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Galina JM, Miller SD, Whelan TJ, Pavlesen S, Ferrick MR. Incidence of Intraoperative Cardiothoracic Intervention During Open Surgery Following Acute Posterior Sternoclavicular Joint Injury: A Case Series and Review of the Literature. J Pediatr Orthop 2024:01241398-990000000-00561. [PMID: 38712689 DOI: 10.1097/bpo.0000000000002696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND Acute posterior sternoclavicular joint injuries are rare but potentially lethal injuries-signs of mediastinal compression range from nonspecific to neurovascular compromise. Currently, orthopaedic experts recommend a cardiothoracic surgeon be placed on standby during open surgery for potential intraoperative complications. However, few studies have reported on how often cardiothoracic intervention is required. METHODS First, we identified patients in our institution by CPT codes 23530, 23525, and 23532 from January 1, 2002 to May 1, 2023. Demographic variables and intraoperative cardiothoracic intervention rates were collected. Second, we systematically reviewed the literature to identify articles on acute posterior sternoclavicular injury using PubMed, Embase, and CINAHL databases (through August 20, 2023). Exclusion criteria included conservative treatment, successful closed reduction, chronic injury (>6 wk) cadaver studies, reviews, and nonavailable text. RESULTS Thirteen local patients underwent open surgery for an acute posterior sternoclavicular joint injury, 11 males and 2 females with an average age of 18.2 years old (range: 15 to 32.4). The most common mechanism of injury was sports (n=9; 69.2%). Four (30.8%) patients had physical or radiographic evidence of mediastinal compression. No patients required intraoperative cardiothoracic intervention in our institution. The literature search yielded 132 articles and 512 open surgeries for acute posterior sternoclavicular joint injuries. Four patients required intraoperative cardiothoracic intervention, all of whom presented with polytrauma and/or clinical or radiographic signs of neurovascular compromise, giving a combined overall rate of 0.76%. CONCLUSIONS Expert opinion commonly recommends cardiothoracic backup during open surgery for acute posterior sternoclavicular joint injuries. On the basis of our local data and systematic literature review, we found an overall cardiothoracic intervention rate of 0.76%. In the presence of polytrauma and/or findings of neurovascular compromise, we suggest having cardiothoracic surgery on close standby during the procedure. However, a patient with an isolated acute posterior sternoclavicular joint injury and no clinical or radiographic findings of neurovascular compromise does not appear to require a cardiothoracic surgeon on standby. Ultimately, the decision to involve cardiothoracic backup during open surgery for an acute posterior sternoclavicular injury should be made on a case-by-case basis after a thorough physical and radiographic evaluation of the patient. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jesse M Galina
- Department of Orthopaedic Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | | | - Timothy J Whelan
- Department of Orthopaedic Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Sonja Pavlesen
- Department of Orthopaedic Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Michael R Ferrick
- Department of Orthopaedic Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
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2
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Whelan TJ, Fyles A, Parpia S, Nielsen T, Levine MN. LUMINA: Using molecular biomarkers to guide decision making for breast radiotherapy. Radiother Oncol 2024; 190:110074. [PMID: 38163484 DOI: 10.1016/j.radonc.2023.110074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
In this opinion piece, we respond to comments about the LUMINA trial by Meattini and colleagues in the Journal. LUMINA was a prospective cohort study which evaluated the omission of radiotherapy after breast conserving surgery (BCS) in patients treated with endocrine therapy with low risk clinico-pathologic features and luminal A breast cancer. We address their areas of concern including the single cohort design that required careful patient selection, the relatively short follow-up period of 5 years, and the limited follow-up on younger patients. The Ki67 biomarker was key to defining the luminal A phenotype. We clarify the evidence supporting the Ki67 criteria used. The compliance with endocrine therapy was high and similar to other contemporary trials. Based on the results of LUMINA, and mounting evidence from other trials, we feel comfortable offering our patients the option of no radiotherapy after BCS if they fit the trial eligibility criteria from LUMINA and have decided to receive adjuvant endocrine therapy. We concur that a patient-centered approach to treatment decision making should be used to make patients aware of all available information including the results of the LUMINA trial when deciding on post-operative breast radiotherapy.
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Affiliation(s)
- Timothy J Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Anthony Fyles
- Department of Radiation Oncology, University of Toronto and Princess Margaret Hospital, Toronto, ON, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Torsten Nielsen
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University, Hamilton, ON, Canada
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3
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Goodwin PJ, Chen BE, Gelmon KA, Whelan TJ, Ennis M, Lemieux J, Ligibel JA, Hershman DL, Mayer IA, Hobday TJ, Bliss JM, Rastogi P, Rabaglio-Poretti M, Thompson AM, Rea DW, Stos PM, Shepherd LE, Stambolic V, Parulekar WR. Effect of Metformin Versus Placebo on New Primary Cancers in Canadian Cancer Trials Group MA.32: A Secondary Analysis of a Phase III Randomized Double-Blind Trial in Early Breast Cancer. J Clin Oncol 2023; 41:5356-5362. [PMID: 37695982 PMCID: PMC10713140 DOI: 10.1200/jco.23.00296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/28/2023] [Accepted: 07/20/2023] [Indexed: 09/13/2023] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned coprimary or secondary analyses are not yet available. Clinical trial updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.Metformin has been associated with lower cancer risk in epidemiologic and preclinical research. In the MA.32 randomized adjuvant breast cancer trial, metformin (v placebo) did not affect invasive disease-free or overall survival. Here, we report metformin effects on the risk of new cancer. Between 2010 and 2013, 3,649 patients with breast cancer younger than 75 years without diabetes with high-risk T1-3, N0-3 M0 breast cancer (any estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2) were randomly assigned to metformin 850 mg orally twice a day or placebo twice a day for 5 years. New primary invasive cancers (outside the ipsilateral breast) developing as a first event were identified. Time to events was described by the competing risks method; two-sided likelihood ratio tests adjusting for age, BMI, smoking, and alcohol intake were used to compare metformin versus placebo arms. A total of 184 patients developed new invasive cancers: 102 metformin and 82 placebo, hazard ratio (HR), 1.25; 95% CI, 0.94 to 1.68; P = .13. These included 48 contralateral invasive breast cancers (27 metformin v 21 placebo), HR, 1.29; 95% CI, 0.72 to 2.27; P = .40 and 136 new nonbreast primary cancers (75 metformin v 61 placebo), HR, 1.24; 95% CI, 0.88 to 1.74; P = .21. Metformin did not reduce the risk of new cancer development in these nondiabetic patients with breast cancer.
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Affiliation(s)
- Pamela J. Goodwin
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bingshu E. Chen
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Karen A. Gelmon
- University of British Columbia, BC Cancer Agency, Vancouver, BC, Canada
| | | | | | | | | | - Dawn L. Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | | | | | - Judith M. Bliss
- ICR-CTSU, Institute of Cancer Research (UK), London, United Kingdom
| | - Priya Rastogi
- NRG Oncology and University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Manuela Rabaglio-Poretti
- IBCSG and Department of Oncology, Bern University Hospital, University of Bern, Berne, Switzerland
| | | | - Daniel W. Rea
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Paul M. Stos
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Lois E. Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Vuk Stambolic
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
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4
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Nielsen TO, Leung SCY, Riaz N, Mulligan AM, Kos Z, Bane A, Whelan TJ. Ki67 assessment protocol as an integral biomarker for avoiding radiotherapy in the LUMINA breast cancer trial. Histopathology 2023; 83:903-911. [PMID: 37609778 DOI: 10.1111/his.15032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/21/2023] [Accepted: 07/30/2023] [Indexed: 08/24/2023]
Abstract
AIMS The LUMINA trial demonstrated a very low local recurrence rate in women ≥55 years with low-risk luminal A breast cancer (defined as grade I-II, T1N0, hormone receptor positive, HER2 negative and Ki67 index ≤13.25%) treated with breast-conserving surgery and endocrine therapy (but no other systemic therapy), supporting the safe omission of radiation in these women. Here we describe the protocol for Ki67 assessment, the companion diagnostic used to guide omission of adjuvant radiotherapy. METHODS Ki67 immunohistochemistry was performed on full-face sections at one of three regional labs. Pathologists trained in the International Ki67 in Breast Cancer Working Group (IKWG) method demarcated tumour areas on scanned slides and scored 100 nuclei from each of at least five randomly selected 1-mm fields. For cases with high Ki67 heterogeneity, further virtual cores were selected and scored in order to confidently assign a case as luminal A (≤13.25%) or B (>13.25%). Interlaboratory variability was assessed through an annual quality assurance programme during the study period. RESULTS From the quality assurance programme, the mean Ki67 index across all cases/labs was 13%. The observed intraclass correlation coefficient (ICC) and kappa statistics were ≥0.9 and ≥0.7, respectively, indicating a substantial level of agreement. Median scoring time was 4 min per case. The IKWG-recommended scoring method, performed directly from slides, requiring up to four scored fields, is concordant with the LUMINA scoring method (ICC ≥ 0.9). CONCLUSION Ki67 is a practical, reproducible, and inexpensive biomarker that can identify low-risk luminal A breast cancers as potential candidates for radiation de-escalation. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov number, NCT01791829.
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Affiliation(s)
- Torsten O Nielsen
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Samuel C Y Leung
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nazia Riaz
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anna M Mulligan
- University Health Network, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Zuzana Kos
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anita Bane
- University Health Network, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Timothy J Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Wu CHD, Wierzbicki M, Parpia S, Kundapur V, Bujold A, Filion EJ, Lau H, Faria S, Ahmed N, Leong N, Okawara G, Hirmiz KJ, Owen TE, Louie AV, Wright J, Whelan TJ, Swaminath A. Long-Term Toxicity in Patients Receiving Radiotherapy for Ultracentral Stage I Non-Small Cell Lung Cancer - A Secondary Analysis of the LUSTRE Randomized Trial. Int J Radiat Oncol Biol Phys 2023; 117:S171. [PMID: 37784427 DOI: 10.1016/j.ijrobp.2023.06.636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Hypofractionated and stereotactic body radiotherapy (SBRT) are increasingly used in the treatment of centrally located, early-stage non-small cell lung cancer (NSCLC), though there are concerns of increased morbidity and mortality in patients with ultracentral tumors (UC). We report on the long-term toxicity of patients with UC lung cancer treated on a prospective randomized clinical trial of SBRT versus conventionally hypofractionated radiotherapy (CRT) for stage I NSCLC (NCT01968941). MATERIALS/METHODS Patients with UC tumors, defined as those where the planning target volume directly overlaps with the proximal bronchial tree (PBT), were identified from the larger cohort of patients treated on the trial. These patients received either SBRT with 60 Gy in 8 fractions or CRT with 60 Gy in 15 fractions. The primary endpoint of this secondary analysis was development of any grade 3 or higher toxicity defined using CTCAE version 3.0. Secondary endpoints included local control, as well as dosimetric analysis of the PBT, using EQD2 with α/β ratio of 3 to assess the relationship between dose to the PBT and toxicity. RESULTS Twenty-nine patients were identified with UC tumors; 21 received SBRT and 8 received CRT. Median age was 72 years (range 55-88 years) and 59% were female. Median FEV1 was 1.46L (range 0.64-2.37L). Patients had either T1 (59%) or T2 (41%) lesions, with median tumor size 2.5cm (range 1.1-4.9cm). Most patients had histologically confirmed disease (squamous cell, n = 10; adenocarcinoma, n = 8; radiographically suspicious, n = 11). The median follow-up was 2.9 years (range 0.7-5.2 years). The 3-year local control rate of all patients was 88.3% (95% confidence interval: 75.7-100%). There were 3 patients with late (>3 months) grade 3 toxicity (bronchial stricture, chest pain, and atelectasis) and 1 patient with late grade 5 toxicity (bleeding/hemorrhage), all treated in the SBRT arm. Median EQD2 dose to PBT in patients with grade ≥3 late toxicity compared to the rest of the cohort was: Dmax, 132 vs 129 Gy; D0.1cc, 129 vs 119 Gy; D1cc, 124 vs 80 Gy; and D5cc, 83 vs 41 Gy. Median EQD2 volumetric doses in grade ≥3 patients (compared to the rest) to PBT were: V65 Gy, 9.7 vs 2.2cc; V80 Gy, 7.9 vs 1.1cc; V90 Gy, 6.2 vs 0.4cc; and V100 Gy, 4.8 vs 0.3cc. The single patient with grade 5 toxicity had the highest D5cc (116 Gy) and V100 Gy (7cc) among all patients. CONCLUSION Stereotactic radiation with 60 Gy in 8 fractions for UC lung cancer provides good local control but carries an approximately 15-20% rate of late grade ≥3 toxicity. There appears to be a dosimetric association between toxicity and dose to the PBT. It may be more important to minimize volumetric PBT dose rather than maximum point dose to reduce risk of severe late toxicity.
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Affiliation(s)
- C H D Wu
- BC Cancer Agency, Victoria, BC, Canada
| | - M Wierzbicki
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - S Parpia
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - V Kundapur
- Saskatoon Cancer Centre, Saskatoon, SK, Canada
| | - A Bujold
- Hopital Maisonneuve-Rosemont, Universite de Montreal, Montreal, QC, Canada
| | - E J Filion
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - H Lau
- University of Calgary, Calgary, AB, Canada
| | - S Faria
- McGill University Health Center, Montreal, QC, Canada
| | - N Ahmed
- Department of Radiation Oncology, Cancer Care Manitoba, Winnipeg, MB, Canada
| | - N Leong
- Allan Blair Cancer Centre, Regina, SK, Canada
| | - G Okawara
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - K J Hirmiz
- Windsor Regional Hospital Cancer Program, Windsor, ON, Canada
| | - T E Owen
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada
| | - A V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Wright
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - T J Whelan
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - A Swaminath
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
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6
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Whelan TJ, Smith S, Parpia S, Fyles AW, Bane A, Liu FF, Rakovitch E, Chang L, Stevens C, Bowen J, Provencher S, Théberge V, Mulligan AM, Kos Z, Akra MA, Voduc KD, Hijal T, Dayes IS, Pond G, Wright JR, Nielsen TO, Levine MN. Omitting Radiotherapy after Breast-Conserving Surgery in Luminal A Breast Cancer. N Engl J Med 2023; 389:612-619. [PMID: 37585627 DOI: 10.1056/nejmoa2302344] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
BACKGROUND Adjuvant radiotherapy is prescribed after breast-conserving surgery to reduce the risk of local recurrence. However, radiotherapy is inconvenient, costly, and associated with both short-term and long-term side effects. Clinicopathologic factors alone are of limited use in the identification of women at low risk for local recurrence in whom radiotherapy can be omitted. Molecularly defined intrinsic subtypes of breast cancer can provide additional prognostic information. METHODS We performed a prospective cohort study involving women who were at least 55 years of age, had undergone breast-conserving surgery for T1N0 (tumor size <2 cm and node negative), grade 1 or 2, luminal A-subtype breast cancer (defined as estrogen receptor positivity of ≥1%, progesterone receptor positivity of >20%, negative human epidermal growth factor receptor 2, and Ki67 index of ≤13.25%), and had received adjuvant endocrine therapy. Patients who met the clinical eligibility criteria were registered, and Ki67 immunohistochemical analysis was performed centrally. Patients with a Ki67 index of 13.25% or less were enrolled and did not receive radiotherapy. The primary outcome was local recurrence in the ipsilateral breast. In consultation with radiation oncologists and patients with breast cancer, we determined that if the upper boundary of the two-sided 90% confidence interval for the cumulative incidence at 5 years was less than 5%, this would represent an acceptable risk of local recurrence at 5 years. RESULTS Of 740 registered patients, 500 eligible patients were enrolled. At 5 years after enrollment, recurrence was reported in 2.3% of the patients (90% confidence interval [CI], 1.3 to 3.8; 95% CI, 1.2 to 4.1), a result that met the prespecified boundary. Breast cancer occurred in the contralateral breast in 1.9% of the patients (90% CI, 1.1 to 3.2), and recurrence of any type was observed in 2.7% (90% CI, 1.6 to 4.1). CONCLUSIONS Among women who were at least 55 years of age and had T1N0, grade 1 or 2, luminal A breast cancer that were treated with breast-conserving surgery and endocrine therapy alone, the incidence of local recurrence at 5 years was low with the omission of radiotherapy. (Funded by the Canadian Cancer Society and the Canadian Breast Cancer Foundation; LUMINA ClinicalTrials.gov number, NCT01791829.).
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Affiliation(s)
- Timothy J Whelan
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Sally Smith
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Sameer Parpia
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Anthony W Fyles
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Anita Bane
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Fei-Fei Liu
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Eileen Rakovitch
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Lynn Chang
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Christiaan Stevens
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Julie Bowen
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Sawyna Provencher
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Valerie Théberge
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Anna Marie Mulligan
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Zuzana Kos
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Mohamed A Akra
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - K David Voduc
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Tarek Hijal
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Ian S Dayes
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Gregory Pond
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - James R Wright
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Torsten O Nielsen
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
| | - Mark N Levine
- From the Department of Oncology, McMaster University and the Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (T.J.W., I.S.D., J.R.W.), the Division of Radiation Oncology, Department of Surgery, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Victoria (S.S.), the Department of Oncology, McMaster University, Hamilton, ON (S. Parpia, G.P., M.N.L.), the Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Cancer Centre (A.W.F., F.-F.L.), the Department of Pathology, University of Toronto (A.B.), and the Department of Radiation Oncology, University of Toronto and Sunnybrook Odette Cancer Centre (E.R.), Toronto, the Department of Radiation Oncology, University of Ottawa and Ottawa Regional Cancer Centre, Ottawa (L.C.), the Department of Radiation Oncology, University of Toronto and Royal Victoria Regional Health Centre, Barrie, ON (C.S.), the Department of Radiation Oncology, Laurentian University and Radiation Treatment Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON (J.B.), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (S. Provencher), the Department of Radiation Oncology, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC (V.T.), the Department of Laboratory Medicine and Pathobiology, and the Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto (A.M.M.), the Department of Pathology and Laboratory Medicine, University of British Columbia, and the BC Cancer Agency, Vancouver (Z.K.), the Department of Radiation Oncology, University of Manitoba and Cancer Care Manitoba, Winnipeg (M.A.A.), the Department of Radiation Oncology, University of British Columbia and Radiation Therapy Program, BC Cancer Agency, Vancouver (K.D.V.), the Department of Radiation Oncology, McGill University, Montreal (T.H.), and the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver (T.O.N.) - all in Canada
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Hershman DL, Chen BE, Sathe C, Parulekar WR, Lemieux J, Ligibel JA, Gelmon KA, Whelan TJ, Goodwin PJ. Metformin, placebo, and endocrine therapy discontinuation among participants in a randomized double-blind trial of metformin vs placebo in hormone receptor-positive early-stage breast cancer (CCTG MA32). Breast Cancer Res Treat 2023; 200:93-102. [PMID: 37157006 DOI: 10.1007/s10549-023-06922-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/18/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND The MA32 study investigated whether 5 years of metformin (versus placebo) improves invasive disease-free survival in early-stage breast cancer (BC). Non-adherence to endocrine therapy (ET) and medications for chronic conditions is common and increases with drug toxicity and polypharmacy. This secondary analysis evaluates rates and predictors of early discontinuation of metformin, placebo, and ET among participants with HR-positive BC. METHODS Patients with high-risk non-metastatic BC were randomized to 60 months of metformin (850 mg BID) or placebo BID. Patients were administered bottles of metformin/placebo every 180 days. Metformin/placebo adherence was defined as a bottle dispensed at month 48 or later. The ET adherence analysis included patients with HR-positive BC who received ET with start and stop date reported, with adherence defined as > 48 months of use. Associations of covariates with study drug and ET adherence were examined using multivariable models. RESULTS Among the 2521 HR-positive BC patients, 32.9% were non-adherent to study drug. Non-adherence was higher among patients on metformin vs placebo (37.1% vs 28.7%, p < 0.001). Reassuringly, ET discontinuation rates were similar between treatment arms (28.4% vs 28.0%, p = 0.86). Patients who were non-adherent to ET were more likely to discontinue study therapy (38.8% vs 30.1%, p < 0.0001). In a multivariable analysis, study drug non-adherence was increased with metformin vs placebo (OR: 1.50, 95% CI 1.25-1.80; p < 0.0001); non-adherence to ET (OR: 1.47, 95% CI 1.20-1.79, p < 0.0001); grade 1 or greater GI toxicity during the first 2 years; lower age; and higher body mass index. CONCLUSION While non-adherence was higher among patients on metformin, it was still considerable among patients on placebo. Reassuringly, treatment arm allocation did not impact ET adherence. Attention to global medication adherence is needed to improve BC and non-oncological outcomes in cancer survivors. TRIAL REGISTRATION ClinicalTrials.gov: NCT01.
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Affiliation(s)
- Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA.
| | - Bingshu E Chen
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Claire Sathe
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Wendy R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | | | | | - Karen A Gelmon
- BC Cancer Agency, University of British Columbia, Vancouver, BC, Canada
| | - Timothy J Whelan
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Pamela J Goodwin
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Riaz N, Chen B, Bane A, Gao D, Stovgaard E, Kos Z, Leung S, Shenasa E, Parulekar W, Chambers S, Nielson T, Whelan TJ. Abstract P4-02-16: Prognostic and Predictive Capacity of Tumor Infiltrating Lymphocytes in the MA.20 regional radiotherapy trial. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p4-02-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: The benefit of regional nodal irradiation (RNI) in patients with low burden metastatic axillary disease was established in MA.20 showing that patients randomized to receive adjuvant whole breast irradiation (WBI) plus RNI experienced a significantly better disease free survival (DFS) and distant disease free survival (DDFS) compared to those who received WBI alone and this advantage was maintained in the hormone receptor negative subgroup. Stromal tumor infiltrating lymphocytes (sTILs) have shown prognostic and predictive value in HER2 positive and triple negative breast cancers. To date, clinical importance of immune infiltrates as prognostic and predictive biomarkers in the context of benefit from RNI has not been shown. Methods: 1064 full-face hematoxylin and eosin (H&E) stained sections and formalin fixed paraffin embedded primary tumor blocks assembled into 16 tissue microarrays (TMAs) in quadruplicates linked with clinical data were accessible from the original 1832 patients in the MA.20 trial for this retrospective-prospective translational study conducted according to the REMARK guidelines. sTILs were assessed on scanned images of H&E sections according to the International Immuno-Oncology Working Group method, and on TMAs by CD8 immunohistochemistry (IHC) using a validated assay. Biomarkers were scored by pathologists blinded to the clinical data and analyzed as continuous and categorical variables using prespecified median cutpoints. The median follow-up was 9.5 years. Cox proportional regression modelling was used after adjusting for clinicopathological factors and treatments. Hazard ratios (HR) with 95% confidence intervals (CI) were reported for the primary endpoint of DFS and secondary endpoint of DDFS. Predictive value was assessed by the interaction test between the treatment arm and the biomarkers in the full cohort and an IHC defined non-luminal A subgroup. Results: 1035 cases were evaluable for sTILs on H&E sections. Of these 52.6% (n=544) cases with ≥10% sTILs displayed a significant correlation with age < 50 years, grade III, tumor size >2cm, hormone receptor negative status, and non-luminal A subgroup (p < 0.05). Of the 857 evaluable cases on TMAs, CD8+sTILs (≥16) were observed in 49.8% (n=427) cases and showed a significant association with grade III, ER negativity and non-luminal A status (p < 0.05). For the full cohort, H&E sTILs assessed as a continuous parameter, were not prognostic for DFS (HR 0.993; 95% CI 0.984-1.003; p=0.18) but provided prognostic information for DDFS (HR 0.988; 95% CI 0.977-0.999; p=0.04) in multivariate analyses. H&E sTILs did not show predictive value as a continuous variable. Similarly, using the prespecified cutpoint (≥10%), H&E sTILs were neither prognostic nor predictive. Increasing level of CD8+sTILs was associated with significantly improved DFS (HR 0.99; 95% CI 0.983-0.998; p=0.02) and DDFS (HR 0.98; 95% CI 0.97-0.99; p=0.002) in multivariate analyses. For the full cohort, CD8+sTILs as a continuous variable, showed a significant improvement in DDFS for patients randomized to WBI and RNI (HR 0.979; 95%CI 0.959-0.999; p(interaction) =0.04) compared to WBI alone and a trend (HR 0.977; 95%CI 0.954-1.001; p(interaction) =0.06) for better outcome was observed for the non-luminal A subgroup. CD8+sTILs at the prespecified cutpoint (≥16) were not prognostic or predictive. Conclusions: Pre-treatment tumoral infiltration with stromal lymphocytes provided positive prognostic information for DFS (CD8+sTILs) and DDFS (H&E sTILs and CD8+sTILs) when examined as a continuous variable but failed to do so at prespecified cutpoints. While CD8+sTILs as a continuous variable predicted benefit from RNI, significant prediction results were not seen for prespecified cutpoint or related biomarker H&E sTIL. These results require further validation.
Citation Format: Nazia Riaz, Bingshu Chen, Anita Bane, Dongxia Gao, Elisabeth Stovgaard, Zuzana Kos, Samuel Leung, Elahe Shenasa, Wendy Parulekar, Shelley Chambers, Torsten Nielson, Timothy J. Whelan. Prognostic and Predictive Capacity of Tumor Infiltrating Lymphocytes in the MA.20 regional radiotherapy trial [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 P4-02-16.
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Affiliation(s)
- Nazia Riaz
- 1University of British Columbia, British Columbia, Canada
| | | | - Anita Bane
- 3University of Toronto, Toronto, Ontario, Canada
| | - Dongxia Gao
- 4University of British Columbia, British Columbia, Canada
| | | | - Zuzana Kos
- 6University of British Columbia, British Columbia, Canada
| | - Samuel Leung
- 7University of British Columbia, Vancouver, British Columbia, Canada
| | - Elahe Shenasa
- 8University of British Columbia, Vancouver, British Columbia, Canada
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Nielson T, Leung S, Riaz N, Kos Z, Bane A, Whelan TJ. Abstract P6-04-02: Ki67 Assessment Protocol: Companion Diagnostic Biomarker for LUMINA Prospective Cohort Study. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p6-04-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Introduction: Luminal A breast cancer is associated with low proliferation, indolent disease biology and limited benefit from chemotherapy. The LUMINA prospective study recently demonstrated a very low 5 year local recurrence rate (2.3%) in women ≥55 years with grade I-II, T1N0 luminal A breast cancer (defined as ER ≥ 1%, PR>20%, HER2 negative and Ki67 index ≤ 13.25%) treated with breast conservation surgery and endocrine therapy without radiation, supporting the safe omission of radiation in this molecularly defined low risk group. Here, we report the protocol for multicentre Ki67 scoring, the embedded integral companion diagnostic employed in LUMINA. Methodology: Ki67 immunohistochemistry was performed on full-face sections at one of the 3 labs and scored by pathologists using an adaptation of the International Ki67 Working Group (IKWG) method. Prior to the start of the study, quality assurance and quality control programs were set up to standardize staining and scoring protocols. All pathologists completed the IKWG training and calibration exercise using a tissue microarray-based series of 18 breast cancers. Inter-laboratory variability was assessed annually during the study period on a set of 9 breast cancer cases with a range of Ki67 scores that purposely over-represented the 13.25% threshold. Stained slides were scanned and images annotated to demarcate invasive carcinoma. Next, 5 random, non-overlapping, 1 mm virtual cores were generated via software and 100 nuclei assessed per core using a keyboard-based counting aid. Ki67 index was derived as the percentage of all counted tumor nuclei that are positively stained. For cases with high Ki67 heterogeneity, additional virtual cores were generated and scored and a 95% confidence interval (CI) of Ki67 index was estimated. The goal was to confidently assign a case as luminal A (≤13.25%) or B (> 13.5%). If the 95% CI crossed 13.25% a recount was performed by an additional pathologist. Results: Quality Assurance Programs: Mean Ki67 index across all cases, labs and years was 13% with high concordance across specimens and score ranges. Observed intra-class correlation coefficients (ICC) were ≥ 0.9, showing near perfect agreement in quantitative Ki67 evaluation. About the 13.25% cutpoint, the observed Kappa statistics were ≥ 0.7 indicating excellent agreement for assignment of luminal A vs. B status. A sub-study was conducted to compare the method of randomly selected virtual fields with the IKWG ‘global weighted score’ method for visual assessment of full-face sections. For this purpose, the 9 quality control cases were reassessed by the same pathologist using the updated IKWG method. Results showed an ICC of 0.96 (0.95% CI: 0.91-0.98) indicating that the Ki67 score generated by the methodology employed in LUMINA trial is highly concordant with the IKWG scoring methodology validated for use on full face sections. Ki67 index summary statistics across LUMINA: Of the 724 eligible cases, 69% (n=500) were assigned as luminal A (median Ki67=7.5%; IQR 5.2-9.8%) and 31% (n=224) as luminal B (median Ki67=19%; IQR 17-23%). Median pathologist scoring time was 4 minutes/case; 45% of cases required scoring of > 5 virtual cores. Per protocol, 39% cases where the initial CI crossed 13.25% were rescored by additional pathologist for final luminal A consensus assignment. Conclusions: Ki67 is a practical biomarker for identifying molecularly defined low-risk luminal A cancers. Our structured quality assurance approach for the trial led to excellent reproducibility and concordance among decentralized labs, supporting applicability of a distributed, inexpensive methodology beyond clinical trial settings and in resource restricted environments.
Citation Format: Torsten Nielson, Samuel Leung, Nazia Riaz, Zuzana Kos, Anita Bane, Timothy J. Whelan. Ki67 Assessment Protocol: Companion Diagnostic Biomarker for LUMINA Prospective Cohort Study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-04-02.
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Affiliation(s)
| | - Samuel Leung
- 2University of British Columbia, Vancouver, BC, Canada, Vancouver, British Columbia, Canada
| | - Nazia Riaz
- 3University of British Columbia, British Columbia, Canada
| | - Zuzana Kos
- 4University of British Columbia, British Columbia, Canada
| | - Anita Bane
- 5University of Toronto, Toronto, Ontario, Canada
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Goldberg M, Bridhikitti J, Khan AJ, McGale P, Whelan TJ. A Meta-Analysis of Trials of Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2023; 115:60-72. [PMID: 36155214 DOI: 10.1016/j.ijrobp.2022.09.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Partial breast irradiation (PBI) is the delivery of radiation therapy (RT) limited to the tumor bed after breast conserving surgery. The results of recent trials of PBI compared with whole breast irradiation (WBI) have suggested conflicting results with respect to local control and toxicity. The purpose of this meta-analysis was to assess effectiveness of PBI and to compare the different techniques. METHODS AND MATERIALS A meta-analysis of aggregate data from published randomized trials was performed to examine the effectiveness of PBI compared with WBI in patients with invasive breast cancer and ductal carcinoma in situ. Relevant data were extracted. The primary outcome was any ipsilateral breast event (invasive or noninvasive). Secondary outcomes included acute and late toxicity. The results of randomized trials were pooled using a fixed effects model and the inverse variance method. RESULTS Fifteen trials involving 16,474 patients were identified. The majority of enrolled patients were >60 years of age and had T1N0 grade 1 to 2 disease treated with hormone therapy. The percent of ipsilateral breast events was higher in patients treated with PBI compared with WBI (5.0% vs 2.8%; risk ratio [RR], 1.72; 95% confidence interval [CI], 1.47-2.02). Heterogeneity (P = .0002) was observed between the 4 PBI techniques: external beam RT without computed tomography (CT) planning (RR, 2.06; 95% CI, 1.36-3.12); brachytherapy (RR, 1.21; 95% CI, 0.65-2.25); intraoperative RT (RR, 2.79; 95% CI, 2.08-3.73); and external beam RT with CT planning (RR, 1.25; 95% CI, 0.99-1.58). When external beam RT without CT planning and intraoperative RT trials were excluded, the percent of ipsilateral breast events was 3.3% versus 2.6%, respectively (RR, 1.25; 95% CI, 1.00-1.55; P = .05), and no heterogeneity was observed (P = .92). Overall, acute toxicity was less with PBI, and the effect on late toxicity varied by technique. CONCLUSIONS Overall, WBI was more effective than PBI, but the effectiveness of PBI was technique related. PBI was less effective when given by external beam RT without CT planning or intraoperative therapy. Although PBI given by multicatheter brachytherapy or external beam RT with CT planning tended to be statistically less effective than WBI, the absolute difference between groups for ipsilateral breast events was very small (<1%), supporting these approaches for women considering PBI.
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Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jidapa Bridhikitti
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul McGale
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Timothy J Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada.
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Chua BH, Link EK, Kunkler IH, Whelan TJ, Westenberg AH, Gruber G, Bryant G, Ahern V, Purohit K, Graham PH, Akra M, McArdle O, O'Brien P, Harvey JA, Kirkove C, Maduro JH, Campbell ID, Delaney GP, Martin JD, Vu TTT, Muanza TM, Neal A, Olivotto IA. Radiation doses and fractionation schedules in non-low-risk ductal carcinoma in situ in the breast (BIG 3-07/TROG 07.01): a randomised, factorial, multicentre, open-label, phase 3 study. Lancet 2022; 400:431-440. [PMID: 35934006 DOI: 10.1016/s0140-6736(22)01246-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 06/20/2022] [Accepted: 06/29/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Whole breast irradiation (WBI) after conservative surgery for ductal carcinoma in situ (DCIS) reduces local recurrence. We investigated whether a tumour bed boost after WBI improved outcomes, and examined radiation dose fractionation sensitivity for non-low-risk DCIS. METHODS The study was an international, randomised, unmasked, phase 3 trial involving 136 participating centres of six clinical trials organisations in 11 countries (Australia, New Zealand, Singapore, Canada, the Netherlands, Belgium, France, Switzerland, Italy, Ireland, and the UK). Eligible patients were women aged 18 years or older with unilateral, histologically proven, non-low-risk DCIS treated by breast-conserving surgery with at least 1 mm of clear radial resection margins. They were assigned to one of four groups (1:1:1:1) of no tumour bed boost versus boost after conventional versus hypofractionated WBI, or randomly assigned to one of two groups (1:1) of no boost versus boost after each centre prespecified conventional or hypofractionated WBI. The conventional WBI used was 50 Gy in 25 fractions, and hypofractionated WBI was 42·5 Gy in 16 fractions. A boost dose of 16 Gy in eight fractions, if allocated, was delivered after WBI. Patients and clinicians were not masked to treatment allocation. The primary endpoint was time to local recurrence. This trial is registered with ClinicalTrials.gov (NCT00470236). FINDINGS Between June 25, 2007, and June 30, 2014, 1608 patients were randomly assigned to have no boost (805 patients) or boost (803 patients). Conventional WBI was given to 831 patients, and hypofractionated WBI was given to 777 patients. Median follow-up was 6·6 years. The 5-year free-from-local-recurrence rates were 92·7% (95% CI 90·6-94·4%) in the no-boost group and 97·1% (95·6-98·1%) in the boost group (hazard ratio 0·47; 0·31-0·72; p<0·001). The boost group had higher rates of grade 2 or higher breast pain (10% [8-12%] vs 14% [12-17%], p=0·003) and induration (6% [5-8%] vs 14% [11-16%], p<0·001). INTERPRETATION In patients with resected non-low-risk DCIS, a tumour bed boost after WBI reduced local recurrence with an increase in grade 2 or greater toxicity. The results provide the first randomised trial data to support the use of boost radiation after postoperative WBI in these patients to improve local control. The international scale of the study supports the generalisability of the results. FUNDING National Health and Medical Research Council of Australia, Susan G Komen for the Cure, Breast Cancer Now, OncoSuisse, Dutch Cancer Society, Canadian Cancer Trials Group.
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Affiliation(s)
- Boon H Chua
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia.
| | - Emma K Link
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
| | - Ian H Kunkler
- Edinburgh Cancer Research Centre, Institute of Genetic and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Timothy J Whelan
- McMaster University, Department of Oncology, Hamilton, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada
| | | | - Guenther Gruber
- Institute for Radiotherapy, Klinik Hirslanden, Zurich, Switzerland
| | - Guy Bryant
- University of Queensland, Brisbane, QLD, Australia
| | - Verity Ahern
- University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Westmead, NSW, Australia
| | - Kash Purohit
- University of Sheffield, Sheffield, UK; Weston Park Hospital, Broomhall, Sheffield, UK
| | - Peter H Graham
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; St George Hospital, Kogarah, NSW, Australia
| | - Mohamed Akra
- University of Manitoba, Winnipeg, MB, Canada; Cancer Care Manitoba, Winnipeg, MB, Canada
| | - Orla McArdle
- Cancer Trials Ireland, Dublin, Ireland; St Luke's Radiation Oncology Network, Beaumont Hospital, Beaumont, Dublin, Ireland
| | - Peter O'Brien
- University of Newcastle, Newcastle, NSW, Australia; GenesisCare, Gateshead, NSW, Australia
| | - Jennifer A Harvey
- University of Queensland, Brisbane, QLD, Australia; Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Carine Kirkove
- Université Catholique de Louvain, Brussels, Belgium; Cliniques Universitaires St Luc, Bruxelles, Belgium
| | - John H Maduro
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Ian D Campbell
- University of Auckland, Auckland, New Zealand; Waikato Hospital, Hamilton, New Zealand
| | - Geoff P Delaney
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | - Joseph D Martin
- National University of Ireland, Galway, Ireland; University Hospital Galway, Galway, Ireland
| | - T Trinh T Vu
- Université de Montréal, Montreal, QC, Canada; Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
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Goodwin PJ, Chen BE, Gelmon KA, Whelan TJ, Ennis M, Lemieux J, Ligibel JA, Hershman DL, Mayer IA, Hobday TJ, Bliss JM, Rastogi P, Rabaglio-Poretti M, Mukherjee SD, Mackey JR, Abramson VG, Oja C, Wesolowski R, Thompson AM, Rea DW, Stos PM, Shepherd LE, Stambolic V, Parulekar WR. Effect of Metformin vs Placebo on Invasive Disease-Free Survival in Patients With Breast Cancer: The MA.32 Randomized Clinical Trial. JAMA 2022; 327:1963-1973. [PMID: 35608580 PMCID: PMC9131745 DOI: 10.1001/jama.2022.6147] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 03/31/2022] [Indexed: 02/02/2023]
Abstract
Importance Metformin, a biguanide commonly used to treat type 2 diabetes, has been associated with potential beneficial effects across breast cancer subtypes in observational and preclinical studies. Objective To determine whether the administration of adjuvant metformin (vs placebo) to patients with breast cancer without diabetes improves outcomes. Design, Setting, and Participants MA.32, a phase 3 randomized, placebo-controlled, double-blind trial, conducted in Canada, Switzerland, US, and UK, enrolled 3649 patients with high-risk nonmetastatic breast cancer receiving standard therapy between August 2010 and March 2013, with follow-up to October 2020. Interventions Patients were randomized (stratified for hormone receptor [estrogen receptor and/or progesterone receptor {ER/PgR}] status, positive vs negative; body mass index, ≤30 vs >30; human epidermal growth factor receptor 2 [ERBB2, formerly HER2 or HER2/neu], positive vs negative; and any vs no chemotherapy) to 850 mg of oral metformin twice a day (n = 1824) or oral placebo twice a day (n = 1825) for 5 years. Main Outcomes and Measures The primary outcome was invasive disease-free survival in hormone receptor-positive breast cancer. Of the 8 secondary outcomes, overall survival, distant relapse-free survival, and breast cancer-free interval were analyzed. Results Of the 3649 randomized patients (mean age, 52.4 years; 3643 women [99.8%]), all (100%) were included in analyses. After a second interim analysis, futility was declared for patients who were ER/PgR-, so the primary analysis was conducted for 2533 patients who were ER/PgR+. The median duration of follow-up in the ER/PgR+ group was 96.2 months (range, 0.2-121 months). Invasive disease-free survival events occurred in 465 patients who were ER/PgR+. The incidence rates for invasive disease-free survival events were 2.78 per 100 patient-years in the metformin group vs 2.74 per 100 patient-years in the placebo group (hazard ratio [HR], 1.01; 95% CI, 0.84-1.21; P = .93), and the incidence rates for death were 1.46 per 100 patient-years in the metformin group vs 1.32 per 100 patient-years in the placebo group (HR, 1.10; 95% CI, 0.86-1.41; P = .47). Among patients who were ER/PgR-, followed up for a median of 94.1 months, incidence of invasive disease-free survival events was 3.58 vs 3.60 per 100 patient-years, respectively (HR, 1.01; 95% CI, 0.79-1.30; P = .92). None of the 3 secondary outcomes analyzed in the ER/PgR+ group had statistically significant differences. Grade 3 nonhematological toxic events occurred more frequently in patients taking metformin than in patients taking placebo (21.5% vs 17.5%, respectively, P = .003). The most common grade 3 or higher adverse events in the metformin vs placebo groups were hypertension (2.4% vs 1.9%), irregular menses (1.5% vs 1.4%), and diarrhea (1.9% vs 7.0%). Conclusions and Relevance Among patients with high-risk operable breast cancer without diabetes, the addition of metformin vs placebo to standard breast cancer treatment did not significantly improve invasive disease-free survival. Trial Registration ClinicalTrials.gov Identifier: NCT01101438.
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Affiliation(s)
- Pamela J. Goodwin
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bingshu E. Chen
- Canadian Cancer Trials Group, Queen’s University, Kingston, Ontario, Canada
| | - Karen A. Gelmon
- Department of Medicine, University of British Columbia, BC Cancer Agency, Vancouver, Canada
| | - Timothy J. Whelan
- Department of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | | | - Julie Lemieux
- Department of Hematology Research, CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Jennifer A. Ligibel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Dawn L. Hershman
- Department of Medicine, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
| | - Ingrid A. Mayer
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | | | - Judith M. Bliss
- Division of Clinical Studies, ICR-CTSU, Institute of Cancer Research United Kingdom, London, United Kingdom
| | - Priya Rastogi
- Department of Medicine, NRG Oncology and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Manuela Rabaglio-Poretti
- Department of Medical Oncology, IBCSG and Department of Oncology, Bern University Hospital, University of Bern, Berne, Switzerland
| | - Som D. Mukherjee
- Department of Oncology, Juravinski Cancer Center, McMaster University, Hamilton, Ontario, Canada
| | - John R. Mackey
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | | | - Conrad Oja
- Department of Medicine, University of British Columbia, BC Cancer Agency, Vancouver, Canada
| | - Robert Wesolowski
- Department of Internal Medicine, James Cancer Hospital, Ohio State Comprehensive Cancer Center, Columbus, Ohio
| | | | - Daniel W. Rea
- School of Cancer and Genomic Science, Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Paul M. Stos
- Canadian Cancer Trials Group, Queen’s University, Kingston, Ontario, Canada
| | - Lois E. Shepherd
- Canadian Cancer Trials Group, Queen’s University, Kingston, Ontario, Canada
| | - Vuk Stambolic
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Wendy R. Parulekar
- Canadian Cancer Trials Group, Queen’s University, Kingston, Ontario, Canada
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Sadigh G, Gray RJ, Sparano JA, Yanez B, Garcia SF, Timsina LR, Obeng-Gyasi S, Gareen I, Sledge GW, Whelan TJ, Cella D, Wagner LI, Carlos RC. Assessment of Racial Disparity in Survival Outcomes for Early Hormone Receptor-Positive Breast Cancer After Adjusting for Insurance Status and Neighborhood Deprivation: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Oncol 2022; 8:579-586. [PMID: 35175284 PMCID: PMC8855314 DOI: 10.1001/jamaoncol.2021.7656] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Racial disparities in survival outcomes among Black women with hormone receptor-positive breast cancer have been reported. However, the association between individual-level and neighborhood-level social determinants of health on such disparities has not been well studied. OBJECTIVE To evaluate the association between race and clinical outcomes (ie, relapse-free interval and overall survival) adjusting for individual insurance coverage and neighborhood deprivation index (NDI), measured using zip code of residence, in women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS This was a post hoc analysis of 9719 women with breast cancer in the Trial Assigning Individualized Options for Treatment, a randomized clinical trial conducted from April 7, 2006, to October 6, 2010. All participants received a diagnosis of hormone receptor-positive, ERBB2-negative, axillary node-negative breast cancer. The present data analysis was conducted from April 1 to October 22, 2021. MAIN OUTCOMES AND MEASURES A multivariate model was developed to evaluate the association between race and relapse-free interval and overall survival adjusting for insurance and NDI level at study entry, early discontinuation of endocrine therapy 4 years after initiation, and clinicopathologic characteristics of cancer. Median follow-up for clinical outcomes was 96 months. RESULTS A total of 9719 women (4.2% [n = 405] Asian; 7.1% [n = 693] Black; 84.3% [n = 8189] White; 4.4% [n = 403] others/not specified) were included; 9.1% of included women [n = 889] were Hispanic or Latino. Median (SD) age was 56 (9.2) years. In multivariate models, Black race compared with White race was associated with statistically significant shorter relapse-free interval (hazard ratio [HR], 1.39; 95% CI, 1.05-1.84; P = .02) and overall survival (HR, 1.49; 95% CI, 1.10-2.99; P = .009), adjusting for insurance and NDI level at study entry and other factors. Although uninsured status was not associated with clinical outcomes, patients with Medicare (HR, 1.30; 95% CI, 1.01-1.68; P = .04) and Medicaid (HR, 1.44; 95% CI, 1.01-2.05; P = .05) had shorter overall survival compared with those with private insurance. Participants living in neighborhoods in the highest NDI quartile experienced shorter overall survival compared with those in the lowest quartile (HR, 1.34; 95% CI, 1.01-1.77; P = .04), regardless of self-identified race. CONCLUSIONS AND RELEVANCE The findings of this post hoc analysis of a randomized clinical trial suggest that Black women with breast cancer have significantly shorter relapse-free interval and overall survival compared with White women. Early discontinuation of endocrine therapy, clinicopathologic characteristics, insurance coverage, and NDI do not fully explain the observed disparity. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00310180.
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Affiliation(s)
- Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Robert J. Gray
- Dana Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, Massachusetts
| | - Joseph A. Sparano
- Department of Hematology and Oncology, The Mount Sinai Hospital, New York, New York
| | - Betina Yanez
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sofia F. Garcia
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lava R. Timsina
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus
| | - Ilana Gareen
- Center for Statistical Sciences, Brown University, Providence, Rhode Island
| | | | - Timothy J. Whelan
- Canadian Cancer Trials Group, McMaster University, Hamilton, Ontario, Canada
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynne I. Wagner
- Wake Forest University Health Sciences, Winston Salem, North Carolina
| | - Ruth C. Carlos
- University of Michigan Comprehensive Cancer Center, Ann Arbor
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14
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Goodwin PJ, Chen BE, Gelmon KA, Whelan TJ, Ennis M, Lemieux J, Ligibel JA, Hershman DL, Mayer IA, Hobday TJ, Bliss JM, Rastogi P, Rabaglio-Poretti M, Mukherjee SD, Mackey RR, Abramson VG, Oja C, Wesolowski R, Thompson AM, Rea DW, Stos PM, Shepherd LE, Stambolic V, Parulekar WR. Abstract GS1-08: CCTGMA.32, a phase III randomized double-blind placebo controlled adjuvant trial of metformin (MET) vs placebo (PLAC) in early breast cancer (BC): Results of the primary efficacy analysis (clinical trials.gov NCT01101438). Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-gs1-08] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: MET has been associated with beneficial anti-cancer effects in epidemiologic and preclinical research. It may act indirectly by reversing obesity associated physiologic changes or directly via mitochondrial mediated effects on LKB1/AMPK/mTOR and other mechanisms. MA.32 investigated the effect of MET vs PLAC (in addition to standard therapy) on adjuvant BC outcomes. Design: Randomized, placebo-controlled double-blind Phase III clinical trial conducted within the NCI US National Clinical Trials Network, NCRI (UK) BG, IBCSG. Methods: Between 2010-2013 BC patients < 75 yo without diabetes (DM) with high risk T1-3, N0-3 M0 BC regardless of ER, PgR, HER2 and with adequate cardiac, renal and hepatic function were randomized (stratified for ER/PgR + vs -, BMI < vs > 30 kg/m2, HER2 +ve vs -ve, any vs no chemo) within 1 year of BC diagnosis to MET 850 mg po bid or PLAC bid for 5 years. Dose was reduced for toxicity with re-escalation when possible. Subjects were followed for Invasive Disease-Free Survival (IDFS primary outcome; events included invasive local/regional recurrences, distant recurrences, new ipsilateral/contralateral invasive BCs, new non-breast primary cancers, any death), Overall Survival (OS), Distant Relapse Free Survival (DRFS), BC Specific Survival (BCSS), BC Free Interval (BCFI), contralateral BC and cardiovascular (CV) events/new DM. 3582 subjects were required for 80% power to detect HR 0.76 (431 events). In 2011, entry was restricted to higher risk BC, leading to 80% power to detect HR 0.785 (544 events). In 2016, after the 2nd interim analysis at 29.5 months median F/U, the DSMB recommended (i) the intervention be continued with primary analysis triggered at 544 events be conducted in ER/PgR +ve (any HER2) subjects only and (ii) ER/PgR -ve subjects stop study drug for futility but blinding and follow-up continue. In 2021, a time driven analysis in ER/PgR +ve BC was approved (465 events providing 80% power to detect the original HR 0.76). Time to event survival described by the Kaplan-Meier method. Two-sided log-rank tests adjusting for stratification factors were primarily used to compare IDFS between arms. Cox proportional hazards models were used to identify and adjust for factors significantly related to IDFS. Results: 3649 subjects were enrolled. In the 2533 ER/PgR +ve subjects included in the primary analysis, baseline mean (± SD) age was 52.7 (±9.9 yrs); mean BMI 28.8 (±6.4) kg/m2. Baseline tumor characteristics were balanced: T stage 1/2/3/4 = 832/1351/349/1; N stage 0/1/2/3 = 964/1097/449/23; HER2+ 429. 1901 (75%) received XRT. 2150 (84.9%) received (neo)adj chemo, 2223 (87.8%) (neo)adj hormones and 434 (17.1%) HER2 targeted therapy. Any Grade ≥ 3 toxicity was similar in MET and PLAC arms (21.7% and 18.7%, P = 0.06). Median follow-up was 96.2 (range 0.2-121.0) months with 465 IDFS events (234 MET, 231 PLAC, 76% due to BC). Efficacy results are shown below.
MET vs PLACMET vs PLACIDFSOSPopulation Included# subjectsHR (95% CI)HR (95% CI)PRIMARY ANALYSISER/PgR +ve (any HER2)*25331.01 (0.84-1.21). P=0.920.89 (0.64-1.23). P=0.46ER/PgR -ve (any HER211161.01 (0.79-1.30. P=0.92)0.89 (0.64-1.23). P=0.46Exploratory. AnalysisHER2 +ve (any ER/PgR)6200.64 (0.43-0.95. P=0.0260.53 (0.30-0.98. P=0.0398**in ER/PgR pos BC HRs were similar for BCFI, DRFS, BCSS (ranging from 0.98-1.09)Conclusions: MET did not improve IDFS or other BC outcomes in ER/PgR positive or ER/PgR negative BC and should not be used as adjuvant treatment. Exploratory findings suggesting benefit in HER2+ve BC should be further investigated. Funded by: CCSRI, NCI (US), CBCF, BCRF, CRUK, Hold’Em for Life Charity, Apotex (Canada)
Citation Format: Pamela J. Goodwin, Bingshu E Chen, Karen A Gelmon, Timothy J Whelan, Marguerite Ennis, Julie Lemieux, Jennifer A Ligibel, Dawn L Hershman, Ingrid A Mayer, Timothy J Hobday, Judith M Bliss, Priya Rastogi, Manuela Rabaglio-Poretti, Som D. Mukherjee, Robert R Mackey, Vandana G Abramson, Conrad Oja, Robert Wesolowski, Alastair M Thompson, Daniel W Rea, Paul M Stos, Lois E Shepherd, Vuk Stambolic, Wendy R Parulekar. CCTGMA.32, a phase III randomized double-blind placebo controlled adjuvant trial of metformin (MET) vs placebo (PLAC) in early breast cancer (BC): Results of the primary efficacy analysis (clinical trials.gov NCT01101438) [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 GS1-08.
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Affiliation(s)
- Pamela J. Goodwin
- Mount Sinai Hospital/Lunenfeld-Tanenbaum Research Institute, University of Toronto, Toronto, ON, Canada
| | - Bingshu E Chen
- Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
| | - Karen A Gelmon
- British Columbia Cancer Agency, University of British Columbia, Vancouver, BC, Canada
| | - Timothy J Whelan
- Juravinski Cancer Center, McMaster University, Hamilton, ON, Canada
| | | | - Julie Lemieux
- CHU de Quebec, University Laval, Quebec City, QC, Canada
| | | | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
| | | | | | | | - Priya Rastogi
- NRG Oncology, University of Pittsburgh, Pittsburgh, PA
| | | | - Som D. Mukherjee
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | | | - Conrad Oja
- British Columbia Cancer Agency, University of British Columbia, Surrey, BC, Canada
| | - Robert Wesolowski
- James Cancer Hospital and the Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Daniel W Rea
- CRTCU, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Paul M Stos
- Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
| | - Lois E Shepherd
- Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
| | - Vuk Stambolic
- Princess Margaret Cancer Center, University Health Network, Dept of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Wendy R Parulekar
- Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
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Garcia SF, Gray RJ, Sparano JA, Tevaarwerk AJ, Carlos RC, Yanez B, Gareen IF, Whelan TJ, Sledge GW, Cella D, Wagner LI. Fatigue and endocrine symptoms among women with early breast cancer randomized to endocrine versus chemoendocrine therapy: Results from the TAILORx patient-reported outcomes substudy. Cancer 2022; 128:536-546. [PMID: 34614209 PMCID: PMC8776586 DOI: 10.1002/cncr.33939] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 07/17/2021] [Accepted: 07/23/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND TAILORx (Trial Assigning Individualized Options for Treatment) prospectively assessed fatigue and endocrine symptoms among women with early-stage hormone receptor-positive breast cancer and a midrange risk of recurrence who were randomized to endocrine therapy (E) or chemotherapy followed by endocrine therapy (CT+E). METHODS Participants completed the Functional Assessment of Chronic Illness Therapy-Fatigue, the Patient-Reported Outcomes Measurement Information System-Fatigue Short Form, and the Functional Assessment of Cancer Therapy-Endocrine Symptoms at the baseline and at 3, 6, 12, 24, and 36 months. Linear regression was used to model outcomes on baseline symptoms, treatment, and other factors. RESULTS Participants (n = 458) in both treatment arms reported greater fatigue and endocrine symptoms at early follow-up in comparison with the baseline. The magnitude of change in fatigue was significantly greater for the CT+E arm than the E arm at 3 and 6 months but not at 12, 24, or 36 months. The CT+E arm reported significantly greater changes in endocrine symptoms from the baseline to 3 months in comparison with the E arm; change scores were not significantly different at later time points. Endocrine symptom trajectories by treatment differed by menopausal status, with the effect larger and increasing for postmenopausal patients. CONCLUSIONS Adjuvant CT+E was associated with greater increases in fatigue and endocrine symptoms at early time points in comparison with E. These differences lessened over time, and this demonstrated early chemotherapy effects more than long-term ones. Treatment arm differences in endocrine symptoms were more evident in postmenopausal patients. LAY SUMMARY Participants in TAILORx (Trial Assigning Individualized Options for Treatment) with early-stage hormone receptor-positive breast cancer and an intermediate risk of recurrence were randomly assigned to endocrine or chemoendocrine therapy. Four hundred fifty-eight women reported fatigue and endocrine symptoms at the baseline and at 3, 6, 12, 24, and 36 months. Both groups reported greater symptoms at early follow-up versus the baseline. Increases in fatigue were greater for the chemoendocrine group than the endocrine group at 3 and 6 months but not later. The chemoendocrine group reported greater changes in endocrine symptoms in comparison with the endocrine group at 3 months but not later.
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Affiliation(s)
| | - Robert J. Gray
- Dana Farber Cancer Institute
- ECOG-ACRIN Biostatistics Center
| | | | | | | | | | - Ilana F. Gareen
- Center for Statistical Sciences & Department of Epidemiology, Brown University School of Public Health
- Center for Statistical Sciences & Department of Epidemiology, Brown University School of Public Health
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Goodwin PJ, Dowling RJO, Ennis M, Chen BE, Parulekar WR, Shepherd LE, Gelmon KA, Whelan TJ, Ligibel JA, Hershman DL, Mayer IA, Hobday TJ, Rastogi P, Rabaglio-Poretti M, Lemieux J, Thompson AM, Rea DW, Stambolic V. Cancer Antigen 15-3/Mucin 1 Levels in CCTG MA.32: A Breast Cancer Randomized Trial of Metformin vs Placebo. JNCI Cancer Spectr 2021; 5:pkab066. [PMID: 34485814 PMCID: PMC8410139 DOI: 10.1093/jncics/pkab066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 11/18/2022] Open
Abstract
Background Circulating levels of cancer antigen (CA) 15-3, a tumor marker and regulator of cellular metabolism, were reduced by metformin in a nonrandomized neoadjuvant study. We examined the effects of metformin (vs placebo) on CA 15-3 in participants of MA.32, a phase III randomized trial in early-stage breast cancer. Methods A total of 3649 patients with T1-3, N0-3, M0 breast cancer were randomly assigned; pretreatment and 6-month on-treatment fasting plasma were centrally assayed for CA 15-3. Genomic DNA was analyzed for the rs11212617 single nucleotide polymorphism. Absolute and relative change of CA 15-3 (metformin vs placebo) were compared using Wilcoxon rank and t tests. Regression models adjusted for baseline differences and assessed key interactions. All statistical tests were 2-sided. Results Mean (SD) age was 52.4 (10.0) years. The majority of patients had T2/3, node-positive, hormone receptor-positive, HER2-negative breast cancer treated with (neo)adjuvant chemotherapy and hormone therapy. Mean (SD) baseline CA 15-3 was 17.7 (7.6) and 18.0 (8.1 U/mL). At 6 months, CA 15-3 was statistically significantly reduced in metformin vs placebo arms (absolute geometric mean reduction in CA 15-3 = 7.7% vs 2.0%, P < .001; relative metformin: placebo level of CA 15-3 [adjusted for age, baseline body mass index, and baseline CA 15-3] = 0.94, 95% confidence interval = 0.92 to 0.96). This reduction was independent of tumor characteristics, perioperative systemic therapy, baseline body mass index, insulin, and the single nucleotide polymorphism status (all Ps > .11). Conclusions Our observation that metformin reduces CA 15-3 by approximately 6% was corroborated in a large placebo-controlled randomized trial. The clinical implications of this reduction in CA 15-3 will be explored in upcoming efficacy analyses of breast cancer outcomes in MA.32.
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Affiliation(s)
- Pamela J Goodwin
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Bingshu E Chen
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Wendy R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Lois E Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Karen A Gelmon
- University of British Columbia, BC Cancer Agency, Vancouver, BC, Canada
| | - Timothy J Whelan
- McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada
| | | | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, NY, USA
| | | | | | - Priya Rastogi
- NRG Oncology and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Manuela Rabaglio-Poretti
- IBCSG and Department of Oncology, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Daniel W Rea
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Vuk Stambolic
- Department of Medical Biophysics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada and University of Toronto, Toronto, ON, Canada
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Yanez B, Gray RJ, Sparano JA, Carlos RC, Sadigh G, Garcia SF, Gareen IF, Whelan TJ, Sledge GW, Cella D, Wagner LI. Association of Modifiable Risk Factors With Early Discontinuation of Adjuvant Endocrine Therapy: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Oncol 2021; 7:2780917. [PMID: 34137783 PMCID: PMC8377561 DOI: 10.1001/jamaoncol.2021.1693] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/14/2021] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Early discontinuation of adjuvant endocrine therapy (ET) is problematic among breast cancer survivors, with previous studies suggesting that up to 50% of women do not adhere to the recommended full 5 years of ET treatment. OBJECTIVE To identify the association between early discontinuation of ET in the Trial Assigning Individualized Options for Treatment (TAILORx) and modifiable risk factors, polypharmacy, and types of additional medications such as antidepressants and opioids. DESIGN, SETTING, AND PARTICIPANTS This post hoc analysis includes a subgroup of 954 patients with breast cancer in TAILORx, a randomized clinical trial conducted from April 7, 2006, to October 6, 2010. All participants received a diagnosis of hormone receptor-positive, ERBB2-negative, axillary node-negative breast cancer and started ET within a year of study entry. Analyses were conducted in the intent-to-treat population. Statistical analysis took place from January 15, 2020, to April 6, 2021. MAIN OUTCOMES AND MEASURES Participants completed measures on cancer-related health-related quality of life including physical well-being and social well-being prior to initiating ET. Early discontinuation of ET was defined as discontinuation less than 4 years from initiation for reasons other than death or recurrence. Kaplan-Meier estimates were used to calculate discontinuation, and Cox proportional hazards regression joint prediction models were used to analyze the association between rates of adherence to ET with patient-level factors. RESULTS A total of 954 women (mean [SD] age, 56.6 [8.9] years) were included in this analysis. In a joint model, receipt of chemoendocrine therapy (vs receipt of ET only; hazard ratio [HR], 0.57; 95% CI, 0.35-0.92; P = .02) and age older than 40 years (vs ≤40 years; HR for 41-50 years, 0.39; 95% CI, 0.18-0.85; P = .02; HR for 51-60 years, 0.28; 95% CI, 0.13-0.60; P = .001; HR for 61-70 years, 0.40; 95% CI, 0.18-0.86; P = .02; and HR for >70 years, 0.23; 95% CI, 0.07-0.77; P = .02) were associated with a lower probability of early discontinuation of ET. Adjusted for these factors, a history of depression compared with no history of depression (HR, 1.82; 95% CI, 1.19-2.77; P = .005), worse physical well-being compared with better physical well-being (HR, 2.12; 95% CI, 1.30-3.45; P = .002), and worse social well-being compared with better social well-being (HR, 1.94; 95% CI, 1.20-3.13; P = .006) were individually and significantly associated with a higher probability of early discontinuation of ET. Only antidepressant use at study baseline was associated with early discontinuation (HR, 1.87; 95% CI, 1.23-2.84; P = .003). CONCLUSIONS AND RELEVANCE In this post hoc analysis of a randomized clinical trial, baseline patient-reported health-related quality of life components, such as poor social well-being, poor physical well-being, and comorbid depression, were significant risk factors for early discontinuation of endocrine therapies. These results support systematic screening for patient-reported outcomes and depressive symptoms to identify women at risk for discontinuation of ET. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00310180.
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Affiliation(s)
- Betina Yanez
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert J. Gray
- Eastern Cooperative Oncology Group–American College of Radiology Imaging Network Biostatistics Center, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Joseph A. Sparano
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ruth C. Carlos
- Department of Radiology, University of Michigan Comprehensive Cancer Center, Ann Arbor
| | - Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Sofia F. Garcia
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ilana F. Gareen
- Center for Statistical Sciences, Brown University, Providence, Rhode Island
| | - Timothy J. Whelan
- Canadian Cancer Trials Group, McMaster University, Hamilton, Ontario, Canada
| | - George W. Sledge
- Department of Medicine, Stanford Cancer Center Palo Alto, Stanford, California
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynne I. Wagner
- Department of Social Sciences and Health Policy, Wake Forest University Health Sciences, Winston Salem, North Carolina
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18
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Goodwin PJ, Dowling RJO, Ennis M, Chen BE, Parulekar WR, Shepherd LE, Burnell MJ, Vander Meer R, Molckovsky A, Gurjal A, Gelmon KA, Ligibel JA, Hershman DL, Mayer IA, Whelan TJ, Hobday TJ, Rastogi P, Rabaglio-Poretti M, Lemieux J, Thompson AM, Rea DW, Stambolic V. Effect of metformin versus placebo on metabolic factors in the MA.32 randomized breast cancer trial. NPJ Breast Cancer 2021; 7:74. [PMID: 34103538 PMCID: PMC8187713 DOI: 10.1038/s41523-021-00275-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/03/2021] [Indexed: 12/26/2022] Open
Abstract
Metformin may exert anticancer effects through indirect (mediated by metabolic changes) or direct mechanisms. The goal was to examine metformin impact on metabolic factors in non-diabetic subjects and determine whether this impact varies by baseline BMI, insulin, and rs11212617 SNP in CCTG MA.32, a double-blind placebo-controlled randomized adjuvant breast cancer (BC) trial. 3649 subjects with T1-3, N0-3, M0 BC were randomized; pretreatment and 6-month on-treatment fasting plasma was centrally assayed for insulin, leptin, highly sensitive C-reactive protein (hsCRP). Glucose was measured locally and homeostasis model assessment (HOMA) calculated. Genomic DNA was analyzed for the rs11212617 SNP. Absolute and relative change of metabolic factors (metformin versus placebo) were compared using Wilcoxon rank and t-tests. Regression models were adjusted for baseline differences and assessed interactions with baseline BMI, insulin, and the SNP. Mean age was 52 years. The majority had T2/3, node positive, hormone receptor positive, HER2 negative BC treated with (neo)adjuvant chemotherapy and hormone therapy. Median baseline body mass index (BMI) was 27.4 kg/m2 (metformin) and 27.3 kg/m2 (placebo). Median weight change was -1.4 kg (metformin) vs +0.5 kg (placebo). Significant improvements were seen in all metabolic factors, with 6 month standardized ratios (metformin/placebo) of 0.85 (insulin), 0.83 (HOMA), 0.80 (leptin), and 0.84 (hsCRP), with no qualitative interactions with baseline BMI or insulin. Changes did not differ by rs11212617 allele. Metformin (vs placebo) led to significant improvements in weight and metabolic factors; these changes did not differ by rs11212617 allele status.
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Affiliation(s)
- Pamela J Goodwin
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | | | | | - Bingshu E Chen
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Wendy R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Lois E Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Margot J Burnell
- Department of Oncology, Saint John Regional Hospital, St. John, NB, Canada
| | - Rachel Vander Meer
- Department of Oncology, Niagara Health System, St. Catharines, ON, Canada
| | - Andrea Molckovsky
- Department of Medical Oncology, Grand River Regional Cancer Centre, Kitchener, ON, Canada
| | - Anagha Gurjal
- Abbotsford Centre, British Columbia Cancer Agency, Abbotsford, BC, Canada
| | - Karen A Gelmon
- University of British Columbia, BC Cancer Agency, Vancouver, BC, Canada
| | | | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, Columbia, NY, USA
| | | | - Timothy J Whelan
- McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada
| | | | - Priya Rastogi
- NRG Oncology and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Manuela Rabaglio-Poretti
- IBCSG and Department of Oncology, Bern University Hospital, University of Bern, Berne, Switzerland
| | | | | | - Daniel W Rea
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Vuk Stambolic
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
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19
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Albain KS, Gray RJ, Makower DF, Faghih A, Hayes DF, Geyer CE, Dees EC, Goetz MP, Olson JA, Lively T, Badve SS, Saphner TJ, Wagner LI, Whelan TJ, Ellis MJ, Wood WC, Keane MM, Gomez HL, Reddy PS, Goggins TF, Mayer IA, Brufsky AM, Toppmeyer DL, Kaklamani VG, Berenberg JL, Abrams J, Sledge GW, Sparano JA. Race, Ethnicity, and Clinical Outcomes in Hormone Receptor-Positive, HER2-Negative, Node-Negative Breast Cancer in the Randomized TAILORx Trial. J Natl Cancer Inst 2021; 113:390-399. [PMID: 32986828 PMCID: PMC8599918 DOI: 10.1093/jnci/djaa148] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/22/2020] [Accepted: 09/09/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Black race is associated with worse outcomes in early breast cancer. We evaluated clinicopathologic characteristics, the 21-gene recurrence score (RS), treatment delivered, and clinical outcomes by race and ethnicity among women who participated in the Trial Assigning Individualized Options for Treatment. METHODS The association between clinical outcomes and race (White, Black, Asian, other or unknown) and ethnicity (Hispanic vs non-Hispanic) was examined using proportional hazards models. All P values are 2-sided. RESULTS Of 9719 eligible women with hormone receptor-positive, HER2-negative, node-negative breast cancer, there were 8189 (84.3%) Whites, 693 (7.1%) Blacks, 405 (4.2%) Asians, and 432 (4.4%) with other or unknown race. Regarding ethnicity, 889 (9.1%) were Hispanic. There were no substantial differences in RS or ESR1, PGR, or HER2 RNA expression by race or ethnicity. After adjustment for other covariates, compared with White race, Black race was associated with higher distant recurrence rates (hazard ratio [HR] = 1.60, 95% confidence intervals [CI] = 1.07 to 2.41) and worse overall survival in the RS 11-25 cohort (HR = 1.51, 95% CI = 1.06 to 2.15) and entire population (HR = 1.41, 95% CI = 1.05 to 1.90). Hispanic ethnicity and Asian race were associated with better outcomes. There was no evidence of chemotherapy benefit for any racial or ethnic group in those with a RS of 11-25. CONCLUSIONS Black women had worse clinical outcomes despite similar 21-gene assay RS results and comparable systemic therapy in the Trial Assigning Individualized Options for Treatment. Similar to Whites, Black women did not benefit from adjuvant chemotherapy if the 21-gene RS was 11-25. Further research is required to elucidate the basis for this racial disparity in prognosis.
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Affiliation(s)
- Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernadin Cancer Center, Loyola University Medical Center, Maywood, IL, USA
| | | | - Della F Makower
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Amir Faghih
- Thunder Bay Regional Health Science Centre, Thunder Bay, Ontario, Canada
| | | | | | | | | | - John A Olson
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tracy Lively
- National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - Sunil S Badve
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Lynne I Wagner
- Wake Forest University Health Service, Winston Salem, NC, USA
| | | | | | | | | | - Henry L Gomez
- Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | | | | | | | | | | | | | | | - Jeffrey Abrams
- National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | | | - Joseph A Sparano
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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20
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Woodward WA, Barlow WE, Jagsi R, Buchholz TA, Shak S, Baehner F, Whelan TJ, Davidson NE, Ingle JN, King TA, Ravdin PM, Osborne CK, Tripathy D, Livingston RB, Gralow JR, Hortobagyi GN, Hayes DF, Albain KS. Association Between 21-Gene Assay Recurrence Score and Locoregional Recurrence Rates in Patients With Node-Positive Breast Cancer. JAMA Oncol 2020; 6:505-511. [PMID: 31917424 DOI: 10.1001/jamaoncol.2019.5559] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance The 21-gene assay recurrence score is increasingly used to personalize treatment recommendations for systemic therapy in postmenopausal women with estrogen receptor (ER)- or progesterone receptor (PR)-positive, node-positive breast cancer; however, the relevance of the 21-gene assay to radiotherapy decisions remains uncertain. Objective To examine the association between recurrence score and locoregional recurrence (LRR) in a postmenopausal patient population treated with adjuvant chemotherapy followed by tamoxifen or tamoxifen alone. Design, Setting, and Participants This cohort study was a retrospective analysis of the Southwest Oncology Group S8814, a phase 3 randomized clinical trial of postmenopausal women with ER/PR-positive, node-positive breast cancer treated with tamoxifen alone, chemotherapy followed by tamoxifen, or concurrent tamoxifen and chemotherapy. Patients at North American clinical centers were enrolled from June 1989 to July 1995. Medical records from patients with recurrence score information were reviewed for LRR and radiotherapy use. Primary analysis included 316 patients and excluded 37 who received both mastectomy and radiotherapy, 9 who received breast-conserving surgery without documented radiotherapy, and 5 with unknown surgical type. All analyses were performed from January 22, 2016, to August 9, 2019. Main Outcomes and Measures The LRR was defined as a recurrence in the breast; chest wall; or axillary, infraclavicular, supraclavicular, or internal mammary lymph nodes. Time to LRR was tested with log-rank tests and Cox proportional hazards regression for multivariate models. Results The final cohort of this study comprised 316 women with a mean (range) age of 60.4 (44-81) years. Median (interquartile range) follow-up for those without LRR was 8.7 (7.0-10.2) years. Seven LRR events (5.8%) among 121 patients with low recurrence score and 27 LRR events (13.8%) among 195 patients with intermediate or high recurrence score occurred. The estimated 10-year cumulative incidence rates were 9.7% for those with a low recurrence score and 16.5% for the group with intermediate or high recurrence score (P = .02). Among patients who had a mastectomy without radiotherapy (n = 252), the differences in the 10-year actuarial LRR rates remained significant: 7.7 % for the low recurrence score group vs 16.8% for the intermediate or high recurrence score group (P = .03). A multivariable model controlling for randomized treatment, number of positive nodes, and surgical type showed that a higher recurrence score was prognostic for LRR (hazard ratio [HR], 2.36; 95% CI, 1.02-5.45; P = .04). In a subset analysis of patients with a mastectomy and 1 to 3 involved nodes who did not receive radiation therapy, the group with a low recurrence score had a 1.5% rate of LRR, whereas the group with an intermediate or high recurrence score had a 11.1% LRR (P = .051). Conclusions and Relevance This study found that higher recurrence scores were associated with increased LRR after adjustment for treatment, type of surgical procedure, and number of positive nodes. This finding suggests that the recurrence score may be used, along with accepted clinical variables, to assess the risk of LRR during radiotherapy decision-making.
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Affiliation(s)
- Wendy A Woodward
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Thomas A Buchholz
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Steven Shak
- Department of Pathology, Genomic Health Inc, Redwood City, California
| | - Frederick Baehner
- Department of Pathology, Genomic Health Inc, Redwood City, California.,Department of Pathology, University of California San Francisco, San Francisco
| | - Timothy J Whelan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nancy E Davidson
- Division of Medical Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.,Division of Medical Oncology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - James N Ingle
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Tari A King
- Department of Surgery, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Peter M Ravdin
- Department of Medicine, Cancer Therapy & Research Center, University of Texas Health Science Center, San Antonio
| | - C Kent Osborne
- Department of Medicine, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Debasish Tripathy
- Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Robert B Livingston
- Department of Medicine, Division of Hematology and Oncology, University of Arizona, Tucson
| | - Julie R Gralow
- Department of Medicine, Division of Oncology, University of Washington/Seattle Cancer Care Alliance, Seattle
| | - Gabriel N Hortobagyi
- Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Daniel F Hayes
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Kathy S Albain
- Department of Medicine, Division of Hematology/Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
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21
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Donovan EK, Greenspoon J, Schnarr KL, Whelan TJ, Wright JR, Hann C, Whitton A, Chow T, Parpia S, Swaminath A. A pilot study of stereotactic boost for malignant epidural spinal cord compression: clinical significance and initial dosimetric evaluation. Radiat Oncol 2020; 15:267. [PMID: 33208170 PMCID: PMC7672889 DOI: 10.1186/s13014-020-01710-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/06/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Metastatic epidural spinal cord compression (MESCC) is a devastating complication of advanced malignancy, which can result in neurologic complications and significant deterioration in overall function and quality of life. Most patients are not candidates for optimal surgical decompression and as a result, receive urgent 3D conformal radiotherapy (3DCRT) to prevent or attempt to reverse neurologic progression. Multiple trials indicate that response and ambulatory rates after 3DCRT are inferior to surgery. The advent of stereotactic body radiation therapy (SBRT) has created a method with which a “radiosurgical decompression” boost may facilitate improve outcomes for MESCC patients. Methods We are conducting a pilot study to investigate SBRT boost after urgent 3D CRT for patients with MESCC. The aim of the study is to establish feasibility of this two-phase treatment regimen, and secondarily to characterize post-treatment ambulation status, motor response, pain control, quality of life and survival. Discussion We describe the study protocol and present a case report of one patient. A quality assurance review was conducted after the first seven patients, and resultant dose-constraints were revised to improve safety and feasibility of planning through more conservative organ at risk constraints. There have been no severe adverse events (grade 3–5) to date. We have illustrated clinical and dosimetric data of an example case, where a patient regained full strength and ambulatory capacity. Conclusions Our study aims to determine if SBRT is a feasible option in addition to standard 3DCRT for MESCC patients, with the goal to consider future randomized trials if successful. Having a robust quality assurance process in this study ensures translatability going forward if future trials with multicenter and increased patient representation are to be considered. Trial registration clinicaltrials.gov; registration no. NCT03529708; https://clinicaltrials.gov/ct2/show/NCT03529708; First posted May 18, 2018.
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Affiliation(s)
- Elysia K Donovan
- Sunnybrook Odette Cancer Centre, Department of Radiation Oncology, University of Toronto, 2075 Bayview Avenue, T2 Wing, Toronto, ON, M4N3M5, Canada
| | - Jeffrey Greenspoon
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Kara L Schnarr
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Timothy J Whelan
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - James R Wright
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Crystal Hann
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Anthony Whitton
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Tom Chow
- Juravinski Cancer Centre, Department of Medical Physics, McMaster University, 4th Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Sameer Parpia
- Juravinski Cancer Centre, Department of Oncology, McMaster University, 1st Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Anand Swaminath
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada.
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22
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Abstract
Purpose of Review Accelerated partial breast irradiation (APBI) is an alternative approach to breast conserving therapy (BCT) where radiation (RT) is delivered over a shorter period of time compared with whole breast irradiation (WBI), resulting in improved patient convenience and cost savings. APBI can be delivered using brachytherapy, intraoperative RT, or conformal external beam radiation therapy (EBRT) techniques. In this review, the authors appraise the latest modern randomized controlled trials (RCTs) of APBI and discuss the application of the data to clinical practice. Recent Findings The OCOG-RAPID and NSABP B-39/RTOG 0413 trials recently reported long-term outcomes of APBI. The OCOG-RAPID trial delivered 38.5 Gy/10 fractions twice daily (at least 6 h apart using EBRT) or WBI and demonstrated non-inferiority of APBI compared with WBI (8-year cumulative rate of ipsilateral breast tumor recurrence (IBTR) was 3% after APBI or 2.8% after WBI, HR 1.27, 90%CI: 0.84–1.91). While acute toxicity was reduced, late toxicity and breast cosmesis were worse with APBI. The NSABP B-39 trial included higher risk patients and was unable to demonstrate equivalence between APBI (38.5 Gy/10 fractions delivered twice daily using EBRT or brachytherapy techniques) and WBI. However, 10-year IBTR rates were low: 4.6% vs. 3.9%, respectively, HR 1.22, 90%CI: 0.94–1.58. The University of Florence demonstrated low rates of local recurrence at 10 years and overall excellent breast cosmetic outcomes when APBI was delivered using EBRT to a dose of 30 Gy/5 fractions delivered on non-consecutive days. Summary Recent RCTs of APBI have shed light on important factors for the integration of APBI into clinical practice, including patient selection and treatment delivery. APBI should be limited to patients with low-risk ductal carcinoma in situ or early stage (T1) invasive ductal cancer with clear margins of excision, estrogen receptor positivity, and node negative disease. Ongoing research should focus on the optimal dose/fractionation for delivery of EBRT-based APBI.
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Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
| | - Timothy J. Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
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23
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Wagner LI, Gray RJ, Sparano JA, Whelan TJ, Garcia SF, Yanez B, Tevaarwerk AJ, Carlos RC, Albain KS, Olson JA, Goetz MP, Pritchard KI, Hayes DF, Geyer CE, Dees EC, McCaskill-Stevens WJ, Minasian LM, Sledge GW, Cella D. Patient-Reported Cognitive Impairment Among Women With Early Breast Cancer Randomly Assigned to Endocrine Therapy Alone Versus Chemoendocrine Therapy: Results From TAILORx. J Clin Oncol 2020; 38:1875-1886. [PMID: 32271671 DOI: 10.1200/jco.19.01866] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Cancer-related cognitive impairment (CRCI) is common during adjuvant chemotherapy and may persist. TAILORx provided a novel opportunity to prospectively assess patient-reported cognitive impairment among women with early breast cancer who were randomly assigned to chemoendocrine therapy (CT+E) versus endocrine therapy alone (E), allowing us to quantify the unique contribution of chemotherapy to CRCI. METHODS Women with a 21-gene recurrence score of 11 to 25 enrolled in TAILORX were randomly assigned to CT+E or E. Cognitive impairment was assessed among a subgroup of 552 evaluable women using the 37-item Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) questionnaire, administered at baseline, 3, 6, 12, 24, and 36 months. The FACT-Cog included the 20-item Perceived Cognitive Impairment (PCI) scale, our primary end point. Clinically meaningful changes were defined a priori and linear regression was used to model PCI scores on baseline PCI, treatment, and other factors. RESULTS FACT-Cog PCI scores were significantly lower, indicating more impairment, at 3, 6, 12, 24, and 36 months compared with baseline for both groups. The magnitude of PCI change scores was greater for CT+E than E at 3 months, the prespecified primary trial end point, and at 6 months, but not at 12, 24, and 36 months. Tests of an interaction between menopausal status and treatment were nonsignificant. CONCLUSION Adjuvant CT+E is associated with significantly greater CRCI compared with E at 3 and 6 months. These differences abated over time, with no significant differences observed at 12 months and beyond. These findings indicate that chemotherapy produces early, but not sustained, cognitive impairment relative to E, providing reassurance to patients and clinicians in whom adjuvant chemotherapy is indicated to reduce recurrence risk.
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Affiliation(s)
| | - Robert J Gray
- ECOG-ACRIN Cancer Research Group Biostatistics Center, Boston, MA
| | - Joseph A Sparano
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Timothy J Whelan
- McMaster University, Canadian Cancer Trials Group, Hamilton, Ontario, Canada
| | | | - Betina Yanez
- Northwestern University School of Medicine, Chicago, IL
| | | | - Ruth C Carlos
- The University of Michigan Rogel Cancer Center, Ann Arbor, MI
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - John A Olson
- University of Maryland School of Medicine, Baltimore, MD
| | | | - Kathleen I Pritchard
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Daniel F Hayes
- The University of Michigan Rogel Cancer Center, Ann Arbor, MI
| | - Charles E Geyer
- Virginia Commonwealth University Massey Cancer Center Minority/Underserved National Cancer Institute Community Oncology Research Program, Richmond, VA
| | | | | | | | | | - David Cella
- Northwestern University School of Medicine, Chicago, IL
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24
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Whelan TJ, Julian JA, Berrang TS, Kim DH, Germain I, Nichol AM, Akra M, Lavertu S, Germain F, Fyles A, Trotter T, Perera FE, Balkwill S, Chafe S, McGowan T, Muanza T, Beckham WA, Chua BH, Gu CS, Levine MN, Olivotto IA. External beam accelerated partial breast irradiation versus whole breast irradiation after breast conserving surgery in women with ductal carcinoma in situ and node-negative breast cancer (RAPID): a randomised controlled trial. Lancet 2019; 394:2165-2172. [PMID: 31813635 DOI: 10.1016/s0140-6736(19)32515-2] [Citation(s) in RCA: 242] [Impact Index Per Article: 48.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whole breast irradiation delivered once per day over 3-5 weeks after breast conserving surgery reduces local recurrence with good cosmetic results. Accelerated partial breast irradiation (APBI) delivered over 1 week to the tumour bed was developed to provide a more convenient treatment. In this trial, we investigated if external beam APBI was non-inferior to whole breast irradiation. METHODS We did this multicentre, randomised, non-inferiority trial in 33 cancer centres in Canada, Australia and New Zealand. Women aged 40 years or older with ductal carcinoma in situ or node-negative breast cancer treated by breast conserving surgery were randomly assigned (1:1) to receive either external beam APBI (38·5 Gy in ten fractions delivered twice per day over 5-8 days) or whole breast irradiation (42·5 Gy in 16 fractions once per day over 21 days, or 50 Gy in 25 fractions once per day over 35 days). Patients and clinicans were not masked to treatment assignment. The primary outcome was ipsilateral breast tumour recurrence (IBTR), analysed by intention to treat. The trial was designed on the basis of an expected 5 year IBTR rate of 1·5% in the whole breast irradiation group with 85% power to exclude a 1·5% increase in the APBI group; non-inferiority was shown if the upper limit of the two-sided 90% CI for the IBTR hazard ratio (HR) was less than 2·02. This trial is registered with ClinicalTrials.gov, NCT00282035. FINDINGS Between Feb 7, 2006, and July 15, 2011, we enrolled 2135 women. 1070 were randomly assigned to receive APBI and 1065 were assigned to receive whole breast irradiation. Six patients in the APBI group withdrew before treatment, four more did not receive radiotherapy, and 16 patients received whole breast irradiation. In the whole breast irradiation group, 16 patients withdrew, and two more did not receive radiotherapy. In the APBI group, a further 14 patients were lost to follow-up and nine patients withdrew during the follow-up period. In the whole breast irradiation group, 20 patients were lost to follow-up and 35 withdrew during follow-up. Median follow-up was 8·6 years (IQR 7·3-9·9). The 8-year cumulative rates of IBTR were 3·0% (95% CI 1·9-4·0) in the APBI group and 2·8% (1·8-3·9) in the whole breast irradiation group. The HR for APBI versus whole breast radiation was 1·27 (90% CI 0·84-1·91). Acute radiation toxicity (grade ≥2, within 3 months of radiotherapy start) occurred less frequently in patients treated with APBI (300 [28%] of 1070 patients) than whole breast irradiation (484 [45%] of 1065 patients, p<0·0001). Late radiation toxicity (grade ≥2, later than 3 months) was more common in patients treated with APBI (346 [32%] of 1070 patients) than whole breast irradiation (142 [13%] of 1065 patients; p<0·0001). Adverse cosmesis (defined as fair or poor) was more common in patients treated with APBI than in those treated by whole breast irradiation at 3 years (absolute difference, 11·3%, 95% CI 7·5-15·0), 5 years (16·5%, 12·5-20·4), and 7 years (17·7%, 12·9-22·3). INTERPRETATION External beam APBI was non-inferior to whole breast irradiation in preventing IBTR. Although less acute toxicity was observed, the regimen used was associated with an increase in moderate late toxicity and adverse cosmesis, which might be related to the twice per day treatment. Other approaches, such as treatment once per day, might not adversely affect cosmesis and should be studied. FUNDING Canadian Institutes for Health Research and Canadian Breast Cancer Research Alliance.
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Affiliation(s)
- Timothy J Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada.
| | - Jim A Julian
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Tanya S Berrang
- Radiation Therapy Program, BC Cancer - Victoria, University of British Columbia, Vancouver, BC, Canada
| | - Do-Hoon Kim
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Isabelle Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada
| | - Alan M Nichol
- Division of Radiation Oncology, University of British Columbia and BC Cancer - Vancouver, BC, Canada
| | - Mohamed Akra
- Department of Radiation Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Sophie Lavertu
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Francois Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada; Division of Radiation Oncology, University of British Columbia and BC Cancer - Kelowna, BC, Canada
| | - Anthony Fyles
- Department of Radiation Oncology, University of Toronto and Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Francisco E Perera
- Department of Oncology, Western University and London Regional Cancer Program, London, ON, Canada
| | | | - Susan Chafe
- Department of Oncology, Division of Radiation Oncology, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Thomas McGowan
- Trillium Health Partners Credit Valley Hospital, Mississauga, ON, Canada
| | - Thierry Muanza
- Department of Oncology, McGill University and Jewish General Hospital Segal Cancer Centre, Montreal, QC, Canada
| | - Wayne A Beckham
- Department of Physics and Astronomy, University of Victoria and BC Cancer - Victoria, BC, Canada
| | - Boon H Chua
- University of New South Wales and Prince of Wales Hospital, Sydney, NSW, Australia
| | - Chu Shu Gu
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
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Dowling RJO, Sparano JA, Goodwin PJ, Bidard FC, Cescon DW, Chandarlapaty S, Deasy JO, Dowsett M, Gray RJ, Henry NL, Meric-Bernstam F, Perlmutter J, Sledge GW, Thorat MA, Bratman SV, Carey LA, Chang MC, DeMichele A, Ennis M, Jerzak KJ, Korde LA, Lohmann AE, Mamounas EP, Parulekar WR, Regan MM, Schramek D, Stambolic V, Whelan TJ, Wolff AC, Woodgett JR, Kalinsky K, Hayes DF. Toronto Workshop on Late Recurrence in Estrogen Receptor-Positive Breast Cancer: Part 2: Approaches to Predict and Identify Late Recurrence, Research Directions. JNCI Cancer Spectr 2019; 3:pkz049. [PMID: 32337478 PMCID: PMC7050024 DOI: 10.1093/jncics/pkz049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 12/20/2022] Open
Abstract
Late disease recurrence (more than 5 years after initial diagnosis) represents a clinical challenge in the treatment and management of estrogen receptor-positive breast cancer (BC). An international workshop was convened in Toronto, Canada, in February 2018 to review the current understanding of late recurrence and to identify critical issues that require future study. The underlying biological causes of late recurrence are complex, with the processes governing cancer cell dormancy, including immunosurveillance, cell proliferation, angiogenesis, and cellular stemness, being integral to disease progression. These critical processes are described herein as well as their role in influencing risk of recurrence. Moreover, observational and interventional clinical trials are proposed, with a focus on methods to identify patients at risk of recurrence and possible strategies to combat this in patients with estrogen receptor-positive BC. Because the problem of late BC recurrence of great importance, recent advances in disease detection and patient monitoring should be incorporated into novel clinical trials to evaluate approaches to enhance patient management. Indeed, future research on these issues is planned and will offer new options for effective late recurrence treatment and prevention strategies.
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Affiliation(s)
- Ryan J O Dowling
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Joseph A Sparano
- Departments of Medicine and Medical Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, Albert Einstein Cancer Center, New York, NY
| | - Pamela J Goodwin
- Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, Sinai Health System, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - David W Cescon
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sarat Chandarlapaty
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center; Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill-Cornell Medical College, New York, NY
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mitch Dowsett
- Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, The Royal Marsden NHS Foundation Trust, Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK
| | - Robert J Gray
- Department of Biostatistics, Dana-Farber Cancer Institute, Boston, MA
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - N Lynn Henry
- University of Utah, Salt Lake City, UT
- Huntsman Cancer Institute, Salt Lake City, UT
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - George W Sledge
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Scott V Bratman
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Lisa A Carey
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Martin C Chang
- University of Vermont Medical Center, Larner College of Medicine, Burlington, VT
| | - Angela DeMichele
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | - Katarzyna J Jerzak
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Larissa A Korde
- Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Ana Elisa Lohmann
- Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, Sinai Health System, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Wendy R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Meredith M Regan
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Daniel Schramek
- Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, Sinai Health System, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Vuk Stambolic
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Timothy J Whelan
- McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Jim R Woodgett
- Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | - Kevin Kalinsky
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Daniel F Hayes
- University of Michigan Rogel Cancer Center, and Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Dowling RJO, Kalinsky K, Hayes DF, Bidard FC, Cescon DW, Chandarlapaty S, Deasy JO, Dowsett M, Gray RJ, Henry NL, Meric-Bernstam F, Perlmutter J, Sledge GW, Bratman SV, Carey LA, Chang MC, DeMichele A, Ennis M, Jerzak KJ, Korde LA, Lohmann AE, Mamounas EP, Parulekar WR, Regan MM, Schramek D, Stambolic V, Thorat MA, Whelan TJ, Wolff AC, Woodgett JR, Sparano JA, Goodwin PJ. Toronto Workshop on Late Recurrence in Estrogen Receptor-Positive Breast Cancer: Part 1: Late Recurrence: Current Understanding, Clinical Considerations. JNCI Cancer Spectr 2019; 3:pkz050. [PMID: 32337479 PMCID: PMC7049988 DOI: 10.1093/jncics/pkz050] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/20/2019] [Accepted: 07/10/2019] [Indexed: 12/12/2022] Open
Abstract
Disease recurrence (locoregional, distant) exerts a significant clinical impact on the survival of estrogen receptor-positive breast cancer patients. Many of these recurrences occur late, more than 5 years after original diagnosis, and represent a major obstacle to the effective treatment of this disease. Indeed, methods to identify patients at risk of late recurrence and therapeutic strategies designed to avert or treat these recurrences are lacking. Therefore, an international workshop was convened in Toronto, Canada, in February 2018 to review the current understanding of late recurrence and to identify critical issues that require future study. In this article, the major issues surrounding late recurrence are defined and current approaches that may be applicable to this challenge are discussed. Specifically, diagnostic tests with potential utility in late-recurrence prediction are described as well as a variety of patient-related factors that may influence recurrence risk. Clinical and therapeutic approaches are also reviewed, with a focus on patient surveillance and the implementation of extended endocrine therapy in the context of late-recurrence prevention. Understanding and treating late recurrence in estrogen receptor-positive breast cancer is a major unmet clinical need. A concerted effort of basic and clinical research is required to confront late recurrence and improve disease management and patient survival.
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Affiliation(s)
- Ryan J O Dowling
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Kevin Kalinsky
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Daniel F Hayes
- University of Michigan Rogel Cancer Center and the Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | | | - David W Cescon
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sarat Chandarlapaty
- Human Oncology and Pathogenesis Program, and Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill-Cornell Medical College, New York, NY
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mitch Dowsett
- Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, The Royal Marsden NHS Foundation Trust, Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK
| | - Robert J Gray
- Department of Biostatistics, Dana-Farber Cancer Institute, Boston, MA
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - N Lynn Henry
- University of Utah, Huntsman Cancer Institute, Salt Lake City, UT
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - George W Sledge
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Scott V Bratman
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Lisa A Carey
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Martin C Chang
- University of Vermont Medical Center, Larner College of Medicine, Burlington, VT
| | - Angela DeMichele
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | - Katarzyna J Jerzak
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Larissa A Korde
- Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Ana Elisa Lohmann
- Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, Sinai Health System, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Wendy R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Meredith M Regan
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Daniel Schramek
- Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, Sinai Health System, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Vuk Stambolic
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Timothy J Whelan
- McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Jim R Woodgett
- Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | - Joseph A Sparano
- Departments of Medicine and Medical Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, Albert Einstein Cancer Center, New York, NY
| | - Pamela J Goodwin
- Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, Sinai Health System, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Rakovitch E, Sutradhar R, Hallett M, Thompson AM, Gu S, Dumeaux V, Whelan TJ, Paszat L. The time-varying effect of radiotherapy after breast-conserving surgery for DCIS. Breast Cancer Res Treat 2019; 178:221-230. [PMID: 31368035 DOI: 10.1007/s10549-019-05377-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/24/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND A better understanding underlying radiation (RT) response after breast-conserving surgery (BCS) is needed to mitigate over-treatment of DCIS. The hazard ratio (HR) measures the effect of RT but assumes the effect is constant over time. We examined the hazard function adjusted for adherence to surveillance mammography to examine variations in LR risk and the effect of RT over time. METHODS Crude hazard estimates for the development of LR in a population cohort of DCIS treated by BCS ± RT were computed. Multivariable extended Cox models and hazard plots were used to examine the association between receipt of RT and risk of each outcome adjusted for baseline covariates and adherence to mammography. RESULTS Population cohort includes 3262 women treated by BCS; 1635 received RT. Median follow-up was 13 years. LR developed in 364 women treated by BCS alone and 274 treated with RT. LR risk peaked at 2 years, declined until year 7, and then remained steady. The peak hazard of LR was associated with adverse features of DCIS. Early LR risk was attenuated in patients treated with RT but late annual risks of LR and invasive LR were similar among the two treatment groups. On multivariate analysis, RT was associated with a reduction in early LR risk (HR = 0.52, 95% CI 0.43-0.63, p < 0.0001) but did not reduce the risk of late LR (HR = 0.89, 95% CI: 0.67, 1.19, p = 0.44) (interaction, p = 0.002). CONCLUSIONS The effect of RT is not uniform over time and greatest in the first 7 years after BCS for DCIS, which can guide future research to understand mechanisms underlying RT response and optimize future management of DCIS.
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Affiliation(s)
- Eileen Rakovitch
- Department of Radiation Oncology, Toronto, ON, Canada.
- ICES, Toronto, ON, Canada.
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
- LC Campbell Chair in Breast Cancer Research, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Rinku Sutradhar
- ICES, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Michael Hallett
- Department of Biology, Concordia University, Montreal, QC, Canada
- School of Computer Science, McGill University, Montreal, QC, Canada
| | - Alastair M Thompson
- Dan L Duncan Comprehensive Cancer Center, Division of Surgical, Baylor College of Medicine, Houston, TX, USA
| | | | - Vanessa Dumeaux
- Department of Biology, Concordia University, Montreal, QC, Canada
- PERFORM Centre, Concordia University, Montréal, QC, Canada
| | - Timothy J Whelan
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Lawrence Paszat
- Department of Radiation Oncology, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Sparano JA, Gray RJ, Ravdin PM, Makower DF, Pritchard KI, Albain KS, Hayes DF, Geyer CE, Dees EC, Goetz MP, Olson JA, Lively T, Badve SS, Saphner TJ, Wagner LI, Whelan TJ, Ellis MJ, Paik S, Wood WC, Keane MM, Gomez Moreno HL, Reddy PS, Goggins TF, Mayer IA, Brufsky AM, Toppmeyer DL, Kaklamani VG, Berenberg JL, Abrams J, Sledge GW. Clinical and Genomic Risk to Guide the Use of Adjuvant Therapy for Breast Cancer. N Engl J Med 2019; 380:2395-2405. [PMID: 31157962 PMCID: PMC6709671 DOI: 10.1056/nejmoa1904819] [Citation(s) in RCA: 303] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use of adjuvant chemotherapy in patients with breast cancer may be guided by clinicopathological factors and a score based on a 21-gene assay to determine the risk of recurrence. Whether the level of clinical risk of breast cancer recurrence adds prognostic information to the recurrence score is not known. METHODS We performed a prospective trial involving 9427 women with hormone-receptor-positive, human epidermal growth factor receptor 2-negative, axillary node-negative breast cancer, in whom an assay of 21 genes had been performed, and we classified the clinical risk of recurrence of breast cancer as low or high on the basis of the tumor size and histologic grade. The effect of clinical risk was evaluated by calculating hazard ratios for distant recurrence with the use of Cox proportional-hazards models. The initial endocrine therapy was tamoxifen alone in the majority of the premenopausal women who were 50 years of age or younger. RESULTS The level of clinical risk was prognostic of distant recurrence in women with an intermediate 21-gene recurrence score of 11 to 25 (on a scale of 0 to 100, with higher scores indicating a worse prognosis or a greater potential benefit from chemotherapy) who were randomly assigned to endocrine therapy (hazard ratio for the comparison of high vs. low clinical risk, 2.73; 95% confidence interval [CI], 1.93 to 3.87) or to chemotherapy plus endocrine (chemoendocrine) therapy (hazard ratio, 2.41; 95% CI, 1.66 to 3.48) and in women with a high recurrence score (a score of 26 to 100), all of whom were assigned to chemoendocrine therapy (hazard ratio, 3.17; 95% CI, 1.94 to 5.19). Among women who were 50 years of age or younger who had received endocrine therapy alone, the estimated (±SE) rate of distant recurrence at 9 years was less than 5% (≤1.8±0.9%) with a low recurrence score (a score of 0 to 10), irrespective of clinical risk, and 4.7±1.0% with an intermediate recurrence score and low clinical risk. In this age group, the estimated distant recurrence at 9 years exceeded 10% among women with a high clinical risk and an intermediate recurrence score who received endocrine therapy alone (12.3±2.4%) and among those with a high recurrence score who received chemoendocrine therapy (15.2±3.3%). CONCLUSIONS Clinical-risk stratification provided prognostic information that, when added to the 21-gene recurrence score, could be used to identify premenopausal women who could benefit from more effective therapy. (Funded by the National Cancer Institute and others; ClinicalTrials.gov number, NCT00310180.).
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Affiliation(s)
- Joseph A Sparano
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Robert J Gray
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Peter M Ravdin
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Della F Makower
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Kathleen I Pritchard
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Kathy S Albain
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Daniel F Hayes
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Charles E Geyer
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Elizabeth C Dees
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Matthew P Goetz
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - John A Olson
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Tracy Lively
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Sunil S Badve
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Thomas J Saphner
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Lynne I Wagner
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Timothy J Whelan
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Matthew J Ellis
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Soonmyung Paik
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - William C Wood
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Maccon M Keane
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Henry L Gomez Moreno
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Pavan S Reddy
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Timothy F Goggins
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Ingrid A Mayer
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Adam M Brufsky
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Deborah L Toppmeyer
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Virginia G Kaklamani
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Jeffrey L Berenberg
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Jeffrey Abrams
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - George W Sledge
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); University of Texas, San Antonio (P.M.R.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O., J.A.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); the National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and the University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and the University of Hawaii Cancer Center, Honolulu (J.L.B.)
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Critchley P, Jadad AR, Taniguchi A, Woods A, Stevens R, Reyno L, Whelan TJ. Are Some Palliative Care Delivery Systems More Effective and Efficient than Others? A Systematic Review of Comparative Studies. J Palliat Care 2019. [DOI: 10.1177/082585979901500407] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Patrick Critchley
- Department of Family Medicine, Palliative Care Services, St. Joseph's Hospital, Hamilton Health Sciences Corporation, Hamilton, Ontario
| | - Alejandro R. Jadad
- Department of Clinical Epidemiology & Biostatistics, Program in Evidence-Based Care, Cancer Care Ontario, McMaster University, Hamilton, Ontario
| | | | - Anne Woods
- Palliative Care Services, St. Joseph's Hospital, Hamilton, Ontario
| | - Robert Stevens
- Health Information Research Unit, Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario
| | - Leonard Reyno
- Medical Oncology, Nova Scotia Cancer Centre, Halifax, Nova Scotia
| | - Timothy J. Whelan
- Department of Medicine, Supportive Cancer Care Research Unit, McMaster University, Hamilton, Ontario, Canada
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Wagner LI, Gray RJ, Garcia S, Whelan TJ, Tevarweerk A, Yanez B, Carlos R, Gareen I, McCaskill-Stevens W, Cella D, Sparano JA, Sledge GW. Abstract GS6-03: Symptoms and health-related quality of life on endocrine therapy alone (E) versus chemoendocrine therapy (C+E): TAILORx patient-reported outcomes results. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-gs6-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: TAILORx patient-reported outcomes (PRO) quantify symptoms and health-related quality of life (HRQL) from C+E beyond E alone from the patient's perspective, thus can inform decision-making for women in the intermediate risk group for whom chemotherapy may still be considered.
Methods: TAILORx participants with OncoType DX Recurrence Scores 11-25 were randomly assigned to E or C+E. All TAILORx participants enrolled 1/2010-10/2010 (N=612) completed PROs measuring fatigue, endocrine symptoms, cognitive impairments (PCI), and fear of recurrence at baseline, 3, 6, 12, 24 and 36 months. HRQL was assessed at baseline, 12, and 36 months. Linear regression (LR) examined PRO scores among the per-protocol sample.
Results: Overall, participants reported significantly more fatigue, endocrine symptoms and PCI at 3, 6, 12, 24 and 36 months compared to baseline and those randomized to C+E reported a greater magnitude of change baseline-3 months compared to those randomized to E alone (Table 1). Overall, by 12 months symptoms were comparable between groups. Pre-menopausal women had comparable symptoms at 24 and 36 months. Post-menopausal women randomized to C+E had greater endocrine symptoms at 24 and 36 months and greater fatigue at 6 and 24 months. Fear of recurrence was comparable between arms during treatment and follow-up. Multiple linear regression identified increased fatigue (LR slope β=0.67), endocrine symptoms (β =0.14), and PCI (β=0.11) as significant predictors of decreased HRQL across arms (p< 0.001). HRQL was comparable between E and C+E at 12- and 36-months.
Mean PRO change scores from baseline by treatment arm and menopausal status in per protocol population Months 36122436N=Overall454469458384343n=Pre-menopausal153151150118103n=Post-menopausal301318308266240FACIT-Fatigue Overall sample C+E-8.77-4.37-4.01-4.27-3.67E-2.48-1.97-2.14-1.49-1.83LMED-5.32***-1.55-1.01-1.76-0.90Pre-M C+E-8.01-3.26-2.99-2.45-1.60E-3.87-1.66-1.32-2.52-2.11LMED-3.11-0.82-1.121.021.46Post-M C+E-9.22-4.97-4.55-5.14-4.67E-1.87-2.10-2.52-1.09-1.71LMED-6.42***-1.99*-1.16-3.02*-2.01FACT-Endocrine Symptoms Overall sample C+E-5.56-5.63-6.96-6.81-7.14E-3.61-4.24-5.62-5.31-5.17LMED-1.62*-0.97-1.08-1.05-1.69Pre-M C+E-7.62-8.34-7.94-8.29-8.96E-5.96-6.19-8.95-10.39-10.84LMED-1.44-1.631.062.272.18Post-M C+E-4.39-4.19-6.45-6.10-6.28E-2.55-3.41-4.10-3.23-2.87LMED-1.49-0.45-2.04-2.39*-3.17**Significance between mean change scores *p<0.05;**p<0.01;***p<0.001. LMED=estimated tx difference using linear model regressing score on baseline value and tx
Conclusions: TAILORx is the first trial to examine patient-reported fatigue, endocrine symptoms, PCI and HRQL among breast cancer patients randomized to endocrine therapy alone vs chemoendocrine therapy, thus allowing us to quantify acute and long-term symptoms uniquely attributable to chemotherapy. As expected, chemotherapy is associated with greater fatigue, endocrine symptoms and PCI acutely during treatment, and for post-menopausal women with greater long-term endocrine symptoms. Increased symptoms were associated with poorer HRQL. Long-term HRQL was comparable between groups.
Citation Format: Wagner LI, Gray RJ, Garcia S, Whelan TJ, Tevarweerk A, Yanez B, Carlos R, Gareen I, McCaskill-Stevens W, Cella D, Sparano JA, Sledge, Jr. GW, On behalf of the TAILORx Study Team. Symptoms and health-related quality of life on endocrine therapy alone (E) versus chemoendocrine therapy (C+E): TAILORx patient-reported outcomes results [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 GS6-03.
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Affiliation(s)
- LI Wagner
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - RJ Gray
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - S Garcia
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - TJ Whelan
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - A Tevarweerk
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - B Yanez
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - R Carlos
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - I Gareen
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - W McCaskill-Stevens
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - D Cella
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - JA Sparano
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
| | - GW Sledge
- Wake Forest School of Medicine, Winston Salem, NC; Dana-Farber Cancer Institute, Boston, MA; Northwestern University School of Medicine, Chicago, IL; McMaster University, Hamilton, ON, Canada; University of Wisconsin, Madison, WI; University of Michigan, Ann Arbor, MI; Brown University, Providence, RI; National Institutes of Health, National Cancer Institute, Bethesda, MD; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Stanford University Medical Center, Stanford, CA
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Albain K, Gray RJ, Sparano JA, Makower DF, Pritchard KI, Hayes DF, Geyer CE, Dees EC, Goetz MP, Olson JA, Lively T, Badve SS, Saphner TJ, Wagner LI, Whelan TJ, Ellis MJ, Paik S, Wood WC, Ravdin PM, Keane MM, Gomez HL, Reddy PS, Goggins TF, Mayer IA, Brufsky AM, Toppmeyer DL, Kaklamani VG, Berenberg JL, Abrams J, Sledge GW. Abstract GS4-07: Race, ethnicity and clinical outcomes in hormone receptor-positive, HER2-negative, node-negative breast cancer: results from the TAILORx trial. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-gs4-07] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Black race is associated with worse outcomes in localized hormone receptor (HR)-positive breast cancer in population-based and in clinical trial cohorts, whether using self-identified race (Albain et al. JNCI 2009 [PMID: 19584328; Sparano et al. JNCI 2012 [PMID: 22250182) or genetically-identified race (Schneider et al. J Precision Oncol 2017 [PMID: 29333527]). This disparity persists after adjustment for treatment delivery parameters (Hershman et al. JCO 2009 [PMID:19307504]). We evaluated clinicopathologic characteristics, treatment delivered and clinical outcomes in the Trial Assigning Individualized Options for Treatment (TAILORx) by race and ethnicity (Sparano et al. NEJM 2018 [PMID: 29860917]).
Methods: The analysis included 9719 evaluable TAILORx participants. The association between clinical outcomes and race (white, black, Asian, other/unknown) and ethnicity (Hispanic vs. non-Hispanic) was examined, including invasive disease-free survival (iDFS), distant relapse-free interval (DRFI), relapse-free interval (RFI), and overall survival (OS). Proportional hazards models were fit including age (5 categories), tumor size (>2 cm vs. <=2 cm), histologic grade (high vs. medium vs. low vs. unknown), continuous recurrence score (RS), race, and ethnicity in the overall population and randomized treatment arms in the RS 11-25 cohort.
Results: The study population included 8189 (84%) whites, 693 (7%) blacks, 405 (4%) Asians, and 432 (4%) with other/unknown race. Regarding ethnicity, 7635 (79%) were non-Hispanic, 889 (9%) Hispanic, and 1195 (12%) unknown. There was no significant difference in RS distribution (p=0.22) in blacks compared with whites, or in median (17 vs. 17) or mean RS (19.1 vs. 18.2). There was likewise no difference in Hispanic vs. non-Hispanic ethnicity for RS distribution (p=0.72) or median (17 vs. 17) or mean RS (18.5 vs. 18.0). Black race (39% vs. 30%) and Hispanic ethnicity (39% vs. 30%) were both associated with younger age (</=50 years) at diagnosis. The use and type of adjuvant chemotherapy and endocrine therapy, and duration of endocrine therapy, were similar in black (vs. white) and Hispanic (vs. non-Hispanic) populations. In proportional hazards models, black race (compared with white race) was associated with worse clinical outcomes in the entire population and in those with a RS 11-25 (see table). Hispanic ethnicity was generally associated with better outcomes (compared with non-Hispanic ethnicity). For the cohort with a RS of 11-25, there was no evidence for chemotherapy benefit for any racial or ethnic group.
Race (black vs.white) and clinical outcomes in proportional hazards modelsClinical endpointEntire Population (N=693 black) Hazard ratio for eventRS 11-25 (N=471 black) Hazard ratio for eveniDFS1.33 (p=0.005)1.49 (p=0.001)DRFI1.21 (p=0.28)1.60 (p=0.02)RFI1.39 (p=0.02)1.80 (p<0.001)OS1.52 (p=0.005)1.67 (p=0.003
Conclusions: In patients eligible and selected for participation in TAILORx, black women had worse clinical outcomes despite similar 21-gene assay RS results and comparable systemic therapy. This adds to an emerging body of evidence suggesting a biologic basis or other factors contributing to racial disparities in HR-positive breast cancer that requires further evaluation.
Citation Format: Albain K, Gray RJ, Sparano JA, Makower DF, Pritchard KI, Hayes DF, Geyer, Jr. CE, Dees EC, Goetz MP, Olson, Jr. JA, Lively T, Badve SS, Saphner TJ, Wagner LI, Whelan TJ, Ellis MJ, Paik S, Wood WC, Ravdin PM, Keane MM, Gomez HL, Reddy PS, Goggins TF, Mayer IA, Brufsky AM, Toppmeyer DL, Kaklamani VG, Berenberg JL, Abrams J, Sledge, Jr. GW. Race, ethnicity and clinical outcomes in hormone receptor-positive, HER2-negative, node-negative breast cancer: results from the TAILORx trial [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 GS4-07.
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Affiliation(s)
- K Albain
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - RJ Gray
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - JA Sparano
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - DF Makower
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - KI Pritchard
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - DF Hayes
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - CE Geyer
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - EC Dees
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - MP Goetz
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - JA Olson
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - T Lively
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - SS Badve
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - TJ Saphner
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - LI Wagner
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - TJ Whelan
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - MJ Ellis
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - S Paik
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - WC Wood
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - PM Ravdin
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - MM Keane
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - HL Gomez
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - PS Reddy
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - TF Goggins
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - IA Mayer
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - AM Brufsky
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - DL Toppmeyer
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - VG Kaklamani
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - JL Berenberg
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - J Abrams
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
| | - GW Sledge
- Loyola University Chicago Stritch School of Medicine, Maywood, IL; Dana Farber Cancer Institute, Boston, MA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Sunnybrook Research Institute, Toronto, Canada; University of Michigan, Ann Arbor, MI; Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond, VA; University of North Carolina, Chapel Hill, NC; Mayo Clinic, Rochester, MN; University of Maryland School of Medicine, Baltimore, MD; National Institutes of Health, National Cancer Institute, Bethesda, MD; Indiana University School of Medicine, Indianapolis, IN; Vince Lombardi Cancer Clinic, Two Rivers, WI; Wake Forest University Health Service, Winston Salem, NC; McMaster University, Hamilton, Canada; Baylor College of Medicine, Houston, TX; Yonsei University College of Medicine, Seoul, South Korea; Emory University, Atlanta, GA; , San Antonio, TX; Cancer Trials Ireland, Dublin, Ireland; Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; C
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Dubsky P, Curigliano G, Burstein HJ, Winer EP, Gnant M, Loibl S, Colleoni M, Regan MM, Piccart-Gebhart M, Senn HJ, Thürlimann B, André F, Baselga J, Bergh J, Bonnefoi H, Brucker SY, Cardoso F, Carey L, Ciruelos E, Cuzick J, Denkert C, Di Leo A, Ejlertsen B, Francis P, Galimberti V, Garber J, Gulluoglu B, Goodwin P, Harbeck N, Hayes DF, Huang CS, Huober J, Khaled H, Jassem J, Jiang Z, Karlsson P, Morrow M, Orecchia R, Osborne KC, Pagani O, Partridge AH, Pritchard K, Ro J, Rutgers EJT, Sedlmayer F, Semiglazov V, Shao Z, Smith I, Toi M, Tutt A, Viale G, Watanabe T, Whelan TJ, Xu B. Reply to 'The St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2017: the point of view of an International Panel of Experts in Radiation Oncology' by Kirova et al. Ann Oncol 2018; 29:281-282. [PMID: 29045519 DOI: 10.1093/annonc/mdx543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- P Dubsky
- Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria.,Klinik St. Anna, Luzern, Switzerland
| | - G Curigliano
- Breast Cancer Program, Istituto Europeo di Oncologia, Milan, Italy
| | - H J Burstein
- Breast Oncology Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - E P Winer
- Breast Oncology Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - M Gnant
- Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - S Loibl
- German Breast Group, Neu-Isenburg, Germany
| | - M Colleoni
- Breast Cancer Program, Istituto Europeo di Oncologia, Milan, Italy
| | - M M Regan
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | | | - H-J Senn
- Tumor and Breast Center ZeTuP, St Gallen, Switzerland
| | - B Thürlimann
- Breast Center, Kantonsspital St. Gallen, St Gallen, Switzerland
| | | | - F André
- Institut de Cancérologie Gustave Roussy, Villejuif, France
| | - J Baselga
- Memorial Sloan Kettering Cancer Center, New York, USA
| | - J Bergh
- Karolinska Institute and University Hospital, Stockholm, Sweden
| | - H Bonnefoi
- University of Bordeaux, Bordeaux, France
| | - S Y Brucker
- Universitäts-Frauenklinik Tübingen, Tübingen, Germany
| | - F Cardoso
- Champalimaud Cancer Centre, Lisbon, Portugal
| | - L Carey
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, USA
| | - E Ciruelos
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | - J Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - C Denkert
- Institut für Pathologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - A Di Leo
- Azienda Usl Toscana Centro, Prato, Italy
| | | | - P Francis
- Peter McCallum Cancer Centre, Melbourne, Australia
| | - V Galimberti
- Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - J Garber
- Klinik St. Anna, Luzern, Switzerland
| | - B Gulluoglu
- Marmara University School of Medicine, Istanbul, Turkey
| | - P Goodwin
- University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - N Harbeck
- University of Munich, München, Germany
| | - D F Hayes
- Comprehensive Cancer Center, University of Michigan, Ann-Arbor, USA
| | - C-S Huang
- National Taiwan University Hospital, Taipei, Taiwan
| | | | - H Khaled
- The National Cancer Institute, Cairo University, Cairo, Egypt
| | - J Jassem
- Medical University of Gdansk, Gdansk, Poland
| | - Z Jiang
- Hospital Affiliated to Military Medical Science, Beijing, China
| | - P Karlsson
- Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrensky University Hospital, Gothenburg, Sweden
| | - M Morrow
- Memorial Sloan Kettering Cancer Center, New York, USA
| | - R Orecchia
- Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | | | - O Pagani
- Institute of Oncology Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | | | - K Pritchard
- University of Toronto, Sunnybrook Odette Cancer Center, Toronto, Canada
| | - J Ro
- National Cancer Center, Ilsandong-gu, Goyang-si, Gyeonggi-do, Korea
| | - E J T Rutgers
- Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - F Sedlmayer
- LKH Salzburg, Paracelsus Medical University Clinics, Salzburg, Austria
| | - V Semiglazov
- N.N.Petrov Research Institute of Oncology, St. Petersburg, Russian Federation
| | - Z Shao
- Fudan University Cancer Hospital, Shanghai, China
| | - I Smith
- The Royal Marsden, Sutton, Surrey, UK
| | - M Toi
- Graduate School of Medicine Kyoto University, Sakyo-ku Kyoto City, Japan
| | - A Tutt
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK
| | - G Viale
- University of Milan, Milan, Italy.,Istituto Europeo di Oncologia, Milan, Italy
| | - T Watanabe
- Hamamatsu Oncology Center, Hamamatsu, Japan
| | | | - B Xu
- National Cancer Center, Chaoyang District, Beijing, China
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Curigliano G, Burstein HJ, Winer EP, Gnant M, Dubsky P, Loibl S, Colleoni M, Regan MM, Piccart-Gebhart M, Senn HJ, Thürlimann B, André F, Baselga J, Bergh J, Bonnefoi H, Brucker SY, Cardoso F, Carey L, Ciruelos E, Cuzick J, Denkert C, Di Leo A, Ejlertsen B, Francis P, Galimberti V, Garber J, Gulluoglu B, Goodwin P, Harbeck N, Hayes DF, Huang CS, Huober J, Khaled H, Jassem J, Jiang Z, Karlsson P, Morrow M, Orecchia R, Osborne KC, Pagani O, Partridge AH, Pritchard K, Ro J, Rutgers EJT, Sedlmayer F, Semiglazov V, Shao Z, Smith I, Toi M, Tutt A, Viale G, Watanabe T, Whelan TJ, Xu B. De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol 2018; 29:2153. [PMID: 29733336 DOI: 10.1093/annonc/mdx806] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Elit LM, Fyles AW, Gu CS, Pond GR, D’Souza D, Samant R, Anthes M, Thomas G, Filion M, Arsenault J, Dayes I, Whelan TJ, Gulenchyn KY, Metser U, Dhamanaskar K, Levine MN. Effect of Positron Emission Tomography Imaging in Women With Locally Advanced Cervical Cancer: A Randomized Clinical Trial. JAMA Netw Open 2018; 1:e182081. [PMID: 30646153 PMCID: PMC6324512 DOI: 10.1001/jamanetworkopen.2018.2081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In women with locally advanced cancer of the cervix (LACC), staging defines disease extent and guides therapy. Currently, undetected disease outside the radiation field can result in undertreatment or, if disease is disseminated, overtreatment. OBJECTIVE To determine whether adding fludeoxyglucose F 18 positron emission tomography-computed tomography (PET-CT) to conventional staging with CT of the abdomen and pelvis affects therapy received in women with LACC. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial was conducted. Women with newly diagnosed histologically confirmed International Federation of Gynecology and Obstetrics stage IB to IVA carcinoma of the cervix who were candidates for chemotherapy and radiation therapy (CRT) were allocated 2:1 to PET-CT plus CT of the abdomen and pelvis or CT alone. Enrollment occurred between April 2010 and June 2014 at 6 regional cancer centers in Ontario, Canada. The PET-CT scanners were at 6 associated academic institutions. The median follow-up at the time of the analysis was 3 years. The analysis was conducted on March 30, 2017. INTERVENTIONS Patients received either PET-CT plus CT of the abdomen and pelvis or CT of the abdomen and pelvis. MAIN OUTCOMES AND MEASURES Treatment delivered, defined as standard pelvic CRT vs more extensive CRT, ie, extended field radiotherapy or therapy with palliative intent. RESULTS One hundred seventy-one patients were allocated to PET-CT (n = 113) or CT (n = 58). The trial stopped early before the planned target of 288 was reached because of low recruitment. Mean (SD) age was 48.1 (11.2) years in the PET-CT group vs 48.9 (12.7) years in the CT group. In the 112 patients who received PET-CT, 68 (60.7%) received standard pelvic CRT, 38 (33.9%) more extensive CRT, and 6 (5.4%) palliative treatment. The corresponding data for the 56 patients who received CT alone were 42 (75.0%), 11 (19.6%), and 3 (5.4%). Overall, 44 patients (39.3%) in the PET-CT group received more extensive CRT or palliative treatment compared with 14 patients (25.0%) in the CT group (odds ratio, 2.05; 95% CI, 0.96-4.37; P = .06). Twenty-four patients in the PET-CT group (21.4%) received extended field radiotherapy to para-aortic nodes and 14 (12.5%) to common iliac nodes compared with 8 (14.3%) and 3 (5.4%), respectively, in the CT group (odds ratio, 1.64; 95% CI, 0.68-3.92; P = .27). CONCLUSIONS AND RELEVANCE There was a trend for more extensive CRT with PET-CT, but the difference was not significant because the trial was underpowered. This trial provides information on the utility of PET-CT for staging in LACC. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00895349.
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Affiliation(s)
- Lorraine M. Elit
- Juravinski Cancer Centre, Department of Obstetrics & Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Anthony W. Fyles
- Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Gregory R. Pond
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - David D’Souza
- London Regional Cancer Centre, Department of Oncology, University of Western Ontario, London, Ontario, Canada
| | - Rajiv Samant
- Ottawa Hospital Cancer Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Margaret Anthes
- Thunder Bay Regional Cancer Centre, Thunder Bay, Ontario, Canada
| | - Gillian Thomas
- Odette Sunnybrook Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Marc Filion
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Julie Arsenault
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Ian Dayes
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Timothy J. Whelan
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Karen Y. Gulenchyn
- Hamilton Health Sciences, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ur Metser
- Princess Margaret Hospital, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Kavita Dhamanaskar
- Hamilton Health Sciences, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Mark N. Levine
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Timothy J Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Sparano JA, Gray RJ, Makower DF, Pritchard KI, Albain KS, Hayes DF, Geyer CE, Dees EC, Goetz MP, Olson JA, Lively T, Badve SS, Saphner TJ, Wagner LI, Whelan TJ, Ellis MJ, Paik S, Wood WC, Ravdin PM, Keane MM, Gomez Moreno HL, Reddy PS, Goggins TF, Mayer IA, Brufsky AM, Toppmeyer DL, Kaklamani VG, Berenberg JL, Abrams J, Sledge GW. Adjuvant Chemotherapy Guided by a 21-Gene Expression Assay in Breast Cancer. N Engl J Med 2018; 379:111-121. [PMID: 29860917 PMCID: PMC6172658 DOI: 10.1056/nejmoa1804710] [Citation(s) in RCA: 1318] [Impact Index Per Article: 219.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The recurrence score based on the 21-gene breast cancer assay predicts chemotherapy benefit if it is high and a low risk of recurrence in the absence of chemotherapy if it is low; however, there is uncertainty about the benefit of chemotherapy for most patients, who have a midrange score. METHODS We performed a prospective trial involving 10,273 women with hormone-receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative, axillary node-negative breast cancer. Of the 9719 eligible patients with follow-up information, 6711 (69%) had a midrange recurrence score of 11 to 25 and were randomly assigned to receive either chemoendocrine therapy or endocrine therapy alone. The trial was designed to show noninferiority of endocrine therapy alone for invasive disease-free survival (defined as freedom from invasive disease recurrence, second primary cancer, or death). RESULTS Endocrine therapy was noninferior to chemoendocrine therapy in the analysis of invasive disease-free survival (hazard ratio for invasive disease recurrence, second primary cancer, or death [endocrine vs. chemoendocrine therapy], 1.08; 95% confidence interval, 0.94 to 1.24; P=0.26). At 9 years, the two treatment groups had similar rates of invasive disease-free survival (83.3% in the endocrine-therapy group and 84.3% in the chemoendocrine-therapy group), freedom from disease recurrence at a distant site (94.5% and 95.0%) or at a distant or local-regional site (92.2% and 92.9%), and overall survival (93.9% and 93.8%). The chemotherapy benefit for invasive disease-free survival varied with the combination of recurrence score and age (P=0.004), with some benefit of chemotherapy found in women 50 years of age or younger with a recurrence score of 16 to 25. CONCLUSIONS Adjuvant endocrine therapy and chemoendocrine therapy had similar efficacy in women with hormone-receptor-positive, HER2-negative, axillary node-negative breast cancer who had a midrange 21-gene recurrence score, although some benefit of chemotherapy was found in some women 50 years of age or younger. (Funded by the National Cancer Institute and others; TAILORx ClinicalTrials.gov number, NCT00310180 .).
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Affiliation(s)
- Joseph A Sparano
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Robert J Gray
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Della F Makower
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Kathleen I Pritchard
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Kathy S Albain
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Daniel F Hayes
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Charles E Geyer
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Elizabeth C Dees
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Matthew P Goetz
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - John A Olson
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Tracy Lively
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Sunil S Badve
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Thomas J Saphner
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Lynne I Wagner
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Timothy J Whelan
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Matthew J Ellis
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Soonmyung Paik
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - William C Wood
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Peter M Ravdin
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Maccon M Keane
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Henry L Gomez Moreno
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Pavan S Reddy
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Timothy F Goggins
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Ingrid A Mayer
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Adam M Brufsky
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Deborah L Toppmeyer
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Virginia G Kaklamani
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Jeffrey L Berenberg
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - Jeffrey Abrams
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
| | - George W Sledge
- From Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.), and McMaster University, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Chicago Stritch School of Medicine, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), and Duke University Medical Center, Durham (J.A.O.) - both in North Carolina; Mayo Clinic, Jacksonville, FL (M.P.G.); National Institutes of Health, National Cancer Institute, Bethesda, MD (T.L., J.A.); Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.), Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Washington University, St. Louis (M.J.E.); National Surgical Adjuvant Breast and Bowel Project Pathology Office (S.P.) and University of Pittsburgh (A.M.B.), Pittsburgh; Emory University, Atlanta (W.C.W.); University of Texas, San Antonio (P.M.R.); Cancer Trials Ireland, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); and University of Hawaii Cancer Center, Honolulu (J.L.B.)
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Wagner LI, Zhao F, Goss PE, Chapman JAW, Shepherd LE, Whelan TJ, Mattar BI, Bufill JA, Schultz WC, LaFrancis IE, Nagargoje GG, Vemuri R, Nikcevich DA, Sledge GW, Cella D. Patient-reported predictors of early treatment discontinuation: treatment-related symptoms and health-related quality of life among postmenopausal women with primary breast cancer randomized to anastrozole or exemestane on NCIC Clinical Trials Group (CCTG) MA.27 (E1Z03). Breast Cancer Res Treat 2018; 169:537-548. [PMID: 29455298 PMCID: PMC6092930 DOI: 10.1007/s10549-018-4713-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 02/06/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Aromatase inhibitors are the most commonly prescribed adjuvant endocrine therapy for hormone-dependent early breast cancer in postmenopausal women. Among Canadian Cancer Trials Group MA.27 participants, anastrozole and exemestane had comparable 5-year event-free survival. This companion study examined differences in patient-reported treatment-related symptoms (TRS) and health-related quality of life (HRQL) among postmenopausal women randomized to anastrozole or exemestane. METHODS MA.27 participants (N = 686, of 7576) randomized to 5 years of anastrozole (1 mg/day, n = 371, Arm A) or exemestane (25 mg/day, n = 315, Arm E) completed the 56-item Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES) questionnaire to assess TRS and HRQL. The FACT-ES was completed at baseline, 3, 6, 12, and 24 months. RESULTS No significant differences in FACT-ES median scores measuring TRS and HRQL were observed between treatment arms at any time point. Change in TRS from baseline was statistically significant at 3, 6, 12, and 24 months. HRQL was stable over time in both arms. Greater TRS burden was associated with poorer HRQL (coefficient = 0.57, p < 0.001). Twenty percent of patients discontinued AI therapy by month 24 and 32% discontinued AIs at 4 years. In both arms, patients reporting more side effect bother prior to initiating study treatment had a higher risk of discontinuing treatment before completing protocol therapy (hazard ratio [HR] 1.29, 95% CI 1.08-1.55, p = 0.01). CONCLUSIONS TRS and HRQL were comparable between anastrozole and exemestane. TRS negatively affect HRQL. Women who report being bothered by treatment side effects prior to initiating an AI are at increased risk for early treatment discontinuation.
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Affiliation(s)
- Lynne I Wagner
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC, 27151, USA.
| | | | - Paul E Goss
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Timothy J Whelan
- Canadian Cancer Trials Group (CCTG), Kingston, Canada
- McMaster University, Hamilton, ON, Canada
| | | | - Jose A Bufill
- Michiana Hematology-Oncology, P.C., Mishawaka, IN, USA
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38
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Yerushalmi R, Dong B, Chapman JW, Goss PE, Pollak MN, Burnell MJ, Levine MN, Bramwell VHC, Pritchard KI, Whelan TJ, Ingle JN, Shepherd LE, Parulekar WR, Han L, Ding K, Gelmon KA. Impact of baseline BMI and weight change in CCTG adjuvant breast cancer trials. Ann Oncol 2018; 28:1560-1568. [PMID: 28379421 DOI: 10.1093/annonc/mdx152] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Indexed: 12/12/2022] Open
Abstract
Background We hypothesized that increased baseline BMI and BMI change would negatively impact clinical outcomes with adjuvant breast cancer systemic therapy. Methods Data from chemotherapy trials MA.5 and MA.21; endocrine therapy MA.12, MA.14 and MA.27; and trastuzumab HERA/MA.24 were analyzed. The primary objective was to examine the effect of BMI change on breast cancer-free interval (BCFI) landmarked at 5 years; secondary objectives included BMI changes at 1 and 3 years; BMI changes on disease-specific survival (DSS) and overall survival (OS); and effects of baseline BMI. Stratified analyses included trial therapy and composite trial stratification factors. Results In pre-/peri-/early post-menopausal chemotherapy trials (N = 2793), baseline BMI did not impact any endpoint and increased BMI from baseline did not significantly affect BCFI (P = 0.85) after 5 years although it was associated with worse BCFI (P = 0.03) and DSS (P = 0.07) after 1 year. BMI increase by 3 and 5 years was associated with better DSS (P = 0.01; 0.01) and OS (P = 0.003; 0.05). In pre-menopausal endocrine therapy trial MA.12 (N = 672), patients with higher baseline BMI had worse BCFI (P = 0.02) after 1 year, worse DSS (P = 0.05; 0.004) after 1 and 5 years and worse OS (P = 0.01) after 5 years. Increased BMI did not impact BCFI (P = 0.90) after 5 years, although it was associated with worse BCFI (P = 0.01) after 1 year. In post-menopausal endocrine therapy trials MA.14 and MA.27 (N = 8236), baseline BMI did not significantly impact outcome for any endpoint. BMI change did not impact BCFI or DSS after 1 or 3 years, although a mean increased BMI of 0.3 was associated with better OS (P = 0.02) after 1 year. With the administration of trastuzumab (N = 1395) baseline BMI and BMI change did not significantly impact outcomes. Conclusions Higher baseline BMI and BMI increases negatively affected outcomes only in pre-/peri-/early post-menopausal trial patients. Otherwise, BMI increases similar to those expected in healthy women either did not impact outcome or were associated with better outcomes. Clinical Trials numbers CAN-NCIC-MA5; National Cancer Institute (NCI)-V90-0027; MA.12-NCT00002542; MA.14-NCT00002864; MA.21-NCT00014222; HERA, NCT00045032;CAN-NCIC-MA24; MA-27-NCT00066573.
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Affiliation(s)
- R Yerushalmi
- Department of Medical Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva and Tel-Aviv University, Tel Aviv, Israel
| | - B Dong
- Canadian Cancer Trials Group (CCTG; Formerly, NCIC Clinical Trials Group), Queen's University, Kingston, Canada
| | - J W Chapman
- Canadian Cancer Trials Group (CCTG; Formerly, NCIC Clinical Trials Group), Queen's University, Kingston, Canada
| | - P E Goss
- Massachusetts General Hospital Cancer Center, Boston, USA
| | - M N Pollak
- Department of Medical Oncology, Jewish General Hospital, McGill University, Montreal
| | - M J Burnell
- Department of Medical Oncology, Saint John Regional Hospital, Saint John
| | - M N Levine
- Department of Oncology, McMaster University, Juravinski Cancer Center, Hamilton, Ontario
| | - V H C Bramwell
- Department of Medical Oncology, Tom Baker Cancer Centre, Alberta Health Services and University of Calgary, Calgary
| | - K I Pritchard
- Department of Medical Oncology, Sunnybrook Odette Cancer Centre and the University of Toronto, Toronto, Canada
| | - T J Whelan
- Department of Oncology, Juravinski Cancer Center, McMaster University, Hamilton, Ontario
| | - J N Ingle
- Department of Oncology, Mayo Clinic, Rochester, USA
| | - L E Shepherd
- Canadian Cancer Trials Group (CCTG; Formerly, NCIC Clinical Trials Group), Queen's University, Kingston, Canada
| | - W R Parulekar
- Canadian Cancer Trials Group (CCTG; Formerly, NCIC Clinical Trials Group), Queen's University, Kingston, Canada
| | - L Han
- Canadian Cancer Trials Group (CCTG; Formerly, NCIC Clinical Trials Group), Queen's University, Kingston, Canada
| | - K Ding
- Canadian Cancer Trials Group (CCTG; Formerly, NCIC Clinical Trials Group), Queen's University, Kingston, Canada
| | - K A Gelmon
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, Canada
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Lemieux J, Brundage MD, Parulekar WR, Goss PE, Ingle JN, Pritchard KI, Celano P, Muss H, Gralow J, Strasser-Weippl K, Whelan K, Tu D, Whelan TJ. Quality of Life From Canadian Cancer Trials Group MA.17R: A Randomized Trial of Extending Adjuvant Letrozole to 10 Years. J Clin Oncol 2018; 36:563-571. [PMID: 29328860 DOI: 10.1200/jco.2017.75.7500] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose MA.17R was a Canadian Cancer Trials Group-led phase III randomized controlled trial comparing letrozole to placebo after 5 years of aromatase inhibitor as adjuvant therapy for hormone receptor-positive breast cancer. Quality of life (QOL) was a secondary outcome measure of the study, and here, we report the results of these analyses. Methods QOL was measured using the Short Form-36 (SF-36; two summary scores and eight domains) and menopause-specific QOL (MENQOL; four symptom domains) at baseline and every 12 months up to 60 months. QOL assessment was mandatory for Canadian Cancer Trials Group centers but optional for centers in other groups. Mean change scores from baseline were calculated. Results One thousand nine hundred eighteen women were randomly assigned, and 1,428 women completed the baseline QOL assessment. Compliance with QOL measures was > 85%. Baseline summary scores for the SF-36 physical component summary (47.5 for letrozole and 47.9 for placebo) and mental component summary (55.5 for letrozole and 54.8 for placebo) were close to the population norms of 50. No differences were seen between groups in mean change scores for the SF-36 physical and mental component summaries and the other eight QOL domains except for the role-physical subscale. No difference was found in any of the four domains of the MENQOL Conclusion No clinically significant differences were seen in overall QOL measured by the SF-36 summary measures and MENQOL between the letrozole and placebo groups. The data indicate that continuation of aromatase inhibitor therapy after 5 years of prior treatment in the trial population was not associated with a deterioration of overall QOL.
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Affiliation(s)
- Julie Lemieux
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Michael D Brundage
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Wendy R Parulekar
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Paul E Goss
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - James N Ingle
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Kathleen I Pritchard
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Paul Celano
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Hyman Muss
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Julie Gralow
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Kathrin Strasser-Weippl
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Kate Whelan
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Dongsheng Tu
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
| | - Timothy J Whelan
- Julie Lemieux, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec; Michael D. Brundage, Cancer Centre of Southeastern Ontario at Kingston General Hospital; Wendy R. Parulekar, Kate Whelan, and Dongsheng Tu, Canadian Cancer Trials Group, Kingston; Kathleen I. Pritchard, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto; Timothy J. Whelan, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada; Paul E. Goss, Massachusetts General Hospital Cancer Center, Boston, MA; James N. Ingle, North Central Cancer Treatment Group, Mayo Clinic, Rochester, NY; Paul Celano; Greater Baltimore Medical Center, Baltimore, MD; Hyman Muss, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Julie Gralow, University of Washington, Seattle, WA; and Kathrin Strasser-Weippl, Wilhelminen Hospital, Vienna, Austria
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Curigliano G, Burstein HJ, Winer EP, Gnant M, Dubsky P, Loibl S, Colleoni M, Regan MM, Piccart-Gebhart M, Senn HJ, Thürlimann B, André F, Baselga J, Bergh J, Bonnefoi H, Brucker SY, Cardoso F, Carey L, Ciruelos E, Cuzick J, Denkert C, Di Leo A, Ejlertsen B, Francis P, Galimberti V, Garber J, Gulluoglu B, Goodwin P, Harbeck N, Hayes DF, Huang CS, Huober J, Khaled H, Jassem J, Jiang Z, Karlsson P, Morrow M, Orecchia R, Osborne KC, Pagani O, Partridge AH, Pritchard K, Ro J, Rutgers EJT, Sedlmayer F, Semiglazov V, Shao Z, Smith I, Toi M, Tutt A, Viale G, Watanabe T, Whelan TJ, Xu B. De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol 2017; 28:1700-1712. [PMID: 28838210 PMCID: PMC6246241 DOI: 10.1093/annonc/mdx308] [Citation(s) in RCA: 696] [Impact Index Per Article: 99.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The 15th St. Gallen International Breast Cancer Conference 2017 in Vienna, Austria reviewed substantial new evidence on loco-regional and systemic therapies for early breast cancer. Treatments were assessed in light of their intensity, duration and side-effects, seeking where appropriate to escalate or de-escalate therapies based on likely benefits as predicted by tumor stage and tumor biology. The Panel favored several interventions that may reduce surgical morbidity, including acceptance of 2 mm margins for DCIS, the resection of residual cancer (but not baseline extent of cancer) in women undergoing neoadjuvant therapy, acceptance of sentinel node biopsy following neoadjuvant treatment of many patients, and the preference for neoadjuvant therapy in HER2 positive and triple-negative, stage II and III breast cancer. The Panel favored escalating radiation therapy with regional nodal irradiation in high-risk patients, while encouraging omission of boost in low-risk patients. The Panel endorsed gene expression signatures that permit avoidance of chemotherapy in many patients with ER positive breast cancer. For women with higher risk tumors, the Panel escalated recommendations for adjuvant endocrine treatment to include ovarian suppression in premenopausal women, and extended therapy for postmenopausal women. However, low-risk patients can avoid these treatments. Finally, the Panel recommended bisphosphonate use in postmenopausal women to prevent breast cancer recurrence. The Panel recognized that recommendations are not intended for all patients, but rather to address the clinical needs of the majority of common presentations. Individualization of adjuvant therapy means adjusting to the tumor characteristics, patient comorbidities and preferences, and managing constraints of treatment cost and access that may affect care in both the developed and developing world.
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Affiliation(s)
- G Curigliano
- Breast Cancer Program, Istituto Europeo di Oncologia, Milano, Italy
| | - H J Burstein
- Breast Oncology Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - E P Winer
- Breast Oncology Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - M Gnant
- Department of Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - P Dubsky
- Department of Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
- Klinik St. Anna, Luzern, Switzerland
| | - S Loibl
- German Breast Group, Neu-Isenburg, Germany
| | - M Colleoni
- Breast Cancer Program, Istituto Europeo di Oncologia, Milano, Italy
| | - M M Regan
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - M Piccart-Gebhart
- Department of Medical Oncology, Institut Jules Bordet, UniversitÕ Libre de Bruxelles, Brussels, Belgium
| | - H-J Senn
- Tumor and Breast Center ZeTuP, St. Gallen
| | - B Thürlimann
- Breast Center, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - F André
- Institut de Cancérologie Gustave Roussy, Villejuif, France
| | - J Baselga
- Memorial Sloan Kettering Cancer Center, New York, USA
| | - J Bergh
- Karolinska Institute and University Hospital, Stockholm, Sweden
| | - H Bonnefoi
- University of Bordeaux, Bordeaux, France
| | - S Y Brucker
- Universitäts-Frauenklinik Tübingen, Tübingen, Germany
| | - F Cardoso
- Champalimaud Cancer Centre, Lisbon, Portugal
| | - L Carey
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, USA
| | - E Ciruelos
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | - J Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - C Denkert
- Institut für Pathologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - A Di Leo
- Azienda Usl Toscana Centro, Prato, Italy
| | | | - P Francis
- Peter McCallum Cancer Centre, Melbourne, Australia
| | - V Galimberti
- Breast Cancer Program, Istituto Europeo di Oncologia, Milano, Italy
| | - J Garber
- Breast Oncology Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - B Gulluoglu
- Marmara University School of Medicine, Istanbul, Turkey
| | - P Goodwin
- University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - N Harbeck
- University of Munich, München, Germany
| | - D F Hayes
- Comprehensive Cancer Center, University of Michigan, Ann-Arbor, USA
| | - C-S Huang
- National Taiwan University Hospital, Taipei, Taiwan
| | | | - H Khaled
- The National Cancer Institute, Cairo University, Cairo, Egypt
| | - J Jassem
- Medical University of Gdansk, Gdansk, Poland
| | - Z Jiang
- Hospital Affiliated to Military Medical Science, Beijing, China
| | - P Karlsson
- Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrensky University Hospital, Gothenburg, Sweden
| | - M Morrow
- Memorial Sloan Kettering Cancer Center, New York, USA
| | - R Orecchia
- Breast Cancer Program, Istituto Europeo di Oncologia, Milano, Italy
| | | | - O Pagani
- Institute of Oncology Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - A H Partridge
- Breast Oncology Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - K Pritchard
- Sunnybrook Odette Cancer Center, University of Toronto, Toronto, Canada
| | - J Ro
- National Cancer Center, Ilsandong-gu, Goyang-si, Gyeonggi-do, Korea
| | - E J T Rutgers
- Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - F Sedlmayer
- LKH Salzburg, Paracelsus Medical University Clinics, Salzburg, Austria
| | - V Semiglazov
- N.N. Petrov Research Institute of Oncology, St. Petersburg, Russian Federation
| | - Z Shao
- Fudan University Cancer Hospital, Shanghai, China
| | - I Smith
- The Royal Marsden, Sutton, Surrey, UK
| | - M Toi
- Graduate School of Medicine Kyoto University, Sakyo-ku, Kyoto City, Japan
| | - A Tutt
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK
| | - G Viale
- University of Milan, Milan, Italy
- Istituto Europeo di Oncologia, Milan, Italy
| | - T Watanabe
- Hamamatsu Oncology Center, Hamamatsu, Japan
| | | | - B Xu
- National Cancer Center, Chaoyang District, Beijing, China
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Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, Hudis CA, Hwang ES, Kirshner JJ, Morrow M, Salerno KE, Sledge GW, Solin LJ, Spears PA, Whelan TJ, Somerfield MR, Edge SB. Reply to L.B. Marks et al. J Clin Oncol 2017; 35:1258-1259. [PMID: 28068171 DOI: 10.1200/jco.2016.71.3966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Abram Recht
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Elizabeth A Comen
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Richard E Fine
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Gini F Fleming
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Patricia H Hardenbergh
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Alice Y Ho
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Clifford A Hudis
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - E Shelley Hwang
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Jeffrey J Kirshner
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Monica Morrow
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Kilian E Salerno
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - George W Sledge
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Lawrence J Solin
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Patricia A Spears
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Timothy J Whelan
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Mark R Somerfield
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
| | - Stephen B Edge
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Memorial Sloan Kettering Cancer Center, New York, NY; Richard E. Fine, The West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; Alice Y. Ho, Memorial Sloan Kettering Cancer Center, New York, NY; Clifford A. Hudis, American Society of Clinical Oncology, Alexandria, VA; E. Shelley Hwang, Duke University Medical Center, Durham, NC; Jeffrey J. Kirshner, Hematology-Oncology Associates of Central New York, East Syracuse, NY; Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY; Kilian E. Salerno, Roswell Park Cancer Institute, Buffalo, NY; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Patricia A. Spears, North Carolina State University, Raleigh, NC; Timothy J. Whelan, McMaster University, Hamilton, Ontario, Canada; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY
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Swaminath A, Wierzbicki M, Parpia S, Wright JR, Tsakiridis TK, Okawara GS, Kundapur V, Bujold A, Ahmed N, Hirmiz K, Kurien E, Filion E, Gabos Z, Faria S, Louie AV, Owen T, Wai E, Ramchandar K, Chan EK, Julian J, Cline K, Whelan TJ. Canadian Phase III Randomized Trial of Stereotactic Body Radiotherapy Versus Conventionally Hypofractionated Radiotherapy for Stage I, Medically Inoperable Non–Small-Cell Lung Cancer – Rationale and Protocol Design for the Ontario Clinical Oncology Group (OCOG)-LUSTRE Trial. Clin Lung Cancer 2017; 18:250-254. [DOI: 10.1016/j.cllc.2016.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 08/23/2016] [Indexed: 12/27/2022]
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Gillgrass AE, Pond GR, Levine MN, Whelan TJ, Hassell JA, Bane AL. Abstract P4-12-09: The immune response in triple negative breast cancer. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p4-12-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Triple Negative Breast Cancer (TNBC) is often associated with a poor prognosis. However TNBC is a heterogeneous group of tumors and while some patients have a poor prognosis others appear to do well long-term. There are currently no clinical or pathologic tumor features that distinguish poor from good outcome. Some TNBCs have infiltration with immune cells and the degree of this infiltration correlates with prognosis.
Objectives: 1) To comprehensively examine immune factors associated with outcome in a cohort of TNBC patients, and 2) to develop an immune gene signature that can stratify patients into low and high risk groups.
Methods: We profiled RNA from 22 TNBCs (10 who had experienced a recurrence) from our institutional cohort using the PanCancer Immune Profiling Panel from NanoString. This panel consists of an extensive list of 770 genes designed to evaluate the immune microenvironment of tumors. The genes fall into a number of functional categories including; 1. Genes that identify specific immune cells, 2. Cytokines that promote an effective immune response and others that are associated with immunosuppression, 3. Chemokines, which attract immune cells into the tumor, 4. Genes that assess both the activation and inhibition of immune cell function, 5. Genes that identify tumor specific antigens. Analysis was performed in the nSolver Advanced Analysis Program.
Results: Using unsupervised hierarchical clustering of genes that were highly differentially expressed, the tumors were classified into 3 immune groups with distinct clinical outcomes. Group 1 ('Immune Excluded'), consisted of tumors with the lowest levels of expression of the immune markers assessed, suggesting that these tumors have a low or absent immune infiltrate; 7 of 7 patients in this group recurred. Group 2 ('Immune Activated') contains tumors that had the highest levels of anti-tumoral immune cell genes and their activation markers. This we interpret to represent a tumor group with a robust anti-tumor immune response; 0 of the 6 patients in this group recurred. In comparison Group 3 ('Immune Low') had moderate to low levels of expression of the majority of immune genes assessed. This we interpret to represent a group of tumors with limited immune cells present; 3 of 9 patients in this group recurred. Lastly, when comparing scores for immune cells, patients that recurred had lower scores for cytotoxic cells, CD8 T cells, Th1 cells and B cells.
Conclusion: In this pilot study high expression of anti-tumoral immune genes correlated with good outcome, whereas lower/absent expression of these genes correlated with poor outcome. We are currently extending these findings to our entire cohort of 180 TNBC patients.
Citation Format: Gillgrass AE, Pond GR, Levine MN, Whelan TJ, Hassell JA, Bane AL. The immune response in triple negative breast cancer [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 P4-12-09.
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Affiliation(s)
| | - GR Pond
- McMaster University, Hamilton, ON, Canada
| | - MN Levine
- McMaster University, Hamilton, ON, Canada
| | - TJ Whelan
- McMaster University, Hamilton, ON, Canada
| | - JA Hassell
- McMaster University, Hamilton, ON, Canada
| | - AL Bane
- McMaster University, Hamilton, ON, Canada
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Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, Hudis CA, Hwang ES, Kirshner JJ, Morrow M, Salerno KE, Sledge GW, Solin LJ, Spears PA, Whelan TJ, Somerfield MR, Edge SB. Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. J Clin Oncol 2016; 34:4431-4442. [PMID: 27646947 DOI: 10.1200/jco.2016.69.1188] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT). Methods A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data. Recommendations The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.
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Affiliation(s)
- Abram Recht
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth A Comen
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Richard E Fine
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Gini F Fleming
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Patricia H Hardenbergh
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Alice Y Ho
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Clifford A Hudis
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - E Shelley Hwang
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey J Kirshner
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Monica Morrow
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Kilian E Salerno
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - George W Sledge
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence J Solin
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Patricia A Spears
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Timothy J Whelan
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Mark R Somerfield
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Stephen B Edge
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
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Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, Hudis CA, Hwang ES, Kirshner JJ, Morrow M, Salerno KE, Sledge GW, Solin LJ, Spears PA, Whelan TJ, Somerfield MR, Edge SB. Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. Ann Surg Oncol 2016; 24:38-51. [PMID: 27646018 PMCID: PMC5179596 DOI: 10.1245/s10434-016-5558-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Indexed: 12/24/2022]
Abstract
Purpose A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT). Methods A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data. Recommendations The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast. Electronic supplementary material The online version of this article (doi:10.1245/s10434-016-5558-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Richard E Fine
- West Clinic Comprehensive Breast Center, Germantown, TN, USA
| | | | | | - Alice Y Ho
- Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | | | - Timothy J Whelan
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Mark R Somerfield
- American Society of Clinical Oncology, 2318 Mill Road, Suite 800, Alexandria, VA, 22314, USA.
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Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, Hudis CA, Hwang ES, Kirshner JJ, Morrow M, Salerno KE, Sledge GW, Solin LJ, Spears PA, Whelan TJ, Somerfield MR, Edge SB. Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. Pract Radiat Oncol 2016; 6:e219-e234. [PMID: 27659727 DOI: 10.1016/j.prro.2016.08.009] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/12/2016] [Accepted: 08/17/2016] [Indexed: 10/21/2022]
Abstract
A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT). METHODS A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data. RECOMMENDATIONS The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.
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Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | - Alice Y Ho
- Memorial Sloan Kettering Cancer Center, New York
| | | | | | | | | | | | | | | | | | - Timothy J Whelan
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
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Pignol JP, Truong P, Rakovitch E, Sattler MG, Whelan TJ, Olivotto IA. Ten years results of the Canadian breast intensity modulated radiation therapy (IMRT) randomized controlled trial. Radiother Oncol 2016; 121:414-419. [PMID: 27637858 DOI: 10.1016/j.radonc.2016.08.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 08/20/2016] [Accepted: 08/29/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE We report the long-term outcomes in patients enrolled in a multicenter randomized controlled trial comparing Intensity Modulated Radiation Therapy (IMRT) with standard wedge radiotherapy. MATERIALS AND METHODS Trial participants were assessed to compare long-term side effects between treatment arms. The primary endpoint was chronic breast pain assessed by trained observers blinded to treatment allocation. Secondary endpoints included cosmesis and quality of life measures. RESULTS Median follow-up time was 9.8years and 241 patients were available for assessment. There was no significant difference in chronic pain between treatment arms (OR=0.74, range 0.432-1.271). There were also no differences for the secondary endpoints. Univariate and multivariate analyses identified young age (p=0.013) and pain during RT (p<0.001) to be associated with chronic pain. Acute moist desquamation was associated with late subcutaneous fibrosis (p=0.003) and telangiectasia (p=0.039). Pain during RT was associated with a long-term poorer self-assessed cosmetic outcome (p<0.001) and quality of life (p<0.001). CONCLUSIONS Breast IMRT cannot be recommended for all patients to reduce long-term side effects. However, late toxicities were significantly correlated with acute side effects, which are increased in patients having poor dose distribution. Breast IMRT may hence be useful for selected patients.
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Affiliation(s)
- Jean-Philippe Pignol
- Erasmus MC Cancer Institute, Radiation Oncology Department, Rotterdam, The Netherlands.
| | - Pauline Truong
- Vancouver Island Cancer Centre, Radiation Oncology Department, Victoria, Canada
| | - Eileen Rakovitch
- Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences and Radiation Oncology Department, Toronto, Canada
| | - Margriet G Sattler
- Erasmus MC Cancer Institute, Radiation Oncology Department, Rotterdam, The Netherlands
| | - Timothy J Whelan
- Hamilton Health Sciences, Juravinski Cancer Centre, Hamilton, Canada
| | - Ivo A Olivotto
- Tom Baker Cancer Centre, Division of Radiation Oncology, Calgary, Canada
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Chapman JAW, Shepherd LE, Ingle JN, Muss HB, Pritchard KI, Gelmon KA, Whelan TJ, Elliott C, Goss PE. Competing risks of death in women treated with adjuvant aromatase inhibitors for early breast cancer on NCIC CTG MA.27. Breast Cancer Res Treat 2016; 156:343-9. [PMID: 27006189 DOI: 10.1007/s10549-016-3761-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 10/22/2022]
Abstract
Baseline patient and tumor characteristics differentially affected type of death in the MA.17 placebo-controlled letrozole trial where cardiovascular death was not separately identified. The MA.27 trial allowed competing risks analysis of breast cancer (BC), cardiovascular, and other type (OT) of death. MA.27 was a phase III adjuvant breast cancer trial of exemestane versus anastrozole. Effects of baseline patient and tumor characteristics were tested for whether factors were associated with (1) all cause mortality and (2) cause-specific mortality. We also fit step-wise forward cause-specific-adjusted models. 7576 women (median age 64 years; 5417 (72 %) < 70 years and 2159 (28 %) ≥ 70 years) were enrolled and followed for median 4.1 years. The 432 deaths comprised 187 (43 %) BC, 66 (15 %) cardiovascular, and 179 (41 %) OT. Five baseline factors were differentially associated with type of death. Older patients had greater BC (p = 0.03), cardiovascular (p < 0.001), and other types (p < 0.001) of mortality. Patients with pre-existing cardiovascular history had worse cardiovascular mortality (p < 0.001); those with worse ECOG performance status had worse OT mortality (p < 0.001). Patients with T1 tumors (p < 0.001) and progesterone receptor positive had less BC mortality (p < 0.001). Fewer BC deaths occurred with node-negative disease (p < 0.001), estrogen receptor-positive tumors (p = 0.001), and without adjuvant chemotherapy (p = 0.005); worse cardiovascular mortality (p = 0.01), with trastuzumab; worse OT mortality, for non-whites (p = 0.03) and without adjuvant radiotherapy (p = 0.003). Overall, 57 % of deaths in MA.27 AI-treated patients were non-breast cancer related. Baseline patient and tumor characteristics differentially affected type of death with women 70 or older experiencing more non-breast cancer death.
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Affiliation(s)
- Judith-Anne W Chapman
- Canadian Cancer Trials Group (formerly, NCIC Clinical Trials Group), Queen's University, Kingston, ON, Canada.
| | - Lois E Shepherd
- Canadian Cancer Trials Group (formerly, NCIC Clinical Trials Group), Queen's University, Kingston, ON, Canada
| | | | - Hyman B Muss
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | | | - Karen A Gelmon
- British Columbia Cancer Agency, Vancouver Centre, Vancouver, BC, Canada
| | - Timothy J Whelan
- Juravinski Cancer Centre at Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Catherine Elliott
- Canadian Cancer Trials Group (formerly, NCIC Clinical Trials Group), Queen's University, Kingston, ON, Canada
| | - Paul E Goss
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
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Sparano JA, Gray RJ, Makower DF, Pritchard KI, Albain KS, Hayes DF, Geyer CE, Dees EC, Perez EA, Olson JA, Zujewski J, Lively T, Badve SS, Saphner TJ, Wagner LI, Whelan TJ, Ellis MJ, Paik S, Wood WC, Ravdin P, Keane MM, Gomez Moreno HL, Reddy PS, Goggins TF, Mayer IA, Brufsky AM, Toppmeyer DL, Kaklamani VG, Atkins JN, Berenberg JL, Sledge GW. Prospective Validation of a 21-Gene Expression Assay in Breast Cancer. N Engl J Med 2015; 373:2005-14. [PMID: 26412349 PMCID: PMC4701034 DOI: 10.1056/nejmoa1510764] [Citation(s) in RCA: 931] [Impact Index Per Article: 103.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prior studies with the use of a prospective-retrospective design including archival tumor samples have shown that gene-expression assays provide clinically useful prognostic information. However, a prospectively conducted study in a uniformly treated population provides the highest level of evidence supporting the clinical validity and usefulness of a biomarker. METHODS We performed a prospective trial involving women with hormone-receptor-positive, human epidermal growth factor receptor type 2 (HER2)-negative, axillary node-negative breast cancer with tumors of 1.1 to 5.0 cm in the greatest dimension (or 0.6 to 1.0 cm in the greatest dimension and intermediate or high tumor grade) who met established guidelines for the consideration of adjuvant chemotherapy on the basis of clinicopathologic features. A reverse-transcriptase-polymerase-chain-reaction assay of 21 genes was performed on the paraffin-embedded tumor tissue, and the results were used to calculate a score indicating the risk of breast-cancer recurrence; patients were assigned to receive endocrine therapy without chemotherapy if they had a recurrence score of 0 to 10, indicating a very low risk of recurrence (on a scale of 0 to 100, with higher scores indicating a greater risk of recurrence). RESULTS Of the 10,253 eligible women enrolled, 1626 women (15.9%) who had a recurrence score of 0 to 10 were assigned to receive endocrine therapy alone without chemotherapy. At 5 years, in this patient population, the rate of invasive disease-free survival was 93.8% (95% confidence interval [CI], 92.4 to 94.9), the rate of freedom from recurrence of breast cancer at a distant site was 99.3% (95% CI, 98.7 to 99.6), the rate of freedom from recurrence of breast cancer at a distant or local-regional site was 98.7% (95% CI, 97.9 to 99.2), and the rate of overall survival was 98.0% (95% CI, 97.1 to 98.6). CONCLUSIONS Among patients with hormone-receptor-positive, HER2-negative, axillary node-negative breast cancer who met established guidelines for the recommendation of adjuvant chemotherapy on the basis of clinicopathologic features, those with tumors that had a favorable gene-expression profile had very low rates of recurrence at 5 years with endocrine therapy alone. (Funded by the National Cancer Institute and others; ClinicalTrials.gov number, NCT00310180.).
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Affiliation(s)
- Joseph A Sparano
- From the Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.A.S., D.F.M.); Dana-Farber Cancer Institute, Boston (R.J.G.); Sunnybrook Research Institute, Toronto (K.I.P.) and Juravinski Cancer Center, Hamilton, ON (T.J.W.) - both in Canada; Loyola University Medical Center, Maywood (K.S.A.), and Northwestern University, Chicago (L.I.W., V.G.K.) - both in Illinois; University of Michigan, Ann Arbor (D.F.H.); Virginia Commonwealth University School of Medicine and the Massey Cancer Center, Richmond (C.E.G.); University of North Carolina, Chapel Hill (E.C.D.), Duke University Medical Center, Durham (J.A.O.), Wake Forest University Health Service, Winston-Salem (L.I.W.), and Southeast Clinical Oncology Research Consortium, Goldsboro (J.N.A.) - all in North Carolina; Mayo Clinic, Jacksonville, FL (E.A.P.); University of Maryland School of Medicine, Baltimore (J.A.O.), and National Institutes of Health, Bethesda (J.Z., T.L.) - both in Maryland; Indiana University School of Medicine (S.S.B.) and Indiana University Hospital (G.W.S.) - both in Indianapolis; Vince Lombardi Cancer Clinic, Two Rivers (T.J.S.), and Fox Valley Hematology and Oncology, Appleton (T.F.G.) - both in Wisconsin; Baylor College of Medicine, Houston (M.J.E.), and University of Texas, San Antonio (P.R.) - both in Texas; Washington University, St. Louis (M.J.E.); Allegheny General Hospital (S.P.) and University of Pittsburgh (A.M.B.) - both in Pittsburgh; the Department of Medical Oncology and Breast Center, Yonsei University College of Medicine, Seoul, South Korea (S.P.); Emory University, Atlanta (W.C.W.); Irish Clinical Oncology Research Group, Dublin (M.M.K.); Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru (H.L.G.M.); Cancer Center of Kansas, Wichita (P.S.R.); Vanderbilt University, Nashville (I.A.M.); Rutgers Cancer Institute of New Jersey, New Brunswick (D.L.T.); University of Hawaii Cancer Center, Honolulu (J.L.B.); and Stanford University, Stanford, CA (G.W.S.)
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