Abstract P5-13-07: An investigator-initiated registry trial of simple oral therapy for low risk breast cancer

Background: Across multiple studies performed in several countries with widely instituted screening mammography programs at different intervals between exams, up to 19% of breast cancer identified is in patients whose disease would otherwise go undetected and not have caused any ill effect if left untreated. Recent advances in pathologic and multigene assays have demonstrated promise to better identify low risk breast cancer and appropriately tailor treatments. Nonetheless, most women who may have such low-risk, estrogen receptor expressing lesions continue to be offered only an aggressive treatment paradigm. This most commonly includes surgery and lymph node evaluation and, in the case of breast conservation, breast irradiation following surgery, with the option of endocrine therapy for 5-10 years.

Trial design: We propose a multi-center US registry study of post-menopausal, female breast cancer patients age 60 and older who will be managed 5 years with oral endocrine therapy for mammographically screen-detected, node-negative, unifocal invasive disease with low clinical grade, high estrogen/progesterone receptor expression, negative Her2 expression, Ki67 rate <20%, and low-risk multigene expression analysis with Mammaprint Breast Cancer Recurrence Assay. Target lesions will be confirmed with a pre-treatment bilateral breast MRI and imaged routinely with standard mammography or ultrasound at 3-month intervals during months 1-36 and at 6-month intervals during months 37-60 to assess for disease response. Enrolled patients will have an ECOG performance status of 0-2. Medication history will be documented at routine follow-up visits.

Our primary objective will be to determine the frequency of conversion from a low-toxicity approach with oral endocrine therapy to conventional care with surgery +/- radiation therapy as a result of progression of disease or patient/provider choice. Progression of disease will be quantified objectively as >20% growth of the target lesion as compared to baseline in imaging measurements. After 5 years of endocrine therapy sans disease progression, patients may elect to continue or stop treatment or convert to standard care.

Statistical methods: We will determine the conversion rate from oral therapy for any cause to conventional management (compliance). Compared to the most pessimistic assumed true-rate for compliance of 0.5, we predict >90% power to detect a decrease of 0.1 in outcomes with an alpha of 5% (corresponds to a 95% Confidence Interval). Using descriptive statistics, we will also quantify for disease responses and progression-free survival. Our sample size will be ample for multiple sub-analyses including measurement of differences emanating from tertiary care versus local oncologic management, advanced imaging outcomes (if performed on any subset of patients), effect of type of endocrine therapy type (SERM vs AI), and effect of age and/or comorbidity severity interaction.

Accrual: Clinic sites with large patient cohorts are now being selected nationwide to enroll and manage patients' disease with endocrine treatment only. We will select up to 20 sites and enroll 300 patients with low-risk disease.

Citation Format: Gadi VK, Preusse C, Calhoun KE, Kim J, Linden HM, Rendi M, Etzioni RB, Gooley T, Lyman G, Stork L, van der Baan B, Barth N, Rahbar H. An investigator-initiated registry trial of simple oral therapy for low risk 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 P5-13-07.

Abstract P3-08-11: Pregnancy after breast cancer and recurrence risk

Background: Several retrospective studies report an improved overall (and possibly disease-free) survival of women who become pregnant following breast cancer diagnosis compared to women who choose not to or are unable to become pregnant. The objective of the current study is to evaluate associations with breast cancer biologic and stage characteristics from the baseline tumor with different recurrence outcomes in women with and without a pregnancy subsequent to their cancer diagnosis.

Methods: From a population-based cohort study of all women aged 20-44 diagnosed with invasive breast cancer in the three county Seattle-Puget Sound metropolitan area, we conducted a secondary recontact interview. Recontact information included cancer recurrence and obstetric history, including all pregnancies occurring after breast cancer diagnosis. Univariate associations were evaluated using chi square. A time-to-event analysis was conducted, evaluating the relationship between pregnancy and recurrence, with consideration of stage and tumor type (triple negative tumor or not) as confounders.

Results: At this interim, an approximately 70% response rate for the re-contact study was achieved, yielding data from 458 women overall. Excluding 8 women who were pregnant at the time of their breast cancer diagnosis, 450 were available for analysis. Of these, 13 (2.9%) became pregnant at least once after their breast cancer diagnosis. Among women with complete pathologic information available (n = 274), those with a pregnancy subsequent to their cancer diagnosis had triple negative tumor types more often than those who did not have a subsequent pregnancy (4/8, 50% vs. 44/266, 17%, p = 0.03). Tumor stage did not differ between women with and without a subsequent pregnancy. Overall, 30 total cancer recurrences were captured in the re-contacted cohort; none of these occurred among women with subsequent pregnancy (0/13, 0% vs. 30/437, 6.9% among women without subsequent pregnancy), p = 0.3. For 448/450 women with complete information on timing of recurrence, a time-to-event analysis adjusting for tumor type did not show a significant association between subsequent pregnancy and recurrence risk, p = 0.14 by Likelihood Ratio test.

Conclusions: In this population, breast cancer recurrence risk was not increased among women with a pregnancy subsequent to their cancer diagnosis. Despite the more common triple negative tumor type among the group of women with subsequent pregnancy, none of these women experienced a cancer recurrence. Our study adds to a substantial literature suggesting that pregnancy after breast cancer does not appear to have a detrimental effect on disease recurrence. The relationship between tumor type and its potential influence on both decision-making regarding pregnancy and the biology of pregnancy as it relates to breast cancer recurrence merits further investigation.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-11.

[Quality assurance in excision of suspected malignant, preoperatively marked and unmarked, breast lesions. A one-year analysis]

The breast cancer incidence is increasing for all industrial countries in the last years. Therefore the relevance of screening methods especially of mammography for early registration of suspected lesions becomes more and more important. One result of using screening methods is an increased rate of patients with lesions which are suspected for cancer but non palpable. For the background of that fact we are describing our one year experience with the therapy of cancer suspected breast lesions in 136 female patients. In 47 cases (34.6%) there was a palpable and in 89 cases (65.4%) a non-palpable lesion. The need for mammography was assured in 43 patients (48.3%) through mastopathic controls, in 23 patients (25.8%) within the frame work of a preventive first mammography and in 15 patients (16.8%) through controls after operative therapy for breast cancer. All non-palpable lesions were marked preoperatively through mammography 88.8% (n = 79), sonography 6.7% (n = 6), or through magnet resonance imaging MRI 4.7% (n = 4). Every mammographic marked case was followed by an intraoperative specimen mammography. In 16.8% (n = 15 from 89) of the non-palpable marked areas, a carcinoma was found. 16.7% (n = 3) of the detected cancers were diagnosed in an in-situ-stage, all others in an early stage (pT1-, pN0-, M0-stage) and treated. Besides the early diagnosis of breast cancer and the resulted improvement of prognosis also the rate of breast saving therapies can be increased. Reflecting our datas it should be demanded a regular screening for defined risk groups. In conclusion to improve the prognosis of breast cancer patients and reduce the risk of ablative therapies it is necessary to release a consequent marking of non-palpable cancer suspected breast lesions, a consequent aseptic handling before operation, an intraoperative mammography of the resected area and a frozen section.

[Improved prognosis in breast carcinoma by excision of non-palpable carcinoma-suspected lesions. Analysis of 319 ambulatory surgery operations]

A retrospective study is described according to which 319 outpatients had been operated on for suspected carcinoma because of breast lesion, in the course of three years in this hospital. In 113 cases (35.4%) the lesion was palpable, in 206 cases (64.6%) it was not. In the non-palpable cases, mammography was indicated in 98 patients (47.6%) undergoing controls for mastopathy, in 41 patients (19.9%) undergoing a first mammography in the course of preventive check-ups, and in 33 patients (16.0%) undergoing a check-up after operative therapy of breast cancer. Prior to operation, 84.0% (n = 173) of the non-palpable lesions were marked by mammography, 11.2% (n = 23) by sonography, and 4.8% (n = 10) by magnet resonance imaging (MRI). Intraoperative specimen mammography was made in every case marked by mammography. In 19.4% (n = 40) out of the 206 cases of marked though non-palpable focuses a tumour was found. 25% (n = 10) of all marked tumours were diagnosed and treated as in-situ stage tumours, 65% (n = 26) were diagnosed and treated as tumours in the pT1 stage. As regards the nodal stage, 85% (n = 34) of the tumours were diagnosed and treated as being pN0 tumours, and 100% (n = 40) were found to be free from any distant metastases. Consequently, for improving prognosis and, at the same time, for reducing the rate of breast amputations as a means of curative therapy of breast cancer, regular screening in defined risk groups is necessary. Surgical treatment of patients with small and non-palpable findings should be reserved for departments with marking and quick-freezing facilities.

[The radiological and surgical management of nonpalpable breast lesions]

In this retrospective study the results of surgical biopsy of suspected breast cancer in 319 outpatients are reported. In 113 cases (35.4%) the lesion was palpable, in 206 cases (64.6%) it was not. Concerning the nonpalpable lesions, mammography was performed in 98 patients (47.6%) for work-up of fibrocystic changes, in 41 patients (19.9%) for initial participation in a breast cancer prevention program, and in 33 patients (16.0%) for surveillance after breast conservation therapy. Prior to operation, 84.0% (n = 173) of the nonpalpable lesions were detected by mammography, 11.2% (n = 23) by sonography, and 4.8% (n = 10) by magnetic resonance imaging. Intra-operative specimen mammography was carried out in every case detected by mammography. In 19.4% (n = 40) of 206 nonpalpable lesions a malignant tumor was found. Twenty-five percent (n = 10) of all marked tumors were diagnosed and treated as in-situ stage tumors, while 65% (n = 26) were diagnosed and treated as tumors in the pT1 stage. As regards the nodal stage, 85% (n = 34) of the tumors were diagnosed and treated as pNO tumors, and 100% (n = 40) were found to be free from any distant metastases. Consequently, for improving prognosis and, at the same time, for reducing the rate of breast amputations as a means of curative therapy of breast cancer, regular screening in defined risk groups is necessary. Surgical treatment of patients with small and nonpalpable findings should be reserved for departments with marking and quick-freezing facilities.

Effects of modification of the allocation system on ischemia duration and costs of heart transplantation. Transplantation Cooperation UNI-NRW

BACKGROUND

In order to optimize regional utilization of transplantable thoracic organs, the seven university hospitals in North-Rhine-Westfalia have formed a transplant cooperation meanwhile approved by Eurotransplant.

METHODS

Heart transplant and organ donation activities of the cooperating hospitals in the year before the foundation of the cooperation (period A, 7/95 - 6/96) and in the year thereafter (period B, 7/96 - 6/97) were retrospectively analysed.

RESULTS

In period A, a total of 39 heart transplants and 74 heart donations were performed, whereas in period B 67 heart transplantations and 78 heart donations could be achieved. The regional utilization of the donor organs increased from 4% to 30% with a significantly shorter ischemia time of regionally or locally allocated donor hearts than of nationally or internationally allocated ones.

CONCLUSIONS

A high rate of regional or local heart transplant procedures with short ischemia times clearly demonstrate the benefits of a regionalization of heart transplant medicine for medical as well as economical reasons.

Hypertrophic cardiomyopathy: a desensitized cardiac beta-adrenergic system in the presence of normal plasma catecholamine concentrations

Only few data are available concerning the biochemical and functional state of the beta-adrenergic system in hypertrophied human myocardium. The present study was to investigate the myocardial beta-adrenergic signal transduction system in hypertrophic obstructive cardiomyopathy (HOCM). Thin myocardial strips were prepared from surgically excised, septal myocardium from 7 patients with HOCM and their force of contraction was measured in vitro. The positive inotropic effects of calcium and dihydro-ouabain, both acting independently of beta-adrenoceptors and cAMP, were similar in these preparations to those, previously published, seen with nonfailing myocardium. In contrast, the beta-adrenoceptor agonist isoprenaline and the phosphodiesterase inhibitor 3-isobutyl-1-methylxanthine (IBMX) had reduced positive inotropic effects. Their EC50-values were about 10 fold higher than the respective EC50-values published for nonfailing myocardium. The positive inotropic potencies of isoprenaline and IBMX were reduced in HOCM by as much as they were in the additionally investigated myocardium from 6 patients with severe mitral regurgitation (MR, NYHA III). In order to clarify whether the functional alterations are related to changes in the beta-adrenoceptors, beta-adrenoceptor density and beta 1: beta 2-adrenoceptor subtype distribution were determined in the same myocardium using 125I-Iodocyanopindolol saturation binding. Myocardial beta-adrenoceptor density was reduced to 68% in HOCM and to 56% in MR compared to nonfailing myocardium controls (NF: 64.8 +/- 6.5 fmol/mg protein). In HOCM, this reduction was due to a selective down regulation of beta 1-adrenoceptors (24.9 +/- 3.7 fmol/mg protein vs NF: 46.4 +/- 6.8 fmol/mg protein, P < 0.05), whereas beta 2-adrenoceptor density was unchanged (19.0 +/- 1.9 fmol/mg protein vs NF: 18.4 +/- 3.3 fmol/mg protein, n.s.). In MR both beta-adrenoceptor subtypes were reduced (beta 1: 26.9 +/- 1.4 fmol/mg protein, beta 2: 9.6 +/- 1.7 fmol/mg protein; both P < 0.05 vs NF). Electrochemically determined plasma catecholamine levels were elevated in MR. However, plasma catecholamine levels were normal or slightly below normal in HOCM. In summary, myocardial beta-adrenoceptors are downregulated and their function is impaired in HOCM. This desensitization is not caused by a negative feedback regulation due to increased plasma catecholamines. The present results show that the desensitizations of the beta-adrenergic system associated with HOCM has characteristics that indicate a major deviation in its development from that of the beta-adrenergic desensitization previously described to occur in congestive heart failure.