A Canadian national guideline on the neoadjuvant treatment of invasive breast cancer, including patient assessment, systemic therapy, and local management principles

Purpose

The neoadjuvant treatment of breast cancer (NABC) is a rapidly changing area that benefits from guidelines integrating evidence with expert consensus to help direct practice. This can optimize patient outcomes by ensuring the appropriate use of evolving neoadjuvant principles.

Methods

An expert panel formulated evidence-based practice recommendations spanning the entire neoadjuvant breast cancer treatment journey. These were sent for practice-based consensus across Canada using the modified Delphi methodology, through a secure online survey. Final recommendations were graded using the GRADE criteria for guidelines. The evidence was reviewed over the course of guideline development to ensure recommendations remained aligned with current relevant data.

Results

Response rate to the online survey was almost 30%; representation was achieved from various medical specialties from both community and academic centres in various Canadian provinces. Two rounds of consensus were required to achieve 80% or higher consensus on 59 final statements. Five additional statements were added to reflect updated evidence but not sent for consensus.

Conclusions

Key highlights of this comprehensive Canadian guideline on NABC include the use of neoadjuvant therapy for early stage triple negative and HER2 positive breast cancer, with subsequent adjuvant treatments for patients with residual disease. The use of molecular signatures, other targeted adjuvant therapies, and optimal response-based local regional management remain actively evolving areas. Many statements had evolving or limited data but still achieved high consensus, demonstrating the utility of such a guideline in helping to unify practice while further evidence evolves in this important area of breast cancer management.

CANDIED: A Pan-Canadian Cohort of Immune Checkpoint Inhibitor-Induced Insulin-Dependent Diabetes Mellitus

Simple Summary

Immune checkpoint inhibitor-induced insulin-dependent diabetes mellitus (ICI-induced IDDM) is an emerging form of autoimmune diabetes. We describe the characteristics of 34 patients who developed ICI-induced IDDM across five Canadian cancer centres. We observed that presentation with hyperglycemic crisis is common and that patients treated with combination immunotherapy regimens develop ICI-induced IDDM earlier than those treated with monotherapy. Our results suggest that ICI-induced IDDM is irreversible but is associated with high tumor response rates and prolonged survival. The data generated by this study may help clinicians manage ICI-induced IDDM.

Abstract

Immune checkpoint inhibitor (ICI)-induced insulin-dependent diabetes mellitus (IDDM) is a rare but potentially fatal immune-related adverse event (irAE). In this multicentre retrospective cohort study, we describe the characteristics of ICI-induced IDDM in patients treated across five Canadian cancer centres, as well as their tumor response rates and survival. In 34 patients identified, 25 (74%) were male and 19 (56%) had melanoma. All patients received anti-programed death 1 (anti-PD1) or anti-programmed death ligand-1 (anti-PD-L1)-based therapy. From ICI initiation, median time to onset of IDDM was 2.4 months (95% CI 1.1–3.6). Patients treated with anti-PD1/PD-L1 in combination with an anti-cytotoxic T lymphocyte antigen 4 antibody developed IDDM earlier compared with patients on monotherapy (1.4 vs. 3.9 months, p = 0.05). Diabetic ketoacidosis occurred in 21 (62%) patients. Amongst 30 patients evaluable for response, 10 (33%) had a complete response and another 10 (33%) had a partial response. Median overall survival was not reached (95% CI NE; median follow-up 31.7 months). All patients remained insulin-dependent at the end of follow-up. We observed that ICI-induced IDDM is an irreversible irAE and may be associated with a high response rate and prolonged survival.

Pan-Canadian cohort of immune checkpoint inhibitor-induced insulin-dependent diabetes mellitus (CANDIED)

2640

Background: Endocrine immune-related adverse events (irAEs) are frequent with immune checkpoint inhibitors (ICIs); however, ICI-related insulin-dependent diabetes mellitus (IDDM) is a rare but serious endocrine irAE. We describe the characteristics of patients who developed ICI-related IDDM across five academic Canadian cancer centres. Methods: In this multicentre, retrospective study, we included both patients who developed IDDM and patients with non-IDDM (NIDDM) or pre-DM who became insulin-dependent while on treatment with ICI. We collected data on primary tumor type, ICI regimen (single agent or combination), time to development of IDDM from ICI initiation, comorbidities, laboratory parameters at the time of IDDM diagnosis, tumor response and survival. A p value < 0.05 was considered statistically significant. Results: We identified 27 patients between July 2016 and August 2019. Median age was 60 (39-79) years, 20 (74%) were male, 15 (55%) had melanoma and 4 each (15%) non-small cell lung cancer (NSCLC) and renal cell carcinoma. Seven (26%) patients had prior NIDDM or pre-DM; 5 (18%) had an auto-immune disease (2 psoriasis, 2 inflammatory bowel disease, and 1 systemic lupus erythematosus). Laboratory parameters at presentation and management of IDDM are presented in the Table. Mean A1c was not statistically different between patients with or without prior NIDDM or pre-DM (8.4% vs. 8.6%; p = 0.9). All IDDM events were irreversible; 1 (4%) patient died of diabetic ketoacidosis. At time of IDDM diagnosis, 17 (63%) patients were receiving single agent anti-PD1 and 10 (37%) anti-PD1-based combinations (7 anti-CTLA-4, and 3 other compounds). Median time for development of IDDM from ICI initiation was 2.7 months (95% CI 0.2-5.3). Patients receiving combination ICI developed IDDM earlier than those treated with single agent (1.4 vs 4.8 months; p = 0.05). Amongst patients with metastatic disease (n = 24), 9 (38%) had a complete response and 7 (29%) had a partial response. Two patients (8%) were treated in the adjuvant setting; 1 (4%) received consolidation ICI. IDDM led to ICI discontinuation in 12 (44%) patients. After a median follow up of 21 months from ICI initiation, median survival was 30 months (95% CI NE) and was not reached in patients with melanoma and NSCLC. Conclusions: ICI-related IDDM is a rare and typically irreversible irAE that occurs early in the course of treatment and develops earlier with combination ICI. In this cohort, patients who developed ICI-related IDDM had a high tumor response rate and prolonged survival, especially melanoma and NSCLC patients. Prospective evaluation of autoantibodies to predict development of IDDM is ongoing.[Table: see text]

Ten ways to get a grip on designing and implementing a competency-based medical education training program

BACKGROUND

Globally there is a move to adopt competency-based medical education (CBME) at all levels of the medical training system. Implementation of a complex intervention such as CBME represents a marked paradigm shift involving multiple stakeholders.

METHODS

This article aims to share tips, based on review of the available literature and the authors' experiences, that may help educators implementing CBME to more easily navigate this major undertaking and avoid "black ice" pitfalls that educators may encounter.

RESULTS

Careful planning prior to, during and post implementation will help programs transition successfully to CBME. Involvement of key stakeholders, such as trainees, teaching faculty, residency training committee members, and the program administrator, prior to and throughout implementation of CBME is critical. Careful and selective choice of key design elements including Entrustable Professional Activities, assessments and appropriate use of direct observation will enhance successful uptake of CBME. Pilot testing may help engage faculty and learners and identify logistical issues that may hinder implementation. Academic advisors, use of curriculum maps, and identifying and leveraging local resources may help facilitate implementation. Planned evaluation of CBME is important to ensure choices made during the design and implementation of CBME result in the desired outcomes.

CONCLUSION

Although the transition to CBME is challenging, successful implementation can be facilitated by careful design and strategic planning.

Impact of Personalized Genetic Breast Cancer Risk Estimation With Polygenic Risk Scores on Preventive Endocrine Therapy Intention and Uptake

Endocrine therapy is underutilized to reduce breast cancer incidence among women at increased risk. Polygenic risk scores (PRSs) assessing 77 breast cancer genetic susceptibility loci personalizes risk estimates. We examined effect of personalized PRS breast cancer risk prediction on intention to take and endocrine therapy uptake among women at increased risk. Eligible participants had a 10-year breast cancer risk ≥5% by Tyrer-Cuzick model [International Breast Cancer Intervention Study (IBIS)] or ≥3.0 % 5-year Gail Model risk with no breast cancer history or hereditary breast cancer syndrome. Breast cancer risk was estimated, endocrine therapy options were discussed, and endocrine therapy intent was assessed at baseline. After genotyping, PRS-updated breast cancer risk estimates, endocrine therapy options, and intent to take endocrine therapy were reassessed; endocrine therapy uptake was assessed during follow-up. From March 2016 to October 2017, 151 patients were enrolled [median (range) age, 56.1 (36.0-76.4 years)]. Median 10-year and lifetime IBIS risks were 7.9% and 25.3%. Inclusion of PRS increased lifetime IBIS breast cancer risk estimates for 81 patients (53.6%) and reduced risk for 70 (46.4%). Of participants with increased breast cancer risk by PRS, 39 (41.9%) had greater intent to take endocrine therapy; of those with decreased breast cancer risk by PRS, 28 (46.7%) had less intent to take endocrine therapy (P < 0.001). On multivariable regression, increased breast cancer risk by PRS was associated with greater intent to take endocrine therapy (P < 0.001). Endocrine therapy uptake was greater among participants with increased breast cancer risk by PRS (53.4%) than with decreased risk (20.9%; P < 0.001). PRS testing influenced intent to take and endocrine therapy uptake. Assessing PRS effect on endocrine therapy adherence is needed.Prevention Relevance: Counseling women at increased breast cancer risk using polygenic risk score (PRS) risk estimates can significantly impact preventive endocrine therapy uptake. Further development of PRS testing to personalize breast cancer risk assessments and endocrine therapy counselling may serve to potentially reduce the incidence of breast cancer in the future.

PD-1 inhibition in malignant melanoma and lack of clinical response in chronic lymphocytic leukemia in the same patients: a case series

Chronic lymphocytic leukemia (cll) is the most common adult leukemia in the Western world. Unfortunately, affected patients are often immunosuppressed and at increased risk of infection and secondary malignancy. Previous meta-analysis has found that patients with cll have a risk of melanoma that is increased by a factor of 4 compared with the general population. Recent advances in the understanding of the PD receptor pathway have led to immunotherapies that target cancer cells. The use of PD-1 inhibitors is now considered first-line treatment for BRAF wild-type metastatic melanoma. Interestingly, early preclinical data suggest that inhibition of that pathway could also be used in the treatment of cll; however, recent clinical data did not support the effectiveness of that approach. In this case series, we highlight 2 cases in which patients with cll and concurrent malignant melanoma underwent treatment with PD-1 inhibitors and were found to experience reductions in their white blood cell counts without improvement in their hemoglobin. Those cases further illustrate that treatment of cll with PD-1 inhibitors is ineffective.

A Comparative Study of Spelling Performance of Sighted and Blind Students in Senior High School

This study compared the spelling competency of 7 functonally blind braille-reading students with that of 180 sighted students using conventional print. The students were all attending regular high school classes, grades 9 to 11, within the province of Quebec, Canada. A 100-word dictation was given to these students and then analyzed for mistakes in both grammar and usage. The results indicated a significant gap in the spelling competency between the two groups. The functionally blind students were significantly ahead of their sighted peers. These students made less than half the number of usage mistakes than did their sighted peers. The most important gap involves grammatical spelling, again in the favor of the functionally blind students.

Abstract PD3-03: Impact of the breast cancer polygenic risk score on preventive endocrine therapy adherence and endocrine therapy usage on quality of life - The Genetic Risk Estimate (GENRE) trial

Background: Studies demonstrate breast cancer risk reduction of 50-65% with the use of endocrine therapy (ET) and yet drug uptake and adherence in this setting is suboptimal even among high risk women. A Polygenic Risk Score (PRS) comprised of 77 BC genetic susceptibility loci (Single Nucleotide Polymorphisms (SNP)) can provide a personalized risk assessment and potentially influence ET adherence. We assessed ET adherence at 1 year comparing women whose risk estimate increased due to PRS versus women whose risk estimate decreased due to PRS. The effect of ET use on quality of life (hot flashes, night sweats, vaginal dryness, weight gain, joint pain) was evaluated.

Methods: Eligible women required either a 5 year Gail Model risk of ≥3% or 10 year IBIS ( International Breast Intervention Study or Tyrer-Cuzick model) of ≥5%. Women with a history of breast cancer (BC) or hereditary BC syndrome were excluded. High risk women were counseled at baseline using their Gail and IBIS risk scores and ET options were discussed including benefits and risks. Participants completed a self-reported questionnaire at baseline to assess their understanding of breast cancer risk and decision to take preventive ET. Blood samples were obtained and genotyped for 77 SNPs, and the odds ratio from the SNPs were used to modify the IBIS and Gail risk estimates. The BC -PRS risk estimate information was shared with study participants that reflected the IBIS and Gail risk estimates for 5 year, 10 year, & lifetime BC risk with and without the PRS. Follow up questionnaires at year 1 were administered to assess drug adherence and ET usage on quality of life.

Results: 151 women were enrolled at Mayo Clinic Rochester and CancerCare Manitoba from 2016 to 2017. The median age was 56.1 (range 36-76.4), 35.6% were premenopausal, 98.7% were Caucasian and 64.7% had&gt;1 family member with BC. Median 5yr, 10yr, & lifetime IBIS- PRS risk estimates were 3.8% (2.0-11.5), 7.9% (5.0-23.1), and 25.3% (5.5 to 92.2). At year 1 (n=112 women) 46 % of those with an increase in risk when considering the BC-PRS score and 16 % with a decrease in risk were taking ET ( p&lt; 0.001). Types of ET taken: tamoxifen-18, raloxifene- 3, exemestane -14 and missing-1. Women taking ET reported weight gain ( 19.4% vs 6.7%, p=0.04) and more joint pain ( 27.8 % vs 12%, p=0.04) when compared to women not taking ET.

Conclusion: In high risk women, BC-PRS risk estimates in addition to standard BC risk calculators had a significant impact on preventive ET adherence. ET use was associated with weight gain and joint pain.

Citation Format: Sandhya Pruthi, Julian O Kim, Daniel Schaid, Andrew Cooke, Christina Kim, Benjamin Goldenberg, Jason Sinnwell, Debjani Grenier, Fergus Couch, Celine Vachon. Impact of the breast cancer polygenic risk score on preventive endocrine therapy adherence and endocrine therapy usage on quality of life - The Genetic Risk Estimate (GENRE) trial [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD3-03.

Growth of a single bubble in semi-hard cheese: Comparison between simulation and experiment

This paper proposes a model for bubble growth in semi-hard cheese coupling mechanical behaviour and mass transport. The modelling follows previous work centred on the mechanical aspects, and focuses in this paper on the mass transport phenomena. Data are compared to experimental results obtained on industrial-size cheeses, both under the rind and at core, and a sensitivity study is conducted to discuss the results. The model is in agreement with experiment at core, and underlines the great influence of the carbon dioxide production rate and the amount of cheese material surrounding the bubble on bubble growth. Under the rind, the model yielded poorer agreement, due to the fact that this region in the cheese is less homogeneous, and therefore with more intra- and inter-batch variation on the parameters that were characterized.

Randomized Trial of Standard Adjuvant Chemotherapy Regimens Versus Capecitabine in Older Women With Early Breast Cancer: 10-Year Update of the CALGB 49907 Trial

PURPOSE

Older women with breast cancer remain under-represented in clinical trials. The Cancer and Leukemia Group B 49907 trial focused on women age 65 years and older. We previously reported the primary analysis after a median follow-up of 2.4 years. Standard adjuvant chemotherapy showed significant improvements in recurrence-free survival (RFS) and overall survival compared with capecitabine. We now update results at a median follow-up of 11.4 years.

PATIENTS AND METHODS

Patients age 65 years or older with early breast cancer were randomly assigned to either standard adjuvant chemotherapy (physician's choice of either cyclophosphamide, methotrexate, and fluorouracil or cyclophosphamide and doxorubicin) or capecitabine. An adaptive Bayesian design was used to determine sample size and test noninferiority of capecitabine. The primary end point was RFS.

RESULTS

The design stopped accrual with 633 patients at its first sample size assessment. RFS remains significantly longer for patients treated with standard chemotherapy. At 10 years, in patients treated with standard chemotherapy versus capecitabine, the RFS rates were 56% and 50%, respectively (hazard ratio [HR], 0.80; P = .03); breast cancer-specific survival rates were 88% and 82%, respectively (HR, 0.62; P = .03); and overall survival rates were 62% and 56%, respectively (HR, 0.84; P = .16). With longer follow-up, standard chemotherapy remains superior to capecitabine among hormone receptor-negative patients (HR, 0.66; P = .02), but not among hormone receptor-positive patients (HR, 0.89; P = .43). Overall, 43.9% of patients have died (13.1% from breast cancer, 16.4% from causes other than breast cancer, and 14.1% from unknown causes). Second nonbreast cancers occurred in 14.1% of patients.

CONCLUSION

With longer follow-up, RFS remains superior for standard adjuvant chemotherapy versus capecitabine, especially in patients with hormone receptor-negative disease. Competing risks in this older population dilute overall survival benefits.

Impact of a breast cancer (BC) polygenic risk score (PRS) on the decision to take preventive endocrine therapy (ET): The Genetic Risk Estimate (GENRE) trial

1501

Background: Despite BC risk reduction of 50-65% by preventive endocrine therapy (ET), very few at-risk women choose to take them. A woman’s perceived BC risk correlates with uptake of ET. A PRS comprised of 77 BC genetic susceptibility loci (Single Nucleotide Polymorphisms (SNP) improves the accuracy of risk prediction for BC. We examined the impact of the addition of individualized PRS BC risk prediction to standard risk calculator estimates on intent to take BC prevention medication. Methods: Eligible women had ≥5% 10 yr BC Tyrer-Cuzick risk (IBIS) or 5 year Gail score ≥3%, with no history of BC or hereditary BC syndrome. Standard BC risk estimates (IBIS or Gail) were incorporated into the counselling on BC preventive ET. A self-reported questionnaire at baseline quantified intention to take ET and explored factors associated with this decision. Blood samples were obtained and genotyped for 77 SNPs, individualized PRS were calculated then incorporated into IBIS and Gail predictions for 5 yr, 10 yr, & lifetime BC risk. At a second visit, PRS risk & prevention recommendations were revisited. Post visit questionnaires assessed change in intent to take ET. Multivariable linear regression was performed to assess impact of baseline variables on change in intent to take medication. Results: From 2016 to 2017, 151 women in Canada & USA were enrolled, median age: 56.1 (range 36-76.4), 35.6% were premenopausal, 98.7% were Caucasian. Median 5yr, 10yr, & lifetime IBIS risk estimates were 3.8% (2.0-11.5), 7.9% (5.0-23.1), and 25.3% (5.5 to 92.2). PRS increased BC risk estimates in 84 (55.6%) and reduced BC risk estimates in 67 (44%) women. After PRS risk counselling, intention to take ET significantly changed (p<0.001): 41.9% of those with increased PRS were more inclined, and 46.7% of women with decreased PRS were less inclined to take ET. On multivariable regression, increase in PRS (p<0.0001) and less concern about ET side effects (p<0.0001) were associated with greater intent to take ET. Conclusions: In high risk women, PRS significantly changed BC risk estimates & intent to take preventive ET. Further assessments of the impact of PRS scores on compliance with ET are warranted. Clinical trial information: NCT02517593.

Neoadjuvant Therapy for Breast Cancer: Updates and Proceedings From the Seventh Annual Meeting of the Canadian Consortium for Locally Advanced Breast Cancer

Therapy for breast cancer involves a complex interplay of three main treatment modalities: surgery, systemic therapy, and radiation therapy. The Canadian Consortium for Locally Advanced Breast Cancer (LABC) was established with the goal to convene a strong multidisciplinary team of breast oncology clinicians and scientists who are dedicated to the advancement of LABC research and treatment, with a vision to drive progress through increased collaboration across disciplines and throughout Canada. The most recent meeting in May 2017 highlighted the latest evidence and literature about the optimal use of neoadjuvant systemic therapy in breast cancer. There is a need for increased clinical and scientific collaboration and the development of guidelines for the use of emerging treatment strategies. The interactive meeting sessions fostered unique opportunities for academic debate and nurtured collaboration between the attendees.

Outcomes of women with small, early-stage breast cancer in Manitoba from 2006-2011

e12000

Background: The incidence of early-stage breast cancers has increased dramatically over the past decades. Treatment decisions for patients with stage I breast cancers are challenging, as there are significant variations in outcomes based on biologic subtypes. The objectives were to describe the distribution, molecular phenotypes, management, and long-term outcomes of women with early-stage breast cancer (T1mic/T1a/T1b N0 M0) in Manitoba from 2006-2011. Methods: Using the Manitoba Cancer Registry, we created a retrospective cohort of patients with primary breast cancer of ≤1.0 cm, diagnosed between 2006 and 2011. Data included patient demographics, tumour size, treatment modalities (surgery, radiotherapy, chemotherapy and trastuzumab), estrogen-receptor (ER) and progesterone-receptor (PR) status, and human epidermal growth factor receptor 2 (HER2) status. Node-positive cancers were excluded. Patient outcomes were evaluated, including rates of recurrence and overall survival using univariate and multivariable models. Kaplan-Meier curves and cumulative incidence curves were used to illustrate overall survival and recurrence, respectively. Results: Our study included 733 women. Mean age at diagnosis was 62. ER/PR positivity and HER2 positivity (HER2+) were 84% and 8.9%, respectively. Tumours were: T1mic in 14.0%, T1a in 19.1%, and T1b in 66.9%. 98% of patients had surgery, 60% had adjuvant radiation, 3.8% received trastuzumab, and 11% received chemotherapy. The adjusted hazard ratio (HR) for disease recurrence for patients with HER2+ versus HER2- status was 4.31 (95% CI, 2.18 to 8.50; P = 0.0001), and the HR for overall survival was 1.63 (95% CI, 0.72 to 3.67; P = 0.2402). The HR for disease recurrence in HER2+ patients receiving trastuzumab versus HER2+ patients who did not receive trastuzumab was 1.92 (95% CI, 0.61 to 5.97; P = 0.2621). Conclusions: HER2-positivity appears to be an important risk factor for recurrence in small, early-stage breast cancers. In our cohort, trastuzumab did not appear to reduce the risk of recurrence compared to those who did not receive it. This may be due to limited power and selection bias, in which patients with higher risk cancers received trastuzumab.

Anti-inflammatory Activity of a High-molecular-weight Cranberry Fraction on Macrophages Stimulated by Lipopolysaccharides from Periodontopathogens

Periodontitis is a chronic inflammatory disease affecting oral tissues. The continuous, high production of cytokines by host cells triggered by periodontopathogens is thought to be responsible for the destruction of tooth-supporting tissues. Macrophages play a critical role in this host inflammatory response to periodontopathogens. The aim of this study was to investigate the effect of non-dialyzable material prepared from cranberry juice concentrate on the pro-inflammatory cytokine response of macrophages induced by lipopolysaccharides (LPS) from Actinobacillus actinomycetemcomitans, Fusobacterium nucleatum subsp. nucleatum, Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia, and Escherichia coli. Interleukin-1 beta (IL-1β), IL-6, IL-8, tumor necrosis factor alpha (TNF-α), and Regulated on Activation Normal T-cell Expressed and Secreted (RANTES) production by macrophages treated with the cranberry fraction prior to stimulation by LPS was evaluated by ELISA. Our results clearly indicate that the cranberry fraction was a potent inhibitor of the pro-inflammatory cytokine and chemokine responses induced by LPS. This suggests that cranberry constituents may offer perspectives for the development of a new therapeutic approach to the prevention and treatment of periodontitis.

Black tea theaflavins attenuate Porphyromonas gingivalis virulence properties, modulate gingival keratinocyte tight junction integrity and exert anti-inflammatory activity

BACKGROUND AND OBJECTIVE

Over the last 10 years, bioactive plant food compounds have received considerable attention in regard to their beneficial effects against periodontal disease. In this study, we investigated the effects of black tea theaflavins (TFs) on the virulence properties of Porphyromonas gingivalis and gingival keratinocyte tight junction integrity. In addition, the effects of black tea TFs on the nuclear factor-κB (NF-κB) signaling pathway and proinflammatory cytokine/matrix metalloproteinase (MMP) secretion by monocytes/macrophages were assessed.

MATERIAL AND METHODS

Virulence factor gene expression in P. gingivalis was investigated by quantitative real-time PCR. A fluorescence assay was used to determine P. gingivalis adherence to, and invasion of, a gingival keratinocyte monolayer. Tight junction integrity of gingival keratinocytes was assessed by determination of transepithelial electrical resistance. Proinflammatory cytokine and MMP secretion by P. gingivalis-stimulated macrophages was quantified by ELISA. The U937-3xκB-LUC monocyte cell line transfected with a luciferase reporter gene was used to monitor NF-κB activation. Gelatin degradation was monitored using a fluorogenic assay.

RESULTS

Black tea TFs dose-dependently inhibited the expression of genes encoding the major virulence factors of P. gingivalis and attenuated its adherence to gingival keratinocytes. A treatment of gingival keratinocytes with black tea TFs significantly enhanced tight junction integrity and prevented P. gingivalis-mediated tight junction damage as well as bacterial invasion. Black tea TFs reduced the secretion of interleukin (IL)-1β, tumor necrosis factor-α, IL-6, chemokine (C-X-C) ligand 8, MMP-3, MMP-8 and MMP-9 by P. gingivalis-stimulated macrophages and attenuated the P. gingivalis-mediated activation of the NF-κB signaling pathway. Lastly, black tea TFs inhibited gelatin degradation by MMP-9.

CONCLUSION

This study provides clear evidence that black tea TFs represent promising multifunctional therapeutic agents for prevention and treatment of periodontal disease.

Comparison of viscoelastic property characterization of plastisol phantoms with magnetic resonance elastography and high-frequency rheometry

This study aims at evaluating Magnetic Resonance Elastography (MRE) as a reliable technique for the characterization of viscoelastic properties of soft tissues. Three phantoms with different concentrations of plastisol and softener were prepared in order to mechanically mimic a broad panel of healthy and pathological soft tissues. Once placed in a MRI device, each sample was excited by a homemade external driver, inducing shear waves within the medium. The storage (G') and loss (G") moduli of each phantom were then reconstructed from MRE acquisitions over a frequency range from 300 to 1,000 Hz, by applying a 2D Helmholtz inversion algorithm. At the same time, mechanical tests were performed on four samples of each phantom with a High-Frequency piezo-Rheometer (HFR) over an overlapping frequency range (from 160 to 630 Hz) with the same test conditions (temperature, ageing). The comparison between both techniques shows a good agreement in the measurement of the storage and loss moduli, underlying the capability of MRE to noninvasively assess the complex shear modulus G* of a medium and its interest for investigating the viscoelastic properties of living tissues. Moreover, the phantoms with varying concentrations of plastisol used in this study show interesting rheological properties, which make them good candidates to simulate the broad variety of viscoelastic behaviors of healthy and pathological soft tissues.

Clinical predictors of benefit from fulvestrant in advanced breast cancer: A Meta-analysis of randomized controlled trials

BACKGROUND

Data on the comparative efficacy of fulvestrant and other endocrine treatments are inconsistent. Clinical markers predictive of greater benefit from fulvestrant compared to the alternate endocrine agents have not been identified.

METHODS

We searched the literature from inception to May 2015, using MEDLINE, EMBASE, and major conference proceedings. We included randomized controlled trials (RCTs) that compared fulvestrant containing arm to either tamoxifen or an aromatase inhibitors (AI) and presented results for subgroup analyses as Hazard Ratios (HR) for Time to Progression (TTP) or Progression Free Survival (PFS). Subgroup analyses reported in at least two RCTs were included. Data were then weighted using generic inverse variance approach and pooled in meta-analysis using RevMan 5.3 software. Difference between sub-groups was tested with chi(2) statistics.

RESULTS

Analysis included 4 RCTs comparing fulvestrant-based therapy to AI alone and comprising 2382 patients (1190 on fulvestrant and 1192 on control arms). TTP/PFS was the primary endpoint in all included studies. Four sub-groups fulfilled our criteria. Fulvestrant was associated with greater benefit in patients with visceral metastasis (HR 0.85 vs 1.02 for no visceral disease, p for difference=0.05) and in those patients with a time to recurrence >5 years (HR 0.80 vs 1.09 for recurrence ⩽5 years, p for difference=0.02). There was no apparent difference in benefit based on age >65 years (HR 0.86 vs 0.96, p for difference=0.32) or HER2/neu status (HR 0.36 vs 0.92, p for difference=0.09).

CONCLUSION

Patients with advanced breast cancer with visceral involvement and longer time from diagnosis to recurrence had significantly better TTP/PFS with the use of fulvestrant. These results may have implications for selection of patients in the design of future clinical trials and to inform treatment decisions in clinical practice.

Abstract P5-14-02: Clinical predictors of benefit from fulvestrant in advanced breast cancer: A meta-analysis of randomized controlled trials

Background: While fulvestrant is approved by the United Stated Food and Drug Administration as an alternate endocrine therapy for treatment of advanced breast cancer, data on its efficacy compared to other endocrine treatments are inconsistent. Clinical markers predictive of greater benefit from fulvestrant compared to the alternate endocrine agents have not been identified.

Methods: We searched the literature from inception to May, 2015 from MEDLINE, EMBASE, and major conference proceedings. We included randomized controlled trials that evaluated Fulvestrant compared to either tamoxifen or an AI. We collected the efficacy data reported as Time to Progression (TTP) or Progression Free Survival (PFS) on 7 distinct subgroup of patients from the RCTs defined by: age, time to cancer reoccurrence from primary diagnosis, presence of visceral metastasis, previous chemotherapy exposure, presence of measurable disease, hormone receptor status and, HER-2 status. Data on rates of occurrences of 9 most frequently reported adverse events were also collected from both arms of the studies. Data on both efficacy and toxicity were then weighted using generic inverse variance approach and pooled in a meta-analysis using RevMan 5.3 software.

Results: We identified 8 RCTs that fulfilled our criteria and involved 4,024 patients (2,032 on fulvestrant and 1,992 on control arms). TTP/PFS was the primary endpoint in 7 out of 8 RCTs and secondary endpoint in one. Compared to an AI or tamoxifen, there was a statistically significant improvement in TTP favoring fulvestrant in patients who had visceral metastasis [Hazards Ratio (HR) 0.86; 95% Confidence Interval (CI) 0.77 to 0.96, p&lt;0.01], measurable disease [HR 0.74; 95% CI 0.58 to 0.93, p=0.01], and HER-2 overexpression [HR 0.43; 95% CI 0.27 to 0.70, p&lt;0.001]. Similar effect sizes were observed in a sensitivity analysis excluding the trials of combinations of fulvestrant and AI in the experimental arm. Rates of occurrences of adverse events were similar between fulvestrant and other endocrine agents.

Conclusion: Patients with advanced breast cancer that have visceral disease, measurable disease, or HER-2 driven disease are likely to derive higher benefits from treatment with fulvestrant compared to tamoxifen or an AI. These results may have implications for selection of patients in the design of future clinical trials and to inform treatment decisions in clinical practice.

Citation Format: Niraula S, Pitz M, Gordon V, Grenier D, Amir E, Brandes L. Clinical predictors of benefit from fulvestrant in advanced breast cancer: A meta-analysis of randomized controlled trials. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-14-02.

Vitamin D inhibits the growth of and virulence factor gene expression by Porphyromonas gingivalis and blocks activation of the nuclear factor kappa B transcription factor in monocytes

BACKGROUND AND OBJECTIVE

Increasing evidence suggests that 1,25-dihydroxyvitamin D3 (1,25(OH)2 D3 ), a fat-soluble secosteroid hormone, has a positive impact on periodontal health through diverse mechanisms. The present study was aimed at investigating the effect of 1,25(OH)2 D3 on the growth of and virulence factor gene expression by the periodontopathogenic bacterium Porphyromonas gingivalis. The effect of 1,25(OH)2 D3 on P. gingivalis-mediated activation of nuclear factor kappa B (NF-κB) transcription factor in monocytes was also assessed.

MATERIAL AND METHODS

A broth microdilution assay was used to determine the antibacterial activity of 1,25(OH)2 D3 . The modulation of virulence factor gene expression in P. gingivalis was assessed by quantitative reverse transcription-polymerase chain reaction. NF-κB activation was assessed using a human monocytic cell line stably transfected with a luciferase reporter containing NF-κB binding sites.

RESULTS

Minimal inhibitory concentrations of 1,25(OH)2 D3 against P. gingivalis ranged from 3.125 to 6.25 μg/mL. Moreover, a partial synergistic effect was observed when 1,25(OH)2 D3 was used in association with metronidazole. 1,25(OH)2 D3 attenuated the virulence of P. gingivalis by reducing the expression of genes coding for important virulence factors, including adhesins (fimA, hagA and hagB) and proteinases (rgpA, rgpB and kgp). 1,25(OH)2 D3 dose-dependently prevented P. gingivalis-induced NF-κB activation in a monocyte model.

CONCLUSION

Our study suggested that 1,25(OH)2 D3 selectively inhibits the growth of and virulence factor gene expression by P. gingivalis, in addition to attenuating NF-κB activation by this periodontopathogen. This dual action on P. gingivalis and the inflammatory response of host cells may be of particular interest with a view to developing a novel and inexpensive preventive/therapeutic strategy.

Abstract P3-07-13: Outcomes of women with small, early-stage breast cancer in Manitoba from 1995-2011

OBJECTIVES:

The objectives of this study were to describe the distribution, management, and outcomes of women with early-stage breast cancer in Manitoba during the period from 1995-2011. Specifically, we looked at tumours 1cm or smaller in size (T1mic/T1a/T1b) across the spectrum of molecular phenotypes: estrogen-receptor (ER) status, progesterone-receptor (PR) status, and human epidermal growth factor receptor 2 (HER2) status. This is the first study to evaluate these objectives in Manitoba, and will contribute significantly to the limited data of long-term outcomes for smaller-sized breast tumours.

METHODS:

Using the Manitoba Cancer Registry, we created a retrospective cohort of all patients with primary breast cancer of 1.0 cm or less, between 1995 and 2011. Women with previous or synchronous contralateral breast cancers were excluded. Data included patient demographics, diagnostic procedure, tumour size, nodal disease, treatment modalities (surgery, radiotherapy, hormone therapy, and chemotherapy), ER status, PR status, and HER2 status. Linkage to the Manitoba Health Drug Program Information Network (DPIN) database allowed capture of all hormonal therapies. Patient outcomes were evaluated, including risk of recurrence, overall survival and relative survival. Risk of recurrence was illustrated using cumulative incidence of recurrence, accounting for the competing risk of death. Kaplan-Meier curves were used to illustrate overall survival. The relative survival estimate was used to estimate the probability of surviving from breast cancer while controlling for differences in mortality due to other causes.

RESULTS:

Our study captured 2,341 women. Mean age at diagnosis was 62. ER+, PR+, and HER2+ status were 71% (11% unknown), 61.6% (11% unknown), and 8.6% (31% unknown), respectively. Clinically, 78% were Stage I disease, and by tumour size overall: T1mic 11.5%, T1a 18.9%, and T1b 69.7%. Ninety-eight percent had primary surgery, 58% had primary radiation, 48% received hormone therapy, and 16% received chemotherapy. At last follow-up, 21% of all patients were deceased. Relative survival estimates revealed that the survival of the overall cohort was not different than the general population, when comparing based on age groupings for Manitoban females.

Recurrence occurred in 6.6% (156) of all cases. ER+, PR+, and HER2+ status were 63% (4% unknown), 58% (4% unknown), and 48% (5% unknown), respectively. By staging, 65% were Stage I disease and by tumour size 60% were T1b. Overall, 64% of recurrences were node-negative. For the HER2+, node-negative subpopulation at diagnosis: 21% of the T1mic group recurred, 41% of T1a recurred, and 19% of T1b recurred. In all recurrences, 39% of patients were deceased at last follow-up.

CONCLUSIONS:

Small, early-stage breast cancers are common and a significant proportion of patients recur. HER2-positivity appears to be an important risk factor for recurrence and may independently warrant treatment with trastuzumab, regardless of primary tumour size.

Citation Format: Aly-Khan Lalani, Katherine Fradette, Rashid Ahmed, Debjani Grenier, Marshall Pitz. Outcomes of women with small, early-stage breast cancer in Manitoba from 1995-2011 [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-13.

Green tea extract and its major constituent, epigallocatechin-3-gallate, induce epithelial beta-defensin secretion and prevent beta-defensin degradation by Porphyromonas gingivalis

BACKGROUND AND OBJECTIVE

Antimicrobial peptides, such as beta-defensins, secreted by gingival epithelial cells, are thought to play a major role in preventing periodontal diseases. In the present study, we investigated the ability of green tea polyphenols to induce human beta-defensin (hBD) secretion in gingival epithelial cells and to protect hBDs from proteolytic degradation by Porphyromonas gingivalis.

MATERIAL AND METHODS

Gingival epithelial cells were treated with various amounts (25-200 μg/mL) of green tea extract or epigallocatechin-3-gallate (EGCG). The secretion of hBD1 and hBD2 was measured using ELISAs, and gene expression was quantified by real-time PCR. The treatments were also carried out in the presence of specific kinase inhibitors to identify the signaling pathways involved in hBD secretion. The ability of green tea extract and EGCG to prevent hBD degradation by proteases of P. gingivalis present in a bacterial culture supernatant was evaluated by ELISA.

RESULTS

The secretion of hBD1 and hBD2 was up-regulated, in a dose-dependent manner, following the stimulation of gingival epithelial cells with a green tea extract or EGCG. Expression of the hBD gene in gingival epithelial cells treated with green tea polyphenols was also increased. EGCG-induced secretion of hBD1 and hBD2 appeared to involve extracellular signal-regulated kinase 1/2 and p38 mitogen-activated protein kinase. Lastly, green tea extract and EGCG prevented the degradation of recombinant hBD1 and hBD2 by a culture supernatant of P. gingivalis.

CONCLUSION

Green tea extract and EGCG, through their ability to induce hBD secretion by epithelial cells and to protect hBDs from proteolytic degradation by P. gingivalis, have the potential to strengthen the epithelial antimicrobial barrier. Future clinical studies will indicate whether these polyphenols represent a valuable therapeutic agent for treating/preventing periodontal diseases.

Relationship between halitosis and periodontal disease - associated oral bacteria in tongue coatings

AIM

The objective of our study was to investigate the relationship between halitosis and oral bacteria in tongue coating (TC) and saliva samples from patients with halitosis, and to evaluate the effect of tongue cleaning on halitosis.

METHODS

Ninety-four participants complaining of oral malodour were included in the study. Organoleptic (OR) values, volatile sulphur compound (VSC) concentrations determined by gas chromatography and TC scores were used as clinical parameters of halitosis. Quantitative real-time polymerase chain reactions were used to determine the numbers of periodontal disease-associated oral bacteria.

RESULTS

There was a significant correlation between TC scores and OR values, methylmercaptan (CH3 SH) concentrations and VSC concentrations (Spearman's rank-correlation coefficient test, P < 0.01). There was also a positive correlation between the clinical parameters of halitosis and total bacterial numbers and Prevotella intermedia, Fusobacterium nucleatum and Campylobacter rectus concentrations in the TC samples. However, there was no similar correlation with respect to the saliva samples. The participants were sub-divided into two groups based on whether they had the habit of tongue cleaning or not. The participants with the habit of tongue cleaning had significantly lower OR scores, VSC concentrations and P. intermedia, F. nucleatum and C. rectus levels than the other participants (Mann-Whitney U-test, P < 0.05).

CONCLUSION

These results suggested that periodontal disease-associated oral bacteria in TCs are closely related to halitosis and that tongue cleaning may be an effective method for improving halitosis.

Promoting consultation recording practice in oncology: identification of critical implementation factors and determination of patient benefit

OBJECTIVE

The objectives of this implementation study were to (i) address the evidentiary, contextual, and facilitative mechanisms that serve to retard or promote the transfer and uptake of consultation recording use in oncology practice and (ii) follow patients during the first few days following receipt of the consultation recording to document, from the patient's perspective, the benefits realized from listening to the recording.

METHODS

Nine medical and nine radiation oncologists from cancer centers in three Canadian cities (Calgary, Vancouver, and Winnipeg) recorded their primary consultations for 228 patients newly diagnosed with breast (n = 174) or prostate cancer (n = 54). The Digital Recording Use Semi-Structured Interview was conducted at 2 days and 1 week postconsultation. Each oncologist was provided a feedback letter summarizing the consultation recording benefits reported by their patients.

RESULTS

Sixty-nine percent of patients listened to at least a portion of the recording within the first week following the consultation. Consultation recording favorableness ratings were high: 93.6% rated the intervention between 75 and 100 on a 100-point scale. Four main areas of benefit were reported: (i) anxiety reduction; (ii) enhanced retention of information; (iii) better informed decision making; and (iv) improved communication with family members. Eight fundamental components of successful implementation of consultation recording practice were identified.

CONCLUSIONS

Further randomized trials are recommended, using standardized measures of the patient-reported benefit outcomes reported herein, to strengthen the evidence base for consultation recording use in oncology practice.

Promoting consultation recording practice in oncology: Identification of critical implementation factors and determination of patient benefit

155

Background: The objectives of this implementation study were to 1) identify and address the evidentiary, contextual, and facilitative mechanisms that serve to retard or promote the transfer and uptake of consultation recording use in oncology practice, and 2) follow patients during the first few days following receipt of the consultation recording to document, from the patient’s perspective, the benefits realized from listening to the recording.

Methods: Nine medical and 9 radiation oncologists from cancer centers in three Canadian cities (Calgary, Vancouver, Winnipeg) recorded their primary treatment consultations for 228 patients newly diagnosed with prostate or breast cancer. The Digital Recording Use Semi-Structured Interview (DRUSSI) was conducted at two days post-consultation and at 1-week post-consultation. Each oncologist was given a feedback letter summarizing the consultation recording benefits reported by their patients.

Results: Sixty-nine percent of patients listened to at least a portion of the recording within the first week following the consultation. Consultation recording favourableness ratings were high: 93.6% rated the intervention between 75–100 on a 100-point scale. Four main areas of benefit were reported: 1) Anxiety reduction; 2) Enhanced retention of information; 3) Better informed decision making; and 4) Improved communication with family members. Eight fundamental components of successful transfer and uptake of consultation recording practice were identified.

Conclusions: Implementation research and additional randomized trials are needed to facilitate the transfer and uptake of consultation recording use so that far more patients and significant others may realize the associated benefits.

Licorice and its potential beneficial effects in common oro-dental diseases

Licorice, the name given to the roots and stolons of Glycyrrhiza species, has been used since ancient times as a traditional herbal remedy. Licorice contains several classes of secondary metabolites with which numerous human health benefits have been associated. Recent research suggests that licorice and its bioactive ingredients such as glycyrrhizin, glabridin, licochalcone A, licoricidin, and licorisoflavan A possess potential beneficial effects in oral diseases. This paper reviews the effects of licorice and licorice constituents on both the oral microbial pathogens and the host immune response involved in common ora-dental diseases (dental caries, periodontitis, candidiasis, and recurrent aphthous ulcers). It also summarizes results of clinical trials that investigated the potential beneficial effects of licorice and its constituents for preventing/treating oro-dental diseases.

The utility of cardiac biomarkers, tissue velocity and strain imaging, and cardiac magnetic resonance imaging in predicting early left ventricular dysfunction in patients with human epidermal growth factor receptor II-positive breast cancer treated with adjuvant trastuzumab therapy

OBJECTIVES

The aim of this study was to evaluate whether cardiac biomarkers, tissue velocity (TVI) and strain imaging, and cardiac magnetic resonance imaging can predict early left ventricular (LV) dysfunction in human epidermal growth factor receptor II-positive breast cancer patients treated with trastuzumab in the adjuvant setting.

BACKGROUND

Early indexes of LV systolic dysfunction with noninvasive cardiac imaging would be useful for addressing the cardiac safety profile of trastuzumab, potentially avoiding the detrimental effects of heart failure.

METHODS

We used cardiac biomarkers, TVI and strain imaging, and cardiac magnetic resonance imaging to detect pre-clinical changes in LV systolic function, before conventional changes in left ventricular ejection fraction (LVEF) in human epidermal growth factor receptor II-positive breast cancer patients treated with trastuzumab in the adjuvant setting.

RESULTS

Of 42 patients (mean age 47 ± 9 years) prospectively followed between 2007 and 2009, 10 (25%) developed trastuzumab-mediated cardiomyopathy (CM). Troponin T, C-reactive protein, and brain natriuretic peptide did not change over time. Within 3 months of adjuvant therapy with trastuzumab, there was a significant difference in the lateral S' between the normal cohort and the CM group (9.1 ± 1.6 cm/s and 6.4 ± 0.6 cm/s, respectively, p < 0.05). Similarly, the peak global longitudinal and radial strain decreased as early as 3 months in the trastuzumab-mediated cardiotoxicity group. As compared with both global longitudinal and radial strain, only S' was able to identify all 10 patients who developed trastuzumab-mediated CM. The LVEF subsequently decreased at 6 months of follow-up in all 10 patients, necessitating discontinuation of the drug. All 10 patients demonstrated delayed enhancement of the lateral wall of the LV within the mid-myocardial portion, consistent with trastuzumab-induced CM.

CONCLUSIONS

Both TVI and strain imaging were able to detect pre-clinical changes in LV systolic function, before conventional changes in LVEF, in patients receiving trastuzumab in the adjuvant setting.

Inhibition of host- and bacteria-derived proteinases by natural anthocyanins

BACKGROUND AND OBJECTIVES

Host- and bacteria-derived proteinases are considered to play critical roles in periodontitis progression. This study investigated the ability of a blackcurrant extract and its major anthocyanins (cyanidin-3-O-glucoside, cyanidin-3-O-rutinoside and delphinidin-3-O-rutinoside) to inhibit the activity of matrix metalloproteinases (MMPs), neutrophil elastase and periodontopathogen (Porphyromonas gingivalis, Tannerella forsythia and Treponema denticola) proteinases.

MATERIAL AND METHODS

Enzyme inhibition was detected using fluorometric and colorimetric assays after incubating blackcurrant extract and its major anthocyanins (at concentrations of 6.25, 12.5, 25 and 50 μg/mL) with MMPs, elastase or bacterial proteinases, along with their specific substrates. Substrate degradation was recorded every hour for up to 4 h.

RESULTS

The blackcurrant extract (50 μg/mL) inhibited all proteinases tested. MMP-1 and MMP-9 were significantly inhibited by pure anthocyanins at concentrations ranging from 6.25 to 50 μg/mL. Elastase activity was inhibited by cyanidin-3-O-glucoside and cyanidin-3-O-rutinoside in the range of 6.25-50 μg/mL and by delphinidin-3-O-rutinoside at 50 μg/mL. P. gingivalis, T. forsythia and T. denticola proteinases were also significantly inhibited by pure anthocyanins. In all cases, enzyme inhibition was time-dependent.

CONCLUSION

Our study showed that a blackcurrant extract and its major anthocyanins were able to inhibit the activity of host- and bacteria-derived proteinases. This suggests that such natural compounds may represent promising agents for use in adjunctive treatments for periodontitis.

Study protocol: addressing evidence and context to facilitate transfer and uptake of consultation recording use in oncology: a knowledge translation implementation study

BACKGROUND

The time period from diagnosis to the end of treatment is challenging for newly diagnosed cancer patients. Patients have a substantial need for information, decision aids, and psychosocial support. Recordings of initial oncology consultations improve information recall, reduce anxiety, enhance patient satisfaction with communication, and increase patients' perceptions that the essential aspects of their disease and treatment have been addressed during the consultation. Despite the research evidence supporting the provision of consultation recordings, uptake of this intervention into oncology practice has been slow. The primary aim of this project is to conduct an implementation study to explicate the contextual factors, including use of evidence, that facilitate and impede the transfer and uptake of consultation-recording use in a sample of patients newly diagnosed with breast or prostate cancer.

METHODS

Sixteen oncologists from cancer centres in three Canadian cities will participate in this three-phase study. The preimplementation phase will be used to identify and address those factors that are fundamental to facilitating the smooth adoption and delivery of the intervention during the implementation phase. During the implementation phase, breast and prostate cancer patients will receive a recording of their initial oncology consultation to take home. Patient interviews will be conducted in the days following the consultation to gather feedback on the benefits of the intervention. Patients will complete the Digital Recording Use Semi-Structured Interview (DRUSSI) and be invited to participate in focus groups in which their experiences with the consultation recording will be explored. Oncologists will receive a summary letter detailing the benefits voiced by their patients. The postimplementation phase includes a conceptual framework development meeting and a seven-point dissemination strategy.

DISCUSSION

Consultation recording has been used in oncology, family medicine, and other medicine specialties, and despite affirming evidence and probable applications to a large number of diseases and a variety of clinical contexts, clinical adoption of this intervention has been slow. The proposed study findings will advance our conceptual knowledge of the ways to enhance uptake of consultation recordings in oncology.

Abstract P3-14-15: Lapatinib Plus Capecitabine in Trastuzumab Pre-Treated HER2- Positive Metastatic Breast Cancer: The Canadian Lapatinib Expanded Access Program Experience

BACKGROUND:

The global lapatinib expanded access programme (LEAP) provided access to lapatinib (L) combined with capecitabine (C) for women with HER2- positive metastatic breast cancer (MBC) who were previously treated with an anthracycline (A), taxane (T) and trastuzumab (TRAS) in 45 countries. The eligibility criteria and the dose of given drugs resembled that used in the phase III clinical trial EGF 100151, with the exception that patients (pts)previously exposed to C and pts with an ECOG performance status of 2 could be included as well. L is a dual tyrosine kinase inhibitor of EGFR and HER2. L plus C is an effective treatment option in T-refractory HER2-positive MBC. 148 Canadian pts were enrolled. METHODS:

LEAP enrolled patients with ErbB2-positive, locally advanced and MBC showing progressive disease following prior therapies with A, T, TRAS-containing regimens. Pts received L (1,250 mg/day) and C (2,000 mg/m2/day, days 1-14, every 21 days). We analyzed 148 Canadian LEAP pts recruited from seven centres for demographics, duration of therapy, L compliance, left ventricular function, progression-free survival (PFS), and overall survival (OS). RESULTS:

Data cut off for these analyses was Jan 10, 2010. [Data were not available for all 148 pts. The median age was 52 y (range 29-80 y) for 147 pts (145 women, 2 men). Ninety-five pts (64.6%) had no prior C and 52 (35.4%) had prior C (n=147). Study medication was discontinued for 142 pts (96.6%): 110 (74.8%) for progressive disease; 17 (11.6%) for adverse events; 8 (5.4%) for patient preference; and 3 (2%) were transitioned to the commercial supply of L. The median duration of therapy was 18.95 wk, ranging 0.1 to 96 wk (n=137). L compliance data showed that 73.7% of pts received ≥80% of the L dose (n=122). Median baseline left ventricular function (LVF) was 60%, ranging 50% to 81% (n=142). The median LVF at study end was 61%, ranging 37% to 83% (n = = 96). There was an amendment in June 2008 to end the collection of disease progression and/or death dates. Median PFS and OS were 22.1 wk (95% CI: 18.9-26.7), and 48 wk (95% CI: 42.3-…), respectively (n=71). CONCLUSIONS:

L combined with C is an effective option for women with refractory HER2-positive MBC. The results seen in the Canadian subset enrolled in LEAP were similar to the results of EGF 100151 and the Global LEAP in the efficacy and safety data.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-14-15.

Soluble CD14 induces cytokine release by human oral epithelial cells

BACKGROUND AND OBJECTIVE

The epithelial cell barrier is the first line of host defense against bacterial aggression in periodontal sites. In view of the fact that oral epithelial cells do not express membrane CD14 and that high levels of the soluble form of the CD14 receptor have been detected in the gingival crevicular fluid of patients with periodontitis, we investigated the effects of recombinant soluble CD14 (rsCD14), alone and in combination with Aggregatibacter actinomycetemcomitans lipopolysaccharide (LPS) on the inflammatory response of human oral epithelial cells.

MATERIAL AND METHODS

The oral epithelial cell line GMSM-K was stimulated with rsCD14, alone or in combination with A. actinomycetemcomitans LPS, and the levels of the inflammatory mediators interleukin (IL)-6, IL-8 and chemokine (C-C motif) ligand 5 (CCL5) were determined using ELISAs. Activation of the transcription factors nuclear factor-κB (NF-κB) and activator protein-1 was also monitored using ELISAs.

RESULTS

rsCD14 significantly induced the secretion of IL-6, IL-8 and CCL5 by oral epithelial cells. The combination of rsCD14 and A. actinomycetemcomitans LPS augmented this effect. Activation of the NF-κB pathway was significantly increased in epithelial cells treated with rsCD14 compared with a nonstimulated control, whereas there was no effect on the activation of activator protein-1.

CONCLUSION

rsCD14 stimulated the inflammation cascade in oral epithelial cells, both alone or when associated with bacterial LPS, through an NF-κB-dependent pathway. This suggests that the presence of soluble CD14 in periodontitis lesions may contribute to the inflammatory process of periodontal disease.

Synergistic effects of lipopolysaccharides from periodontopathic bacteria on pro-inflammatory cytokine production in an ex vivo whole blood model

Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia have been strongly associated with chronic periodontitis. This disease is characterized by an accumulation of inflammatory cells in periodontal tissue and subgingival sites. The secretion of high levels of inflammatory cytokines by those cells is believed to contribute to periodontal tissue destruction. The aim of this study was to investigate the inflammatory response of whole blood from periodontitis patients following challenges with whole cells of P. gingivalis, T. denticola, and T. forsythia or their lipopolysaccharides (LPS), individually and in combination. Whole blood collected from seven periodontitis patients was stimulated with whole cells or LPS and the production of interleukin (IL)-1beta, IL-6, IL-8, and tumor necrosis factor alpha (TNF-alpha) were quantified by enzyme-linked immunosorbent assays. The mono and mixed challenges with whole bacterial cells or LPS induced the secretion of high amounts of IL-1beta, IL-6, IL-8, and TNF-alpha by the mixed leukocyte population from periodontitis patients. In addition, P. gingivalis LPS, T. denticola LPS, and T. forsythia LPS acted in synergy to induce high levels of IL-1beta and TNF-alpha. This study suggests that P. gingivalis, T. denticola, and T. forsythia may contribute to the immunodestructive host response characteristic of periodontitis through synergistic effects of their LPS on the inflammatory response induced by a mixed population of leukocytes.

Adherence and persistence with oral adjuvant chemotherapy in older women with early-stage breast cancer in CALGB 49907: adherence companion study 60104

PURPOSE

Patient adherence is critical in evaluating the effectiveness of an oral therapy. We sought to measure adherence among women randomly assigned to capecitabine in a preplanned substudy of a multicenter clinical trial.

PATIENTS AND METHODS

Cancer and Leukemia Group B study CALGB 49907 was a randomly assigned trial comparing standard chemotherapy versus oral chemotherapy with capecitabine in patients age 65 years or older with early-stage breast cancer. We used microelectronic monitoring system (MEMS) caps on participants' capecitabine bottles to record pill bottle openings. Capecitabine was given in two divided daily doses for 14 consecutive days of a 21-day cycle for six cycles. Adherence was calculated as the number of doses taken divided by doses expected, taking into account toxicity-related dosing changes. A participant was defined as adherent if 80% or more of expected doses were recorded by MEMS.

RESULTS

Overall, 161 patients were enrolled. Median age was 71 years (range, 65 to 89 years); 124 patients (83%) persisted with capecitabine to completion of planned protocol therapy. Adherence was 78% across all cycles, and adherence did not vary by cycle (P = .32). Twenty-five percent of participants took fewer than 80% of expected doses and were nonadherent. In a logistic regression model, participants with node-negative disease (P = .01) and mastectomy (P = .01) were more likely to be nonadherent. Adherence was not related to age, tumor stage, or hormone receptor status. Adherence was not significantly associated with relapse-free survival or grade 3 or 4 toxicity.

CONCLUSION

Most older women with early-stage breast cancer were adherent to short-term oral chemotherapy in a randomized clinical trial. Age was not associated with adherence.

Detection of herpetic viruses in gingival crevicular fluid of patients suffering from periodontal diseases: prevalence and effect of treatment

BACKGROUND/AIM

Although the role of bacteria in the etiology of periodontitis is well established, it has been suggested that herpetic viruses could contribute to the initiation and progression of this disease. The aim of this study was to determine the prevalence of human cytomegalovirus (HCMV), Epstein-Barr virus (EBV) and herpes simplex virus (HSV) in gingival crevicular fluid (GCF) samples obtained from periodontally healthy, gingivitis and periodontitis patients. In addition, the effect of periodontal treatment (scaling and root planing) on the persistence of herpetic viruses was evaluated in a sub-group of patients suffering from chronic periodontitis.

METHODS

The presence of viruses in GCF samples was assessed by a nested PCR amplification technique. The persistence of viruses in periodontal sites was evaluated following a scaling and root planing therapy.

RESULTS

A statistically significant higher prevalence of HCMV was observed in periodontitis patients as compared to healthy control subjects (35 vs. 8%, respectively; P = 0.0377). A trend for a higher prevalence of HSV was also noted in the periodontitis group, in comparison with healthy control subjects. In addition, a higher prevalence of HCMV was associated with deep periodontal pockets in subjects suffering from periodontitis. In the sub-group of periodontitis patients, periodontal therapy resulted in the elimination (HCMV and EBV) or reduction (HSV) of the herpetic viruses.

CONCLUSIONS

This study showed that the prevalence of HCMV and HSV viruses in GCF is higher in patients suffering from periodontitis compared to periodontally healthy subjects, and that the prevalence of HCMV is higher in deep periodontal pockets. It also brought evidences that periodontal therapy may be associated with virus elimination in diseased sites.

Porphyromonas gingivalis mediates the shedding and proteolysis of complement regulatory protein CD46 expressed by oral epithelial cells

INTRODUCTION

Human cells express membrane-bound complement regulatory proteins to prevent complement-mediated autologous tissue damage. In this study, we hypothesized that Porphyromonas gingivalis, the major etiological agent of chronic periodontitis, causes the shedding or proteolysis of the complement regulatory protein CD46 expressed by oral epithelial cells.

METHODS

Oral epithelial cells were treated with a culture of P. gingivalis before measurement of membrane-bound and shed CD46 by enzyme-linked immunosorbent assay (ELISA). The effect of soluble recombinant CD46 on secretion of interleukin-8 (IL-8) by epithelial cells was evaluated by ELISA. The susceptibility of soluble recombinant CD46 to proteolytic degradation by cells and purified Lys-gingipain of P. gingivalis was investigated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis/western immunoblotting analysis.

RESULTS

Oral epithelial cells treated with a culture of P. gingivalis showed a lower reactivity with antibodies directed to CD46. ELISA revealed that such a treatment resulted in increased amounts of CD46 in the conditioned media suggesting that P. gingivalis caused the shedding of membrane-anchored CD46. Stimulation of epithelial cells with soluble recombinant CD46 induced IL-8 secretion in a dose-dependent manner. Whole cells and purified Lys-gingipain of P. gingivalis degraded recombinant CD46 in a dose-dependent manner.

CONCLUSION

This study showed the ability of P. gingivalis to induce the shedding/ proteolysis of CD46 from the surface of oral epithelial cells. This may render host cells susceptible to the complement system and contribute to tissue damage and the inflammatory process in periodontitis.

Cranberry proanthocyanidins inhibit MMP production and activity

Matrix metalloproteinases (MMPs) produced by resident and inflammatory cells in response to periodontopathogens play a major role in periodontal tissue destruction. Our aim was to investigate the effects of A-type cranberry proanthocyanidins (AC-PACs) on: (i) the production of various MMPs by human monocyte-derived macrophages stimulated with Aggregatibacter actinomycetemcomitans lipopolysaccharide (LPS), and (ii) the catalytic activity of recombinant MMP-1 and MMP-9. The effects of AC-PACs on the expression of 5 protein kinases and the activity of nuclear factor-kappa B (NF-kappaB) p65 in macrophages stimulated with LPS were also monitored. Our results indicated that AC-PACs inhibited the production of MMPs in a concentration-dependent manner. Furthermore, the catalytic activity of MMP-1 and MMP-9 was also inhibited. The inhibition of MMP production was associated with reduced phosphorylation of key intracellular kinases and the inhibition of NF-kappaB p65 activity. AC-PACs thus show potential for the development of novel host-modulating strategies to inhibit MMP-mediated tissue destruction during periodontitis.