Cohort profile: The Swedish Tattoo and Body Modifications Cohort (TABOO)

PURPOSE

The Swedish Tattoo and Body Modifications Cohort (TABOO) cohort was established to provide an infrastructure for epidemiological studies researching the role of tattoos and other body modifications as risk factors for adverse health outcomes. It is the first population-based cohort with detailed exposure assessment of decorative, cosmetic, and medical tattoos, piercing, scarification, henna tattoos, cosmetic laser treatments, hair dyeing, and sun habits. The level of detail in the exposure assessment of tattoos allows for investigation of crude dose-response relationships.

PARTICIPANTS

The TABOO cohort includes 13 049 individuals that participated in a questionnaire survey conducted in 2021 (response rate 49%). Outcome data are retrieved from the National Patient Register, the National Prescribed Drug Register and the National Cause of Death Register. Participation in the registers is regulated by Swedish law, which eliminates the risk of loss to follow-up and associated selection bias.

FINDINGS TO DATE

The tattoo prevalence in TABOO is 21%. The cohort is currently used to clarify the incidence of acute and long-lasting health complaints after tattooing based on self-reported data. Using register-based outcome data, we are investigating the role of tattoos as a risk factor for immune-mediated disease, including hypersensitisation, foreign body reactions and autoimmune conditions.

FUTURE PLANS

The register linkage will be renewed every third year to update the outcome data, and we have ethical approval to reapproach the responders with additional questionnaires.

A21 ROLE OF SIALIC ACID O-ACETYLATION IN MAINTAINING MUCUS INTEGRITY AND HOMEOSTASIS OF THE COLONIC MUCOSA

Background

The mucus network provides innate immune defense to protect our gastrointestinal tract from pathogens, and promote homeostasis with our resident microbiota. This network is constituted by the mucin MUC2 (Muc2 in mouse), which is ~80% complex O-linked glycans by weight. Sialic acid (Sia) is a key capping monosaccharide on complex O-glycans which has recently been linked to preserving mucus integrity. Sia can undergo enzymatic modifications including the addition of O-acetyl groups. The 9-O-acetyltransferase CasD1 is responsible for the 9-OAc Sia variants. Functionally, the OAc-modification is known to inhibit microbial sialidase activities which may preserve Sia’s protective roles on mucins. However, the extent of these OAc modifications in human and murine Mucin-2, and how they influence mucus function is unclear.

Purpose: To determine whether and how Sia O-acetylation on colonic mucus regulates mucus integrity, host-microbe interactions, and colitis susceptibility.

Method

We used viral-derived probes that target specific OAc-Sia analogues on mucus on sections from human feces and mouse feces and colon tissues to visualize their spatial arrangement and microbial interaction in situ. For glycomics, OAc-Sia analogues were quantitated on purified human MUC2 and mouse Muc2 by HPLC-MS after derivatization with 4,5-dimethyl-1,2-diaminobenzamine (DMBA). O-glycans were released via non-reductive ammonia-catalyzed β-elimination and analyzed by mass spectrometry. For in vivo work, we generated intestinal epithelial cell-specific Casd1 KO mice (Casd1^flox/flox;VillinCre or IEC Casd1^-/- mice) and analyzed their mucins. Sialidase activities were quantified in the supernatants of colon fecal materials from WT and IEC Casd1^-/- mutants mice using a fluorogenic substrate 4-MU-NeuNAc. Colitis susceptibility was monitored using 1.5% w/v Dextran Sodium Sulfate (DSS).

Result(s)

We found Sias on both human MUC2 and murine Muc2 were heavily O-acetylated, with ~75% and ~45% of Sias having 9-OAc-based modification in humans and mice respectively, and were distributed throughout the niche and barrier layers of mucus in situ. IEC Casd1^-/- mice were viable and healthy with knockdown confirmed by 9-OAc staining, western blot of protein lysates and mucins, and sialylomics. The mucus encapsulation appeared overall intact regardless of OAc status. However, IEC Casd1^-/- mice showed heightened susceptibility to 1.5% DSS colitis, linked to thinning of the mucus in IEC Casd1^-/- vs WT littermates after challenge. Consistent with the role of OAc Sia in sialidase inhibition, loss of OAc Sia was associated with increased sialidase activities as assessed by heightened 4 MU signal in fecal supernatants in WT vs littermate IEC Casd1^-/- mice. O-glycomics also showed reduction in the number of sialylated O-glycan structures upon loss of 9-OAc Sia.

Conclusion(s)

Sia O-acetylation appears important in maintaining key aspects of Sia-dependent mucus function and protecting from inflammatory insult.

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Disclosure of Interest

None Declared

Depression or anxiety in adult twins is associated with asthma diagnosis but not with offspring asthma

BACKGROUND

Asthma is common in both children and adults in the Western world, just like anxiety and depression. While some research has revealed that these diseases might share important environmental and pathophysiological aspects, the exact mechanisms still remain unclear.

OBJECTIVE

To study the correlation firstly between depression or anxiety and asthma diagnosis in adult twins and secondly the association between parental depression or anxiety and offspring asthma in children of twins.

METHODS

In total, 24 685 adult twins aged 20-47 years were interviewed or completed a Web-based questionnaire and their children were identified through the Multi-Generation Register. Asthma diagnosis was obtained from the Patient Register and the Prescribed Drug Register. Assessment of depression and anxiety was obtained from questionnaires using Center for Epidemiologic Studies Depression Scale (CES-D), major depression and generalized anxiety disorder (GAD) from DSM-IV. The association between depression or anxiety and asthma was analyzed with logistic regression adjusting for confounders in twins and offspring. To address genetic and familial environmental confounding, we performed a cotwin analysis using disease-discordant twin pairs.

RESULTS

We found an association between asthma and CES-D, major depression and GAD, for example adjusted OR for major depression and register-based asthma 1.56 (1.36-1.79). Most of the point estimates remained in the co-twin control analysis, indicating that the association was likely not due to genetic or familial environmental factors. There was no association between parental depression and/or anxiety and asthma diagnosis in the offspring which implies lack of genetic confounding.

CONCLUSIONS

We found an association between own asthma diagnosis and anxiety or depression, but not with offspring asthma. Our results indicate that the associations were not due to confounding from genes or environment shared by the twins.

Abstract P5-08-09: Use of oral contraceptives and risk of breast cancer in BRCA1 and BRCA2 mutation carriers: An international prospective cohort study; for the studies of EMBRACE, GENEPSO, HEBON, kConFab and BCFR

This abstract was withdrawn by the authors.

Risk of second primary cancer in patients treated with radiotherapy for rectal cancer

BACKGROUND

Many patients with rectal cancer receive radiotherapy (RT) to reduce the risk of local recurrence. Radiation may give rise to adverse effects, including second primary cancers. In view of the divergent results of previous studies, the present study evaluated the risk of second primary cancer following RT in all randomized RT rectal cancer trials conducted in Sweden and in the Swedish ColoRectal Cancer Registry (SCRCR).

METHODS

Patients included in five randomized trials and the SCRCR were linked to the Swedish Cancer Registry. Cox regression models estimated the hazard ratio (HR) of second primary cancer among patients who received RT compared with those who did not.

RESULTS

A total of 13 457 patients were included in this study; 7024 (52·2 per cent) received RT and 6433 (47·8 per cent) had surgery alone. Overall, no increased risk of second primary cancer was observed with RT (HR 1·03; 95 per cent c.i. 0·92 to 1·15), independently of follow-up time and location within or outside of the irradiated volume. In the randomized trials, with longer follow-up (maximum 31 years), a slight increase was observed outside of (HR 1·33, 1·01 to 1·74) but not within (HR 1·11, 0·73 to 1·67) the irradiated volume. Irradiated men had a lower risk of prostate cancer than those treated with surgery alone (HR 0·68, 0·51 to 0·91).

CONCLUSION

Overall, there was no increased risk of second primary cancer following RT for rectal cancer within or outside of the irradiated volume up to 20 years of follow-up. Men with rectal cancer who received RT had a reduced risk of prostate cancer.

Avoidance of sun exposure as a risk factor for major causes of death: a competing risk analysis of the Melanoma in Southern Sweden cohort

OBJECTIVE

Women with active sunlight exposure habits experience a lower mortality rate than women who avoid sun exposure; however, they are at an increased risk of skin cancer. We aimed to explore the differences in main causes of death according to sun exposure.

METHODS

We assessed the differences in sun exposure as a risk factor for all-cause mortality in a competing risk scenario for 29 518 Swedish women in a prospective 20-year follow-up of the Melanoma in Southern Sweden (MISS) cohort. Women were recruited from 1990 to 1992 (aged 25-64 years at the start of the study). We obtained detailed information at baseline on sun exposure habits and potential confounders. The data were analysed using modern survival statistics.

RESULTS

Women with active sun exposure habits were mainly at a lower risk of cardiovascular disease (CVD) and noncancer/non-CVD death as compared to those who avoided sun exposure. As a result of their increased survival, the relative contribution of cancer death increased in these women. Nonsmokers who avoided sun exposure had a life expectancy similar to smokers in the highest sun exposure group, indicating that avoidance of sun exposure is a risk factor for death of a similar magnitude as smoking. Compared to the highest sun exposure group, life expectancy of avoiders of sun exposure was reduced by 0.6-2.1 years.

CONCLUSION

The longer life expectancy amongst women with active sun exposure habits was related to a decrease in CVD and noncancer/non-CVD mortality, causing the relative contribution of death due to cancer to increase.

St Gallen molecular subtypes in screening-detected and symptomatic breast cancer in a prospective cohort with long-term follow-up

Background

Diagnosis by screening mammography is considered an independent positive prognostic factor, although the data are not fully in agreement. The aim of the study was to explore whether the mode of detection (screening‐detected versus symptomatic) adds prognostic information to the St Gallen molecular subtypes of primary breast cancer, in terms of 10‐year cumulative breast cancer mortality (BCM).

Methods

A prospective cohort of patients with primary breast cancer, who had regularly been invited to screening mammography, were included. Tissue microarrays were constructed from primary tumours and lymph node metastases, and evaluated by two independent pathologists. Primary tumours and lymph node metastases were classified into St Gallen molecular subtypes. Cause of death was retrieved from the Central Statistics Office.

Results

A total of 434 patients with primary breast cancer were included in the study. Some 370 primary tumours and 111 lymph node metastases were classified into St Gallen molecular subtypes. The luminal A‐like subtype was more common among the screening‐detected primary tumours (P = 0·035) and corresponding lymph node metastases (P = 0·114) than among symptomatic cancers. Patients with screening‐detected tumours had a lower BCM (P = 0·017), and for those diagnosed with luminal A‐like tumours the 10‐year cumulative BCM was 3 per cent. For patients with luminal A‐like lymph node metastases, there was no BCM. In a stepwise multivariable analysis, the prognostic information yielded by screening detection was hampered by stage and tumour biology.

Conclusion

The prognosis was excellent for patients within the screening programme who were diagnosed with a luminal A‐like primary tumour and/or lymph node metastases. Stage, molecular pathology and mode of detection help to define patients at low risk of death from breast cancer.

Low‐risk group identified

Risk of basal cell carcinoma in Swedish organ transplant recipients: a population-based study

BACKGROUND

Risk of basal cell carcinoma (BCC) has been reported to be several-fold increased among organ transplant recipients (OTRs). However, due to lack of reliable BCC registration, population-based risk estimates are scarce.

OBJECTIVES

To characterize risk of BCC among OTRs compared with the general population, and contrast with risk of cutaneous squamous cell carcinoma (SCC).

SUBJECTS AND METHODS

OTRs transplanted during 2004-2011 were identified through national healthcare registers and linked with the nationwide Swedish BCC Register initialized in 2004. Relative risk of BCC was expressed as standardized incidence ratios (SIR) with 95% confidence intervals (CI).

RESULTS

Altogether, 4023 transplanted patients developed 341 BCCs during follow-up. Compared with the general population, the relative risk of BCC was increased sixfold (SIR 6·1, 95% CI 5·4-6·9). The risk was higher in kidney and heart/lung than in liver recipients (SIRkidney 7·2, 6·3-8·3; SIRheart/lung 5·8, 4·0-8·2; SIRliver 2·6, 1·7-4·0), and risk increased with time since transplantation (Ptrend < 0·01). The SCC to BCC ratio was 1 : 1·7 and BCC developed earlier after transplantation than SCC. Distribution of anatomical sites and histological types did not differ substantially between OTR- and population-BCCs.

CONCLUSIONS

Risk of BCC was strikingly elevated in OTRs compared with the general population. Risk was higher in kidney recipients and increased with follow-up time. These findings support a tumour-promoting effect of immunosuppressive drugs in BCC development. The low SCC to BCC ratio was possibly attributed to short follow-up time.

Parallel mechanisms of polypyrrole self-discharge in aqueous media

Self-discharge of oxidized polypyrrole is composed of two parallel self-discharge mechanisms and their relative contributions depend on pH and potential.

The clinical significance of BRAF and NRAS mutations in a clinic-based metastatic melanoma cohort

BACKGROUND

BRAF and NRAS mutations are frequently found in melanoma tumours, and recently developed BRAF-targeted therapies demonstrate significant clinical benefit.

OBJECTIVES

We sought to investigate the clinical significance of BRAF and NRAS mutations in a clinic-based metastatic melanoma cohort.

METHODS

In total, 237 tumours, mostly metastatic lesions, from 203 patients were screened for mutations in exon 15 of BRAF and exon 2 of NRAS using Sanger sequencing. BRAF and NRAS mutation status was analysed in relation to clinical and histopathological characteristics, and outcome.

RESULTS

Mutation in BRAF and NRAS was present in 43% (88% V600E, 10% V600K) and 30% (48% Q61K, 40% Q61R) of metastatic melanomas, respectively. We found consistent BRAF and NRAS mutation status in all but one of 27 patients with multiple metastases. BRAF mutation was associated with younger age at primary diagnosis (P = 0.02). Among patients with distant metastatic melanoma, patients with BRAF-mutant tumours without BRAF inhibitor treatment had inferior survival compared with patients with BRAF inhibitor treatment [hazard ratio (HR) 2.35, 95% confidence interval (CI) 1.10-5.01, P = 0.03]. We also observed a trend towards better prognosis for patients with wild-type and NRAS-mutant tumours compared with BRAF V600E-mutant tumours (HR 0.64, 95% CI 0.39-1.04, P = 0.07; and HR 0.76, 95% CI 0.48-1.21, P = 0.25, respectively).

CONCLUSIONS

We were able to confirm the effect of BRAF inhibitor treatment in a single clinical institution. The results suggest further that BRAF mutation is a weak prognostic factor but a strong predictive factor and that BRAF-mutant melanoma might constitute one or more distinct subtypes of the disease with certain aetiology and clinical outcome.

Avoidance of sun exposure is a risk factor for all-cause mortality: results from the Melanoma in Southern Sweden cohort

BACKGROUND

Sunlight exposure and fair skin are major determinants of human vitamin D production, but they are also risk factors for cutaneous malignant melanoma (MM). There is epidemiological evidence that all-cause mortality is related to low vitamin D levels.

METHODS

We assessed the avoidance of sun exposure as a risk factor for all-cause mortality for 29 518 Swedish women in a prospective 20-year follow-up of the Melanoma in Southern Sweden (MISS) cohort. Women were recruited from 1990 to 1992 and were aged 25 to 64 years at the start of the study. We obtained detailed information at baseline on their sun exposure habits and potential confounders. Multivariable flexible parametric survival analysis was applied to the data.

RESULTS

There were 2545 deaths amongst the 29 518 women who responded to the initial questionnaire. We found that all-cause mortality was inversely related to sun exposure habits. The mortality rate amongst avoiders of sun exposure was approximately twofold higher compared with the highest sun exposure group, resulting in excess mortality with a population attributable risk of 3%.

CONCLUSION

The results of this study provide observational evidence that avoiding sun exposure is a risk factor for all-cause mortality. Following sun exposure advice that is very restrictive in countries with low solar intensity might in fact be harmful to women's health.

Abstract P6-06-52: Increased expression of insulin-like growth factor-1 receptor is associated with better prognosis in a cohort of tamoxifen treated women

Background: Treatment resistance is a well-known problem in estrogen receptor (ER) positive breast cancer. Complementary therapies are investigated for women who do not respond or who develop resistance against standard ER targeted treatment. Insulin-like growth factor-1 receptor (IGF1R) and its signaling pathway has been suggested to cause estrogen-independent cell growth and survival. Therapy against targets within the pathway is currently investigated in clinical trials. The aim of this study was to investigate if the IGF1R/mTOR pathway was activated or deregulated in breast cancer patients and to explore if any of the markers were prognostic, with or without adjuvant tamoxifen.

Material and methods: Two patient cohorts were investigated by immunohistochemistry using tissue microarrays. The first cohort (N = 264) consisted of mainly post-menopausal women with stage II breast cancer treated with tamoxifen for 2 years irrespective of ER status. The second cohort (N = 206) consisted of mainly medically untreated, pre-menopausal patients with node-negative breast cancer. The protein expression of IGF1R, p-mTOR and p-S6rp were investigated. Cytoplasmic staining was evaluated for all markers and membrane staining was additionally evaluated for IGF1R. Statistical analyses were based on the intensity (0-3) of staining. Expression of IGF1R gave similar results in the cytoplasm and membrane, and p-values for cytoplasmic staining are reported below. Distant disease free survival (DDFS) at 5 years was used as end-point.

Results: IGF1R expression was positively associated with ERa (p&lt;0.001 in Mann-Whitney ranksum test), PgR (p&lt;0.001) and HER2 (p = 0.042) expression in cohort 1, and also with Ki67 (p = 0.006) in cohort 2. p-S6rp was positively associated with ERα in cohort 1 (p&lt;0.001) and HER2 (p = 0.004) in cohort 2. p-mTOR was positively associated only with Ki67 (p&lt;0.001) in cohort 1. High expression of IGF1R was associated with a significantly better prognosis in cohort 1 (HR = 0.7 per intensity step, 95% CI = 0.5-0.9, p = 0.016 using Cox regression). When stratifying for ER status the effect was found in ER negative (ER-) (N = 80, HR = 0.6, 95% CI = 0.4-1.0, p = 0.03) but not in ER positive (ER+) patients (N = 174, HR 1.2, 95% CI = 0.8-2.0, p = 0.40). Both the effect in the ER- subgroup as well as the difference between ER- and ER+ patients were confirmed in interaction analysis and remains after adjustment for age, tumor size, node status, HER2, Ki67, and menopausal status (p = 0.06 for interaction). In cohort 2, no relation to DDFS could be found for IGF1R. p-mTOR and p-S6rp showed no relationship to prognosis in either of the cohorts.

Conclusion: We found that high IGF1R expression was associated with a better prognosis for tamoxifen treated women. This effect could be seen in the ER- but not in the ER+ subgroup of patients. The lack of co-activation of downstream markers (p-mTOR and p-S6rp) in the IGF1R pathway shows that the prognostic effect is not due to complete activation of this pathway.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-52.

Abstract P2-18-10: High risk of late in-breast tumour recurrence after BRCA1/2-associated breast cancer

Background: In the general population, partial mastectomy followed by postoperative radiotherapy (PMRT) reduces the risk of local recurrences of breast cancers to a level comparable to the risk after mastectomy (M). However, for BRCA1/2 mutation carriers, a potentially increased risk of a new primary breast cancer in the ipsilateral breast must be taken into account when recommendations about type of surgery are given. To address this question, we conducted a retrospective study on the risk of in-breast tumor recurrence (IBTR) after PMRT in BRCA1/2 mutation carriers.

Methods: Women with invasive breast cancer from families with a pathogenic mutation in BRCA1 or BRCA2 identified at a single institution were included in the study (n = 174). Median age at diagnosis was 43 years and median follow-up was 10.8 years for patients alive at end of follow-up. Patients who were treated with PMRT (n = 45) were compared with patients who had M as primary surgery (n = 118). Endpoints were local recurrence as first failure (LR [IBTR or thoracic wall recurrence]), overall survival (OS), breast cancer-specific survuval (BCSS) and distant disease-free survival (DDFS). LR, OS, BCSS and DDFS were estimated using the Kaplan-Meier method and compared by the log-rank test. For calculation of hazard ratios and for multivariable analysis, the Cox proportional hazards model was used.

Results: In univariate analysis, no difference in OS, BCSS or DDFS was seen between the PMRT and M groups (HR 0.9 [95% CI 0.5-1.4], HR 0.9 [CI 0.5-1.7] and HR 0.8 [CI 0.5-1.5], respectively). In multivariable analysis, adjusting for tumor stage, age and use of adjuvant chemotherapy, the hazard ratios were lower (HR 0.8 [95% CI 0.4-1.3], HR 0.6 [CI 0.3-1.3] and HR 0.6 [CI 0.3-1.1], respectively), but remained inconclusive.

Compared to M, PMRT was associated with an increased risk for LR in univariate analysis (HR 4.0 [CI 1.6-9.8]). In the M group, all local recurrences were seen in the first 5 years. As opposed to this, in the PMRT group the rate of IBTR was rather constant over 15 years of follow-up. The cumulative risk for IBTR in the PMRT group was 19%, 32% and 43% after 5, 10 and 15 years, respectively.

Conclusion: BRCA1/2 mutation carriers treated with PMRT have a high risk for IBTR, many of which are new primary breast cancers. This must be thoroughly discussed with the patient and is an example of how rapid treatment-focused genetic testing already could influence choice of treatment.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-10.

Drug survival on TNF inhibitors in patients with rheumatoid arthritis comparison of adalimumab, etanercept and infliximab

Objective

To compare drug survival on adalimumab, etanercept and infliximab in patients with rheumatoid arthritis (RA).

Methods

Patients with RA (n=9139; 76% women; mean age 56 years) starting their first tumour necrosis factor (TNF) inhibitor between 2003 and 2011 were identified in the Swedish Biologics Register (ARTIS). Data were collected through 31 December 2011. Drug survival over up to 5 years of follow-up was compared overall and by period of treatment start (2003–2005/2006–2009; n=3168/4184) with adjustment for age, sex, education, period, health assessment questionnaire (HAQ), disease duration, concomitant disease modifying antirheumatic drug (DMARD) treatment and general frailty (using hospitalisation history as proxy).

Results

During 20 198 person-years (mean/median 2.2/1.7 years) of follow-up, 3782 patients discontinued their first biological (19/100 person-years; 51% due to inefficacy, 36% due to adverse events). Compared with etanercept, infliximab (adjusted HR 1.63, 95% CI 1.51 to 1.77) and adalimumab initiators had higher discontinuation rates (1.26, 95% CI 1.16 to 1.37), and infliximab had a higher discontinuation rate than adalimumab (1.28, 95% CI 1.18 to 1.40). These findings were consistent across periods, but were modified by time for adalimumab versus etanercept (p<0.001; between-drug difference highest the 1st year in both periods). The discontinuation rate was higher for starters in 2006–2009 than 2003–2005 (adjusted HR 1.12, 95% CI 1.04 to 1.20). The composition of 1-year discontinuations also changed from 2003–2005 vs 2006–2009: adverse events decreased from 45% to 35%, while inefficacy increased from 43% to 53% (p<0.001).

Conclusions

Discontinuation rates were higher for infliximab compared with adalimumab and etanercept initiators, and for adalimumab versus etanercept during the 1st year. Discontinuation rates increased with calendar period, as did the percentage discontinuations due to inefficacy.

Population-based data from the Swedish Colon Cancer Registry

BACKGROUND

Evaluating the external validity of clinical trials requires knowledge not only of the study population but also of a relevant reference population. The main aim of this study was to present data from a large, contemporary, population-based cohort of patients with colonic cancer.

METHODS

Data on patients diagnosed between 2007 and 2011 were extracted from the Swedish Colon Cancer Registry. The data, registered prospectively in a national population of almost 10 million, included over 99 per cent of all diagnosed adenocarcinomas of the colon.

RESULTS

This analysis included 18,889 patients with 19,526 tumours (3·0 per cent had synchronous tumours). The sex distribution was fairly equal, and the median age was 74·1 (interquartile range 65-81) years. The overall and relative (cancer-specific) survival rates after 3 years were 62·7 and 71·4 per cent respectively. Some 88·0 per cent of the patients were operated on, and 83·8 per cent had tumours resected. Median blood loss during bowel resection was 200 (mean 311) ml, and the median operating time was 160 min; 5·6 per cent of the procedures were laparoscopic. Preoperative chemotherapy was administered to 2·1 per cent of patients; postoperative chemotherapy was planned in 90·1 per cent of fit patients aged less than 75 years with stage III disease. In patients operated on in an emergency setting (21·5 per cent), the preoperative evaluation was less extensive, the proportion of R0 resections was lower, and the outcomes were poorer, in both the short and long term.

CONCLUSION

These population-based data represent good-quality reference points.

Abstract P2-10-37: Long-term prognosis of early breast cancer in a population-based cohort with a known BRCA1/2 mutation status

Background: The impact of germline BRCA1/2 mutations on breast cancer prognosis and treatment is currently not clear. We investigate how different factors, including BRCA1/2 mutation status, correlate with long-term outcome in early breast cancer in a population-based cohort.

Methods: As previously reported, all women in the Southern Health Care Region in Sweden with breast cancer diagnosed before age 41 years between 1990 and 1995 (n = 262) were contacted in 1996 and offered mutation analysis of the BRCA1 and BRCA2 genes. Mutation analysis was performed on 234 of them, the others were excluded from further studies. 23 pathogenic mutations were found; 18 in BRCA1 and 5 in BRCA2. We will now present data on tumor and patient characteristics, treatment and long-term follow-up for the patients from this population-based cohort. Three patients have declined further study follow-up and were therefore excluded. Six patients had metastatic breast cancer at the time diagnosis (one of them a BRCA2 mutation carrier) and are also excluded, leaving 225 in the present analysis.

Results: Among the 225 cases estrogen receptor (ER) status is known for 191 (49% ER+, 51% ER−); histologic grade for 169 (24% grade I; 33% grade II; 43% grade III); stage for 225 (36% stage I, 44% stage II, 20% stage III); type of surgery, adjuvant systemic treatment and postoperative radiotherapy for 225. In the cohort, 46% received adjuvant or neoadjuvant chemotherapy, whereas 15% were given adjuvant endocrine therapy. There is complete follow-up &gt; 10 years for 205 and present vital status for 224.

Of the 225 women, 128 (57%) have had a local, regional or distant recurrence of breast cancer (contralateral breast cancer not included) at the date of last follow-up. One hundred and six patients (47%) have died, 98 of whom from breast cancer and 2 from presumably radiation-induced malignancies caused by postoperative radiotherapy. Thirteen of the 22 BRCA1/2 mutation carriers (59 %) have died, all from breast cancer. Of the 9 mutation carriers that are alive today, 3 have had an in-breast tumor recurrence and 3 have had a contralateral breast cancer; the 3 women that have had neither have all performed bilateral prophylactic mastectomy as well as prophylactic salpingo-ooforectomy.

Data on how the long-term prognosis of early breast cancer is correlated to BRCA1/2 mutation status, adjuvant treatment, stage at diagnosis, histologic grade and ER status of the tumor will be presented.

Conclusion: Women with early breast cancer in this cohort from the early 90ies had a poor long-term prognosis. The prognosis for women diagnosed with early breast cancer today is likely to be better, thanks to more modern chemotherapy regimens, endocrine and targeted treatments. The prognostic significance of BRCA1/2 mutation status will be further analyzed.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-37.

Abstract P2-10-36: Analysis of biomarker expression and biological subtype in primary tumour, corresponding lymph node and distant metastasis with 5-year follow-up

Background: Biological variation in genotype and phenotype of primary breast cancer explains the heterogeneity of the disease and subsequent outcome. Choice of treatment is routinely based on the biomarker expression of the primary tumour with regard to estrogen- (ER) and progesterone (PR) receptor status, human epidermal growth factor receptor 2 (HER2) status and the proliferation marker Ki67, individually. Recently, gene expression profiling and subsequent immunohistochemical studies have identified biologically distinct subtypes by using a combination of biomarkers which have been shown to be of prognostic value beyond the previous known. However, tumour progression theories propose a change in biomarker expression during development from primary tumour to distant metastasis with implications on choice of therapy. The aim of this study was to compare biomarker expression individually and according to biological subtype between tumour samples from primary tumour, lymph node metastasis and distant metastasis from the same patient.

Material and methods: From an original cohort of 569 patients with primary breast cancer, tissue microarrays were constructed from archival tissue blocks of primary tumour (n = 521), paired lymph node metastasis (n = 147) and biopsies from distant metastasis (n = 42). The samples were evaluated by two independent pathologists. The individual biomarker expression as well as subtype classification (Luminal A: ER+ and/or PR+, Ki67≤ 20% and HER2−. Luminal B: ER+ and/or PR+, Ki67&gt; 20% and/or HER2+. HER2 type: ER/PR−, HER2+. Basal-like: ER/PR−, HER2−, CK5/6+ and/or EGFR+) were compared between primary tumour, lymph node metastasis and distant metastasis. Survival outcome were estimated using the Kaplan-Meier method and log rank test. The primary end-point was distant disease-free survival (DDFS).

Results: Distribution according to subtype.

P1-08-06: Breast Cancer among Patients with Diabetes, Obesity and Abnormal Blood Lipids – A Population-Based Register Study in Sweden

Objective: To study how the incidence of breast cancer is related to diabetes, obesity or abnormal blood lipids.

Methods: Diagnosis of diabetes, obesity or abnormal blood lipids was studied 0–10 years prior to the diagnosis of cancer in 2724 cases of cancer and in 20542 controls matched regarding age, sex and domicile in a population based material. Diagnoses were obtained by using out and inpatient population based registries. Also the use of glargine and metformin was studied in relation to cancer risk in diabetic patients using the national pharmacy prescription registry. Conditional logistic regression was used for the analyses.

Results: Diabetes was significantly more common prior to diagnosis in patients with breast cancer with diabetes diagnosed 0–4 years prior to the cancer diagnosis. The findings remained after adjusting for obesity and high blood lipids. Obesity was significantly more common in patients with breast cancer above the age of 60 years in those where obesity was diagnosed close to the diagnosis of cancer. High blood lipids were significantly less common in patients with breast cancer close to diagnosis.

Glargine use was associated with a doubled risk 2.88 (1.15−6.64) and metformin use with a lower risk of cancer in diabetic patients 0.92 (0.82−1.09).

Interactions between oral contraceptive status and GSTM1 and GSTT1 deletions on insulin-like growth factor-1 (IGF-1) plasma levels in young healthy women

OBJECTIVE

Insulin-like growth factor-1 (IGF-1) is essential for the pubertal growth spurt and for normal mammary gland development. IGF-1 increases premenopausal breast cancer risk. Oral contraceptives (OCs) decrease IGF-1 in most women. The endogenous estrogens and their metabolites also influence IGF-1 levels. Glutathione S-transferases (GSTs) are involved in estrogen metabolism. We aimed to study IGF-1 levels and body size in relation to GSTM1 and GSTT1 deletions, and GSTP1*1B and current oral contraceptive (OC) status.

DESIGN

Questionnaires on reproductive factors and OC use were completed and blood samples were obtained during menstrual cycle day 18-23 in healthy women (≤40 years) from breast cancer high-risk families. IGF-1 was analyzed with radioimmunoassay. Genetic analyses were done with PCR based methods. Initially 258 women were included. After exclusion 229 women were finally included in the analyses of IGF-1 in relation to GSTM1 and GSTT1.

RESULTS

Among the 142 non-OC users, GSTM1*0/*0 or GSTT1*0/*0 alone were associated with lower IGF-1 levels while homozygous GSTM1*0/*0/GSTT1*0/*0 carriers had higher IGF-1 levels (P(interaction)=0.024). In the 87 OC users, GSTM1*0/*0 or GSTT1*0/*0 alone were associated with higher IGF-1 levels while homozygous GSTM1*0/*0/GSTT1*0/*0 carriers had lower IGF-1 levels (P(interaction)=0.010). Among all 229 women, a three-way interaction model showed an interaction between the GSTM1*0/*0/GSTT1*0/*0 genotype and OC use on IGF-1 levels (P(interaction)=0.003). GSTP1*1B was not associated with IGF-1. The GSTM1*1/GSTT1*0/*0 genotype was associated with high body weight (P=0.003) and GSTM1*0/*0/GSTT1*0/*0 was associated with early growth (P=0.003).

CONCLUSION

Both OC use and GSTT1 and GSTM1 genotypes may influence IGF-1 levels. Further studies are warranted to confirm our finding and elucidate the clinical importance.

Association of MC1R variants and host phenotypes with melanoma risk in CDKN2A mutation carriers: a GenoMEL study

Background

Carrying the cyclin-dependent kinase inhibitor 2A (CDKN2A) germline mutations is associated with a high risk for melanoma. Penetrance of CDKN2A mutations is modified by pigmentation characteristics, nevus phenotypes, and some variants of the melanocortin-1 receptor gene (MC1R), which is known to have a role in the pigmentation process. However, investigation of the associations of both MC1R variants and host phenotypes with melanoma risk has been limited.

Methods

We included 815 CDKN2A mutation carriers (473 affected, and 342 unaffected, with melanoma) from 186 families from 15 centers in Europe, North America, and Australia who participated in the Melanoma Genetics Consortium. In this family-based study, we assessed the associations of the four most frequent MC1R variants (V60L, V92M, R151C, and R160W) and the number of variants (1, ≥2 variants), alone or jointly with the host phenotypes (hair color, propensity to sunburn, and number of nevi), with melanoma risk in CDKN2A mutation carriers. These associations were estimated and tested using generalized estimating equations. All statistical tests were two-sided.

Results

Carrying any one of the four most frequent MC1R variants (V60L, V92M, R151C, R160W) in CDKN2A mutation carriers was associated with a statistically significantly increased risk for melanoma across all continents (1.24 × 10⁻⁶ ≤ P ≤ .0007). A consistent pattern of increase in melanoma risk was also associated with increase in number of MC1R variants. The risk of melanoma associated with at least two MC1R variants was 2.6-fold higher than the risk associated with only one variant (odds ratio = 5.83 [95% confidence interval = 3.60 to 9.46] vs 2.25 [95% confidence interval = 1.44 to 3.52]; P_trend = 1.86 × 10⁻⁸). The joint analysis of MC1R variants and host phenotypes showed statistically significant associations of melanoma risk, together with MC1R variants (.0001 ≤ P ≤ .04), hair color (.006 ≤ P ≤ .06), and number of nevi (6.9 × 10⁻⁶ ≤ P ≤ .02).

Conclusion

Results show that MC1R variants, hair color, and number of nevi were jointly associated with melanoma risk in CDKN2A mutation carriers. This joint association may have important consequences for risk assessments in familial settings.

Occupational exposure to pesticides and bile tract carcinoma in men: results from a European multicenter case-control study

OBJECTIVES

To estimate the associations between occupational exposure to pesticides and extrahepatic biliary tract carcinoma in men, a population-based case-control study was carried out.

METHODS

Cases (n = 104), aged 35-70, diagnosed in 1995-1997, were sampled by active reporting systems from hospitals. Controls (n = 1,401) were a random sample of the general male population. Information on occupation and confounding factors was obtained by questionnaires. Exposures were quantified with respect to time, application methods, and use of personal protective equipment. Intensity was evaluated by using a published algorithm which weighted the exposure assigned according to the use of personal protective equipment and mode of application. Logistic regression analyses were conducted adjusted for gallstones, age, and country.

RESULTS

Being ever exposed to pesticides resulted in an odds ratio (OR) of 1.0 [95%-confidence interval (CI) 0.6-1.6]. A modestly elevated risk was found for backpack mounted sprayers OR = 1.4 [95% CI 0.7-2.6] and vine farmers OR = 2.5 [95% CI 0.9-7.2]. Using time periods and exposure frequency as intensity measure, no elevated risks were found. The only exception was year of maximum exposure which yielded an OR of 1.6 [95% CI 0.7-3.5]. However, no clear trend was observed in this analysis.

CONCLUSIONS

This study does not rule out that pesticide exposure represents an occupational risk factor for extrahepatic biliary tract carcinoma, but no indication of a strong association was observed. Some modes of exposure were weakly, albeit not significantly associated with carcinoma risk. The observed estimates of effects may be influenced by a lack of precise exposure assessment. Different chemical compositions of pesticides were utilized during a long time span of pesticide exposure, and it should be considered that the exposure is assessed with substantial uncertainty that could non-differential and bias results toward the null.

Risk Factors of Breast Cancer in Relation to Classical Histopathology

Background: Classical histopathological groups of breast cancer have recently been less studied in relation to etiological factors than the new more molecular oriented taxonomy such as luminal A,B, Her2-neu and basal type of breast cancer. In the present investigation we have related histopathology to breast cancer risk factors to shed light on the possibility that the classical taxonomy may have a biological meaning presently not fully recognized.Material and methods:In 1677 consecutive breast cancer patients the following risk factors were related to histopathology; parity, HRT use, breast cancer screening, vertical inheritance of breast cancer (possibly dominant), horizontal inheritance of breast cancer (possibly recessive), and germline mutation carrier status (BRCA1, BRCA2, CDKN2A, p53). Patients with mixed tumor types were excluded. All analyses were age adjusted and factors were simultaneously adjusted for.Results: A germline mutation was present in 1.5% of the cases. A relationship between medullary tumors and BRCA1 mutations was seen. Germline mutation carriers were in further analysis excluded. Among remaining cases a vertical family history was present in 23% and a horizontal one in 5% of the cases. A horizontal family history was significantly associated with tubular tumor type (OR=3.9, 1.4-10.4) and age, and non-significantly associated with tumor progesterone receptor content (OR=1.7, 0.8-4.0), and lobular tumor type (OR=1.4, 0.6-3.2). A vertical family history was significantly related to tumor multifocality (OR=2.3, 1.5-3.5), tumor bilaterality (OR=2.1, 1.4-3.0) and screening detection (OR=1.5, 1.1-2.1), while age and a tubuloductal tumor type (OR=0.5, 0.3-0.9) were significantly negatively related. Patients with ductal and mucinous tumors had significantly fewer children (OR=0.9, 0.8-0.99) and (OR=0.6, 0.4-0.8) respectively, while patients with comedocancer had significantly more children (OR=1.2, 1.1-1.4) .HRT use increased non significantly the risk for lobular breast cancer, while significantly being related to mixed lobular cases.Conclusion.These results demonstrate that classical histopathological groups are related to breast cancer risk factors and indeed may have a biological relationship to etiological factors.Especially factors related to parity, HRT use and family history seem to relate to different histopathological groups. Molecular signatures as well as classical histopathology should be used in future risk factor studies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6065.

Comorbidity prior to diagnosis in patients with common cancer diagnoses

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Background: Chronic disease as diabetes, hypertonia and anemia may be associated with cancer risk as well as affect the short term survival of the malignancy. Methods: Using population based registry data from specialist and primary care in our health care region comorbidity in the form of anemia, hypertonia, diabetes, rheumatoid arthritis, chronic obstructive pulmonary diasease (KOL), and alcohol related diseases for patients with colon-, rectal-, lung-, prostate and breast cancer and survival were studied. Altogether 2047 colon cancer cases, 985 rectal cancer cases, 2017 lung cancer cases, 3578 breast cancer cases and 5106 prostate cancer cases diagnosed 2000–2005 were included. Results: were age and sex adjusted and one year survival was calculated. Comorbidity was studied prior to cancer diagnosis and in order to compare with the general population all first comorbidity diagnoses within 90 days were censored. Results The prevalence of the chronic diseases in the general population was for all ages diabetes 3.2%, rheumatoid arthritis 0.5%, hypertonia 6.8%, anemia 1.1%, KOL 1.0% and alcohol related diagnoses 0.7%. Patients with colon and rectal cancer had a higher prevalence of anemia, and diabetes. Patients with lung cancer had a higher prevalence of anemia, KOL, diabetes, rheumatoid arthritis for both men and women and for men also a higher prevalence of alcohol related diseases. Except for alcohol related diseases in females with breast cancer comorbidity for the above diseases was not significantly elevated for breast or prostate cancer. For all diagnoses hypertonia was significantly lower than in the general population. Survival of the different cancer diagnoses was not significantly related to the comorbidity except for a tendency of worse survival for patients with alcohol related disease. Conclusions: The prevalence of some common chronic diseases are elevated especially in colon-, rectal and lung cancer patients. The comorbidity does not seem to affect short term survival of the cancer patient except for alcohol related diagnoses. Our study also indicates the necessity to have all levels of care included in the study base of comorbidity and also emphasizes the need to censor time prior to diagnosis when comparing data with the general population.

No significant financial relationships to disclose.

A prospective Swedish study on body size, body composition, diabetes, and prostate cancer risk

Obesity may be associated with increased risk of prostate cancer (PCa). According to one hypothesis, obesity could lower the risk of non-aggressive tumours, while simultaneously increasing the risk of aggressive cancer. Furthermore, central adiposity may be independently associated with PCa risk; it is also associated with diabetes, which itself may influence risk of PCa. We studied the associations between height, body composition, and fat distribution, diabetes prevalence and risk of total, aggressive, and non-aggressive PCa in 10 564 initially cancer-free men (aged 45–73 years) of the population-based Malmö Diet and Cancer cohort. Anthropometric and body composition measurements, including bioelectrical impedance for estimation of fat mass, were performed by study nurses. Diabetes prevalence was self-reported. Cancer cases and clinical characteristics were ascertained through national and regional registry data. Dietary and other background data were obtained through a modified diet history method and an extensive questionnaire. During a mean follow-up of 11.0 years, 817 incidental PCa cases were diagnosed. Of these, 281 were classified as aggressive. There were 202 cases occurring before 65 years of age. Height was positively associated with total and non-aggressive PCa risk. Waist–hip ratio (WHR), a measure of central adiposity, was positively associated with PCa before age 65, and less strongly, with total PCa. This association was independent of body mass index (BMI) and other potential confounders. General adiposity, expressed as BMI or body fat percentage, and prevalent diabetes were not associated with PCa risk. In this study, WHR and body height were stronger PCa predictors than general adiposity.

Relief of pruritus as an early sign of spinal cord compression in Hodgkin's disease

In a patient with advanced Hodgkin's disease (HD) associated with generalized pruritus, an unexpected relief of itching was found to be an early sign of spinal cord compression. Following irradiation of an extradural mass at the Th II level, itching recurred. Although the mechanisms bringing about itching in HD are unknown, the relief and recurrence of the symptom in our patient are in line with a peripheral origin of pruritus in the disease. Spontaneous relief of pruritus in HD despite other signs of active disease should prompt a neurological examination, since early recognition and treatment of spinal cord compression in lymphoma are important to avoid residual neurological disability.

Supradiaphragmatic presentation of non-Hodgkin's lymphoma in men occupationally exposed to organic solvents

Using a standardized interview schedule, occupational exposure to organic solvents was investigated in 61 consecutive male patients with the diagnosis of non-Hodgkin's lymphoma. When exposure was defined as handling of organic solvents every working day for at least one year, 23 patients were exposed and 38 non-exposed. Of 15 patients with clinical stage I-II above the diaphragm, 12 (80%) were occupationally exposed to organic solvents. Only 1 (11%) of 9 patients with clinical stage I-II disease located below the diaphragm was exposed. Thirty-seven patients had clinical stage III-IV disease at the time of diagnosis and 10 (27%) of these were exposed. The predominance of exposed patients in the group with stage I-II disease above the diaphragm is significant and the results indicate a relation between exposure to organic solvents and supradiaphragmatic presentation of non-Hodgkin's lymphoma. No correlation was found between exposure and the morphology of the lymphomas.

Diagnosis of deep vein thrombosis with 99Tcm-plasmin

The diagnostic efficiency of 99Tcm-plasmin test was evaluated by X-ray contrast phlebography in 110 consecutive patients with suspected deep vein thrombosis (DVT). The test was positive in 50 of 55 patients with DVT (sensitivity 91%) and negative in 18 of 55 without DVT (specificity 33%). The positive plasmin test in patients without DVT was in most cases due to another inflammatory process or a post-thrombotic state. The 99Tcm-plasmin test is a rapid and sensitive screening method for th diagnosis of DVT, but as it is based on comparison between the legs, it may be unreliable in cases of bilateral thrombosis. The low specificity makes it less valuable in patients with concomitant inflammatory disease or previous thrombosis in either leg. When the plasmin test is positive, the diagnosis of DVT should in most cases be confirmed by X-ray contrast phlebography.