A phase II feasibility study of palbociclib in combination with adjuvant endocrine therapy for hormone receptor-positive invasive breast carcinoma

BACKGROUND

The CDK4/6 inhibitor palbociclib prolongs progression-free survival in hormone receptor-positive/HER2-negative (HR+/HER2-) metastatic breast cancer when combined with endocrine therapy. This phase II trial was designed to determine the feasibility of adjuvant palbociclib and endocrine therapy for early breast cancer.

PATIENTS AND METHODS

Eligible patients with HR+/HER2- stage II-III breast cancer received 2 years of palbociclib at 125 mg daily, 3 weeks on/1 week off, with endocrine therapy. The primary end point was discontinuation from palbociclib due to toxicity, non-adherence, or events related to tolerability. A discontinuation rate of 48% or higher would indicate the treatment duration of 2 years was not feasible, and was evaluated under a binomial test using a one-sided α = 0.025.

RESULTS

Overall, 162 patients initiated palbociclib; over half had stage III disease (52%) and most received prior chemotherapy (80%). A total of 102 patients (63%) completed 2 years of palbociclib; 50 patients discontinued early for protocol-related reasons (31%, 95% CI 24% to 39%, P = 0.001), and 10 discontinued due to protocol-unrelated reasons. The cumulative incidence of protocol-related discontinuation was 21% (95% CI 14% to 27%) at 12 months from start of treatment. Rates of palbociclib-related toxicity were congruent with the metastatic experience, and there were no cases of febrile neutropenia. Ninety-one patients (56%) required at least one dose reduction.

CONCLUSION

Adjuvant palbociclib is feasible in early breast cancer, with a high proportion of patients able to complete 2 years of therapy. The safety profile in the adjuvant setting mirrors that observed in metastatic disease, with approximately half of the patients requiring dose-modification. As extended duration adjuvant palbociclib appears feasible and tolerable for most patients, randomized phase III trials are evaluating clinical benefit in this population.

CLINICALTRIALS.GOV REGISTRATION

NCT02040857.

Evaluating the addition of bevacizumab to endocrine therapy as first-line treatment for hormone receptor-positive metastatic breast cancer: a pooled analysis from the LEA (GEICAM/2006-11_GBG51) and CALGB 40503 (Alliance) trials

BACKGROUND

Randomised trials comparing the efficacy of standard endocrine therapy (ET) versus experimental ET + bevacizumab (Bev) in 1st line hormone receptor-positive patients with metastatic breast cancer have thus far shown conflicting results.

PATIENTS AND METHODS

We pooled data from two similar phase III randomised trials of ET ± Bev (LEA and Cancer and Leukemia Group B 40503) to increase precision in estimating treatment effect. Primary end-point was progression-free survival (PFS). Secondary end-points were overall survival (OS), objective response rate (ORR), clinical benefit rate (CBR) and safety. Exploratory analyses were performed within subgroups defined by patients with recurrent disease, de novo disease, prior endocrine sensitivity or resistance and reported grades III-IV hypertension and proteinuria.

RESULTS

The pooled sample consisted of 749 patients randomised to ET or ET + Bev. Median PFS was 14.3 months for ET versus 19 months for ET + Bev (unadjusted hazard ratio [HR] 0.77; 95% confidence interval [CI] 0.66-0.91; p < 0.01). ORR and CBR with ET and ET + Bev were 40 versus 61% (p < 0.01) and 64 versus 77% (p < 0.01), respectively. There was no difference in OS (HR 0.96; 95% CI 0.77-1.18; p = 0.68). PFS was superior for ET + Bev for endocrine-sensitive patients (HR 0.68; 95% CI 0.53-0.89; p = 0.004). Grade III-IV hypertension (2.2 versus 20.1%), proteinuria (0 versus 9.3%), cardiovascular (0.5 versus 4.2%) and liver events (0 versus 2.9%) were significantly higher for ET + Bev (all p < 0.01). Hypertension and proteinuria were not predictors of efficacy (interaction test p = 0.33).

CONCLUSION

The addition of Bev to ET increased PFS overall and in endocrine-sensitive patients but not OS at the expense of significant additional toxicity.

TRIALS REGISTRATION

ClinicalTrial.Gov NCT00545077 and NCT00601900.

The immune profile of small HER2-positive breast cancers: a secondary analysis from the APT trial

BACKGROUND

Previous data suggest that the immune microenvironment plays a critical role in human epidermal growth factor receptor 2 (HER2) -positive breast cancer; however, there is little known about the immune profiles of small HER2-positive tumors. In this study, we aimed to characterize the immune microenvironment of small HER2-positive breast cancers included in the Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer (APT) trial and to correlate the immune markers with pathological and molecular tumor characteristics.

PATIENTS AND METHODS

The APT trial was a multicenter, single-arm, phase II study of paclitaxel and trastuzumab in patients with node-negative HER2-positive breast cancer. The study included 406 patients with HER2-positive, node-negative breast cancer, measuring up to 3 cm. Exploratory analysis of tumor infiltrating lymphocytes (TIL), programmed death-ligand 1 (PD-L1) expression (by immunohistochemistry), and immune gene signatures using data generated by nCounter PanCancer Pathways Panel (NanoString Technologies, Seattle, WA), and their association with pathological and molecular characteristics was carried out.

RESULTS

Of the 406 patients, 328 (81%) had at least one immune assay carried out: 284 cases were evaluated for TIL, 266 for PD-L1, and 213 for immune gene signatures. High TIL (≥60%) were seen with greater frequency in hormone-receptor (HR) negative, histological grades 2 and 3, as well in HER2-enriched and basal-like tumors. Lower stromal PD-L1 (≤1%) expression was seen with greater frequency in HR-positive, histological grade 1, and in luminal tumors. Both TIL and stromal PD-L1 were positively correlated with 10 immune cell signatures, including Th1 and B cell signatures. Luminal B tumors were negatively correlated with those signatures. Significant correlation was seen among these immune markers; however, the magnitude of correlation did not indicate a monotonic relationship between them.

CONCLUSION

Immune profiles of small HER2-positive breast cancers differ according to HR status, histological grade, and molecular subtype. Further work is needed to explore the implication of these findings on disease outcome.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT00542451.

Overall survival and updated progression-free survival outcomes in a randomized phase II study of combination cediranib and olaparib versus olaparib in relapsed platinum-sensitive ovarian cancer

BACKGROUND

Olaparib is a poly(ADP-ribose) polymerase inhibitor and cediranib is an oral anti-angiogenic. In the primary analysis of this phase II study, combination cediranib/olaparib improved progression-free survival (PFS) compared with olaparib alone in relapsed platinum-sensitive ovarian cancer. This updated analysis was conducted to characterize overall survival (OS) and update PFS outcomes.

PATIENTS AND METHODS

Ninety patients were enrolled to this randomized, open-label, phase II study between October 2011 and June 2013 across nine United States-based academic centers. Data cut-off was 21 December 2016, with a median follow-up of 46 months. Participants had relapsed platinum-sensitive ovarian cancer of high-grade serous or endometrioid histology or had a deleterious germline BRCA1/2 mutation (gBRCAm). Participants were randomized to receive olaparib capsules 400 mg twice daily or cediranib 30 mg daily and olaparib capsules 200 mg twice daily until disease progression.

RESULTS

In this updated analysis, median PFS remained significantly longer with cediranib/olaparib compared with olaparib alone (16.5 versus 8.2 months, hazard ratio 0.50; P = 0.007). Subset analyses within stratum defined by BRCA status demonstrated statistically significant improvement in PFS (23.7 versus 5.7 months, P = 0.002) and OS (37.8 versus 23.0 months, P = 0.047) in gBRCA wild-type/unknown patients, although OS was not statistically different in the overall study population (44.2 versus 33.3 months, hazard ratio 0.64; P = 0.11). PFS and OS appeared similar between the two arms in gBRCAm patients. The most common CTCAE grade 3/4 adverse events with cediranib/olaparib remained fatigue, diarrhea, and hypertension.

CONCLUSIONS

Combination cediranib/olaparib significantly extends PFS compared with olaparib alone in relapsed platinum-sensitive ovarian cancer. Subset analyses suggest this margin of benefit is driven by PFS prolongation in patients without gBRCAm. OS was also significantly increased by the cediranib/olaparib combination in this subset of patients. Additional studies of this combination are ongoing and should incorporate analyses based upon BRCA status.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT0111648.

Abstract OT2-04-01: An open label, phase II trial of continuous low-irradiance photodynamic therapy (CLIPT) using verteporfin for the treatment of cutaneous breast cancer metastases

Background

Cutaneous metastases occur in approximately 20% of patients (pts) with metastatic breast cancer (mBC) and can be highly symptomatic and distressing. Radiation therapy is frequently used, but progression often occurs quickly. Systemic therapies are also typically used, but also often result in limited benefit. Photodynamic therapy is a promising approach with encouraging results in small studies. Here we will evaluate a novel Continuous Low-Irradiance Photodynamic Therapy (CLIPT) system that emits 690nm LED via a handheld Power Pack attached to a single-use sterile Light Patch to deliver a total energy level of 20J/cm2. Verteporfin (Visudyne®) is a photosensitizer approved for ophthalmological use that, when combined with CLIPT, generates activated oxygen species which can destroy tumor cells with limited normal tissue reaction.

Methods

This open label, Phase 2 study will evaluate the efficacy and safety of CLIPT with verteporfin in 15 patients with cutaneous lesions from mBC. Patients will receive a single IV injection of Verteporfin on day 1. The 9x9cm Light Patch with an adhesive border is placed over the treatment site and attached to the CLIPT portable Power Pack. The patient turns the device on at home 6 hours after the Verteprofin injection and it automatically turns off after 24 hours. The patient then removes the Light Patch and returns to clinic on day 3. The primary endpoint is objective response rate (RR) at 3 weeks following CLIPT using a modified RECIST which accounts for nodular or diffuse plaque-like lesions. Response will be confirmed by independent dermatologist review. Secondary endpoints include RR at 2, 8 and 12 weeks, toxicity, and quality of life (using FACT-B and Brief Pain Inventory). A novel Participant Symptom Scale (PSS) will also be used in which the first 8 patients will list their most distressing symptoms from cutaneous metastases and score the severity of the symptoms from 1 to 10. The six most common symptoms among the first 8 patients will then be used in the PSS for the remaining 7 patients. The PSS will be assessed at baseline and at subsequent visits to explore any improvement in severity of symptoms after treatment with CLIPT. Patients who derive clinical benefit may be retreated up to 3 times to the same or different region. Eligible patients will have: cutaneous metastases from mBC with measurable disease by protocol defined modified RECIST 1.1, ≥ 1 line of prior systemic or local therapy for mBC, ≥ 14 days from prior systemic therapy or 60 days from radiation to target lesion, and no expectation for systemic therapy for ≥ 14 days after CLIPT. RR will be reported with 95% CI. With 15 patients, if ≥ 3 responses (RR ≥ 20%) are observed, the null hypothesis of RR ≤ 5% will be rejected. At the time of abstract submission, 4 patients have been accrued. Clinical Trials Reg: NCT02939274

Citation Format: Isakoff SJ, Rogers GS, Hill S, McMullen P, Habin KR, Chen ST, Bartenstein DW, Barry W, Overmoyer BA. An open label, phase II trial of continuous low-irradiance photodynamic therapy (CLIPT) using verteporfin for the treatment of cutaneous breast cancer metastases [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-04-01.

Abstract OT3-05-08: PALLAS: PALbociclib CoLlaborative Adjuvant Study: A randomized phase 3 trial of palbociclib with standard adjuvant endocrine therapy versus standard adjuvant endocrine therapy alone for HR+/HER2- early breast cancer

Background:

Cell cycle inhibition is a proven target for novel cancer therapeutics. Palbociclib (P) is an orally active inhibitor of CDK4/6, and arrests the cell cycle at the G1-S transition. P in combination with endocrine therapy (ET) has demonstrated efficacy in phase II and III randomized trials for patients with newly diagnosed and recurrent hormone receptor positive/HER2 negative (HR+/HER2-) metastatic breast cancer (MBC), and is approved in these settings. Given confirmed benefits of P and ET for MBC, the PALLAS study was designed to determine if the addition of P to adjuvant ET improves outcomes over ET alone in HR+/HER2- early breast cancer.

Trial Design:

PALLAS is an international open-label phase III trial randomizing (1:1) patients (pts) to 2 years of P (125 mg daily, 21 days on 7 days off in a 28-day cycle) combined with at least 5 years of provider choice ET (AI, tamoxifen, +/- LHRH agonist), versus ET alone. The primary objective of the study is to compare invasive disease-free survival (iDFS) for the combination of P and ET, versus ET alone. Secondary objectives include comparison of iDFS excluding cancer of non-breast origin, DRFS, LRRFS, OS, as well as safety. The principal objective of the translational investigations is to determine the predictive or prognostic utility of defined genomic subgroups with respect to iDFS and OS. Additional objectives include evaluation of cfDNA and tissue biomarkers predictive of benefit or resistance, pharmacogenomics, adherence, and patient-reported QOL. Eligible pts are pre- or post-menopausal women or men with stage II-III, HR+/HER2- breast cancer. Patients may have already initiated ET, but must be randomized within 12 months of diagnosis and 6 months of initiation of adjuvant ET. Trial sample size is 4600 pts and stage IIA pts will be capped at a total accrual of 1000 pts. Interim analyses for safety, futility/efficacy and sample size re-estimation are planned. PALLAS opened in 9/2015 and accrual is ongoing. Contact information: emayer@partners.org

Key words: palbociclib, CDK4/6 inhibition, HR+/HER2- early breast cancer, adjuvant endocrine therapy.

Citation Format: Mayer E, DeMichele A, Gnant M, Barry W, Pfeiler G, Metzger O, Burstein H, Miller K, Rastogi P, Loibl S, Goulioti T, Zardavas D, Fesl C, Koehler M, Huang-Bartlett C, Huang X, Piccart M, Winer E, Wolff A. PALLAS: PALbociclib CoLlaborative Adjuvant Study: A randomized phase 3 trial of palbociclib with standard adjuvant endocrine therapy versus standard adjuvant endocrine therapy alone for HR+/HER2- early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-05-08.

Abstract OT1-02-02: A phase II study of pembrolizumab in combination with palliative radiotherapy for metastatic hormone receptor positive breast cancer

BACKGROUND: Despite recent advances in the treatment of patients with metastatic hormone receptor positive (HR+)/HER2- breast cancer (BC), it remains an incurable disease. The activity of immune checkpoint inhibitors (ICI) as monotherapy in patients with metastatic HR+/HER2- BC has been limited. Therefore, the addition of other strategies that elicit an immunogenic tumor microenvironment may be needed. We hypothesize that radiation therapy (RT) will potentiate the efficacy of the PD-1 inhibitor pembrolizumab in patients with metastatic HR+/HER2- BC. METHODS: Trial Design: This is a phase II single arm study assessing objective response rate (ORR) according to RECIST 1.1 in patients with metastatic HR+/HER2- BC who will receive pembrolizumab in combination with palliative RT. Pembrolizumab 200 mg intravenously will be administered 2-7 days before day 1 of RT, and will be given every 21 days until disease progression. Biopsies will be performed in the same lesion at baseline (mandatory if tumor tissue is accessible outside the field of RT) and during cycle 2 within 7-14 days before the day 1 of cycle 3 of pembrolizumab. Key Eligibility Criteria: Patients with metastatic HR+/HER2- BC, with measurable disease outside the field of radiation, for whom palliative RT to at least one bone, lymph node, or soft tissue lesion is indicated. Radiation of visceral lesions (such as lung or hepatic lesions) is not permitted. Although prior RT is allowed, patients must be at least 3 months free from RT; Re-irradiation of the same field is not allowed. There is no limit to the number of previous treatments, and systemic treatment naive patients for metastatic disease are also eligible. Specific Aims: The primary aim is to evaluate the efficacy of the combination, as defined by objective response rate (ORR) outside the field of RT according to RECIST 1.1. Secondary objectives include to determine the ORR according to immune-related criteria, the progression-free survival, the abscopal response rate, the clinical benefit rate, the safety and the tolerability of the combination. In addition, correlative studies will be performed to explore the correlation of immunosuppressive and/or immune-stimulating immune marker profiles at baseline and after cycle 2 to disease response to therapy. Statistical Methods: Using the Simons “optimal” method, in the first stage, 8 patients will be enrolled. If there is at least 1 response, accrual will continue to the second stage where up to 19 additional patients will be enrolled. If at least 3 of these 27 patients have an objective response (≥10%), the regimen will be considered worthy of further study. With this design, the probability of stopping the trial early is 78% if the true response rate is 3%. If the true response rate is 20% the chance that the regimen is declared worthy of further study is 80%. Patient accrual and target accrual: The trial opened in April/2017, and so far, has accrued 2 patients with a target accrual of 27 patients. Accrual should be complete in 14-25 months. Clinical trial information: NCT03051672.

Citation Format: Barroso-Sousa R, Gao H, Barry WT, Krop IE, Schoenfeld JD, Tolaney SM. A phase II study of pembrolizumab in combination with palliative radiotherapy for metastatic hormone receptor positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-02-02.

Abstract PD6-09: The immune microenvironment in hormone receptor-positive breast cancer patients and relationship to treatment outcome following preoperative chemotherapy plus bevacizumab

Background: Hormone receptor-positive (HR+) tumors have fewer tumor-infiltrating lymphocytes (TILs) and lower response rates to immune checkpoint inhibitors (ICI), either as single agents or in combination with chemotherapy, than triple negative cancers. However, some HR+ cancers do respond to ICI and biomarkers that accurately reflect the immune microenvironment may help guide the use of ICI therapy. Prior evidence suggests that macrophage-related immune pathways may be relevant to the pathophysiology of HR+ BC.

Methods: HR+/HER2- patients were identified from a prospective trial of preoperative bevacizumab (preop bev) followed by bev with adriamycin/cyclophosphamide/paclitaxel dose-dense chemotherapy (chemo). Tumor samples were collected at diagnosis and surgery (pre-tx and post-tx), and PD-L1 expression (by immunohistochemistry), TILs, and Nanostring PanCancer Immune Profiling Panel were evaluated on both pre-tx and post-tx specimens. Pre-tx whole transcriptome sequencing was performed. Pathologic response at surgery was centrally assessed by Miller-Payne (MP) and residual cancer burden (RCB) scores. An immune score was calculated for each pre-tx specimen by integrating 10 published immune signatures. Immune cell subsets were inferred from bulk transcriptional data using CIBERSORT and immune cell-specific signatures from MSigDB.

Results: 55 patients who received trial therapy and had at least 1 evaluable specimen were included for analysis. Pre-tx TILs and tumor PD-L1 (tPD-L1) scores are shown in the table. 18% of pre-tx tumors had “high” (≥10%) TILs and “high” TILs were associated with significantly higher immune signature score (p=0.004). Immune score correlated highly with proportion of CIBERSORT anti-tumor M1 macrophages as well as CD8 T-cell signatures (r&gt;0.65 and p&lt;0.001). Higher pre-tx TILs, tPD-L1, or immune score were each significantly associated with more favorable RCB and MP in unadjusted analyses (all Spearman p&lt;0.01 for pathologic markers; ANOVA p&lt;0.04 for immune score). After adjustment for age and tumor grade, higher pre-tx TILs and tPD-L1 were associated with favorable RCB (p&lt;0.01 for both), and higher pre-tx tPD-L1 correlated with favorable MP (p=0.03). Pathologic complete response occurred in 4 pts; all 4 had high pre-tx TILs, pre-tx tPD-L1, or both. Among patients with residual disease, large changes (&gt;5%) in TILs or tPD-L1 from pre-tx to post-tx were rare: 2 pts each had large changes in TIL or tPD-L1 score (N=38/N=31 pairs, respectively).

Conclusions: High levels of tumor-lymphocyte interaction were seen in only a minority of untreated HR+ breast tumors, and did not typically change with chemo plus bev. An immune score derived from bulk RNAseq correlated with histological observations in these specimens. Nonetheless, TILs, tPD-L1, and signature-derived immune score were significantly associated with pathologic response to preop treatment in HR+ disease. Early data suggest that the role of M1 macrophages in HR+ tumors warrants further investigation.

ScoreTILs (N=50 evaluable)Tumor PD-L1 (N=51)0%0 pts (0%)28 pts (55%)&gt;0-5% (low)19 (38%)18 (35%)&gt;5-10% (intermediate)22 (44%)3 (6%)&gt;10% (high)9 (18%)2 (4%)

Citation Format: Waks AG, Stover DG, Barry W, Dillon D, Gjini E, Rodig SJ, Brock J, Baltay M, Savoie J, Winer EP, Krop I, Tolaney SM. The immune microenvironment in hormone receptor-positive breast cancer patients and relationship to treatment outcome following preoperative chemotherapy plus bevacizumab [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD6-09.

Abstract P1-07-04: Physical activity, weight and outcomes in patients receiving first-line chemotherapy for metastatic breast cancer: Results from CALGB 40502 (Alliance)

Background: Obesity and inactivity are associated with an increased risk of cancer-related and overall mortality in women with early-stage breast cancer, but there are few data in advanced breast cancer.

Methods: C40502 was a Phase III trial of first-line chemotherapy for patients with metastatic breast cancer (MBC). Participants were randomized to weekly paclitaxel, nab-paclitaxel or ixabepilone. Height and weight at the time of study enrollment were abstracted from medical records. After study activation, the protocol was amended to collect physical activity (PA) data. Participants completed the Nurses' Health Study Exercise Questionnaire, indicating the frequency, type and duration of recreational PA in which they engaged at study enrollment. Metabolic equivalent (MET)-hours of weekly PA (MET-hrs/wk) were calculated using the Ainsworth Compendium. PA was dichotomized to 0-9 or 9+ MET-hrs/wk based on data in early stage breast cancer suggesting that women who engaged in &gt; 9 MET-hrs of PA/wk had lower cancer-specific mortality. Association with clinical endpoints was evaluated using multivariate Cox proportional hazard models adjusting for treatment assignment, age, tumor hormone-receptor status, prior taxane use, disease-free interval and visceral metastases.

Results: 799 patients enrolled in C40502 between 2008 and 2011. Baseline body mass index (BMI) was available for 792 patients and PA data for 500 participants. Median follow up was 60 months. Median age was 56.7 years; 72% of patients had hormone receptor (HR)-positive cancers. Median BMI was 28.6 kg/m2 (IQR: 24.7-33.1 kg/m2). Patients engaged in a median of 3.3 MET-hrs/wk of PA (about 1 hour of moderate-intensity PA/wk) (IQR: 0.7-12.7 MET-hrs/wk). Neither BMI nor PA was significantly associated with progression-free (PFS) or overall survival (OS).

BMI and OutcomesBMI (kg/m2)N (%)PFS (months)Adj HRP valueOS (months)Adj HRP value18.5-24.9209 (26.4)10.0 (9.1-11.2)ref0.4826.1 (23.3-33.2)ref0.5425-29.9248 (31.3)9.0 (7.6-10.3)1.00 (0.83-1.22) 22.0 (20.0-25.4)1.05 (0.85-1.30) ≥30335 (42.3)8.7 (7.7-9.7)0.97 (0.81-1.17) 25.5 (23.1-29.5)0.95 (0.78-1.16) 

PA and OutcomesPA (MET-hrs/wk)N (%)PFS (months)Adj HRP valueOS (months)Adj HRP value0-9344 (68.8)7.9 (7.4-9.2)ref0.1323.6 (20.1-26.8)ref0.21&gt;9156 (31.2)9.8 (8.9-12.0)0.86 (0.71-1.05) 27.4 (22.3-35.6)0.87 (0.70-1.08) 

There was a trend toward longer PFS and OS in patients who reported PA &gt; 9 MET-hrs/wk vs 0-9 MET-hrs/wk, especially in individuals with HR+ cancers (median PFS 11.7 vs 9.2 months [adj HR = 0.84 (0.66-1.05)] and OS 34.0 vs 26.5 months [adj HR = 0.83 (0.66-1.05)] with PA &gt;9 vs 0- 9 MET-hrs/wk).

Conclusions: In some of the first data looking at the relationship between lifestyle factors and outcomes in MBC, there was no relationship between BMI and PFS or OS in patients receiving first-line chemotherapy for advanced disease. A trend toward improved PFS and OS was seen in multivariate analysis in patients who reported higher levels of PA, but results were not statistically significant and could have been influenced by other patient factors. More information is needed regarding the relationship between PA and cancer outcomes, especially in patients with HR+ cancers.

Citation Format: Ligibel JA, Huebner LJ, Rugo HS, Burstein H, Toppmeyer DL, Anders CK, Ma C, Hudis CA, Winer EP, Barry WT. Physical activity, weight and outcomes in patients receiving first-line chemotherapy for metastatic breast cancer: Results from CALGB 40502 (Alliance) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-04.

Abstract P2-01-01: Trajectory patterns of circulating tumor cells (CTC) in chemotherapy-treated metastatic breast cancer (MBC) patients predict poor clinical outcomes: CALGB 40502 (Alliance)/NCCTG N063H study

Little is known about the dynamics of CTCs during treatment and its clinical significance. We examined the predictive utility of serial CTC analysis in ER+HER2- MBC patients (pts) treated with chemotherapy in the CALGB 40502/NCCTG N063H study, a randomized phase III trial of weekly paclitaxel compared to weekly nanoparticle albumin bound nab-paclitaxel or ixabepilone +/- bevacizumab as first-line therapy (ClinicalTrials.gov Identifier: NCT00785291, Support: U10CA180821, U10CA180882).

Methods: Of the 783 pts treated, 469 had ≥3 serial blood samples (including baseline) successfully analyzed for CTCs by CellSearch® and were included in this analysis (n=2,202). Samples with ≥5 CTCs per 7.5 mLs of blood were considered CTC+. The prognostic and predictive performance of baseline CTCs (bCTC) and CTC status from baseline to cycle 2 (b2CTC) were compared to a novel latent mixture model classification based on trajectory of CTCs (tCTC). Akaike Information Criterion (AIC) was used to select the model (bCTC vs b2CTC vs tCTC) that best predicts overall survival (OS), progression-free survival (PFS), and time-to-treatment failure (TTF).

Results: 53% of the pts were CTC+ at baseline. b2CTC status changed in 36% of the pts, most of whom were CTC+CTC- (35%), and very few CTC-CTC+ (1%); the rest of the pts did not experience a change in b2CTC status (46% CTC-CTC- and 19% CTC+CTC+). Mixture model analysis revealed 4 groups of pts that show distinct tCTC patterns over the course of treatment: consitently very low/undectectable CTCs (tCTCneg, 56%), low (tCTClo, 24%), intermediate (tCTCmid, 15%), or high (tCTChi, 5%). bCTC, b2CTC, and tCTC were significantly correlated with tumor subtype (all p &lt;0.0022) and presence of bone metastasis (all p &lt;0.0001). Multivariate analysis showed that pts who were CTC+ at baseline, and those whose b2CTC status remained positive (CTC+CTC+) had significantly reduced OS, PFS and TTF.

 OSPFSTTFModelsHR (95% CI)p-valueHR (95% CI)p-valueHR (95% CI)p-valuebCTC (vs CTC-)      → CTC+2.5(1.8-3.3)&lt;0.00011.6(1.3-2.0)&lt;0.00011.3(1.1-1.6)0.0046b2CTC (vs CTC+CTC-)      → CTC-CTC+1.6(0.5-5.4)0.41491.6(0.6-4.5)0.39051.6(0.6-4.3)0.3961→ CTC+CTC+2.7(1.9-3.8)&lt;0.00011.8(1.4-2.5)&lt;0.00011.8(1.3-2.4)&lt;0.0001→ CTC-CTC-0.5(0.4-0.8)0.00020.8(0.6-0.9)0.01600.9(0.7-1.1)0.2771tCTC (vs tCTCneg)      → tCTClo2.6(1.9-3.7)&lt;0.00011.9(1.4-2.4)&lt;0.00010.9(0.7-1.1)0.0033→ tCTCmid5.3(3.6-8.0)&lt;0.00012.5(1.8-3.4)&lt;0.00011.8(1.4-2.5)0.0001→ tCTChi10.8(6.1-19)&lt;0.00013.0(1.8-5.0)&lt;0.00012.3(1.4-3.7)0.0009CTC- (&lt;5 CTCs per 7.5 mLs); CTC+ (≥5 CTCs per 7.5 mLs)

Pts with tCTClo, tCTCmid and tCTChi had significantly shorter OS, PFS and TTF compared to those with tCTCneg. After adjustment for potential confounders, AIC analysis revealed that the tCTC model best predicts OS and PFS, while b2CTC best predicts TTF.

 AIC Score*ModelsOSPFSTTFbCTC243240514199b2CTC240540384186tCTC237940264188*The lowest AIC score indicates the best model.

Conclusions: Analysis of CTC trajectory patterns identified pts with poor outcome who could potentially benefit from more effective treatment. Validation in independent cohorts is warranted to confirm the findings in this study.

Citation Format: Magbanua MJ, Hendrix L, Hyslop T, Barry WT, Winer EP, Hudis C, Toppmeyer D, Burnstein H, Qadir M, Ma C, Scott JH, Park JW, Rugo HS. Trajectory patterns of circulating tumor cells (CTC) in chemotherapy-treated metastatic breast cancer (MBC) patients predict poor clinical outcomes: CALGB 40502 (Alliance)/NCCTG N063H study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-01-01.

Abstract PD5-06: Adjuvant palbociclib plus endocrine therapy for hormone receptor positive/HER2 negative breast cancer: A phase II feasibility study

Background:

The CDK4/6 inhibitor palbociclib (P) combined with endocrine therapy (ET) prolongs progression-free survival in previously untreated and treated hormone receptor positive/HER2 negative (HR+/HER2-) metastatic breast cancer (MBC). The most common toxicity with P is neutropenia, typically non-cumulative and uncomplicated. Given observed benefits of P in metastatic BC, this single arm phase II trial was designed to determine the feasibility and toxicity of combination adjuvant P and ET for HR+/HER2- early BC (EBC).

Methods:

Eligible patients (pts) had HR+/HER2- stage II (not T2N0)-III EBC, with prior completion of 3-24 mo of ET (either AI or tamoxifen) without significant adverse events (AE). Pts received P at 125 mg daily, 3 wk on/1 wk off in a 28d cycle, plus continuous ET, for planned duration 2 yrs. Pts were removed from study for toxicity, non-adherence, or other events related to tolerability; pts who recurred or completed 2 yrs of therapy were censored for the primary endpoint. The primary objective was to evaluate the treatment discontinuation rate at 2 yrs; a rate of &gt;50%, would indicated a non-feasible treatment duration (null hypothesis). Discontinuation rates at 2 yrs are estimated by Kaplan Meier with 95% confidence bands. A sample size of 160 pts provided 92% power to reject the null hypothesis using a one-sided alpha = 0.025 if the true rate of discontinuation is &lt;33.3%, and accounting for a censoring rate of up to 20% over the 2 yrs. Secondary endpoints include toxicity, adherence, QOL, and pharmacogenomics.

Results:

Between 3/2014 and 11/2015, 162 pts initiated P; the majority had stage III EBC (52%) and received prior chemotherapy (63%). As of 05/2017, 120 (74%) have completed at least 1 yr of P + ET, and 50 (31%) have completed 2 yrs of P + ET. Early discontinuation of protocol treatment was reported for 59 pts (36%), including 49 events (30%) related to protocol-mandated (9%) and non-mandated (21%) tolerability. The cumulative rate of all discontinuations was 15.1% at 6 mos, 20.9% at 12 mos and 27.8% at 18 mos. Half of all non-mandated discontinuations occurred within the first 6 mos of initiation of therapy, and the rate decreased with greater provider and pt education. Median duration of pts still on treatment is 20 mos (inter-quartile range: 18 to 21 mos). The rate of grade 3/4 neutropenia was 77%, with 0 cases of febrile neutropenia. Other common all-grade P-related AE &gt; 20% included fatigue 65%, alopecia 25%, mucositis 24%, and anemia 24%. 32% of pts required one dose reduction, 16% required two. There have been 2 BC recurrence events and 1 chemotherapy-related AML. Updated data for the primary analysis of feasibility and tolerability, as well as pharmacogenomics, QOL, and adherence, will be presented.

Conclusions:

In this single arm phase II trial, the majority of pts have completed at least 1 year of adjuvant P + ET therapy, with no new toxicity signals. Non-protocol discontinuations have decreased with education. Updated results for the primary analysis will be presented. As in the MBC setting, extended duration palbociclib appears feasible and tolerable for most pts. The efficacy of 2 years of P and ET will be addressed by the phase III PALLAS trial (NCT NCT02513394).

Citation Format: Mayer EL, DeMichele AM, Guo H, Miller KD, Rugo HS, Schneider B, Waks AG, Come SE, Mulvey T, Huang Bartlett C, Koehler M, Barry W, Winer EP, Burstein HJ. Adjuvant palbociclib plus endocrine therapy for hormone receptor positive/HER2 negative breast cancer: A phase II feasibility study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD5-06.

Abstract P1-07-05: Integrated transcriptional analysis of the triple negative 'proliferation paradox': High proliferation, chemosensitivity, and poor prognosis

Background: In triple-negative breast cancers (TNBC), high proliferation is associated with greater chemosensitivity but, paradoxically, also associated with poor prognosis. We hypothesized that this subset of TNBC has distinct transcriptional features that contribute to poor prognosis.

Approach: To evaluate transcriptional signatures associated with this 'proliferation paradox,' we identified 17 study cohorts of TNBC treated with neoadjuvant chemotherapy (NAC) that reported receptor status, pathologic response, and had expression data from biopsies obtained prior to NAC (n=446). In 6 studies, distant metastasis-free survival (DMFS) data was available for 235 patients with a median follow-up of 31.2 months. We calculated scores for 135 published gene expression signatures for each tumor and evaluated the association with response to chemotherapy and DMFS.

Results: Using recursive partitioning to develop a model of response using a training set (n=340), six of the 135 expression signatures stratify primary tumors into four groups based on signatures of proliferation, BRCA1 mutation, immune, luminal, Ras, and PI3K phenotypes (Table 1.). Response to NAC ranged from 11% to 61% pCR/RCB-I and results were highly concordant when applied to a validation set (n = 106, p = 0.006). The group that was highly proliferative but chemoresistant ('resistant' group) had a distinct transcriptional profile, including lower 'BRCA-ness' and DNA damage expression signatures with higher Ras and stem cell signatures. The 'resistant' group had the poorest DMFS (HR 2.48 [1.52-4.06]; log-rank p=0.002) and this poor survival was validated among chemotherapy-treated TNBCs in a separate dataset, METABRIC. Analyses of only patients with residual disease after NAC demonstrated that the 'resistant' group remained poorest prognosis, with median DMFS of only 31 months from diagnosis.

Conclusions: Using a novel approach to categorize primary TNBC tumors based on six signatures, we can effectively distinguish subgroups with higher versus lower pCR rates. One specific group demonstrated high proliferation but low response to chemotherapy and particularly poor survival. This group demonstrates expression signatures implicating DNA damage repair, stemness, and Ras pathway activity as potential mediators of the phenotype. We identify specific molecular characteristics for investigation in patients within a poor prognosis subgroup of TNBC.

Table 1. Proportion Pathologic Complete Response or RCB-I and Survival Low ProlifHigh Prolif / ResistantHigh Prolif / SensitiveHigh ImmuneSignature StratificationLow GGI + High LuminalHigh GGI + Low BRCA1mut or High RasHigh GGI + High PI3K or Low RasHigh TNBC ImmunepCR/RCB-I rate: Training Set11/105 (10.5%)26/127 (20.5%)42/81 (51.9%)16/27 (59.3%)pCR/RCB-I rate: Validation Set3/23 (13.0%)11/45 (24.4%)13/29 (44.8%)6/9 (66.7%)pCR/RCB-I rate: TOTAL14/128 (10.9%)37/172 (21.5%)55/110 (50.0%)22/36 (61.1%)Overall Survival (n=235)Hazard Ratio (95% CI)1.62 (0.99-2.64)2.48 (1.52-4.06)(ref.)0.47 (0.29-0.77)Signatures GGI (Sotiriou, JNCI 2006); Luminal (Lim, Nat Med 2009); BRCA1 mutation (van't Veer, Nature 2002); Ras (Pratilas, PNAS 2009); PI3K (Gatza, PNAS 2010), TNBC Immune (Lehmann, JCI 2011)

Citation Format: Stover DG, Selfors LM, Winer EP, Partridge AH, Barry WT. Integrated transcriptional analysis of the triple negative 'proliferation paradox': High proliferation, chemosensitivity, and poor prognosis [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 P1-07-05.

Abstract S5-05: Impact of pre-operative exercise on breast cancer gene expression

Background: Exercise is linked to a lower risk of developing and dying from breast cancer, but the biological mechanisms through which exercise could impact breast cancer are unclear. In animal models, exercise impacts tumor formation and progression, but there are few data regarding direct effects of exercise on tumor tissue in humans. The Pre-Operative Health and Body (PreHAB) Study was a randomized window of opportunity trial designed to explore the impact of exercise on molecular pathways in women with breast cancer.

Methods: Inactive women with Stage I-III breast cancer were enrolled through Dana-Farber Cancer Institute and Yale University prior to surgery. Participants were randomized 1:1 to an aerobic and strength training exercise intervention or mind body control intervention and participated in the interventions between enrollment and the time of surgery. Tumor tissue was collected at enrollment and surgery; samples were reviewed by a breast pathologist and were macrodissected to include sections of tumor with at least 10% cellularity. Capture RNA-sequencing of the transcriptome coding regions was performed using the Illumina Truseq RNA access platform.

Results: 49 women were randomized (27 exercise and 22 control). At baseline, mean age was 52.6, BMI was 30.2kg/m2 and exercise was 49 min/wk. Mean time between enrollment and surgery was 4.2 weeks. Participants in the exercise arm significantly increased exercise vs. controls (increase of 203 vs. 23 min/wk, p&lt;0.0001). Transcriptomic analysis was performed on the tumors from the pre and post intervention biopsies from 32 patients (16 exercise and 16 control). Quality Control analysis of the RNA-sequencing data showed an average read depth of 25 million reads per sample, mapping ∼79% to exonic regions. Principal Component Analysis revealed no read bias or batch effects and unsupervised clustering showed that pre- and post-operative samples clustered together by patient. Differential gene expression analysis by DEseq2 revealed a limited number of individual genes with significant changes after the intervention. KEGG pathway analysis, however, of 214 KEGG pathways using the bioconductor package GAGE (Generally Applicable Gene-Set Enrichment for Pathway Analysis) demonstrated upregulation of 13 unique pathways between the baseline biopsy and surgical excision in exercise participants and none in mind body participants (q&lt;0.1). The top ranked upregulated pathway was cytokine-cytokine receptor interactions (q=6.93E-05, set size=238 genes). Il6, CCL3 and other cytokines are among the genes upregulated in this pathway. Analysis also demonstrated downregulation of 13 unique pathways (q&lt;0.1) including cell cycle, RNA transport and DNA replication pathways, in exercise participants over the intervention period.

Conclusions: A pre-operative exercise intervention led to alterations in gene expression in tumor tissue in women with breast cancer. Validation in additional data sets and an analysis of which cellular compartments within the tumor are responsible for the changes is needed. These findings demonstrate that exercise may have a direct effect on breast tumor tissue in humans, providing new insights into the biologic mechanisms through which exercise could lower the risk of developing and dying from breast cancer.

Citation Format: Ligibel JA, Irwin M, Dillon D, Barry W, Giobbie-Hurder A, Frank E, Winer EP, McTiernan A, Cornwell M, Pun M, Brown M, Jeselsohn R. Impact of pre-operative exercise on breast cancer gene expression [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 S5-05.

Abstract OT1-01-09: Feasibility and safety of avoiding granulocyte colony-stimulating factor prophylaxis during the paclitaxel portion of dose dense doxorubicin-cyclophosphamide and paclitaxel regimen

Background: The need for granulocyte-colony stimulating factor (G-CSF) support during dose-dense (DD) paclitaxel (T) after doxorubicin and cyclophosphamide (AC) is unclear. Given that G-CSF is not devoid of adverse effects, and adds significant costs to treatment, we are examining the feasibility and safety of avoiding G-CSF during dose dense T. Methods: This is a single center, single-arm, phase II, two stage study. The primary aim is to evaluate the rate of T treatment completion within 7 weeks (from D1 of cycle 1 to D1 of cycle 4 of T) omitting Pegfilgrastim using pre-specified safety rules. Secondary aims include: characterization of the utilization of Pegfilgrastim using pre-specified safety rules in patients receiving dose dense T; evaluation of the safety of omitting routine Pegfilgrastim support in patients receiving dose dense T; evaluation of total cost ($ United States) of omitting routine Pegfilgrastim use during dose dense T. As a secondary aim we will evaluate the safety of simplifying the pre-medication regimen used for the T portion of the regimen (withholding corticosteroids in cycle 3 and 4 if no evidence of allergic reactions in cycle 1 and 2). A Simon Optimal design was selected with an overall one-side type I error of 10% and 90% power to detect the difference between unacceptable T completion rate (75%) and desirable completion rate (85%). In the first stage, 51 evaluable patients will be enrolled. If during the first stage, at any point, a total of 12 or more patients do not complete treatment within 7 weeks the trial will be closed permanently. Among the 51 patients enrolled after the first stage, if at least 40 patients complete treatment without dose delay, accrual will continue to the second stage where an additional 74 evaluable patients will be enrolled. If there are at least 100 among the 125 evaluable patients completing treatment without dose delay, the regimen will be considered worthy of further study. If during the second stage, at any point, a total of 26 patients do not complete treatment within 7 weeks the trial will be closed permanently and the study intervention will not be of clinical interest. If the true treatment completion rate is 75%, the chance the regimen is declared ineffective is 91% (exact alpha = 0.094) and if the true treatment completion rate is 85% the chance that the regimen is falsely declared ineffective is 10% (exact power = 0.899). The estimated accrual rate is 6-8 patients/month. Accrual started in April 2016. Clinical trial information: NCT02698891.

Citation Format: Barroso-Sousa R, Vaz-Luis I, Guo H, Barry WT, Brackett AM, Brock VA, Roche KA, Kasparian E, Winer EP, Lin NU. Feasibility and safety of avoiding granulocyte colony-stimulating factor prophylaxis during the paclitaxel portion of dose dense doxorubicin-cyclophosphamide and paclitaxel regimen [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 OT1-01-09.

Abstract P1-07-08: Time trends in incidence rates and survival for women with de novo metastatic lobular vs. ductal carcinoma, a population-based study

Background: Survival for metastatic breast cancer (MBC) patients (pts) has modestly improved over time. Until the early 2000's, incidence rates for invasive lobular carcinoma (ILC) had steadily risen, in contrast to the stable rates observed for invasive ductal carcinoma (IDC). Historically, ILC was deemed to have a more favorable prognosis than IDC. Nevertheless, data on recent time trends in incidence and survival of lobular vs. ductal histology among newly diagnosed MBC pts are limited.

Pts and Methods: Using the Surveillance, Epidemiology, and End Results (SEER) 9 registries, we included 10,767 pts diagnosed with de novo lobular or ductal MBC from 1990-2011, and followed through 2012. Time trends in annual age-adjusted incidence rates were analyzed, stratified by histology. Multivariable Cox regression models were fit to investigate the association of year of diagnosis and overall survival (OS) by stratum, adjusting for features presented in Table 1. We examined interactions between year of diagnosis and histology. In sensitivity analyses, we modeled year of diagnosis as categorical, and restricted the cohort to hormone-receptor positive pts.

Table 1IDC N= 9,376 (87%)ILC N= 1,391 (13%)Cohort characteristics%Age, yearsƚ &lt;407240-49151050-59232160-692327≥703240Raceƚ White7585Black1710Other/Unknown85Gradeƚ I410II3027III/IV4914Unknown1749Hormone Receptorƚ +7391-279IncidenceRates (per 100,000/year)Year of diagnosis 19901.650.1320001.540.2120112.170.34SurvivalHR of death (95% CI)*Year of diagnosis 1-year trend0.98(0.98-0.99)1.01(0.99-1.02)5-years trend0.94(0.92-0.96)1.05(0.99-1.11)p&lt;.01 for differences between groups*Adjusted for: cohort characteristics, SEER registry, and marital status

Results: 9,376 (87%) pts had IDC and 1,391 (13%) had ILC. Overall, we found a 1.4 fold increase in incidence rates for de novo MBC over the study period, (with a 1.3- and 2.6-fold increase for IDC and ILC, respectively). OS improved over the study period for the overall cohort (Hazard ratio (HR) of death=0.99; 95% confidence interval (CI)=0.98-0.99; 1% decrease/year; 5% decrease/5 years; p=.0059 for the interaction year of diagnosis-histology on OS). ILC pts had better outcomes than IDC pts (median OS=28 vs. 21 months; adjusted HR of death= 0.93; 95%CI=0.87-0.99). For IDC pts, we found a statistically significant improvement in OS over time (HR of death=0.98; 95%CI=0.98-0.99; 2% decrease/year; 6% decrease/5 years). However, we observed no significant change in survival outcomes for ILC pts (HR of death=1.01; 95%CI=0.99-1.02) (Table 1). Results from sensitivity analyses were similar.

Conclusions: From 1990-2011, incidence rates for de novo MBC increased. In this cohort, ILC pts had a better prognosis than IDC pts. Nevertheless, although we found an expected overall improvement in OS for MBC pts, this effect was restricted to IDC pts, with no significant improvement among ILC pts. Dedicated studies are warranted to understand whether our results can be confirmed in other datasets and to investigate the reasons driving this discrepancy, such as the impact of patterns of care, new drug approvals, and tumor molecular subtype.

Citation Format: Di Meglio A, Freedman RA, Lin NU, Barry WT, Metzger-Filho O, Keating NL, Winer EP, Vaz-Luis I. Time trends in incidence rates and survival for women with de novo metastatic lobular vs. ductal carcinoma, a population-based study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-07-08.

Abstract P1-10-18: Contraception use in young women with breast cancer

Background: Young women with breast cancer need highly effective contraception given the potential implications of unplanned pregnancy for optimal treatment, and the teratogenic risks. We sought to determine the contraceptive methods used by young women after diagnosis (dx) of breast cancer and factors associated with use of less effective methods or no contraceptive method, which confers a 6-90% annual risk of pregnancy in sexually active women in contrast to highly effective methods (risk &lt;1%).

Methods: As part of a randomized trial conducted in 54 sites to test an education and support intervention for young women with breast cancer and their oncologists, we surveyed women about their pre-dx, current, and planned contraceptive use, and about communication with their providers regarding contraception. Women enrolled within 3 months of dx; contraception items were included on 3- and 12-month post-enrollment surveys. Intrauterine device (IUD) use, tubal sterilization, hysterectomy or bilateral salpingo-oophorectomy (hyst/BSO) after dx, or male partner vasectomy were classified as highly effective methods; all other methods and non-use were categorized as less effective. We excluded women not at risk of pregnancy: hyst/BSO prior to dx, or no indication for contraception. We used logistic regression to explore factors associated with use of less effective methods.

Results: Of 424 women who completed the 3-month post-enrollment survey, median age at dx was 39 (range 22-45). 312 women at risk of pregnancy were included in this analysis, including 291 reporting sexual activity with a male partner within the last 6 months, and 21 reporting no recent sexual activity but reporting use of birth control. 123 women (39%) used highly effective contraceptive methods prior to dx; after dx, 161 (52%) reported current use of or a plan to use a highly effective method. 19 women (6%) reported use of a hormonal birth control method since dx; 7 (2%) reported withdrawal as their only contraceptive method; 25 (8%) reported no contraception. 30% of women did not recall a discussion of avoiding pregnancy or need for contraception during treatment with their providers. In multivariable analyses (N=310), desire for additional biologic children (OR 7.54, 95% CI 3.88-14.66) and provider discussion of contraception and pregnancy (OR 2.13 95% CI 1.20-3.78) were associated with use of less effective contraception. Age, race/ethnicity, disease stage, and partner status were not significantly associated with use of less effective methods.

Conclusion: About half of women who are at risk of pregnancy reported use or planned use of less effective contraceptive methods or no method of contraception following dx of breast cancer. Women with breast cancer and their providers may benefit from targeted education on contraceptive options and method effectiveness.

Citation Format: Rosenberg SM, Dutton CR, Ligibel J, Barry W, Ruddy KJ, Sprunck-Harrild K, Emmons KM, Partridge AH. Contraception use in young women with breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-18.

Abstract P3-12-02: Patient prognostic score and survival benefit offered by radiotherapy for ductal carcinoma in situ

Background: In general, radiotherapy (RT) follows breast-conserving surgery (BCS) and remains the standard of care for the surgical management of both invasive carcinoma and ductal carcinoma in situ (DCIS). Although it is associated with better local control, the magnitude of survival benefit conferred by RT for DCIS has not yet been established. We sought to evaluate whether a survival benefit exists with the addition of RT for patients with DCIS and to validate a patient prognostic score to predict survival benefit.

Methods: We performed a retrospective longitudinal cohort study by using the Surveillance Epidemiology and End Results database (SEER 17). Between 1988-2007, we identified 32,144 eligible patients who underwent BCS for DCIS. Using age, year of diagnosis, race, tumor size, hormone receptor status, tumor grade, marital status and SEER region, we calculated propensity score weights to balance clinicopathologic factors between patients receiving only surgery and those receiving surgery and RT. This cohort was divided into seven groups according to the previously validated patient prognostic score proposed by Smith et al. Breast cancer mortality (BCM) was assessed using a log-rank test and a multivariable Cox proportional hazards model.

Results: Of 32,144 cases of DCIS, 20,329 cases (63%) were treated with RT (+RT group) and 11,815 cases (37%) were treated with surgery alone (-RT group). There were 304 breast cancer-specific deaths observed over the follow-up period (median 96 months). The weighted cumulative incidence of BCM at ten-years was 1.8% for the +RT group compared to 2.1% for the -RT group (p= 0.003). The effect of RT on survival differed by nuclear grade (p= 0.007), age (p= 0.004), and tumor size (p=0.02). We found that the survival benefit for the +RT group was significantly greater than for the –RT group in subgroups of patients with higher nuclear grade, younger age, and larger tumor size, whereas a statistical reduction of BCM with RT was not observed among patients without these prognostic factors. Moreover, the magnitude of survival benefit was significantly correlated with the patient prognostic score [p&lt;0.0001, Table].

Conclusion: In this population-based cohort study, the patient prognostic score for DCIS accurately estimated the magnitude of survival benefit offered by radiotherapy after BCS, suggesting that decisions for RT could be tailored based on prognostic score and patient preference. Limitations of this study include unmeasured confounders such as a lack of information about patients' comorbidities, margin status and endocrine therapy, and further external validation is needed to confirm our results.

Patient Prognostic Score and Hazard Ratio (HR) Comparing Mortality between Radiotherapy Group and non-Radiotherapy GroupPatient Prognostic ScoreNumber of patients in -RT groupNumber of patients in +RT groupWeighted HR of BCM95% CIWeighted HR of OM95% CI078213881.20.67 - 2.10.910.76 - 1.11267744801.00.70 - 1.50.880.78 - 0.992410570800.690.51 - 0.940.710.63 - 0.793304854170.730.48 - 1.10.680.58 - 0.81496517010.310.16 - 0.580.420.30 - 0.5852232480.290.09 - 0.910.430.21 - 0.9161515N.A. N.A. Abbreviation: RT, Radiotherapy; BCM, Breast Cancer Mortality; OM, Overall Mortality: N.A., not available

Citation Format: Sagara Y, Freedman RA, Vaz-Luis I, Mallory MA, Wong S, Aydogan F, DeSantis S, Barry WT, Golshan M. Patient prognostic score and survival benefit offered by radiotherapy for ductal carcinoma in situ. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-12-02.

Predicting response and survival in chemotherapy-treated triple-negative breast cancer

BACKGROUND

In this study, we evaluated the ability of gene expression profiles to predict chemotherapy response and survival in triple-negative breast cancer (TNBC).

METHODS

Gene expression and clinical-pathological data were evaluated in five independent cohorts, including three randomised clinical trials for a total of 1055 patients with TNBC, basal-like disease (BLBC) or both. Previously defined intrinsic molecular subtype and a proliferation signature were determined and tested. Each signature was tested using multivariable logistic regression models (for pCR (pathological complete response)) and Cox models (for survival). Within TNBC, interactions between each signature and the basal-like subtype (vs other subtypes) for predicting either pCR or survival were investigated.

RESULTS

Within TNBC, all intrinsic subtypes were identified but BLBC predominated (55-81%). Significant associations between genomic signatures and response and survival after chemotherapy were only identified within BLBC and not within TNBC as a whole. In particular, high expression of a previously identified proliferation signature, or low expression of the luminal A signature, was found independently associated with pCR and improved survival following chemotherapy across different cohorts. Significant interaction tests were only obtained between each signature and the BLBC subtype for prediction of chemotherapy response or survival.

CONCLUSIONS

The proliferation signature predicts response and improved survival after chemotherapy, but only within BLBC. This highlights the clinical implications of TNBC heterogeneity, and suggests that future clinical trials focused on this phenotypic subtype should consider stratifying patients as having BLBC or not.

Impact of delivery models on understanding genomic risk for type 2 diabetes

BACKGROUND

Genetic information, typically communicated in-person by genetic counselors, can be challenging to comprehend; delivery of this information online--as is becoming more common--has the potential of increasing these challenges.

METHODS

To address the impact of the mode of delivery of genomic risk information, 300 individuals were recruited from the general public and randomized to receive genomic risk information for type 2 diabetes mellitus in-person from a board-certified genetic counselor or online through the testing company's website.

RESULTS

Participants were asked to indicate their genomic risk and overall lifetime risk as reported on their test report as well as to interpret their genomic risk (increased, decreased, or same as population). For each question, 59% of participants correctly indicated their risk. Participants who received their results in-person were more likely than those who reviewed their results on-line to correctly interpret their genomic risk (72 vs. 47%, p = 0.0002) and report their actual genomic risk (69 vs. 49%, p = 0.002).

CONCLUSIONS

The delivery of personal genomic risk through a trained health professional resulted in significantly higher comprehension. Therefore, if the online delivery of genomic test results is to become more widespread, further evaluation of this method of communication may be needed to ensure the effective presentation of results to promote comprehension.

Abstract OT2-4-02: Young and strong: A randomized trial to evaluate a program for young women with breast cancer

Young women with newly diagnosed breast cancer face substantial challenges including higher risk of disease recurrence and likelihood of harboring a genetic mutation compared with older women. Many young women are also very concerned about their future fertility and this population often feels isolated from other breast cancer survivors due to their age and life stage. Some worry that their doctors are unsure of how to treat them. To address these issues, we developed a comprehensive program at our institution to coordinate and enhance the care, support, and education for young women with breast cancer. The Young and Strong study is a randomized clinical trial (RCT) to evaluate a virtual, exportable, scalable version of this program designed to improve the quality of care and the psychosocial well-being of this vulnerable population.

The specific aims of this program are:

1) To develop, pilot, and refine an exportable and sustainable educational and support intervention for young women with breast cancer and their oncology providers (Young Women's Intervention; YWI).

2) To determine the effect of the YWI compared to a contact-time control intervention focused on promoting physical activity (Physical Activity Intervention; PAI) on attention to fertility issues in a RCT: “Young and Strong”.

We initially conducted 4 focus groups (n = 36) and 20 key informant interviews, and developed, piloted, and refined the YWI as well as the PAI. Based on this successful work, we launched the Young and Strong study in June 2012 as a cluster-randomized trial at a total of 54 sites (40 community and 14 academic sites across the United States). Randomization is 1:1 between sites, and stratified by practice type (community vs. academic). Each community site will enroll 5-10 participants, each academic site 15 participants. Total recruitment will be 410-610 pts. The primary objective is to evaluate whether YWI, as compared to PAI, is associated with greater attention to fertility issues, assessed via medical record review. In addition, participants will complete assessments at baseline, 3, 6, and 12 months that assess satisfaction with care, psychosocial well-being, physical activity and anthropomorphic changes.

Young and Strong activated in June 2012 and all sites have been identified. As of 6/11/2013 the study has been initiated at 53 out of 54 sites, and total of 282 women have enrolled on the study.

Eligibility Criteria:

1. Women age 18-45 years at diagnosis

2. Stage I-III invasive breast cancer without known recurrence or metastatic disease

3. Newly-diagnosed (within 3 months of initial diagnosis)

4. Have 1st appt. with a medical oncologist at participating site after the site opens to enrollment

5. Able to read and write in English

For further information, contact Ann Partridge, MD, MPH at 888-814-3324.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-4-02.

Abstract P5-14-04: Preoperative single-fraction partial breast radiotherapy – Initial results from a novel phase I dose-escalation protocol with exploration of radiation response biomarkers

Purpose/Objectives(s): Women with biologically favorable early stage breast cancer are increasingly treated with accelerated partial breast techniques. However, many alternative techniques require costly specialized equipment not routinely available in most radiation oncology facilities. In addition, suboptimal cosmetic outcomes have been reported with the external beam technique, possibly related to large post-operative treatment volumes. To address these issues, we designed a phase I dose-escalation protocol to determine the maximally tolerated dose (MTD) of a single radiosurgery treatment delivered preoperatively to the intact tumor plus a small margin.

Materials/Methods: Women aged 55 or older with clinically node negative, ER and/or PR+, HER2-, T1 invasive carcinomas were enrolled (n = 26). Patients with low/intermediate grade in situ disease &lt;2cm were also included (n = 6). Breast MRI was required for target volume delineation. An intensity-modulated treatment plan was designed to deliver 15, 18, or 21Gy in a single fraction. An additional breast MRI, including T1-weighted, T2-weighted, diffusion-weighted and dynamic-contrast enhanced imaging, was obtained prior to lumpectomy which took place within 10 days of radiation treatment. Acute toxicity was assessed 3-4 weeks after radiation and any grade 3/4 toxicity possibly, probably, or definitely related to treatment was considered dose limiting.

Tumor tissue was obtained from diagnostic and lumpectomy specimens. Immunohistochemistry (IHC) for Fas was performed on paraffin-embedded samples before and after radiation. A histoscore was created using the average membrane and cytoplasmic staining intensity multiplied by the percentage of positive cells.

Results: Thirty-two women were treated, 8 each at the 15, 18, and 21Gy dose levels with an additional expansion cohort at the final 21Gy dose level. The maximally tolerated dose was not reached. Three patients required post-operative conventional radiation due to high-risk tumor features (ex. larger primary, nodal involvement).

At a median follow-up of 6.8 months, primarily mild toxicities (grade 1-2 dermatitis, fibrosis, and pain) were noted. At 6 months (n = 20), all reported cosmetic outcomes are excellent or good. At 12 months (n = 10), 80% are excellent or good. Both patients with a fair/poor cosmetic outcome received radiosurgery plus post-operative conventional treatment; one experienced grade 3 breast atrophy. There have been no local or distant recurrences to date.

Post-treatment MRIs were obtained in 20/32 patients, with early indicators of decreased cell density and increased vascular permeability. Sixteen patients had evaluable paired IHC and six demonstrated significant Fas up-regulation after radiation. The mean combined post-treatment histoscore was about twice as high as the mean pre-treatment score.

Conclusion: Preoperative stereotactic radiotherapy to the intact breast tumor can be delivered with widely available clinical tools in a convenient single fraction, and provides a unique opportunity to study breast cancer radiation response. 21Gy did not yield dose-limiting toxicity and will be utilized for future studies.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-14-04.

Abstract P3-06-07: Ki67 as a Predictive Marker of Response to Neoadjuvant Chemotherapy in Patients with Early-Stage Breast Cancer (ESBC): A Systematic Review and Evidence Summary

Background: Immunohistochemical (IHC) assessment of the proportion of cells staining for the KI67 nuclear antigen is being increasing utilized in the management of patients with early-stage breast cancer (ESBC). A comprehensive systematic review and evidence synthesis of biomarkers potentially predictive of response to systemic therapy was initiated as a part of an NCI-funded comparative effectiveness research program.

Methods: Studies of chemotherapy response prediction based on baseline IHC assessment of Ki67 in patients with ESBC receiving neoadjuvant systemic therapy were identified. Response was specified as pathologic complete response (pCR) or clinical response (ClinR). Assay predictive performance for response was assessed on the basis of sensitivity, specificity, predictive value and predictive odds ratio (POR±95%CLs) utilizing mixed effects models. Study results were fitted in an ROC analysis based on the method of DerSimonian and Laird. Publication bias was evaluated on the basis of funnel plot asymmetry assessed by Egger's regression intercept and Begg and Mazumdar's rank correlation.

Results: Of 469 potentially eligible studies, dual blind full text review identified 42 eligible studies reporting 44 independent cohorts with 6,716 patients (21–979). While Ki67 cutpoints varied considerably, they were most commonly between 10%–30% (median 20%, range 1–50%). The analysis prsented here is limited to the 30 studies of ESBC patients (N = 3,343) receiving neoadjuvant therapy of which 14 reported fewer than 100 patients. The proportion of patients with elevated Ki67 across studies ranged from 0.20–0.92 (median = 0.54). Sensitivity and specificity for treatment response in patients with high vs. low baseline Ki67 was 0.65 [0.61, 0.68] and 0.52 [0.50, 0.54], respectively. Estimated response rates across studies in patients with high vs. low Ki67 were 31% [29%, 34%] and 19% [17%, 21%], respectively. The estimated POR for response across studies was 2.82 [2.14, 3.72; P &lt; .001].

P5-13-17: Multigene Signature Assays in Patients with Early-Stage Breast Cancer (ESBC) Receiving Neoadjuvant Chemotherapy: An NCI-Funded Systematic Review and Evidence Summary of Predictive Performance

Background: A comprehensive literature search and evidence synthesis of multigene signatures predictive of response to systemic chemotherapy in patients with breast cancer was initiated as a part of an NCI-funded program on Comparative Effectiveness Research.

Methods: Validation studies were sought of multigene signatures for prediction of chemotherapy response (favorable vs unfavorable) in ESBC patient cohorts different from those used for signature development. Pooled estimates [±95% CI] of assay performance for predicting clinical outcome included sensitivity, specificity, likelihood ratio, predictive value (PV) and predictive odds ratio (POR) utilizing mixed effects models based on the method of Mantel-Haenszel. Exploratory metaregression analyses on log (POR) were also performed. Studies were classified by validation type including cell lines to patients, independent internal sample, random split sample, or external validation. Evidence for publication bias was assessed by Egger's regression intercept and Begg and Mazumdar's rank correction. Results: Dual-blind review of abstracts identified 33 studies of neoadjuvant chemotherapy response of which 29 stratified treatment response by signature classifier category. Classifier development was based on tumor response prediction in 20 studies, prognosis in 5, and molecular classification in 4. The Table shows assay performance measures overall and by study validation type. Assay performance based on the POR was positively associated with overall study quality (P=.015) and journal impact factor (P=.020). However, strong evidence for publication bias was observed based on both regression intercept (P&lt;.001) and rank correlation (P=.005). No significant differences in assay performance were noted for assays originally developed for response prediction (POR=5.3), prognosis (POR=6.6) or molecular classification (P=6.9) (P=.770).

P3-14-04: Assessment of Genomic Prognostic Signatures as Predictors of Response to Neoadjuvant Chemotherapy in Patients with Early Stage Breast Cancer

Background: Based on results from randomized clinical trials, adjuvant and neoadjuvant chemotherapy (NCT) strategies in early stage breast cancer patients (ESBC) achieve comparable long term results. Recently, a number of genomic signatures have been reported, distinguishing patients with low versus high risk of recurrence. While developed primarily as prognostic assays, these classifiers have also been proposed to be predictive of benefit from systemic chemotherapy. Neoadjuvant studies provide an opportunity to evaluate their predictive value for response to NCT.

Methods: A systematic review of gene expression profile studies in ESBC patients receiving chemotherapy was conducted. Medline search of original research articles of human studies published between January 2000 and February 2011 was based on key words and MeSH heading terms. Publications presenting outcomes for chemotherapy treated patients in groups stratified by multi-gene array signatures and utilizing a new independent cohort of patients compared to the original development cohort were selected. Information from eligible studies was extracted by dual abstraction. Reported results were synthesized into combined diagnostic odds ratio (DOR) using method of Mantel-Haenszel. This analysis is restricted to neoadjuvant studies investigating the association of genomic signature prognostic categories with objective tumor response to chemotherapy. Results: A total of 42 articles were eligible for data abstraction. Out of these, 6 publications evaluated response to NCT in good (low risk of recurrence) versus poor prognosis groups based on genomic prediction. Since two of the studies analyzed the same signature on a cohort with large overlap, only 5 studies were included in the final analysis, accounting for n=918 patients. Response consisted of pathologic complete response (pCR) in 3 studies, pCR or minimal residual disease (1 study), and clinical complete response (1 study). Prognostic genomic assays included Oncotype DX (1), MammaPrint (1), Genomic Grade Index (2) and PAM50 Risk of Relapse Score (1). Eight different chemotherapy regimens were utilized. The most common drugs were cyclophosphamide, anthracyclines, taxanes, and 5-fluorouracil. Across all genomic signatures, good prognosis patients, as defined by gene expression data, demonstrated consistently low rates of response to chemotherapy (median 3%, range 0–12%) compared to patients with less favorable prognosis (median 32%, range 19–43%). Odds ratio for response in poor versus good prognosis patients ranged from 3.9 to 21.7 with combined DOR= 6.6 (95% CI 3.9−11.3, P&lt;0.0001). No heterogeneity was determined across studies (P=0.4). The C-statistic estimating assay discriminatory ability was reported in 3 studies ranged from 0.72 to 0.78.

Conclusions: Across all genomic prognostic signatures reported, only a very small proportion of patients with signature predicted good prognosis achieved complete response to NCT. This suggests low sensitivity to chemotherapy among good prognosis patients, as determined by the prognostic genomic signatures. This further confirms the association between poor prognosis tumors and higher responsiveness to chemotherapy.

Funding: NCI: UC2CA14041-01

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-14-04.

Rapid Optical Imaging of Breast Tumor Margins: Final Results from a 100-Patient Clinical Study

Background: Increasing attention has been given to the surgical margin status in primary breast conserving therapy (BCT) due to reports which indicate that 20-70% of patients undergoing BCT must undergo multiple surgeries for complete tumor resection. For the past 4 years, our multidisciplinary group has been working to address this clinical need via the development of an optically-based intraoperative breast tumor margin assessment device. This device, based on diffuse reflectance spectroscopy, is sensitive to biochemical and morphological changes associated with cancer and has a sensing depth of 1-2 mm which is compatible with widely used criteria for cancer-free margins. The device is capable of surveying the entire specimen surface intraoperatively in imaging mode. Here we report the results of a non-significant-risk study of the device in over 100 patients at Duke University Medical Center.Materials and Methods: Under an institutionally-approved protocol, we tested our device on consented patients undergoing a partial mastectomy at DukeUniversity Medical Center for invasive or in situ malignancies. Optical spectral images of tumor margins were recorded within 20 minutes of excision and converted into tissue compositional parameter maps that reflect the vascular density, fat content and cell density in the tissue. The pathologic status of the imaged margins was collected from standard post-operative surgical pathology reports. Intraoperative frozen section and touch prep analysis was not performed on these specimens. Margins were considered positive if residual malignancy was found within 2 mm of the tissue surface.Results and Discussion: BCT specimens from 121 patients have been imaged with the optical device. One to four margins were imaged on each BCT specimen. Data from 112 patients were retained for analysis (51 negative margins, and 47 margins containing cancer within 1mm). Images of negative margins from patients with at least one positive margin (9 patients) elsewhere on the specimen were excluded from analysis due to the potential for presence of margin positivity that was not identified pathologically. For each margin, a set of 8 tissue composition maps were generated, from which a set of 36 image-descriptive variables were obtained. Wilcoxon rank-sum tests were used to determine which of the variables best separated negative from positive margins. A predictive model was developed using conditional inference trees to identify the optimal partitions from all 36 image-descriptive variables. The model selected variables related to the light scattering properties, total hemoglobin content, and β-carotene content of the underlying tissue, which are related to tissue density and morphology, vascular volume, and fat content, respectively. This model resulted in a sensitivity of 80% for detecting cancer at the margin, a sensitivity of 73% for detecting residual disease within 1mm of the margin, and a specificity of 65%. These results are promising and a prospective validation trial of the device is under development.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5017.

Characterizing the clinical relevance of an embryonic stem cell phenotype in lung adenocarcinoma

11001

Background: Cancer cells possess traits reminiscent of those ascribed to normal stem cells. It is unclear whether these phenotypic similarities between normal/embryonic stem cells and mature tumor cells, specific to lung cancer, are a result of underlying biologic processes, such as specific molecular pathways and regulatory networks. Methods: Using a large cohort of lung cancer cell lines with associated gene expression data, genes associated with an embryonic stem cell identity were used to develop a ‘signature’ representative of embryonic stemness (ES) activity specific to lung adenocarcinoma. Differential biology was evaluated using Gene Set Enrichment Analysis (GSEA) and signatures of oncogenic pathway deregulation. The ES signature was applied to three independent early (stage I - IIIa) lung adenocarcinoma data sets (N = 634) with clinically annotated gene expression data. The relationship between the ES phenotype and cisplatin sensitivity was also evaluated. Results: Using Bayesian regression analysis, a 100 gene signature representative of ES activity in lung adenocarcinoma was developed and validated in a leave-one-out-analysis. GSEA identified gene sets significantly represented in the ES signature: signature of neoplastic transformation, signature of undifferentiated cancer, BRCA pathway, and fibroblast serum response pathway, all associated with cancer invasiveness. Adenocarcinomas with ES demonstrated increased activation of RAS (p = 0.0002), MYC (p = 0.0057), wound healing (angiogenesis) (p < 0.0001), chromosomal instability (p < 0.0001), and invasiveness (p < 0.0001) gene signatures. Adenocarcinomas (N= 634) with ES had a decreased survival (p<0.04). The ES signature was not prognostic in prostate, ovarian, or breast adenocarcinomas. Lung tumors (N=634) and adenocarcinoma cell lines (N=31) with ES were more resistant to cisplatin (p<0.0001 and p=0.0063, respectively). Conclusions: Lung adenocarcinomas that share a common gene expression pattern with normal stem cells were associated with decreased survival and increased likelihood of resistance to cisplatin, indicating the aggressiveness of lung tumors with a stem cell phenotype.

No significant financial relationships to disclose.

Patient preference as a determinant of breast cancer adjuvant chemotherapy use in older women: CALGB #369901

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Background: Decisions about use of breast cancer chemotherapy in women 65 and older (“older”) can be complex due to comorbidity, uncertain efficacy and limited data on patient preference. Methods: Older women diagnosed with invasive, non-metastatic breast cancer between 2004 and 2008 were recruited from 53 CALGB sites for an observational study of preferences and chemotherapy use. Data on preferences and other factors were collected from patient interviews and clinical data were abstracted from charts. Generalized estimating equation regression was used to assess associations between chart-reported chemotherapy and independent variables; associations were also evaluated in 2 subgroups: “chemotherapy indicated” (estrogen receptor [ER] negative and/or node positive) and “consider chemotherapy” (ER positive and node negative). Results: Among 935 eligible women registered, 815 (87.2%) completed interviews. The mean age of the cohort was 73 years (range 65–100); 38% were node positive, 82% were ER positive and all had tumors ≥ 1 cm (44% were AJCC stage 1, 44% stage 2 and 12% stage 3). Based on ER and nodal status, chemotherapy was “indicated” for 47% and could be “considered” for 53%. Crude chemotherapy rates were 70% in the “indicated” group and 17% in the “considered” group, for an overall rate of 42%. Women who would choose chemotherapy for an increase in survival of ≤12 months were 4.1 times (95% CI 2.5–6.7, p<.0001) more likely to receive chemotherapy than women who would only choose chemotherapy if it added more than 12 months, controlling for age, tumor factors, comorbidity and other covariates. Stronger preferences were seen among women with “indications” for chemotherapy (OR 7.9, 95% CI 3.7–17.0, p<.001) than in those where treatment might be “considered” (OR 1.8, 95% CI 0.9–3.4, p=.08). Higher patient rating of communication with providers was independently related to a decision to use chemotherapy among women where chemotherapy could be “considered” but not among those where chemotherapy was “indicated”. Conclusions: Beyond clinical indications, older women's preferences and communication with providers are important correlates of chemotherapy use.

[Table: see text]

Thermometry in paediatric practice

Body temperature is commonly measured to confirm the presence or absence of fever. However, there remains considerable controversy regarding the most appropriate thermometer and the best anatomical site for temperature measurement. Core temperature is generally defined as the temperature measured within the pulmonary artery. Other standard core temperature monitoring sites (distal oesophagus, bladder, and nasopharynx) are accurate to within 0.1-0.2 degrees C of core temperature and are useful surrogates for deep body temperature. However, as deep-tissue measurement sites are clinically inaccessible, physicians have utilised other sites to monitor body temperature including the axilla, skin, under the tongue, rectum, and tympanic membrane. Recent studies have shown that tympanic temperature accurately reflects pulmonary artery temperature, even when body temperature is changing rapidly. Once outstanding issues are addressed, the tympanic site is likely to become the gold standard for measuring temperature in children.

Transcriptomic analysis of F344 rat nasal epithelium suggests that the lack of carcinogenic response to glutaraldehyde is due to its greater toxicity compared to formaldehyde

Formaldehyde is cytotoxic and carcinogenic to the rat nasal respiratory epithelium inducing tumors after 12 months. Glutaraldehyde is also cytotoxic but is not carcinogenic to nasal epithelium even after 24 months. Both aldehydes induce similar acute and subchronic histopathology that is characterized by inflammation, hyperplasia, and squamous metaplasia. Because early aldehyde-induced lesions are microscopically similar, we investigated whether transcriptional patterns using cDNA technology could explain the different cancer outcomes. Treatments included 1-, 5-, or 28-day exposure by nasal instillation of formaldehyde solution (400 mM) or glutaraldehyde solution (20 mM). Animals were euthanized and the nasal respiratory epithelium removed for gene expression analysis and a subset of rats treated for 28 days was processed for microscopic examination. RNA was isolated and processed for expression assessment using Clontech Atlas Toxicology II Arrays. Both aldehydes induced hyperplasia, squamous metaplasia, and inflammatory infiltrates with scattered apoptotic bodies in the epithelium covering luminal surfaces of the nasoturbinate, maxilloturbinate, and nasal septum. A subset of 80 genes that were the most variant between the treated and control included the functional categories of DNA repair and apoptosis. Hierarchical clustering discriminated chemical treatment effects after 5 days of exposure, with 6 clusters of genes distinguishing formaldehyde from glutaraldehyde. These data suggest that although both aldehydes induced similar short-term cellular phenotypes, gene expression could distinguish glutaraldehyde from formaldehyde. The gene expression patterns suggest that glutaraldehyde's lack of carcinogenicity may be due to its greater toxicity from lack of DNA-repair, greater mitochondrial damage, and increased apoptosis.

A comparison of brain angiotensin II receptors during lactation and diestrus of the estrous cycle in the rat

During lactation there are many dramatic alterations in the hypothalamic-pituitary (HP) axis, as well as an increased demand for food and water. The renin-angiotensin system (RAS) is one of the major mediators of the HP axis. This study examined the receptors for ANG II in the rat brain during lactation and diestrus. Compared with diestrus, lactating rats had significant decreases in ANG II receptor binding in several forebrain regions, most notably in the arcuate nucleus/median eminence, dorsomedial hypothalamic nucleus (DMH), and lateral hypothalamic area (LHA). In contrast, there was an increase in ANG II receptor binding in the preoptic area during lactation. These significant changes in ANG II binding in the brain during lactation support the hypothesis that changes in the RAS may contribute to the dramatic changes in the HP axis during lactation. In addition, the significant reduction in ANG II binding in the DMH and LHA may be indicative of a role in the regulation of food intake, a function only recently associated with the RAS.

Association of fever and severe clinical course in bronchiolitis

Little attention has been given to the relation between fever and the severity of bronchiolitis. Therefore, the relation between fever and the clinical course of 90 infants (59 boys, 31 girls) hospitalised during one season with bronchiolitis was studied prospectively. Fever (defined as a single recording > 38.0 degrees C or two successive recording > 37.8 degrees C) was present in 28 infants. These infants were older (mean age, 5.3 v 4.0 months), had a longer mean hospital stay (4.2 v 2.7 days), and a more severe clinical course (71.0% v 29.0%) than those infants without fever. Radiological abnormalities (collapse/consolidation) were found in 60. 7% of the febrile group compared with 14.8% of the afebrile infants. These results suggest that monitoring of body temperature is important in bronchiolitis and that fever is likely to be associated with a more severe clinical course and radiological abnormalities.

Predictors of survival and the role of gender in postoperative myocardial infarction

PURPOSE

To identify risk factors for mortality after postoperative myocardial infarction.

METHOD

Retrospective study of 266 patients.

RESULTS

The crude in-hospital mortality rate was 25%. This was more than twice as high as the mortality rate in patients admitted from home with an acute myocardial infarction. Women with postoperative infarction were the same age as men, but had a lower Acute Physiology and Chronic Health Evaluation (APACHE) II score prior to infarction (P = 0.03) and a higher crude mortality rate. Multivariate analysis showed that female gender (relative risk 2.2, 95% confidence limits 1.2 to 4.2), current cigarette smoking (relative risk 2.3 [1.2 to 4.7]), a history of congestive heart failure (relative risk 2.1 [1.04 to 4.1], resuscitation status (relative risk 8.1 [2.0 to 32.9]), and high preoperative APACHE II score were significant independent predictors of in-hospital mortality.

CONCLUSION

Postoperative myocardial infarction is one of the most serious events a patient can experience. Women and current smokers are at especially high risk for mortality after postoperative myocardial infarction.

Thrombin and vascular smooth muscle cell proliferation: implications for atherosclerosis and restenosis

Despite long-standing knowledge about the relationship between thrombosis and atherosclerosis, the specific role of thrombin in modulating atherosclerosis and the response to vascular injury is not well understood. Thrombin receptor stimulation in vitro signals many cellular events that are associated with the response to vascular injury (atherosclerosis) in vivo. Proliferation of smooth muscle cells (SMCs) is an important component of the response to vascular injury. We have previously shown that human alpha-thrombin and the 14-amino acid human thrombin receptor-activating peptide (huTRAP-14) stimulate proliferation of cultured rat aortic SMCs. However, thrombin-induced SMC proliferation demonstrates delayed kinetics relative to platelet-derived growth factor (PDGF-BB, another potent SMC mitogen). Several mechanisms may be responsible for these delayed kinetics in vitro, including production of necessary secondary growth factors and thrombin-induced upregulation of its receptor. In vivo studies have demonstrated that thrombin inhibition limits the response to vascular injury in a hypercholesterolemic rabbit model of focal femoral atherosclerosis. However, this effect does not appear to be mediated by effects on early SMC proliferation. In this discussion, we will address the mechanisms of thrombin-induced SMC proliferation in vitro and apply this knowledge to our understanding of the role of thrombin inhibition in limiting the response to vascular injury in vivo.

Amlodipine combined with beta blockade for chronic angina: Results of a multicenter, placebo-controlled, randomized double-blind study

Amlodipine, a potent long-acting dihydropyridine calcium antagonist, was compared with placebo in a parallel, randomized, double-blind study in 134 patients with chronic stable angina pectoris maintained on beta-adrenergic blocking agents. After a single-blind, two-week placebo period, patients were randomized to receive either amlodipine (2.5, 5, and 10 mg) or placebo once daily for four weeks. The effects of amlodipine on maximal exercise time, work, time to angina onset, and subjective indices including angina frequency, nitroglycerin tablet consumption, and patient and investigator ratings were assessed. Each dose of amlodipine produced increases in exercise time and calculated total work accomplished compared to baseline. Improvements at 5 and 10 mg were significantly greater than placebo which produced no significant change (p less than 0.05). Qualitative improvements in the severity of angina were produced by amlodipine at 5 and 10 mg daily assessed by patient-rating questionnaires (p less than 0.05). Reductions in angina frequency attacks per week and weekly nitroglycerin tablet consumption occurred but were not statistically significant when compared with placebo. Adverse effects observed during amlodipine treatment prompted discontinuation of treatment in only 2 out of 100 patients. Three patients discontinued treatment for reported lack of efficacy. No laboratory abnormalities prompted treatment discontinuation and minor side effects of dizziness, nausea, headache, and fatigue were observed infrequently. The results of this controlled, large-scale multicenter trial suggest that amlodipine significantly increased exercise capacity and was well tolerated when added to the antianginal regimen of patients remaining symptomatic while receiving beta-blocking agents.

Intravenous immunoglobulin therapy for toxic shock syndrome

Staphylococcus aureus and group A Streptococcus pyogenes produce toxic shock syndrome characterized by hypotension and multisystem organ failure. While conventional therapy has consisted of antibiotics and intensive supportive care, some experimental evidence suggests that immunoglobulins directed against the toxins may be effective additional therapy. We report a case of "toxic strep syndrome" in which intravenous immunoglobulin was administered when signs and symptoms were worsening while the patient was receiving conventional therapy. Within hours of administration of the intravenous immunoglobulin, the patient experienced dramatic clinical improvement. This response suggests a possible therapeutic benefit of intravenous immunoglobulin in toxic shock syndrome.

Once or twice daily theophylline in childhood asthma

We conducted a randomized, single-blind, crossover trial to compare two sustained release theophylline preparations. Fifty-nine chronic asthmatics, aged 7-14 years, were randomly allocated to receive Slophyllin (SP) twice daily followed by Uniphyllin (UP) taken as a single dose at bedtime, or UP followed by SP. Two 4-week periods on therapeutic doses of each preparation were compared. Thirty-six patients completed the study. Eight were non-compliant, seven defaulted and eight withdrew because of theophylline related side-effects (seven on UP). Symptom scores, beta-agonist usage, compliance by pill counts, evening peak flow rates and maximal expiratory flow-volume curves were similar on both treatments. Blood levels of theophylline at 11 am and morning peak flow rates were significantly higher on UP. UP may be more helpful for patients with early morning symptoms, but is associated with an increased frequency of severe side effects.

Measurement of choroidal melanomas: a comparison of methods

The prognosis for death from metastatic choroidal melanoma following enucleation has been shown to be strongly correlated with a number of risk factors of which the most important are age of onset, aggressive cell types and tumour volume. The advantages of enucleation for the treatment of choroidal melanomas are put into question by the singular lack of a parallel increase in life expectancy following this treatment, and evidence that it may promote the development of metastatic disease. Alternative forms of treatment have been introduced including observation of small and asymptomatic tumours. We are using a computer-aided system for serial measurement and statistical analysis of area and volume of choroidal melanomas. A comparison of results using our method and the conventional method of estimating volume by the product of basal area and height for 51 measurements on 15 eyes over a 6-month period showed an overestimation of volume by conventional methods which could be corrected by applying a "shape constant" determined by linear regression. Calculation of tumour growth rates is also shape-dependent, and a slowing in growth rate or even a reduction in melanoma size is possible.