Exploring the infectious contribution to intussusception causality using the effects of COVID-19 lockdowns in Australia: An ecological study

INTRODUCTION

Intussusception is the primary cause of acute bowel obstruction in infants. The majority of cases under 2 years of age are classed as idiopathic with viral infection implicated as one of the causes. COVID-19 public health measures led to significant decreases in communicable disease prevalence. During these times, reductions in intussusception frequency were reported - reductions greater than would be expected with our previous understanding of its infectious aetiology.

METHODS

We conducted a retrospective, multi-state, ecological study over a twelve-year period. Monthly case numbers of ICD-10-AM K56.1 'Intussusception' coded admissions were acquired from state-wide admissions datasets from New South Wales (NSW), Victoria and Queensland, representing 77.62% of the eligible Australian population. These counts within differing jurisdictional lockdowns were compared to non-lockdown periods in order to investigate a correlation between intussusception frequency and lockdown periods.

RESULTS

We found a negative association between intussusception frequency and lockdown periods in both eligible states. The largest reductions were seen in the under 2 year age groups with Victoria experiencing a 62.7% reduction (Rate ratio (RR) = 0.37, p < 0.0001) and NSW a 40.1% reduction (RR = 0.599, p = 0.006) during lockdown times. Controls for variations in lockdown restrictions between both regional and metropolitan areas also showed expected decreases.

CONCLUSION

Our ecological study demonstrates significant decreases in the frequency of paediatric intussusception admissions during the COVID-19 lockdown periods. The unexpected magnitude of the reductions suggests that the true proportion of infectious disease-caused idiopathic intussusception is greatly underestimated.

Rotavirus genotypes in children under five years hospitalized with diarrhea in low and middle-income countries: Results from the WHO-coordinated Global Rotavirus Surveillance Network

Rotavirus is the most common pathogen causing pediatric diarrhea and an important cause of morbidity and mortality in low- and middle-income countries. Previous evidence suggests that the introduction of rotavirus vaccines in national immunization schedules resulted in dramatic declines in disease burden but may also be changing the rotavirus genetic landscape and driving the emergence of new genotypes. We report genotype data of more than 16,000 rotavirus isolates from 40 countries participating in the Global Rotavirus Surveillance Network. Data from a convenience sample of children under five years of age hospitalized with acute watery diarrhea who tested positive for rotavirus were included. Country results were weighted by their estimated rotavirus disease burden to estimate regional genotype distributions. Globally, the most frequent genotypes identified after weighting were G1P[8] (31%), G1P[6] (8%) and G3P[8] (8%). Genotypes varied across WHO Regions and between countries that had and had not introduced rotavirus vaccine. G1P[8] was less frequent among African (36 vs 20%) and European (33 vs 8%) countries that had introduced rotavirus vaccines as compared to countries that had not introduced. Our results describe differences in the distribution of the most common rotavirus genotypes in children with diarrhea in low- and middle-income countries. G1P[8] was less frequent in countries that had introduced the rotavirus vaccine while different strains are emerging or re-emerging in different regions.

Cardiac safety of dual anti-HER2 blockade with pertuzumab plus trastuzumab in early HER2-positive breast cancer in the APHINITY trial

BACKGROUND

Trastuzumab increases the incidence of cardiac events (CEs) in patients with breast cancer (BC). Dual blockade with pertuzumab (P) and trastuzumab (T) improves BC outcomes and is the standard of care for high-risk human epidermal growth factor receptor 2 (HER2)-positive early BC patients. We analyzed the cardiac safety of P and T in the phase III APHINITY trial.

PATIENTS AND METHODS

Left ventricular ejection fraction (LVEF) ≥ 55% was required at study entry. LVEF assessment was carried out every 3 months during treatment, every 6 months up to month 36, and yearly up to 10 years. Primary CE was defined as heart failure class III/IV and a significant decrease in LVEF (defined as ≥10% from baseline and to <50%), or cardiac death. Secondary CE was defined as a confirmed significant decrease in LVEF, or CEs confirmed by the cardiac advisory board.

RESULTS

The safety analysis population consisted of 4769 patients. With 74 months of median follow-up, CEs were observed in 159 patients (3.3%): 83 (3.5%) in P + T and 76 (3.2%) in T arms, respectively. Most CEs occurred during anti-HER2 therapy (123; 77.4%) and were asymptomatic or mildly symptomatic decreases in LVEF (133; 83.6%). There were two cardiac deaths in each arm (0.1%). Cardiac risk factors indicated were age > 65 years, body mass index ≥ 25 kg/m², baseline LVEF between 55% and <60%, and use of an anthracycline-containing chemotherapy regimen. Acute recovery from a CE based on subsequent LVEF values was observed in 127/155 patients (81.9%).

CONCLUSIONS

Dual blockade with P + T does not increase the risk of CEs compared with T alone. The use of anthracycline-based chemotherapy increases the risk of a CE; hence, non-anthracycline chemotherapy may be considered, particularly in patients with cardiovascular risk factors.

Aetiology and incidence of diarrhoea requiring hospitalisation in children under 5 years of age in 28 low-income and middle-income countries: findings from the Global Pediatric Diarrhea Surveillance network

INTRODUCTION

Diarrhoea remains a leading cause of child morbidity and mortality. Systematically collected and analysed data on the aetiology of hospitalised diarrhoea in low-income and middle-income countries are needed to prioritise interventions.

METHODS

We established the Global Pediatric Diarrhea Surveillance network, in which children under 5 years hospitalised with diarrhoea were enrolled at 33 sentinel surveillance hospitals in 28 low-income and middle-income countries. Randomly selected stool specimens were tested by quantitative PCR for 16 causes of diarrhoea. We estimated pathogen-specific attributable burdens of diarrhoeal hospitalisations and deaths. We incorporated country-level incidence to estimate the number of pathogen-specific deaths on a global scale.

RESULTS

During 2017-2018, 29 502 diarrhoea hospitalisations were enrolled, of which 5465 were randomly selected and tested. Rotavirus was the leading cause of diarrhoea requiring hospitalisation (attributable fraction (AF) 33.3%; 95% CI 27.7 to 40.3), followed by Shigella (9.7%; 95% CI 7.7 to 11.6), norovirus (6.5%; 95% CI 5.4 to 7.6) and adenovirus 40/41 (5.5%; 95% CI 4.4 to 6.7). Rotavirus was the leading cause of hospitalised diarrhoea in all regions except the Americas, where the leading aetiologies were Shigella (19.2%; 95% CI 11.4 to 28.1) and norovirus (22.2%; 95% CI 17.5 to 27.9) in Central and South America, respectively. The proportion of hospitalisations attributable to rotavirus was approximately 50% lower in sites that had introduced rotavirus vaccine (AF 20.8%; 95% CI 18.0 to 24.1) compared with sites that had not (42.1%; 95% CI 33.2 to 53.4). Globally, we estimated 208 009 annual rotavirus-attributable deaths (95% CI 169 561 to 259 216), 62 853 Shigella-attributable deaths (95% CI 48 656 to 78 805), 36 922 adenovirus 40/41-attributable deaths (95% CI 28 469 to 46 672) and 35 914 norovirus-attributable deaths (95% CI 27 258 to 46 516).

CONCLUSIONS

Despite the substantial impact of rotavirus vaccine introduction, rotavirus remained the leading cause of paediatric diarrhoea hospitalisations. Improving the efficacy and coverage of rotavirus vaccination and prioritising interventions against Shigella, norovirus and adenovirus could further reduce diarrhoea morbidity and mortality.

Immune responses to SARS-CoV-2 in three children of parents with symptomatic COVID-19

Compared to adults, children with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have predominantly mild or asymptomatic infections, but the underlying immunological differences remain unclear. Here, we describe clinical features, virology, longitudinal cellular, and cytokine immune profile, SARS-CoV-2-specific serology and salivary antibody responses in a family of two parents with PCR-confirmed symptomatic SARS-CoV-2 infection and their three children, who tested repeatedly SARS-CoV-2 PCR negative. Cellular immune profiles and cytokine responses of all children are similar to their parents at all timepoints. All family members have salivary anti-SARS-CoV-2 antibodies detected, predominantly IgA, that coincide with symptom resolution in 3 of 4 symptomatic members. Plasma from both parents and one child have IgG antibody against the S1 protein and virus-neutralizing activity detected. Using a systems serology approach, we demonstrate higher levels of SARS-CoV-2-specific antibody features of these family members compared to healthy controls. These data indicate that children can mount an immune response to SARS-CoV-2 without virological confirmation of infection, raising the possibility that immunity in children can prevent the establishment of SARS-CoV-2 infection. Relying on routine virological and serological testing may not identify exposed children, with implications for epidemiological and clinical studies across the life-span.

A framework to support quality of care for patients with chronic intestinal failure requiring home parenteral nutrition

BACKGROUND AND AIM

Chronic intestinal failure requiring home parenteral nutrition (HPN) is a disabling condition that is best facilitated by a multidisciplinary approach to care. Variation in care has been identified as a key barrier to achieving quality of care for patients on HPN and requires appropriate strategies to help standardize management.

METHOD

The Australasian Society for Parenteral and Enteral Nutrition (AuSPEN) assembled a multidisciplinary working group of 15 clinicians to develop a quality framework to assist with the standardization of HPN care in Australia. Obstacles to quality care specific to Australia were identified by consensus. Drafts of the framework documents were based on the available literature and refined by two Delphi rounds with the clinician work group, followed by a further two involving HPN consumers. The Oxford Centre for Evidence-Based Medicine Levels of Evidence was used to assess the strength of evidence underpinning each concept within the framework documents.

RESULTS

Quality indicators, standards of care, and position statements have been developed to progress the delivery of quality care to HPN patients.

CONCLUSION

The quality framework proposed by AuSPEN is intended to provide a practical structure for clinical and organizational aspects of HPN service delivery to reduce variation in care and improve quality of care and represents the initial step towards development of a national model of care for HPN patients in Australia. While developed for implementation in Australia, the evidence-based framework also has relevance to the international HPN community.

Efficacy of live oral rotavirus vaccines by duration of follow-up: a meta-regression of randomised controlled trials

BACKGROUND

The duration of protection offered by rotavirus vaccines varies across the world, and this variation is important to understanding and predicting the effects of the vaccines. There is now a large body of evidence on the efficacy of live oral rotavirus vaccines in different settings, but these data have never been synthesised to obtain robust estimates of efficacy by duration of follow-up. Our aim is to estimate the efficacy of live oral rotavirus vaccines at each point during follow-up and by mortality stratum.

METHODS

In our meta-regression study, we identified all randomised controlled trials of rotavirus vaccines published until April 4, 2018, using the results of a Cochrane systematic review, and cross checked these studies against those identified by another systematic review. We excluded trials that were based on special populations, trials without an infant schedule, and trials without clear reporting of numbers of enrolled infants and events in different periods of follow-up. For all reported periods of follow-up, we extracted the mean duration of follow-up (time since administration of the final dose of rotavirus vaccination), the number of enrolled infants, and case counts for rotavirus-positive severe gastroenteritis in both non-vaccinated and vaccinated groups. We used a Bayesian hierarchical Poisson meta-regression model to estimate the pooled cumulative vaccine efficacy (VE) and its waning with time for three mortality strata. We then converted these VE estimates into instantaneous VE (iVE).

FINDINGS

In settings with low mortality (15 observations), iVE pooled for infant schedules of Rotarix and RotaTeq was 98% (95% credibility interval 93-100) 2 weeks following the final dose of vaccination and 94% (87-98) after 12 months. In medium-mortality settings (11 observations), equivalent estimates were 82% (74-92) after 2 weeks and 77% (67-84) after 12 months. In settings with high mortality (24 observations), there were five different vaccines with observation points for infant schedules. The pooled iVE was 66% (48-81) after 2 weeks of follow-up and 44% (27-59) after 12 months.

INTERPRETATION

Rotavirus vaccine efficacy is lower and wanes more rapidly in high-mortality settings than in low-mortality settings, but the earlier peak age of disease in high-mortality settings means that live oral rotavirus vaccines are still likely to provide substantial benefit.

FUNDING

Bill & Melinda Gates Foundation.

Abstract P1-08-27: Advanced stage at diagnosis and worse clinicopathologic features in young woman with breast cancer. A sub-analysis of Brazilian population through the AMAZONA III study (GBECAM 0115)

BACKGROUND: Breast cancer (BC) in young women is uncommon and often more aggressive. There are disparities in terms of screening coverage, diagnostic features and access to optimal treatment among young BC patients worldwide. To better understand this scenario through real world data we performed a sub-analysis of AMAZONA III study. METHODS: The AMAZONA III study (GBECAM 0115) is a prospective registry that included 2950 women newly diagnosed with invasive BC in Brazil during the period of January 2016 to March 2018 within 22 sites. Of them, 2888 patients had valid data regarding age at diagnosis and complete baseline information. For the purpose of comparisons of epidemiologic and clinicopathologic features at the time of diagnosis of BC, patients were divided in two groups: women aged ≤40 years (Group 1) and &gt;40 years (Group 2). Quantitative variables were expressed with mean, while categorical variables were described as their count and percentage and compared using the chi-square test. RESULTS: Of 2888 women, 486 (17%) were ≤40 years of age. No differences were found between ethnicity, performance status, body mass index, personal income, health insurance and family history of cancer between the two groups. Young women had higher educational level (p&lt;0.001), were more involved into a labor activity (p&lt;0.001) and were more frequently married (p&lt;0.001). There were also significant differences regarding nulliparity (p&lt;0.001) and previous use of oral contraceptives (p&lt;0.001). Mode of detection of BC was symptomatic in 73.4% of young group versus 64.5% in older group and screen-detected was only 26.6% vs. 35.5% respectively (p&lt;0.001). Table 1 describes clinicopathological characteristics of the two groups. Young women presented more frequently with stage III,T3/T4, Grade 3 tumors and HER-2 positive, Luminal B and triple negative subtypes. Women older than 40 years had more stage I, Luminal A and Grade 1/2 tumors. CONCLUSION: Brazilian women under the age of 40 have unfavorable clinicopathological features of BC at diagnosis with more aggressive subtypes and advanced stage compared with older women. No differences in socioeconomic and ethnical aspects were found but a higher percentage of young women had symptomatic detection of BC which could explain the later stage of disease at diagnosis. Young women were economically active and the majority married which highlights the socioeconomic impact of this disease in Brazil.

Breast cancer features by age groups at diagnosis in Brazilian women.InformationGroup 1 (≤40 years)Group 2 (&gt; 40 years)p-valueN: 2888486 (16.83%)2402 (83.17%) Stage at diagnosis  p&lt; 0.001I76 (19.2%)541 (27.8%) II156 (39.4%)816 (41.9%) III146 (36.8%)489 (25.1%) IV19 (4.6%)101 (5.2%) Tumor size  p&lt; 0.001T1114 (27.1%)749 (36.9%) T2141 (33.6%)764 (37.6%) T3101 (24.1%)282 (13.9%) T464 (15.2%)235 (11.6%) Tumor grade  p &lt; 0.001Grade 146 (10.7%)381 (17.9%) Grade 2198 (46.2%)1150 (52.0%) Grade 3185 (43.1%)641 (30.1%) Molecular Subtype  p &lt; 0.001Luminal A106 (30.6%)957 (51.3%) Luminal B - HER 2 negative55 (15.8%)212 (11.4%) Luminal B- HER 2 positive79 (22.8%)298 (16.0%) HER 2 positive27 (7.8%)135 (7.2%) Triple negative80 (23.0%)264 (14.1%) 

Citation Format: Franzoi MA, Rosa D, Barrios C, Bines J, Cronemberger E, Queiroz G, Cordeiro de Lima VC, Junior R, Couto J, Emerenciano K, Resende H, Crocamo S, Reinert T, Van Evyl B, Neron Y, Dybal V, Lazaretti N, Costamilan RdC, de Andrade D, Mathias C, Zerwes Vacaro G, Borges G, Silva K, Werutsky G, Morelle A, Sampaio Filho CA, Mano M, Zaffaroni F, Simon S, Liedke PE. Advanced stage at diagnosis and worse clinicopathologic features in young woman with breast cancer. A sub-analysis of Brazilian population through the AMAZONA III study (GBECAM 0115) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-08-27.

Abstract GS2-04: Efficacy results from CIBOMA/2004-01_GEICAM/2003-11 study: A randomized phase III trial assessing adjuvant capecitabine after standard chemotherapy for patients with early triple negative breast cancer

Background: Triple negative breast cancers (TNBC) have a greater risk of relapse than non-TNBC. New therapeutic approaches are needed for these patients (pts). CIBOMA/2004-01_GEICAM/2003-11 is a multinational, randomized phase III trial exploring adjuvant capecitabine (X) after completion of standard treatment in early TNBC pts.

Materials and Methods: Patients with operable, node-positive (or node-negative with tumor size ≥ 1 cm), centrally confirmed hormone receptor-negative, HER2-negative early BC, who had received 6–8 cycles (cy) of standard anthracycline and/or taxane-containing chemotherapy or 4 cy of doxorubicin-cyclophosphamide (for node-negative disease) in the (neo)adjuvant setting, were eligible. Patients were randomized to either 8 cy of X (1,000 mg/m2 bid, days 1–14, every 3 weeks) or observation. Stratification factors included center, prior taxane-based therapy, number of involved axillary lymph nodes and phenotype (basal vs non-basal, according to cytokeratins 5/6 and/or EGFR positivity). The primary objective was to compare the disease-free survival (DFS) between both treatment arms, and secondary objectives included the comparison in terms of 5-year DFS, overall survival (OS) and safety. Assuming a 30% risk reduction in DFS rate at 5 years (from 64.7% to 73.7%, hazard ratio 0.70) with 80% power and a two-tailed log-rank test at 0.05, 834 evaluable pts were needed. 876 pts had to be finally enrolled considering a drop-out rate of 5%.

Results: Recruitment of 876 pts from 8 countries was completed in September 2011. Median age was 49 years; 68.5% of pts were postmenopausal, 55.5% were lymph node negative, 71.7% had a basal phenotype, 67.5% received chemotherapy based on anthracyclines and taxanes. Median follow-up was 7.3 years (range 0.0 to 11.1). DFS was not significantly prolonged with X vs observation (hazard ratio (HR) 0.82; 95% confidence interval (CI), 0.63 to 1.06; P=0.1353). Five-year DFS was 79.6% (95% CI, 75.8% to 83.4%) with X and 76.8% (95% CI, 72.7% to 80.9%) with observation. OS was not statistically different between treatment arms (HR 0.92; 95% CI, 0.66 to 1.28; P=0.6228). In subgroup analysis for DFS, we found no statistically significant interaction between X treatment and different subgroups, with the exception of basal vs non-basal phenotypes (basal HR 0.97, 95% CI 0.72 to 1.32, P=0.8620; non-basal HR 0.51, 95% CI, 0.31 to 0.86, P=0.0101; interaction P=0.0357). Similar results were found for OS (basal HR 1.20, 95% CI 0.81 to 1.77, P=0.3684; non-basal HR 0.48, 95% CI, 0.26 to 0.91, P=0.0205; interaction P=0.0155). 75.2% of pts completed 8 cy of X, with a median relative dose intensity of 86.3%. Grade (G) 3 or higher adverse events (AEs) were observed in 40.4% of pts in X arm. In 9.6% of pts the AEs were related with X. Hand-foot syndrome was the most common AE in X arm (G3 on 18.8% of pts).

Conclusions: In our study, the addition of adjuvant X after standard (neo) adjuvant anthracycline and/or taxane-containing chemotherapy was not associated with a statistically significant improvement of DFS or OS compared to observation in pts with early TNBC. However, in a subgroup analysis a significant DFS and OS improvement was observed with X in pts with non-basal phenotype.

Sponsor: CIBOMA.

Citation Format: Martín M, Barrios CH, Torrecillas L, Ruiz-Borrego M, Bines J, Segalla J, Ruiz A, García-Sáenz JA, Torres R, de la Haba J, García E, Gómez HL, Llombart A, Rodríguez de la Borbolla M, Baena JM, Barnadas A, Calvo L, Pérez-Michel L, Ramos M, Castellanos J, Rodríguez-Lescure A, Cárdenas J, Vinholes J, Martínez de Dueñas E, Godes MJ, Seguí MA, Antón A, López-Álvarez P, Moncayo J, Amorim G, Villar E, Reyes S, Sampaio C, Cardemil B, Escudero MJ, Bezares S, Carrasco E, Lluch A. Efficacy results from CIBOMA/2004-01_GEICAM/2003-11 study: A randomized phase III trial assessing adjuvant capecitabine after standard chemotherapy for patients with early triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS2-04.

Abstract P1-08-29: Current status of clinical and pathological characteristics of breast cancer patients in Brazil: Results of the AMAZONA III study (GBECAM 0115)

BACKGROUND

Breast cancer (BC) is the most common tumor in women in Brazil with about 60 thousand new cases estimated per year. In low and middle-income countries, patients with BC are diagnosed with more advanced stages as compared with high-income countries. In Brazil, disparities in access to new therapies are recognized; previous data suggests worse survival of BC patients treated in the public system. The aim of AMAZONA III study (GBECAM 0115) is to describe the current status of BC care in Brazil. Here we report patients data at baseline.

METHODS

The AMAZONA III is a prospective BC registry that included women 18 years or older with newly diagnosed stage I to IV BC from 22 sites in Brazil in the period of January 2016 to March 2018. All patients provided written informed consent; data was collected from interview and medical charts, comprising clinical-demographic variables, initial treatment and a planned follow-up for 5 years. BC subtypes were defined by hormone receptor (HR) expression, HER2 status and grade according to von Minckwitz G. et al 2012. Here we present a descriptive analysis of the patients' baseline characteristics. Continuous variables are shown as mean (standard-deviation) and categorical variables by its absolute and relative frequencies. The study is registered in clinicaltrials.gov NCT02663973.

RESULTS

A total of 2950 patients were included in the study. Median age at diagnosis was 53 years old (8.4% &lt;= 35 years, 34.8% 36-50 years, 56.8% &gt; 50 years), 58.6% were white, 34.4% had brown skin-color, 83% had children before BC diagnosis (median of 1 child/patient) and 63.1% had public health insurance. In terms of method of detection 34% were screen-detected whereas 66% were symptomatic, the last was even higher (70%) in patients in younger than 50 years. The distribution of BC stage at diagnosis was I (26.4%), II (41.6%), III (27%) and IV (5%). The most common histologies were ductal (80.9%) and lobular carcinoma (6.9%). The pathological characteristics were HR positive in 78.0%, HER-2 positive in 23.4% and grade 2 in 51%. BC subtypes were as follows: Luminal A 48%, Luminal B 12%, Luminal HER2 positive 17%, Non-luminal HER2 positive 7.3% and Triple negative 15.5%.

DISCUSSION

Breast cancer is diagnosed at an earlier age among Brazilian patients. The majority of patients were detected through symptomatic BC and therefore a significant proportion is still diagnosed in stages III and IV. Among other factors, these findings could have a significant impact in treatment outcomes. Further analysis of this large cohort of patients will help to identify other important elements and direct future strategies for breast cancer control.

TRIAL REGISTRY: NCT02663973

KEYWORDS: Breast Cancer; Epidemiology; Treatment; Brazil

Citation Format: Rosa D, Barrios C, Bines J, Werustky G, Cronemberger E, Queiroz GS, Lima VC, Freitas-Júnior R, Couto J, Emerenciano K, Resende H, Crocamo S, Reinert T, Van Eyil B, Néron Y, Dybal V, Lazaretti N, Costamilan RC, Andrade DA, Mathias C, Vacaro GZ, Borges G, Torres KL, Morelle A, Sampaio Filho CA, Mano M, Zaffaroni F, Simon S. Current status of clinical and pathological characteristics of breast cancer patients in Brazil: Results of the AMAZONA III study (GBECAM 0115) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-08-29.

The AMAZONA Project: Retrospective Cohort Study Describing Breast Cancer Patients' Characteristics and Survival in Brazil

Background: Breast cancer is the most common cancer in women in Brazil and worldwide. There is large variation in survival among patients and molecular subtypes are important prognostic factors. However, most of the data comes from developed countries such as the United States and in Europe. Aim: Our goal was to describe breast cancer patients' demographic and pathologic characteristics, as well as their survival according to estimated molecular subtypes, assessed by common immunohistochemistry stains. Methods: AMAZONA study is a retrospective cohort conducted from June 2008 to January 2009 including women of at least 18 years old, with histologically proven breast cancer diagnosed in the period between 1 January 2001 and 31 December 2001 and between 1 January 2006 and 31 December. Estimated molecular subtypes by local immunohistochemical stains were luminal A, luminal B, HER-2 positive and triple-negative. Data were obtained from medical records and public databases. Kaplan-Meier method was used for data description and log-rank test for comparison between the subgroups. Results: 2296 patients were included in this analysis. Mean age was 54 years. Most subjects included came from hospitals located in the southeast region of the country, treated in the public health system and had stage II invasive ductal carcinoma of breast. Regarding subtype, 71.3% had hormonal receptor positive disease, 15.7% were HER-2 positive and 21.1% had triple-negative breast cancer. Overall survival (OS) was significantly different among molecular subtypes and was independent of pathologic stage for stages II and III patients. For stage III patients 5-years OS for luminal A subtype was 75.8% and for triple-negative was 56.1% ( P .0002). Conclusion: Classification of breast cancer patients in predicted molecular subtypes using immunohistochemistry is currently available in most underdeveloped countries and is a useful prognostic tool that goes beyond clinical or pathologic stage.

Abstract P1-13-07: Incidence and management of diarrhea with adjuvant pertuzumab and trastuzumab in HER2-Positive breast cancer

Background

Diarrhea is the most commonly reported adverse event (AE) on pertuzumab (Ptz) in both early and metastatic breast cancer (BC) settings. We report safety analyses of diarrhea from the large adjuvant APHINTY study in HER2 positive early breast cancer (EBC).

Patients and methods

In this exploratory analysis, the safety population included 2364 patients in the Ptz arm and 2405 in the placebo (Pla) arm. No specific prophylaxis was mandated by the protocol, however early intervention with loperamide as well as fluid and electrolyte replacement was recommended. Diarrhea incidence, severity (NCI-CTCAE v4.0), onset and management were analyzed.

Results

Diarrhea was the most common AE in the Ptz arm (71.3% vs. 45.2% in the Pla arm) and the events were mostly G1. Diarrhea ≥G3 was observed in 9.8% and 3.7% in Ptz and Pla arms, respectively. The highest incidence was reported during administration of HER2 targeted therapy and taxane (61.4% vs. 33.8% with Ptz and Pla, respectively) with a marked decrease observed upon chemotherapy cessation (18.1% vs. 9.2% with Ptz and Pla, respectively). The median time from first targeted treatment to onset of diarrhea during the chemotherapy phase was 7 and 10 days (Ptz/Pla). On average, diarrhea events lasted longer in the Ptz than in the Pla arm (median 8 vs. 6 days). Diarrhea events were more frequent with the administration of docetaxel + carboplatin and targeted agents, irrespective of the severity. Detailed results are reported in Table 1.

Conclusions

In the curative setting, diarrhea due to Ptz was mild, generally manageable with common antidiarrheals and did not affect patients' ability to receive treatment. The APHINITY findings are consistent with the well-characterized pattern of pertuzumab-related diarrhea across the HER2 BC spectrum.

Diarrhea incidence, severity (NCI-CTCAE v4.0), onset and management Ptz, n=2364Pla, n=2405Incidence and severityTotal number of patients with at least one adverse event$1685 (71.3%)1086 (45.2%)Total number of events$34151792NCI CTC AE Grade (highest grade per patient)!n1683 (71.2%)1085 (45.1%)Grade 1829 (35.1%)690 (28.7%)Grade 2622 (26.3%)305 (12.7%)Grade 3229 (9.7%)90 (3.7%)Grade 43 (0.1%)0Onset and duration$Median time (days) from 1st HER2 targeted treatment to onset (min-max)7 (1 – 358)10 (1 - 384)Median Duration (days) of each event (min-max)8 (1 - 811)6 (1 - 1022)ManagementAntidiarrheals$898 (38.0%)386 (16.0%)Dose modification* of any study drug!210 (8.9%)74 (3.1%)Dose modification* of HER2 targeted treatment!69 (2.9%)18 (0.7%)Discontinuation of any study drug!38 (1.6%)7 (0.3%)Discontinuation of HER2 Targeted treatment!20 (0.8%)2 (&lt;0.1%)$ Based on a basket of preferred terms for diarrhea ! Based only on the preferred term diarrhea * Includes dose reductions (chemotherapy only), delays or interruptions during infusion

Citation Format: Bines J, de Azambuja E, Zardavas D, Procter M, Restuccia E, Viale G, Suter T, Arahmani A, van Dooren V, Clark E, Eng-Wong J, Gelber R, Piccart M, von Minckwitz G, Baselga J. Incidence and management of diarrhea with adjuvant pertuzumab and trastuzumab in HER2-Positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-13-07.

Abstract P1-17-10: Survival outcomes related to health care coverage in breast cancer patients with brain metastases in Brazil: A sub-analysis from the LACOG-0312 study

Background

The incidence of brain metastases among women with metastatic breast cancer (MBC) ranges from 10 to 30% depending of breast cancer (BC) subtype. Inequities in the access to optimal treatment and shorter survival of BC by type of health care coverage were previously reported in an observational study in Brazil. The present analysis aims to analyze the impact of the type of health care coverage on survival outcomes of patients with MBC and brain involvement.

Methods

LACOG-0312 is a retrospective cohort study that enrolled patients with metastatic or locally advanced/recurrent unresectable BC diagnosed during 2012 in Brazil. Overall survival (OS) was defined as the time from the diagnosis of brain metastases and death from any cause. Comparisons were made using the Kaplan-Meier method based on the type of health care coverage (public vs. private) among patients who developed brain metastases. Cox regression analysis was performed for identification of independent prognostic factors associated with survival after brain metastases diagnosis.

Results

Among the 690 MBC patients included in the LACOG-0312 study, 145 (21%) were diagnosed with brain metastases. Of them, 94 (71,75%) were covered by the Brazilian public health care and 37 (28,25%) had private coverage. Baseline characteristics such as age at MBC diagnosis, stage IV at diagnosis and tumor subtypes were similar between both groups.

Median time to develop brain metastases after diagnosis of MBC was 14 months in the whole population with no differences between public and private patients (13 vs. 17 months p=0.172).

Median OS from the date of brain metastases diagnosis was similar for both groups: 10.0 months in private and 9.0 months in public health insured patients (HR 0.92 – 95%CI 0.55-1.51; p=0.729). In a multivariable analysis including type of health care coverage, only the triple negative BC subtype was associated with a worse survival post brain metastases diagnosis.

Conclusion

Our study indicates that health care coverage is not associated with survival outcomes in patients with MBC and brain metastases. Potential differences in the access to optimal care such as radiotherapy, surgery and systemic treatments may not play a significant role in the survival of theses patients possibly due to small clinical benefit of the current treatment options for brain metastases in breast cancer.

Citation Format: Albuquerque C, Debiasi M, Werutsky G, Uema D, Cronenberger E, Cordeiro de Lima VC, de Sant'ana RO, Bines J, Santi PX, Goés RS, Liedke P, Batista MLM, Dybal V, Nerón YV, Beato CA, Borges G, Giacomazzi J, dos Santos LV, Ismael G, Rosa DD, Azambuja A, Andrade D, Martinez-Mesa J, Zaffaroni F, Barrios CH. Survival outcomes related to health care coverage in breast cancer patients with brain metastases in Brazil: A sub-analysis from the LACOG-0312 study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-17-10.

Abstract P4-10-15: Impact of delay in breast cancer diagnosis and treatment according to health insurance status in southwest Brazil and Houston, Texas

Background: Access to medical care vary across the world and is related to different health systems with an impact in recurrence.Objective: To evaluate disparities in breast cancer(BC) diagnosis and treatment between public and private services in southwest Brazil and at two public safety net hospitals in Houston, Texas.Methods: Women diagnosed with BC stages I-III between 2009 to 2011, and treated at the four hospitals in Brazil and two health centers in US were included. All statistical analyses were performed in R studio software, and p&lt;0.05 was considered significant.Results: 1245 women were included: 967 from public health system (PHS) (20.3% from Houston, Texas) and 274 from private system(PS). Recurrence rate was higher in PHS (14.6% vs. 2.6%, p&lt;0.001)

Table 1. Clinical and demographic characteristics of the patientsCharacteristicsPublic (%), n=967Private (%), n=274pDiscovery of BC   By patient530 (54.8)92 (33.5) Routine exam87 (9)109 (39.8) Screening mammography270 (27.9)23 (8.4) Other80 (8.3)50 (18.3)&lt;0.001Initial treatment   Surgery687 (71)241 (88) Neo-adjuvant chemotherapy224 (23.2)27 (9.8) Neo-adjuvant hormone therapy23 (2.3)27 (9.8) Not available33 (3.4)3 (1.1)&lt;0.001Clinical Stage   I293 (30.3)113 (41.2) II342 (35.4)52 (19) III271 (28)15 (5.5) Unknown61 (6.3)94 (34.3)&lt;0.001Subtype   HR+/HER2 -561 (58)192 (70.1) HR-/HER2+108 (11.1)29 (10.6) HR-/HER2+76 (7.9)14 (5.1) Triple negative149 (15.4)28 (10.2) Unknown73 (7.6)11 (4)0.012Symptomatic at Diagnosis   Yes591 (61.1)100 (36.5) No306 (31.6)97 (35.4) Unknown70 (7.2)77 (28.1)&lt;0.001Recurencen=772n=146 No719 (74.4)193 (70.4) Yes142 (14.6)7 (2.6) Unknown106 (11)74 (27)&lt;0.001

. Considering the interval in weeks: symptoms to diagnosis, diagnosis to first treatment (either surgery or neoadjuvant chemotherapy), diagnosis to first systemic treatment, diagnosis to surgical treatment and diagnosis to radiotherapy were longer in public patients (24.1 vs. 8.7; 11.1 vs. 3.5; 18.6 vs. 9.8; 16.9 vs. 5.6; 51.4 vs. 26.1; p&lt;0.001).

Table 2. Delay disparities between public and private health system PublicPrivatepSymptoms to diagnosis   Number of patients575146 Time (weeks)24.1 (0.4-104.9)8.7 (0.0-43.7)&lt;0.001Diagnosis to first treatment   Number of patients663180 Time (weeks)11.1 (2.0-31.5)3.5 (0.0-11.0)&lt;0.001Diagnosis to first systemic treatment   Number of patients526106 Time (weeks)18.6 (2.6-44.7)9.8 (1.9-29.3)&lt;0.001Diagnosis to surgical treatment   Number of patients657178 Time (weeks)16.9 (3.4-45.6)5.6 (0.0-32.9)&lt;0.001Diagnosis to radiotherapy   Number of patients465127 Time (weeks)51.4 (18.7-88.4)26.1 (5.6-66.4)&lt;0.001

In multivariate analysis, PHS (HR 1.72; 95% CI 1.34-1.88; p adj=0.003), presence of symptoms (HR 2.29; 95% CI 1.39-3.78; p adj=0.001), clinical stage III (HR 1.62; 95% CI 1.35-1.93; p adj&lt;0.001), and triple negativity and HER2neu positivity (1.18; 95% CI 1.03-1.35; p adj=0.021) were all associated with a higher recurrence rate.Conclusions: There were significant disparities between PHS and PS. Women in the PHS presented higher rates of recurrence, advanced clinical stages at diagnosis, symptoms and more aggressive subtypes by IHC. additionally, the interval between symptoms to diagnosis and diagnosis to treatments was longer in PHS.

Citation Format: NematiShafaee M, Natal RA, Ramalho S, Dória MT, Conz L, Cabello V, Pavanello M, Mano MS, Linck RDM, Batista LS, Pedro EP, Bines J, de Paula BH, Zucca-Matthes G, Bondy ML, Ellis MJ, Podany E, Debord L, Makawita S, Stewart K, Cabello C. Impact of delay in breast cancer diagnosis and treatment according to health insurance status in southwest Brazil and Houston, Texas [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-15.

Abstract P4-10-17: Survival outcomes related to health care coverage in metastatic breast cancer in Brazil: A sub-analysis from the LACOG-0312 study

Background

Metastatic breast cancer (MBC) is an incurable disease in which latest therapies have evolving and improving patients survival. Inequities in the access to optimal treatment and shorter survival of BC by type of health care coverage were previously reported in an observational study in Brazil. In Brazil patients with private health coverage have access to the most recent therapies, however the public health system does not provide several therapies approved for the treatment of MBC such as everolimus, trastuzuman, eribulin, TDM-1, pertuzumab among others. The present analysis aims to analyze the impact of the type of health care coverage on survival outcomes of patients with MBC.

Methods

LACOG-0312 is a retrospective cohort study that enrolled patients with metastatic or locally advanced/recurrent unresectable BC diagnosed during 2012 in Brazil. Overall survival was defined as the time from the diagnosis of MBC and death from any cause. Comparisons were made using the Kaplan-Meier method based on the type of health care coverage (public vs. private). Cox regression analysis was performed for identification of independent prognostic factors associated with overall survival.

Results

A total of 634 patients with MBC were included in the study. Baseline characteristics by type of health care coverage was similar for visceral disease (43% in public and 44% in private, p=0.78), age at MBC diagnosis (median 62 years in public and 64 years in private, p=0.25), BC subtype (p=0.89), however more patients public insured were metastatic at diagnosis (42% vs. 33%) and had performance status &gt;= 2 (12% vs. 3%).

The proportion of patients that received any first-line systemic therapy was similar in both groups (95.2% in public and 95.5% in private, p=1.0), however more patients with private insurance received second (82% vs. 71.6%, p=0.013) and third line (56% vs. 45%, p=0.024) therapy compared to public health covered patients.

OS from the date of MBC diagnosis in whole population was 36 months. There was no difference in terms of OS between private (42 months) and public (35 months) health insured patients (p=0.65). OS by BC subtype was 15 months for triple negative, 23 months in HER2 positive, 44 and 42 months for Luminal A and B respectively. There was no difference in OS by type of health insurance coverage in any BC subtypes.

In a multivariate analysis type of health care coverage did not associate with survival, only triple negative (HR (95% CI) – 3.495 (2.448 - 4.989); p &lt;0.001), HER2 positive (HR (95% CI) - 2.287 (1.394 - 3.572); p = 0.001) BC subtypes and visceral metastases (HR (95% CI) – 1.413 (1.075 - 1.858); p &lt;0.013) were correlated with a worse survival.

Conclusion

Our study suggestes that health care coverage is not associated with survival outcomes in patients with MBC. Potential differences in the access to optimal systemic treatments may not play a significant role in the survival of these patients. Real-world studies addressing the impact of new cancer therapies for different BC subtypes in MBC are needed.

Citation Format: Werutsky G, Zaffaroni F, Uema D, Cronenberger E, Cordeiro de Lima VC, de Sant'ana RO, Bines J, Santi PX, Goés RS, Liedke P, Batista MLM, Dybal V, Nerón YV, Beato CA, Borges G, Giacomazzi J, dos Santos LV, Ismael G, Rosa DD, Azambuja A, Andrade D, Martinez-Mesa J, Debiasi M, Barrios CH. Survival outcomes related to health care coverage in metastatic breast cancer in Brazil: A sub-analysis from the LACOG-0312 study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-17.

Trends in progression-free survival (PFS) and time to progression (TTP) over time within first-line aromatase inhibitors trials in hormone receptor-positive advanced breast cancer

BACKGROUND

Over the last 20 years, aromatase inhibitors (AI) have been tested in clinical trials as first-line therapy for hormone receptor-positive (HR-positive) advanced breast cancer (ABC), firstly as experimental arms, when they proved to be effective, and recently as control arms. This analysis aims to evaluate trends in progression-free survival (PFS) and time to progression (TTP) over time.

PATIENTS AND METHODS

A literature review was conducted using the MEDLINE database to identify randomized controlled phase II or III trials which reported PFS or TTP of at least one arm using first-line AI HR-positive ABC patients. A linear correlation was used to access the association between the year of the first patient enrolled and the observed PFS/TTP.

RESULTS

The search retrieved 19 trials, accounting for 4552 postmenopausal patients divided into 21 separate AI treatment arms. The PFS/TTP increased from 6 to 9 months in the earlier trials to 13-16 months in the current era, representing an absolute gain of approximately 7 months, without the addition of any other drug. Our analysis showed a positive correlation between the year of the first patient enrolled in these trials and median PFS/TTP reported (R ² = 0.34; p < 0.01). No correlation was found between the year of the first patient included in these trials and other potential prognostic factors such as visceral metastasis at baseline (R ² = 0.26; p = 0.20) or exposure to adjuvant therapy (R ² = 0.05; p = 0.18).

CONCLUSION

Patients treated with first-line AIs in the more recently conducted trials have longer PFS/TTP when compared to their counterparts treated with the same drugs in older studies. These findings have important implications for the estimation of sample size and follow-up periods for the planning of future trials as well as in the translation of the results into clinical practice decisions.

Abstract P6-16-04: Real World data and patterns of care of metastatic breast cancer (MBC) in Brazil: First results of LACOG 0312 retrospective study

Background

Randomised clinical trials (RCT) are considered a gold standard generating efficacy and safety data supporting drug approval. However, real world data (RWD) reflecting health care delivery is becoming increasingly important. RWD on patient profiles and patterns of care in MBC are scarce in developing countries. As an example, observational studies suggest that despite guideline recommendations clearly indicating ET for hormone receptor positive MBC, a considerable proportion of patients in clinical practice begin chemotherapy in early lines of therapy. This pragmatic information addresses the uptake and applicability of the RCT results and should be able to help informing health care planning complementing RCT generated data. The objective of this study is to describe patient characteristics and evaluate actual physician-reported treatments for MBC in Brazil.

Methods

This analysis addresses the first 362 patients included in LACOG-0312, a retrospective study planning to recruit over 700 patients (cut-off date April 30th 2016) with recurrent locally advanced or MBC diagnosed in 2012 in 18 institutions across Brazil. Patient characteristics, type of health insurance coverage, treatment and survival outcome were analysed.

Results

Median age at BC diagnosis was 53 years and 37% were premenopausal. Regarding the educational level, 63.2% had completed elementary (primary) schooling, 75.7% were covered by the public health system while 24.3% had some form of private coverage. 70% of patients had hormone receptor positive (HR+) and 18% had HER2 positive tumors. Median disease free survival time from surgery was 29 months. Interestingly, 30% of patients underwent a biopsy of a metastatic site. Of the 362 patients, 349 (96.9%) received some form of palliative systemic therapy. Median time from diagnosis of metastatic disease to first-line therapy initiation was 46 days but a significant difference was noted between patients with public versus private health insurance (50 vs. 33 days p=0.012). Half of the patients received at least 3 lines of therapy (chemo or endocrine) to a maximum of 9 lines. In patients with HR+ tumors, endocrine therapy was administered in 47% in first, 65% in second and 61% in third-line, respectively. Median overall survival (OS) from diagnosis of metastatic disease was 34 months (CI 95%: 25.7-44.3) and no differences in OS were observed between patients with public or private coverage (34 months vs. 35 months p=0.808). Causes of death were cancer in 85.2% of patients and treatment toxicity in 3.6%.

Conclusion

Our study included a population with predominantly low educational level and mostly public health insurance. This likely corresponds to the majority of cases and reflects cancer care patterns in Brazil and many developing countries. A considerable proportion of patients were premenopausal at MBC diagnosis. More than half of HR+ patients received at least 3 lines of endocrine therapy although 54% of them had chemotherapy as the first systemic treatment. Patients from the public health system experienced a delay in starting first-line therapy but this didn't seem to jeopardize cancer outcomes in this setting.

Citation Format: Barrios CH, Uema D, Cronenberger E, Lima V, Bines J, de Sant'ana RO, Batista ML, Dybal V, Liedke P, Beato C, Nerón YV, Giacomazzi J, dos Santos L, Ismael G, Azambuja A, Andrade D, Rosa DD, Borges G, Mano M, Martinez-Mesa J, Zaffaroni F, Werutsky G. Real World data and patterns of care of metastatic breast cancer (MBC) in Brazil: First results of LACOG 0312 retrospective study [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 P6-16-04.

Rotavirus specific maternal antibodies and immune response to RV3-BB neonatal rotavirus vaccine in New Zealand

BACKGROUND

Maternal antibodies, acquired passively via placenta and/or breast milk, may contribute to the reduced efficacy of oral rotavirus vaccines observed in children in developing countries. This study aimed to investigate the effect of rotavirus specific maternal antibodies on the serum IgA response or stool excretion of vaccine virus after any dose of an oral rotavirus vaccine, RV3-BB, in parallel to a Phase IIa clinical trial conducted at Dunedin Hospital, New Zealand. At the time of the study rotavirus vaccines had not been introduced in New Zealand and the burden of rotavirus disease was evident.

METHODS

Rotavirus specific IgG and serum neutralizing antibody (SNA) levels in cord blood and IgA levels in colostrum and breast milk samples collected ∼4 weeks, ∼20 weeks and ∼28 weeks after birth were measured. Infants were randomized to receive the first dose of vaccine at 0-5 d (neonatal schedule) or 8 weeks (infant schedule). Breast feeding was with-held for 30 minutes before and after vaccine administration. The relationship between rotavirus specific IgG and SNA levels in cord blood and IgA in colostrum and breast milk at the time of first active dose of RV3-BB vaccine and level of IgA response and stool excretion after 3 doses of vaccine was assessed using linear and logistic regression.

RESULTS

Forty infants received 3 doses of RV3-BB rotavirus vaccine and were included in the analysis of the neonatal and infant groups. Rotavirus specific IgA in colostrum (neonatal schedule group) and breast milk at 4 weeks (infant schedule group) was identified in 14/21 (67%) and 14/17 (82%) of infants respectively. There was little evidence of an association between IgA in colostrum or breast milk IgA at 4 weeks, or between cord IgG or SNA level, and IgA response or stool excretion after 3 doses of RV3-BB, or after one dose (neonatal schedule) (all p>0.05).

CONCLUSIONS

The level of IgA in colostrum or breast milk and level of placental IgG and SNA did not impact on the serum IgA response or stool excretion following 3 doses of RV3-BB Rotavirus Vaccine administered using either a neonatal or infant schedule in New Zealand infants.

Rotavirus vaccination and intussusception - Science, surveillance, and safety: A review of evidence and recommendations for future research priorities in low and middle income countries

As of January 2016, 80 countries have introduced rotavirus vaccines into their national immunization programs. Many have documented significant declines in rotavirus-specific and all-cause diarrheal illnesses following vaccine introduction. Two globally licensed rotavirus vaccines have been associated with a low risk of intussusception in several studies. In July 2014, the Rotavirus Organization of Technical Allies Council convened a meeting of research and advocacy organizations, public health experts, funders, and vaccine manufacturers to discuss post-marketing intussusception surveillance and rotavirus vaccine impact data. Meeting objectives were to evaluate updated data, identify and prioritize research gaps, discuss best practices for intussusception monitoring in lower-income settings and risk communication, and provide insight to country-level stakeholders on best practices for intussusception monitoring and communication. Meeting participants agreed with statements from expert bodies that the benefits of vaccination with currently available rotavirus vaccines outweigh the low risk of vaccination-associated intussusception. However, further research is needed to better understand the relationship of intussusception to wild-type rotavirus and rotavirus vaccines and delineate potential etiologies and mechanisms of intussusception. Additionally, evidence from research and post-licensure evaluations should be presented with evidence of the benefits of vaccination to best inform policymakers deciding on vaccine introduction or vaccination program sustainability.

Placebo use in vaccine trials: recommendations of a WHO expert panel

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Placebo controls may be acceptable even when an efficacious vaccine exists, in the following four possible situations:

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When developing a locally affordable vaccine.

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When evaluating the local safety and efficacy of an existing vaccine.

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When testing a new vaccine when an existing vaccine is not considered appropriate locally.

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When determining the local burden of disease.

Vaccines are among the most cost-effective interventions against infectious diseases. Many candidate vaccines targeting neglected diseases in low- and middle-income countries are now progressing to large-scale clinical testing. However, controversy surrounds the appropriate design of vaccine trials and, in particular, the use of unvaccinated controls (with or without placebo) when an efficacious vaccine already exists. This paper specifies four situations in which placebo use may be acceptable, provided that the study question cannot be answered in an active-controlled trial design; the risks of delaying or foregoing an efficacious vaccine are mitigated; the risks of using a placebo control are justified by the social and public health value of the research; and the research is responsive to local health needs. The four situations are: (1) developing a locally affordable vaccine, (2) evaluating the local safety and efficacy of an existing vaccine, (3) testing a new vaccine when an existing vaccine is considered inappropriate for local use (e.g. based on epidemiologic or demographic factors), and (4) determining the local burden of disease.

Activity of megestrol acetate in postmenopausal women with advanced breast cancer after nonsteroidal aromatase inhibitor failure: a phase II trial

BACKGROUND

As novel treatments carry substantial price tags and are mostly cost-prohibitive in low- and middle-income countries, there is an urgent need to develop alternatives, such as off-patent drugs. Megestrol acetate (MA) has a longstanding history in the treatment of breast cancer, but recently it is being used less often due to the advent of newer agents.

PATIENTS AND METHODS

This two-stage phase II trial evaluated the antitumor activity and toxicity of MA in postmenopausal women with hormone-sensitive advanced breast cancer who had experienced disease progression on a third-generation nonsteroidal aromatase inhibitor (NSAI). Eligible patients had metastatic breast cancer treated with a NSAI with at least 6-month progression-free survival (PFS), or relapse after ≥1 year on adjuvant NSAI. Patients received MA at a single daily oral dose of 160 mg. Primary end point was clinical benefit rate (CBR).

RESULTS

Forty-eight patients were enrolled. The CBR was 40% [95% confidence interval (CI) 25% to 55%], and the median duration of clinical benefit was 10.0 (95% CI 8.0-14.2) months. The median PFS was 3.9 (95% CI 3.0-4.8) months. The most common grade 3 adverse events were anemia (2%), dyspnea (2%), fatigue (2%), musculoskeletal pain (4%), deep vein thrombosis (10%), and weight gain (2%).

CONCLUSIONS

This is the first study to prospectively evaluate the efficacy and safety of MA in postmenopausal women with hormone-sensitive disease progressing on a NSAI. MA has demonstrated activity and acceptable tolerability in this setting, and therefore remains a reasonable treatment option in a cost-sensitive environment. These results also provide the background for further evaluation of progestins in the treatment of breast cancer.

CLINICAL TRIALS

local trial number, related to the approval by the IRB: CEP 108/06.

Abstract P4-12-26: A phase II randomized study of lapatinib in combination with capecitabine, vinorelbine or gemcitabine as first or second line-therapy in patients with HER2 positive metastatic breast cancer progressing after taxane (LACOG 0801)

Background:

Lapatinib-Capecitabine (LC) is approved for the treatment of advanced or metastatic breast cancer (MBC) whose tumors overexpress HER2 and who have received prior therapy including an anthracycline, a taxane (T), and trastuzumab (H). LACOG 0801 evaluated different L-based chemotherapies as first and second-line treatments in MBC.

Methods:

This is a randomized, open label, multicenter, phase II trial of L 1250 mg BID given continuously in combination with C 2000 mg/m2 d1-14 (LC), or Vinorelbine (V) 25mg/m2 d1 and 8 (LV) or Gemcitabine (G) 1000 mg/m2 d1 and 8 (LG), in 21 days cycles. Primary endpoint was ORR (RECIST). Secondary endpoints included progression free survival (PFS), overall survival, tolerability and safety. Patients with HER2 positive MBC who had failed a T-based treatment and who had ≤1 chemotherapy regimen in the metastatic setting were included. Prior therapy with H was not mandatory. Patients were stratified by the presence of liver metastasis, previous use of H, and T administered in the neo/adjuvant or the metastatic setting. With an expected ORR of 23% in the control arm (LC), we hypothesized an absolute increase of 12% in the experimental arms using Simon's design.

Results:

A total of 142 pts from Argentina, Brazil and Peru were included from 2009-2012. Patient baseline characteristics were well balanced between the three arms. Median age was 51y, 58% postmenopausal, 65% ECOG 1, 49% had visceral disease (32% liver metastasis), 57% hormone receptor negative and only 47% had received prior H. Median number of administered cycles was 6 (LC = 5; LV = 7; LG = 6). ORR was 47.1% (95%CI 38.5; 67.1), 55.6% (95%CI 29.6; 60.0) and 41.3% (95%CI 43.2; 73.0) in LC, LV and LG, respectively. Median PFS was 9.1m (95%CI 6.1; 14.7), 7.0m (95%CI 5.0; 9.9) and 6.8m (95%CI 5.8; 9.9) in LC, LV and LG arms respectively. Survival data will be updated. The proportion of patients with at least one adverse event (AE) was 96% in all arms. Most common all grade AE were diarrhea (76%), hand-foot syndrome (HFS) (45%) and vomiting (39%) in LC; diarrhea (71%), neutropenia (68%) and nausea (43%) in LV; diarrhea (64%), neutropenia (60%), anemia and increased ALT both 44% in LG. The most frequent grade 3 and 4 AEs were HFS (18%), diarrhea (6%) and increased ALT/AST (4%) in LC; neutropenia (36%), diarrhea (9%) and febrile neutropenia (6%) in LV; and neutropenia (47%), ALT/AST elevation (13%) and rash (4%) in LG. Discontinuation due to toxicity occurred in 16%, 7% and 20% of patients in arms LC, LV and LG respectively.

Conclusion:

LV and LG seems to be active combinations in patients with HER2 positive MBC after T failure. The high ORR observed in this study might be explained, among other factors, by the inclusion of patients with less prior treatment exposure. No new safety signals where reported with these two novel Lapatinib/chemotherapy combinations. The different side effect profile may help in selecting the most appropriate regimen for a particular patient.

Sponsor: Latin American Cooperative Oncology Group (LACOG) with support from GlaxoSmithKline.

ClinicalTrials.gov number NCT01050322.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-26.

Intussusception risk and disease prevention associated with rotavirus vaccines in Australia's National Immunization Program

BACKGROUND

Estimates of the risk of intussusception (IS) associated with currently licensed rotavirus vaccines (RV1 [Rotarix; GSK] and RV5 [RotaTeq; Merck]) diverge. Contemporaneous introduction of both vaccines in Australia enabled a population-based assessment of risk.

METHODS

Confirmed cases of IS in infants aged 1 to <12 months were identified from national hospitalization databases, supplemented by active hospital-based surveillance, from July 2007 through June 2010. Vaccination histories were verified by the Australian Childhood Immunisation Register, which was also used to identify age-matched controls. Self-controlled case series and case-control methods were used to assess the risk of IS associated with both vaccines in prespecified periods after vaccination. The estimated burden of vaccine-attributable IS was compared with estimated reductions in gastroenteritis hospitalizations.

RESULTS

Based on 306 confirmed cases of IS, the relative incidence of IS in the 1-7-day period after the first vaccine dose, was 6.8 (95% confidence interval, 2.4-19.0; P < .001) for RV1, and 9.9 (95% confidence interval, 3.7-26.4; P < .001) for RV5. There was a smaller increased risk 1-7 days after the second dose of each vaccine. The case-control analysis gave similar results. We estimate an excess of 14 IS cases and >6500 fewer gastroenteritis hospitalizations in young children annually in Australia after vaccine introduction.

CONCLUSIONS

We found a similarly increased risk of IS after both vaccines, but the balance of benefits and risks at population level was highly favorable, a finding likely to extend to other settings despite varying incidence of IS and potentially higher morbidity and mortality from both gastroenteritis and IS.

Childhood intussusception: a literature review

Background

Postlicensure data has identified a causal link between rotavirus vaccines and intussusception in some settings. As rotavirus vaccines are introduced globally, monitoring intussusception will be crucial for ensuring safety of the vaccine programs.

Methods

To obtain updated information on background rates and clinical management of intussusception, we reviewed studies of intussusception in children <18 years of age published since 2002. We assessed the incidence of intussusception by month of life among children <1 year of age, seasonality, method of diagnosis, treatment, and case-fatality.

Findings

We identified 82 studies from North America, Asia, Europe, Oceania, Africa, Eastern Mediterranean, and Central & South America that reported a total of 44,454 intussusception events. The mean incidence of intussusception was 74 per 100,000 (range: 9–328) among children <1 year of age, with peak incidence among infants 5–7 months of age. No seasonal patterns were observed. A radiographic modality was used to diagnose intussusception in over 95% of the cases in all regions except Africa where clinical findings or surgery were used in 65% of the cases. Surgical rates were substantially higher in Africa (77%) and Central and South America (86%) compared to other regions (13–29%). Case-fatality also was higher in Africa (9%) compared to other regions (<1%). The primary limitation of this review relates to the heterogeneity in intussusception surveillance across different regions.

Conclusion

This review of the intussusception literature from the past decade provides pertinent information that should facilitate implementation of intussusception surveillance for monitoring the postlicensure safety of rotavirus vaccines.

P1-08-17: Pregnancy-Associated Breast Cancer Does Not Have a Worse Outcome in the 4912 Women with Breast Cancer of the AMAZONA Project

Introduction: Pregnancy traditionally is considered a protective factor for breast cancer. Recent data suggests that pregnancy-associated breast cancer (PABC), a distinct biologic variant possibly related to breast involution, can occur up to 10 years post-partum and may carry a worse prognosis than that of age matched sporadic or nulliparous breast cancer. The Amazona project is a retrospective cohort of 4,912 Brazilian women with breast cancer that has previously reported on worse outcomes of patients according to type of institution where treatment was received (San Antonio 2009 abstr. 3082). We have assessed the outcomes of PABC in the Amazona cohort.

Objectives: 1- To identify whether women who were diagnosed with breast cancer up to 10 years after their first pregnancy had worse disease free survival (DFS) and overall survival (OS) than nulliparous women (NW); 2- to assess if age at first pregnancy is related to age of breast cancer diagnosis and worse DFS or OS; 3- to assess whether number of pregnancies is associated with worse DFS or OS; 4- to assess whether time from first pregnancy to diagnosis or age of first pregnancy are associated with histological grade, clinical stage or tumor expression of ER, PR, and HER2.

Methods: We analyzed 4836 women for whom parous history was available, in respect to DFS, OS, tumor clinical stage, histological grade, expression of ER, PR and HER2, according to age of first pregnancy, diagnosis up to 5 and 10 years after first pregnancy, and number of pregnancies, using NW as controls. Analysis of DFS and OS was done by Cox regression modeling adjusted for institution type, stage, ER, PR, HER2 and grade.

Results: Our cohort had 1996 nulliparous women and 2840 parous women. The median follow up was 28 months and there were 318 deaths and 735 recurrences. We did not find any correlation between PABC with DFS (5 year interval HR 1.15, 95%CI 0.43−3.07; 10 year interval HR 1.01, 95%CI 0.57−1.81) or OS (5 year interval HR 1.88, 95%CI 0.6−5.94; 10 year interval HR 0.5, 95%CI 0.73−3.09), nor was there a correlation between age at first pregnancy with age of breast cancer diagnosis. We also did not see any difference between age of first pregnancy and DFS or OS.

Women with 3 or more pregnancies had worse OS (HR 0.71, 95%CI 0.54−0.93) but not worse DFS (HR 0.93, 95%CI 0.76−1.13).Tumors diagnosed within 5 or 10 years from first pregnancy did not differ by grade, ER, PR, HER2, and clinical stage from those of NW. Women who had their first pregnancy after age 20 tended to have more ER positive (OR 1.99, 95%CI 1.49−2.65), PR positive (OR 1.40, 95%CI 1.06−1.87), and HER2 positive (OR 1.85, 95%CI 1.22−2.79) tumors than NW.

Conclusions: In this large cohort of breast cancer patients from the diverse geographic and socioeconomic spectrum of Brazil we did not find any association between PABC or age of first pregnancy to DFS or OS. The association with worse OS but not DFS for women with 3 or more pregnancies might be due to confounding factors. PABC was not associated with worse clinical prognostic factors. Women who had their first pregnancy after age 20 were more likely to have ER+, PR+ and HER2 + tumors than nulliparous patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-17.

Long-term toxic effects of adjuvant chemotherapy in breast cancer

Breast cancer is the most common malignant tumor affecting women. Adjuvant systemic therapies have been shown to have a significant impact on reducing the risk for breast cancer recurrence and overall mortality. Chemotherapy remains an important and frequently used treatment option in the adjuvant setting, and the associated short-term adverse events are very well described. However, there is insufficient information regarding the long-term sequelae of most chemotherapeutic agents. In this review, we describe different potential long-term adverse events associated with adjuvant chemotherapy in breast cancer, with a particular focus on long-term cardiac toxicity, secondary leukemia, cognitive function, and neurotoxicity. In addition, we discuss the effect of adjuvant chemotherapy on fertility and sexual function of young breast cancer patients. These adverse events are frequently overshadowed by the well-demonstrated clinical efficacy and/or reassuring short-term safety profiles of the different chemotherapy regimens commonly used today. We believe that a proper understanding and appreciation of these adverse events will enable us to refine our strategies for managing breast cancer. The fact that adjuvant chemotherapy is often given to patients who might not really need it urges us to consider the whole spectrum of chemotherapy risks versus benefits to maximize benefit without compromising quality of life.

The burden of hospitalised rotavirus infections in Fiji

Rotavirus is the most common cause of acute severe dehydrating diarrhoea in young children worldwide. We describe the burden of rotavirus disease and the rotavirus types causing it in the largest city in Fiji. During 2006 and 2007, 592 children under 5 years of age were admitted to hospital in Suva, Fiji with acute diarrhoea. Of the 454 children for whom a stool specimen was tested, 39% were positive for rotavirus and the predominant strain found was the serotype G3[P8]. There is a significant burden of disease due to rotavirus in Fiji and the introduction of rotavirus vaccines into the national immunization schedule may drastically reduce inpatient diarrhoeal disease.

A prospective evaluation of combined modality therapy for breast cancer with ipsilateral supraclavicular node metastases

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Background: Based on retrospective data, the most recent breast cancer staging classification changed the status of ipsilateral supaclavicular node mestastases from M1 to N3c. This carried along with it modifications in the treatment of a small subset of breast cancer patients. The aim of this study is to prospectively evaluate surgery and radiation therapy besides systemic treatment in pts with stage IIIC breast cancer. Methods: Phase II single-institution trial. Eligibility: patients with non-metastatic breast cancer and pathological confirmation of ipsilateral supraclaviclular node metastases. Treatment: FAC (fluorouracil 500 mg/m2, doxorubicin 50 mg/m2 and cyclophosphamide 500 mg/m2) q 21 days × 6; followed by modified radical mastectomy (MRM); adjuvant radiotherapy and tamoxifen (if estrogen and/or progesterone receptors positive - ER/PR). Results: Since May 2002, 22 patients entered the trial, with a median follow-up of 25 months (4–50). Median age was 50 years (29–69). Median tumor size was 6 cm (2.5–15), most patients had T4 disease (77%) and ER/PR positive tumors (64%). All patients underwent MRM after neoadjuvant FAC. Clinical response: 1 (5%) complete, 20 (90%) partial, 1 (5%) minor response. Until December 2006, 13 patients progressed and 7 died. Five patients (23%) had loco-regional relapse and 5 (23%) developed brain metastases. Median estimated progression-free survival was 41 months (14.1–67.8) with median survival not reached. The estimated 2-year progression-free and overall survival rates were 32% and 67%, respectively. Conclusions: Our results, collected in a prospective fashion, are in agreement with previous retrospective studies. Combined-modality treatment for breast cancer with ipsilateral supraclavicular node metastases is recommended.

No significant financial relationships to disclose.

Molecular epidemiology of adenovirus isolates from patients diagnosed with intussusception in Melbourne, Australia

Twenty-one intussusception (IS)-associated and 59 temporally linked adenoviral isolates from clinical infections were compared. Species C (15/21 IS- and 32/59 non-IS-associated isolates) dominated. Of these, serotype 2 (AdV-2) (7/15 IS-associated isolates) and serotype 1 (AdV-1) (16/32 non-IS-associated isolates) were the most commonly identified serotypes. DNA restriction analysis of AdV-2 isolates identified six genomic types; of these, type D2 (3/7 IS- and 8/11 non-IS-associated isolates) was the dominant type after BamHI and SmaI digestion. IS-associated isolates are similar to circulating non-IS-associated strains.

Megestrol acetate after aromatase inhibitor failure in metastatic breast cancer

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Background: As aromatase inhibitors (AI) are now an essential component of the adjuvant hormonal treatment in breast cancer, it is important to define strategies after progression. Progestational agents have significant activity in endocrine-responsive breast cancer. This is the first report of megestrol acetate (MA) after AI failure. Methods: We have retrospectively reviewed the charts of all patients treated with MA for the last 2 years at the Instituto Nacional de Câncer, in Brazil. All the patients were postmenopausal and had metastatic breast cancer. The treatment sequence was as follows: tamoxifen ⋄ AI ⋄ MA. MA was given at a dose of 160 mg PO daily. Results: A total of 27 postmenopausal patients were treated between December 2003 and December 2005. Median age was 71 years (37–93). Seven patients had visceral metastases and 20 had bone, soft tissue or pleural disease. Eight patients are still on treatment. Median time to disease progression was 16 weeks (4–81), with no difference between those with or without visceral metastases: 17 and 16 weeks, respectively. Treatment was well tolerated and no patient discontinued therapy due to toxicity. There was no report of venous thromboembolism. Conclusions: Despite the limitations of a retrospective analysis, our results compare favorably with exemestane and high-dose estrogens in a similar setting. These agents have been studied in phase II trials (Lonning PE. JCO 18: 2234, 2000 and BCRT 67: 111, 2001) and showed time to progression of 15 and 18 weeks, respectively. A prospective trial of MA after AI failure is warranted.

No significant financial relationships to disclose.

Changing epidemiology of intussusception in Australia

OBJECTIVES

Oral rotavirus vaccines are expected to become available in Australia within the next 2 years. In light of evidence for an association between a rotavirus vaccine and intussusception, it is important to define the baseline epidemiology of intussusception in Australia and establish a system for intussusception surveillance in the immediate post-licensure period. This study reports on incidence and epidemiology of intussusception in Australia.

METHODS

Data were obtained from the Australian Institute of Health and Welfare on all patients with a discharge diagnosis of intussusception from public and private hospitals in each state and territory of Australia from 1994 to 2000. We examined age at presentation, sex, month and year of presentation, indigenous status and clinical outcomes. The incidence of intussusception was calculated and annual trends examined. Surveillance data on rotavirus gastroenteritis hospitalizations over the same time period were also obtained to compare seasonal patterns.

RESULTS

From 1994 to 2000, a 39% reduction in intussusception incidence in infants aged <1 year was observed in Australia (13.1/10,000 to 8.1/10,000; P < 0.001). The incidence of intussusception was lower in indigenous infants (3.3/10,000 <1 year) compared to non-indigenous infants (10.4/10,000 <1 year; P < 0.001). There was no association between the seasonality of rotavirus infection and intussusception. Only one of 12 deaths due to intussusception was reported in an infant <1 year.

CONCLUSIONS

This study documents the epidemiology of intussusception in Australia from 1994 to 2000 and provides important baseline information for future rotavirus vaccines. A lower risk of intussusception was identified in indigenous compared to non-indigenous infants.

Intussusception and rotavirus vaccines

The association between the first oral rotavirus vaccine to be licensed in the U.S. (Rotashield) and intussusception has presented a major challenge to the effort to reduce the global burden related to rotavirus infection. Although the risk of developing intussusception following immunization with Rotashield is low, debate continues about the estimation of intussusception risk and the events surrounding the withdrawal of the vaccine. The experience with Rotashield has highlighted the wisdom of parallel clinical trials in developing and developed countries and the value of post-licensure surveillance for the detection of uncommon adverse events. This review retraces the steps leading up to the withdrawal of the Rotashield vaccine and reflects on how this experience has influenced the development of other rotavirus vaccines.