Identification of an inhibitory pocket in falcilysin provides a new avenue for malaria drug development

Identification of new druggable protein targets remains the key challenge in the current antimalarial development efforts. Here we used mass-spectrometry-based cellular thermal shift assay (MS-CETSA) to identify potential targets of several antimalarials and drug candidates. We found that falcilysin (FLN) is a common binding partner for several drug candidates such as MK-4815, MMV000848, and MMV665806 but also interacts with quinoline drugs such as chloroquine and mefloquine. Enzymatic assays showed that these compounds can inhibit FLN proteolytic activity. Their interaction with FLN was explored systematically by isothermal titration calorimetry and X-ray crystallography, revealing a shared hydrophobic pocket in the catalytic chamber of the enzyme. Characterization of transgenic cell lines with lowered FLN expression demonstrated statistically significant increases in susceptibility toward MK-4815, MMV000848, and several quinolines. Importantly, the hydrophobic pocket of FLN appears amenable to inhibition and the structures reported here can guide the development of novel drugs against malaria.

Accelerated Identification of Cell Active KRAS Inhibitory Macrocyclic Peptides using Mixture Libraries and Automated Ligand Identification System (ALIS) Technology

Macrocyclic peptides can disrupt previously intractable protein–protein interactions (PPIs) relevant to oncology targets such as KRAS. Early hits often lack cellular activity and require meticulous improvement of affinity, permeability, and metabolic stability to become viable leads. We have validated the use of the Automated Ligand Identification System (ALIS) to screen oncogenic KRAS^G12D (GDP) against mass-encoded mini-libraries of macrocyclic peptides and accelerate our structure–activity relationship (SAR) exploration. These mixture libraries were generated by premixing various unnatural amino acids without the need for the laborious purification of individual peptides. The affinity ranking of the peptide sequences provided SAR-rich data sets that led to the selection of novel potency-enhancing substitutions in our subsequent designs. Additional stability and permeability optimization resulted in the identification of peptide 7 that inhibited pERK activity in a pancreatic cancer cell line. More broadly, this methodology offers an efficient alternative to accelerate the fastidious hit-to-lead optimization of PPI peptide inhibitors.

Phase-separating peptides for direct cytosolic delivery and redox-activated release of macromolecular therapeutics

Biomacromolecules are highly promising therapeutic modalities to treat various diseases. However, they suffer from poor cellular membrane permeability, limiting their access to intracellular targets. Strategies to overcome this challenge often employ nanoscale carriers that can get trapped in endosomal compartments. Here we report conjugated peptides that form pH- and redox-responsive coacervate microdroplets by liquid-liquid phase separation that readily cross the cell membrane. A wide range of macromolecules can be quickly recruited within the microdroplets, including small peptides, enzymes as large as 430 kDa and messenger RNAs (mRNAs). The therapeutic-loaded coacervates bypass classical endocytic pathways to enter the cytosol, where they undergo glutathione-mediated release of payload, the bioactivity of which is retained in the cell, while mRNAs exhibit a high transfection efficiency. These peptide coacervates represent a promising platform for the intracellular delivery of a large palette of macromolecular therapeutics that have potential for treating various pathologies (for example, cancers and metabolic diseases) or as carriers for mRNA-based vaccines.

Abstract SP114: Body Image and Sexual Health

Attention to body image and sexual health after breast cancer are important components of treatment decisions, support through treatment and survivorship care. A high proportion of breast cancer survivors report dissatisfaction with their physical appearance. Body image issues are particularly common among women who undergo mastectomy with or without reconstructive surgery and those who experience weight gain, hair loss from chemotherapy, and other psychosocial issues. Scalp cooling, proactive counseling about potential effects of treatment on weight and physical activity, and psychosocial support through treatment may help to prevent some of these negative effects. Weight loss and subsequent weight maintenance are notoriously difficult to achieve through diet alone, and exercise plays an important role in energy balance through and after treatment. Sexual health is frequently a concern for breast cancer survivors as well, with up to 40% of women reporting issues with sexual interest and 60% with physical sexual function. Issues may arise in the short term following both surgery and chemotherapy, due to factors including lower perceived attractiveness and vaginal dryness. Endocrine therapy with tamoxifen, aromatase inhibitors, and treatment-related amenorrhea or ovarian suppression treatment in premenopausal women are associated with sexual dysfunction. However, a multi-prong approach has been shown to improve such problems. Providers should actively monitor for and manage the consequences of diagnosis and treatment on body image and sexual health in survivors, using psychosocial, behavioral, and pharmacologic tools as needed.

Citation Format: A Partridge. Body Image and Sexual Health [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SP114.

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.

Abstract P1-15-01: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Metzger Filho O, Janiszewska M, Guo H, Yardley D, Mayer I, Spring L, Arteaga C, Wrabel E, DeMeo M, Freedman R, Tolaney S, Waks A, Bardia A, Parsons H, Partridge A, Mayer E, King T, Polyak K, Viale G, Winer E, Krop I. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-01.

Abstract GS6-01: Surgical treatment after neoadjuvant systemic therapy in young women with breast cancer: Results from a prospective cohort study

Background

Young women are more likely than older women to present with higher stage breast cancer (BC) and may benefit to a greater extent from downstaging with neoadjuvant systemic treatment (NST). Young age is also associated with greater likelihood of pathologic complete response (pCR). Using a large prospective cohort of young women with BC, we investigated response to neoadjuvant therapy, eligibility for breast conserving surgery (BCS) pre- and post-NST, and surgical treatment.

Methods

The Young Women's Breast Cancer Study (YWS) is a multi-center cohort of women diagnosed with BC at age ≤40, that enrolled 1302 patients from 2006 to 2016. Disease characteristics and treatment information were obtained through medical record and central pathology review. Surgical recommendation before and after NST, conversion from BCS borderline/ineligible to BCS eligible, surgery, documented reasons for choosing mastectomy (MTX) among BCS eligible women, and final pathologic response were independently reviewed.

Results

Among 1302 women enrolled in YWS, 801 (62%) presented with unilateral stage I-III breast cancer and 317(40%) received NST. Median age was 36 years old (22-40). Pre-NST, 85/317 (27%) were BCS eligible, 49 (15%) were borderline, and 169 (53%) were not eligible (16 inflammatory breast cancer (IBC), 88 large tumor size /cosmetic, 48 diffuse calcifications, and 83 multicentricity). Among the 218 patients who were BCS ineligible/borderline pre-NST, 82 (38%) became eligible for BCS after NST. 4 patients who were BCS eligible pre-NST became ineligible. Of all patients eligible for BCS post-NST (n=163), 80 (49%) attempted BCS, 74 (93%) of whom were successful, and 83 (51%) chose MTX. Reasons for choosing MTX included: patient preference (38/83 (46%)), BRCA or TP53 mutation (31 (37%)), family history (3 (4%)), unknown (11 (13%)). On final pathology, 75 (24%) patients had pCR. Among patients who achieved a pCR, 48 (64%) underwent MTX, fewer than half (21/48 (44%)) were for anatomic indications (IBC, large tumor at diagnosis, diffuse calcifications, multicentric disease).

Conclusion

While NST doubled the proportion of young women eligible for BCS, nearly half chose MTX regardless of response to NST, mostly for personal preference or high-risk preventative reasons. These data highlight that surgical decision making among young women with breast cancer is often driven by factors beyond extent of disease and clinical response to therapy.

Table 1.Clinical-pathologic characteristicsCharacteristicsNumber%Pre NST surgical recommendation  BCS eligible8526.8Borderline4915.5BCS ineligible16953.3Unknown144.4Clinical Response  Complete20263.7Partial9229.0Stable30.9Progressing72.2Unknown134.1Pathologic Response  pCR (No invasive or DCIS)7524No pCR24276Post NST Surgical recommendation  BCS eligible16351.4BCS ineligible14445.4Unknown103.2Attempted surgery  BCS8025.2MTX23674.1Unknown20.6Final Surgery  BCS7423.3MTX24176unknown20.6

Citation Format: Kim HJ, Dominici L, Rosenberg S, Pak LM, Poorvu PD, Ruddy K, Tamimi R, Schapira L, Come S, Peppercorn J, Borges V, Warner E, Vardeh H, Collins L, King T, Partridge A. Surgical treatment after neoadjuvant systemic therapy in young women with breast cancer: Results from a prospective cohort study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS6-01.

Abstract OI: Breast Cancer in Young Women: Understanding Differences to Improve Outcomes

Breast cancer is the leading cause of cancer related deaths in women age 40 years and younger in the United States, and a major cause of morbidity and mortality worldwide. Young women are more likely to develop more aggressive subtypes of breast cancer. Emerging data suggest the effect of age on breast cancer recurrence and death varies by tumor subtype, with young age particularly prognostic in women with ER-positive disease. Greater understanding of the biologic and genetic underpinnings of cancers that arise in younger women, potential differences in tumor and host responses including disease presenting in very premenopausal women or recently pregnant women, is critical to develop novel treatments to improve outcomes. There is also mounting evidence that access to care and behavioral differences leading to suboptimal treatment contribute to disparities in young women, including relatively poor adherence to adjuvant hormonal therapy. Prevention, detection and management of non-adherence, with attention to unique issues facing young women including desire for future fertility and pregnancy, has been the subject of recent research for this vulnerable population who, unsurprisingly, are at increased risk of psychosocial distress compared with older breast cancer survivors. Decision-support tools, and innovative, acceptable, scalable interventions to address anxiety and distress are under investigation. Finally, given that most young women will live for many decades after a diagnosis of breast cancer, it is imperative that we follow this population, in particular, over time and study their long-term, late effects in survivorship.

Citation Format: Partridge A. Breast Cancer in Young Women: Understanding Differences to Improve Outcomes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OI.

Abstract GS3-02: Invasive disease-free survival and gene expression signatures in CALGB (Alliance) 40601, a randomized phase III neoadjuvant trial of dual HER2-targeting with lapatinib added to chemotherapy plus trastuzumab

Purpose

Dual HER2 targeting increases pathologic complete response (pCR) rate to neoadjuvant therapy and improves outcomes in both early and metastatic HER2-positive disease. CALGB 40601 is a randomized phase III trial examining the impact of dual HER2 blockade consisting of trastuzumab (H) and lapatinib (L) added to paclitaxel (T) on pCR, considering tumor and microenvironment molecular features. We previously found that pCR was numerically but not significantly increased with dual therapy, and that tumor molecular subtype and evidence of immune activation significantly and independently affected pCR (Carey et al, JCO 2016). In this secondary analysis, we sought to evaluate the effects of treatment arm and gene expression-defined subgroups on invasive disease free survival (IDFS).

Patients and Methods

Patients (Pts) with stage II to III HER2-positive breast cancer underwent tumor biopsy followed by random assignment with equal probabilityto paclitaxel plus trastuzumab alone (TH) or with the addition of lapatinib (THL) for 16 weeks before surgery. A paclitaxel plus lapatinib (TL) arm was closed early based on reports of futility from other trials. A secondary endpoint was IDFS, defined as the time from surgery until local or distant recurrence, new primary, or death from any cause, whichever was first. Gene expression signatures were identified by RNA sequencing.

Results

Between 12/2008 and 2/2012, 305 pts were enrolled. 261 pts had IDFS and gene expression information available (THL, n = 103; TH, n =101; TL, n = 57); there were no significant differences in clinical characteristics between this subset and the entire population. The median IDFS follow-up was 4.6 years with 40 IDFS events having occurred (THL, n=7; TH, n=19; TL, n=14). IDFS was significantly longer in the THL arm compared to standard TH (HR=0.34; 95% CI: 0.14-0.82; p=0.02). IDFS was also significantly longer among pCR than non-pCR pts (HR=0.40; 95% CI: 0.19-0.81; p=0.01), and did not differ by hormone receptor (HR) status, clinical stage, tumor size, race, menopausal status or age. Among gene expression signatures, only immune activation measured by an IgG signature was associated with longer IDFS (HR=0.71; 95% CI: 0.51-0.98; p=0.04); this signature was previously also associated with pCR. Multivariate analysis showed dual therapy (HR=0.35; p=0.02), pCR (HR=0.36; p=0.01), IgG (HR=0.69; p=0.05), and molecular subtype (LumA vs HER2E, HR=0.24, p=0.005) were associated with longer IDFS. A subgroup analysis by hormone receptor status revealed that among pts with HR+ disease, pts with luminal A experienced longer IDFS (HR=0.23; p=0.02) compared to those with luminal B or HER2-enriched molecular subtypes.

Conclusion

Dual HER2-targeting with lapatinib added to 16 weeks of TH produced significantly longer IDFS than TH alone, despite modest effects on pCR. Similar to pts with HER2-negative disease, pts with luminal A had better IDFS than those with other molecular subtypes. Immune activation as measured by RNA-based signature independently predicted both pCR and IDFS.

Support: U10CA180882, U10CA180821, U24CA196171, P50-CA58823, Susan G Komen, BCRF

Citation Format: Krop IE, Hillman D, Polley M-Y, Tanioka M, Parker J, Huebner L, Henry NL, Tolaney SM, Dang C, Harris L, Berry DA, Perou CM, Partridge A, Winer EP, Carey LA. Invasive disease-free survival and gene expression signatures in CALGB (Alliance) 40601, a randomized phase III neoadjuvant trial of dual HER2-targeting with lapatinib added to chemotherapy plus trastuzumab [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 GS3-02.

Abstract P4-20-04: Young women with breast cancer in Mexico: A report of the pilot phase of the “Mujer Joven y Fuerte” prospective cohort

Background: Despite high rates of breast cancer in young women from low-and-middle-income countries (LMICs), their needs and concerns are not systematically studied or addressed. Understanding the characteristics of young women with breast cancer (YWBC) and the issues they face is of great relevance to the medical community, in order to tailor clinical interventions and supportive care for this unique and understudied patient population. The Mexican cohort “Mujer Joven y Fuerte” (Young and Strong Woman) has the goal of comprehensively characterizing and assessing the needs of YWBC in Mexico using patient- and physician-based surveys. Methods: A prospective cohort of newly diagnosed YWBC was established in November 2014 at two Mexican cancer centers in Mexico City and Monterrey. Eligible women answer web-based surveys on relevant topics including physical activity, genetics, psychosocial needs, and fertility. Clinicians complete pre-specified surveys using the US NIH BOLD Task Force common data elements registering clinical/pathologic characteristics and outcomes. Patients are evaluated at diagnosis, after 6 months, and annually for 5 years. Sub-studies assessing changes in cognition, sexual function and satisfaction, quality of life and depression/anxiety are being conducted, and biologic samples are stored for future research. Results: 96 YWBC with median age at diagnosis of 34 (21-41 y) were accrued to our pilot phase. 26% were single and 25% childless. 43% had higher education and 28% were employed. 90% presented with a self-detected mass. Clinical stage at diagnosis was distributed as follows: stage 0: 2%; I: 15%; IIA: 13%; IIB: 17%; III: 47%, and stage IV: 6%. The most frequent molecular subtype was HR+/HER2- (47%), followed by HER2+ (26%) and triple negative (21%). First follow-up results will be available shortly. Conclusions: To our knowledge, this represents the first prospective cohort of YWBC in Latin America. We are expanding this project to other centers in the region. Our findings will help develop culturally tailored interventions aimed at improving the psychosocial and medical outcomes of this vulnerable patient population.

Citation Format: Villareal-Garza CM, Platas A, Castro-Sánchez A, Miaja M, Bargalló-Rocha E, Martinez-Cannon BA, Vega Y, Fonseca A, Ramos-Elias P, Márquez-Perez CJ, Bukowski A, Goss P, St. Louis J, Chapman J-A, Partridge A, Meneses A, Mohar A. Young women with breast cancer in Mexico: A report of the pilot phase of the “Mujer Joven y Fuerte” prospective cohort [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-20-04.

Abstract PD4-01: Acupuncture for chemotherapy-induced peripheral neuropathy in breast cancer, preliminary results of a pilot randomized controlled trial

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is one of the major dose-limiting side effects in breast cancer patients, with up to 97% of patients receiving an adjuvant taxane experiencing this symptom in the months and years after breast cancer treatment. CIPN often leads to loss of physical function; difficulties in activities of daily living and decreased of quality of life (QOL). Few effective interventions have been developed to alleviate CIPN in this patient population. We conducted a pilot randomized controlled trial to assess the feasibility, safety and preliminary effect of an acupuncture intervention on CIPN in breast cancer survivors.

METHODS: Patients with stage I-III breast cancer who were experiencing CIPN after the completion of a taxane-containing adjuvant chemotherapy regimen were enrolled and randomized 1:1 to immediate participation in an acupuncture intervention or to a delayed intervention control group. Participants randomized to the acupuncture arm received 18 sessions of a standardized acupuncture protocol over 8 weeks while the control group received a lower-dose acupuncture protocol consisting of 9 acupuncture sessions over 8 weeks, after the initial 8-week control period. Measures including the Patient Neurotoxicity Questionnaire (PNQ), Functional Assessment of Cancer Therapy Neurotoxicity subscale (FACT-NTX), and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Chemotherapy-induced Peripheral Neuropathy 20 (EORTC QLQ-CIPN20) were collected at baseline and at 8 weeks after enrollment.

RESULTS: A total of 40 patients were enrolled; 20 were randomized to the immediate acupuncture group and 20 to control. All enrolled patients were female, median age was 54, median time between enrollment and completion of chemotherapy was 14.3 months, and 72.5% of participants were White. Thirty-two patients (84%) completed at least 80% of the required sessions. No serious acupuncture-related side effects were observed. Participants randomized to the acupuncture arm experienced improvements in the PNQ sensory score (p=0.02), FACT-NTX summary score (p=0.002) and EORTC QLQ-CIPN20 score (p=0.006), respectively equivalent to 40%, 36% and 53% improvement in CIPN symptoms, as compared to controls.

MeasurementsTime pointsAcupunctureUsual CareP-valueNMeanSDMeanSDPNQ summary sensory score (0-4)Baseline202.50.82.50.90.97Changes at 8 week15-1.00.9-0.30.60.02FACT-NTX summary score (0-44)Baseline2025.08.422.19.40.40Changes at 8 week159.09.21.25.40.002EORTC QLQ-CIPN20 sensory score (0-100)Baseline2044.919.945.022.30.93Changes at 8 week15-23.818.1-5.16.40.006

CONCLUSIONS: Women with CIPN after adjuvant taxane therapy for early breast cancer experienced a significant and clinically meaningful improvement in neuropathy symptoms as a result of an 8-week acupuncture protocol. Given the prevalence of taxane-induced neuropathy in women treated for early breast cancer, acupuncture could significantly improve QOL and functional status of thousands of women treated for breast cancer every year. Larger studies are needed to confirm these findings and evaluate the impact of acupuncture on functional measures in women with CIPN.

Citation Format: Lu W, Giobbie-Hurder A, Freedman R, Yung R, Lin N, Partridge A, Shockro L, Stecker K, O'Connor KA, Rosenthal DS, Ligibel JA. Acupuncture for chemotherapy-induced peripheral neuropathy in breast cancer, preliminary results of a pilot randomized controlled trial [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 PD4-01.

Abstract P6-12-12: Phase I study of the JAK 1/2 inhibitor ruxolitinib with weekly paclitaxel for the treatment of HER2 negative metastatic breast cancer (MBC)

This abstract was not presented at the symposium.

Factors affecting uptake and adherence to breast cancer chemoprevention: a systematic review and meta-analysis

BACKGROUND

Preventive therapy is a risk reduction option for women who have an increased risk of breast cancer. The effectiveness of preventive therapy to reduce breast cancer incidence depends on adequate levels of uptake and adherence to therapy. We aimed to systematically review articles reporting uptake and adherence to therapeutic agents to prevent breast cancer among women at increased risk, and identify the psychological, clinical and demographic factors affecting these outcomes.

DESIGN

Searches were carried out in PubMed, CINAHL, EMBASE and PsychInfo, yielding 3851 unique articles. Title, abstract and full text screening left 53 articles, and a further 4 studies were identified from reference lists, giving a total of 57. This review was prospectively registered with PROSPERO (CRD42014014957).

RESULTS

Twenty-four articles reporting 26 studies of uptake in 21 423 women were included in a meta-analysis. The pooled uptake estimate was 16.3% [95% confidence interval (CI) 13.6-19.0], with high heterogeneity (I(2) = 98.9%, P < 0.001). Uptake was unaffected by study location or agent, but was significantly higher in trials [25.2% (95% CI 18.3-32.2)] than in non-trial settings [8.7% (95% CI 6.8-10.9)] (P < 0.001). Factors associated with higher uptake included having an abnormal biopsy, a physician recommendation, higher objective risk, fewer side-effect or trial concerns, and older age. Adherence (day-to-day use or persistence) over the first year was adequate. However, only one study reported a persistence of ≥ 80% by 5 years. Factors associated with lower adherence included allocation to tamoxifen (versus placebo or raloxifene), depression, smoking and older age. Risk of breast cancer was discussed in all qualitative studies.

CONCLUSION

Uptake of therapeutic agents for the prevention of breast cancer is low, and long-term persistence is often insufficient for women to experience the full preventive effect. Uptake is higher in trials, suggesting further work should focus on implementing preventive therapy within routine care.

Abstract OT2-01-08: POSITIVE: A study evaluating pregnancy and disease outcome and safety of interrupting endocrine therapy for young women with endocrine responsive breast cancer who desire pregnancy (IBCSG 48-14/BIG 8-13)

Background

Young breast cancer (BC) patients often face the disease before completing their family planning. The best available retrospective evidence suggests that pregnancy after BC does not negatively impact disease outcome in patients with endocrine sensitive BC and is safe for the offspring. However, given the need for prolonged adjuvant endocrine therapy for 5-10 years, it is not feasible to wait until completion of therapy in most of these women and thus there is a need to explore the safety of temporary interruption of endocrine therapy to allow pregnancy. To date, no definitive prospective study has been conducted in young women desiring future pregnancy.

Trial Design

Young patients with endocrine responsive early BC and pregnancy desire will interrupt endocrine treatment for up to 2 yrs to attempt pregnancy. As resumption of menses and conception depends on many factors, e.g. patient's age and adjuvant treatment received, the 2-yr interruption period is approximate, intended to include treatment wash-out (3 mos) conception (∼3-6 mos), delivery (∼9 mos), breast feeding (∼6 mos). Patients will be strongly advised to resume ET as soon as pregnancy attempts are concluded, and to complete 5-10 yrs ET at the local investigator discretion.

Major Eligibility Criteria

-Histologically-proven stage I-III endocrine-responsive BC.

-Age ≥ 18 and ≤ 42 years at enrollment.

-Adjuvant endocrine therapy (SERM alone, GnRH analogue plus SERM or AI) for ≥18 months but ≤30 months, stopped within 1 month prior to enrollment.

-Patient wishes to become pregnant.

-Premenopausal status at BC diagnosis.

Specific Aim

To assess the risk of BC relapse associated with temporary interruption of ET to permit pregnancy and to evaluate pregnancy success.

Statistical Methods

A true risk of BC recurrence of 2% per year is assumed for patients who do not interrupt endocrine treatment. With 500 patients enrolled in 4.0 yrs and an additional 1.6 yrs of follow up, there will be approximately 1600 patient-yrs of follow up and a median follow up of approximately 3 yrs at the time of the primary analysis, anticipated to occur 5.6 yrs after enrollment of the first patient. If the true risk of BC recurrence is 2% per yr, we anticipate 31 BC recurrences and an estimated 3-yr breast cancer free interval (BCFI) failure of 5.6% (95% CI 4.0% to 7.9%).

Translational Research will investigate different ovarian function parameters; uterine evaluation; and circulating tumor DNA. FFPE tissue of the primary tumor will be collected to integrate different parameters related to biology of BC arising in young women. All material will be banked centrally.

Psycho-oncological Companion Study on fertility concerns, psychological well-being and decisional conflicts is mandatory in the United States and open to interested centers elsewhere.

Accrual: Target: 500; Actual: 4 (31 May 2015)

Contact Information

POSITIVE is conducted and sponsored by the International Breast Cancer Study Group. Alliance for Clinical Trials in Oncology is US sponsor for NCTN network. Contact Trial Coordinators at ibcsg48_positive@fstrf.org.

Citation Format: Pagani O, Partridge A, Azim Jr HA, Peccatori FA, Ruggeri M, Sun Z. POSITIVE: A study evaluating pregnancy and disease outcome and safety of interrupting endocrine therapy for young women with endocrine responsive breast cancer who desire pregnancy (IBCSG 48-14/BIG 8-13). [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 OT2-01-08.

Abstract PD1-08: Factors affecting uptake and adherence to breast cancer chemoprevention: A systematic review and meta-analysis

Chemoprevention is a risk reduction option for women who have increased risk of breast cancer. Selective Estrogen Receptor Modulators (SERMs) have been extensively tested, and alternative agents are being evaluated. Long-term adherence to chemoprevention is critical to obtaining the drug's full benefit. We systematically reviewed articles reporting uptake rates and adherence among healthy adult women, who were prescribed medication to prevent primary breast cancer. We also extracted data on the clinical, socio-demographic and psychological predictors of uptake and adherence.

Searches were performed in PubMed, CINAHL, EMBASE, and PsychInfo, yielding 3851 unique articles. Title, abstract and full text screening left 53 articles that met inclusion criteria, and a further 4 studies were identified from reference lists, giving a total of 57. The mean quality score using the Mixed Methods Appraisal Tool was 3 out of 4.

Thirty-one articles reported uptake, of which 14 tested predictors, and 23 reported adherence of which 11 tested predictors. Seven studies reported qualitative data. Most studies (50) involved SERMs, but 5 tested Aromatase Inhibitors, 1 tested Aspirin, 1 tested a statin. Twenty studies included data from a clinical setting, 35 reported trial data, and 2 reported both.

Twenty-four studies reporting 26 instances of uptake in 21,423 women were included in a meta-analysis. The pooled uptake estimate was 16.3% (95% CI, 13.6-19.0), with high heterogeneity (I^2=98.9%, p&lt;0.0001). Uptake was unaffected by study location or agent, but was significantly higher in trials (25.2% [95% CI, 18.3-32.2]) than in clinical settings (8.7% [95% CI, 6.8-10.9]). Factors associated with higher uptake in two or more studies included having an abnormal biopsy, a physician recommendation, higher objective risk, fewer side-effect or trial-related concerns, and older age. Heterogeneity in data collection prevented a meta-analysis of adherence. Data suggested adequate day-to-day adherence among women who initiated treatment, with 5/6 studies reporting ≥80% of medications being taken appropriately. Persistence over 3-12 months was also high, with 5/7 studies reporting that ≥80% women were still taking chemoprevention. Long-term persistence was lower, with only 1/10 studies reporting a persistence of ≥80% by 5-years. Factors associated with lower adherence or persistence included allocation to Tamoxifen (vs. placebo or Raloxifene), depression, smoking, and older age. Objective and subjective risk was a theme in all qualitative studies, although other topics involved in decision-making included concerns about medications (6/7), low knowledge (3/7), lack of information (2/7), and trial-related issues (2/7).

Chemoprevention uptake for the prevention of breast cancer is low, and long-term adherence is often insufficient for the full preventive effect. Uptake rates were higher in trials than in clinical settings, suggesting further work should focus on implementing chemoprevention within routine patient care. Further research is warranted to identify factors amenable to modification and to improve informed decision-making surrounding chemoprevention.

Citation Format: Smith SG, Sestak I, Forster A, Partridge A, Side L, Horne R, Wardle J, Cuzick J. Factors affecting uptake and adherence to breast cancer chemoprevention: A systematic review and meta-analysis. [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 PD1-08.

Abstract P5-11-02: Survival benefit needed to undergo chemotherapy: Patients and physicians preferences

Background: Data regarding patients (pts) and physicians' preferences for modern adjuvant chemotherapy (CT) are limited. Prior studies suggested that most pts with early stage breast cancer were willing to receive 6 months of adjuvant cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) for modest survival benefits (e.g. most women would have accepted 3-6 months extension of life).

Methods: E5103 was a phase III trial which randomized node positive or high risk node negative breast cancer pts to receive adjuvant CT (doxorubicin, cyclophosphamide and paclitaxel) with either placebo or bevacizumab. Telephone based surveys were administered to all pts enrolled on E5103 between 01/Jan/10 and 08/Jun/10, as part of a Decision-Making/Quality of Life component. Results presented here are part of the 18 months post-enrollment follow-up. Pts were asked to rate the survival benefit needed to justify 6 months of CT. A complementary survey was sent to all physicians who registered at least one pt on E5103.

Results: 465 out of 519 eligible pts (90%) responded to this survey at 18 months. Main reasons for non response were: inability to reach the patient (6%) or patient refusal (2%). Median pts age was 51 (25-76); 42% of pts had at least a college degree. The majority had at least Stage II cancer.

179 (16%) physicians participated, among whom median age was 50 (35-70). The median years in practice was 17 (3-38); 78% of physicians worked on large size practices, 72% saw at least 5 new breast cancer pts/month, and 77% enroll between 1-4 pts on trials/month.

We found considerable variation in pts preferences particularly for modest survival benefits: a substantial minority of pts (24%) would consider 6 months of CT definitely worthwhile for 1 month survival benefit, 18% would possibly consider it and 56% would not. The percentage considering CT definitely worthwhile increased with greater benefit, but did not reach 100%, even with 24 months survival benefit. About half of pts considered 6 months of CT definitely worthwhile for 9 months benefit, 70% for 12 months and 84% for 24 months.

Physicians were less likely to accept CT for a small chance of benefit (34% of pts vs. 5% of physicians would definitely consider CT worthwhile for 2 months of benefit). For longer benefit, pts and physicians choices were similar (84% of pts vs. 92% of physicians would definitely consider CT worthwhile for 24 months benefit).

Table Yes, definitely worthwhileYes, maybeNo, not worthwhileNo answerConsider 6 months of CT to live:PtsPhysiciansPtsPhysiciansPtsPhysiciansPts/Physicians*1 month longer24%3%18%15%56%80%2%2 months longer34%5%23%32%41%60%2%6 months longer44%32%35%54%19%12%2%9 months longer53%51%34%42%11%5%2%12 months longer70%75%23%22%5%1%2%24 months longer84%92%12%5%2%1%2%n Pts= 465; n Physicians= 179; * equal results in both groups

Conclusions: This subgroup of pts who had undergone modern adjuvant CT in a large multicenter randomized controlled trial and these physicians who registered pts on the same trial had different cutoffs for acceptable levels of benefits and risks when considering adjuvant chemotherapy. It is important to engage pts in determining whether CT is or is not a "reasonable" option for treatment.

Citation Format: Vaz Luis I, O'Neill A, Sepucha K, Miller KD, Baker E, Dang CT, Northfelt DW, Winer EP, Sledge GW, Schneider BP, Partridge A. Survival benefit needed to undergo chemotherapy: Patients and physicians preferences. [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 P5-11-02.

Genetic variant predicts bevacizumab-induced hypertension in ECOG-5103 and ECOG-2100

BACKGROUND

Bevacizumab has broad anti-tumour activity, but substantial risk of hypertension. No reliable markers are available for predicting bevacizumab-induced hypertension.

METHODS

A genome-wide association study (GWAS) was performed in the phase III bevacizumab-based adjuvant breast cancer trial, ECOG-5103, to evaluate for an association between genotypes and hypertension. GWAS was conducted in those who had experienced systolic blood pressure (SBP) >160 mm Hg during therapy using binary analysis and a cumulative dose model for the total exposure of bevacizumab. Common toxicity criteria (CTC) grade 3-5 hypertension was also assessed. Candidate SNP validation was performed in the randomised phase III trial, ECOG-2100.

RESULTS

When using the phenotype of SBP>160 mm Hg, the most significant association in SV2C (rs6453204) approached and met genome-wide significance in the binary model (P=6.0 × 10(-8); OR=3.3) and in the cumulative dose model (P=4.7 × 10(-8); HR=2.2), respectively. Similar associations with rs6453204 were seen for CTC grade 3-5 hypertension but did not meet genome-wide significance. Validation study from ECOG-2100 demonstrated a statistically significant association between this SNP and grade 3/4 hypertension using the binary model (P-value=0.037; OR=2.4).

CONCLUSIONS

A genetic variant in SV2C predicted clinically relevant bevacizumab-induced hypertension in two independent, randomised phase III trials.

Abstract P6-08-03: Informational needs and psychosocial assessment of patients in their first year after metastatic breast cancer diagnosis

Background: Psychosocial distress is common after a diagnosis of breast cancer. Little is known about the informational needs and the psychosocial adjustment of patients diagnosed with metastatic breast cancer (MBC) within the first year of their diagnosis.

Methods: Patients with MBC from a single academic institution completed a cross-sectional self-administered paper survey. The survey included demographics, the Medical Outcomes Study Short Form-36 (SF-36), the Hospital Anxiety and Depression Scale (HADS), and Toronto Informational Needs Questionnaire-Breast Cancer (TINQ). Medical history was obtained by chart review. The Spearman correlation coefficient assessed the relationship between TINQ and the following: age at MBC diagnosis, disease free interval (DFI), time between survey completion and MBC diagnosis, number of lines of therapy, and HADS.

Results: Fifty-two (90%, 50F 2M) patients completed the survey. Median age at MBC diagnosis was 52 yrs (range 22–81). Thirty-nine (75%) patients had completed college, 92% were Caucasian. Median time between MBC diagnosis and survey completion was 6 months (range 1–12). Sixteen (31%) patients had de novo stage 4 disease. At time of survey completion, 36 (69%) patients were on 1st line therapy with some patients were receiving their 4th line of therapy. SF-36 scores were lower in all 8 subscales compared to the general population. In particular, role limitations due to physical health (Norm-based transformation mean score 39.3, SD=12.1), social functioning (Mean 41.8, SD=12.7), role limitations due to emotional problems (Mean 43.3, SD=13.3), vitality (Mean 44.1, SD=10.8) and general health (Mean 44.3, SD=12.1) were diminished. The Physical and Mental Component Summary norm-based transformation scores were 43.2 (SD = 11.7) and 45.4 (SD = 11.3) respectively.9/48 (19%) patients met criteria for anxiety, and 4/48 (8%) patients met criteria for depression by HADS criteria (scores &gt; 11). TINQ scores range from 51 to 255, with 35/52 (69%) having a total score &gt; 200, suggesting high informational need. Of the 5 subscales, treatment information was most important, followed by information about disease, physical care, psychosocial needs and investigative tests. The most important informational issues for patients were: if there was cancer anywhere else in their body (Mean score 4.78), how to deal with side effects (Score 4.78), and if there were ways to prevent treatment side effects (Score 4.77), with a score of 5=extremely important, and 1= not important.

Only DFI correlated with TINQ (Spearman coefficient −0.413, p = 0.011), with patients who had a shorter DFI having greater informational needs. Age at MBC diagnosis, time of completion of survey, number of lines and HADS were not significant.

Conclusion: Based on this study, patients with recently diagnosed MBC have high informational needs and poor psychosocial adjustment. The overall quality of life appears to be worse in this population of patients compared to the general population. There is also a subset of patients who are dealing with significant anxiety and depression. Additional research, education, and supportive care services aimed at meeting the informational and psychosocial needs of women living with MBC are warranted.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-08-03.

PD04-05: Body Image Issues in Young Breast Cancer Patients: The Impact of Chemotherapy, Hormone Treatment, and Surgery

Background: While there is evidence that younger women with breast cancer are more likely to experience compromised quality of life compared to older women, few studies have prospectively explored the impact of treatment, including surgery, chemotherapy, and hormone therapy, on body image, in particular, in very young women (≤40 years old). This analysis examined treatment-associated differences in self-reported body image among a large cohort of young women diagnosed with breast cancer.

Methods: 431 women enrolled in an ongoing multi-center prospective cohort study with Stage 0-Stage III breast cancer were included in this analysis. Body image was measured at baseline (1-12 months following diagnosis) using three items from the Cancer Rehabilitation Evaluation System (CARES) survey. CARES scores range from 0–4, with higher scores indicative of greater image concerns. Mean differences in CARES scores between treatment groups (chemotherapy within the last month vs. none; hormone therapy vs. none; lumpectomy vs. mastectomy alone vs. mastectomy + reconstruction) were estimated using T-tests and one-way ANOVA. To control for concurrent treatment, stage, and time since diagnosis, multiple linear regression models were fit and least squares means estimated and compared between treatment groups. Multiple comparisons were adjusted for using the Bonferroni correction.

Results: Median age at diagnosis was 37 (range: 17–40) and median time from diagnosis to study enrollment was 5 months (range: 1–12 months). In the unadjusted analysis, there were no significant differences in scores between women who had received chemotherapy within the last month and those who did not (p=0.80), while women who reported hormone treatment had higher mean CARES scores compared to women who did not (p=0.04). Among women who had undergone surgery (n=370), women who had lumpectomies had a mean CARES score of 0.95, which was significantly lower (p&lt;.0001) compared to both women who had undergone mastectomy alone (CARES: 1.89) and women who reported mastectomy + reconstruction (CARES: 1.53). After adjusting for concurrent treatment (including radiation), time since diagnosis, and stage of disease, only differences between surgical groups remained significant (p&lt;.0001), with mean scores among women who had either undergone mastectomy alone (CARES: 2.02) or together with reconstruction (CARES: 1.58) higher compared to those who had a breast conserving procedure (CARES: 0.92) Conclusion: To the best of our knowledge, this is the largest analysis of treatment-related body image issues in young women with breast cancer. Treatment with chemotherapy and hormonal therapy did not appear to affect short-term body image. However, women who had a breast conserving procedure had the fewest body image concerns as measured by the CARES, while women undergoing more radical surgery appear to be at increased risk for low perceived body image though this may be mitigated to a degree by reconstruction. Further analyses will explore whether differences between surgical groups persist over time as well as examine the trajectory of change over the course of follow-up.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD04-05.

P4-11-12: Molecular Phenotype of Breast Cancers in a Large Cohort of Young Women According to Time Interval Since Pregnancy

Background: The increase in breast cancer risk during pregnancy and post partum is well recognized. The cross-over to protective effect does not occur until many years later and varies with age at first birth. Recently, a genomic signature specific to the pregnant compared with the non-pregnant breast has been identified; this signature remains present in the postmenopausal parous breast. Given this, we investigated whether time interval since pregnancy affects the phenotype of breast cancers arising in young women compared with nulliparous women. Methods: We examined molecular phenotype, according to histologic grade and biomarker status, in relation to time since pregnancy in an ongoing prospective cohort study (n=355) of young women (≤40yrs) with breast cancer. Medical records were reviewed for tumor stage and receptor status. Parity was ascertained from questionnaires completed within 9 months of diagnosis. Tumor grade was determined by central pathology review. Using tumor grade and biomarker expression, cancers were categorized as luminal A (ER+ and/or PR+, HER2−, histologic grade 1 or 2); luminal B ( ER+ and/or PR+, HER2+, or ER and/or PR+, HER2− and grade 3); HER2 type (ER-, PR-, HER2+); and triple negative (ER-, PR-, HER2−).

Results: The median age of the study population is 37 years (range 17–40). Overall, 80% of women had stage 1 or 2 disease; 67% of cancers were ER positive and 32% showed HER2 overexpression. The distribution of breast cancer molecular phenotypes by time interval since last pregnancy is shown in the table.

Distribution of molecular phenotype by interval between last pregnancy and diagnosis

Resorufin Butyrate as a Soluble and Monomeric High-Throughput Substrate for a Triglyceride Lipase

Triglyceride lipases such as lipoprotein lipase, endothelial lipase, and hepatic lipase play key roles in controlling the levels of plasma lipoprotein. Accordingly, small-molecule modulation of these species could alter patient lipid profiles with corresponding health effects. Screening of these enzymes for small-molecule therapeutics has historically involved the use of lipid-based particles to mimic native substrates. However, particle-based artifacts can complicate the discovery of therapeutic molecules. As a simplifying solution, the authors sought to develop an approach involving a soluble and monomeric lipase substrate. Using purified bovine lipoprotein lipase as a model system, they show that the hydrolysis of resorufin butyrate can be fluorescently monitored to give a robust assay (Z′ > 0.8). Critically, using parallel approaches, they show that resorufin butyrate is soluble and monomeric under assay conditions. The presented assay should be useful as a simple and inexpensive primary or secondary screen for the discovery of therapeutic lipase modulators.

Structural correlates of antibodies associated with acute reversal of amyloid beta-related behavioral deficits in a mouse model of Alzheimer disease

Immunotherapy targeting of amyloid beta (Abeta) peptide in transgenic mouse models of Alzheimer disease (AD) has been widely demonstrated to resolve amyloid deposition as well as associated neuronal, glial, and inflammatory pathologies. These successes have provided the basis for ongoing clinical trials of immunotherapy for treatment of AD in humans. Acute as well as chronic Abeta-targeted immunotherapy has also been demonstrated to reverse Abeta-related behavioral deficits assessing memory in AD transgenic mouse models. We observe that three antibodies targeting the same linear epitope of Abeta, Abeta(3-7), differ in their ability to reverse contextual fear deficits in Tg2576 mice in an acute testing paradigm. Reversal of contextual fear deficit by the antibodies does not correlate with in vitro recognition of Abeta in a consistent or correlative manner. To better define differences in antigen recognition at the atomic level, we determined crystal structures of Fab fragments in complex with Abeta. The conformation of the Abeta peptide recognized by all three antibodies was highly related and is also remarkably similar to that observed in independently reported Abeta:antibody crystal structures. Sequence and structural differences between the antibodies, particularly in CDR3 of the heavy chain variable region, are proposed to account for differing in vivo properties of the antibodies under study. These findings provide a structural basis for immunotherapeutic strategies targeting Abeta species postulated to underlie cognitive deficits in AD.

The Quality of Decisions about Adjuvant Chemotherapy for Early Stage Breast Cancer

Background: Decisions about adjuvant chemotherapy are highly challenging for many women with early stage breast cancer. We sought to assess the quality of breast cancer patients' decisions about chemotherapy by measuring their knowledge and the degree to which their treatment decisions reflect their goals and preferences.Methods: We mailed a survey to early stage (I, II) breast cancer survivors who were treated at one of four sites, as part of a larger study to validate decision quality instruments. A subset of women completed the chemotherapy module, which included questions about the patient-provider interaction, about facts, about treatment goals, and about the patient's preferred treatment. Characteristics associated with knowledge were identified with linear regression. Characteristics associated with chemotherapy were identified with logistic regression.The percentage of patients who received their preferred treatment was calculated.Results: 358 patients completed the survey (response rate 59%). 64% of patients had Stage I disease, and 57% had chemotherapy. Average age was 56.9 years, 82.6% were white, and 63.7% had a college degree.Decision making: 70% of patients reported that their provider mentioned chemotherapy as an option. 43% reported that their provider asked for their preference about chemotherapy. 23% said the doctor mainly made the decision, 29% said they mainly made the decision, and 46% said both made the decision.Most women (92%) felt their level of involvement was about right.Knowledge: The mean knowledge score was 39.6% (SD 20.3). 29.9% knew that less than half of women with early stage breast cancer eventually die from breast cancer without chemotherapy or hormone therapy.21.8% knew that more than half are free from recurrence in 10 years without chemotherapy or hormone therapy. Chemotherapy treatment and the doctor having discussed chemotherapy were significantly associated (p&lt;0.05) with higher knowledge. Younger age at diagnosis, white race, higher income, and a college degree were also significantly associated with higher knowledge (p&lt;0.05).Treatment: Factors associated with having chemotherapy were younger age (OR 1.71, 95% CI 1.01, 2.91) and not having hormone therapy (OR 3.2, 95% CI 1.92, 5.42). Factors associated with not having chemotherapy were lower stage (OR 0.17, 95% CI 0.10, 0.30), mastectomy (OR 0.47, 95% CI 0.26, 0.86), and the goal “live as long as possible” (OR 1.41, 95% CI 1.10, 1.80).Concordance with preferences: 81.6% of patients who preferred chemotherapy received it, and 92.6% of patients who preferred no chemotherapy received no chemotherapy.Conclusion: Breast cancer patients had substantial knowledge deficits about chemotherapy, which were even more prevalent among older, non-white, less educated, and lower-income women. In addition, more than half of women reported they were not asked about their preferences, and some reported getting chemotherapy treatment that was not concordant with their preferences.Oncologists should address knowledge deficits and explicitly ask patients their preferences.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2083.

Decisions about Breast Reconstruction after Mastectomy: Patient Involvement, Knowledge, and Preferences

Background:Most breast cancer patients who have a mastectomy do not have breast reconstruction, and rates of reconstruction vary by race, education, and geographic location, suggesting problems with decision making. We sought to assess the quality of decisions about breast reconstruction by measuring patient involvement in decision making, patient knowledge, and the degree to which decisions reflected patients' goals.Methods: Breast cancer survivors from four sites who were treated with mastectomy in the past 3 years completed a mailed survey, as part of a larger study to validate decision quality instruments. The survey contained questions about the decision making process, factual questions, and questions about personal goals and concerns. Characteristics associated with knowledge were identified with linear regression. Goals/concerns associated with reconstruction were identified using logistic regression. The percent match between treatment preference and treatment received was calculated.Results: The larger study recruited 456 patients (overall response rate 59%). 91 patients completed the reconstruction module. Average age was 56.9 years, 82.6% were white, 63.7% had a college degree, and 64% had Stage I disease. 45.8% had reconstruction.Decision making: 78% of patients reported that their doctor mentioned reconstruction. Most reported a discussion of the pros of reconstruction (63.8%), whereas the minority reported a discussion of the cons (20.9%). 76% reported being asked for their preference about reconstruction. 3% said the doctor mainly made the decision, 74% said they made the decision, and 15% said both made the decision. Most (81%) felt their level of involvement was about right.Knowledge:The mean knowledge score was 32.9% (SD=19). 41% knew that reconstruction has little effect on cancer surveillance. 54% knew that recovery after implant surgery is easier than after flap surgery. 3.3% knew that about 1/3 of patients have a major complication. On bivariate analysis, reconstruction (43.3 vs. 32.6, p=0.053), higher income (43.4 vs. 26.3, p=0.008), a college degree (43.4 vs. 26.2, p&lt;0.01), and being married (40.9 vs. 29, p=0.04) were associated with higher knowledge. On multivariate analysis, higher income was associated with higher knowledge (p=0.0013).Preferences:The following goals were associated with reconstruction: “use your own tissue to make a breast” (OR 1.309, CI 1.028, 1.605), “avoid using a prosthesis” (OR 1.254, CI 1.039, 1.512), and “wake up after mastectomy with reconstruction underway” (OR 1.254, CI 1.057, 1.487). Patients who felt it was important to “avoid putting foreign material in your body” were less likely to have reconstruction (OR 0.682, CI 0.518, 0.899).The majority of patients (81%) had treatment that was concordant with preference.Conclusions: Despite reporting high involvement in decisions about reconstruction, breast cancer patients undergoing mastectomy had major knowledge deficits, and many reported having treatment they did not prefer. In addition to involving patients in decisions about reconstruction, surgeons should discuss both the pros and the cons and should explicitly ask patients for their preference about reconstruction.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3103.

Quality of Life of Early Stage Breast Cancer Patients 65 Years Old or Older Randomized to Standard Chemotherapy or Capecitabine: A Cancer and Leukemia Group B Study (CALGB 49907)

Background: CALGB conducted a randomized Phase III trial (49907) to test whether older cancer patients receiving capecitabine would have a similar clinical outcome as those receiving standard chemotherapy, but less toxicity. This represented an important quality of life (QoL) paradigm in which treatment recommendations might be based on QoL findings if there was less toxicity for capecitabine with similar clinical outcomes as those achieved with standard chemotherapy. Materials and Methods: A preplanned QoL assessment was preformed in 350 patients randomized to either standard chemotherapy (CMF or AC) (n= 182) or capecitabine (n=168). All patients were interviewed by telephone using standardized questionnaires conducted at baseline, mid-treatment, at 1 month post-treatment, and at 12, 18 and 24 months. Data were analyzed using pattern mixture models and analysis of covariance with repeated measures, in which the sample was divided into groups based on the period of time they had completed assessments. Results: Patients in the capecitabine arm reported a better overall QoL (EORTC p&lt; 0.0001), less fatigue (EORTC p&lt; 0.0001), less nausea and vomiting (EORTC, p&lt; 0.0001), less constipation (EORTC, p&lt; 0.0001), less systemic side effects (EORTC, p&lt; 0.0001), better appetite (EORTC, p&lt; 0.0001), better body image (EORTC, p&lt; 0.0001), less psychological distress (Hospital Anxiety and Depression scale, p&lt; 0.0001), better role (EORTC, p&lt; 0.0001) and social functioning (EORTC, p&lt; 0.0001) than did those in the standard chemotherapy arm at either mid-treatment and/or the end of treatment for those assessed through 24 months. Capecitabine patients reported worse diarrhea (EORTC, p&lt; 0.0001) at mid-treatment, and worse hand–foot symptoms (p&lt; 0.0001) at mid and end of treatment than did those receiving standard chemotherapy. There were no significant differences in most of these measures by 12 months. Discussion: With clinical results showing a significantly improved relapse-free and overall survival for patients who received standard chemotherapy vs. capecitabine (Muss et al., NEJM 2009; 360: 2118), the QoL results will not guide treatment recommendations. However, the QoL results largely confirmed that patients treated with capecitabine experience significantly better QoL vs. those treated with standard chemotherapy due to less toxicity during and at the end of treatment for the sizable group of patients who had completed interviews through 24 months (n=245). These results indicate that despite the worse clinical outcome of patients who receive capecitabine treatment, the majority of capecitabine patients did not experience a worsening QoL from 12 months through 24 months compared to patients receiving standard chemotherapy. Further, these findings are relevant in selecting treatments in the metastatic setting where QoL endpoints often drive decision-making and the goal is to achieve a reasonable level of efficacy while minimizing toxicity.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5035.

Dose-dense (DD) doxorubicin and cyclophosphamide (AC) followed by weekly paclitaxel (P) with trastuzumab (T) and lapatinib (L) in HER2/neu-positive breast cancer is not feasible due to excessive diarrhea: updated results

Abstract #2108

Background: DD q 2 weekly (w) AC → P + T x 1 year (y) has an acceptable safely profile w/ congestive heart failure (CHF) rate of 1/70 pts (Dang, JCO 2008). Lapatinib (L) is effective in HER2 (+) BC. We conducted a pilot study of dd AC → w P + T + L to determine its feasibility and cardiac safety.&#x2028; Methods: Enrolled pts had HER2 (+) BC; LVEF &gt; 50%. Rx consisted of AC at 60/600 mg/m2 x 4 q 2 w (w/ pegfilgrastim 6 mg day 2) → P at 80 mg/m2 x 12 q w + T x 1 y; L (1000 mg daily beginning w/ P + T and continued x 1 y). MUGA is obtained at baseline and at months (mo) 2, 6, 9, and 18. Rx is considered feasible if 1) &gt; 80% pts can complete the PTL phase without a dose delay or reduction and 2) the cardiac event rate (CHF or cardiac death) is &lt; 4%. Pts can remain on-Rx w/ one dose reduction of L (1000 mg → 750 mg) for a G 3 event or &lt; G 3 toxicity (unacceptable).&#x2028; Results: From March 2007 to April 2008, we enrolled 95 pts. Median (med) age was 45 years (range, 28-73). At a med follow-up of 7 months, 90 are evaluable. Of the 90 pts, 34 (37%) withdrew from study during the PTL phase; 29 for a 2nd event of G 3 or unacceptable &lt; G 3 toxicities (15 G 3 diarrhea, 4 G 1/2 diarrhea, 1 G 3 rash, 2 G 2 rash, 1 G 3 dyspnea and also had G 3 diarrhea, 1 G 3 ↑QTc also had G 3 diarrhea, 1 G 3 ↑ALT also had G 3 diarrhea, 1 G 3 paronychia, 1 G 3 pneumonitis, 1 asymptomatic LVEF ↓, 1 myocarditis) and 5 for other reasons (2 personal reason, 1 PCP pneumonia, 1 progression, 1 P hypersensitivity). Overall, 25/90 (27%) pts had G 3 diarrhea and 31/90 (34%) pts required a dose reduction of lapatinib. Med LVEF at baseline is 67% (N=95), at mo 2 is 68% (N=90), at mo 6 is 65% (N=53), and mo 9 is 65% (N=28). To date there are no patient drop-outs due to significant LVEF declines after dd AC; one patient dropped during PTL out due to an asymptomatic LVEF decline.&#x2028; Discussion: L at 1000 mg/day is not feasible combined w/ weekly P and T by protocol stipulation (&gt; 20% pts required L dose reduction) primarily due to excessive G 3 diarrhea. These results have led to the modification of Design 2 (Arm D) of ALTTO. We will report updated results.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2108.

Practical clinical guidelines for assessing and managing menopausal symptoms after breast cancer

BACKGROUND

The purpose of this study was to provide practical, evidence-based guidelines for evaluating and treating common menopausal symptoms following breast cancer.

METHODS

Literature review of the causes, assessment and management of menopausal symptoms in breast cancer patients.

RESULTS

A number of nonhormonal treatments are effective in treating hot flashes. Whether pharmacological treatment is given will depend on the severity of symptoms and on patient wishes. For severe and frequent hot flashes, the best data support the use of venlafaxine, paroxetine and gabapentin in women with breast cancer. Side-effects are relatively common with all these agents. For vaginal dryness, topical estrogen treatment is the most effective but the safety of estrogens following breast cancer is not established. There are limited data on effective treatments for sexual dysfunction during menopause.

CONCLUSION

Menopausal symptoms after breast cancer should be evaluated and managed as warranted using a systematic approach and may benefit from multidisciplinary input.

Genetic testing in young women with breast cancer: Results from a web-based survey

21093

Background: Young women with breast cancer have an increased risk of harboring a BRCA1/2 mutation. The frequency of genetic testing in this population is not well described. We evaluated the reported frequency and factors associated with genetic testing among young breast cancer survivors identified through the Young Survival Coalition (YSC), an international advocacy group for young women with breast cancer. Methods: Items regarding family history and genetic testing were included in a large web-based survey addressing quality of life and fertility issues for young women with breast cancer. All YSC members were invited by email in March 2003 (N= 1,703 women) to participate in this cross-sectional survey. Results: 657 women completed the on-line survey; 622 were eligible for this analysis (age <40, no metastatic or recurrent disease). Mean age at breast cancer diagnosis was 33 years; mean age when surveyed 35.5 years. Stages included: 0 (10%), I (27%), II (49%), III (12%), missing (3%). 90% of women were white; 64% married; 49% with children; 78% had at least a college education; 42% of women reported a 1st or 2nd degree relative with breast or ovarian cancer, and 13% considered themselves high-risk for harboring a genetic mutation at the time of diagnosis. At the time of the survey, 23% of women had undergone genetic testing, and 26% of those tested reported that a mutation was found. In a multivariate model, women who were younger (age 36–40 vs. age =30, O.R. 2.26, p=0.004), more educated (< college vs. > college education, O.R. 2.62, p=0.0009), had a family history of breast or ovarian cancer (O.R. 3.15, p<0.0001), and had had a mastectomy (O.R. 1.99, p=0.001) were more likely to have undergone genetic testing. Non-significant covariates included: age at survey, stage, time since diagnosis, race, marital status, employment, finances, insurance, number of children, comorbidities, baseline anxiety and depression, and fear of recurrence. Conclusion: The majority of women diagnosed with breast cancer age 40 and younger do not undergo genetic testing. Younger, more educated women with a family history of breast or ovarian cancer are more likely to get tested. Further research to define the appropriateness of genetic testing in this relatively high-risk population is warranted.

No significant financial relationships to disclose.

Impact of physical activity on insulin levels in breast cancer survivors

555

Background: Accumulating data suggest that body weight and physical activity may affect breast cancer risk and outcomes. Biological mechanisms underlying these relationships are not clear. Studies have demonstrated that high levels of insulin, often seen in obese and sedentary individuals, are also associated with an increased risk of breast cancer recurrence and breast cancer-related death. We sought to analyze whether exercise lowers insulin levels in a population of breast cancer survivors. Methods: Inactive women with early stage breast cancer who had completed adjuvant treatment were randomized to a 16 week, mixed cardiovascular and strength training exercise intervention, or to a normal care control group. Target exercise goals included 2 supervised strength training sessions and 90 minutes of unsupervised cardiovascular exercise each week. Fasting insulin and glucose levels, as well as measurement of weight, body composition, and circumference at the waist and hip, were collected at baseline and after 16 weeks in both groups, and changes in these measures were assessed. Results: One hundred and one women were randomized. Comparison of changes in anthropometric measures are presented in Table 1 . Baseline insulin levels were similar in the 2 groups. After the 16-week exercise or control period, insulin levels decreased by 2.86 μIU/ml in the exercise group (p=0.03), and by 0.27 μIU/ml in the control group (p=0.65). A comparison of the change in insulin levels across time in the 2 groups approached statistical significance (p=0.07). There was also a trend toward improvements in insulin sensitivity in the exercise group (p=0.09), with no change seen in fasting glucose levels. Conclusions: Physical activity was associated with a decrease in insulin levels and in hip circumference in breast cancer survivors. The relationship between physical activity and breast cancer prognosis may be mediated, at least partially, through changes in insulin levels and/or changes in fat mass or deposition.

[Table: see text]

No significant financial relationships to disclose.

The impact of an exercise intervention on body composition, fat distribution, and weight in breast cancer survivors

590

Background: Recent research has demonstrated that obesity increases a woman’s risk of breast cancer recurrence. Although the mechanism is not well understood, it is known that obese women have higher levels of insulin and other hormones related to energy balance. In this study, we sought to explore the impact of an exercise intervention on body composition, fat distribution, weight, and insulin levels in a population of breast cancer survivors. Methods: Inactive women with early stage breast cancer who had completed adjuvant chemotherapy and/or radiation were randomized to a 16-week exercise intervention or a normal care control group. The exercise intervention consisted of supervised strength training and unsupervised cardiovascular exercise, with a goal of 2 strength training sessions and 90 minutes of cardiovascular exercise each week. Measurement of weight, body composition, and circumference at the waist and hip, were collected at baseline and after 16 weeks in both groups. Fasting blood samples were also collected at these two time points for insulin and glucose levels, so that changes in these levels between the intervention and control groups could be compared. Results: Eighty-five women have been randomized; complete anthropometric data are presently available for 51. Women in the exercise group experienced a nonsignificant decrease in body weight, body fat, and circumference at the waist and hip, as compared to control patients. Participants completed a median of 84% of scheduled strength training sessions and 80% of recommended cardiovascular sessions. Strength increased by an average of 40% during the exercise intervention. Prior studies have demonstrated significant inter-assay variability in biomarker testing, thus insulin and glucose testing will be performed when all patients have completed the protocol. Conclusions: Compliance with the exercise intervention was good. Women in the exercise group experienced non-significant changes in anthropometric measures, and increased strength during the 16-week intervention. Final strength and anthropometric data from the entire cohort will be available for presentation. This project was supported by an ASCO Career Development Award and funding from the Lance Armstrong Foundation.

No significant financial relationships to disclose.

Integrin regulation

Integrin signaling is bidirectional. 'Inside-out' signals regulate integrin affinity for adhesive ligands, and ligand-dependent 'outside-in' signals regulate cellular responses to adhesion. Integrin extracellular domains are yielding to high-resolution structural analyses, and intracellular proteins involved in integrin signaling are being identified. However, a key unresolved question is how integrins propagate signals across the plasma membrane.