stage solid tumors. However, the value of mHealth in ‘after primary treatment’ survivorship phase is less studied. Most BC pts have hormone receptor-positive disease and are eligible for adjuvant ET for 5-10 years. ET is associated with multiple side effects that negatively impact quality of life and treatment adherence. A prior survey among French survivors suggested that pts are willing to use digital companion app to help them in the after-cancer experience. In this setting, we developed a digital companion for survivors of BC receiving ET. Objectives: In this study, we explored acceptability, representations, levers, and barriers to a multimodal mHealth intervention among BC pts treated with ET. Methods: This was a qualitative study based on 3 focus groups (FG) with survivors of BC receiving adjuvant ET. The multimodal mHealth intervention had the following features: measure (symptom reporting), understand, and appease (information on interventions to relieve the symptom). FG were conducted via videoconference, lasted approximately 60-90 min, were recorded and transcribed for analysis. A content, thematic analysis was performed. All participants provided oral informed consent and socio-demographic information. Results: 17 BC survivors from diverse professional and socio-economic background participated. Mean age was 48.5 years (range: 32-61). There was a consensus regarding the acceptability and perception of usefulness of an app during treatment with adjuvant ET. A feeling of loneliness during this period was also expressed. Emergent themes cited included: a) positive representations i) satisfaction with the educational support with language and the level of information of the app judged as appropriate and reliable; ii) hope in the role of the app as a companion to alleviate the loneliness; iii) vehicle to enhance family interaction; iv) tool to boost engagement towards their treatment. b) concerns associated with i) fear of human contact replacement ii) fear of loss of interest over time, particularly in the setting of a 5-10 year journey. Pts were pro-active in providing feedback regarding innovative features that could be integrated: i) including interest on the use of biosensors (step counting, nutritional tracking); ii) to receive personalized encouragement messages and iii) updated information regarding scientific advances related to the treatment of early breast cancer. Most participants found the app to be aesthetically pleasing and easy to use. Conclusions: Findings from this qualitative study are promising regarding the acceptability and perception of usefulness of a personalized app for the mitigation of ET side effects in the adjuvant setting. It highlights the need of personalized educational material, but also maintenance of ‘bi-directional’ communication with health professionals. Optimization of the tool is ongoing and updated FG results will be presented. This tool will be tested in a randomized controlled trial starting in Q1/2022, which will evaluate its effectiveness.

Quotes from participantsThemes emergedParticipants’ quotes from focus groupsSatisfaction with educational support‘’Today we find everything on the internet, bad and good things, we cannot know what is true and what is fake. (⋯) If an app can give us reliable information, good, summarized information, this would be great!’’Satisfaction with educational support; Hope in the role of the app to alleviate loneliness“I didn’t even know we had so many side-effects linked to endocrine therapy. Now I understand that it’s true, it’s not something from my head. It’s related to the treatment and it’s really nice to have this support.”Alleviation of loneliness‘’I often feel lonely, sometimes is difficult to have contact with the doctor.’’, ‘’We feel lonely, even our family cannot understand.’’Alleviation of loneliness‘’We need to exchange with people that lived the same situation.’’, “We go to forums, chats, Instagram⋯”, ‘’We realize that we are not alone, that we are not the only ones with the symptoms.’’Fear of human contact replacement‘’It is a good addition, but it will never replace the relationship that we have with our doctor.’’Fear of loss of interest over time‘’It is a good app to start endocrine therapy⋯ How to make the app interesting and useful during several years of treatment?’’

Citation Format: Elise Martin, Antonio Di Meglio, Pietro Lapidari, Daniele Presti, Davide Soldato, Léna Degousee, Marion Aupomerol, Barbara Pistilli, Léonor Fasse, Diane Boinon, Florian Scotte, Gwenn Menvielle, Agnès Dumas, Céline Lazorthes, Jonathan Benhamou, Matthieu Pozza, Raphaëlle Martin-Neuville, Nicolas Helleringer, Jeanne Eelkema, Fabrice Andre, Ines Vaz-Luis, Maria Alice Franzoi. A multimodal and personalized digital companion to help survivors of breast cancer (BC) manage side effects of adjuvant endocrine therapy (ET): A qualitative exploration [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-27.

Abstract P4-11-09: Cancer-related cognitive impairment (CRCI) in early breast cancer (BC) survivors

Background: Up to 35% BC survivors who receive adjuvant treatment (tx) experience severe CRCI, which has a significant impact on quality of life, disrupting daily functioning as well as self-esteem, self-confidence, and work ability. However, limited tools exist to predict the risk of CRCI. We aimed to develop a comprehensive model of severe CRCI, including clinical and serum inflammatory protein data. Methods: We included 8875 patients (pts) with stage I-III BC from the multicenter, prospective CANTO cohort (NCT01993498). Longitudinal data were collected at diagnosis (dx), 1 (T1), 2 (T2) and 4 (T3) years post-dx. Our outcome of interest was severe cognitive impairment at T1, T2, and T3 (score &lt; 75/100, EORTC QLQ-C30, Giesinger JM 2020). Multivariable logistic regression models retained associations between baseline clinical variables (sociodemographic, psychological, tumor, and tx-related) with severe CRCI by bootstrapped Augmented Backwards Elimination (ABE). Among a subset of patients with HR+/HER2- BC (N= 1151), blood samples were profiled at dx using a multi-biomarker inflammatory panel assessing IL6, TNFα, IL1RA, CRP, IL2, IL1β, IFNγ, IL10, IL1A, IL4, IL8, and monocyte chemoattractant protein-1 (MCP-1). All biomarkers were incorporated simultaneously into a model of severe CRCI and retained only if significantly associated with CRCI by ABE (p&lt;0.05). Previously retained clinical associations were forced into the model. Results: In the overall cohort, mean age at dx was 56.7 years (SD 11.3), and 52.7% and 81.3% of pts received chemotherapy and hormonal therapy, respectively. Prevalence rates of severe CRCI were 31.2% (dx), 31.4% (T1), 30.9% (T2), and 29.9% (T3). Severe post-tx CRCI was consistently associated with severe pre-tx pain and severe pre-tx CRCI. Severe pre-tx fatigue, younger age, anxiety symptoms and hot flashes at dx were also associated with increased odds of severe CRCI at some post-dx time-points (Table 1). Models Area Under the Curve (AUC) were 0.73 (95% confidence intervals [CI] 0.70-0.76) at T1, 0.69 (CI 0.65-0.72) at T2, and 0.68 (CI 0.63-0.72) at T3. Among pts with available serum biomarkers, no significant associations were observed between inflammatory proteins and CRCI at any time point. Performance of models incorporating inflammatory biomarkers was similar to clinical-only models (Table 2). Conclusions: Almost 1/3 of BC survivors in this cohort reported severe CRCI. This rate was stable throughout the survivorship period and did not seem to be affected by cancer-specific or tx-related factors, or inflammatory biomarkers. Pts age and concomitant symptom burden at dx emerged as consistent associations with severe CRCI. A description of the average population risk of CRCI using a self-reported, global evaluation scale may not fully describe the granularity of this phenomenon. Further studies building on dedicated, objective measurements, may help identify latent classes of pts experiencing a major decline in cognitive function following BC tx, and for whom a contribution of biology may help explain inter-individual variability and underlying biological processes.

Table 1.Models of severe CRCI in the overall cohort: clinical predictors.T1 (N=7724)T2 (N=6825)T3 (N=4706)OR* (95% CI)OR* (95% CI)OR* (95% CI)Severe Pain**, vs no1.50 (1.09-2.07)1.93 (1.39-2.69)1.55 (1.03-2.34)Severe pre-tx CRCI**, vs no3.69 (2.70-5.05)2.53 (1.85-3.46)2.21 (1.47-3.32)Severe Fatigue**, vs no1.50 (1.06-2.11)1.61 (1.13-2.28)1.08 (0.69-1.70)Age (continous)0.98 (0.97-0.99)NR0.98 (0.96-0.99)Menopause, post- vs pre-NR0.73 (0.54-0.98)NRAnxiety, case vs normalNRNR1.82 (1.13-2.92)Anxiety, borderline vs normalNRNR1.84 (1.17-2.91)Hot flashes, vs no1.25 (0.92-1.69)1.20 (0.87-1.65)1.64 (1.10-2.43)Corrected AUC0.73 (0.70-0.76)0.69 (0.65-0.72)0.68 (0.63-0.72)OR= Odds Ratio, CI= Confidence Interval, NR= Not Retained; *Adjusted by BMI, alcohol, smoke, socioeconomic, psychological, tumor and tx; **QLQ-C30

Table 2.Models of severe CRCI in the overall cohort**: biological biomarkers.T1 (N=1094)T2 (N=1091)T3 (N=870)OR* (95% CI)OR* (95% CI)OR* (95% CI)IL6NR0.80 (0.46-1.40)1.01 (0.64-1.60)IL1RA0.66 (0.37-1.17)0.88 (0.50-1.55)NRCRP0.94 (0.60-1.48)1.44 (0.92-2.27)NRIL20.93 (0.55-1.57)1.10 (0.61-1.97)NRIL1βNR1.55 (0.71-3.40)NRIFNγ1.86 (0.69-5.01)0.75 (0.25-2.22)NRIL101.05 (0.34-3.27)1.27 (0.58-2.78)NRIL1A0.71 (0.15-3.33)0.80 (0.17-3.66)NRIL80.96 (0.58-1.58)NRNRTNFαNR1.35 (0.67-2.73)NRMCP-11.07 (0.64-1.78)0.83 (0.51-1.35)0.80 (0.48-1.31)Corrected AUC0.72 (0.67-0.77)0.70 (0.65-0.75)0.67 (0.62-0.72)OR= Odds Ratio, CI= Confidence Interval, NR= Not Retained; *Adjusted by BMI, alcohol, smoke, socioeconomic, psychological, tumor and tx; ** Clinical predictors from previous models were forced in the models at each time-point

Citation Format: Daniele Presti, Florence Joly, Davide Soldato, Stergios Christodoulidis, Antonin Della Noce, Julie Havas, Florine Dubuisson, Barbara Pistilli, Valerie Camara-Clayette, Fabrice André, Anne-Laure Martin, Alexandra Jacquet, Sandrine Boyault, Ivan Bièche, Charles Coutant, Paul-Henry Cournede, Stefan Michiels, Caroline Pradon, Ines Vaz-Luis, Antonio Di Meglio. Cancer-related cognitive impairment (CRCI) in early breast cancer (BC) survivors [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-09.

Development and Validation of a Predictive Model of Severe Fatigue After Breast Cancer Diagnosis: Toward a Personalized Framework in Survivorship Care

PURPOSE

Fatigue is common and troublesome among breast cancer survivors; however, limited tools exist to predict its risk.

PATIENTS AND METHODS

Participants with stage I-III breast cancer were prospectively included from CANTO (ClinicalTrials.gov identifier: NCT01993498), collecting longitudinal data at diagnosis (before the initiation of any cancer treatment) and 1 (T1), 2 (T2), and 4 (T3) years after diagnosis. The main outcome was severe global fatigue at T2 (score ≥ 40/100, European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-C30). Analyses at T3 were exploratory. Secondary outcomes included physical, emotional, and cognitive fatigue (EORTC Quality of Life Questionnaire-FA12). Multivariable logistic regression models retained associations with severe fatigue by bootstrapped Augmented Backward Elimination. Validation methods included 10-fold internal cross-validation, overoptimism-corrected area under the receiver operating characteristic curves, and external validation.

RESULTS

Among 5,640, 5,000, and 3,400 patients at T1, T2, and T3, respectively, the prevalence of post-treatment severe global fatigue was 35.6%, 34.0%, and 31.5% in the development cohort. Retained risk factors for severe global fatigue at T2 were severe pretreatment fatigue (adjusted odds ratio v no 3.191 [95% CI, 2.704 to 3.767]); younger age (for 1-year decrement 1.015 [1.009 to 1.022]), higher body mass index (for unit increment 1.025 [1.012 to 1.038]), current smoking behavior (v never 1.552 [1.291 to 1.866]), worse anxiety (v noncase 1.265 [1.073 to 1.492]), insomnia (for unit increment 1.005 [1.003 to 1.007]), and pain at diagnosis (for unit increment 1.014 [1.010 to 1.017]), with an area under the receiver operating characteristic curve of 0.73 (95% CI, 0.72 to 0.75). Receipt of hormonal therapy was a risk factor for severe fatigue at T3 (v no 1.448 [1.165 to 1.799]). Dimension-specific risk factors included body mass index for physical fatigue and emotional distress for emotional and cognitive fatigue.

CONCLUSION

We propose a predictive model to assess fatigue among breast cancer survivors, within a personalized survivorship care framework. This may help clinicians to provide early management interventions or to correct modifiable risk factors and offer more tailored monitoring and education to patients at risk of severe post-treatment fatigue.

Lifestyle and quality of life in patients with early-stage breast cancer receiving adjuvant endocrine therapy

PURPOSE OF REVIEW

A comprehensive approach to survivorship care for women with early-stage, hormone-receptor positive breast cancer should systematically include the proactive assessment and adequate management of endocrine therapy-associated symptoms, in order to assure optimal balance between preserving quality of life (QOL) and maximizing treatment adherence. We reviewed the recent literature focused on lifestyle factors, including physical activity, diet and nutrition, weight management, smoke, and alcohol behavior, and their link with symptomatology and QOL among women receiving adjuvant endocrine therapy.

RECENT FINDINGS

Recent studies confirm the safety, feasibility, and effectiveness of lifestyle interventions in mitigating several common endocrine therapy-related effects, including musculoskeletal pain, fatigue, and insomnia, and in improving physical and emotional wellbeing as well as overall health-related QOL among women with early-stage breast cancer.

SUMMARY

Healthy lifestyle behaviors have the potential to modulate the downstream impact of endocrine therapy and improve QOL among women with early-stage breast cancer. Considerations for real-world clinical care implementation emerged, including a need to evaluate the long-term uptake of healthy behaviors and facilitate the postintervention maintenance of an improved lifestyle. Some facilitators to health promotion in breast cancer survivors were also suggested, such as individualized and one-to-one supervised programs, and digital solutions providing real-time feedback, building on personalized, direct patient engagement.

Molecular differences between lymph nodes and distant metastases compared with primaries in colorectal cancer patients

Lymph nodes (LNs) and distant metastases can arise from independent subclones of the primary tumor. Herein, we characterized the molecular landscape and the differences between LNs, distant metastases and primary colorectal cancers (CRCs). Samples were analyzed using next generation sequencing (NGS, MiSeq on 47 genes, NextSeq on 592 genes) and immunohistochemistry. Tumor mutational burden (TMB) was calculated based on somatic nonsynonymous missense mutations, and microsatellite instability (MSI) was evaluated by NGS of known MSI loci. In total, 11,871 samples were examined, comprising primaries (N = 5862), distant (N = 5605) and LNs metastases (N = 404). The most frequently mutated genes in LNs were TP53 (72%), APC (61%), KRAS (39%), ARID1A (20%), PIK3CA (12%). LNs showed a higher mean TMB (13 mut/MB) vs distant metastases (9 mut/MB, p < 0.0001). TMB-high (≥17mut/MB) and MSI-H (8.8% and 6.9% vs 3.7%, p < 0.001 and p = 0.017, respectively) classifications were more frequent in primaries and LNs vs distant metastases (9.5% and 8.8% vs 4.2%, p < 0.001 and p = 0.001, respectively). TMB-high is significantly more common in LNs vs distant metastases and primaries (P < 0.0001), regardless MSI-H status. Overall, LNs showed significantly different rates of mutations in APC, KRAS, PI3KCA, KDM6A, and BRIP1 (p < 0.01) vs primaries, while presenting a distinct molecular profile compared to distant metastases. Our cohort of 30 paired samples confirmed the molecular heterogeneity between primaries, LNs, and distant metastases. Our data support the hypothesis that lymphatic and distant metastases harbor different mutational landscape. Our findings are hypothesis generating and need to be examined in prospective studies.

Update on the Management of Breast Cancer during Pregnancy

The diagnosis of breast cancer during pregnancy represents a challenging situation for the patient, her caregivers and physicians. Pregnancy adds complexity to oncological treatment planning, as many therapies can be potentially dangerous to the fetus. Therefore, a multidisciplinary approach is needed to offer a proper care for obtaining the best possible outcomes for the mother and the future child. Breast surgery is feasible throughout the pregnancy while radiotherapy should be postponed after delivery. Administration of chemotherapy is considered safe and can be given during the second and third trimesters, while it is contraindicated in the first trimester due to the high risk of fetal malformations. Endocrine therapy and targeted agents are not recommended during the whole pregnancy period; however, limited data are available on the use of the majority of new anticancer drugs in this context. The aim of the current review is to provide an update on the current state of art about the management of women diagnosed with breast cancer during pregnancy.

Burning Questions in the Oncofertility Counseling of Young Breast Cancer Patients

The improved prognosis of breast cancer patients makes survivorship issues an area of crucial importance. In this regard, an increased attention is needed toward the development of potential anticancer treatment-related long-term side-effects, including gonadal failure and infertility in young women. Therefore, fertility preservation and family planning are crucial issues to be addressed in all young women of reproductive age with newly diagnosed cancer. Despite a growing availability of data on the efficacy and safety of fertility preservation options and the fact that conceiving after prior history of breast cancer has become more accepted over time, there are still several gray zones in this field so that many physicians remain uncomfortable to deal with these topics. The purpose of this review is to answer some of the most controversial questions frequently asked by patients during their oncofertility counseling, in order to provide a detailed and up-to-date overview on the evidence available in this field to physicians involved in the care of young women with breast cancer.

Comprehensive Genomic Profiling of Gastroenteropancreatic Neuroendocrine Neoplasms (GEP-NENs)

PURPOSE

GEP-NENs are rare malignancies with increasing incidence. Their molecular characteristics are still undefined. We explored the underlying biology of GEP-NENs and the differences between gastrointestinal (GI) and pancreatic (PNEN), high-grade (HG), and low-grade (LG) tumors.

EXPERIMENTAL DESIGN

GEP-NENs were analyzed using next-generation sequencing (NGS; MiSeq on 47 genes, NextSeq on 592 genes), IHC, and in situ hybridization. Tumor mutational burden (TMB) was calculated on the basis of somatic nonsynonymous missense mutations, and microsatellite instability (MSI) was evaluated by NGS of known MSI loci.

RESULTS

In total, 724 GEP-NENs were examined: GI (N = 469), PNEN (N = 255), HG (N = 135), and LG (N = 335). Forty-nine percent were female, and median age was 59. Among LG tumors, the most frequently mutated genes were ATRX (13%), ARID1A (10%), and MEN1 (10%). HG tumors showed TP53 (51%), KRAS (30%), APC (27%), and ARID1A (23%). Immune-related biomarkers yielded a lower prevalence in LG tumors compared with HG [MSI-H 0% vs. 4% (P = 0.04), PD-L1 overexpression 1% vs. 6% (P = 0.03), TMB-high 1% vs. 7% (P = 0.05)]. Compared with LG, HG NENs showed a higher mutation rate in BRAF (5.4% vs. 0%, P < 0.0001), KRAS (29.4% vs. 2.6%, P < 0.0001), and PI3KCA (7% vs. 0.3%, P < 0.0001). When compared with GI, PNEN carried higher frequency of MEN1 (25.9% vs. 0.0%, P < 0.0001), FOXO3 (8.6% vs. 0.8%, P = 0.005), ATRX (20.6% vs. 2.0%, P = 0.007), and TSC2 (6.3% vs. 0.0%, P = 0.007), but lower frequency of mutations in APC (1.0% vs. 13.8%, P < 0.0001).

CONCLUSIONS

Significant molecular differences were observed in GEP-NENs by tumor location and grade, indicating differences in carcinogenic pathways and biology.

Italian survey on managing immune checkpoint inhibitors in oncology during COVID-19 outbreak

BACKGROUND

During COVID-19 outbreak, oncological care has been reorganized. Patients with cancer have been reported to experience a more severe COVID-19 syndrome; moreover, there are concerns of a potential interference between immune checkpoint inhibitors (ICIs) and SARS-CoV-2 pathogenesis.

MATERIALS AND METHODS

Between 6 and 16 May 2020, a 22-item survey was sent to Italian physicians involved in administering ICIs. It aimed at exploring the perception about SARS-CoV-2-related risks in cancer patients receiving ICIs, and the attitudes towards their management.

RESULTS

The 104 respondents had a median age of 35.5 years, 58.7% were females and 71.2% worked in Northern Italy. 47.1% of respondents argued a synergism between ICIs and SARS-CoV-2 pathogenesis leading to worse outcomes, but 97.1% would not deny an ICI only for the risk of infection. During COVID-19 outbreak, to reduce hospital visits, 55.8% and 30.8% opted for the highest labelled dose of each ICI and/or, among different ICIs for the same indication, for the one with the longer interval between cycles, respectively. 53.8% of respondents suggested testing for SARS-CoV-2 every cancer patient candidate to ICIs. 71.2% declared to manage patients with onset of dyspnoea and cough as infected by SARS-CoV-2 until otherwise proven; however, 96.2% did not reduce the use of steroids to manage immune-related toxicities. The administration of ICIs in specific situations for different cancer types has not been drastically conditioned.

CONCLUSIONS

These results highlight the uncertainties around the perception of a potential interference between ICIs and COVID-19, supporting the need of focused studies on this topic.

To switch or not to switch? A real-life experience using dexamethasone in combination with abiraterone

The recently published phase II prospective SWITCH trial evaluated whether patients with metastatic castration-resistant prostate cancer (mCRPC) treated with abiraterone acetate could benefit from a ‘steroid switch’ from prednisone to dexamethasone. A total of 26 patients, both chemonaïve (14 patients) or pretreated with docetaxel (12 patients), with biochemical and/or limited radiological progression, were enrolled in this trial. Primary endpoint was prostate specific antigen (PSA) 30 defined as the proportion of patients with a PSA level decline 30% or more after 6 weeks of treatment with abiraterone acetate + dexamethasone. Secondary endpoints were: a PSA50 rate (defined as the proportion of patients with PSA decline of 50% or more after 12 weeks on abiraterone acetate + dexamethasone), biochemical and radiological progression-free survival (bPFS and rPFS, respectively), benefit from subsequent treatment and identification of biomarkers of response. Primary endpoint was reached in 46.2% of patients (12 patients), and two patients had an objective partial response on computed tomography scan. Median bPFS and rPFS were 5.3 months and 11.8 months. We present a case series of 11 patients who were consecutively treated with a steroid switch at our institution from January 2016 to August 2018 to investigate if this strategy could be used in a ‘real-life’ setting. We observed a PSA30 response in two patients (18%), median bPFS was 4.77 months (95% confidence interval [CI] 2.5–14.6) and median rPFS was 7.2 months (95% CI 3.8–15.5). Seven patients had a radiological stable disease as best response to steroid switch. Three patients were being still treated with abiraterone acetate + dexamethasone at data cut-off time. Our case series confirms that switching from prednisone to dexamethasone during abiraterone acetate treatment produces biochemical and radiological responses in both a predocetaxel and a postdocetaxel setting, providing a clinical benefit in mCRPC patients. However, to date, there is no clear indication as to which patient could benefit most from this kind of strategy.

Impact of phosphoinositide-3-kinase and vitamin D3 nuclear receptor single-nucleotide polymorphisms on the outcome of malignant melanoma patients

Background

Several studies associating single nucleotide polymorphisms (SNPs) frequencies with tumors outcome have been conducted, nevertheless malignant melanoma literature data are inconclusive.

Therefore we evaluate the impact of different genotypes for phosphoinositide-3-kinase (PI3K) and vitamin D3 nuclear receptor (VDR) SNPs on melanoma patients’ outcome.

Materials and methods

Genomic DNA of 88 patients was extracted from blood and tumor samples. SNPs were determined by PCR using TaqMan assays. We selected polymorphisms of the regulatory and catalytic subunit of PI3K (PIK3R1 and PIK3CA genes, respectively), analyzing rs2699887C>T of PIK3CA and rs3730089G>A of PIK3R1 SNPs. Furthermore we considered the following VDR SNPs: rs2228570A>G (Fok1), rs731236A>G (Taq1) and rs1544410C>T (Bsm1).

Progression free survival (PFS) and overall survival (OS) were estimated with the Kaplan-Meier method and with Mantel-Haenszel log-rank test.

Results

The statistical analysis for Fok1 of VDR showed a significant difference in PFS after the first line therapy (median PFS= 21.2 months in the homozygous recessive genotype group vs. 3.3 months of homozygous dominant and heterozygous ones, p= 0.03). In particular, in homozygous recessive patients for Fok1 SNPs of VDR a high rate of histological regression and BRAF (B- Rapidly Accelerated Fibrosarcoma gene) mutation were observed. Furthermore, more efficacy of BRAF +/- MEK (MAPK-ERK-Kinase) inhibitors therapies in homozygous recessive patients vs. homozygous dominant and heterozygous ones was shown.

Conclusions

Our study showed a significant correlation between homozygous recessive genotype of Fok1 SNPs of VDR gene and an increased PFS in patients who underwent a first line therapy with BRAF inhibitors.