Stay on Track: A Pilot Randomized Control Trial on the Feasibility of a Diet and Exercise Intervention in Patients with Breast Cancer Receiving Radiotherapy

PURPOSE

Among patients with breast cancer undergoing radiotherapy, posttreatment cardiovascular disease and worsened quality of life (QoL) are leading causes of morbidity and mortality. To overcome these negative radiotherapy effects, this prospective, randomized clinical trial pilots a 12-week Stay on Track exercise and diet intervention for overweight patients with nonmetastatic breast cancer undergoing whole-breast radiotherapy.

EXPERIMENTAL DESIGN

The intervention group (n = 22) participated in three personal exercise and dietary counseling sessions, and received three text reminders/week to adhere to recommendations. The control group (n = 22) was administered a diet/exercise information binder. All patients received a Fitbit, and at baseline, 3 months, and 6 months, measurements of biomarkers, dual-energy X-ray absorptiometry scans, QoL and physical activity surveys, and food frequency questionnaires were obtained. A satisfaction survey was administered at 3 months.

RESULTS

Stay on Track was well received, with high rates of adherence and satisfaction. The intervention group showed an increase in self-reported physical activity and preserved QoL, a decrease in body mass index and visceral fat, and higher American Cancer Society/American Institute of Cancer Research dietary adherence. The control participants had reduced QoL, anti-inflammatory markers, and increased metabolic syndrome markers. Both groups had decreased overall body mass. These changes were within group effects. When comparing the intervention and control groups over time, there were notable improvements in dietary adherence in the intervention group.

CONCLUSIONS

Targeted lifestyle interventions during radiotherapy are feasible and could decrease cardiovascular comorbidities in patients with breast cancer. Larger-scale implementation with longer follow-up can better determine interventions that influence cardiometabolic health and QoL.

SIGNIFICANCE

This pilot study examines cardiometabolic benefits of a combined diet and exercise intervention for patients with breast cancer undergoing radiotherapy. The intervention included an activity tracker (FitBit) and text message reminders to promote adherence to lifestyle interventions. Large-scale implementation of such programs may improve cardiometabolic outcomes and overall QoL among patients with breast cancer.

Dietary and serum advanced glycation end-products and clinical outcomes in breast cancer

One in five women with breast cancer will relapse despite ideal treatment. Body weight and physical activity are strongly associated with recurrence risk, thus lifestyle modification is an attractive strategy to improve prognosis. Trials of dietary modification in breast cancer are promising but the role of specific diets is unclear, as is whether high-quality diet without weight loss can impact prognosis. Advanced glycation end-products (AGEs) are compounds produced in the body during sugar metabolism. Exogenous AGEs, such as those found in food, combined with endogenous AGEs, make up the total body AGE load. AGEs deposit in tissues over time impacting cell signaling pathways and altering protein functions. AGEs can be measured or estimated in the diet and measured in blood through their metabolites. Studies demonstrate an association between AGEs and breast cancer risk and prognosis. Here, we review the clinical data on dietary and serum AGEs in breast cancer.

Frequency of Hepatic Metastatic Disease in Patients with Stage IV Breast Cancer Is Similar for Steatotic and Non-Steatotic Livers

Background

Breast cancer is the most common non-cutaneous malignancy and the second leading cause of cancer mortality in the United States. Breast cancer is a heterogeneous disease; diagnosis at an early stage renders it potentially curable, whereas advanced metastatic disease carries a worse prognosis.

Objectives

To investigate whether hepatic steatosis (HS) is associated with liver metastases in patients with newly diagnosed stage IV female breast cancer patients (either de novo metastatic breast cancer or recurrent metastatic breast cancer) using non-contrast computed tomography (CT) as a marker of HS.

Design

Retrospective analysis.

Methods

We retrospectively identified 168 patients with stage IV breast cancer with suitable imaging from a prospectively maintained oncologic database. Three radiologists manually defined hepatic regions of interest on non-contrast CT images, and attenuation data were extracted. HS was defined as a mean attenuation <48 Hounsfield units. The frequency of hepatic metastatic disease was calculated for patient with and without HS. Relationships between HS and various patient (age, body mass index, race) and tumor (hormone receptor status, HER2 status, tumor grade) characteristics were also analyzed.

Results

There were 4 patients with liver metastasis in the HS group (41 patients) versus 20 patients with liver metastases in the non-HS group (127 patients). The difference in frequencies of liver metastases among patients with (9.8%) versus without (15.7%) hepatic steatosis (odds ratio = 1.72 [0.53-7.39]) was not statistically significant (P = .45). Body mass index was significantly higher (P = .01) among patients with hepatic steatosis (32.2 ± 7.3 vs 28.8 ± 7.1 kg/m2). Otherwise, there were no significant differences between patients with versus without HS with respect to regarding age, race, hormone receptor status, HER2 status, or tumor grade.

Conclusion

The frequency of hepatic metastatic disease in patients with stage IV breast cancer is similar for steatotic and non-steatotic livers.

Genomic Complexity Predicts Resistance to Endocrine Therapy and CDK4/6 Inhibition in Hormone Receptor-Positive (HR+)/HER2-Negative Metastatic Breast Cancer

PURPOSE

Clinical biomarkers to identify patients unlikely to benefit from CDK4/6 inhibition (CDK4/6i) in combination with endocrine therapy (ET) are lacking. We implemented a comprehensive circulating tumor DNA (ctDNA) analysis to identify genomic features for predicting and monitoring treatment resistance.

EXPERIMENTAL DESIGN

ctDNA was isolated from 216 plasma samples collected from 51 patients with hormone receptor-positive (HR+)/HER2-negative (HER2-) metastatic breast cancer (MBC) on a phase II trial of palbociclib combined with letrozole or fulvestrant (NCT03007979). Boosted whole-exome sequencing (WES) was performed at baseline and clinical progression to evaluate genomic alterations, mutational signatures, and blood tumor mutational burden (bTMB). Low-pass whole-genome sequencing was performed at baseline and serial timepoints to assess blood copy-number burden (bCNB).

RESULTS

High bTMB and bCNB were associated with lack of clinical benefit and significantly shorter progression-free survival (PFS) compared with patients with low bTMB or low bCNB (all P < 0.05). Dominant APOBEC signatures were detected at baseline exclusively in cases with high bTMB (5/13, 38.5%) versus low bTMB (0/37, 0%; P = 0.0006). Alterations in ESR1 were enriched in samples with high bTMB (P = 0.0005). There was a high correlation between bTMB determined by WES and bTMB determined using a 600-gene panel (R = 0.98). During serial monitoring, an increase in bCNB score preceded radiographic progression in 12 of 18 (66.7%) patients.

CONCLUSIONS

Genomic complexity detected by noninvasive profiling of bTMB and bCNB predicted poor outcomes in patients treated with ET and CDK4/6i and identified early disease progression before imaging. Novel treatment strategies including immunotherapy-based combinations should be investigated in this population.

Prospective associations between accelerometry-derived physical activity and sedentary behaviors and mortality among cancer survivors

BACKGROUND

Survival benefits of self-reported recreational physical activity (PA) during cancer survivorship are well-documented in common cancer types, yet there are limited data on the associations between accelerometer-derived PA of all domains, sedentary behavior, and mortality in large, diverse cohorts of cancer survivors.

METHODS

Participants included adults who reported a cancer diagnosis in the National Health and Nutrition Examination Survey and wore an accelerometer for up to 7 days in 2003-2006. Participants were followed for subsequent mortality through 2015. We examined the association of light PA, moderate to vigorous PA, total PA, and sedentary behavior, with all-cause mortality. Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for demographics and health indicators.

RESULTS

A total of 480 participants (mean age of 68.8 years [SD = 12.4] at the time of National Health and Nutrition Examination Survey assessment) reported a history of cancer. A total of 215 deaths occurred over the follow-up period. For every 1-h/d increase in light PA and moderate to vigorous PA (MVPA), cancer survivors had 49% (HR = 0.51, 95% CI = 0.34 to 0.76) and 37% (HR = 0.63 , 95% CI = 0.40 to 0.99) lower hazards of all-cause mortality, respectively. Total PA demonstrated similar associations with statistically significantly lower hazards of death for each additional hour per day (HR = 0.68, 95% CI = 0.54 to 0.85), as did every metabolic equivalents of task-hour per day increase in total PA estimations of energy expenditure (HR = 0.88, 95% CI = 0.82 to 0.95). Conversely, more sedentary time (1 h/d) was not associated with statistically significantly higher hazards (HR = 1.08, 95% CI = 0.94 to 1.23).

CONCLUSIONS

These findings reinforce the current recommendations for cancer survivors to be physically active and underscore the continued need for widespread PA promotion for long-term survival in older cancer survivors.

Abstract PD12-09: PD12-09 Serum Advanced Glycation End-Products are Associated with Breast Cancer Prognosis

Background: Tumor characteristics such as grade, stage and receptor status are associated with breast cancer (BC) prognosis. Less is known about modifiable factors and BC prognosis. Advanced glycation end-products (AGEs) are reactive metabolites produced as a by-product of sugar metabolism, generated in conditions of increased oxidative stress. AGEs irreversibly accumulate in our tissues over time with pathogenic effects on genetic fidelity, protein function, cell signaling pathways, and chronic inflammatory diseases. The total body AGE pool is composed of endogenous AGEs and exogenous AGEs (consumed mainly through processed foods and those cooked at high temperatures). Serum AGE (sAGE) levels, a reflection of total body AGE, are higher in people with poor diet quality, lower levels of physical activity, and in women with BC compared to healthy controls. AGEs promote growth, migration and invasion in BC cell lines and activate prognostic inflammatory mediators such as interleukin-6 and C-reactive protein. Dietary AGEs have been associated with increased BC risk and increased mortality after BC diagnosis whereas lifestyle interventions can lower dietary and sAGE levels. The impact of sAGE levels, a better estimate of total body AGE than dietary AGE, on BC prognosis has not been previously evaluated. Methods: The Women’s Healthy Eating and Living (WHEL) study randomized 3088 BC patients stage I-III who completed their primary therapy to a high-vegetable, low-fat diet or control and followed for a median of 7.3 years. Main outcomes were invasive BC events (recurrence or new primary N=518), death due to BC (N=262) and deaths from any cause (N=315). sAGE was measured as the AGE metabolite carboxymethyllysine (ug/ml) from WHEL fasting blood specimens at study entry. sAGE was logged and corrected for plate batch effect via linear regression and analyzed in continuous scale and in quintiles. The Kaplan-Meier method and Cox regression model were performed for risk impact of sAGE on overall survival (OS), recurrence free survival (RFS), breast cancer specific survival (BCSS) and distant metastasis free survival (DMFS). We additionally adjusted in Cox models for potential confounding variables (age, race, BMI, smoking, alcohol use, physical activity, tumor characteristics). Results: 2564 participants had sAGE available. After excluding samples for excessive variabilities, 2315 samples were analyzed. Raw corrected sAGE ranged from 0.0-48.15 ug/ml (median 7.39); logged and corrected range -5.04-1.67. sAGE was positively associated with BMI (p&lt;.0001, rs 0.10) and negatively associated with physical activity (p&lt; .001, rs.-0.06). sAGE was not significantly associated with tumor stage, grade, receptor status, or race or menopausal status. Comparing the highest quintile (logged and corrected range=0.33~1.67) to the lowest quintile (range=-5.04~-0.30), sAGE was significantly associated with all survival outcomes (Table 1). As a continuous variable, AGE was associated with worse OS (HR 1.38, P=.031, β .32) and RFS (HR 1.29, P=.028, β .25) with a trend towards worse DMFS (HR 1.28, P=.067, β .25) and BCSS (HR 1.36, P=.06, β .31). Conclusions: Higher sAGEs are associated with worse survival outcomes in BC and may represent a novel, lifestyle-linked, modifiable prognostic biomarker in BC. Interventions aimed at lowering sAGE levels should be tested for their impact on known prognostic biomarkers as well as clinical outcomes. Individualized cancer-specific lifestyle recommendations are a crucial but currently lacking component of personalized cancer medicine.

Citation Format: Lindsay L. Peterson, Yu Tao, Jingqin Luo, Graham A. Colditz, Yikyung Park, Jennifer A. Ligibel, David Turner. PD12-09 Serum Advanced Glycation End-Products are Associated with Breast Cancer Prognosis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD12-09.

Abstract OT3-11-01: TK IMPACT: Treatment Monitoring of Hormone Receptor Positive (HR+), HER2 Negative (HER2-) Metastatic Breast Cancer (MBC) Patients Receiving CDK 4/6 Inhibitors (CDK4/6i) with DiviTum® Thymidine Kinase 1 Activity

Background: CDK 4/6i have altered the therapeutic landscape of HR+, HER2- MBC, improving progression free and overall survival (PFS and OS) compared to endocrine therapy (ET) alone. Despite durable responses to CDK 4/6i in a large majority of patients, treatment response monitoring in this population has historically included numerous serial blood-based and imaging studies at frequent time points. There is a growing global interest in utilizing novel non-invasive biomarker-driven disease monitoring assessments to improve patient outcomes and reduce health care costs. Thymidine kinase 1 (TK1), a key cell-cycle regulated enzyme important for nucleotide metabolism during DNA synthesis, is regulated by the E2F pathway, downstream of CDK 4/6. Studies have shown that DiviTum® TK1 activity (TKa) may serve as both a prognostic and predictive biomarker of CDK 4/6i treatment response (McCartney et al, Clin Canc Res, 2020; Malorni et al, Eur J Cancer, 2022; Bagegni et al, Breast Cancer Res, 2017). Early TKa suppression within 2 weeks (wk) post CDK 4/6i therapy initiation is associated with improved PFS, suggesting a subgroup of patients who may be able to de-escalate imaging frequency. Elevated TKa at baseline and post CDK 4/6i may identify patients with CDK 4/6i-resistant disease and disease progression (PD) requiring early therapy modification. TK IMPACT is a prospective, single-arm trial designed to assess the impact of incorporation of DiviTum® TKa on a physician’s decision regarding subsequent timing of routine disease monitoring modalities in patients with advanced HR+, HER2- MBC receiving ET plus CDK 4/6i (NCT04968964). Methods: Blood sample collections will be analyzed using DiviTum® TKa at baseline (bl), wk 2, 4, 6, 8, and Q 4 wks thereafter beginning at wk 8 during the first 24-wk time period of study enrollment (+/- 3 days); followed by Q 12 wks thereafter, until PD or 36 months, whichever occurs first. Optional repeat TKa within 2-4 wks (+/-3 days) is permitted in case of rising TKa. Research blood (bl, wk 2, 12, 24, 48, and PD) and optional archival tumor tissue collection at diagnosis and PD will be obtained for correlatives. The investigator will record intended imaging modalities and timing prior to receipt of TKa, followed by documentation of any changes in imaging testing interval after receipt of TKa. Key eligibility criteria include postmenopausal women age ≥18 years with HR+, HER2- MBC, to initiate (Cohort 1) or are currently receiving (≤24 months, Cohort 2) any FDA approved first line ET plus CDK 4/6i with a life expectancy &gt; 6 months. The primary endpoint is any physician-reported intended change in imaging testing interval post TKa by study cohort, within the first 48-wk period of study participation. Key secondary endpoints are concordance rate between TKa values and progression status at first on-study imaging and longitudinal TKa dynamics. Key exploratory endpoints include plasma and tumor tissue-based biomarkers of CDK 4/6i response and resistance. A total of 40 patients will be enrolled (n=20/Cohort). The expected change rate is 20% with a 95% Wilson confidence interval of 0.105~0.248 across all patients and if within each cohort, with a 95% Wilson confidence interval of 0.081~0.416 for N=20. N=40 allows the lower limit of the 95% CI &gt; 10% and that of the N=20 in Cohort 1 to be ~10%, indicating some clinically meaningful influence of TKa progression on patient management. The study is open to accrual and has presently enrolled 5 patients.

Citation Format: Nusayba A. Bagegni, Isabella Grigsby, Leslie Nehring, Jingqin Luo, Jennifer Powers Carson, David W. Gibson, Meghan Horvath, Katherine K. Clifton, Foluso O. Ademuyiwa, Rama Suresh, Ashley Frith, Andrew A. Davis, Lindsay L. Peterson, Ron Bose, Amy Williams, Mattias Bergqvist, Cynthia Ma. TK IMPACT: Treatment Monitoring of Hormone Receptor Positive (HR+), HER2 Negative (HER2-) Metastatic Breast Cancer (MBC) Patients Receiving CDK 4/6 Inhibitors (CDK4/6i) with DiviTum® Thymidine Kinase 1 Activity [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT3-11-01.

Abstract P3-06-06: Real-world analysis of adverse events of patients with triple negative breast cancer receiving therapy per KEYNOTE-522

Background: KEYNOTE-522 was a randomized, double-blind, placebo-controlled phase 3 trial which resulted in the FDA approval of pembrolizumab with neoadjuvant chemotherapy for patients (pts) with newly diagnosed, high-risk, early-stage triple negative breast cancer (TNBC). Given the improvement in pathological complete response (pCR) and event-free survival rates, this regimen has emerged as standard-of-care (SOC) therapy. Adverse events in pts on this treatment regimen in clinical practice is unknown and understanding the real-world toxicity of this regimen is critical.

Methods: In this IRB approved retrospective, single-center study we examined pts with early-stage TNBC who received planned treatment per KEYNOTE-522 per SOC from 2021-present. This regimen includes a year of pembrolizumab combined with 4 cycles of neoadjuvant carboplatin/paclitaxel followed by 4 cycles of doxorubicin/cyclophosphamide. Number and length of treatment delays, treatment related toxicities of all grades, and pCR rate were collected from the electronic medical record.

Results: Of the 87 identified pts, 2 were excluded due to locally recurrent or metastatic disease and 6 did not receive immunotherapy due to concerns for toxicity or patient preference. Of the 79 pts who initiated treatment with chemotherapy and immunotherapy, median age of the cohort was 52 (27-77). 9 pts had a BRCA1 mutation and 1 pt had a BRCA2 mutation. 41 (51.9%) had T1-2 disease and 38 (48.1%) had T3-4 disease. 37 (46.8%) pts had N0 disease and 42 (53.2%) had N1-3 disease. 15 pts had baseline comorbidities, including heart disease, kidney disease, type II DM, and/or peripheral neuropathy. 68 pts (86.1%) had baseline ECOG 0, 9 (11.4%) had ECOG 1, and 2 (2.5%) had ECOG 2. At the time of analysis, 70 pts (88.6%) were receiving active treatment, of which 47 (67.1%) had completed ≥50% of the planned neoadjuvant therapy. Of pts completing ≥50% of planned neoadjuvant therapy and pts off therapy (N=56), 31 (55.4%) had 1 or more hospitalizations and 23 (41.1%) had 1 or more emergency room visits. 30 pts had treatment delays (53.6%) and 21 pts (37.5%) had dose reductions. Rates of adverse events are presented in Table 1. Of the 79 analyzed pts, 35 have undergone surgery. pCR rate was 45.7% (N=16). 8 (22.9%) pts had RCB-I, 4 (11.4%) pts had RCB-II, 3 (8.6%) pts had RCB-III, and 4 (11.4%) pts had residual disease without RCB calculation. Updated analysis will be included at time of presentation.

Conclusions: In this single-center retrospective study of pts receiving chemoimmunotherapy for TNBC, we found higher rates of grade 3 toxicity, including nausea, fatigue, neutropenia, diarrhea, peripheral neuropathy, and hypothyroidism, and lower pCR rate than was reported in the KEYNOTE-522 trial. This may reflect a more heterogeneous population of pts treated in routine clinical practice who are typically less fit than pts on clinical trials. Additionally, pts in this study had higher T stages (48.1% with T3-4 disease vs 26.0% in trial) and node positive disease (53.7% with N1-3 disease vs 48.8% in trial). Limitations include immaturity of data and small sample size; however, these data warrant validation through longer-term follow-up and multicenter validation.

Adverse Events in pts receiving Keynote-522 regimen as SOC and on clinical trial

Citation Format: Mara Hofherr, Jennifer Hedgecorth, Foluso O. Ademuyiwa, Lindsay L. Peterson, Nusayba A. Bagegni, Rama Suresh, Ashley Frith, Ron Bose, Katherine Weilbaecher, Cynthia Ma, Andrew A. Davis, Katherine K. Clifton. Real-world analysis of adverse events of patients with triple negative breast cancer receiving therapy per KEYNOTE-522 [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-06-06.

Abstract PD13-09: PD13-09 Clinical outcomes of patients with HR+ HER2- advanced breast cancer with early progression on CDK4/6 inhibitors

Background: CDK4/6 inhibitors (CDK4/6i) paired with endocrine therapy (ET) are considered first-line (1L) therapy for patients (pts) with HR+ HER2- advanced breast cancer (aBC). A minority of pts will demonstrate primary resistance to CDK4/6i, as characterized by early progression. Thymidine kinase 1 (TK1) is a cell-cycle regulated enzyme downstream of CDK4/6 and involved in nucleotide metabolism during DNA synthesis. Prior studies have shown TK1 may serve as a biomarker of response to CDK4/6i, with early TK1 activity (TK1a) suppression after initiation of CDK 4/6i therapy associated with improved PFS. Lack of TK1a suppression may be associated with primary resistance to CDK4/6i. In this study, we aim to analyze response to subsequent lines of therapy and overall survival (OS) of pts with early progression on 1L CDK4/6i. Methods: Pts with HR+ HER2- aBC from a phase II trial of an alternative schedule of palbociclib (palbo alt dosing trial NCT 3007979) and from a retrospective palbociclib study were included in this analysis. Pts in the palbo alt dosing trial underwent baseline and C1D15 TK1a analysis after initiation on CDK4/6i. C1D15 TK1a suppression was defined at TK1a &lt; 30 Du/L. Pts in the retrospective palbociclib study included pts receiving palbo as part of their standard of care 1L therapy for HR+ HER2- aBC at Washington University in Saint Louis from 2016 to 2021. Clinical information, including treatment start and stop dates on each of the next-line therapies, were collected from the electronic medical record. PFS was estimated by the treatment duration on a specified treatment regimen. Early progression on CDK4/6i was defined as PFS &lt; 6 mo. Best response was defined as next line of therapy with the numerically longest PFS. OS was defined as time to death from the initiation of CDK4/6i. Results: Of the 54 pts enrolled on the palbo alt dosing trial, 51 pts were evaluable for clinical benefit and 46 pts were evaluable for TK1a suppression rate at C1D15. 7 pts (15.2%) were found without TK1a suppression at C1D15. This lack of TK1a suppression on palbo was associated with a significantly shorter PFS (median PFS=3.1 mo) compared to not reached in pts with TK1a suppression at C1D15. We conducted clinical analysis on N=26 pts who exhibited early progression on CDK4/6i which included 10 pts from the palbo alt dosing trial and 16 from the retrospective study. The average subsequent line of therapies in this cohort was 3, with the most common second line (2L) therapy being chemotherapy (N=17, 65.4%) and ET (N=8, 30.8%). The median PFS for pts receiving 2L chemotherapy and ET was 4.09 mo and 3.64 mo, respectively. 10 pts received both chemotherapy and ET with 7 (70.0%) achieving best response with chemotherapy compared to 3 pts (30.0%) who achieved best response with ET. The median OS for the cohort was 14.6 mo. Conclusions: Early progression on CDK4/6i is associated with a particularly poor prognosis. In our cohort, the median OS was far below the expected median OS for pts receiving 1L palbo as reported in the PALOMA-2 trial (14.6 mo vs 53.9 mo). Early progression on CDK4/6i is associated with more aggressive disease which may respond more favorably to chemotherapy, as demonstrated by best response to therapy. Further prospective studies are warranted to explore this treatment approach.

Citation Format: Katherine K. Clifton, Shana N. Thomas, Jingqin Luo, Jing Xi, Nusayba A. Bagegni, Foluso O. Ademuyiwa, Rama Suresh, Ashley Frith, Andrew A. Davis, Ron Bose, Katherine Weilbaecher, Whitney L. Hensing, Timothy Pluard, Massimo Cristofanilli, Hyo S. Han, Adam M. Brufsky, Kevin Kalinsky, Shom Goel, Seth A. Wander, Lindsay L. Peterson, Cynthia Ma. PD13-09 Clinical outcomes of patients with HR+ HER2- advanced breast cancer with early progression on CDK4/6 inhibitors [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD13-09.

Designing home-based physical activity programs for rural cancer survivors: A survey of technology access and preferences

Background

While technology advances have increased the popularity of remote interventions in underserved and rural cancer communities, less is understood about technology access and preferences for home-based physical activity programs in this cancer survivor population.

Purpose

To determine access, preferences, and needs, for a home-based physical activity program in rural cancer survivors.

Methods

A Qualtrics Research Panel was recruited to survey adults with cancer across the United States. Participants self-reported demographics, cancer characteristics, technology access and usage, and preferences for a home-based physical activity program. The Godin Leisure Time Exercise Questionnaire (GLTEQ) assessed current levels of physical activity. Descriptive statistics included means and standard deviations for continuous variables, and frequencies for categorical variables. Independent samples t-tests explored differences between rural and non-rural participants.

Results

Participants (N=298; mean age=55.2 ± 16.5) had a history of cancer (mean age at diagnosis=46.5), with the most commonly reported cancer type being breast (25.5%), followed by prostate (16.1%). 74.2% resided in rural hometowns. 95% of participants reported accessing the internet daily. On a scale of 0-100, computer/laptop (M=63.4) and mobile phone (M=54.6) were the most preferred delivery modes for a home-based physical activity intervention, and most participants preferred balance/flexibility (72.2%) and aerobic (53.9%) exercises. Desired intervention elements included a frequency of 2-3 times a week (53.5%) for at least 20 minutes (75.7%). While there were notable rural disparities present (e.g., older age at diagnosis, lower levels of education; ps<.001), no differences emerged for technology access or environmental barriers (ps>.08). However, bias due to electronic delivery of the survey should not be discounted.

Conclusion

These findings provide insights into the preferred physical activity intervention (e.g., computer delivery, balance/flexibility exercises) in rural cancer survivors, while highlighting the need for personalization. Future efforts should consider these preferences when designing and delivering home-based interventions in this population.

Correlates of physical activity among older breast cancer survivors: Findings from the Women's Health Initiative LILAC study

INTRODUCTION

Physical activity can attenuate cancer-related declines in physical functioning, improve emotional well-being, and prolong survival among older (≥65 years) breast cancer survivors. However, factors associated with physical activity among older breast cancer survivors are not well-understood.

MATERIALS AND METHODS

Participants were enrolled in the Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) study. Descriptive statistics, multiple linear regression, and relative risk [RR] regression were used to assess the association of demographic, clinical, physical and psychosocial variables with the total duration of and participation in physical activity among postmenopausal breast cancer survivors. Age-specific correlates (65-74 years vs. 75-84 years vs. ≥85 years) of physical activity were also examined.

RESULTS

The majority of participants (n = 3710, mean age = 78.8 ± 5.9) were white (90.7%) and had in situ/localized breast cancer (78.9%). Women who had higher education (RR = 1.47 for graduate/professional school versus high school or less, 95% CI: 1.32, 1.63), higher self-rated health (RR = 1.04 for 10 point increase, 95% CI:1.02, 1.07), higher physical functioning (RR = 1.03 for 5 point increase, 95% CI: 1.02, 1.04), and higher social support (RR = 1.41 for social support all of the time versus none of the time, 95% CI: 1.01, 1.96), were more likely to engage in any physical activity. Similar results were observed for duration of physical activity. Among women aged <75, radiation therapy, but not chemotherapy, was associated with longer duration of total physical activity (adjusted difference = 19.7 min/week, 95% CI: 6.1, 33.3), but was not associated with duration among older women. The association between pain and duration of moderate/strenuous activity also differed with age: among women aged <75, those with moderate pain averaged fewer minutes of moderate/strenuous physical activity than those with no pain (adjusted difference:-14.4 min/week, 95% CI:-28.5, -0.1). However, among women aged ≥85, those with moderate pain averaged more minutes of moderate/strenuous physical activity per week than those with no pain (adjusted difference:16.6 min/week; 95% CI:2.9, 30.3).

DISCUSSION

Multiple factors were associated with physical activity among older breast cancer survivors in the WHI. Future physical activity interventions should focus on age-related (e.g., comorbidities) and treatment-related factors (e.g., radiation) as well as certain subgroups, such as women with higher symptom burden.

Abstract P5-13-20: Identifying a metabolite signature that correlates with tumor proliferation in early-stage breast cancer patients treated with CDK4/6 inhibitors from matched plasma and serum samples

Background: Cyclin-dependent kinase 4/6 inhibitors (CKD4/6i) have demonstrated clinical utility extending progression-free survival (PFS) and overall survival (OS) for advanced hormone receptor positive and HER2 negative (HR+/HER2-) breast cancer patients. The efficacy in early-stage breast cancer (eBC) is unclear, with conflicting results from adjuvant CDK4/6i trials on invasive disease-free survival. Thus, there is a critical need to identify biomarkers of response (BoR) to determine which, if any, eBC patients could benefit from this treatment. This BoR could also stratify advanced BC patients for likelihood to respond to CDK4/6i. Metabolism is influenced by both genome and environment, and changes in the metabolome can be correlated with drug responsiveness. Thus, metabolite BoRs may serve to identify eBC patients for which CDK4/6i would offer a therapeutic benefit.Methods: Plasma and serum samples from 50 early-stage ER+/HER2- breast cancer patients, treated with neoadjuvant CDK4/6 inhibitor palbociclib (palbo) and aromatase inhibitor (AI) anastrozole on NeoPalAna trial (ClinicalTrials.gov identifier NCT01723774), were collected from treatment-naïve patients (BL) and 3 consecutive time points: anastrozole,1 mg daily for 4 weeks (C1D1), anastrozole plus palbo,125 mg daily, for 15 days (C1D15), and for 4-5 months before surgery (SURG). Metabolites were extracted from all samples via methanol and chloroform precipitation and quantified using an unbiased, non-destructive, nuclear magnetic resonance (NMR)-based profiling platform (Olaris®, Inc., Waltham, MA). Statistical analysis and machine learning was used to identify differential metabolites and generate predictive models. A separate validation set of samples was collected from a subset of patients (N=6) who received an additional cycle of palbo treatment prior to surgery to assess model accuracy. Results: Non-parametric differential expression analysis of BL/C1D1, BL/C1D15, and C1D1/C1D15 identified 53 ,97, and 90 differential NMR resonances in plasma (p&lt;0.05) and 36, 34, and 25 differential NMR resonances in serum (p&lt;0.05), respectively. Based on the proliferative marker Ki67 levels at C1D15, 37 patients were classified as responders (Ki67≤2.7%) and 6 patients as non-responders (Ki67&gt;2.7%). Analysis of the responder (R) and non-responder (NR) groups identified that 13 plasma and 14 serum resonances (21 unique resonances and 6 overlapping) were differentially expressed (p&lt;0.05) at C1D1. Many of the differential resonances could be mapped back to amino acid metabolites including several branched chain amino acids such as leucine, valine, and isoleucine, and positively charged amino acids such as lysine. A Olaris® BoR score was generated using 5 differential resonances that had an AUC of 0.931 (training set) and 100% accuracy when predicting palbo-response in a blinded test set (N=6).Conclusion: The differential metabolites identified from matching plasma and serum samples suggest that, compared to serum, plasma has a better representation of the metabolic changes associated with palbo treatment-response. While comparing samples from R and NR patients, amino acids were found to be consistently altered in both serum and plasma before palbo treatment. In addition, a BoR model based on select metabolites could precisely stratify palbo-response in a blinded dataset. A larger independent validation cohort is ongoing.

Citation Format: Chen Dong, Shana Thomas, Chandrashekhar Honrao, Leonardo O. Rodrigues, Nathalie Tessier, Bo Zhang, Souzan Sanati, Kiran Vij, Brenda J. Ernst, Karen S. Anderson, Mateusz Opyrchal, Foluso Ademuyiwa, Lindsay L. Peterson, Matthew P. Goetz, Donald Northfelt, Elizabeth O'Day, Cynthia Ma. Identifying a metabolite signature that correlates with tumor proliferation in early-stage breast cancer patients treated with CDK4/6 inhibitors from matched plasma and serum samples [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-13-20.

Yoga Therapy During Chemotherapy for Early-Stage and Locally Advanced Breast Cancer

Background:

Chemotherapy is associated with decreased quality of life (QOL), fatigue, depression, and weight gain in patients with breast cancer. Weight gain is associated with poorer prognosis. Yoga improves QOL, fatigue, and mood in women with breast cancer but its effect on treatment-related weight gain has not been studied. The aim of this trial was to determine the feasibility of personalized yoga therapy in women receiving treatment for early-stage or locally advanced breast cancer and assess its impact on weight gain.

Methods:

Thirty women were randomized 1:1 to receive yoga therapy by a certified yoga therapist during treatment or a control group. Participants in the yoga arm were asked to complete three 30 minute yoga sessions weekly (which included movement, breath work, mindfulness, and relaxation) throughout adjuvant or neoadjuvant chemotherapy (N = 29) or endocrine (N = 1); the control arm received breast cancer treatment without yoga. For comparability between participants randomized to yoga therapy, the single patient treated with endocrine therapy was excluded from the analysis. Primary outcomes were feasibility and weight change. Additional outcomes were mood, fatigue, QOL, serum tumor necrosis factor-alpha (TNF-alpha), and C-reactive protein (CRP) as immune mediator biomarkers.

Results:

Mean age was 51.6 years, 75.9% were white and 24.1% were people of color, reflecting the cancer center population. 80% had stage II-III disease. Enrollment was completed in 9 months. Compliance was lower than predicted; however, participants participated in on average 1.7 yoga sessions/week for a mean 15.6 weeks duration. There were no adverse events. Control arm participants gained on average 2.63% body weight during treatment while yoga participants lost 0.14% body weight (weight change = −0.36 in yoga arm vs. 2.89 in standard of care arm, Wilcoxon rank sum test P = .024). Control participants reported increased fatigue and decreased QOL, while yoga participants reported no change in QOL. No significant change in TNF-alpha or CRP was noted in either arm.

Conclusion:

This feasibility study suggests that personalized yoga therapy is beneficial for QOL and weight maintenance among women undergoing chemotherapy for early-stage or locally advanced breast cancer. Weight maintenance associated with yoga therapy may be of clinical significance in this population given the poorer prognosis associated with weight gain in breast cancer survivors.

Trial Registration:

NIH Clinicaltrials.gov #NCT03262831; August 25, 2017. https://clinicaltrials.gov/ct2/show/NCT03262831

Dietary Advanced Glycation End-Products and Mortality after Breast Cancer in the Women's Health Initiative

BACKGROUND

Advanced glycation end-products (AGE) are formed through nonenzymatic glycation of free amino groups in proteins or lipid. They are associated with inflammation and oxidative stress, and their accumulation in the body is implicated in chronic disease morbidity and mortality. We examined the association between postdiagnosis dietary Nε-carboxymethyl-lysine (CML)-AGE intake and mortality among women diagnosed with breast cancer.

METHODS

Postmenopausal women aged 50 to 79 years were enrolled in the Women's Health Initiative (WHI) between 1993 and 1998 and followed up until death or censoring through March 2018. We included 2,023 women diagnosed with first primary invasive breast cancer during follow-up who completed a food frequency questionnaire (FFQ) after diagnosis. Cox proportional hazards (PH) regression models estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) of association between tertiles of postdiagnosis CML-AGE intake and mortality risk from all causes, breast cancer, and cardiovascular disease.

RESULTS

After a median 15.1 years of follow-up, 630 deaths from all causes were reported (193 were breast cancer-related, and 129 were cardiovascular disease-related). Postdiagnosis CML-AGE intake was associated with all-cause (HRT3vsT1, 1.37; 95% CI, 1.09-1.74), breast cancer (HRT3vsT1, 1.49; 95% CI, 0.98-2.24), and cardiovascular disease (HRT3vsT1, 1.91; 95% CI, 1.09-3.32) mortality.

CONCLUSIONS

Higher intake of AGEs was associated with higher risk of major causes of mortality among postmenopausal women diagnosed with breast cancer.

IMPACT

Our findings suggest that dietary AGEs may contribute to the risk of mortality after breast cancer diagnosis. Further prospective studies examining dietary AGEs in breast cancer outcomes and intervention studies targeting dietary AGE reduction are needed to confirm our findings.

Intermittent fasting in the prevention and treatment of cancer

Chronic caloric restriction (CR) has powerful anticarcinogenic actions in both preclinical and clinical studies but may be difficult to sustain. As an alternative to CR, there has been growing interest in intermittent fasting (IF) in both the scientific and lay community as a result of promising study results, mainly in experimental animal models. According to a survey by the International Food Information Council Foundation, IF has become the most popular diet in the last year, and patients with cancer are seeking advice from oncologists about its beneficial effects for cancer prevention and treatment. However, as discussed in this review, results from IF studies in rodents are controversial and suggest potential detrimental effects in certain oncologic conditions. The effects of IF on human cancer incidence and prognosis remain unknown because of a lack of high-quality randomized clinical trials. Preliminary studies suggest that prolonged fasting in some patients who have cancer is safe and potentially capable of decreasing chemotherapy-related toxicity and tumor growth. However, because additional trials are needed to elucidate the risks and benefits of fasting for patients with cancer, the authors would not currently recommend patients undergoing active cancer treatment partake in IF outside the context of a clinical trial. IF may be considered in adults seeking cancer-prevention benefits through means of weight management, but whether IF itself affects cancer-related metabolic and molecular pathways remains unanswered.

Genetic Counseling and Testing in African American Patients With Breast Cancer: A Nationwide Survey of US Breast Oncologists

PURPOSE

To determine if physicians' self-reported knowledge, attitudes, and practices regarding genetic counseling and testing (GCT) vary by patients' race.

METHODS

We conducted a nationwide 49-item survey among breast oncology physicians in the United States. We queried respondents about their own demographics, clinical characteristics, knowledge, attitudes, practices, and perceived barriers in providing GCT to patients with breast cancer.

RESULTS

Our survey included responses from 277 physicians (females, 58.8%; medical oncologists, 75.1%; academic physicians, 61.7%; and Whites, 67.1%). Only 1.8% indicated that they were more likely to refer a White patient than refer an African American patient for GCT, and 66.9% believed that African American women with breast cancer have lower rates of GCT than White women. Regarding perceived barriers to GCT, 63.4% of respondents indicated that African American women face more barriers than White women do and 21% felt that African American women require more information and guidance during the GCT decision-making process than White women. Although 32% of respondents indicated that lack of trust was a barrier to GCT in all patients, 58.1% felt that this was a greater barrier for African American women (P < .0001). Only 13.9% believed that noncompliance with GCT is a barrier for all patients, whereas 30.6% believed that African American women are more likely than White women to be noncompliant (P < .0001).

CONCLUSION

We demonstrated that racial differences exist in oncology physicians' perceived barriers to GCT for patients with breast cancer. This nationwide survey will serve as a basis for understanding physicians' determinants of GCT for African American women and highlights the necessity of education and interventions to address bias among physicians. Awareness of such physician biases can enable further work to address inequities, ultimately leading to improved GCT equity for African American women with breast cancer.

Endocrine Treatment and Targeted Therapy for Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Metastatic Breast Cancer: ASCO Guideline Update

PURPOSE

To update recommendations of the ASCO systemic therapy for hormone receptor (HR)-positive metastatic breast cancer (MBC) guideline.

METHODS

An Expert Panel conducted a systematic review to identify new, potentially practice-changing data.

RESULTS

Fifty-one articles met eligibility criteria and form the evidentiary basis for the recommendations.

RECOMMENDATIONS

Alpelisib in combination with endocrine therapy (ET) should be offered to postmenopausal patients, and to male patients, with HR-positive, human epidermal growth factor receptor 2 (HER2)-negative, PIK3CA-mutated, ABC, or MBC following prior endocrine therapy with or without a cyclin-dependent kinase (CDK) 4/6 inhibitor. Clinicians should use next-generation sequencing in tumor tissue or cell-free DNA in plasma to detect PIK3CA mutations. If no mutation is found in cell-free DNA, testing in tumor tissue, if available, should be used as this will detect a small number of additional patients with PIK3CA mutations. There are insufficient data at present to recommend routine testing for ESR1 mutations to guide therapy for HR-positive, HER2-negative MBC. For BRCA1 or BRCA2 mutation carriers with metastatic HER2-negative breast cancer, olaparib or talazoparib should be offered in the 1st-line through 3rd-line setting. A nonsteroidal aromatase inhibitor (AI) and a CDK4/6 inhibitor should be offered to postmenopausal women with treatment-naïve HR-positive MBC. Fulvestrant and a CDK4/6 inhibitor should be offered to patients with progressive disease during treatment with AIs (or who develop a recurrence within 1 year of adjuvant AI therapy) with or without one line of prior chemotherapy for metastatic disease, or as first-line therapy. Treatment should be limited to those without prior exposure to CDK4/6 inhibitors in the metastatic setting.Additional information can be found at www.asco.org/breast-cancer-guidelines.

Effects of a DVD-delivered randomized controlled physical activity intervention on functional health in cancer survivors

Background

Supervised physical activity interventions improve functional health during cancer survivorship, but remain costly and inaccessible for many. We previously reported on the benefits of a DVD-delivered physical activity program (FlexToBa™) in older adults. This is a secondary analysis of the intervention effects among cancer survivors in the original sample.

Methods

Low active, older adults who self-reported a history of cancer (N = 46; M time since diagnosis = 10.7 ± 9.4 years) participated in a 6-month, home-based physical activity intervention. Participants were randomized to either the DVD-delivered physical activity program focused on flexibility, toning, and balance (FlexToBa™; n = 22) or an attentional control condition (n = 24). Physical function was assessed by the Short Physical Performance Battery (SPPB) at baseline, end of intervention, and at 12 and 24 months after baseline.

Results

Repeated measures linear mixed models indicated a significant group*time interaction for the SPPB total score (β = − 1.14, p = 0.048), driven by improved function from baseline to six months in the FlexToBa™ group. The intervention group also had improved balance (β = − 0.56, p = 0.041) compared with controls. Similar trends emerged for the SPPB total score during follow-up; the group*time interaction from 0 to 12 months approached significance (β = − 0.97, p = 0.089) and was significant from 0 to 24 months (β = − 1.84, p = 0.012). No significant interactions emerged for other outcomes (ps > 0.11).

Conclusions

A DVD-delivered physical activity intervention designed for cancer-free older adults was capable of eliciting and maintaining clinically meaningful functional improvements in a subgroup of cancer survivors, with similar effects to the original full sample. These findings inform the dissemination of evidence-based physical activity programs during survivorship.

Trial registration

ClinicalTrials.govNCT01030419. Registered 11 December 2009

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08608-8.

Predictors of Distant Metastases in Triple-Negative Breast Cancer Without Pathologic Complete Response After Neoadjuvant Chemotherapy

BACKGROUND

Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) for triple-negative breast cancer (TNBC) predicts decreased distant metastasis. However, most patients do not experience pCR, and other risk factors for distant metastasis after NAC are poorly characterized. This study investigated factors predictive of distant metastasis in TNBC without pCR after NAC.

METHODS

Women with TNBC treated with NAC, surgery, and radiation therapy in 2000 through 2013 were reviewed. Freedom from distant metastasis (FFDM) was compared between patients with and without pCR using the Kaplan-Meier method. In patients without pCR, univariate and multivariable Cox analyses were used to determine factors predictive of distant metastasis.

RESULTS

We identified 153 patients with median follow-up of 4.0 years (range, 0.5-14.0 years). After NAC, 108 had residual disease (pCR, 29%). Five-year FFDM was 98% and 55% in patients with and without pCR, respectively (P<.001). Factors independently predicting FFDM in patients without pCR were pathologic nodal positivity (hazard ratio, 3.08; 95% CI, 1.54-6.14; P=.001) and lymphovascular space invasion (hazard ratio, 1.91; 95% CI, 1.07-3.43; P=.030). Patients with a greater number of factors had worse FFDM; 5-year FFDM was 76.5% for patients with no factors (n=38) versus 54.9% and 27.5% for patients with 1 (n=44) and 2 factors (n=26), respectively (P<.001).

CONCLUSIONS

Lack of pCR after NAC resulted in worse overall survival and FFDM, despite trimodality therapy. In patients with residual disease after NAC, pathologic lymph node positivity and lymphovascular space invasion predicted worse FFDM.

Mutation profile differences in younger and older patients with advanced breast cancer using circulating tumor DNA (ctDNA)

PURPOSE

Little is known regarding the mutation profiles of ctDNA in the older adult breast cancer population. The objective of this study is to assess differences in mutation profiles in the older adult breast cancer population using a ctDNA assay as well as assess utilization of testing results.

METHODS

Patients with advanced breast cancer underwent molecular profiling using a plasma-based ctDNA NGS assay (Guardant360) between 5/2015 and 10/2019 at Siteman Cancer Center. The profiling results of a multi-institutional database of patients with advanced breast cancer who had undergone molecular profiling were obtained. Associations between mutations and age group (≥ 65 vs. < 65) were examined using a Fisher's exact test.

RESULTS

In the single-institutional cohort, 148 patients (69.2%) were < 65 years old and 66 patients (30.8%) ≥ 65 years old. ATM, BRAF, and PIK3CA mutations were found more frequently in older patients with ER + HER2- breast cancers (p < 0.01). In the multi-institutional cohort, 5367 (61.1%) were < 65 years old and 3417 (38.9%) ≥ 65 years old. ATM, PIK3CA, and TP53 mutations were more common in the older cohort (p < 0.0001) and MYC and GATA3 mutations were less common in the older cohort (p < 0.0001). CtDNA testing influenced next-line treatment management in 40 (19.8%) patients in the single-institutional cohort.

CONCLUSION

When controlling for subtype, results from a single institution were similar to the multi-institutional cohort showing that ATM and PIK3CA were more common in older adults. These data suggest there may be additional molecular differences in older adults with advanced breast cancers.

Radiation-Induced Brachial Plexopathy in Patients With Breast Cancer Treated With Comprehensive Adjuvant Radiation Therapy

Purpose

Our purpose was to describe the risk of radiation-induced brachial plexopathy (RIBP) in patients with breast cancer who received comprehensive adjuvant radiation therapy (RT).

Methods and Materials

Records for 498 patients who received comprehensive adjuvant RT (treatment of any residual breast tissue, the underlying chest wall, and regional nodes) between 2004 and 2012 were retrospectively reviewed. All patients were treated with conventional 3 to 5 field technique (CRT) until 2008, after which intensity modulated RT (IMRT) was introduced. RIBP events were determined by reviewing follow-up documentation from oncologic care providers. Patients with RIBP were matched (1:2) with a control group of patients who received CRT and a group of patients who received IMRT. Dosimetric analyses were performed in these patients to determine whether there were differences in ipsilateral brachial plexus dose distribution between RIBP and control groups.

Results

Median study follow-up was 88 months for the overall cohort and 92 months for the IMRT cohort. RIBP occurred in 4 CRT patients (1.6%) and 1 IMRT patient (0.4%) (P = .20). All patients with RIBP in the CRT cohort received a posterior axillary boost. Maximum dose to the brachial plexus in RIBP, CRT control, and IMRT control patients had median values of 56.0 Gy (range, 49.7-65.1), 54.8 Gy (47.4-60.5), and 54.8 Gy (54.2-57.3), respectively.

Conclusions

RIBP remains a rare complication of comprehensive adjuvant breast radiation and no clear dosimetric predictors for RIBP were identified in this study. The IMRT technique does not appear to adversely affect the development of this late toxicity.

Landmark trials in the medical oncology management of early stage breast cancer

With the advent of breast cancer screening programs, the majorities of patients with newly diagnosed breast cancer are diagnosed with early stage disease and are likely to experience cure with proper treatment. Significant advances have been made in the management of early-stage breast cancer to personalize treatment according to disease biology. This progress has led to improvement in survival outcomes and quality of life for our patients. In this review, we discuss landmark clinical trials in medical oncology that have shaped the current standard of care for early stage ER-positive, HER2-positive, and triple negative breast cancer.

Hepatic lipids promote liver metastasis

Obesity predisposes to cancer and a virtual universality of nonalcoholic fatty liver disease (NAFLD). However, the impact of hepatic steatosis on liver metastasis is enigmatic. We find that while control mice were relatively resistant to hepatic metastasis, those which were lipodystrophic or obese, with NAFLD, had a dramatic increase in breast cancer and melanoma liver metastases. NAFLD promotes liver metastasis by reciprocal activation initiated by tumor-induced triglyceride lipolysis in juxtaposed hepatocytes. The lipolytic products are transferred to cancer cells via fatty acid transporter protein 1, where they are metabolized by mitochondrial oxidation to promote tumor growth. The histology of human liver metastasis indicated the same occurs in humans. Furthermore, comparison of isolates of normal and fatty liver established that steatotic lipids had enhanced tumor-stimulating capacity. Normalization of glucose metabolism by metformin did not reduce steatosis-induced metastasis, establishing the process is not mediated by the metabolic syndrome. Alternatively, eradication of NAFLD in lipodystrophic mice by adipose tissue transplantation reduced breast cancer metastasis to that of control mice, indicating the steatosis-induced predisposition is reversible.

Nonalcoholic fatty liver disease promotes liver metastasis in mice, likely due to lipid transfer to tumor cells.

Predictors of Locoregional Recurrence After Failure to Achieve Pathologic Complete Response to Neoadjuvant Chemotherapy in Triple-Negative Breast Cancer

BACKGROUND

This study evaluated factors predictive of locoregional recurrence (LRR) in women with triple-negative breast cancer (TNBC) treated with neoadjuvant chemotherapy who do not experience pathologic complete response (pCR).

METHODS

This is a single-institution retrospective review of women with TNBC treated with neoadjuvant chemotherapy, surgery, and radiation therapy in 2000 through 2013. LRR was estimated between patients with and without pCR using the Kaplan-Meier method. Patient-, tumor-, and treatment-specific factors in patients without pCR were analyzed using the Cox proportional hazards method to evaluate factors predictive of LRR. Log-rank statistics were then used to compare LRR among these risk factors.

RESULTS

A total of 153 patients with a median follow-up of 48.6 months were included. The 4-year overall survival and LRR were 70% and 15%, respectively, and the 4-year LRR in patients with pCR was 0% versus 22.0% in those without (P<.001). In patients without pCR, lymphovascular space invasion (LVSI; hazard ratio, 3.92; 95% CI, 1.64-9.38; P=.002) and extranodal extension (ENE; hazard ratio, 3.32; 95% CI, 1.35-8.15; P=.009) were significant predictors of LRR in multivariable analysis. In these patients, the 4-year LRR with LVSI was 39.8% versus 15.0% without (P<.001). Similarly, the 4-year LRR was 48.1% with ENE versus 16.1% without (P=.002). In patients without pCR, the presence of both LVSI and ENE were associated with an even further increased risk of LRR compared with patients with either LVSI or ENE alone and those with neither LVSI nor ENE in the residual tumor (P<.001).

CONCLUSIONS

In patients without pCR, the presence of LVSI and ENE increases the risk of LRR in TNBC. The risk of LRR is compounded when both LVSI and ENE are present in the same patient. Future clinical trials are warranted to lower the risk of LRR in these high-risk patients.

Abstract A43: Dietary advanced glycation end-products (AGEs) and breast cancer in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO)

Introduction: Advanced glycation end-products (AGEs) are implicated in chronic diseases and cancer. AGEs are produced endogenously but can also be consumed in foods. AGE formation in food is accelerated during cooking at high temperatures. The objective of the study is to assign and quantify dietary AGE (dAGE) content in food and investigate the association between dAGE intake and breast cancer risk in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO).

Methods: The PLCO enrolled women aged 55 to 74 years into a randomized controlled trial examining various cancer screening modalities. In this prospective analysis, the study sample included only women enrolled in the intervention arm who were cancer-free at baseline and completed a baseline questionnaire and food frequency questionnaire (DQX) (n=28,127). dAGE values were assigned and quantified to foods in the DQX using a published AGE database. Descriptive analysis was used to obtain means and percentages while Pearson correlation was used to obtain correlation coefficient of dAGE intake with dietary factors linked to AGEs.

Results: After a median 11.6 years of follow-up, 1,642 women were diagnosed with breast cancer. The average dAGE consumption among all the women was 11,355 KU/day (SD: 6614 KU/day) and ranged between 715 and 87,129 KU/day. A higher proportion of overweight and obese women, African American women, and women who were diagnosed with breast cancer during follow-up were in the higher quintile of dAGE intake as compared to the lowest quintile. Significant positive correlations were observed between dAGE intake and dietary sources of animal protein (0.74), monounsaturated fatty acids (MUFA) (0.83), polyunsaturated fatty acid (PUFA) (0.70), and saturated fatty acids (SF) (0.83), while the correlations between dAGE and fructose (0.12), carbohydrates (0.39), and plant protein (0.40) were weaker.

Conclusion: A higher proportion of women who were diagnosed with breast cancer during follow-up were in the highest quintile of dAGE intake at baseline compared to the lowest quintile. The strong positive correlation observed between dAGE and fat and protein intake reflects the high AGE levels found in meats, especially those cooked at high temperatures. Further analyses using Cox proportional hazards will be conducted examining the association between dAGE intake and breast cancer risk.

Citation Format: Omonefe O. Omofuma, David P. Turner, Lindsay L. Peterson, Anwar T. Merchant, Jiajia Zhang, Susan E. Steck. Dietary advanced glycation end-products (AGEs) and breast cancer in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) [abstract]. In: Proceedings of the AACR Special Conference on Environmental Carcinogenesis: Potential Pathway to Cancer Prevention; 2019 Jun 22-24; Charlotte, NC. Philadelphia (PA): AACR; Can Prev Res 2020;13(7 Suppl): Abstract nr A43.

Abstract C024: Lifestyle-associated advanced glycation end products are elevated in ER+ positive breast cancer patients, alter response to therapy, and can be targeted by lifestyle intervention

Lifestyle factors associated with personal behavior can alter tumor-associated biologic pathways and thereby increase cancer risk, growth and disease recurrence. Advanced glycation end products (AGEs) are reactive metabolites produced endogenously as a byproduct of normal metabolism. A Western lifestyle consisting of high-fat, high-sugar and processed foods as well as little exercise can lead to a significant increase in AGE accumulation in the body and is also associated with driving cancer disparity. Increased AGE accumulation promotes disease phenotypes through modification of the genome, protein crosslinking and dysfunction, and aberrant cell signaling. We evaluated AGE levels in biospecimens from ER+ and ER- breast cancer patients, examined their role in therapy resistance, and assessed the ability of a lifestyle intervention to reduce circulating AGE levels in ER+ breast cancer survivors. A correlation between ER status and AGE levels was observed in tumor and serum samples. AGE treatment of ER+ breast cancer cells impacted pathways associated with ER regulation. We observed a significant increase in phosphorylation of ERalpha following AGE treatment when compared to untreated control with no change in total ERalpha levels. We also observed a significant increase in both AKT and ERK phosphorylation in ER+ cell lines in response to AGE treatment in a time-dependent manner. Inhibition of AKT with Ly294002 and inhibition of ERK with the MEK inhibitor U0126 significantly reduced ERalpha phosphorylation in the presence of AGE. Significantly, ER+ cells treated with AGEs no longer responded to hormonal therapy with tamoxifen. In a proof-of-concept study we examined the ability of a defined exercise and dietary intervention (i.e., cardiac rehabilitation) to reduce circulatory AGE levels in ER+ breast cancer survivors. A significant increase in average very active minutes and average calories burned was observed as a result of the intervention. This was accompanied by a significant reduction in dietary-AGE intake and also showed significant reductions in circulating AGE levels when fasting serum samples were analyzed by ELISA. An analysis of IL6 and CRP levels by ELISA in the same AGE assessed samples revealed no significant differences at any time point. There is a potential prognostic and therapeutic role for lifestyle-derived AGEs in cancer disparity. Given the potential benefits of lifestyle intervention on cancer incidence and mortality, opportunities exist for the development of community health and nutritional programs aimed at reducing AGE exposure in order to improve cancer prevention and treatment outcomes. Lifestyle interventions that lower AGE levels may then be utilized to reduce breast cancer incidence and improve prognosis in cancer disparity populations.

Citation Format: Katherine R. Walter, Ford E. Ford, Mathew J. Gregoski, Rita M. Kramer, Kendrea D. Knight, Laura Spruill, Lourdes M. Nogueira, Bradley A. Krisanits, Marian H. Taylor, Amanda C. La Rue, Michael B. Lilly, Stefan Ambs, King Chan, Tonya F. Turner, Heidi Varner, Shweta Singh, Jaime Uribarri, Elizabeth Garrett-Mayer, Kent E. Armeson, Ebony J. Hilton, Mark Clair, Victoria J. Findlay, Lindsay L. Peterson, Gayenell Magwood, David P. Turner. Lifestyle-associated advanced glycation end products are elevated in ER+ positive breast cancer patients, alter response to therapy, and can be targeted by lifestyle intervention [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C024.

Abstract B102: Body mass index, physical activity, and breast cancer subtype in European American, African American, and Sea Island breast cancer survivors

BACKGROUND: Breast cancer (BCa) is the second leading cause of cancer death among women in the United States and large racial/ethnic disparities are evident. Higher levels of body mass index (BMI), lower rates of physical activity (PA), and hormone receptor-negative BCa sub-type are associated with poorer BCa treatment outcomes. PURPOSE: To evaluate the prevalence of high BMI, low PA level, and BCa sub-type among three BCa survivor groups: European Americans (EAs), African Americans without Sea Island ancestry (AAs), and AAs with SI ancestry (SIs). METHODS: A state central cancer registry database was used to identify 137 (42 EAs, 66 AAs, and 29 SIs) women diagnosed with BCa between May 2012 and October 2013, who were within 6-21 months of diagnosis at the time of the study. RESULTS: Regardless of racial/ethnic group, most participants (82%) were overweight/obese (p=0.46). BMI was highest in younger AAs (p=0.02). The CDC PA guidelines (≥150 minutes/week) were met by only 28% of participants. In terms of BCa sub-type, among the 86 participants who provided saliva samples, the frequency of triple-negative BCa and estrogen-receptor-negative BCa was lower in EAs and SIs than in AAs (p&lt; 0.05). CONCLUSIONS: This is the first study to identify differences in obesity rates, PA rates, and BCa sub-type in EAs, AAs, and SIs. Future research could explore dietary and PA behavioral interventions to reduce BCa recurrence risk, and could evaluate potential differential immune responses linked to the frequency of triple-negative BCa in AAs.

Citation Format: Marvella E Ford, Colleen E Bauza, Victoria J Findlay, David P Turner, Latecia M Abraham-Hilaire, Leslie A Moore, Gayenell Magwood, Anthony J Alberg, Kadeidre Gaymon, Kendrea D Knight, Ebony Hilton, Angela M Malek, Rita M Kramer, Lindsay L Peterson, Susan Bolick, Deborah Hurley, Catishia Mosley, Tonya R Hazelton, Dana R Burshell, Lourdes Nogueira, Franshawn Mack, Erika T Brown, Judith D Salley, Keith E Whitfield, Joan E Cunningham. Body mass index, physical activity, and breast cancer subtype in European American, African American, and Sea Island breast cancer survivors [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B102.

Dietary Advanced Glycation End-products (AGE) and Risk of Breast Cancer in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO)

Advanced glycation end-products (AGEs) are implicated in the pathogenesis of several chronic diseases including cancer. AGEs are produced endogenously but can also be consumed from foods. AGE formation in food is accelerated during cooking at high temperatures. Certain high fat or highly processed foods have high AGE values. The objective of the study was to assign and quantify N^ϵ-carboxymethyl-lysine (CML)-AGE content in food and investigate the association between dietary AGE intake and breast cancer risk in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. The study included women enrolled in the intervention arm who were cancer-free at baseline and completed a baseline questionnaire and food frequency questionnaire (DQX). CML-AGE values were assigned and quantified to foods in the DQX using a published AGE database. Cox proportional hazards models were used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) of breast cancer among all women, and stratified by race/ethnicity, invasiveness of disease, and hormone receptor status. After a median 11.5 years of follow-up, 1,592 women were diagnosed with breast cancer. Higher CML-AGE intake was associated with increased risk of breast cancer among all women (HR_Q5VSQ1, 1.30; 95% CI, 1.04-1.62; P _trend = 0.04) and in non-Hispanic white women (HR_T3VST1, 1.21; 95% CI, 1.02-1.44). Increased CML-AGE intake was associated with increased risk of in situ (HR_T3VST1, 1.49; 95% CI, 1.11-2.01) and hormone receptor-positive (HR_T3VST1, 1.24; 95% CI, 1.01-1.53) breast cancers. In conclusion, high intake of dietary AGE may contribute to increased breast cancer.

Dietary advanced glycation end products and the risk of postmenopausal breast cancer in the National Institutes of Health-AARP Diet and Health Study

BACKGROUND

Advanced glycation end products (AGEs) are reactive metabolites produced as a by-product of sugar metabolism and are consumed through the diet in high-fat and highly processed foods. They are associated with chronic inflammatory diseases, and evidence suggests that they play a role in carcinogenesis. The authors evaluated the association of dietary AGE intake and the risk of postmenopausal invasive breast cancer.

METHODS

This was a prospective cohort study of 183,548 postmenopausal women in the National Institutes of Health-AARP Diet and Health Study. The main outcome was incident invasive breast cancer. AGE intake was estimated from food-frequency questionnaires. Incident breast cancer cases were identified through state cancer registries. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals for developing breast cancer according to AGE intake quintiles. Multivariable regression models were adjusted for breast cancer risk factors.

RESULTS

The mean follow-up was 12.8 years, and 9851 breast cancers (1978 advanced stage) were identified. The median AGE daily intake was 5932 kilo units per 100 kilocalories (KU/1000 kcal). Women with higher intake tended to have lower education levels, higher body mass index, less physical activity, were current smokers, and had higher fat and meat intake. The highest quintile of AGE intake (compared with the lowest) was associated with an increased risk of breast cancer (HR, 1.09; 95% CI, 1.02-1.16; P = .03) after adjusting for breast cancer risk factors and particularly was associated with 37% of advanced-stage tumors (HR, 1.37; 95% CI, 1.09-1.74; P < .02) after adjusting for risk factors and fat and meat intake.

CONCLUSIONS

Dietary AGEs may play a role in the development of postmenopausal breast cancer.

Age-related disparities in older women with breast cancer

Improvements in breast cancer (BC) mortality rates have not been seen in the older adult community, and the fact that older adults are more likely to die from their cancer than younger women establishes a major health disparity. Studies have identified that despite typically presenting with more favorable histology, older women present with more advanced disease, which may be related in part to delayed diagnosis. This is supported by examination of screening practices in older adults. Older women have a worse prognosis than younger women in both early stage disease, and more advanced and metastatic disease. Focus on the treatment of older adults has often concentrated on avoiding overtreatment, but in fact undertreatment may be one reason for the age-related differences in outcomes, and treatments need to be individualized for every older adult, and take into account patient preferences and functional status and not chronologic age alone. Given the aging population in the US, identifying methods to improve early diagnosis in this population and identify additional factors will be important to reducing this age-related disparity.

Adjuvant chemotherapy and survival among patients 70 years of age and younger with node-negative breast cancer and the 21-gene recurrence score of 26-30

Background

The benefits of chemotherapy in node-negative, hormone receptor-positive, and human epidermal growth factor receptor 2 (HER2)-negative breast cancer patients with the 21-gene recurrence score (RS) of 18–30, particularly those with RS 26–30, are not known.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) data, we retrospectively identified 29,137 breast cancer patients with the 21-gene RS of 18–30 diagnosed between 2004 and 2015. Mortality risks according to the RS and chemotherapy use were compared by the Kaplan-Meier method and Cox’s proportional hazards model.

Results

Among the breast cancer patients with the RS 18–30, 21% of them had RS 26–30. Compared to breast cancer patients with RS 18–25, patients with RS 26–30 had more aggressive tumor characteristics and chemotherapy use and increased risk of breast cancer-specific mortality and overall mortality. In breast cancer patients who were aged ≤ 70 years and had RS of 26–30, chemotherapy administration was associated with a 32% lower risk of breast cancer-specific mortality (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.47–0.99) and a 42% lower risk of overall mortality (HR, 0.58; 95% CI, 0.44–0.76). Survival benefits were most pronounced in breast cancer patients who were younger or had grade III tumor.

Conclusions

The 21-gene RS of 18–30 showed heterogeneous outcomes, and the RS 26–30 was a significant prognostic factor for an increased risk of mortality. Adjuvant chemotherapy could improve the survival of node-negative, hormone receptor-positive, and HER2-negative breast cancer patients with the 21-gene RS 26–30 and should be considered for patients, especially younger patients or patients with high-grade tumors.

Electronic supplementary material

The online version of this article (10.1186/s13058-019-1190-4) contains supplementary material, which is available to authorized users.

The Plausibility of Obesity Paradox in Cancer-Point

In contrast to the convincing evidence that obesity (measured by body mass index, BMI) increases the risk of many different types of cancer, there is an ambiguity in the role of obesity in survival among cancer patients. Some studies suggested that higher BMI decreased mortality risk in cancer patients, a phenomenon called the obesity paradox. The spurious positive association between BMI and cancer survival is likely to be explained by several methodologic limitations including confounding, reverse causation, and collider stratification bias. Also, the inadequacy of BMI as a measure of body fatness in cancer patients commonly experiencing changes in body weight and body composition may have resulted in the paradox. Other factors contributing to the divergent results in literature are significant heterogeneity in study design and method (e.g., study population, follow-up length); time of BMI assessment (pre-, peri-, or post-diagnosis); and lack of consideration for variability in the strength and directions of associations by age, sex, race/ethnicity, and cancer subtype. Robust but practical methods to accurately assess body fatness and body compositions and weight trajectories in cancer survivors are needed to advance this emerging field and to develop weight guidelines to improve both the length and the quality of cancer survival. Cancer Res; 78(8); 1898-903. ©2018 AACR.

Abstract 619: Dietary advanced glycation end-products and postmenopausal breast cancer risk in the NIH AARP diet and health study

Purpose: Advanced glycation end-products (AGE) are hypothesized to be involved in carcinogenesis. We analyzed dietary AGE intake in relation to invasive breast cancer (BC) to advance our knowledge of the impact of diet on BC risk.

Methods: Dietary AGE intake was estimated from the food-frequency questionnaire in postmenopausal women in the NIH AARP Diet and Health study, prospective cohort (n=183,548). Incident BC cases were identified through linkage with state cancer registries. Cox proportional hazards regression models were used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for developing BC according to quintiles of AGE levels. Multivariate regression models were adjusted for established BC risk factors.

Results: During a mean follow-up of 12.8 years, 9,851 BCs (1,978 advanced stage) were identified. Median daily AGE intake was 5,932 KU/1,000 kcal (10th- 90th percentile, 3,555 - 8,644). Women with higher AGE intake tended to have lower education level, higher BMI, younger age at menarche, menopause, first birth, more children, less physical activity, current smoking and higher total fat and meat intake. AGE intake was associated with increased risk of BC in the multivariate model 1, but the association was attenuated and no longer significant after adjusting for total meat and fat intakes (Table). The association between AGE intake and BC did not differ by BMI, hormone therapy use, or alcohol consumption. AGE intake was not related to BC hormone receptor status, histologic type, or grade. However, AGE intake was associated with increased risks of advanced stage tumors (highest vs. lowest quintile of AGE intake, RR 1.37 95% CI 1.09-1.74) even after controlling for total meat and fat intakes. The risk of advanced stage BC increased by 14% (RR 1.14 95% CI 1.04-1.25 in multivariate model 2) per 2,500 KU/1,000 kcal increase in AGE intake.

Conclusions: Dietary AGEs may play a role in the development of postmenopausal BC, particularly in advanced stage BC.

Relative Risks (95% CI) of breast cancer for quintiles of AGE intakeQuintiles of AGE intake12345P valueContinuous AGETotal invasive breast cancerNo. of cases1,8992,0231,9321,9952,002Age-adjusted model1 reference1.07 (1.01-1.14)1.03 (0.97-1.10)1.08 (1.01-1.15)1.10 (1.04-1.17).0051.05 (1.02-1.07)Multivariate model 11 reference1.06 (0.99-1.13)1.01 (0.95-1.08)1.05 (0.99-1.12)1.09 (1.02-1.16).031.04 (1.02-1.07)Multivariate model 21 reference1.00 (0.93-1.08)0.94 (0.86-1.02)0.96 (0.88-1.06)1.00 (0.90-1.11).991.03 (0.99-1.08)StageLocalizedNo. of cases1,0211,0169741,001989Age-adjusted model1 reference1.00 (0.92-1.09)0.97 (0.88-1.05)1.00 (0.92-1.09)1.01 (0.92-1.10).891.02 (0.99-1.06)Multivariate model 11 reference0.99 (0.90-1.08)0.95 (0.87-1.04)0.98 (0.90-1.07)1.00 (0.92-1.10).921.02 (0.98-1.06)Multivariate model 21 reference0.90 (0.81-0.99)0.84 (0.75-0.94)0.86 (0.76-0.98)0.90 (0.78-1.04).321.02 (0.96-1.09)Distant/RegionalNo. of cases341414377408438Age-adjusted model1 reference1.22 (1.06-1.41)1.12 (0.97-1.29)1.22 (1.05-1.41)1.33 (1.15-1.53)&lt;.0011.11 (1.05-1.17)Multivariate model 11 reference1.21 (1.04-1.39)1.10 (0.94-1.27)1.18 (1.02-1.37)1.28 (1.11-1.48).0041.09 (1.03-1.16)Multivariate model 21 reference1.25 (1.06-1.47)1.15 (0.95-1.40)1.25 (1.02-1.54)1.37 (1.09-1.74).021.14 (1.04-1.25)

Citation Format: Lindsay L. Peterson, Seho Park, Yikyung Park, Narges Anbardar, David Turner. Dietary advanced glycation end-products and postmenopausal breast cancer risk in the NIH AARP diet and health study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 619.

Abstract P1-15-05: Is absolute lymphocyte count associated with platinum-sensitivity? A phase II single arm study evaluating the efficacy of neoadjuvant carboplatin and docetaxel in triple negative breast cancer

Background: Platinum-based chemotherapy is still considered investigational for the treatment of sporadic triple negative breast cancer (TNBC). Since patients with TNBC have a high rate of chemotherapy resistance, it is critical to identify platinum-sensitive individuals prior to initiating therapy. Higher absolute lymphocyte count (ALC) is associated with improved clinical response to anthracycline-based chemotherapy, the current standard of care in TNBC. We report the initial results of a phase II single arm study evaluating the efficacy of neoadjuvant carboplatin and docetaxel in TNBC. We also report results of an exploratory analysis assessing whether ALC can be used to predict pathologic complete response (pCR) after treatment with platinum-based chemotherapy.

Patients and Methods: 78 patients with clinical stage II or III TNBC have been enrolled in this ongoing study evaluating the efficacy of neoadjuvant carboplatin and docetaxel (NCT201404107). Patients received docetaxel 75 mg/m2 and carboplatin AUC 6 every three weeks for a total of 6 cycles. Blood samples were collected prior to each cycle, and a posttreatment sample was collected &gt; 3 weeks after completing cycle 6. pCR was defined as no residual invasive disease in the breast, with or without ductal carcinoma in situ, and no tumor deposits in sampled lymph nodes. Baseline characteristics of patients were summarized with descriptive statistics. Univariate and multivariate logistic regression analyses were used to identify factors associated with pCR.

Results: Out of the 78 enrolled patients, 60 have completed all 6 treatment cycles and surgery. The preliminary pCR rate is 46.7%. Age, race, clinical stage, and tumor grade determined at time of diagnosis were not significantly different between pCR patients and non-pCR patients. In univariate analyses, patients with higher ALCs at the posttreatment time point were more likely to have pCR than those who had lower ALCs (OR 5.5, 95% CI 1.5-20.7, p=0.011). Additionally, patients who had higher minimum ALCs were also more likely to have pCR (OR 9.1, 95% CI 1.5-54.9, p=0.016). Baseline ALC values were not associated with pCR. The associations of posttreatment and minimum ALCs to pCR remained statistically significant even after controlling for age and clinical stage at time of diagnosis (posttreatment ALC OR 7.6, 95% CI 1.7-34.8, p=0.009; minimum ALC OR 9.0, 95% CI 1.5-55.2, p=0.018).

Conclusion: The pCR rate of our cohort is similar to that of other trials evaluating neoadjuvant platinum-based chemotherapy in TNBC. Baseline ALC did not predict which patients would achieve pCR. However, the associations of posttreatment and minimum ALCs with pCR indicate patients who are able to maintain a robust population of circulating lymphocytes throughout treatment with platinum-based chemotherapy are more likely to respond favorably. The link between patient immunity and platinum-based chemotherapy suggests addition of immunotherapy agents to neoadjuvant chemotherapy may improve patient outcomes.

Citation Format: Chen I, Guo F, Summa T, Luo J, Ellis MJ, Ma CX, Weilbaecher KN, Naughton MJ, Suresh R, Peterson LL, Cherian MA, Bose R, Frith AE, Hernandez-Aya LF, Gillanders WE, Ademuyiwa FO. Is absolute lymphocyte count associated with platinum-sensitivity? A phase II single arm study evaluating the efficacy of neoadjuvant carboplatin and docetaxel in 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 P1-15-05.

Association of fried food consumption with all cause, cardiovascular, and cancer mortality: prospective cohort study

OBJECTIVE

To examine the prospective association of total and individual fried food consumption with all cause and cause specific mortality in women in the United States.

DESIGN

Prospective cohort study.

SETTING

Women's Health Initiative conducted in 40 clinical centers in the US.

PARTICIPANTS

106 966 postmenopausal women aged 50-79 at study entry who were enrolled between September 1993 and 1998 in the Women's Health Initiative and followed until February 2017.

MAIN OUTCOME MEASURES

All cause mortality, cardiovascular mortality, and cancer mortality.

RESULTS

31 558 deaths occurred during 1 914 691 person years of follow-up. For total fried food consumption, when comparing at least one serving per day with no consumption, the multivariable adjusted hazard ratio was 1.08 (95% confidence interval 1.01 to 1.16) for all cause mortality and 1.08 (0.96 to 1.22) for cardiovascular mortality. When comparing at least one serving per week of fried chicken with no consumption, the hazard ratio was 1.13 (1.07 to 1.19) for all cause mortality and 1.12 (1.02 to 1.23) for cardiovascular mortality. For fried fish/shellfish, the corresponding hazard ratios were 1.07 (1.03 to 1.12) for all cause mortality and 1.13 (1.04 to 1.22) for cardiovascular mortality. Total or individual fried food consumption was not generally associated with cancer mortality.

CONCLUSIONS

Frequent consumption of fried foods, especially fried chicken and fried fish/shellfish, was associated with a higher risk of all cause and cardiovascular mortality in women in the US.

Advanced glycation end products are elevated in estrogen receptor-positive breast cancer patients, alter response to therapy, and can be targeted by lifestyle intervention

Purpose

Lifestyle factors associated with personal behavior can alter tumor-associated biological pathways and thereby increase cancer risk, growth, and disease recurrence. Advanced glycation end products (AGEs) are reactive metabolites produced endogenously as a by-product of normal metabolism. A Western lifestyle also promotes AGE accumulation in the body which is associated with disease phenotypes through modification of the genome, protein crosslinking/dysfunction, and aberrant cell signaling. Given the links between lifestyle, AGEs, and disease, we examined the association between dietary-AGEs and breast cancer.

Methods

We evaluated AGE levels in bio-specimens from estrogen receptor-positive (ER+) and estrogen receptor-negative (ER−) breast cancer patients, examined their role in therapy resistance, and assessed the ability of lifestyle intervention to reduce circulating AGE levels in ER+ breast cancer survivors.

Results

An association between ER status and AGE levels was observed in tumor and serum samples. AGE treatment of ER+ breast cancer cells altered ERα phosphorylation and promoted resistance to tamoxifen therapy. In a proof of concept study, physical activity and dietary intervention was shown to be viable options for reducing circulating AGE levels in breast cancer survivors.

Conclusions

There is a potential prognostic and therapeutic role for lifestyle derived AGEs in breast cancer. Given the potential benefits of lifestyle intervention on incidence and mortality, opportunities exist for the development of community health and nutritional programs aimed at reducing AGE exposure in order to improve breast cancer prevention and treatment outcomes.

Electronic supplementary material

The online version of this article (10.1007/s10549-018-4992-7) contains supplementary material, which is available to authorized users.

Abstract P5-21-30: Retrospective review of palbociclib (Pal) efficacy and benefit from subsequent treatments following Pal progression in patients (pts) with hormone receptor positive (HR+) and HER2 negative (HER2-) metastatic breast cancer (MBC)

Background

The cyclin-dependent kinase (CDK) 4/6 inhibitor Pal is approved for HR+ HER2- MBC. However, the optimal therapy following Pal progression is unknown. Therefore we conducted this retrospective study to review Pal efficacy and summarize the practice pattern and responses to subsequent treatments post Pal progression.

Methods

We performed a chart review of pts with HR+ HER2- MBC who began Pal treatment at Washington University Siteman Cancer Center between Feb 16, 2015 and July 13, 2016 and collected information on pts demographics, diagnosis, and treatment history. Duration of therapy was used to calculate the progression free survival (PFS) for each regimen. Treatment was considered first-line if administered without any prior systemic therapy or at least 1 year from completion of adjuvant hormonal therapy (HT). Treatments received after progression on 1st line therapy or upon relapse during or within 1 year from the completion of adjuvant HT were considered second-line regimens.

Statistical analyses were performed on SAS software, version 9.4. The Kaplan-Meier method was used to generate time-to-event curves, from which median PFS was calculated. A stratified log-rank test was used for all comparisons, and the P value derived from the comparison was reported.

Results

We completed a chart review for 81 pts (78 female and 3 male; 63 Caucasian, 14 African American, and 4 other races) with HR+ HER2- MBC (68 were ER+PR+, 13 were ER+PR-) who received Pal plus letrozole (n=65) or fulvestrant (n=15) or anastrozole (n=1), with a median age of 62.0 years (range 28.1 - 85.6) at the start of Pal.

The median follow up was 20.0 months (mos) (range 10.8 – 27.9). 25 pts were still on Pal treatment. The median PFS on Pal was 19.9 mos in the first-line setting (n=20), compared to 12.1 mos and 4.4 mos in the second-line (n=14) and subsequent lines (n=47), respectively (p=0.0287). Among the 54 pts who progressed on Pal, 38 moved on to the next treatment. 20 pts received chemotherapy and 16 pts received HT or a HT combination. 2 pts received fulvestrant plus Pal upon progression on letrozole plus Pal, and treatment was still ongoing at 4 mos and 7 mos of follow up, respectively. The most common treatments post Pal were single-agent capecitabine (Cape) (n=9) and the combination of exemestane (Exe) and everolimus (Eve) (n=8). The median PFS was 4.7 mos with Cape compared to 8.4 mos with Exe and Eve (p=0.60). The median PFS was 4.7 mos for the 20 pts who received chemo, whereas the median PFS was 4.9 mos with subsequent HT (n=16) (p=0.75).

Conclusion

Pal plus letrozole or fulvestrant is effective for the treatment of HR+ HER2- MBC, with activity observed beyond the 1st and 2nd line treatment settings. The PFS of Pal observed in this single center retrospective study is consistent with that of published data. Single-agent cape or the Exe and Eve combination were common treatment choices following progression on Pal. Although the study is limited by its small sample size, the median PFS of 8.4 mos with Exe and Eve indicates its potential efficacy in the setting of Pal progression. Additional pts and followup data will be presented.

Citation Format: Xi J, Oza A, Thomas S, Naughton M, Ademuyiwa F, Weilbaecher KN, Suresh R, Bose R, Cherian MA, Hernandez-Aya L, Frith A, Peterson LL, Krishnamurthy J, Ma CX. Retrospective review of palbociclib (Pal) efficacy and benefit from subsequent treatments following Pal progression in patients (pts) with hormone receptor positive (HR+) and HER2 negative (HER2-) metastatic breast cancer (MBC) [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 P5-21-30.

Obesity and Cancer: Evidence, Impact, and Future Directions

BACKGROUND

Mounting evidence, particularly from prospective epidemiologic studies but with additional support from animal models and mechanistic studies, supported conclusions in 2016 by the International Agency for Research on Cancer (IARC) in their review of the preventive effects of weight control on cancer risk.

CONTENT

The workgroup concluded that obesity is causally related to cancer at 13 anatomic sites (esophagus: adenocarcinoma; gastric cardia; colon and rectum; liver; gallbladder; pancreas; breast: postmenopausal; uterine endometrial; ovary; kidney: renal cell; meningioma; thyroid; and multiple myeloma). Further, avoiding weight gain and excess body fat will prevent cancer. Evidence on weight loss and reduction in risk of cancer is more limited. Ongoing clinical trials address the benefits of weight loss interventions after diagnosis.

SUMMARY

Here, we review the evidence from the 2016 IARC that obesity is causally related to cancer at 13 anatomic sites and identify areas for future research, including the consequences of childhood adiposity, the relation between velocity of weight gain and cancer risk, and improved methods for analysis of life-course adiposity and cancer risk. Refining understanding of mechanisms may further inform prevention strategies.

Abstract P6-07-12: A physical activity and dietary counseling intervention in breast cancer survivors and changes in known and novel prognostic biomarkers

High rates of overweight/obesity are commonly seen in breast cancer (BC) survivors. Observational data show an association between post-treatment increased weight and lack of physical activity (PA) and risk of BC recurrence and death. Increases in prognostic inflammatory associated biomarkers (BM) such as interleukin-6 (IL6) and C-reactive protein (CRP), and their downstream effects, are linked to overweight/obesity and provide a potential mechanistic explanation for this increase in recurrence risk, but studies are mixed regarding the effect of lifestyle interventions on these BM. In addition, better BM may exist. The Getting on Board with an Active Lifestyle (GOAL) study tested the feasibility of a PA and dietary counseling (DC) intervention in BC survivors and included known BM (IL6 , CRP) as well as a novel BM (advanced glycation end-products [AGEs]). AGEs are reactive metabolites produced by an uncontrolled reaction between sugars and proteins and were selected because they are seen in chronic diseases including: diabetes, neuro-degenerative disorders, stroke, heart disease and more recently, BC. Further, dietary AGEs are consumed in high fat and highly processed foods that contribute to overweight/obesity.

Methods: Ten overweight/obese women (BMI≥25) within 36 months of BC diagnosis (stage I-III) participated in a 12-week supervised PA and DC intervention consisting of two supervised PA sessions per week and weekly DC sessions. Body mass index (BMI), resting heart rate (HR) and blood pressure (BP) and blood samples were collected at baseline, week 4, 8, 12, 24, 36, 52. IL-6, CRP and AGEs were assessed in serum using commercially available 96-well format ELISAs. Data through week 12 is presented here.

Results: Ten participants (four African American) completed the 12-week intervention. The age range of participants was 50-68 years (mean 56 years). The average number of daily active minutes increased significantly between baseline (45) and week 11 (71). There was a drop off at week 12 due to right-censoring of the data. Dietary AGE intake decreased in 8 of 10 participants from baseline to week 12 (average reduction 53%). Significant reductions in mean serum AGEs were seen (baseline=53 ug/ml, week 12=38ug/ml, p&lt;0.001). No correlating reductions in CRP or IL6 were found. Correlations were seen between AGE levels and AGE intake (r=0.24 at week 12). There were no significant correlations between AGE levels and IL6 or CRP. Decreases in BMI (average change -.54 kg/m2), resting HR and BP corroborated with AGE reductions.

Conclusions: The GOAL intervention has the potential to improve PA and dietary AGE intake among overweight/obese BC patients. Participants improved weight, resting HR, BP, and number of daily active minutes; which are important metrics for overall health. There were no changes in IL6 and CRP, but reductions in AGEs correlated with reductions in dietary AGE levels, indicating that serum AGEs may be reduced through diet and PA. Serum AGEs may represent a better BM than IL6 and CRP in BC survivors. Further investigation of AGEs in BC survivors is warranted.

Citation Format: Peterson LL, Ford ME, Gregoski MJ, Knight KD, Hilton EJ, Magwood G, Turner DP. A physical activity and dietary counseling intervention in breast cancer survivors and changes in known and novel prognostic biomarkers [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 P6-07-12.

Association between renal function and chemotherapy-related toxicity in older adults with cancer

PURPOSE

To evaluate the association between renal function (RF) and chemotherapy-related toxicity (CRT) in older adults with cancer and to compare the effect of different RF formulas and body weight measurements on this association.

METHODS

This is a secondary analysis of data from a prospective multicenter study of patients ≥ age 65 who were starting a new chemotherapy regimen. RF was estimated with 4 formulas (modified Jelliffe [Jelliffe], Cockcroft-Gault [CG], Wright, and Modification of Diet in Renal Disease [MDRD]), using actual, ideal and adjusted body weights for 492 patients. The association between baseline RF and grade 3-5 CRT was evaluated by unconditional logistic regression.

RESULTS

As a continuous variable, decreased creatinine clearance (CrCl) calculated by CG with actual body weight was associated with increased odds of CRT (OR 1.12, P<0.01; 95% CI 1.04-1.20) indicating that on average for every 10mL/min decrease in CrCl the odds of CRT increased by 12%. Very low RF (in the lowest 10%) with all formulas (CG, Jelliffe, Wright and MDRD) was associated with increased odds for CRT. This association is independent of the type of chemotherapy received (those requiring dose adjustment for renal function vs not). Neither primary dose reduction nor chemotherapy duration was associated with CRT. Serum creatinine alone was not associated with increased odds of CRT (OR 0.67, P=0.15).

CONCLUSIONS

Decreased RF is associated with increased odds of CRT and should be considered when assessing risk of CRT in older adults with cancer. Serum creatinine alone is not adequate for risk assessment.

Disparities in Obesity, Physical Activity Rates, and Breast Cancer Survival

The significantly higher breast cancer (BCa) mortality rates of African-American (AA) women compared to non-Hispanic (NHW) white women constitute a major US health disparity. Investigations have primarily focused on biological differences in tumors to explain more aggressive forms of BCa in AA women. The biology of tumors cannot be modified, yet lifestyle changes can mitigate their progression and recurrence. AA communities have higher percentages of obesity than NHWs and exhibit inefficient access to care, low socioeconomic status, and reduced education levels. Such factors are associated with limited healthy food options and sedentary activity. AA women have the highest prevalence of obesity than any other racial/ethnic/gender group in the United States. The social ecological model (SEM) is a conceptual framework on which interventions could be developed to reduce obesity. The SEM includes intrapersonal factors, interpersonal factors, organizational relationships, and community/institutional policies that are more effective in behavior modification than isolation from the participants' environmental context. Implementation of SEM-based interventions in AA communities could positively modify lifestyle behaviors, which could also serve as a powerful tool in reducing risk of BCa, BCa progression, and BCa recurrence in populations of AA women.

Systemic capillary leak syndrome in a patient receiving adjuvant oxaliplatin for locally advanced colon cancer

Colorectal cancer is the third most common cancer diagnosed in the USA each year. Oxaliplatin, a platinum-based chemotherapy agent, is part of the standard adjuvant chemotherapy regimen FOLFOX (oxaliplatin with 5-fluorouracil [5-FU] and leucovorin [LV]) for the treatment of stage III and some high-risk stage II colorectal cancers. Although oxaliplatin is generally well tolerated, certain side effects such as nausea, vomiting, and peripheral neuropathy are common. We report a case of oxaliplatin-induced capillary-leak syndrome in a 63-year-old man undergoing his 12th and final cycle of FOLFOX for stage III colorectal cancer. To our knowledge, this is the first case of systemic capillary leak syndrome (SCLS) reported in association with oxaliplatin. Currently, there is no prevention for SCLS. Documenting future cases of SCLS attributed to oxaliplatin is vital, as SCLS is associated with significant morbidity and mortality and no standard treatments beyond supportive care measures exist. Early recognition and diagnosis are therefore essential to improving patient outcomes.

A combined modality therapeutic approach to metastatic anal squamous cell carcinoma with systemic chemotherapy and local therapy to sites of disease: case report and review of literature

Cases of metastatic anal carcinoma managed with a combination of systemic chemotherapy and local therapies to both solitary sites of metastases and the primary site have been reported in the literature. We present a case of a 55-year-old male with metastatic anal squamous cell carcinoma to the liver treated with induction chemotherapy with cisplatin (CDDP) and 5-fluorouracil (5FU) followed by liver resection and radiation to the anal primary with concurrent 5FU and mitomycin. This approach resulted in control of disease without evidence of recurrence, and no increased toxicities now 19 months from initial diagnosis to time of reporting. This novel approach resulted in a good treatment response as documented by imaging and symptom improvement and a long disease free interval.

Abstract B07: Design and preliminary outcomes of a study to reduce cancer-associated reactive metabolite levels in breast cancer survivors – The RCAM Study

Breast cancer (BCa) is the 2nd leading cause of cancer death in women in the US. African American (AA) women have higher BCa mortality rates and higher obesity rates compared to other women. It is well known that exercise and a healthier diet can improve prognosis among BCa survivors but little is known about their positive effects on common biological pathways involved in BCa recurrence. The RCAM Study is a 1-year study designed to identify bio-behavioral pathways that may impact BCa recurrence. The study evaluates the effect of the intervention on a novel biomarker associated with cancer recurrence advanced glycation end products (AGEs). The intervention, adapted from the highly successful Diabetes Prevention Program (DPP), consists of a 12-week physical activity and dietary counseling program. The supervised physical activity component is conducted twice a week at a local health system's cardiopulmonary rehabilitation center; the individualized dietary counseling component is conducted weekly at the health system's weight management center. The study participants consist of overweight or obese women who received surgery for invasive BCa and who are within 36 months of diagnosis. In addition, adjuvant therapy must have been received at least four weeks prior to study enrollment. To date, 10 participants have completed the 12-week intervention and will be followed for 1 year. Preliminary ELISA data from blood samples collected pre- and post-12 week intervention show significant post-intervention reductions in inflammatory biomarker levels. Commensurate decreases in body mass, resting heart rate, and blood pressure were also seen. The average pre-/post-intervention decrease in AGE levels was not as dramatic for the AA participants, most of whom were morbidly obese at enrollment, as for the European American (EA) women, most of whom were overweight at enrollment. These data demonstrate the high potential of the RCAM intervention in improving prognosis among BCa survivors and show the need to tailor the intervention to meet the specific needs of AA women.

Citation Format: Marvella E. Ford, David P. Turner, Mathew J. Gregoski, Lindsay L. Peterson, Kendrea D. Knight, Ebony J. Hilton, Gayenell Magwood. Design and preliminary outcomes of a study to reduce cancer-associated reactive metabolite levels in breast cancer survivors – The RCAM Study. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B07.

Identification of global data and partitioning scheme for modeling biological data within the electronic medical record

Using "Black Box" theory we analyzed human physiology. The major physiological means of communication are the vascular and nervous systems. The fundamental partitions of physiology are the vascular capillary fields and efferent and afferent fields of the nervous system. These fields are generally associated with organs and organ systems. Such analysis leads to the conclusion that the global biological data are information carried within the vascular and nervous systems. Data elements and processes within organs are important to other organs only through their effects on these global elements. Incorporation of these concepts into medical databases would allow the partitioning of the software around physiological systems. As a result of partitioning the utility of the electronic medical record, software could be greatly expanded.