Psychological need fulfillment in virtual teaching: insights of residents and faculty

Objective

To explore benefits and challenges experienced by residents and faculty when teaching in virtual settings.

Methods

This was a qualitative descriptive study employing one-on-one semi-structured interviews with 10 residents and 12 faculty in the Department of Family Medicine at the University of Alberta, Canada, from May 2021 to May 2022. Participants were recruited via social media, resident and department events and email lists. Interview transcripts were analyzed descriptively and thematically employing the Self-Determination Theory (SDT) framework to map the identified benefits and challenges as facilitators and barriers to fulfilling teacher's basic psychological needs for autonomy, competence, and relatedness in virtual settings.

Results

Resident and faculty participants used virtual technology not only to deliver education, but also leveraged various platform features to support their needs in virtual settings. The emerging themes within benefits and challenges of virtual teaching were amenable to mapping onto three basic psychological needs of the SDT framework - autonomy (e.g., increased accessibility; lack of control over teaching environment), competence (e.g., increased self-confidence; technological limitations hindering skill development), and relatedness (e.g., timely exchange of information; difficulty with professional identity formation).

Conclusions

Despite the inherent challenges, teaching in virtual settings can support teachers' psychological needs. Recommendations for the future delivery and facilitation of virtual learning include: giving high priority to engagement and active participation; nurturing autonomy and greater individual responsibility for learning; and creating an environment of emotional support. The SDT-informed strategies shown to be effective in in-person teaching need to be examined for their applicability in virtual settings.

O77: DOES MESH IMPROVE PATIENT SATISFACTION AND HEALTH-RELATED QUALITY OF LIFE AFTER IMPLANT-BASED BREAST RECONSTRUCTION? A MULTICENTRE PROSPECTIVE COHORT STUDY

Introduction

Biological and synthetic meshes may improve outcomes of immediate IBBR by facilitating single-stage direct-to-implant procedures. However, high-quality supporting evidence is limited, particularly regarding PROs.

Method

2108 consecutive women undergoing IBBR at 81 centres were prospectively recruited between 2014-2016. Demographic, operative, oncological and 3-month complication data were collected. An 18-month questionnaire assessed PROs using the validated BREAST-Q and a five-point Likert scale rating of overall reconstructive outcome.

The impacts of different IBBR techniques on PROs were explored using mixed-effects regression models adjusted for clinically-relevant confounders and including a random effect to account for clustering by centre. The reference group was two- stage submuscular reconstruction without mesh.

Result

1470 participants consented to receive the questionnaire and 891 completed it. 67 patients underwent two-stage submuscular reconstruction; 764 patients received subpectoral reconstructions with biological mesh (n=495) synthetic mesh (n=95) or dermal sling (n=174). 14 patients underwent prepectoral reconstructions (introduced late in the study).

Compared with two-stage reconstructions, no differences in PROs were seen in biological or synthetic mesh-assisted or dermal sling procedures (p>0.05). However, prepectoral IBBR patients reported better satisfaction with breasts (difference=6.63, 95% confidence interval[1.65–11.61], p=0.009). Outcomes were similar to those in the NMBRA 2008/9 cohort, which included submuscular procedures only.

Conclusion

This study does not suggest that mesh improves PROs of IBBR. It provides early data supporting improved satisfaction with breasts following prepectoral reconstructions. Future trials are needed to robustly evaluate prepectoral techniques.

Abbrev

IBBR: implant-based breast reconstruction, PRO: patient-reported outcome, NMBRA: National Mastectomy and Breast Reconstruction Audit

Take-home message

Although mesh-assisted techniques have become widely adopted, this large, prospective, multicentre cohort study does not suggest that mesh improves patient-reported outcomes of implant-based breast reconstruction compared with standard submuscular techniques. However, it provides early data to support improved satisfaction with breasts in the prepectoral setting, which now requires robust evaluation.

O58: THE IMPACT OF RADIOTHERAPY ON PATIENT-REPORTED OUTCOMES OF IMMEDIATE IMPLANT-BASED BREAST RECONSTRUCTION: RESULTS OF A PROSPECTIVE MULTICENTRE COHORT STUDY

Introduction

Post-mastectomy radiotherapy (PMRT) is increasing given to improve breast cancer outcomes but can increase complication rates following implant-based breast reconstruction (IBBR). Little, however, is known about the impact of PMRT on patient-reported outcomes (PROs) of IBBR, especially in the context of mesh-assisted techniques.

Method

2108 consecutive women undergoing IBBR at 81 UK centres were prospectively recruited between 2014 and 2016. Demographic, operative, oncological and 3-month complication data were collected, and patients who consented received post-operative questionnaires. An 18-month questionnaire assessed PROs using the validated BREAST-Q. The effect of IBBR on PROs was investigated using mixed-effects regression models adjusted for clinically relevant confounders and including a random effect to account for potential clustering by centre.

Result

1693 iBRA participants underwent mastectomy for malignancy, of whom 1187 (70%) consented to receive the 18-month questionnaire and 732 (43%) completed it. Patients undergoing PMRT (n=214) reported significantly worse scores across 3 BREAST-Q domains: satisfaction with breasts (-6.27 points, p=0.008, 95% confidence interval (CI)[-10.91,-1.63]), satisfaction with outcome (-7.53 points, p=0.002, CI[-12.20,-2.85]) and physical well-being (-6.55 points, p<0.001, CI[-9.43,-3.67]). Overall satisfaction was worse in the PMRT group (OR 0.497, p=0.002, CI[0.32,0.77]). Use of biological mesh did not ameliorate the impact of PMRT on patient satisfaction (interaction term p-values [0.173 - 0.826]).

Conclusion:

PMRT adversely affects PROs of IBBR. This should be discussed with patients considering IBBR, especially if PMRT is anticipated or indications are borderline, to enable informed decisions regarding oncological and reconstructive options.

Abbrev

PMRT: post-mastectomy radiotherapy, PRO: patient-reported outcome

Take-home message

This multicentre, prospective cohort study of 732 patients undergoing implant-based breast reconstruction demonstrates worse 18-month patient-reported outcomes in women who received post-mastectomy radiotherapy than those who did not. These data should be discussed with patients to help them make informed decisions about reconstructive surgery.

Managing breast gangrene during the COVID-19 pandemic

At the onset of the COVID-19 crisis, a 63-year-old woman with multiple life-limiting comorbidities was referred with a necrotic infected left breast mass on a background of breast cancer treated with conservation surgery and radiotherapy 22 years previously. The clinical diagnosis was locally advanced breast cancer, but four separate biopsies were non-diagnostic. Deteriorating renal function and incipient sepsis and endocarditis resulted in urgent salvage mastectomy during the peak of the COVID19 pandemic. The final diagnosis was infected ischaemic/infarcted breast (wet gangrene) secondary to vascular insufficiency related to diabetes, cardiac revascularisation surgery and breast radiotherapy.

Palbociclib in combination with endocrine therapy versus capecitabine in hormonal receptor-positive, human epidermal growth factor 2-negative, aromatase inhibitor-resistant metastatic breast cancer: a phase III randomised controlled trial-PEARL

BACKGROUND

Palbociclib plus endocrine therapy (ET) is the standard treatment of hormone receptor-positive and human epidermal growth factor receptor 2-negative, metastatic breast cancer (MBC). However, its efficacy has not been compared with that of chemotherapy in a phase III trial.

PATIENTS AND METHODS

PEARL is a multicentre, phase III randomised study in which patients with aromatase inhibitor (AI)-resistant MBC were included in two consecutive cohorts. In cohort 1, patients were randomised 1 : 1 to palbociclib plus exemestane or capecitabine. On discovering new evidence about estrogen receptor-1 (ESR1) mutations inducing resistance to AIs, the trial was amended to include cohort 2, in which patients were randomised 1 : 1 between palbociclib plus fulvestrant and capecitabine. The stratification criteria were disease site, prior sensitivity to ET, prior chemotherapy for MBC, and country of origin. Co-primary endpoints were progression-free survival (PFS) in cohort 2 and in wild-type ESR1 patients (cohort 1 + cohort 2). ESR1 hotspot mutations were analysed in baseline circulating tumour DNA.

RESULTS

From March 2014 to July 2018, 296 and 305 patients were included in cohort 1 and cohort 2, respectively. Palbociclib plus ET was not superior to capecitabine in both cohort 2 [median PFS: 7.5 versus 10.0 months; adjusted hazard ratio (aHR): 1.13; 95% confidence interval (CI): 0.85-1.50] and wild-type ESR1 patients (median PFS: 8.0 versus 10.6 months; aHR: 1.11; 95% CI: 0.87-1.41). The most frequent grade 3-4 toxicities with palbociclib plus exemestane, palbociclib plus fulvestrant and capecitabine, respectively, were neutropenia (57.4%, 55.7% and 5.5%), hand/foot syndrome (0%, 0% and 23.5%), and diarrhoea (1.3%, 1.3% and 7.6%). Palbociclib plus ET offered better quality of life (aHR for time to deterioration of global health status: 0.67; 95% CI: 0.53-0.85).

CONCLUSIONS

There was no statistical superiority of palbociclib plus ET over capecitabine with respect to PFS in MBC patients resistant to AIs. Palbociclib plus ET showed a better safety profile and improved quality of life.

Early ctDNA dynamics as a surrogate for progression-free survival in advanced breast cancer in the BEECH trial

Background

Dynamic changes in circulating tumour DNA (ctDNA) levels may predict long-term outcome. We utilised samples from a phase I/II randomised trial (BEECH) to assess ctDNA dynamics as a surrogate for progression-free survival (PFS) and early predictor of drug efficacy.

Patients and methods

Patients with estrogen receptor-positive advanced metastatic breast cancer (ER+ mBC) in the BEECH study, paclitaxel plus placebo versus paclitaxel plus AKT inhibitor capivasertib, had plasma samples collected for ctDNA analysis at baseline and at multiple time points in the development cohort (safety run-in, part A) and validation cohort (randomised, part B). Baseline sample ctDNA sequencing identified mutations for longitudinal analysis and mutation-specific digital droplet PCR (ddPCR) assays were utilised to assess change in ctDNA abundance (allele fraction) between baseline and 872 on-treatment samples. Primary objective was to assess whether early suppression of ctDNA, based on pre-defined criteria from the development cohort, independently predicted outcome in the validation cohort.

Results

In the development cohort, suppression of ctDNA was apparent after 8 days of treatment (P = 0.014), with cycle 2 day 1 (4 weeks) identified as the optimal time point to predict PFS from early ctDNA dynamics. In the validation cohort, median PFS was 11.1 months in patients with suppressed ctDNA at 4 weeks and 6.4 months in patients with high ctDNA (hazard ratio = 0.20, 95% confidence interval 0.083–0.50, P < 0.0001). There was no difference in the level of ctDNA suppression between patients randomised to capivasertib or placebo overall (P = 0.904) nor in the PIK3CA mutant subpopulation (P = 0.071). Clonal haematopoiesis of indeterminate potential (CHIP) was evident in 30% (18/59) baseline samples, although CHIP had no effect on tolerance of chemotherapy nor on PFS.

Conclusion

Early on-treatment ctDNA dynamics are a surrogate for PFS. Dynamic ctDNA assessment has the potential to substantially enhance early drug development.

Clinical registration number

NCT01625286.

HIV/HCV/HBV testing in the emergency department: a feasibility and seroprevalence study

OBJECTIVES

The aims of this study were to to assess the feasibility of simultaneous testing for the blood-borne viruses (BBV), HIV, hepatitis C (HCV) and hepatitis B (HBV), in the Emergency Department (ED) and ascertain the seroprevalence for these three viruses in this setting.

METHODS

A pilot BBV testing program was undertaken as part of routine clinical care in the ED. All ED attendees aged between 16 and 65 years old who were able to consent were tested over a 55 week period on an opt out basis. Patients with positive test results were linked to clinical services. Interventions aimed at improving testing rates were implemented and evaluated by quality improvement (QI) methodology.

RESULTS

Of 25,520 age-eligible ED attendees, 6108 (24%) underwent BBV testing; an additional 1160 (4.5%) underwent a standalone HIV test (total of 7268 (28%) individuals).There were 83/7268 (1.1%) non-negative (ie reactive or equivocal) results for HIV and 103/6108 (1.7%) and 32/6108 (0.52%) for anti-HCV IgG and HBsAg, respectively. Of these, 12 (0.17%), 16 (0.26%) and 8 (0.13%) were new reactive tests for HIV, HCV and HBV, respectively, which were able to be confirmed on a second test. Specific QI interventions led to temporary increases in testing rates.

CONCLUSIONS

An opt out BBV testing program in the ED is feasible and effective at finding new cases. However, the testing rate was low at 24%. Although QI interventions led to some improvement in testing rates, further studies are required to identify ways to achieve sustained increases in testing in this setting.

Abstract P4-01-01: Molecular residual disease detection with circulating tumor DNA analysis predicts relapse in patients with early stage breast cancer

Background. Detection of circulating tumor DNA (ctDNA) after treatment of early stage breast cancer may identify molecular residual disease. In a prior proof-of-principle study we demonstrated that detection of ctDNA predicted relapse with high accuracy (Garcia-Murillas et al Science Trans Med 2015). We conducted an independent, prospective, multi-centre validation study.

Methods. In this validation study, a cohort of 170 early stage breast cancer patients were recruited from five hospitals into two prospective sample collection studies. Patients were scheduled to receive standard chemotherapy, surgery +/- radiotherapy, adjuvant endocrine therapy and HER2 antibodies as appropriate. Plasma samples were collected for ctDNA analysis at baseline, post-surgery, three monthly for the first year of follow-up, and six monthly thereafter and shipped to a central lab for processing. Using previously established criteria, tumor was sequenced to identify somatic mutations that were tracked by digital PCR in DNA extracted from 4mls of plasma at all available time points. Buffy coat DNA was analysed at all time-points to control for clonal haematopoesis of indeterminate potential (CHIP) detection. The primary endpoint was to compare invasive disease free survival between patients with and without detection of ctDNA after treatment. A combined analysis of this validation study, and the prior proof-of-principle study, was also conducted to analyse secondary endpoints.

Results. After tumor sequencing, 101 patients from the validation study had at least one mutation to track. At median 35.5 months follow-up, ctDNA was detected in plasma of 15.8% (16/101) patients. Detection of ctDNA strongly predicted relapse, hazard ratio 24.5 (95% CI 6.5 to 93.2, P&lt;0.001 time-dependent Cox model), and was predictive of relapse in all tumor subtypes.

In the combined analysis (N=144), lead-time between ctDNA detection and relapse was 10.7 months (95% CI 7.7-17.0). Six patients had a clinical relapse that was not detected by ctDNA prior to relapse. These patients had a distinct pattern of oligo-metastatic relapse, 3 patients with brain-only metastases (P=0.0068), 1 ovarian oligo-metastasis and 2 local disease recurrence. The level of ctDNA in baseline plasma, prior to treatment, was associated with tumor subtype, highest in triple negative breast cancer (P=0.0036).

Conclusion. Detection of ctDNA after treatment is associated with a high risk of future relapse in early-stage breast cancer. Prospective studies are required to assess the potential of molecular residual disease detection to guide adjuvant therapy.

Citation Format: Turner N, Garcia-Murillas I, Chopra N, Comino-Mendez I, Beaney M, Tovey H, Cutts R, Swift C, Kriplani D, Afentakis M, Hrebien S, Walsh G, Johnston S, Ring A, Russell S, Evans A, Skene A, Wheatley D, Dowsett M, Smith I. Molecular residual disease detection with circulating tumor DNA analysis predicts relapse in patients with early stage 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 P4-01-01.

Abstract OT3-05-02: BYLieve: A phase 2 study of alpelisib with fulvestrant or letrozole for treatment of PIK3CA mutant, hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (aBC) progressing on/after cyclin-dependent kinase (CDK)4/6 inhibitor therapy

Background: Endocrine therapy (ET) is the standard of care for treatment of HR+, HER2– aBC. However, ET resistance occurs frequently leading to disease progression. Dysregulation of the PI3K/AKT/mTOR pathway, specifically mutations in PIK3CA, the gene encoding the p110alpha subunit of PI3K, has been implicated in ET resistance. In a phase 1 study, alpelisib, a PI3Kα-specific inhibitor, in combination with fulvestrant has shown antitumor activity in patients with PIK3CA mutant, HR+, HER2– aBC. The present BYLieve (NCT03056755) study aims to assess the efficacy and safety of alpelisib + fulvestrant/letrozole in PIK3CA-mutant, HR+, HER2– aBC progressing on/after prior CDK4/6 inhibitor (CDK4/6i) therapy.

Methods: BYLieve is a phase 2, multicenter, open-label, 2-cohort, non-comparative study. Men and postmenopausal women (≥ 18 years) with PIK3CA-mutant, HR+, HER2− locally advanced or metastatic breast cancer that has progressed on/after prior CDK4/6i therapy are eligible. Other eligibility criteria include ≥ 1 measurable lesion (RECIST v1.1) or predominantly lytic bone lesion; ECOG PS ≤ 2; and no prior PI3K inhibitor therapy. Patients are allocated to 2 cohorts based on the prior ET partner (aromatase inhibitor (AI) or fulvestrant) used in combination with CDK4/6i. Cohort A (patients who had received CDK4/6i + AI): oral alpelisib (300 mg once daily) + intramuscular fulvestrant (500 mg on days 1 and 15 of cycle 1, and day 1 of cycles ≥ 2 [28-day cycles]) and cohort B (patients who had received CDK4/6i + fulvestrant): oral alpelisib (300 mg once daily) + oral letrozole (2.5 mg once daily). Study treatment will continue until disease progression or intolerable toxicity. The primary end point is the proportion of patients who are alive without disease progression at 6 months (RECIST v1.1; local assessment), which will be evaluated separately in each cohort and presented together with 2-sided 90% confidence intervals using Clopper and Pearson (1934) exact method. Evidence of treatment effect will be demonstrated if the lower bound of the 90% CI is greater than 30%. A total sample size of 80 patients in each cohort is planned. Secondary end points include progression-free survival (PFS), PFS on next-line treatment (PFS2), overall response rate, clinical benefit rate, duration of response, safety, and tolerability. Detection of frequency of PIK3CA mutations in ctDNA and its correlation with response is an exploratory end point.

Citation Format: Rugo HS, Turner N, Chia S, Ciruelos E, Nienstedt C, Ridolfi A, Kong O, Sankaran B, Juric D. BYLieve: A phase 2 study of alpelisib with fulvestrant or letrozole for treatment of PIK3CA mutant, hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (aBC) progressing on/after cyclin-dependent kinase (CDK)4/6 inhibitor therapy [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 OT3-05-02.

Abstract OT1-06-03: The plasmaMATCH trial: A multiple parallel cohort, open-label, multi-centre phase II clinical trial of ctDNA screening to direct targeted therapies in patients with advanced breast cancer (CRUK/15/010)

Introduction

Circulating tumour DNA (ctDNA) is found in the plasma of over 90% of patients with advanced breast cancer (BC). Screening for the presence of mutations in ctDNA provides a current assessment of the genetic profile of the patient's recurrent BC. The plasmaMATCH trial is designed to assess the potential of ctDNA screening to direct targeted therapies in patients with advanced breast cancer.

Methods

plasmaMATCH is a multi-centre phase IIa umbrella trial platform of ctDNA screening and a therapeutic trial. The study will screen 1000 women with advanced breast cancer, who have received prior systemic treatment in the advanced setting, with digital PCR ctDNA assays for hotspot mutations in ESR1, HER2, AKT1, and PIK3CA, with HER2 copy number assessment, in a central laboratory. The study will recruit from up to 50 sites in the UK. Patients with mutations identified will enter the matching treatment cohort, ESR1 – extended dose fulvestrant 500mg every two weeks, HER2 – neratinib +/- fulvestrant, AKT1 – AZD5363 +/- fulvestrant.

Mutation prevalence is presented with corresponding exact 95% confidence intervals (CIs) both overall and excluding 14 patients who were known to have mutations from a prior screening program. Patients with more than one mutation are included once in each relevant row.

Results

We report the results of prospective ctDNA mutation testing in the first 92 patients. plasmaMATCH opened to recruitment on 15/12/2016. As of 08/06/2017, 120 patients have been registered for ctDNA screening from 7 UK centres, of which 92 have ctDNA screening results available:

plasmaMATCH ctDNA screening resultsMutationPrevalence (95% CI)Prevalence excluding 14 patients with known mutations (95% CI)ESR134/92: 37% (27%-48%)26/78: 33% (23%-45%)HER25/90: 6% (2%-12%)2/76: 3% (0%-9%)AKT17/92: 8% (3%-15%)4/78: 5% (1%-13%)PIK3CA*22/92: 24% (16%-34%)21/78: 27% (18%-38%)*No corresponding plasmaMATCH treatment cohort

14 patients had more than one mutation detected (10 ESR1+PIK3CA, 3 ESR1+AKT1, 1 ESR1+ +HER2+AKT1). ctDNA results were reported in a median of 8 working days.

Of the 40 patients with one or more actionable mutation, 15 have entered a cohort, 16 are being screened for entry into a cohort, 5 are currently receiving further systemic treatment prior to cohort entry and 4 will not enter a cohort. One additional patient has entered a treatment cohort on the basis of a mutation detected in an alternative tumour sequencing initiative.

Conclusions

plasmaMATCH ctDNA demonstrates the feasibility and accuracy of ctDNA testing as a screening tool for patients with advanced BC, with a high rate of subsequent recruitment into matching therapeutic trials.

Citation Format: Turner N, Bye H, Kernaghan S, Proszek P, Fribbens C, Moretti L, Morden J, Snowdon C, Macpherson I, Wardley A, Roylance R, Baird R, Bliss J, Ring A. The plasmaMATCH trial: A multiple parallel cohort, open-label, multi-centre phase II clinical trial of ctDNA screening to direct targeted therapies in patients with advanced breast cancer (CRUK/15/010) [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 OT1-06-03.

Abstract P2-02-17: Circulating tumor DNA analysis with ultra-high sensitivity sequencing in metastatic breast cancer

Introduction.

Circulating tumor DNA analysis has the potential to transform the clinical management of patients with breast cancer. We assessed the accuracy of ultra-high sensitivity ctDNA testing in patients with advanced breast cancer.

Methods.

From a prospective tissue collection study, we identified 25 patients with a contemporaneous metastatic tissue biopsy and plasma for ctDNA testing. Tumour DNA from the metastatic tissue biopsy was sequenced with a validated clinical hybrid capture panel, while plasma cell free DNA was sequenced with AVENIO ctDNA technology – a molecular barcoded duplex sequencing based on CAPPseq technology. Sample collection is on-going and results from the full concordance series will be presented at the conference.

Results.

Circulating tumour DNA was detectable in 87% (20/23) of patients, with at least one variant from tissue sequencing identified in plasma. There was overall high agreement between tissue and plasma sequencing. The sensitivity of plasma testing for variants identified in tumour, positive percent agreement, was 75% (24/32). Plasma testing revealed a diversity of sub-clonal mutations including polyclonal ESR1, polyclonal FGFR2 and FGFR3 mutations, rare KRAS mutations, and TSC1 and MSH2 inactivating mutations.

Conclusions.

Circulating tumour DNA testing with molecular barcoded duplex sequencing offers high sensitivity for tumour variant detection. The extent of sub-clonal resistance mutations identified emphasises the genetic diversity of advanced breast cancer.

Citation Format: Garcia-Murillas I, Proszek P, Fribbens C, Yuan L, Bye H, Hubank M, Jiang J, Yuang S, Palma J, Johnston S, Ring A, Turner N. Circulating tumor DNA analysis with ultra-high sensitivity sequencing in metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-02-17.

Tracking evolution of aromatase inhibitor resistance with circulating tumour DNA analysis in metastatic breast cancer

Background

Selection of resistance mutations may play a major role in the development of endocrine resistance. ESR1 mutations are rare in primary breast cancer but have high prevalence in patients treated with aromatase inhibitors (AI) for advanced breast cancer. We investigated the evolution of genetic resistance to the first-line AI therapy using sequential ctDNA sampling in patients with advanced breast cancer.

Patients and methods

Eighty-three patients on the first-line AI therapy for metastatic breast cancer were enrolled in a prospective study. Plasma samples were collected every 3 months to disease progression and ctDNA analysed by digital droplet PCR and enhanced tagged-amplicon sequencing (eTAm-Seq). Mutations identified in progression samples by sequencing were tracked back through samples before progression to study the evolution of mutations on therapy. The frequency of novel mutations was validated in an independent cohort of available baseline plasma samples in the Study of Faslodex versus Exemestane with or without Arimidex (SoFEA) trial, which enrolled patients with prior sensitivity to AI.

Results

Of the 39 patients who progressed on the first-line AI, 56.4% (22/39) had ESR1 mutations detectable at progression, which were polyclonal in 40.9% (9/22) patients. In serial tracking, ESR1 mutations were detectable median 6.7 months (95% confidence interval 3.7-NA) before clinical progression. Utilising eTAm-Seq ctDNA sequencing of progression plasma, ESR1 mutations were demonstrated to be sub-clonal in 72.2% (13/18) patients. Mutations in RAS genes were identified in 15.4% (6/39) of progressing patients (4 KRAS, 1 HRAS, 1 NRAS). In SoFEA, KRAS mutations were detected in 21.2% (24/113) patients although there was no evidence that KRAS mutation status was prognostic for progression free or overall survival.

Conclusions

Cancers progressing on the first-line AI show high levels of genetic heterogeneity, with frequent sub-clonal mutations. Sub-clonal KRAS mutations are found at high frequency. The genetic diversity of AI resistant cancers may limit subsequent targeted therapy approaches.

NAD+ : A key metabolic regulator with great therapeutic potential

Nicotinamide adenine dinucleotide (NAD⁺ ) is a ubiquitous metabolite that serves an essential role in the catabolism of nutrients. Recently, there has been a surge of interest in NAD⁺ biology, with the recognition that NAD⁺ influences many biological processes beyond metabolism, including transcription, signalling and cell survival. There are a multitude of pathways involved in the synthesis and breakdown of NAD⁺ , and alterations in NAD⁺ homeostasis have emerged as a common feature of a range of disease states. Here, we provide an overview of NAD⁺ metabolism and summarise progress on the development of NAD⁺ -related therapeutics.

Abstract P5-04-01: Cell cycle dynamics at single cell level dictates response to CDK4/6 inhibition

This abstract was withdrawn by the authors.

Quality of life with palbociclib plus fulvestrant in previously treated hormone receptor-positive, HER2-negative metastatic breast cancer: patient-reported outcomes from the PALOMA-3 trial

In treating HR+, HER2− metastatic breast cancer, novel agents that enhance endocrine therapy activity but do not worsen quality of life (QoL) are clinically desired. Patient-reported outcomes data from the PALOMA-3 study suggest palbociclib plus fulvestrant allow patients to maintain good QoL in the endocrine resistance setting while experiencing a substantially delayed disease progression.

Background

In the PALOMA-3 study, palbociclib plus fulvestrant demonstrated improved progression-free survival compared with fulvestrant plus placebo in hormone receptor-positive, HER2− endocrine-resistant metastatic breast cancer (MBC). This analysis compared patient-reported outcomes (PROs) between the two treatment groups.

Patients and methods

Patients were randomized 2 : 1 to receive palbociclib 125 mg/day orally for 3 weeks followed by 1 week off (n = 347) plus fulvestrant (500 mg i.m. per standard of care) or placebo plus fulvestrant (n = 174). PROs were assessed on day 1 of cycles 1–4 and of every other subsequent cycle starting with cycle 6 using the EORTC QLQ-C30 and its breast cancer module, QLQ-BR23. High scores (range 0–100) could indicate better functioning/quality of life (QoL) or worse symptom severity. Repeated-measures mixed-effect analyses were carried out to compare on-treatment overall scores and changes from baseline between treatment groups while controlling for baseline. Between-group comparisons of time to deterioration in global QoL and pain were made using an unstratified log-rank test and Cox proportional hazards model.

Results

Questionnaire completion rates were high at baseline and during treatment (from baseline to cycle 14, ≥95.8% in each group completed ≥1 question on the EORTC QLQ-C30). On treatment, estimated overall global QoL scores significantly favored the palbociclib plus fulvestrant group [66.1, 95% confidence interval (CI) 64.5–67.7 versus 63.0, 95% CI 60.6–65.3; P = 0.0313]. Significantly greater improvement from baseline in pain was also observed in this group (−3.3, 95% CI −5.1 to −1.5 versus 2.0, 95% CI −0.6 to 4.6; P = 0.0011). No significant differences were observed for other QLQ-BR23 functioning domains, breast or arm symptoms. Treatment with palbociclib plus fulvestrant significantly delayed deterioration in global QoL (P < 0.025) and pain (P < 0.001) compared with fulvestrant alone.

Conclusion

Palbociclib plus fulvestrant allowed patients to maintain good QoL in the endocrine resistance setting while experiencing substantially delayed disease progression.

Clinical Trial Registration

NCT01942135.

Effectiveness of seasonal influenza vaccine in preventing influenza primary care visits and hospitalisation in Auckland, New Zealand in 2015: interim estimates

Preliminary results for influenza vaccine effectiveness (VE) against acute respiratory illness with circulating laboratory-confirmed influenza viruses in New Zealand from 27 April to 26 September 2015, using a case test-negative design were 36% (95% confidence interval (CI): 11–54) for general practice encounters and 50% (95% CI: 20–68) for hospitalisations. VE against hospitalised influenza A(H3N2) illnesses was moderate at 53% (95% CI: 6–76) but improved compared with previous seasons.

Disparate metabolic response to fructose feeding between different mouse strains

Diets enriched in fructose (FR) increase lipogenesis in the liver, leading to hepatic lipid accumulation and the development of insulin resistance. Previously, we have shown that in contrast to other mouse strains, BALB/c mice are resistant to high fat diet-induced metabolic deterioration, potentially due to a lack of ectopic lipid accumulation in the liver. In this study we have compared the metabolic response of BALB/c and C57BL/6 (BL6) mice to a fructose-enriched diet. Both strains of mice increased adiposity in response to FR-feeding, while only BL6 mice displayed elevated hepatic triglyceride (TAG) accumulation and glucose intolerance. The lack of hepatic TAG accumulation in BALB/c mice appeared to be linked to an altered balance between lipogenic and lipolytic pathways, while the protection from fructose-induced glucose intolerance in this strain was likely related to low levels of ER stress, a slight elevation in insulin levels and an altered profile of diacylglycerol species in the liver. Collectively these findings highlight the multifactorial nature of metabolic defects that develop in response to changes in the intake of specific nutrients and the divergent response of different mouse strains to dietary challenges.

Accessing primary care Big Data: the development of a software algorithm to explore the rich content of consultation records

OBJECTIVE

To develop a natural language processing software inference algorithm to classify the content of primary care consultations using electronic health record Big Data and subsequently test the algorithm's ability to estimate the prevalence and burden of childhood respiratory illness in primary care.

DESIGN

Algorithm development and validation study. To classify consultations, the algorithm is designed to interrogate clinical narrative entered as free text, diagnostic (Read) codes created and medications prescribed on the day of the consultation.

SETTING

Thirty-six consenting primary care practices from a mixed urban and semirural region of New Zealand. Three independent sets of 1200 child consultation records were randomly extracted from a data set of all general practitioner consultations in participating practices between 1 January 2008-31 December 2013 for children under 18 years of age (n=754,242). Each consultation record within these sets was independently classified by two expert clinicians as respiratory or non-respiratory, and subclassified according to respiratory diagnostic categories to create three 'gold standard' sets of classified records. These three gold standard record sets were used to train, test and validate the algorithm.

OUTCOME MEASURES

Sensitivity, specificity, positive predictive value and F-measure were calculated to illustrate the algorithm's ability to replicate judgements of expert clinicians within the 1200 record gold standard validation set.

RESULTS

The algorithm was able to identify respiratory consultations in the 1200 record validation set with a sensitivity of 0.72 (95% CI 0.67 to 0.78) and a specificity of 0.95 (95% CI 0.93 to 0.98). The positive predictive value of algorithm respiratory classification was 0.93 (95% CI 0.89 to 0.97). The positive predictive value of the algorithm classifying consultations as being related to specific respiratory diagnostic categories ranged from 0.68 (95% CI 0.40 to 1.00; other respiratory conditions) to 0.91 (95% CI 0.79 to 1.00; throat infections).

CONCLUSIONS

A software inference algorithm that uses primary care Big Data can accurately classify the content of clinical consultations. This algorithm will enable accurate estimation of the prevalence of childhood respiratory illness in primary care and resultant service utilisation. The methodology can also be applied to other areas of clinical care.

Variation in the Williams syndrome GTF2I gene and anxiety proneness interactively affect prefrontal cortical response to aversive stimuli

Characterizing the molecular mechanisms underlying the heritability of complex behavioral traits such as human anxiety remains a challenging endeavor for behavioral neuroscience. Copy-number variation (CNV) in the general transcription factor gene, GTF2I, located in the 7q11.23 chromosomal region that is hemideleted in Williams syndrome and duplicated in the 7q11.23 duplication syndrome (Dup7), is associated with gene-dose-dependent anxiety in mouse models and in both Williams syndrome and Dup7. Because of this recent preclinical and clinical identification of a genetic influence on anxiety, we examined whether sequence variation in GTF2I, specifically the single-nucleotide polymorphism rs2527367, interacts with trait and state anxiety to collectively impact neural response to anxiety-laden social stimuli. Two hundred and sixty healthy adults completed the Tridimensional Personality Questionnaire Harm Avoidance (HA) subscale, a trait measure of anxiety proneness, and underwent functional magnetic resonance imaging (fMRI) while matching aversive (fearful or angry) facial identity. We found an interaction between GTF2I allelic variations and HA that affects brain response: in individuals homozygous for the major allele, there was no correlation between HA and whole-brain response to aversive cues, whereas in heterozygotes and individuals homozygous for the minor allele, there was a positive correlation between HA sub-scores and a selective dorsolateral prefrontal cortex (DLPFC) responsivity during the processing of aversive stimuli. These results demonstrate that sequence variation in the GTF2I gene influences the relationship between trait anxiety and brain response to aversive social cues in healthy individuals, supporting a role for this neurogenetic mechanism in anxiety.