PACE: A Randomized Phase II Study of Fulvestrant, Palbociclib, and Avelumab After Progression on Cyclin-Dependent Kinase 4/6 Inhibitor and Aromatase Inhibitor for Hormone Receptor-Positive/Human Epidermal Growth Factor Receptor-Negative Metastatic Breast Cancer

PURPOSE

Cyclin-dependent kinase (CDK) 4/6 inhibitors (CDK4/6is) are an important component of treatment for hormone receptor-positive/human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (MBC), but it is not known if patients might derive benefit from continuation of CDK4/6i with endocrine therapy beyond initial tumor progression or if the addition of checkpoint inhibitor therapy has value in this setting.

METHODS

The randomized multicenter phase II PACE trial enrolled patients with hormone receptor-positive/HER2- MBC whose disease had progressed on previous CDK4/6i and aromatase inhibitor (AI) therapy. Patients were randomly assigned 1:2:1 to receive fulvestrant (F), fulvestrant plus palbociclib (F + P), or fulvestrant plus palbociclib and avelumab (F + P + A). The primary end point was investigator-assessed progression-free survival (PFS) in patients treated with F versus F + P.

RESULTS

Overall, 220 patients were randomly assigned between September 2017 and February 2022. The median age was 57 years (range, 25-83 years). Most patients were postmenopausal (80.9%), and 40% were originally diagnosed with de novo MBC. Palbociclib was the most common previous CDK4/6i (90.9%). The median PFS was 4.8 months on F and 4.6 months on F + P (hazard ratio [HR], 1.11 [90% CI, 0.79 to 1.55]; P = .62). The median PFS on F + P + A was 8.1 months (HR v F, 0.75 [90% CI, 0.50 to 1.12]; P = .23). The difference in PFS with F + P and F + P + A versus F was greater among patients with baseline ESR1 and PIK3CA alterations.

CONCLUSION

The addition of palbociclib to fulvestrant did not improve PFS versus fulvestrant alone among patients with hormone receptor-positive/HER2- MBC whose disease had progressed on a previous CDK4/6i plus AI. The increased PFS seen with the addition of avelumab warrants further investigation in this patient population.

Correlation of HER2 Protein Level With mRNA Level Quantified by RNAscope in Breast Cancer

Trastuzumab deruxtecan (T-DXd) has been approved by the US Food and Drug Administration (FDA) to treat patients with metastatic HER2-positive and HER2-low breast cancer, and clinical trials are examining its efficacy against early-stage breast cancer. Current HER2 immunohistochemical (IHC) assays are suboptimal in evaluating HER2-low breast cancers and identifying which patients would benefit from T-DXd. HER2 expression in 526 breast cancer tissue microarray (TMA) cores was measured using the FDA-approved PATHWAY and HercepTest IHC assays, and the corresponding RNA levels were evaluated by RNAscope. HER2 protein levels by regression analysis using a quantitative immunofluorescence score against cell line arrays with known HER2 protein levels determined by mass spectrometry were available in 48 of the cores. RNAscope was also performed in 32 metastatic biopsies from 23 patients who were subsequently treated with T-DXd, and the results were correlated with response rate. HER2 RNA levels by RNAscope strongly correlated with HER2 protein levels (P < .0001) and with HER2 IHC H-scores from the PATHWAY and HercepTest assays (P < .0001). However, neither protein levels nor RNA levels significantly differed between cases scored 0, ultralow, and 1+ by PATHWAY and HercepTest. The RNA levels were significantly higher (P = .030) in responders (6.4 ± 8.2 dots/cell, n = 12) than those in nonresponders (2.6 ± 2.2, n = 20) to T-DXd. RNAscope is a simple assay that can be objectively quantified and is a promising alternative to current IHC assays in evaluating HER2 expression in breast cancers, especially HER2-low cases, and may identify patients who would benefit from T-DXd.

A Discordant Pattern of Uptake on 68 Ga-PSMA PET/CT Versus 18 F-Fluciclovine PET/CT in Radiation-Induced Hepatitis : Implications for Early Postradiotherapy Imaging-Based Response Assessment

ABSTRACT

A 62-year-old woman with right-sided invasive lobular breast carcinoma completed external beam radiotherapy 6 weeks before undergoing a 68 Ga-PSMA PET/CT and 18 F-fluciclovine PET/CT scan as part of an ongoing clinical trial (NCT04750473) assessing the performance of these molecular imaging modalities in invasive lobular breast carcinoma. The 68 Ga-PSMA PET/CT demonstrated a band-like area of increased radiotracer uptake in the dome of the right lobe of the liver anteriorly, whereas 18 F-fluciclovine PET/CT done a day later revealed photopenia in the corresponding area of the liver. The external beam radiotherapy plan confirmed that the radiotherapy field overlaid the region of the hepatic discordant radiotracer uptake on the PET/CT scans.

Using Oncotype DX breast recurrence score® assay to define the role of neoadjuvant endocrine therapy in early-stage hormone receptor-positive breast cancer

PURPOSE

The role of neoadjuvant endocrine therapy in the treatment of patients with early-stage, hormone receptor-positive (HR +) breast cancer is not well defined. Tools to better determine which patients may benefit from neoadjuvant endocrine therapy versus chemotherapy or upfront surgery remain an unmet need.

METHODS

We assessed the rate of clinical and pathologic complete response (cCR, pCR) among a pooled cohort of patients with early-stage HR + breast cancer who had been randomized to neoadjuvant endocrine therapy or neoadjuvant chemotherapy in two earlier studies to understand better how outcomes varied by Oncotype DX Breast Recurrence Score® assay.

RESULTS

We observed that patients with intermediate RS results had no statistically significant differences in pathologic outcomes at the time of surgery based on whether they received neoadjuvant endocrine therapy or neoadjuvant chemotherapy, suggesting that a subgroup of women with a RS 0-25 may omit chemotherapy without compromising outcomes.

CONCLUSION

These data suggest that Recurrence Score® (RS) results may serve as a useful tool in treatment decision-making in the neoadjuvant setting.

Abstract HER2-12: HER2-12 Genomic and Transcriptomic Landscape of HER2-Low Breast Cancer

Introduction: Breast cancer has pioneered precision medicine with prognostic and predictive subtypes, defined by immunohistochemistry (IHC). Novel therapeutic strategies have led to the emergence of HER2-Low (H2L) as a new entity, defined as tumors with HER2 IHC score of 1+ (&gt;10% cell stained), as well as those with 2+ (&gt;10% cell stained) with paired negative in-situ hybridization (ISH) assay. H2L has been reported to represent up to half of all breast cancer. Further investigation into the mutational landscape of H2L compared to historical subtypes is needed to understand the clinical and biologic factors driving mechanisms of resistance and to consider post-progression treatment options within H2L populations. Methods: The Caris Life Sciences database was used to identify H2L breast tumors by IHC and CISH and evaluated for mutations detected by DNA next-generation sequencing (NextSeq 592-gene panel or NovaSeq whole exome panel). PD-L1 expression was tested by IHC (SP142 IC ≥ 1%). Tumor mutational burden (TMB) was measured by totaling somatic mutations per tumor (high ≥ 10 mutations per Mb). Statistical significance was determined using Fisher’s-Exact/Mann Whitney/X2 test with Benjamini-Hochberg-correction-adjusted p value (q value) of &lt;0.05. Results: A total of 19789 breast tumors were included in this study. Using standard definitions, 12480 were defined as hormone receptor positive (HR+), 7309 hormone receptors negative (HRneg), 5564 were TNBC, and 1784 HER2 positive (HER2pos). 4349 cases were also identified as H2L, which included 3403 HR+H2L and 946 HRneg H2L. H2L was 22% (4349/19789) of total population; 27% (3403/12480) of the HR+ population and 12.9% (946/7309) of the HRneg population. Within the H2L tumors, when stratified by HR status, we observed in the HR+H2L tumors an increased frequency of amplifications in CCND1 (15.6% vs 5.0%), FGF3 (13.3% vs 4.7%), FGF4 (13.3% vs 4.2%), FGF19 (14.4% vs 4.7%), ZNF703 (15.6% vs 4.4 %), NSD3 (12.9% vs 5.2%), ADGRA2 (13.1% vs 5.3%), FGFR1 (11.7% vs 3.6%) and EMSY (5.2% vs 1.4%) compared to the HRnegH2L tumors. TP53 mutations were strikingly higher in the HRnegH2L group (74.4% vs 25.0%) compared to HR+H2L tumors. Markers of IO response also showed elevated positivity in PD-L1 (39.6% vs 19.5%) however, no difference was detected in TMB-H status in HRnegH2L tumors compared to HR+H2L tumors, all q&lt;0.05. The genomic landscape differed when comparing HR+HER2pos tumors to HR+H2L tumors. Significantly more prevalent alterations in HR+HER2pos included amplifications in RNF43 (4.4% vs 1.4%), RARA (13.6% vs 0.1%), MLLT6 (19% vs 0.0%), MYC (6.1% vs 2.7%), DDX5 (10.1% vs 2.0%), CLTC (10.4% vs 3.3%) as well as TP53 (64.0% vs 25.0%) mutations and PD-L1 expression (26.6% vs 19.5%). Furthermore, mutations in PTEN (2.5% vs 7.8%), MAP3K1 (2.8% vs 7.1%), ESR1 (4.4% vs 14.3%), CDH1 (5.2% vs 16.4%), AKT1 (0.0% vs 4.3%) were elevated in the HR+H2L tumors compared to the HR+HER2pos tumors, all q&lt;0.05. Interestingly, when the HRnegH2L tumors were compared to TNBC subtype differences were seen in the mutation rate of PIK3CA (33.5% vs 16.7%; q&lt;0.0001), a master regulator of cell growth, and tumor suppressor gene TP53 (74% vs 86%). Conclusions: With some exceptions, H2L breast cancer shared genomic features with its more classically defined subset of either HR+ or HRneg disease. Notable differences in PIK3CA (an actionable mutation) and TP53 (a prognostic alteration) warrant additional assessment, as do amplifications variable between HR+H2L and HR+Her2pos groups. Our findings add tremendously to the current understanding of the molecular profile of the H2L subgroup and comparison to the classically defined breast cancer subgroups. Genomic risk assessments after progression on novel therapeutics will be needed to better define implications for mechanisms of resistance.

Citation Format: Rani Bansal, Julie McGrath, Phil Walker, Matias A. Bustos, Estelamari Rodriguez, Sarah L. Sammons, Melissa K. Accordino, Jane Meisel, Margaret Gatti-Mays, Emily Hsu, Kate I. Lathrop, Virginia Kaklamani, Matthew Oberley, W. Michael Korn, Stephanie L. Graff. HER2-12 Genomic and Transcriptomic Landscape of HER2-Low Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr HER2-12.

Abstract P6-01-20: Luminal androgen receptor subtype and M2 macrophage signatures strongly associate with low pathological complete response rates and poor outcomes in patients with triple negative breast cancer receiving neoadjuvant chemotherapy

Background: Triple negative breast cancers (TNBC) are a heterogeneous group of cancers and it is difficult to predict which patients will respond to neoadjuvant chemotherapies (NACT). Achieving pathologic complete response (pCR) to NACT is prognostically favorable, whereas lack of pCR is associated with high rates of recurrence and death from TNBC. Currently, there is no universally accepted biomarker to predict TNBC response to NACT. Methods: We analyzed 25 in-house TNBC biopsies that were treated with neoadjuvant adriamycin (A), cyclophosphamide (C) and paclitaxel (T) and 31 residual TNBC after NACT-ACT using RNA-seq data from macro-dissected tumor tissues from formalin fixed paraffin embedded (FFPE) blocks. Raw reads were mapped to the Human reference genome GRCH38 using the kallisto aligner v0.46.1. Immune infiltrate fractions were estimated using the Cibersort algorithm derived from the LM22 gene-signature matrix of 22 hematopoietic cell types. TNBCtype-4 classification of samples was determined calculating the enrichment of gene-sets for: Luminal Androgen Receptor (LAR), Basal-like 1 and 2 (BL1, BL2), Mesenchymal(M). Overall immune-infiltrate analysis and cancer-intrinsic subtyping were conducted independently on each transcriptional profile. Results were validated by running our novel analyzing protocol in independent cohorts including 182 TNBC cases treated with NACT-ACT from a published Vanderbilt cohort and 179 TNBC cases from the TCGA database. Results: Twenty one (68%) of the 31 residual TNBC after neoadjuvant ACT were luminal androgen receptor (LAR) subtype and significantly enriched in M2 macrophage signature. The LAR subtype and monocyte or M2 macrophage signaturesstrongly associated with lack of pCR in the 25 TNBC biopsy cases and 182 Vanderbilt TNBC cases treated with NACT-ACT. Survival analysis of 179 TNBC cases from the TCGA database showed a significant association of LAR subtype and M2 macrophage signature with worse survival. Conclusions: We developed a novel RNA-seq analyzing protocol that combines tumor subtype and immune profile. The LAR subtype and M2 macrophage signatures strongly associated with lack of pCR and worse survival in TNBC patients when treated with NACT-ACT. Both tumor subtype and immune profile should be considered in biomarker development and further studied in specimens from patients treated with modern chemoimmunotherapy regimens.

Citation Format: Jane Meisel, Eugene Douglass, Kevin Kalinsky, Lyra M. Griffiths, Zaibo Li, Xiaoxian Li. Luminal androgen receptor subtype and M2 macrophage signatures strongly associate with low pathological complete response rates and poor outcomes in patients with triple negative breast cancer receiving neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-20.

Abstract P6-09-01: Treatment goals and quality of life (QOL) in a survey of patients with ER+/HER2- metastatic breast cancer (mBC)

Introduction: In patients (pts) with ER+/HER2- mBC, insights into the foremost concerns regarding their mBC treatment goals and QOL are often assumed by providers but are vastly understudied. The objectives of this survey were to better comprehend treatment goals and QOL concerns in pts with ER+/HER2- mBC. Methods: The 42-question, online EQUALS (ESR1 QUAlity of Life Survey) survey was sent to US subjects in June 2022 from 1) the Cure Media Group (n=6,625) by email, 2) private Facebook groups of pts with mBC and 3) members of a BC clinic. Subjects were eligible if they had ER+/HER2- mBC. A $10 gift card was obtained at survey completion. Survey answers were summarized descriptively. Results: 213 pts completed the survey. Respondents had a mean age of 57 y (range, 31–83 y), and were mostly white (91%), living in an urban/suburban setting (75%), with a higher education degree (71%) and household income ≥$75k (53%). Mean year of mBC diagnosis was 2018 (range, 1995–2022). Most common first-line mBC treatments were aromatase inhibitor (AI) + CDK4/6 inhibitor (CDK4/6i; 44%), AI alone (18%), or fulvestrant + CDK4/6i (16%);54% had received chemotherapy in the metastatic setting. Pts most frequently received information about new mBC treatments from other people living with mBC (42%), followed by physicians (34%), social media (31%), or medical journals/conferences (28%). Two-thirds of pts (64%) reported good/very good QOL, with 12% reporting poor/very poor QOL. Common side effects mostly/moderately impacting QOL were: fatigue (74%), joint pain (64%), vaginal atrophy/dryness (56%), and vasomotor symptoms (47%). Most (84%) were comfortable/very comfortable discussing side effects with their medical team (MT). Worry about disease progression occurred often: everyday (38%), a few times a week (21%) or month (18%), or only before scans (15%). Upon progression, pts worried more about efficacy of new treatment (76%) and having additional options (70%) than they did about side effects (33%). Pts’ current treatment goals were: control cancer growth/spread (93%), prolong life (82%), maintain QOL (81%), tolerate side effects (61%), and relieve suffering/pain (57%); similar to their goals at diagnosis. Almost two-thirds of MTs addressed these goals at the beginning of treatment (63%) and continued annually (60%). Most pts (70%) were very concerned that their mBC diagnosis impacted their family although 81% felt supported at home. Since diagnosis, major/moderate life impacts were: side effects (82%), mental health/stress (78%), QOL (71%), inability to engage in activities (62%), and finances (61%). Most pts (64%) thought their mBC or treatment impacted their intimate/sexual relationship negatively and half (50%) worried about sexual intimacy. Only 44% of pts were comfortable discussing intimacy/sexual side effects with their MT. More pts were comfortable/very comfortable discussing sexual side effects with their MT if their oncologists were female (64%) vs male (51%), BC (73%) vs general (45%), or academic (70%) vs community hospital (52%) or office-based practice (49%). Most (92%) were concerned that their treatments may have a negative impact on their bones. Conclusion: In this survey of pts with ER+/HER2- mBC, &gt;70% received information about new mBC treatments from other pts or social media vs physicians. Pts’ primary concerns were disease control and treatment options, although treatment side effects had the most impact on QOL. Mental health/stress, intimacy and relationships, and bone health were also impacted. Respondents to online surveys in mBC may portray non-representative populations lacking diversity and attempts to diversify future research are much needed, and further efforts are ongoing to address this knowledge gap.

Citation Format: Sarah L. Sammons, Jane Meisel, Kelly Shanahan, Timothy Pluard, Monica Kozlowski, Dominic Carroll, Elizabeth Attias. Treatment goals and quality of life (QOL) in a survey of patients with ER+/HER2- metastatic breast cancer (mBC) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-09-01.

Abstract GS3-06: GS3-06 Palbociclib After CDK4/6i and Endocrine Therapy (PACE): A Randomized Phase II Study of Fulvestrant, Palbociclib, and Avelumab for Endocrine Pre-treated ER+/HER2- Metastatic Breast Cancer

Background CDK4/6 inhibitors (CDK4/6i) in combination with endocrine therapy (ET) have a well-established role in the management of hormone receptor-positive (HR+)/HER2- metastatic breast cancer (MBC). The benefit of continuing CDK4/6i beyond progression in combination with a different ET has not been confirmed. Preclinical data suggest synergy between CDK4/6i and PD-L1 inhibition. The PACE trial prospectively evaluates whether continuation of the CKD4/6i palbociclib beyond progression on prior CDK4/6i and aromatase inhibitor (AI), with a change in ET to fulvestrant, improves outcomes beyond change to fulvestrant alone, as well as explores the activity of the palbociclib, fulvestrant, and avelumab triplet. Methods PACE is a multicenter randomized open-label investigator-initiated phase II trial, open at 11 U.S. sites. Eligible patients (pts) had HR+/HER2- evaluable MBC with prior progression on AI and any CDK4/6i after &gt; 6 months (mo) of therapy in the MBC setting, or during/within 12 mo in the adjuvant setting, with no more than 1 prior line of chemotherapy for MBC. Pts were randomized 1:2:1 to fulvestrant alone (F); fulvestrant and palbociclib (F+P); or fulvestrant, palbociclib, avelumab (F+P+A), with tumor assessments every 8 weeks. Blood for circulating tumor DNA (ctDNA) analysis was collected at baseline, at times of tumor assessments, and at progression. The primary objective was to evaluate progression-free survival (PFS) with F+P vs F; secondary objectives included PFS with F+P+A vs F, objective response rate (ORR) in all arms, and safety. A sample size of 220 patients was planned to provide 80% power to detect an improvement in PFS with HR 0.6154 with F+P vs F (6.5 vs 4 mo; α(1)=0.05). Results A total of 220 pts were randomized from 9/2017-2/2022 (F: n=55, F+P: n=111, F+P+A: n=54); median age 57 years (range 25-83), 85% non-Hispanic (7.7% non-Hispanic black), 8.6% Hispanic, 6.4% unknown. 40% had de novo MBC, 60% had visceral disease, and 14% bone-only disease. 16% had 1 prior line of chemotherapy for MBC, 90% had received prior palbociclib, 4.5% ribociclib, 4.1% abemaciclib, 1.4% palbociclib and ribociclib. Pts entered the trial after a median 19 mo of prior CDK4/6i plus AI (interquartile range 12-31 mo). A total of 10 (5%) pts received protocol therapy as first line ET for MBC, 169 (77%) as second line, and 41 (17%) as beyond second line. 88% entered the trial directly after progression on CDK4/6i. After a median follow-up of 24 mo, 18 pts remained on protocol treatment. PFS was not improved with F+P vs F (median 4.6 vs 4.8 mo; HR=1.11, 90% CI 0.79-1.55; 2-sided p=0.62). Median PFS was 8.1 mo with F+P+A (HR=0.75 vs F, 90% CI 0.50-1.12; 2-sided p=0.23). ORR was 7.3% (90%CI 1.5-13.0) with F, 9.0% F+P (4.5-13.5%) and 13.0% F+P+A (5.4-20.5%). No new safety signals have been observed. Analysis of ctDNA panel sequencing encompassing 70 genes from 184 baseline samples, including correlation with known and hypothesized resistance genes, will be presented. Conclusions For ER+/HER2- breast cancer, combining palbociclib with fulvestrant beyond progression on prior CDK4/6i and AI did not significantly improve PFS compared with using fulvestrant alone. The observed longer PFS when a PD-L1 inhibitor was added to fulvestrant plus palbociclib is an intriguing signal in this ER+ population. Translational studies of blood and tumor tissue are ongoing and will be presented.

Citation Format: Erica L. Mayer, Yue Ren, Nikhil Wagle, Reshma Mahtani, Cynthia Ma, Angela DeMichele, Massimo Cristofanilli, Jane Meisel, Kathy D. Miller, Trevor Jolly, Elizabeth Riley, Rubina Qamar, Priyanka Sharma, Sonya Reid, Natalie Sinclair, Meredith Faggen, Caroline Block, Naomi Ko, Ann Partridge, Wendy Y. Chen, Michelle K. DeMeo, Victoria Attaya, Amanda Okpoebo, Yuan Liu, Eric Gauthier, Harold Burstein, Meredith Regan, Sara Tolaney. GS3-06 Palbociclib After CDK4/6i and Endocrine Therapy (PACE): A Randomized Phase II Study of Fulvestrant, Palbociclib, and Avelumab for Endocrine Pre-treated ER+/HER2- Metastatic Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr GS3-06.

Abstract P6-09-02: Knowledge of tumor/blood genomic testing (NGS) and ESR1 mutations in a survey of patients with ER+/HER2- metastatic breast cancer (mBC)

Introduction: In patients (pts) with ER+/HER2- mBC, acquired ESR1 mutations after endocrine therapy can lead to treatment resistance, metastasis, and poor prognosis. The objective of this survey was to understand the knowledge of NGS in pts with mBC.

Methods: The 42-question, online EQUALS (ESR1 QUAlity of Life Survey) survey was sent to US subjects in June 2022 from 1) the Cure Media Group (n=6,625) by email, 2) private Facebook groups of pts with mBC and 3) members of a BC clinic. Eligible pts were those with ER+/HER2- mBC. At survey completion, respondents received a $10 gift card. Survey answers were summarized descriptively.

Results: Of 236 pts who responded to the survey, 213 completed. Participants had a mean age of 57 y (range, 31–83 y), mean mBC diagnosis year of 2018 (range, 1995–2022), and were mostly white (91%), living in an urban/suburban setting (75%), with mean household income of ≥$75k (53%), and higher education degree (71%). First-line mBC treatments were aromatase inhibitor (AI) + CDK4/6 inhibitor (CDK4/6i; 44%), AI alone (18%), fulvestrant + CDK4/6i (16%), chemotherapy (12%), selective estrogen receptor modulator (SERM; 4%) or other/clinical trial (7%). Second-line therapies were none (31%), AI + CDK4/6i (28%), fulvestrant + CDK4/6i (18%), or AI alone (12%). Of the 54% (114/213) who received chemotherapy in the metastatic setting, 34% (39/114) had received ≥3 lines of chemotherapy. Pt’s oncologist gender (female 56%) and type (general [52%], breast cancer only [48%]) or setting (office [22%], community [35%], academic [43%]) of oncology practice were well balanced. Most pts’ oncologists (63%) had discussed tumor NGS by a blood test or tumor biopsy with them, but only 29% of them had explained liquid biopsy (assessment of circulating tumor DNA from a blood draw). Regardless, pts knew a lot/moderate amount about NGS (65%), less so of liquid biopsies (44%). NGS awareness by location was different with more suburban pts (73%) knowing a lot/moderate amount than urban (63%) or rural (59%) pts, and by income (&gt;$50k [68%], $35k to &lt;$50k [61%], &lt;$35k [52%]), but not by age (&lt; 50 y [71%]; 50-60 y [62%]; ≥60 y [69%]). When asked if they knew what an ESR1 mutation was, about a third each knew a fair amount, a little bit, or did not know much; only 24% of pts thought they had been tested for an ESR1 mutation. ESR1 awareness (Table) differed by location, with more urban pts (40%) knowing a lot/moderate amount about ESR1 mutations vs rural (30%) or suburban (26%) pts, by income (&gt;$50k [32%], $35k to &lt;$50k [28%], &lt;$35k [14%]) and by oncologist setting (academic [39%] vs office [23%] or community [24%]), but not by age. Slightly more pts had an ESR1 test in urban (26%) vs rural (20%) settings, and with higher (29%) vs lower (10%) incomes, but similar by age. Overall, most pts believed that ESR1 testing results could affect their treatment options/decisions (92%), were comfortable asking about NGS (94%), and would prefer a blood test over a tumor biopsy for more targeted mBC treatments (88%).

Conclusion: In this survey of ER+/HER2- pts living with mBC, most had some knowledge of NGS but knowledge of ESR1 mutations was lower. Discordance between physician discussion of NGS and liquid biopsies was observed. Awareness of NGS and ESR1 mutations analyzed by demographics data suggests socioeconomic disparities in pt education and knowledge. Further education on NGS and ESR1 mutations is needed as NGS testing is becoming an important aspect of mBC treatment.

Table 1. Awareness of ESR1 mutations based on demographics *Never heard of it or heard of it but don’t know what it is.

Citation Format: Jane Meisel, Sarah L. Sammons, Kelly Shanahan, Timothy Pluard, Monica Kozlowski, Dominic Carroll, Elizabeth Attias. Knowledge of tumor/blood genomic testing (NGS) and ESR1 mutations in a survey of patients with ER+/HER2- metastatic breast cancer (mBC) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-09-02.

Abstract OT1-03-06: Phase 1b/2 study of ladiratuzumab vedotin (LV) in combination with pembrolizumab for first-line treatment of triple-negative breast cancer (SGNLVA-002, trial in progress)

Background Patients with metastatic triple-negative breast cancer (mTNBC) have a poor prognosis. Treatment combinations of anti-programmed death protein 1 (anti–PD-1) agents with chemotherapy have shown promise in mTNBC. Ladiratuzumab vedotin (LV) is an investigational antibody-drug conjugate directed to LIV-1, a protein highly expressed on breast cancer cells, via a humanized IgG1 monoclonal antibody conjugated to approximately 4 molecules of monomethyl auristatin E (MMAE) by a protease-cleavable linker. LIV-1–mediated delivery of MMAE disrupts microtubules and induces cell cycle arrest and apoptosis. LV has also been shown to drive immunogenic cell death (ICD) to elicit an immune response. LV + pembrolizumab may result in synergistic activity through LV-induced ICD, creating a microenvironment favorable for enhanced anti–PD-1 activity. Interim results from an ongoing, multi-part, open-label study investigating the safety and efficacy of LV in patients with metastatic breast cancer (SGNLVA-001, NCT01969643), showed weekly LV monotherapy at doses up to 1.5 mg/kg were clinically active and generally well tolerated (Tsai 2021). Based on pharmacokinetic and pharmacodynamic modeling and simulation analysis, an intermittent LV + pembrolizumab dosing regimen is being evaluated to further enhance efficacy and improve the tolerability profile. Due to an unmet medical need for patients with unresectable locally advanced (LA)/mTNBC who are programmed death ligand 1 (PD-L1) low or negative, Part D will focus on this patient population. Trial Design SGNLVA-002 (NCT03310957) is an ongoing global single-arm, open-label phase 1b/2 study of LV + pembrolizumab as 1L therapy for patients with unresectable LA/mTNBC. Part D is currently enrolling ~40 patients. Eligible patients must have advanced disease with no prior cytotoxic/anti–PD-1 treatment, PD-L1 combined positive score &lt; 10, measurable disease per RECIST v1.1, and an ECOG performance status ≤1. Patients with Grade ≥2 pre-existing neuropathy or active central nervous system metastases are not permitted. Patients will receive LV at 1.5 mg/kg on Days 1 and 8 every 21 days plus pembrolizumab 200 mg on Day 1 q3w. The primary objectives are to evaluate the safety/tolerability and objective response rate of LV + pembrolizumab. Secondary objectives include duration of response, disease control rate, progression-free survival, and overall survival. Safety and efficacy endpoints will be summarized with descriptive statistics. Global enrollment is ongoing in the US, EU, and Asia.

Citation Format: Patrick Dillon, Reva Basho, Hyo S. Han, Hans-Christian Kolberg, Katherine Tkaczuk, George Zahrah, Maria Gion, Herman Voss, Jane Meisel, Timothy Pluard, Jenny Fox, Mafalda Oliveira, Ursa Brown-Glaberman, Erica Stringer-Reasor, Luis Manso, Sherko Küemmel, Lin Chi Chen, Sheng Wu, Brandon Croft, Valentina Boni. Phase 1b/2 study of ladiratuzumab vedotin (LV) in combination with pembrolizumab for first-line treatment of triple-negative breast cancer (SGNLVA-002, trial in progress) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT1-03-06.

A Tale of 3 Tracers: Contrasting Uptake Patterns of 18F-Fluciclovine, 68Ga-PSMA, and 18F-FDG in the Uterus and Adnexa

ABSTRACT

A 41-year-old woman with invasive lobular carcinoma of the breast underwent sequential 68Ga-PSMA-11 PET/CT and 18F-fluciclovine PET/CT as part of an ongoing clinical trial (NCT04750473). 68Ga-PSMA PET/CT showed increased radiotracer uptake in the uterine endometrium and left adnexa. 18F-fluciclovine PET/CT showed increased radiotracer uptake in a leiomyomatous uterus. A clinical 18F-FDG PET/CT demonstrated radiotracer uptake in the endometrium and a circumferential area of uptake in the left adnexa, a pattern more similar to the 68Ga-PSMA uptake pattern. This case highlights the discordance in the uptake pattern of 2 radiotracers approved for prostate cancer imaging but increasingly used in non-prostate malignancies imaging.

Study Protocol: Efficacy and Safety of Radioembolization (REM) as an Early Modality (EM) Therapy for Metastatic Breast Cancer (BR) to the Liver with Y90 (REMEMBR Y90)

PURPOSE

The primary objective of the REMEMBR Y90 study is to evaluate the efficacy of Yttrium-90 (Y90) radioembolization in patients with breast cancer metastases to the liver as a 2nd or 3rd line treatment option with systemic therapy by assessing liver-specific and overall progression-free survival. Secondary objectives include quality of life, overall survival benefit, and toxicity in relation to patients' tumor biology.

MATERIALS AND METHODS

This trial is a multi-center, prospective, Phase 2, open-label, IRB-approved, randomized control trial in the final phases of activation. Eligible patients include those over 18 years of age with metastatic breast cancer to the liver with liver-only or liver-dominant disease, and history of tumor progression on 1-2 lines of chemotherapy. 60 patients will be randomized to radioembolization with chemotherapy versus chemotherapy alone. Permissible regimens include capecitabine, eribulin, vinorelbine, and gemcitabine within 2 weeks of enrollment for every patient. Patients receiving radioembolization will receive lobar or segmental treatment within 1-6 weeks of enrollment depending on their lesion. After final radioembolization, patients will receive clinical and imaging follow-up every 12-16 weeks for two years, including contrast-enhanced computed tomography or magnetic resonance imaging of the abdomen and whole-body positron emission tomography/computed tomography.

DISCUSSION

This study seeks to elucidate the clinical benefit and toxicity of Y90 in patients with metastatic breast cancer to the liver who are receiving minimal chemotherapy. Given previous data, it is anticipated that the use of Y90 and chemotherapy earlier in the metastatic disease course would improve survival outcomes and reduce toxicity.

LEVEL OF EVIDENCE

Level 1b, Randomized Controlled Trial.

TRIAL REGISTRATION NUMBER

NCT05315687 on clinicaltrials.gov.

Evaluating the Effectiveness of a Telehealth Cancer Genetics Program: A BRCA Pilot Study

INTRODUCTION

Ashkenazi Jewish (AJ) individuals face a 1 in 40 (2.5%) risk of having a BRCA mutation, which is 10 times the general population risk. JScreen launched the PEACH BRCA Study, a telehealth-based platform for BRCA education and testing, with the goal of creating an effective model for BRCA testing in low-risk AJ individuals who do not meet national testing criteria. Other goals were to determine the rate of BRCA mutations in this group, to assess the adequacy of screening for the 3 common AJ founder mutations only, and to assess satisfaction with the telehealth model to help inform a national launch of a broader cancer genetic testing program.

METHODS

Criteria for participation included those who were AJ, resided in the metro-Atlanta area, were aged 25 and older, and had no personal or close family history of BRCA-related cancers. Pre-test education was provided through a video and written summary, followed by complimentary BRCA1/2 sequencing and post-test genetic counseling. Participants responded to pre- and post-test surveys, which assessed knowledge and satisfaction. Those who were not eligible to participate were sent genetic counseling resources and later surveyed.

RESULTS

Five hundred one participants were tested and the results included 4 positives (0.8% positivity rate), 494 negatives, and 3 variants of uncertain significance. Overall satisfaction with the study process was high (96.9/100), knowledge about BRCA was high (97.5% of participants passed a pre-test knowledge quiz), and satisfaction with pre- and post-test education was high (97.9% of participants were satisfied with the pre-test video and written summary, and 99.5% felt that their post-test genetic counseling session was valuable). Many participants expressed interest in receiving broader cancer testing.

CONCLUSIONS

The BRCA founder mutation rate in a low-risk AJ population was significantly lower than the previously established AJ rate of 1 in 40. It was also determined that a telehealth model for a cancer genetics program is effective and acceptable to the population tested. This study established interest in broader cancer genetic testing through a telehealth platform and suggested that testing may be successful in the Jewish community at a national level and potentially in other populations, provided that patient education and genetic counseling are adequately incorporated.

Are we closer to being able to select patients with node-positive hormone receptor-positive breast cancer who can safely omit chemotherapy?

The treatment of hormone receptor-positive, HER2-negative breast cancer has become increasingly individualized, thanks to the development of genomic testing. Gene expression assays provide clinicians and patients with both prognostic and predictive information regarding breast cancer recurrence risk and potential benefit of chemotherapy. While the ability to tailor therapy based on clinicopathologic and genomic factors has enabled a growing number of women to forego chemotherapy, several questions remain regarding how best to apply genomic assay results across varying subgroups of women. Here, we review the role of genomic assays for patients with both lymph node-negative and lymph node-positive breast cancer, and how these assays may help us more precisely select patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2−) breast cancer with or without lymph node involvement who can safely omit chemotherapy in the future.

Abstract P5-13-29: Analytical and clinical validation of a ctDNA assay for detecting copy number loss and structural rearrangement variants contributing to homologous recombination and repair (HRR) deficiency

Background: Inactivating HRR gene mutations can lead to HRR deficiency (HRD) and predict response to PARPi therapy in patients with breast cancer. Copy number loss and large genomic rearrangements (LGR) can result in HRD but are challenging to detect in ctDNA. Here, we present the analytical validation of homozygous deletions, loss of heterozygosity (LoH) and LGR detection on the Guardant360 (G360) liquid biopsy panel, previously validated for detection of small variants, copy number amplifications, and fusions. We present real-world outcomes of BRCA1/2-mutant PARPi-treated patients to demonstrate the clinical validity of the detected variants. Methods: Analytical validation was performed using the G360 83-gene ctDNA panel. Cell line DNA and clinical patient cfDNA were titrated into matched normal cell line DNA or healthy donor cfDNA to establish the limit of detection (LoD) and precision for copy number loss and LGRs, respectively. Accuracy results were compared to those from an orthogonal, externally validated tissue and ctDNA panel. De-identified, longitudinal, claims data were linked to the cancer genomic profiles in Guardant INFORM, a clinical-genomics database. Advanced PARPi treated breast cancer patients with an inactivating or reversion BRCA1/2 mutation detected by G360 were assessed. Results: The analytical sensitivity (95% LoD) for detecting homozygous and LoH deletions for deletion sizes &gt;10MB was established at tumor fractions (TF) of 12.5% and 25%, respectively. The 95% LoD for LGRs was 0.2% variant allele fraction (VAF). The per-sample false positive rate for copy number loss and LGRs was &lt;0.5%. Prevalence of BRCA1/2 homozygous deletions, LoH and LGRs in &gt;1000 advanced breast cancer patients was 1.8%, 16.6% and 0.25% respectively, compared to 2.4%, 56.7% and 0.3% in TCGA. To verify the clinical impact of cfDNA-detected HRR alterations, overall survival was determined for PARPi-treated patients with &gt;1 BRCA1/2 germline or somatic SNV, indel or LGR reversion mutation to be 23.2 months [16.4, 30, CI, n=75] compared to 54.4 [28, NA, CI, n=14] months for BRCA1/2-mutant patients without a reversion (p-value=0.049). Conclusion:. This analytical validation demonstrates that G360 detection of inactivating mutations, including copy number loss and LGRs, is highly sensitive, reliable and robust. Real-world evidence analysis confirmed worse survival outcomes in PARPi treated patients harboring a BRCA1/2 reversion compared to BRCA1/2-mutant patients with no reversion. This data further supports ctDNA as a compelling non-invasive means to identify potential PARPi sensitizing and resistance mutations in patients with advanced breast cancer.

Citation Format: Jennifer Yen, Leylah Drusbosky, Caroline Weipert, Nicole Zhang, David Hanna, Catalin Barbacioru, Hao Wang, Alex Artyomenko, Arielle Yablonovitch, Yu Fu, Aaron Hardin, Nagesh Alla, Robert Foley, Max Maligska, Bhargavi Panchangam, Phil Yen, Jane Meisel, Neelima Vidula, Massimo Cristofanilli, Jeremy Force, Michael Dorschner, Martina Lefterova, Elena Helman, Becky Nagy, Darya Chudova, AmirAli Talasaz. Analytical and clinical validation of a ctDNA assay for detecting copy number loss and structural rearrangement variants contributing to homologous recombination and repair (HRR) deficiency [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-13-29.

Abstract P2-15-02: Using Oncotype DX Breast Recurrence Score® (RS) assay to define the role of neoadjuvant endocrine therapy (NET) in early-stage hormone receptor positive (HR+) breast cancer (BC)

Background:Adjuvant endocrine therapy remains the standard of care for patients (pts) with early stage, HR+ BC who can safely omit chemotherapy based on RS results; however, the role of NET remains unclear. There are limited data regarding the optimal duration of treatment with NET and the ideal patient (pt) population for NET in terms of age and RS result. This question rose to critical importance amidst the COVID-19 pandemic, during which NET was utilized more broadly in attempts to delay surgery or chemotherapy while preserving optimal pt outcomes. This study re-examines the use of NET among a cohort of pts with HR+ BC randomized to NET or neoadjuvant chemotherapy (NCT) based on RS (performed on initial core biopsy specimens).Methods:Data were pooled from two independent studies performed at Emory’s Winship Cancer Institute and Massey Cancer Center at Virginia Commonwealth University (VCU) from 2010-2012. These studies evaluated rates of clinical and pathologic complete response (pCR) among pts with early stage, HR+ BC assigned to treatment groups based on RS results. Pts with RS 0-10 received NET (Group (Grp) A), RS 11-24/25 (Emory 11-24 vs VCU 11-25) were randomized to NET (Grp B) or NCT (Grp C), and those with RS 25/26-100 received NCT (Grp D). Associations between RS result, neoadjuvant therapy and pCR in the breast, lymph nodes (LN) and breast plus LN were evaluated using Fisher’s exact test. Results:109 pts were included in this analysis. The Emory cohort was younger (median age 56 years (yrs) vs 63 yrs in VCU cohort) and more diverse (37.5% African American (AA) vs 18.6% AA in VCU cohort). The pts were predominantly post-menopausal (69.6% Emory vs 83.1% VCU). Nodal status among the Emory cohort was evenly divided with 50% N0 and 50% N+, while the majority of VCU pts were N0 (76.3% N0 vs 22.0% N+). Pts were grouped based on RS result: RS &lt;11 (18% Emory vs 20.3% VCU), RS 11-24/25 (36% Emory vs 55.9% VCU) and RS 24/25 or higher (46% Emory vs 23.7% VCU). Pts with low RS result were older (median 64 yrs vs 59 yrs among RS &gt; 24/25) with higher percentage of low-grade tumors (47.6% grade 1 vs 5.4% grade 1 among RS &gt;24/25). With regard to pCR, there were no significant differences among pts with low or intermediate RS results, as no pts in these groups achieved pCR in the breast or breast + LN (Table). Pts with RS result 25/26-100 (Grp D) were the only pts shown to achieve pCR in breast + LN (18.9%, p= 0.0043 across groups). Notably, while pts on the Emory study received longer courses of NET (median 10 months vs 5.5 months), there were no significant differences in pCR across RS result subgroups noted between the two institutions. Conclusion:Our results demonstrate that the use of Oncotype DX Breast Recurrence Score® or other genomic assays in the neoadjuvant setting may help guide treatment decisions when considering the use of NET versus NCT. Pt age and length of endocrine therapy as well as pt preferences should be considered when determining neoadjuvant treatment plans. There are currently ongoing studies evaluating the use of NET with CDK4/6 inhibitors that will offer further insight into optimal neoadjuvant treatment strategies in HR+ BC. Subsequent phase III evaluation of the role of genomic assays in the neoadjuvant setting is feasible and may help determine whether NET + CDK 4/6 inhibitors could replace NCT for pts with higher RS values.

Table: pCR according to treatment groups (All Eligible Patients)VariableGroup A (N=21)Group B (N=23)Group C (N=22)Group D (N=37)P value (a)pCR Breast0 (0.0%)0 (0.0%)0 (0.0%)8 (21.6%)0.0016pCR Nodes0 (0.0%)1 (4.3%)3 (13.6%)2 (5.6%)0.2977pCR Breast + Nodes0 (0.0%)0 (0.0%)0 (0.0%)7 (18.9%)0.0043(a) Fisher's exact test was used for categorical variables with cell counts &lt;5.Note: Group A= Recurrence Score &lt;11,Group B= Recurrence Score 11-24 (Emory study) or 11-25 (VCUstudy) receiving NET,Group C= Recurrence Score 11-24 (Emory study) or 11-25 (VCUstudy) receiving NCT,and Group D= Recurrence Score &gt;24 (Emory study) or &gt;25 (VCUstudy).Note: 1 patient did not receive SLNB(sentinel lymph node biopsy) or ALND (axillary lymph node dissection) and is excluded from the denominator for pCR Nodes.

Citation Format: Caitlin Taylor, Aimee Foreman, Christy Russell, Dipankar Bandyopdhyay, Xiaoyan Deng, Lisa Floyd, Amelia Zelnak, Ruth O'Regan, Harry Bear, Jane Meisel. Using Oncotype DX Breast Recurrence Score® (RS) assay to define the role of neoadjuvant endocrine therapy (NET) in early-stage hormone receptor positive (HR+) breast cancer (BC) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-15-02.

Molecular Classification of Triple Negative Breast Cancer and the Emergence of Targeted Therapies

Triple negative breast cancer (TNBC) represents 15% to 20% of all primary breast cancers and is the most aggressive subtype of breast cancer. There has been rapid progress in targeted therapy and biomarker development to identify the optimal treatments for TNBC. To update recent developments, this article comprehensively reviews molecular classification and biomarkers of TNBC and targeted therapy developments in immunotherapy, PARP and AKT pathway inhibitors, antibody-drug conjugates and androgen receptor blockade. The treatment of TNBC has dramatically evolved beyond basic cytotoxic chemotherapy into an expanding domain of targeted therapies tailored to the heterogeneity of this complex and aggressive disease. Progress will continue through the sustained and devoted efforts of our investigators and the patients who dedicatedly enroll in clinical trials. Through a daring persistence to challenge the status quo we now have the opportunity to offer our patients with TNBC a new sense of hope.

Folate Receptor Alpha Is Preferentially Expressed in the Carcinoma Component of Endometrial Carcinosarcomas: A Potential Target for Adjuvant Therapy

Carcinosarcomas (CSs) of the endometrium are biphasic malignancies, composed of high-grade carcinomatous and sarcomatous components. Surgical stage and pathologic characteristics are the most important prognostic findings, with a 5-yr survival of 15% to 30% in advance stage disease. Folate receptor alpha (FRA) overexpression has been observed in endometrial carcinomas and not yet studied in CSs. This study evaluates semiquantitative expression of FRA in both carcinomatous and sarcomatous components of CSs on whole tissue sections. Immunohistochemistry for FRA expression was performed and extent and intensity of staining were recorded for each case for both histologic components. A total of 46 cases were stained for FRA. The majority of these (40/46, 87%) showed FRA staining at variable intensity in the carcinomatous component, stronger in serous carcinomas and high-grade endometrioid, while only a small subset of tumors demonstrated weak staining in the sarcomatous component (2/46, 4.35%). CS is known to be associated with poor prognosis and adjuvant therapy is recommended even in low stage disease. Serous and high-grade endometrioid carcinomas are the most common carcinomatous components of CSs and are known to show consistently high FRA expression. Folate plays a role in tumor cell migration and loss of cellular adhesion, which are key steps in epithelial-mesenchymal transition, the process by which CS develops from carcinoma cells. Our study shows expression of FRA in the carcinomatous component of almost all CS cases (87%), further favoring FRA as a target for adjuvant treatment. While expression of FRA in the sarcomatous component was rarely observed, the carcinomatous component being associated with metastatic potential underscores the importance of anti-FRA therapy for systemic disease control.

Correlates of financial toxicity in adult cancer patients and their informal caregivers

BACKGROUND

Financial toxicity is commonly reported by cancer patients, but few studies have assessed caregiver perceptions. We aimed to validate the modified Comprehensive Score for Financial Toxicity (COST) in cancer caregivers, identify factors associated with financial toxicity in both patients and caregivers, and assess the association of caregiver financial toxicity with patient and caregiver outcomes.

METHODS

Using a convenience sampling method, 100 dyads of adult cancer patients and a primary caregiver visiting outpatient oncology clinics (Jan-Sep 2019) were recruited. We assessed the internal consistency and convergent and divergent validity of the modified COST. Multivariable analyses identified correlates of financial toxicity. Association of financial toxicity with care non-adherence, lifestyle-altering behaviors (e.g., home refinance/sale, retirement/saving account withdrawal), and quality of life (QOL) was investigated.

RESULTS

Recruited patient vs. caregiver characteristics were as follows: mean age: 60.6 vs. 56.5; 34% vs. 46.4% female; 79% vs. 81.4% white. The caregiver COST measure demonstrated high internal consistency (Cronbach α = 0.91). In patients, older age (B, 0.3 [95% CI, 0.1-0.4]) and higher annual household income (B, 14.3 [95% CI, 9.3-19.4]) correlated with lower financial toxicity (P < 0.05). In caregivers, lower patient financial toxicity (B, 0.4 [95% CI, 0.2-0.6]) and cancer stages 1-3 (compared to stage 4) (B, 4.6 [95% CI, 0.4-8.8]) correlated with lower financial toxicity (P < 0.05). Increased caregiver financial toxicity correlated with higher care non-adherence in patients, increased lifestyle-altering behaviors, and lower QOL in patients and caregivers (P < 0.05).

CONCLUSION

The COST measure can also be used to assess caregiver financial toxicity. Caregivers' financial toxicity was associated with negative outcomes for both dyad members.

Evaluation of PD-L1, tumor-infiltrating lymphocytes, and CD8+ and FOXP3+ immune cells in HER2-positive breast cancer treated with neoadjuvant therapies

BACKGROUND

The tumor immune microenvironment plays a critical role in the prognosis and outcome of breast cancers. This study examined the role of tumor-infiltrating lymphocytes (TILs), CD8+, FOXP3+ lymphocytes, PD-L1 expression, and other clinicopathological parameters in HER2+ breast cancer and correlate with tumor response to neoadjuvant therapy.

METHODS

We included 173 HER2+ patients treated with neoadjuvant HER2-targeted chemotherapy regimens from 2010 to 2016. 67 cases had biopsy blocks to evaluate TIL, CD8, FOXP3, and PD-L1 immunohistochemistry staining. Tumors were classified as pCR vs non-pCR group. Clinicopathological parameters, TIL, CD8+ and FOXP3+ cell count, and PD-L1 expression were correlated with pCR rate.

RESULTS

Univariate analyses showed that pCR rate was significantly correlated with low PR, low ER, high Ki-67, high FOXP3, HER2 IHC3+ , high HER2 ratio and copy number. By multivariate analysis, Ki-67 was the only variable significantly correlated with pCR. PD-L1 expression was detected in 9.2% cases. TIL hotspot has a non-significant correlation with pCR rate (p = 0.096).

CONCLUSIONS

High Ki-67 is a strong predictor for pCR in HER2+ breast cancer. TIL and FOXP3 T cells may play a role in tumor response in HER2+ cancer. PD-L1 is expressed in a subset of HER2+ breast cancer, supporting a role of immunotherapy in treating a subset of HER2+ breast cancers. The role of PD-L1, TIL, and other markers of immunogenicity as predictors of response to neoadjuvant chemotherapy in HER2+ breast cancer should be further evaluated.

A Big World Made Small: Using Social Media to Optimize Patient Care

Emerging modalities of communication have transformed the landscape of information dissemination particularly in the context of health care. Within oncology, stakeholders in all roles have formed both role-specific and multidisciplinary communities within the modalities of social media. Two platforms with particularly high adoption and penetration within oncologic practice for clinicians and general oncologic care as well as for patients and the community have been Facebook and Twitter. On both platforms, patients have come together to form disease-specific (or even mutation-specific) groups ripe with discussion on all aspects of their cancer, including disease and treatment symptoms, novel therapeutics, and clinical trial participation. Similarly, clinicians have united within professional communities to facilitate collaboration and community building in this rapidly changing medical practice landscape. Here, we investigate the current state of stakeholder engagement within social media and review strategies and platforms to maximize the impact of social media for patients and clinicians.

Validation of the newly proposed American Joint Committee on Cancer (AJCC) breast cancer prognostic staging group and proposing a new staging system using the National Cancer Database

BACKGROUND

The eighth edition of AJCC cancer staging manual incorporated biomarker status into the prognostic staging group (PSG). We used data from National Cancer Database (NCDB) to validate and improve the PSG.

METHODS

All patients had surgery and at least some systemic treatment (endocrine therapy, chemotherapy or HER2 targeted therapy). Information from 420,520 patients was assessed for potential predictors of overall survival (OS), including age at diagnosis (age), tumor grade (G), hormonal receptor and HER2 status, and presence of lymph vascular invasion (LVI), stratified by stage or sub-stages. Based on the multivariate Cox analyses, we built different point systems to predict OS and evaluated the different point systems by Akaike's information criterion (AIC), Harrell's concordance index (C-index), and Uno's concordance index.

RESULTS

Age, G, hormonal receptor and HER2 status, LVI and being TNBC were significantly associated with OS (all P < 0.0001). Three staging systems were correlated with OS: system 1 was the conventional anatomic TNM staging; system 2 included TNM, age, G, hormonal receptor, HER2, and LVI; system 3 included TNM, age, G, TNBC versus non-TNBC, and LVI. System 3 (C-index; 0.7316; AIC: 488138.91) achieved the best balance between predictive performance and goodness-of-fit to the NCDB data as compared to system 2 (C-index: 0.7325; AIC: 498087.73) and system 1 (C-index: 0.716; AIC: 688536.49).

CONCLUSIONS

The new PSG is a better staging system than the conventional anatomic TNM system. Grouping breast cancer into TNBC versus non-TNBC may be simpler while retaining similar accuracy as using ER/PR/HER2 status to predict OS.

Evaluation of Prognosis in Hormone Receptor-Positive/HER2-Negative and Lymph Node-Negative Breast Cancer With Low Oncotype DX Recurrence Score

INTRODUCTION

Hormone receptor-positive/human epidermal growth factor receptor 2 (HER2)-negative breast cancers without lymph node metastasis have good prognosis. We compared the prognosis of hormone receptor-positive, HER2-negative, lymph node-negative cancers with Oncotype DX score ranges of 1 to 10 (1-10 group) and 11 to < 18 (11-18 group).

PATIENTS AND METHODS

A total of 107 cases in the 1-10 group and 225 cases in the 11-18 group were reviewed. All patients received surgery. The use of chemotherapy, radiotherapy, and endocrine therapy, and overall survival (OS), disease-free survival (DFS), and distant metastasis were compared between groups.

RESULTS

There were no statistical differences in the use of chemotherapy (5.05% vs. 6.05%, P = .724) or radiotherapy (52.53% vs. 59.07%, P = .276) between the 1-10 group and the 11-18 group, respectively. The median OS and DFS were 47 and 45 months, respectively, in the 1-10 group, and 49 and 48 months in the 11-18 group. No significant difference was seen in OS (P = .995), DFS (P = .148), or rates of metastasis (P = .998). The 11-18 group had more death events and distant metastasis (death, 5 events; recurrence, 2 events; metastasis, 2 events) than the 1-10 group (death, 0 events; recurrence, 4 events; metastasis, 0 events). The majority of recurrences seen in both groups were in young patients who failed to comply with their endocrine therapy regimen.

CONCLUSION

Patients in both the 1-10 group and the 11-18 group had good prognoses. Those who experienced recurrence were more likely to be premenopausal and to have failed to comply with the recommended endocrine therapy regimen. Endocrine therapy remains important in these patients.

Abstract P6-16-03: Phase 2 trial of everolimus and/or trastuzumab in hormone refractory, hormone receptor (HR)-positive, HER2-normal metastatic breast cancer (MBC)

Background: Increased signaling through growth factor pathways including PI3K/Akt/mTOR and HER2 have been implicated in hormone resistance. Everolimus (EVE) improves outcomes when added to endocrine therapy for patients with HR-positive MBC. This study evaluated the efficacy of everolimus (EVE) and trastuzumab (TRAS) in hormone refractory HER2-normal metastatic breast cancer.

Methods: Eligible patients had HR-positive, HER2/neu-negative (IHC +1 or +2, HER2-non-amplified) MBC that had progressed within 6 months of the most recent endocrine therapy. Patients continued on the most recent endocrine therapy they received and were randomized to receive EVE 10 mg oral daily or TRAS IV (8 mg/kg loading dose followed by 6 mg/kg every 3 weeks). At progression, the other agent was added (TRAS in the EVE arm and EVE in the TRAS arm). Patients were followed until disease progression or death.

Results: 54 eligible patients were included in the analysis, and were randomized to EVE (n=30) or TRAS (n=24). 33% of patients were on fulvestrant, 31% exemestane, 22% tamoxifen and 7% letrozole, which were continued. The median PFS was 5.7 months for EVE vs. 2 months for TRAS until first progression or death with hazard ratio of 0.45 (95% CI 0.25-0.81, p=0.008). Among 48 patients who had disease progression, EVE was added to 16 patients who were originally treated by TRAS, and TRAS was added to 12 patients who were originally treated by EVE; the median time to the second progression was 6.3 months for the arm where EVE was added vs. 3.1 months in the arm where TRAS was added. Three patients were taken off study due to decrease in ejection fraction.

Conclusions: This trial demonstrates the efficacy of EVE alone or in combination with TRAS in patients with hormone refractory HR-positive, HER2-negative metastatic breast cancer, who remained on the endocrine therapy they had experienced disease progression on. This suggests that mTOR inhibition has the potential of restoring sensitivity to endocrine therapy and potentially allows the re-use of endocrine agents. Updated results and correlative studies will be presented. Clinical trial information: NCT00912340.

Citation Format: Paplomata E, Gogineni K, Meisel J, Santa-Maria C, Yuan L, Kramer J, Bill Li X, Zelnak A, Pakkala S, Kaklamani V, O'Regan R. Phase 2 trial of everolimus and/or trastuzumab in hormone refractory, hormone receptor (HR)-positive, HER2-normal metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-03.

Wilms' tumor of the ovary

Extrarenal Wilms' tumor of the ovary is a very rare tumor likely derived from embryonic mesonephros. We present the first reported case of a teratoid extrarenal Wilms' tumor of the ovary with a short review of the existing literature. In the case, a 26-year-old woman presented with back pain and was found to have a dermoid cyst; three years later, she presented again, now pregnant, with severe abdominal pain. She was diagnosed with an immature teratoma consisting of a Wilms' tumor (immature component) arising within a mature teratoma and treated exclusively with surgery and surveillance. The recovery from surgery was uneventful and the patient remains without evidence of disease with eleven months of follow-up.

Clinical evaluation of a new intracranial pressure monitoring device

BACKGROUND

Continuous monitoring of intracranial pressure (ICP) still plays a key role in the management of patients at risk from intracranial hypertension. Numerous ICP-measuring devices are available. The aim of the present study was to investigate the clinical characteristics and the magnetic resonance imaging (MRI) compatibility of the recently developed Neurovent-P(REHAU AG+CO, REHAU, Germany) ICP monitoring device.

METHOD

In a prospective two-center study, a total of 98 patients with severe head injury, subarachnoid haemorrhage, intracerebral haemorrhage, and non-traumatic brain edema underwent intraparenchymal monitoring of ICP using the Neurovent-P. A control group comprising 50 patients underwent implantation of the Camino-OLM-110-4B ICP monitor. The zero drift of the probes was determined before and after the ICP recording period. Technical and medical complications were documented. The MRI compatibility of the Neurovent-P ICP probe was investigated by evaluating artifacts caused by the probe, probe function and temperature changes during MRI, and probe movement caused by the magnetic field.

FINDINGS

The mean zero drift was 0.2+/-0.41 mmHg (maximum 3 mmHg) for the Neurovent-P ICP probes and 0.4+/-0.57 mmHg (maximum 12 mmHg) for the Camino-OLM-110-4B ICP probes. No significant correlation was identified between the extent of zero drift following the removal of the probes and the length of monitoring. Intraparenchymal haemorrhage spatially related to the probe occurred in 1 out of 50 (2%) patients with a Camino-OLM-110-4B probe and in 1 out of 98 (1%) with a Neurovent-P. Damage of the probe due to kinking or overextension of the cable or glass fiber occurred in 4 of the 50 (8%) Camino-OLM-110-4B ICP probes and in 5 of the 98 (5%) Neurovent-P probes. On T2-weighted MR images, the Neurovent-P ICP probe induced only small artifacts with very good discrimination of the surrounding tissue. On T1-weighted MR images, there was a good imaging quality but artifact-related local disturbances in signal occurred. There was no temperature change in the Neurovent-P probe and in the surrounding brain tissue during MR imaging.

INTERPRETATION

The Neurovent-P ICP measuring system is a safe and reliable tool for ICP monitoring. Handling of the Neurovent-P system is safe when performed properly.

Temporary cardiac asystolia induced by intraoperative irritation of the eighth right sided anterior cervical nerve root

BACKGROUND

The 60 year old women with no prior history of arrhythmia or other cardiac symptoms was operated on for a cervical disc herniation at the level C7/D1. The C8 nerve root was visualized via a posterior approach.

FINDINGS

Removal of the sequestrum and irritation of the anterior root with surgical instruments triggered cardiac arrest.

INTERPRETATION

We offer the opinion that irritation of the anterior root led to diminished activity of the supraspinal sympathetic control system and consecutive hyper-activation of the parasympathetic system.

Concepts and data model for a co-operative neurovascular database

BACKGROUND

Problems of clinical management of neurovascular diseases are very complex. This is caused by the chronic character of the diseases, a long history of symptoms and diverse treatments. If patients are to benefit from treatment, then treatment decisions have to rely on reliable and accurate knowledge of the natural history of the disease and the various treatments.

METHODS

Recent developments in statistical methodology and experience from electronic patient records are used to establish an information infrastructure based on a centralized register.

RESULTS

A protocol to collect data on neurovascular diseases with technical as well as logistical aspects of implementing a database for neurovascular diseases are described. The database is designed as a co-operative tool of audit and research available to co-operating centres.

CONCLUSION

When a database is linked to a systematic patient follow-up, it can be used to study prognosis. Careful analysis of patient outcome is valuable for decision-making.

Associated Cerebral And Spinal AVM in Infant and Adult. Report of Two Cases Treated by Endovascular Approach

SUMMARY

We report two cases of a rare association of brain and spinal arteriovenous malformation (AVM) in an infant and in an adult. Both patients were embolised with glue with good clinical and morphological results. The first patient is an infant with a suspected family history of Rendu Osler Weber disease with multiple AVMs : two hemispheric cerebellar lesions (one of them revealed by a ventricular haemorrhage) and one cervical spinal cord AVM (SCAVM). The associated SCAVM fortuitously bled one month after treatment of the symptomatic cerebellar AV shunt. In the adult case, the management first involved a symptomatic SCAVM with favourable outcome; the cerebral AVM bled secondarily and was then excluded by endovascular approach.

Demographic, morphological, and clinical characteristics of 1289 patients with brain arteriovenous malformation

BACKGROUND AND PURPOSE

The purpose of this study was to assess demographic, clinical, and morphological characteristics of patients with brain arteriovenous malformations (AVMs).

METHODS

Prospectively collected data of 1289 consecutive AVM patients from 3 independent databases (1 multicenter [Berlin/Paris/Middle and Far East, n=662] and 2 single centers [New York, n=337, and Toronto, n=290]) were analyzed. The variables assessed were age at diagnosis, sex, AVM size, AVM drainage pattern, AVM location in functionally important brain areas ("eloquence"), and type of presentation (hemorrhage, seizure, chronic headache, or focal neurologic deficit). Comparisons were made by ANOVA, contingency tables, and log-linear models.

RESULTS

Overall, mean age at diagnosis was 31.2 years (95% CI 30.2 to 32.2 years), and 45% of the patients were female (95% CI 42% to 47%). AVM maximum diameter was <3 cm in 38% (95% CI 35% to 41%). Deep venous drainage was present in 55% (95% CI 52% to 59%). An eloquent AVM location was described in 71% (95% CI 69% to 74%). AVM hemorrhage occurred in 53% (95% CI 51% to 56%). Generalized or focal seizures were described in 30% (95% CI 27% to 33%) and 10% (95% CI 8% to 12%), respectively. Chronic headache was recorded in 14% (95% CI 12% to 16%). Persistent neurological deficits were found in 7% (95% CI 6% to 9%), and progressive neurological deficits in 5% (95% CI 4% to 6%). Significant differences between centers were found for age (P<0.001), sex (P=0.04), eloquence (P=0.04), size (P<0.001), hemorrhage (P=0.006), persistent neurological deficit (P<0.001), and reversible neurological deficit (P=0.013). The intercenter difference found for hemorrhage frequency did not remain after adjustment for AVM size.

CONCLUSIONS

Baseline characteristics differed considerably between centers. The differences found in patient age and AVM size may be explained by center-specific referral patterns and the influence of access to treatment resources, whereas those found for other characteristics may be attributable to center-specific definitions. Analysis of natural history data from tertiary referral center databases may be improved by consistent definitions applicable to the entire population of AVM patients.

Factors associated with intracranial hemorrhage in cases of cerebral arteriovenous malformation

OBJECTIVE

The standard categorization of arteriovenous malformations (AVMs) involves the Spetzler-Martin grading system, which uses a simple analysis of size, location (superficial or deep), and the presence of deep or superficial drainage. Hemodynamic risk factors are also thought to play important roles in the pathogenesis of these lesions and to be associated with the intracranial hemorrhage (ICH) rate. The actual hemodynamic factors for AVMs cannot be easily measured, but angioarchitectural features can be assessed and used as surrogate parameters.

METHODS

The AVM angioarchitectural features for 662 patients were analyzed, and their associations with ICH as a presenting sign were studied. A cross-sectional analysis was used to qualify the strength of associations among clinical features, angioarchitectural characteristics, and ICH before treatment.

RESULTS

The multivariate analysis indicated that arterial stenosis and arterial ectasia were associated with lower ICH rates, whereas venous stenosis increased the rate of ICH. The presence of angiogenesis modified the effects of arterial and venous stenosis. Furthermore, the effect of venous stenosis depended on the location of the nidus. The presented data do not support a direct positive association between associated aneurysms and ICH.

CONCLUSION

Certain angiographic features seem to have prognostic potential with respect to the occurrence of ICH among patients with AVMs. A discriminatory prognostic index is proposed; its relevance must be proven in a future prospective study.

[Therapy of cerebral arteriovenous malformations]

The rapid development of modern endovascular, microsurgical, and radiation therapies has considerably expanded the treatment options for encephalic arteriovenous malformations (AVMs). Surgery has the longest history. Single or staged intravascular procedures (embolizations) using fast-acting glues, sclerotic agents, and thrombogenic coils serve to reduce the size of AVM to that suitable for extirpation and may reduce the risk of surgery. Radiation ("gamma-knife") therapy, most frequently used in small, non-operable AVMs, is also viewed by some authors as an alternative or even superior tool in small, operable malformations. Partial embolization to reduce the mass-effect of space-occupying AVMs, to reverse diaschisis, and to treat AVM-related seizure disorders is being discussed and practiced. Given the in part competing or even controversial options, the selection of optimal treatment for AVM patients is becoming increasingly difficult. Current management is impeded by the paucity of information on the exact risks of invasive therapies and by insufficient criteria for identifying patients at risk of spontaneous bleeding during the natural course, including the seriousness of such hemorrhage.

De Novo Appearance of Three Cavernomas in an Infant with Dural AV Shunts. Case Report

SUMMARY

Cavernomas of the brain and spinal cord are malformations which are generally considered congenital and often found in young adults. Although the distinction of a sporadic and a hereditary type is discussed, the natural history is still poorly understood. We present the unusual case of an infant first submitted to CT scan, MRI and MR-angiography at the age of three months, revealing multiple AV shunts of the superior sagittal and the sigmoid sinus, with a small pial supply. A second angiogram at the age of six months showed an additional parietal pial AVM. At this time, partial embolisation of the dural AV shunts was performed. At the age of three, the child was restudied by MRI and three formerly invisible cavernomas were detected.

A capitated model for a cross-section of severely mentally ill clients: hospitalization

Hospitalization outcomes are examined in a three year random assignment controlled study of two capitated Integrated Service Agencies (ISAs) in California. Study participants were a cross-section of severely mentally ill clients. Using the flexibility of capitated funding, the urban ISA reduced inpatient length of stay and days, but not admissions. Elements of the capitated ISA model worked together to produce clinically appropriate and less costly use of inpatient services. At the rural ISA, admissions were reduced substantially during the first two years of the demonstration but not costs.

A capitated model for a cross-section of severely mentally ill clients: employment outcomes

Employment outcomes are examined in a three year controlled study of two Integrated Service Agencies (ISAs) for a cross-section of severely mentally ill clients. At each site significantly more ISA members than comparison clients obtained some paid employment. At the urban site the difference was dramatic: 73 vs 15 percent worked during the study period, and 29 percent of the ISA clients worked competitively. The significant but still limited ISA results argue for increased employment opportunities for all seriously mentally ill clients.

Mental health costs, other public costs, and family burden among mental health clients in capitated integrated service agencies

This article explores the cost implications of the capitated integrated service agency (ISA) model for persons with severe and persistent mental illness. Two demonstration sites in California were chosen for a randomized comparison between an ISA model and usual care under the existing county service system. Each ISA demonstration program assumed fiscal and service responsibility for approximately 100 clients. Cost information was collected during a 3-year study period. The capitated ISAs reduced the previously skewed distribution of resources to clients and reduced family economic burden (in one site). However, they did not reduce law enforcement, health, and other nontreatment public costs. Although capitated funding enabled programmatic effectiveness and the shifting of services toward rehabilitation, it did not itself ensure such results.

Client outcomes in a three-year controlled study of an integrated service agency model

OBJECTIVE

In a three-year controlled study, two California integrated service agency demonstration programs that combined structural and program reforms were tested to see if they produced improved outcomes for a cross-section of clients with severe and persistent mental illness.

METHODS

Clients at an urban site and a rural site were randomly assigned to an integrated service agency program or to a comparison group who received the usual services. Data on client outcomes, were drawn from databases and client and family interviews.

RESULTS

Compared with the comparison groups, clients served by the integrated service agencies had less hospital care, greater workforce participation, fewer group and institutional housing arrangements, less use of conservatorship, greater social support, more leisure activity, less family burden, and greater client and family satisfaction. Clients in the urban demonstration program, but not those in the rural program, did better than the comparison group on measures of financial stability, personal well-being, and friendship. At the urban site, 72.6 percent of clients participated in the work force during the three-year study period, compared with 14.6 percent of the clients in the comparison group. No differences were found at either site in rates of arrest and conviction and in self-reported ratings of self-esteem, symptoms, medication compliance, homelessness, and criminal victimization. The capitated costs for demonstration clients were much higher than the costs for services used by comparison clients.

CONCLUSIONS

Three-year outcomes for a cross-section of clients with severe mental illness in the integrated service agencies were broadly favorable, but costs of services for those clients were high relative to costs for clients receiving the current standard of care.

Client outcomes in two model capitated integrated service agencies

OBJECTIVE

Client outcomes for the first year of a three-year study were measured in two integrated service agencies (ISAs) for severely mentally ill persons to test the effectiveness of a model combining financing reform (consolidated funding and capitation) with an assertive continuous treatment team approach.

METHODS

Clients referred to pilot ISAs at an urban and a rural site in California were randomly assigned to the ISA programs or to comparison groups receiving usual services. Objective data from clients' records as well as subjective information from interviews were compared.

RESULTS

At both sites, demonstration clients' participation in the work force was significantly higher than that of the comparison groups. At the urban ISA, clients' participation in the work force rose from a baseline rate of 11 percent to 36 percent. Both ISAs decreased use of hospital care, particularly the rural ISA, which reduced admissions from a baseline rate of 40 percent to 21 percent in the study year. Both ISAs retained clients in treatment with significantly more success than did comparison programs, and urban ISA clients reported participating in more leisure and social activities than did clients in the comparison group. No differences were found at either site in rates of long-term hospitalization, arrest, or conviction or in measures of self-esteem, symptomatology, substance use, homelessness, or quality of life.

CONCLUSIONS

After 12 months of a 36-month program, demonstration clients spent less time in hospitals, were more likely to have worked for pay, and were more likely to have remained in treatment.

Heme-dependent catalase activity of lactobacilli

The heme-dependent catalase in Lactobacillus pentosus, L. sake, L. delbrueckii and Enterococcus faecalis was studied. The catalase was formed by cells grown aerobically in the presence of hematin or for lactobacilli when grown without added hematin, after incubation of buffered cells in the presence of hematin. The kinetics of the production of catalase revealed maximum activity for L. pentosus and E. faecalis at late stationary and late logarithmic growth phase, respectively. The physiological role of catalase was studied with L. sake. The presence of hematin allows higher growth yields, since it protects the cells against hydrogen peroxide formed endogenously up to concentrations of 4.6 mmol/l.