Comparing survival outcomes between neoadjuvant and adjuvant chemotherapy within breast cancer subtypes and stages among older women: a SEER-Medicare analysis

BACKGROUND

This study aimed to compare survival outcomes of neoadjuvant (NAC) and adjuvant chemotherapy (AdC) within each breast cancer subtype and stage among older women.

METHODS

Older (≥ 66 years) women newly diagnosed with stage I-III invasive ductal breast cancer during 2010-2017 and treated with both chemotherapy and surgery within one year were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Analyses were performed within each of six groups, jointly defined based on subtype (hormone receptor [HR]-positive/human epidermal growth factor receptor 2 [HER2]-negative, HER2 + , and triple-negative) and stage (I-II and III). Kaplan-Meier curves and multivariable Cox models were used to compare overall and recurrence-free survival between NAC and AdC, with optimal full matching performed for confounding adjustment.

RESULTS

Among 8,495 included patients, 8,329 (20.6% received NAC) remained after matching. Before multiple testing adjustment, Cox models showed that NAC was associated with a lower hazard for death among stage III HER2 + patients (hazard ratio = 0.347, 95% confidence interval CI 0.161-0.745) but a higher hazard for death among triple-negative patients (stage I-II: hazard ratio = 1.558, 95% CI 1.024-2.370; stage III: hazard ratio = 2.453; 95% CI 1.254-4.797). A higher hazard for death/recurrence was associated with NAC among stage I-II HR + /HER2- patients (hazard ratio = 1.305, 95% CI 1.007-1.693). No significant difference remained after multiple testing adjustment.

CONCLUSIONS

The opposite trends (before multiple testing adjustment) of survival comparisons for advanced HER2 + and triple-negative disease warrant further research. Caution is needed due to study limitations such as cancer stage validity.

Neoadjuvant chemotherapy use trends among older women with breast cancer: 2010-2017

PURPOSE

This study assessed chemotherapy use trends before (neoadjuvant chemotherapy [NAC]) or after surgery (adjuvant chemotherapy [AdC]) among older women with breast cancer and examined factors related to NAC receipt.

METHODS

Women (> 65 years) diagnosed with stage I-III breast cancer during 2010-2017 who received NAC or AdC were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. All patients were stratified into six strata based on subtype (hormone receptor-positive/human epidermal growth factor receptor 2-negative [HR + /HER2-], HER2 + , and triple-negative breast cancer [TNBC]) and stage (I-II and III). Cochran-Armitage tests were performed to test temporal trends of NAC use in each stratum. Multivariable logistic regression analyses were performed to identify factors (sociodemographic and clinical) related to NAC use.

RESULTS

Among included older (mean ± standard deviation: 72.3 ± 5.2 years) women (N = 8,495) with stage I-III breast cancer, NAC use increased from 11.7% (2010) to 32.6% (2017). Significant increases in NAC were found in all strata (p < .0001) with more substantial increases in HER2 + disease and TNBC compared to HR + /HER2- disease. Multivariable logistic regressions identified the youngest age category (66-69 years) and later stage as significant (p < 0.05) predictors of NAC receipt in most strata, in addition to diagnosis year.

CONCLUSION

Similar to the overall breast cancer population, NAC use increased among a population of older women. NAC was received by most patients with stage III HER2 + disease or TNBC in more recent years and was more common among younger elderly women and those in stage III.

Germline testing in community oncology patients with somatic BRCA1/2 mutations

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Background: The primary purpose of tumor mutation profiling (TMP) is to molecularly characterize tumors to identify targeted treatments and improve outcomes, but it may also uncover germline mutations with implications for patients and families. In September 2016, the National Comprehensive Cancer Network (NCCN) added “BRCA1/2 mutation detected by TMP” as a criterion for germline BRCA1/2 testing. This study aims to assess rates of germline testing, with and without genetic consultations, for individuals with a somatic BRCA1/2 finding in community oncology centers. Methods: Retrospective data was abstracted from an internal database of results from four TMP laboratories. Individuals with a somatic BRCA1/2 pathogenic/likely pathogenic (P/LP) variant reported from January 1, 2017 to December 31, 2019 were included. Clinical data was obtained from electronic medical records. The project was approved by the Texas Oncology Privacy Board. Results: 221 patients had a P/LP somatic BRCA1/2 result on TMP, 138 of which were BRCA1/2 spectrum tumors (breast, ovary, pancreas, prostate). 144/221 patients (65.2%) had BRCA1/2 germline testing. 133/221 (60.2%) met NCCN guidelines for germline BRCA1/2 testing independent of their somatic results; they were statistically more likely to undergo germline testing than patients who did not otherwise meet germline BRCA1/2 testing criteria (p=2.3e-16) (Table). 70/144 (48.6%) had a germline P/LP BRCA1/2 mutation identified. At locations with genetic providers versus those without, there was a significant difference in rates of genetic consultation (p=0.02) but not in the rate of germline testing (p=0.3). This indicates patients were more likely to receive pre- and post-test counseling at clinics offering in-house genetic consultations. Conclusions: Most individuals who had a P/LP somatic BRCA1/2 mutation identified on TMP underwent germline genetic testing. As 60.2% of our cohort qualified independently for germline testing, somatic BRCA1/2results may not have been the driving force behind germline testing. However, individuals who had a non- BRCA1/2-spectrum tumor were significantly less likely to have the recommended confirmatory germline testing. Quality improvement initiatives can focus on improving rates of counseling and germline testing for patients with somatic BRCA1/2 mutations, regardless of tumor type.[Table: see text]

Primary cardiac angiosarcoma

Primary cardiac sarcoma is a rare clinical entity, with an incidence of 0.0001% in collected autopsy series. The majority of the literature describes a uniformly dismal prognosis with a median survival of only 6 months for these aggressive tumors. Standard surgery, adjuvant chemotherapy, and radiotherapy have been consistently unsuccessful. Early heart transplantation and novel radiation therapy approaches may offer a survival benefit in nonmetastatic tumors, but up to 80% of the patients present with systemic metastasis at diagnosis. Though several chemotherapeutic regimens have been tried, the role of chemotherapy is not well established and outcome data available is minimal. Liposomal doxorubicin (PLD) has been shown to be useful in the treatment of soft tissue sarcomas, and our case supports its use in cardiac angiosarcoma.

Expression and phosphorylation of eukaryotic translation initiation factor 4E binding protein 1 in B-cell lymphomas and reactive lymphoid tissues

CONTEXT

Cap-mediated messenger RNA translation controlled by the eukaryotic initiation factor 4F (eIF-4F) complex plays a key role in human cancer. eIF-4F activity is controlled by a repressor binding protein (4E-BP1), which promotes translation when phosphorylated.

OBJECTIVE

To examine the level of expression and phosphorylation of 4E-BP1 in various subtypes of B-cell lymphoma and reactive lymphoid tissues.

DESIGN

Archival formalin-fixed, paraffin-embedded B-cell lymphoma samples and reactive lymphoid tissues were immunostained and examined for expression of 4E-BP1 and phosphorylated 4E-BP1. Expression of components of the eIF-4F complex and unphosphorylated and phosphorylated 4E-BP1 was confirmed using Western immunoblotting on lysates of frozen lymphoma samples and reactive tissues.

RESULTS

Immunohistochemical analysis demonstrated weak to undetectable 4E-BP1 staining within benign, reactive germinal centers (N = 10). In contrast, 4E-BP1 was consistently expressed (moderate to strong staining) in 98% of various subtypes of mature B-cell lymphoma (N = 50). 4E-BP1 expression was also demonstrable in all 4 lymph nodes with in situ or partial involvement by follicular lymphoma and in all 12 cases of BCL2-negative lymphoma. The level of phosphorylation of 4E-BP1 in lymphomas, evaluated by immunohistochemistry, was heterogeneous.

CONCLUSIONS

The immunohistochemical expression pattern of 4E-BP1 exhibits regional and cellular specificity in reactive lymphoid tissues and may offer a diagnostic tool for distinguishing reactive follicles from neoplastic B-cell proliferations.

Adrenergic shock--an overlooked clinical entity?

We report a case of recurrent shock induced by pheochromocytoma in a previously healthy, normotensive patient. We review pathophysiology and clinical features of shock and cardiomyopathy in patients with pheochromocytoma. We discuss diagnostic evaluation and therapy for pheochromocytoma-induced shock.

Induction of low dose oral tolerance in IL-10 deficient mice with experimental autoimmune encephalomyelitis

IL-10 has been shown to be an important anti-inflammatory mediator that has both down-regulatory and immunomodulatory effects. Utilizing IL-10(-/-) mice we demonstrate the induction of low dose oral tolerance characterized by the up-regulation of TGF-beta and IL-4 and the suppression of Ag specific proliferation with little suppression of INF-gamma. More severe EAE was found in IL-10(-/-) mice than in wild type controls, however, feeding resulted in amelioration of disease severity in both groups. Orally tolerized IL-10(-/-) mice had greater disease severity compared to orally tolerized wild type mice. IL-4 was present in the GALT of IL-10(-/-) mice and up-regulation of TGF-beta was detected in the lamina propria of fed mice. These results demonstrate that IL-10 is not required for the induction of low dose oral tolerance but is required for the regulation of INF-gamma which affects severity of disease in tolerized mice.

Induction of low dose oral tolerance in monocyte chemoattractant protein-1- and CCR2-deficient mice

The chemokine monocyte chemoattractant protein-1 (MCP-1) and its receptor CCR2 have been shown to play an important role in the migration and trafficking of macrophages and Th1 effector cells in experimental autoimmune encephalomyelitis. Also, MCP-1 has been reported to regulate oral tolerance induction by inhibition of Th1 cell-related cytokines and by the ability of Abs to MCP-1 to inhibit oral tolerance. This study demonstrates that neither MCP-1 nor its receptor CCR2 is required for the induction of oral tolerance. Mice deletional for either MCP-1 or CCR2 had suppressed cell-proliferative and Th1 responses following oral administration and immunization with myelin oligodendrocyte glycoprotein (MOG(35-55)). TGF-beta was up-regulated in fed and immunized deletional mice, while IL-4 was absent from deletional mice, but up-regulated in controls. Decreased experimental autoimmune encephalomyelitis severity was found in MOG(35-55)-fed MCP-1 deletional mice, indicating induction of oral tolerance. These results demonstrate that MCP-1 is not required for induction of oral tolerance and that MCP-1 and CCR2 are essential for up-regulation of IL-4 in tolerized mice.