Development and Temporal Validation of a Machine Learning Model to Predict Clinical Deterioration

OBJECTIVES

Early warning scores detecting clinical deterioration in pediatric inpatients have wide-ranging performance and use a limited number of clinical features. This study developed a machine learning model leveraging multiple static and dynamic clinical features from the electronic health record to predict the composite outcome of unplanned transfer to the ICU within 24 hours and inpatient mortality within 48 hours in hospitalized children.

METHODS

Using a retrospective development cohort of 17 630 encounters across 10 388 patients, 2 machine learning models (light gradient boosting machine [LGBM] and random forest) were trained on 542 features and compared with our institutional Pediatric Early Warning Score (I-PEWS).

RESULTS

The LGBM model significantly outperformed I-PEWS based on receiver operating characteristic curve (AUROC) for the composite outcome of ICU transfer or mortality for both internal validation and temporal validation cohorts (AUROC 0.785 95% confidence interval [0.780-0.791] vs 0.708 [0.701-0.715] for temporal validation) as well as lead-time before deterioration events (median 11 hours vs 3 hours; P = .004). However, LGBM performance as evaluated by precision recall curve was lesser in the temporal validation cohort with associated decreased positive predictive value (6% vs 29%) and increased number needed to evaluate (17 vs 3) compared with I-PEWS.

CONCLUSIONS

Our electronic health record based machine learning model demonstrated improved AUROC and lead-time in predicting clinical deterioration in pediatric inpatients 24 to 48 hours in advance compared with I-PEWS. Further work is needed to optimize model positive predictive value to allow for integration into clinical practice.

Abstract GS3-02: PALLET: A neoadjuvant study to compare the clinical and antiproliferative effects of letrozole with and without palbociclib

Background: CDK4/6 inhibitors, such as palbociclib, are used to treat ER+ metastatic breast cancer in combination with endocrine therapy with trials ongoing in patients with primary disease. No biomarkers exist to identify those who do/do not benefit from added CDK4/6 inhibition. PALLET is an investigator-initiated/led phase II randomized trial collaboration between UK and NSABP investigators evaluating the biological and clinical effects of palbociclib with letrozole combination as neoadjuvant therapy.

Methods: Postmenopausal women with ER+ primary breast cancer and tumors >2.0cm (ultrasound) were randomized to one of 4 treatment groups (3:2:2:2 ratio): Group A: letrozole (2.5mg/d) for 14 weeks; Group B: letrozole for 2 weeks followed by letrozole + palbociclib to 14 weeks; Group C: palbociclib for 2 weeks followed by letrozole + palbociclib to 14 weeks; Group D: letrozole + palbociclib for 14 weeks. Palbociclib was given 125mg/d PO on a 21 days on, 7 days off schedule. Post-14 week treatment was at the discretion of the treating clinician including letrozole until surgery. Core-cut biopsies were taken at baseline, 2 weeks and 14 weeks. Co-primary endpoints for letrozole alone vs palbociclib groups (Group A vs Groups B+C+D) were: (i) change in Ki67 (IHC) between baseline and 14 weeks (log-fold change, Mann-Whitney test); (ii) clinical response (ultrasound) after 14 weeks (4 group, ordinal, Mann-Whitney test). Complete cell-cycle arrest (CCCA) (Ki67≤2.7%) was analyzed using a logistic regression model adjusting for recruitment region. Pre-specified exploratory biomarkers included c-PARP (apoptosis).

Results: 307 patients were recruited between 27 Feb 2015 and 08 Mar 2018; 103 were randomized to letrozole alone and 204 to letrozole + palbociclib. 279 (90.9%) patients were evaluable for 14 week clinical response. Clinical response was not significantly different between letrozole vs letrozole + palbociclib groups [(p=0.20; CR+PR 49.5% (46/93) vs 54.3% (101/186) and PD 5.4% (5/93) vs 3.2% (6/186)] nor was the small proportion of patients with pathological CR (1/87, 1.1% vs 6/180, 3.3%; p=0.43). 190 (61.9%) patients were evaluable for 14 week change in Ki67. The median log-fold change in Ki67 was greater with letrozole + palbociclib vs letrozole alone (-4.1 vs -2.2; p<0.001) corresponding to a geometric mean change of -97.4% vs -88.5%. Similarly, a greater proportion of patients who received letrozole + palbociclib achieved CCCA (90% vs 59%, p<0.001). 146 (47.6%) patients were evaluable for c-PARP and the log-fold change (suppression) was greater with letrozole + palbociclib vs letrozole alone (-0.80 vs -0.42; p=0.003) corresponding to a geometric mean change of -56.8% vs -31.4%. Other biomarkers of response / resistance are being evaluated. A higher proportion of patients had a grade ≥3 toxicity on letrozole + palbociclib than letrozole alone (49.8% vs 17.0%; p<0.001) mainly due to asymptomatic neutropenia.

Conclusion: Adding palbociclib to letrozole markedly enhanced the suppression of malignant cell proliferation as assessed by Ki67 but did not substantially increase the clinical response of primary ER+ breast cancer over a 14-week period. Concurrent reductions in cell death may have reduced the speed of tumor shrinkage.

Citation Format: Dowsett M, Jacobs S, Johnston S, Bliss J, Wheatley D, Holcombe C, Stein R, McIntosh S, Barry P, Dolling D, Snowdon C, Perry S, Batten L, Dodson A, Martins V, Modi A, Cornman C, Puhalla S, Wolmark N, Julian T, Pogue-Geile K, Robidoux A, Provencher L, Boileau JF, Shalaby I, Thirlwell M, Fisher K, Huang Bartlett C, Koehler M, Osborne K, Rimawi M. PALLET: A neoadjuvant study to compare the clinical and antiproliferative effects of letrozole with and without palbociclib [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 GS3-02.

Identifying anticipated barriers to help-seeking to promote earlier diagnosis of cancer in Great Britain

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On average, people endorsed three barriers that would put them off seeing a GP.

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Women, younger people and more deprived groups were more likely to endorse barriers.

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Service-related barriers endorsed more than barriers related to GP–patient relations.

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Endorsement of not wanting to be seen making a fuss reveals more social element.

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The results suggest that there may be additional barriers influencing patient behaviour.

Enthusiasm for cancer screening in Great Britain: a general population survey

Background:

With growing concerns about risk of harm from cancer screening, particularly from overdiagnosis, this study aimed to assess public attitudes to cancer screening in Great Britain.

Methods:

We used a population-based survey to assess attitudes to cancer screening, screening history and demographic characteristics, in men and women aged 50–80 years. Data were collected using face-to-face computer-assisted interviews in 2012.

Results:

In our sample of 2024, attitudes to cancer screening were overwhelmingly positive with almost 90% believing that screening is ‘almost always a good idea' and 49% saying they would be tested for cancer even if it was untreatable. Attitudes were particularly positive among those who had previously taken part in breast or colorectal screening.

Conclusions:

Our findings suggest that attitudes to cancer screening are very positive in Great Britain. Widespread enthusiasm for cancer screening may hamper attempts to encourage a greater appreciation of the limitations and potential harms of screening.

The Global Invertebrate Genomics Alliance (GIGA): developing community resources to study diverse invertebrate genomes

Over 95% of all metazoan (animal) species comprise the "invertebrates," but very few genomes from these organisms have been sequenced. We have, therefore, formed a "Global Invertebrate Genomics Alliance" (GIGA). Our intent is to build a collaborative network of diverse scientists to tackle major challenges (e.g., species selection, sample collection and storage, sequence assembly, annotation, analytical tools) associated with genome/transcriptome sequencing across a large taxonomic spectrum. We aim to promote standards that will facilitate comparative approaches to invertebrate genomics and collaborations across the international scientific community. Candidate study taxa include species from Porifera, Ctenophora, Cnidaria, Placozoa, Mollusca, Arthropoda, Echinodermata, Annelida, Bryozoa, and Platyhelminthes, among others. GIGA will target 7000 noninsect/nonnematode species, with an emphasis on marine taxa because of the unrivaled phyletic diversity in the oceans. Priorities for selecting invertebrates for sequencing will include, but are not restricted to, their phylogenetic placement; relevance to organismal, ecological, and conservation research; and their importance to fisheries and human health. We highlight benefits of sequencing both whole genomes (DNA) and transcriptomes and also suggest policies for genomic-level data access and sharing based on transparency and inclusiveness. The GIGA Web site (http://giga.nova.edu) has been launched to facilitate this collaborative venture.

Safety and efficacy of everolimus with exemestane vs. exemestane alone in elderly patients with HER2-negative, hormone receptor-positive breast cancer in BOLERO-2

BACKGROUND

Postmenopausal women with hormone receptor-positive (HR(+)) breast cancer in whom disease progresses or there is recurrence while taking a nonsteroidal aromatase inhibitor (NSAI) are usually treated with exemestane (EXE), but no single standard of care exists in this setting. The BOLERO-2 trial demonstrated that adding everolimus (EVE) to EXE improved progression-free survival (PFS) while maintaining quality of life when compared with EXE alone. Because many women with HR(+) advanced breast cancer are elderly, the tolerability profile of EVE plus EXE in this population is of interest.

PATIENTS AND METHODS

BOLERO-2, a phase III randomized trial, compared EVE (10 mg/d) and placebo (PBO), both plus EXE (25 mg/d), in 724 postmenopausal women with HR(+) advanced breast cancer recurring/progressing after treatment with NSAIs. Safety and efficacy data in elderly patients are reported at 18-month median follow-up.

RESULTS

Baseline disease characteristics and treatment histories among the elderly subsets (≥ 65 years, n = 275; ≥ 70 years, n = 164) were generally comparable with younger patients. The addition of EVE to EXE improved PFS regardless of age (hazard ratio, 0.59 [≥ 65 years] and 0.45 [≥ 70 years]). Adverse events (AEs) of special interest (all grades) that occurred more frequently with EVE than with PBO included stomatitis, infections, rash, pneumonitis, and hyperglycemia. Elderly EVE-treated patients had similar incidences of these AEs as did younger patients but had more on-treatment deaths.

CONCLUSION

Adding EVE to EXE offers substantially improved PFS over EXE and was generally well tolerated in elderly patients with HR(+) advanced breast cancer. Careful monitoring and appropriate dose reductions or interruptions for AE management are recommended during treatment with EVE in this patient population.

Interrater variation in scoring radiological discrepancies

OBJECTIVE

Discrepancy meetings are an important aspect of clinical governance. The Royal College of Radiologists has published advice on how to conduct meetings, suggesting that discrepancies are scored using the scale: 0=no error, 1=minor error, 2=moderate error and 3=major error. We have noticed variation in scores attributed to individual cases by radiologists and have sought to quantify the variation in scoring at our meetings.

METHODS

The scores from six discrepancy meetings totalling 161 scored events were collected. The reliability of scoring was measured using Fleiss' kappa, which calculates the degree of agreement in classification.

RESULTS

The number of cases rated at the six meetings ranged from 18 to 31 (mean 27). The number of raters ranged from 11 to 16 (mean 14). Only cases where all the raters scored were included in the analysis. The Fleiss' kappa statistic ranged from 0.12 to 0.20, and mean kappa was 0.17 for the six meetings.

CONCLUSION

A kappa of 1.0 indicates perfect agreement above chance and 0.0 indicates agreement equal to chance. A rule of thumb is that a kappa ≥0.70 indicates adequate interrater agreement. Our mean result of 0.172 shows poor agreement between scorers. This could indicate a problem with the scoring system or may indicate a need for more formal training and agreement in how scores are applied.

ADVANCES IN KNOWLEDGE

Scoring of radiology discrepancies is highly subjective and shows poor interrater agreement.

Abstract P6-10-03: The PKC inhibitor PKC412 antagonizes breast cancer cell growth and enhances tamoxifen sensitivity

Background: AIB1 (SRC-3, NCoA3), a member of the p160/steroid receptor coactivators family, plays a critical role in cell growth and proliferation. In estrogen receptor-alpha positive (ER+) breast cancer (BC) cells, it coactivates estrogen- and additional transcription factors-dependent gene transcription, reducing the antagonistic activity of tamoxifen and resulting in tamoxifen resistance (TR). We have previously shown that BC patients whose tumors expressed high levels of both AIB1 and HER-2 had worse outcomes with tamoxifen therapy, suggesting that AIB1 may be an important diagnostic and therapeutic target. Our findings that knocking down AIB1 attenuates ER signaling and inhibits breast cancer cell growth further indicate that the manipulation of AIB1 level could be an approach to treating BC and overcoming TR. Recently, it has been shown that protein kinase C (PKC) isoforms phosphorylate AIB1 and prevent its proteasome-mediated degradation. The present study was carried out to test if the multi-targeted kinase and PKC inhibitor PKC412 (midostaurin) is capable of promoting degradation of AIB1, inhibiting BC cell growth, and promoting tamoxifen antagonistic activity.

Methods: The ER+ MCF7, T47D, and ZR75-B BC cells and their tamoxifen-resistant derivatives (TR) were used. The Methylene Blue assay was employed to measure cell viability of BC cell lines after treatment with PKC412 or the combination of PKC412 with tamoxifen. To determine the impact of PKC412 on AIB1 and ER proteins and mRNA levels, we used immunoblotting and RT-qPCR, respectively.

Results: PKC412 successfully inhibited the growth of MCF7, T47D, and ZR75-B cells, and their tamoxifen-resistant derivatives. Treatment with PKC412 depleted AIB1 protein and reduced the level of ER protein without significant alteration in AIB1 mRNA level. Consequently, ER signaling was disrupted, as reflected by decreased expression of ER target genes such as GREB1. PKC412 also enhanced tamoxifen's antagonistic activity in the parental cell lines and sensitized tamoxifen-resistant MCF7 and ZR75-B cells to tamoxifen.

Conclusions: The results of this study suggest that the multi-targeted kinase and PKC inhibitor PKC412 can post-translationally destabilize AIB1 protein and ER, inhibiting BC cell growth and viability. PKC412 enhances tamoxifen's antagonistic activity on BC growth; furthermore, it sensitizes tamoxifen-resistant cells to tamoxifen. Thus, PKC412 is a promising agent to treat BC and, in combination with tamoxifen, to delay or overcome TR.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-10-03.

Abstract P2-16-02: A web-based data management system for a multicenter international breast cancer oriented blood, tissue, and data biobank

The quality of biospecimens and associated data must be consistent and collected according to standardized methods in order to achieve international harmonization and coordination among biobanking networks.

Sharing successful strategies between the Baylor College of Medicine (BCM) Cancer Center and Breast Center Buenos Aires (BCBA) is the driving force for the creation of an Argentinean Breast Cancer oriented Biobank with a shared data management system.

Objective: To create a bilingual web-based tool for biospecimen management, inventory, clinical and breast cancer data registration according to international standards of data security quality assurance (ISO 27001).

Methods/System Characteristics: The system permits users to enter and retrieve data concerning the collection, storage, quality assurance and distribution of biospecimens, and provides clinical and other patient data for samples while maintaining strict patient confidentiality.

It has a multi-tier architecture, developed using Service-Oriented Architecture (SOA) software design principles in .net 4.0, and uses a SQL server database backbone. The system allows multidimensional data analysis trough On Line Analytical Processes (OLAP) and operates with standard web clients, such as Internet Explorer.

User Profiles/Access Levels: Clinical staff (e.g., clinical research coordinator, phlebotomist, pathologist, PA, MD) conduct participant and consent registration and preregistration, epidemiological questionnaire data entry, barcode label generation, form printing, and clinical and pathological cancer data entry.Biospecimen resource staff (e.g., lab technicians) track and store data about biospecimen collection, inventory, tracking and distribution, generate sample barcode labels, and maintain sample allocation and freezer maps for the system.Scientists have the ability to search for biospecimens and associated data for their own translational research projects.

Breast Cancer Database: Detailed clinical, pathological, treatment and follow-up breast cancer information are captured for each patient, including TNM, biopsy and definitive surgery of primary tumor and events, systemic and radiation treatment, recurrences and metastasis, follow-up. A summary screen provides a snapshot of these data to the viewer. Pathology reports and sample collection forms are attached in each corresponding biopsy or surgery screen for easy viewing and quality assurance.

Conclusion: This Biobank Management System was designed by a multidisciplinary team to improve and streamline the workflow for each member of the biobank by: allowing preregistration capabilities before consenting individuals or collecting samples, automatic generation of clinical and sample ID labels, and real-time statistics with certified secure sensible information confidentiality. This system's value is its wide range of uses, from the day-to-day management of a multicenter biobank to the storage of detailed clinical cancer-related data in a user-friendly and intuitive data entry environment.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-16-02.

A family-based paradigm to identify candidate chromosomal regions for isolated congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a developmental defect of the diaphragm that causes high newborn mortality. Isolated or non-syndromic CDH is considered a multifactorial disease, with strong evidence implicating genetic factors. As low heritability has been reported in isolated CDH, family-based genetic methods have yet to identify the genetic factors associated with the defect. Using the Utah Population Database, we identified distantly related patients from several extended families with a high incidence of isolated CDH. Using high-density genotyping, seven patients were analyzed by homozygosity exclusion rare allele mapping (HERAM) and phased haplotype sharing (HapShare), two methods we developed to map shared chromosome regions. Our patient cohort shared three regions not previously associated with CDH, that is, 2q11.2-q12.1, 4p13 and 7q11.2, and two regions previously involved in CDH, that is, 8p23.1 and 15q26.2. The latter regions contain GATA4 and NR2F2, two genes implicated in diaphragm formation in mice. Interestingly, three patients shared the 8p23.1 locus and one of them also harbored the 15q26.2 segment. No coding variants were identified in GATA4 or NR2F2, but a rare shared variant was found in intron 1 of GATA4. This work shows the role of heritability in isolated CDH. Our family-based strategy uncovers new chromosomal regions possibly associated with disease, and suggests that non-coding variants of GATA4 and NR2F2 may contribute to the development of isolated CDH. This approach could speed up the discovery of the genes and regulatory elements causing multifactorial diseases, such as isolated CDH.

Safety of everolimus for women over age 65 with advanced breast cancer (BC): 12.5-month follow-up of BOLERO-2

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Background: Postmenopausal women with estrogen-receptor–positive (ER+) BC who relapse/progress on a nonsteroidal aromatase inhibitor (NSAI) are usually treated with the steroidal AI exemestane (EXE), but there is no currently approved treatment for this indication. The BOLERO-2 trial showed that adding everolimus (EVE), an oral inhibitor of mammalian target of rapamycin (mTOR), to EXE significantly improved clinical benefit beyond that of EXE alone (Hortobagyi et al, SABCS 2011, Abstract S3-7). As many women with advanced BC are elderly, the tolerability profile of EVE + EXE in this population is of interest. Methods: BOLERO-2 is a phase III, randomized trial comparing EVE (10 mg once daily) vs placebo (PBO), both plus EXE (25 mg once daily), in postmenopausal women with advanced ER+ BC progressing or recurring after NSAIs. Safety data with a focus on elderly patients are reported at 12.5 months’ median follow-up. Results: Baseline disease characteristics, age, and prior cancer therapy were well balanced between treatment arms (N = 724). At 12.5 months’ median follow-up, the addition of EVE to EXE significantly improved progression-free survival in patients <65 (HR, 0.37; p < .05) or ≥65 years of age (HR, 0.56; p < .05). Adverse events (AEs) of special interest (all grades) occurring more frequently with EVE vs PBO (overall study population) included stomatitis (66.6% vs 11.3%), infection (50.4% vs 25.2%), rash (44.0% vs 8.4%), pneumonitis (18.7% vs 0.4%), and hyperglycemia (15.4% vs 2.5%). Elderly EVE-treated patients (≥65 years) had similar or marginally lower incidence of stomatitis (52.1%), rash (32.3%), pneumonitis (14.6%), and hyperglycemia (12.5%) compared with the overall population. Grade 3-4 AEs in patients ≥70 years of age (n = 161) reported only among patients receiving EVE (n = 118) included fatigue (10.2%), anemia (10.2%), hyperglycemia (8.5%), stomatitis (7.6%), dyspnea (6.8%), pneumonitis (5.1%), neutropenia (3.4%), and hypertension (3.4%). Conclusions: Adding EVE to EXE was well tolerated in the overall population and in elderly patients with advanced BC; grade 3-4 AEs were uncommon and manageable. Overall, AEs were consistent with the known safety profile of EVE.

A critical review why assessment of steroid hormone receptors in breast cancer should be quantitative

Steroid receptors have been around in the field of breast cancer for decades now. Still, controversy remains on how best to report steroid receptors. In this review, we will convince the reader why benefits outweigh pitfalls, when reporting steroid receptors in a quantitative rather than qualitative way. Summarizing decades of research in this field, we will explore the evidence why quantitative reporting is superior in all settings (neoadjuvant, adjuvant and metastatic settings). Furthermore, we will also summarize different staining methods, definitions and pitfalls that have shown to be important points of discussion in earlier debates. Although the molecular unraveling of breast cancer in the past decade has revolutionized the way we think about breast cancer, we should not easily abandon the classical pathological variables such as steroid receptors in favor of molecular tools.

Safety of everolimus for women over 65 years of age with advanced breast cancer (BC): 12.5-mo follow-up of BOLERO-2

551

Background: Postmenopausal women with estrogen-receptor–positive (ER+) BC who relapse/progress on a nonsteroidal aromatase inhibitor (NSAI) are usually treated with the steroidal AI exemestane (EXE); but there is no currently approved treatment for this indication. The BOLERO-2 trial showed that adding everolimus (EVE), an oral inhibitor of mammalian target of rapamycin (mTOR), to EXE significantly improved clinical benefit beyond that of EXE alone (Hortobagyi et al, SABCS 2011, Abstract S3-7). As many women with advanced BC are elderly, the tolerability profile of EVE + EXE in this population is of interest. Methods: BOLERO-2 is a phase III, randomized, trial comparing EVE (10 mg once daily) vs placebo (PBO), both plus EXE (25 mg once daily) in postmenopausal women with advanced ER+ BC progressing or recurring after NSAIs. Safety data with a focus on elderly patients are reported at 12.5 mo median follow-up. Results: Baseline disease characteristics, age, and prior cancer therapy were well balanced between treatment arms (N = 724). At 12.5 months’ median follow-up, the addition of EVE to EXE significantly improved progression-free survival in patients <65 (HR = 0.37; P < .05) or ≥65 years of age (HR = 0.56; P < .05). Adverse events (AEs) of special interest (all grades) occurring more frequently with EVE vs PBO (overall study population) included stomatitis (66.6% vs 11.3%), infections (50.4% vs 25.2%), rash (44.0% vs 8.4%), pneumonitis (18.7% vs 0.4%), and hyperglycemia (15.4% vs 2.5%). Elderly EVE-treated patients (≥65 years) had similar or marginally lower incidence of stomatitis (52.1%), rash (32.3%), pneumonitis (14.6%), and hyperglycemia (12.5%) compared with the overall population. Grade 3/4 AEs in patients ≥70 years of age (n = 161) reported only among patients receiving EVE (n = 118) included fatigue (10.2%), anemia (10.2%), hyperglycemia (8.5%), stomatitis (7.6%), dyspnea (6.8%), pneumonitis (5.1%), neutropenia (3.4%), and hypertension (3.4%). Conclusions: Adding EVE to EXE was well tolerated in the overall population and in elderly patients with advanced BC; grade 3/4 AEs were uncommon and manageable. Overall, AEs were consistent with the known safety profile of EVE.

Vandetanib, a Dual Inhibitor of Vascular Endothelial Growth Factor Receptor (VEGFR) and Epidermal Growth Factor Receptor (HER1), Potentiates Anti-Tumor Effects of Combined Endocrine and Trastuzumab Treatment in Estrogen Receptor-Positive (ER+)/HER2-Overexpressing Xenografts

Background: Compelling evidence suggests that cross-talk between the pathways of ER and HER1/HER2 contributes to endocrine resistance. Using a xenograft model of human ER+ breast cancer cells engineered to overexpress HER2 (MCF-7/HER2-18), we have shown that tamoxifen (Tam) stimulates tumor growth resulting in de novo resistance. Anti HER1/HER2 targeted treatment overcomes this Tam resistant phenotype, though these effects are transient using single agents like the anti-HER2 antibody trastuzumab (T), thus suggesting that a more potent anti-HER therapy or simultaneous inhibition of alternative pathways is required to reverse resistance. Both ER and HER2 are known to promote angiogenesis. Vandetanib (V) (ZD6474, ZACTIMA) is an orally active, VEGFR/HER1 tyrosine kinase inhibitor that has shown both anti-angiogenic and anti tumor cell activities in different models. We thus hypothesize that in ER+/HER2+ tumors, the addition of V to the combination regimen of Tam+T would increase antitumor effect and delay onset of resistance due to inhibition of tumor angiogenesis and delivery of a more complete blockade of the HER network.Methods: Mice bearing MCF-7/HER2-18 tumors were randomized and treated with Tam given alone or in combination with T (10 mg/Kg, bi-weekly), V (50 mg/Kg, 5 d/week), or T+V. Tumor volumes were followed weekly. Mean tumor regression (M-TR) ± SD and median time to tumor progression (M-TTP, defined by tumor doubling from its size at randomization) and 95% CIs were analyzed by Wilcoxon Rank Sum and survival analysis methods (Kaplan-Meier estimates and generalized Wilcoxon test), respectively. All statistical tests were two-sided and adjusted (Holm) for multiple comparisons.Results: Tam monotherapy had minimal effect on tumor growth (M-TR 22%±15 SD) after which all tumors progressed rapidly [M-TTP 42 (35-56) days, 95% CI]. The addition of either T or V to Tam significantly improved tumor regression compared to Tam monotherapy (M-TR 66%±27, P=0.0012, and 67%±25, P=0.001, respectively) and significantly delayed time to tumor progression [M-TTP 91 (70-119) days, P=0.012, and 77 (63-98) days, P=0.02, respectively]. However, the combined regimen of T+V with Tam was significantly more effective than either T or V added separately to Tam, resulting in further significant tumor regression (M-TR 81%±29, P=0.0086 vs. T and 0.0012 vs. V) and a prolonged M-TTP (&gt;154 d, P=0.02 vs. T and 0.01 vs. V).Conclusions: This study supports the concept that the dual VEGFR/HER1 inhibitor vandetanib can improve efficacy of combined endocrine and anti-HER trastuzumab therapy in ER+/HER2+ tumors, probably due to angiogenesis inhibition and to a more potent blockade of HER family signaling and its cross-talk with ER. Clinical studies to examine this approach are warranted.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5128.

Modeling inheritance of malignant melanoma with DNA markers in Sinclair swine

Cutaneous malignant melanoma in Sinclair swine is a hereditary disease that develops in utero or during the first 6 weeks of life. In many cases, the tumors regress and piglets survive the disease. Two different sets of gene(s) might be involved in the disease: tumor initiator (suppressor) locus or loci and loci affecting the aggressiveness of the disease (number and stage of tumors). We develop maximum-likelihood methods for interval mapping for both types of loci. The experimental design consisted of a boar mated to tumor-bearing sows with recording of tumor status and number of tumors in the 6 weeks of life of the offspring. The model to search for the tumor initiator locus (with alleles T and t) was tested by computer simulation. Estimates of penetrances (Psi(TT) and Psi(Tt) for genotypes TT and Tt, respectively) were accurate even for small family sizes. Statistical power was >99% for a family size of 70 with Psi(TT) = 1 and Psi(Tt) = 0. The models to test for number of tumors incorporated genotype information for the tumor initiator locus. All models were tested with data from a single boar family of 72 piglets over swine chromosomes 6 and 8 (SSC6 and SSC8). No tumor evidence for initiator loci was found associated with these chromosomes. However, association of a QTL affecting number of tumors at birth near microsatellite SW1953 on SSC8 was chromosomewise significant (P<0.0124).

Stewardship and accountability

In March 2003 The Chronicle for Philanthropy reported a sea change in fund development. After 25 years of consistent research on donor motivation, a study came out with new information. Donors ranked on a scale of 1-10 what mattered most to them when considering giving. Until now, most donors reported that a belief in the mission of the organization and the desire to have an impact on the people served was their number one motivation. Certainly gratitude for life-saving or life-changing service made that belief in mission and impact that much more powerful as a motivation. Improving their community was consistently the number two reason for giving. But, according to the 2003 survey, something changed. Six of the 10 reasons involve stewardship and accountability.

Substance abuse by pregnant women: legal and ethical concerns

Court-ordered detention and prosecution of a pregnant woman for substance abuse is an unusual but increasing occurrence in the United States. At least 24 states have attempted to prosecute a pregnant woman on a variety of charges for suspected harm to the fetus. This article reviews the issues involved including personal autonomy duty of caregivers to women and fetuses, and ethical frameworks for discussion.

The European Sero-Epidemiology Network: standardizing the enzyme immunoassay results for measles, mumps and rubella

The ESEN (European Sero-Epidemiology Network) project was established to harmonize the seroepidemiology of five vaccine preventable infections including measles, mumps and rubella in eight European countries. This involved achieving comparability both in the assay results from testing in different centres and also sampling methodology. Standardization of enzyme immunoassay results was achieved through the development of common panels of sera by designated reference centres. The panels were tested at the reference laboratory and then distributed to each participating laboratory for testing using their routine methods. Standardization equations were calculated by regressing the quantitative results against those of the reference laboratory. Our study found large differences in unitage between participants, despite all using an EIA method standardized against an international or local standard. Moreover, our methodology adjusted for this difference. These standardization equations will be used to convert the results of main serosurvey testing into the reference country unitage to ensure inter-country comparability.

Ten years of serological surveillance in England and Wales: methods, results, implications and action

BACKGROUND

The first age-stratified serological survey of antibody to measles, mumps and rubella in the UK was conducted in 1986/87 prior to the introduction of MMR vaccine into the immunization programme. Serum collection and testing have continued annually, allowing trends over time to be monitored. These sera have also been available for ad hoc surveys of other infections.

METHODS

Residual sera are collected in participating laboratories and sent to a central store where they are irrevocably unlinked from identifying data. A unique identity number is assigned to each serum and details of age and sex are collated on a database. The sera are accessed for testing as required.

RESULTS

The results of recurring and other surveys performed over the last ten years are presented. These demonstrate that opportunistic serum samples are an ideal resource for serological surveillance programmes.

CONCLUSIONS

The serological surveillance programme has provided past exposure profiles for many infections. These data have resulted in a number of national policy changes and have been instrumental in shaping the UK vaccination programme.

Multiregional evaluation of the SimPlate heterotrophic plate count method compared to the standard plate count agar pour plate method in water

A new SimPlate heterotrophic plate count (HPC) method (IDEXX Laboratories, Westbrook, Maine) was compared with the pour plate method at 35 degrees C for 48 h. Six laboratories tested a total of 632 water samples. The SimPlate HPC method was found to be equivalent to the pour plate method by regression analysis (r = 0. 95; y = 0.99X + 0.06).

ESEN: a comparison of vaccination programmes - Part three : measles mumps and rubella

Cet article est le dernier d une serie de trois articles portant sur la comparaison, dans huit pays (Danemark, Angleterre et Pays de Galles, Finlande, France, Allemagne, Italie, Suede et Pays-Bas), des programmes vaccinaux et de l impact epidemiologique d

ESEN : a comparison of vaccination programmes Part two : pertussis

This article is the second of a series of three, which compare vaccination programmes, immunisation schedules, vaccine coverage, and the epidemiological impact of vaccination for diphtheria, pertussis, measles, mumps, and rubella in eight countries (Denma

ESEN : a comparison of vaccination programmes Part one: diphtheria

The aim of the European Sero-Epidemiology Network (ESEN) is to coordinate and harmonise the serological surveillance of immunity to vaccine preventable diseases in eight countries in Europe (Denmark, England, France, Germany, Italy, the Netherlands, Finla

Mortality of United Kingdom acrylonitrile workers--an extended and updated study

The mortality experience of 2763 men employed between 1950 and 1978 for at least 1 year at 6 factories involved in the polymerization of acrylonitrile and the spinning of acrylic fiber was followed to the end of 1991. Overall, cancer deaths did not exceed the expected numbers. There were, however, excess cancer deaths among the workers in the jobs more highly exposed to acrylonitrile. The excesses did not reach conventional levels of statistical significance apart from an excess of lung cancer among workers under 45 years of age. Detailed analyses provided no consistent support for a causal association between acrylonitrile exposure and carcinogenesis. The limitations of the study, including a lack of information on smoking habits and very limited estimates of acrylonitrile exposure, need to be borne in mind.

The European Sero-Epidemiology Network

The purpose of serological surveillance is to monitor levels of immunity to particular diseases within a population in order to enhance the quality of information on which public health measures, such as vaccination programmes, are based. Serological surv

General practices and health and safety at work

There is a lack of knowledge and understanding of health and safety legislation in general practice surgeries. As a result, compliance with such laws is also seriously lacking. However, both knowledge and compliance can be significantly improved through information, guidance and contact with the Health and Safety Executive (HSE).

Phase II trial of 5-fluorouracil and high-dose folinic acid as first- or second-line therapy for advanced breast cancer

The use of leucovorin to modulate 5-fluorouracil (FUra)-mediated inhibition of thymidylate synthase has been shown both in vitro and in vivo to improve the antitumor activity of FUra. Based on the activity of this combination in previously untreated patients, we performed a study of FUra and high-dose leucovorin (HDFA) in patients with metastatic breast cancer and minimal prior chemotherapy. Patients were stratified by prior chemotherapy (or relapse within 12 months of completing adjuvant chemotherapy) versus no prior chemotherapy (or relapse at greater than 12 months since completion of adjuvant chemotherapy). FUra was given daily for 5 days at 370 mg/m2/day with HDFA, 500 mg/m2/day, beginning 24 hours before and continuing 12 hours beyond the first and last FUra doses, respectively. Two objective responses occurred among 21 patients in the pretreated group (10%; 95% confidence interval: 1-30%). Four of 36 eligible patients (11%) in the "no prior therapy group" had complete responses (95% confidence interval: 3-26%). The major toxicities were moderate leucopenia and mucositis. We conclude that FUra plus leucovorin has modest antitumor activity in metastatic breast cancer.

Improved curveball hitting through the enhancement of visual cues

This study investigated the effectiveness of using visual cues to highlight the seams of baseballs to improve the hitting of curveballs. Five undergraduate varsity baseball team candidates served as subjects. Behavior change was assessed through an alternating treatments design involving unmarked balls and two treatment conditions that included baseballs with 1/4-in. and 1/8-in. orange stripes marking the seams of the baseballs. Results indicated that subjects hit a greater percentage of marked than unmarked balls. These results suggest that the addition of visual cues may be a significant and beneficial technique to enhance hitting performance. Further research is suggested regarding the training procedures, effect of feedback, rate of fading cues, generalization to live pitching, and generalization to other types of pitches.

Shedding and survival of herpes simplex virus from 'fever blisters'

Shedding of herpesvirus by adults with herpes labialis and survival of the virus in the environment were examined. In nine adults with virus-positive herpes labialis, herpesvirus was detected in the anterior oral pool of seven (78%) and on the hands of six (67%). Herpesviruses isolated from patients with oral lesions were found to survive for as long as two hours on skin, three hours on cloth, and four hours on plastic. These findings support earlier recommendations for the protection of neonates from adults with "fever blisters." In addition, environmental surfaces may be a source of transmission of herpesvirus to the neonate.