Predicted sensitivity to endocrine therapy for stage II-III hormone receptor-positive and HER2-negative (HR+/HER2-) breast cancer before chemo-endocrine therapy

BACKGROUND

We proposed that a test for sensitivity to the adjuvant endocrine therapy component of treatment for patients with stage II-III breast cancer (SET2,3) should measure transcription related to estrogen and progesterone receptors (SET_ER/PR index) adjusted for a baseline prognostic index (BPI) combining clinical tumor and nodal stage with molecular subtype by RNA4 (ESR1, PGR, ERBB2, and AURKA).

PATIENTS AND METHODS

Patients with clinically high-risk, hormone receptor-positive (HR+), human epidermal growth factor receptor 2 (HER2)-negative (HR+/HER2-) breast cancer received neoadjuvant taxane-anthracycline chemotherapy, surgery with measurement of residual cancer burden (RCB), and then adjuvant endocrine therapy. SET2,3 was measured from pre-treatment tumor biopsies, evaluated first in an MD Anderson Cancer Center (MDACC) cohort (n = 307, 11 years' follow-up, U133A microarrays), cut point was determined, and then independent, blinded evaluation was carried out in the I-SPY2 trial (n = 268, high-risk MammaPrint result, 3.8 years' follow-up, Agilent-44K microarrays, NCI Clinical Trials ID: NCT01042379). Primary outcome measure was distant relapse-free survival. Multivariate Cox regression models tested prognostic independence of SET2,3 relative to RCB and other molecular prognostic signatures, and whether other prognostic signatures could substitute for SET_ER/PR or RNA4 components of SET2,3.

RESULTS

SET2,3 added independent prognostic information to RCB in the MDACC cohort: SET2,3 [hazard ratio (HR) 0.23, P = 0.004] and RCB (HR 1.77, P < 0.001); and the I-SPY2 trial: SET2,3 (HR 0.27, P = 0.031) and RCB (HR 1.68, P = 0.008). SET2,3 provided similar prognostic information irrespective of whether RCB-II or RCB-III after chemotherapy, and in both luminal subtypes. Conversely, RCB was most strongly prognostic in cancers with low SET2,3 status (MDACC P < 0.001, I-SPY2 P < 0.001). Other molecular signatures were not independently prognostic; they could effectively substitute for RNA4 subtype within the BPI component of SET2,3, but they could not effectively substitute for SET_ER/PR index.

CONCLUSIONS

SET2,3 added independent prognostic information to chemotherapy response (RCB) and baseline prognostic score or subtype. Approximately 40% of patients with clinically high-risk HR+/HER2- disease had high SET2,3 and could be considered for clinical trials of neoadjuvant endocrine-based treatment.

Risk Management for BRCA1/BRCA2 mutation carriers without and with breast cancer

Purpose of review

We review the management for unaffected BRCA1/2 mutation carriers and the local management of early stage breast cancer.

Recent findings

For unaffected BRCA1/2 mutation carriers, surveillance includes annual magnetic resonance imaging (MRI) and mammogram (MG). Novel imaging modalities, including abbreviated protocol MRI, ultrafast/accelerated MRI, and contrast-enhanced digital mammography are being investigated. Risk reducing mastectomy (RRM) should be considered, and nipple-areolar sparing mastectomy (NSM) is now an option. Additionally, risk reducing salpingo-oophorectomy (RRSO) is strongly recommended as it reduces mortality.In BRCA1/2 mutation carriers with breast cancer, BCT is an appropriate treatment option but to reduce risk of second primary, mastectomy and contralateral risk-reducing mastectomy should be considered.

Prospective evaluation of the cardiac safety of HER2-targeted therapies in patients with HER2-positive breast cancer and compromised heart function: the SAFE-HEaRt study

Purpose

HER2-targeted therapies have substantially improved the outcome of patients with breast cancer, however, they can be associated with cardiac toxicity. Guidelines recommend holding HER2-targeted therapies until resolution of cardiac dysfunction. SAFE-HEaRt is the first trial that prospectively tests whether these therapies can be safely administered without interruptions in patients with cardiac dysfunction.

Methods

Patients with stage I–IV HER2-positive breast cancer candidates for trastuzumab, pertuzumab or ado-trastuzumab emtansine (TDM-1), with left ventricular ejection fraction (LVEF) 40–49% and no symptoms of heart failure (HF) were enrolled. All patients underwent cardiology visits, serial echocardiograms and received beta blockers and ACE inhibitors unless contraindicated. The primary endpoint was completion of the planned HER2-targeted therapies without developing either a cardiac event (CE) defined as HF, myocardial infarction, arrhythmia or cardiac death or significant asymptomatic worsening of LVEF. The study was considered successful if planned oncology therapy completion rate was at least 30%.

Results

Of 31 enrolled patients, 30 were evaluable. Fifteen patients were treated with trastuzumab, 14 with trastuzumab and pertuzumab, and 2 with TDM-1. Mean LVEF was 45% at baseline and 46% at the end of treatment. Twenty-seven patients (90%) completed the planned HER2-targeted therapies. Two patients experienced a CE and 1 had an asymptomatic worsening of LVEF to ≤ 35%.

Conclusion

This study provides safety data of HER2-targeted therapies in patients with breast cancer and reduced LVEF while receiving cardioprotective medications and close cardiac monitoring. Our results demonstrate the importance of collaboration between cardiology and oncology providers to allow for delivery of optimal oncologic care to this unique population.

Electronic supplementary material

The online version of this article (10.1007/s10549-019-05191-2) contains supplementary material, which is available to authorized users.

Abstract PD2-12: Palbociclib in combination with fulvestrant or tamoxifen as treatment for hormone receptor positive (HR+) metastatic breast cancer (MBC) with prior chemotherapy for advanced disease (TBCRC 035) A phase II study with pharmacodynamics markers

Background

Addition of the cyclin dependent kinase 4/6 inhibitor (CDK4/6i) palbociclib to endocrine therapy in the first and later line settings significantly improves progression free survival (PFS) in patients with HR+ MBC. The primary toxicity is neutropenia without an increase in febrile neutropenia. TBCRC035 explored rates of neutropenia in patients who had received prior chemotherapy for MBC with 2 dose levels of palbociclib, and correlated changes in retinoblastoma protein phosphorylation (pRB) and Ki67 expression in proliferating keratinocytes and tumor with response.

Methods

TBCRC035 is a 1:1 randomized multicenter phase II study evaluating palbociclib at either 125 or 100 mg in combination with physician choice fulvestrant or tamoxifen. Eligible patients (pts) with HR+ MBC had received &gt;1 but &lt;3 lines of chemotherapy for MBC, any number of prior hormone therapies, and were naïve to CDK4/6i. The primary endpoint was grade 3/4 neutropenia; secondary endpoints included response, safety/tolerability, inhibition of pRB and change in Ki67 in skin and tumor at day 14-21 of treatment compared to baseline. FFPE sections of skin punch and tumor biopsies obtained before and on treatment were stained using antibodies to Ki67, total RB, and phospho-RB-S780 using BOND polymer red detection. Stained slides were scanned into the Aperio image analysis platform; the percentage of marker positive cells and H-score was determined.

Results

70 pts were enrolled (fully accrued); 35 randomized to 100 vs 125 mg of palbociclib respectively; data for the last 3 pts on the 125 mg arm is pending. Grade 3/4 neutropenia was more common in the 125 mg vs the 100 mg arm (56 vs 34%); dose adjustments for adverse events (AEs) occurred in 47 vs 43%, 4 vs 0 pts discontinued treatment due to AEs. Grade 3 febrile neutropenia was rare (1 patient each arm). Median duration of treatment was 5.2 vs 7.2 months. Response data and correlation with changes in pRB and Ki67 expression in skin and tumor by treatment arm will be reported.

Conclusion

In pts with prior chemotherapy for HR+ MBC, treatment with 100 mg of palbociclib in patients is associated with a lower rate of &gt; grade 3 neutropenia compared to 125 mg. Correlation of response by dose with pRB and Ki67 has the potential to inform palbociclib dosing and reduce toxicity for pts with HR+ MBC.

Citation Format: Rugo HS, Mayer EL, Storniolo AM, Isaacs C, Mayer I, Stearns V, Nanda R, Nangia J, Wabl C, Deluca A, Kochupurakkal B, Wolff AC, Shapiro GI. Palbociclib in combination with fulvestrant or tamoxifen as treatment for hormone receptor positive (HR+) metastatic breast cancer (MBC) with prior chemotherapy for advanced disease (TBCRC 035) A phase II study with pharmacodynamics markers [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 PD2-12.

Abstract P5-15-01: The use of 18F-FDG PET/CT as an initial staging procedure for stage II-III breast cancer reduces false positives, costs, and time to treatment: A multicenter value analysis in the I-SPY2 trial

Introduction: Diagnostic metastatic staging imaging (SI) for asymptomatic stage I-II patients (pts) is not routinely recommended, but is warranted in stage II-III pts with high risk biological subtypes, where previous trials have shown up to a 15% rate of de novo metastatic disease. NCCN guidelines endorse CT CAP and bone scan (STD) for stage III pts, but not PET/CT, and PET/CT is not covered in most parts of the country. We present data on the performance and value of PET/CT.

Methods: Data were available for 799 high risk clinical stage II-III pts screened for I-SPY2 at UCSF, Uminn, UAB, and Georgetown. Of these, 564 pts ranging in age from 25-81 (median = 48) had complete records that were retrospectively reviewed for SI and potential false positives (FP), defined as incidental findings on SI proven benign by subsequent workup. Economic evaluation was conducted from the payer perspective using the mean national 2018 Medicare Physician Fee Schedule and representative costs from the UCSF billing department. The incremental cost effectiveness ratio (ICER) measured the cost of using PET/CT per percent patient (pt) who avoided a FP.

Results: The rate of de novo metastatic disease was 4.8% (38/799), range 3.6-6.4%. Of the 564 pts with complete records, diagnostic SI varied significantly among the four sites (p &lt; 0.0001). STD was used for most pts at UAB (92.8%, 141/152) and Georgetown (85.7%, 54/63), while PET/CT was used for most pts at UCSF (86.6%, 226/261) and Uminn (63.6%, 56/88). Chest X-ray was used for 29.5% (26/88) at Uminn. There were significantly more pts with FP in the group that received STD (22.1%, 51/231) vs. PET/CT (11.1%, 33/298) (p &lt; 0.05). Mean time between incidental finding on SI to determination of FP was 10.8 days. When controlling for institution, mean time from cancer diagnosis to initiation of neoadjuvant chemotherapy was significantly different between STD (44.3 days) and PET/CT (37.5 days) groups (p &lt; 0.05). When aggregating the four sites using mean costs from the 2018 Medicare Physician Fee Schedule, the mean cost/pt was $1132 for STD vs. $1477 for PET/CT. The mean increase in price from baseline SI costs due to FP workup was $216 (23.6%) for STD vs. $65 (4.6%) for PET/CT. The ICER was $31 per percent pt who avoided a FP. When analyzing UCSF pts alone using representative reimbursements from Medicare, the mean cost/pt was $1236 for STD vs. $1081 for PET/CT; using representative reimbursements from Anthem Blue Cross, the mean cost/pt was $3080 for STD vs. $1662 for PET/CT. The ICERs were -$10 and -$95 per percent pt who avoided a FP, respectively.

Conclusion: As compared to STD metastatic staging workup, PET/CT added value by decreasing FP two-fold. This reduced direct costs of FP workup procedures that took a mean time of 10.8 days to resolve. PET/CT also accelerated treatment start. Reducing the chance of FP workup for metastatic disease is of enormous value to pts. Our data establish the value of PET/CT for staging in our high risk clinical stage II-III trial population and highlight the need for alignment between hospital pricing strategies and payer coverage policies in order to deliver high value care to pts.

Citation Format: Hyland CJ, Varghese F, Yau C, Beckwith H, Khoury K, Varnado W, Hirst G, Chien J, Yee D, Isaacs C, Forero-Torres A, Esserman L, Melisko M, I-SPY2 Consortium. The use of 18F-FDG PET/CT as an initial staging procedure for stage II-III breast cancer reduces false positives, costs, and time to treatment: A multicenter value analysis in the I-SPY2 trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-15-01.

Abstract P2-14-01: The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 TRIAL

Background: In women with breast cancer receiving neoadjuvant chemotherapy, residual cancer burden (RCB) predicts distant recurrence and survival. In those with high risk tumors, locoregional recurrence (LRR) remains a concern, and has been associated with type of local therapy received. We evaluated the impact of local therapy on LRR in the ISPY-2 TRIAL.

Methods: Data were analyzed in Stata 14.2, using Chi2 test, log rank test, and a Cox proportional hazards model. RCB was considered a categorical variable (0/1 versus 2/3), as described in prior publications. Breast surgery categories were lumpectomy +/- radiotherapy, or mastectomy +/- radiotherapy. Axillary surgery was defined as sentinel lymph node (SLN) surgery (≤6 nodes removed) or axillary dissection (&gt;6 nodes).

Results: Follow up data from the I-SPY2 TRIAL were available for 630 patients (median follow up 2.76 yrs, range 0.4-7.2). Type of local therapy was significantly associated with clinical stage at presentation, with stage III patients most frequently undergoing mastectomy + radiation (p&lt;0.001). Women with higher RCB were more likely to undergo mastectomy than those with lower RCB (61.3% vs 48.8% mastectomy rate, p=0.002), and more likely to receive adjuvant radiotherapy (62.0% vs 53.9%, p=0.048). There was no association between clinical stage, type of surgery, or radiotherapy and LRR (Table). Higher RCB was significantly associated with LRR, with 3 year locoregional recurrence free rate of 95.1% in RCB 0/1 versus 89.9% in RCB 2/3 (p=0.003).

In a Cox model adjusting for clinical stage, tumor subtype, surgical therapy, RCB status, nodal radiation, and age, significant predictors for LRR were tumor subtype and RCB status. Hazard ratio (HR) for LRR in those with RCB 0/1 was 0.39 compared to those with RCB 2/3 (95% CI 0.17-0.87, p=0.021). There was no difference in LRR between breast conservation and mastectomy; within the breast conservation group, those who had lumpectomy alone had higher hazard of LRR compared to those having lumpectomy + radiation (HR 3.1, 95% CI 1.1-9.2, p=0.043).

Conclusions: Extent of surgical therapy was not associated with local tumor control, regardless of advanced tumor stage at presentation. Rather, tumor biology and response to therapy were the best predictors of LRR. These data highlight the opportunity to minimize the morbidity of extensive surgical therapy for patients with excellent response to systemic therapy.

LRR rates by clinical features and treatment status FrequencyLRR RateP valueClinical Stage  0.5I240 (47.5%)5.8% II185 (36.6%)8.7% III80 (15.8%)6.3% Tumor Subtype  0.014ER+PR+Her2-161 (26.4%)3.1% ER+PR-Her2-56 (9.2%)3.6% Her2+176 (28.9%)6.3% Triple negative216 (35.5%)11.1% Local therapy  0.169Lumpectomy85 (13.5%)11.8% Lumpectomy with radiation198 (31.4%)5.6% Mastectomy173 (27.5%)5.2% Mastectomy with radiation174 (27.6%)8.6% Axillary surgery  0.23None5 (0.8%)20% SLN329 (52.2%)5.8% ALND296 (47%)8.5% Axillary radiation  0.535Yes42 (6.7%)9.5% No588 (93.3%)7.0% Axillary management  0.2No surgery or radiation5 (0.8%)20.0% SLN312 (50%)5.3% SLN+Axillary radiation17 (2.7%)8.3% ALND271 (43%)10.3% ALND+Axillary radiation25 (4%)5.4% RCB  0.0020/1293 (50.1%)3.8% 2/3292 (49.9%)10.3% 

Citation Format: Silverstein J, Suleiman L, Yau C, Price ER, Singhrao R, Yee D, DeMichele A, Isaacs C, Albain KS, Chien AJ, Forero-Torres A, Wallace AM, Pusztai L, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Leyland-Jones B, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, I-SPY 2 TRIAL Consortium, Berry DA, Asare SM, Esserman LJ, Boughey JC, Mukhtar RA. The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 TRIAL [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-01.

Abstract P2-07-03: Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden

Background: Patients achieving a pathologic complete response (pCR) following neoadjuvant therapy have significantly improved event-free survival relative to those who do not; and pCR is an FDA-accepted endpoint to support accelerated approval of novel agents/combinations in the neoadjuvant treatment of high risk early stage breast cancer. Previous studies have shown that recurrence risk increased with increasing burden of residual disease (as assessed by the RCB index). As well, these studies suggest that patients with minimum residual disease (RCB-I class) also have favorable outcomes (comparable to those achieving a pCR) within high risk tumor subtypes. In this study, we assess whether integrating RCB with MRI functional tumor volume (FTV), which in itself is prognostic, can improve prediction of distant recurrence free survival (DRFS); and identify a subset of patients with minimal residual disease with comparable DRFS as those who achieved a pCR. Imaging tools can then be used to identify the subset that will do well early and guide the timing of surgical therapy.

Method: We performed a pooled analysis of 596 patients from the I-SPY2 TRIAL with RCB, pre-surgical MRI FTV data and known follow-up (median 2.5 years). We first assessed whether FTV predicts residual disease (pCR or pCR/RCB-I) using ROC analysis. We applied a power transformation to normalize the pre-surgical FTV distribution; and assessed its association with DRFS using a bi-variate Cox proportional hazard model adjusting for HR/HER2 subtype. We also fitted a bivariate Cox model of RCB index adjusting for subtype; and assessed whether adding pre-surgical FTV to this model further improves association with DRFS using a likelihood ratio (LR) test. For the Cox modeling, penalized splines approximation of the transformed FTV and RCB index with 2 degrees of freedom was used to allow for non-linear effects of FTV and RCB on DRFS.

Result: Pre-surgical MRI FTV is significantly associated with DRFS (Wald p&lt;0.00001), and more effective at predicting pCR/RCB-I than predicting pCR alone (AUC: 0.72 vs. 0.65). Larger pre-surgical FTV remains associated with worse DRFS adjusting for subtype (Wald p &lt;0.00001). The RCB index is also significantly associated with DRFS adjusting for subtype (Wald p&lt;0.00001). Adding FTV to a model containing RCB and subtype further improves association with DRFS (LR p=0.0007). RCB-I patients have excellent DRFS (94% at 3 years compared to 95% in the pCR group). Efforts are underway to identify an optimal threshold for dichotomizing pre-surgical FTV and FTV change measures for use in combination with pCR/RCB-I class to generate integrated RCB (iRCB) groups as a composite predictor of DRFS.

Conclusion: Pre-surgical MRI FTV is effective at predicting minimal residual disease (RCB0/I) in the I-SPY 2 TRIAL. Despite the association between FTV and RCB, FTV appears to provide independent added prognostic value (to RCB and subtype), suggesting that integrating MRI volume measures and RCB into a composite predictor may improve DRFS prediction.

Citation Format: Hylton NM, Symmans WF, Yau C, Li W, Hatzis C, Isaacs C, Albain KS, Chen Y-Y, Krings G, Wei S, Harada S, Datnow B, Fadare O, Klein M, Pambuccian S, Chen B, Adamson K, Sams S, Mhawech-Fauceglia P, Magliocco A, Feldman M, Rendi M, Sattar H, Zeck J, Ocal I, Tawfik O, Grasso LeBeau L, Sahoo S, Vinh T, Yang S, Adams A, Chien AJ, Ferero-Torres A, Stringer-Reasor E, Wallace A, Boughey JC, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, Haugen PK, van't Veer LJ, Perlmutter J, Melisko ME, Wilson A, Peterson G, Asare AL, Buxton MB, Paoloni M, Clennell JL, Hirst GL, Singhrao R, Steeg K, Matthews JB, Sanil A, Berry SM, Abe H, Wolverton D, Crane EP, Ward KA, Nelson M, Niell BL, Oh K, Brandt KR, Bang DH, Ojeda-Fournier H, Eghtedari M, Sheth PA, Bernreuter WK, Umphrey H, Rosen MA, Dogan B, Yang W, Joe B, I-SPY 2 TRIAL Consortium, Yee D, Pusztai L, DeMichele A, Asare SM, Berry DA, Esserman LJ. Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden [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 P2-07-03.

Abstract OT3-04-01: Nivolumab or capecitabine or combination therapy as adjuvant therapy for triple negative breast cancer (TNBC) with residual disease following neoadjuvant chemotherapy: The OXEL study

Background: Long-term follow-up of neoadjuvant studies demonstrates poor clinical outcomes in patients with TNBC who do not achieve pathologic complete response, with only 35% remaining free of recurrence at 10 years. The addition of adjuvant capecitabine in the CREATE-X study prolonged disease free survival and overall survival (OS) in patients with HER2 negative breast cancer with residual invasive disease, with more striking benefit in patients with TNBC. Checkpoint inhibitors have not been approved in breast cancer yet, but recent studies suggest a benefit in combination with chemotherapy and low burden of disease. In the current study, we will evaluate the role of chemoimmunotherapy in the adjuvant setting for patients with TNBC with residual disease after neoadjuvant therapy. We will also investigate the role of the peripheral immunoscore (PIS) in predicting the benefit of immune checkpoint inhibition with or without chemotherapy.

Trial design: OXEL is a pilot open-label three arm randomized study of nivolumab, capecitabine or the combination as adjuvant therapy for 45 patients with residual TNBC after adequate neoadjuvant chemotherapy. Patients enrolled will be randomly assigned to 1 of 3 treatment arms: nivolumab 360 mg iv q3weeks for x 6 cycles; capecitabine 1250mg/m2 po bid D1-D14 q3 weeks x 6 cycles; nivolumab 360mg iv q3weeks + capecitabine 1250mg/m2 po bid D1-D14 q3 weeks x 6 cycles.

Main eligibility criteria: Patients ≥18 years of age with TNBC and ≥1cm of residual disease in the breast and/or node positive disease; receipt of neoadjuvant taxane +/- anthracycline, or platinum, and having completed definitive resection of primary tumor, with no prior use of capecitabine, fluorouracil or immunotherapy, and with no active autoimmune disease or chronic use of systemic steroids.

Specific aims: The primary endpoint is assessing the immunologic effects of capecitabine, nivolumab or the combination in the adjuvant setting by PIS. Additional endpoints include toxicity assessment, distant recurrence free survival (DRFS) and OS at 3-years, association between changes in PIS and circulating tumor DNA at different timepoints with clinical outcome variables and characterization of the immune contexture in residual tumors.

Statistical methods: The study is designed to assess the change in PIS at 6 weeks from baseline in each arm. The sample size of 15 per arm (45 total for 3 arms) will provide preliminary results. A sample size of 15 per arm will have 85% power to detect an effect size of 1 (the difference of the change in PIS from baseline to week 6 between two arms divided by the standard deviation) at 5% significance level.

Present accrual and target accrual: The Institutional Review Board at Georgetown University Medical Center has approved the study. Clinicaltrials.gov NCT03487666. Enrollment of the first patient is expected in July 2018 with a total of 45 patients planned to be recruited. Recruitment sites are MedStar Georgetown University Hospital, MedStar Washington Hospital Center, Hackensack University Medical Center. This trial is supported by Bristol-Meyers Squibb, P30CA051008-25 from NCI, Inivata and the Nina Hyde Center for Breast Cancer Research.

Citation Format: Khoury K, Isaacs C, Gatti-Mays ME, Donahue RN, Schlom J, Wang H, Gallagher C, Graham D, Warren R, Dilawari A, Swain SM, Pohlmann PR, Lynce F. Nivolumab or capecitabine or combination therapy as adjuvant therapy for triple negative breast cancer (TNBC) with residual disease following neoadjuvant chemotherapy: The OXEL 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 OT3-04-01.

Abstract P1-15-02: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Schwab R, Clark A, Yau C, Wolf D, Chien AJ, Majure M, Ewing C, Wallace A, Roesch E, Helsten T, Forero A, Stringer-Reasor E, Vaklavas C, Nanda R, Jaskowiak N, Boughey J, Haddad T, Han H, Lee C, Albain K, Isaacs C, Elias A, Ellis E, Shah P, Lang J, Lu J, Tripathy D, Kemmer K, Yee D, Haley B, Korde L, Edmiston K, Northfelt D, Viscusi R, Khan Q, I-SPY 2 Consortium, Symmans WF, Perlmutter J, Hylton N, Rugo H, Melisko M, Wilson A, Singhrao R, Asare S, van't Veer L, DeMichele A, Berry D, Esserman L. 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 P1-15-02.

Abstract P4-14-05: Confirmation of the TAILORx 21-gene expression trial using a real world observational database

Background: The TAILORx study (NCT00310180)(TRx) has demonstrated the efficacy of endocrine therapy alone in early stage, lymph node negative, hormone receptor positive, her2neu oncogene negative breast cancer harboring an intermediate recurrence score (RS) on a 21-gene profile (OncotypeDx), obviating the need for adjuvant chemotherapy in a large subset of women. The study randomized and followed 6711 patients (pts) and required 9 years to reach its conclusion endpoints. The availability of the electronic health record (EHR) permits automated reviews, facilitating more rapid “real world” hypothesis testing (but not a replacement for randomized clinical trials), especially when there are clear variations in common practice patterns. However physician bias in treatment selection needs to be considered.

Methods: A retrospective review of the Cota Observational Cancer database, drawn from EHRs, of female pts with breast cancer who were 18 to 75 years of age; had hormone-receptor–positive, human epidermal growth factor receptor 2 (HER2)–negative, axillary node–negative breast cancer harboring an OncotypeDx RS 11-25 receiving adjuvant therapy following surgical resection of a 11-50 mm primary tumor (similar to TRx eligibility).

Results: 1009 pts from 23 cancer centers (107 oncologists) were identified, 850 (84.2%) received adjuvant endocrine therapy alone (E) and 159 (15.8%) received adjuvant chemoendocrine therapy (CE) as part of standard care (no randomization). 285 pts were age &lt;50 yrs (E:218, CE:67) and 601 pts has RS 16-25 (E:453, CE:148). Treatment selection was imbalanced with oncologists more likely to utilize CE in younger pts (median age E: 59 yrs, CE: 53 yrs; p&lt;0.01), larger tumors (median tumor size E: 16mm, CE: 20mm; p&lt;0.001) and higher RS (median RS E: 16, CE: 21; p&lt;0.001). With a median follow-up for survival since diagnosis of 3.7 years, the Kaplan-Meier estimated 5 yr overall survival rates were 98.9% with E and 97.8% with CE (p=0.23); the corresponding 5-yr OS in TRx were E: 98% and C: 98.1%. With a median 1.7 years follow-up for recurrence, 19 pts have suffered a disease distant or local recurrence (E: 13, CE: 6) yielding a 5-year recurrence-free survival of E: 95.2% and CE: 91% (p=0.05); the corresponding TRx result was E: 96.9% and CE: 97%. The 5-yr invasive disease-free survival (IDFS = death, local/distant, second primary) with 32 events was E: 92.7% and CE: 81.9% (p= 0.05); corresponding TRx E: 92.8 % and CE: 93.1%. Given the imbalance in treatment allocations, a multivariate analysis was performed, with older age (&lt;0.001), CE choice (&lt;0.006) and larger tumor size (p&lt;0.05) remaining significant, but not increased RS (p=0.16) for 5-year IDFS. Among women age &lt;50 with RS 16-25 (E: 118; CE: 60) the 5-yr IDFS was E: 95% and CE: 94%; the corresponding RS 16-20 TRx E: 92% and CE: 94.7% and RS 21-25 E: 86.3% and CE: 92.1%.

Conclusions: Using a real world data source, endocrine therapy alone appears to yield excellent 5-yr survival rates among pts with 21-gene RS 11-25 similar to the TAILORx trial. Treatment selection bias (with perceived higher risk pts allocated to CE) and shorter median follow-up limits full confirmation by this dataset.

Citation Format: Waintraub SE, Isaacs C, Norden AD, Graham DA, McNamara DM, O'Neill SC, Lakshmanan A, Wu T, Maresca A, Pecora AL, Goy AH, Goldberg SL. Confirmation of the TAILORx 21-gene expression trial using a real world observational database [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-14-05.

Abstract P6-10-05: UPTAKE study - Uptake of preventive surgeries among Latinas with BRCA1/2 mutations

Introduction: Germline testing for BRCA1/2 genes provides an opportunity to reduce mortality and morbidity by adopting appropriate risk reduction and screening options, in particular with risk-reducing bilateral salpingo-oophorectomy (BSO).There is a paucity of data on Latinas and prophylactic measures among BRCA1/2 carriers.Existing studies are limited either by the small number of Latinas, or limited to a specific geographic location.Factors related to decision making have also not been evaluated.

Methods: The UPTAKE study is an observational study of Latinas with germline BRCA1/2 mutations.Subjects were recruited nationally and, by telephone interviews, reported uptake of prophylactic surgeries (BSO, bilateral mastectomy in unaffected women, and contralateral mastectomy in carriers with breast cancer (BC)). Women with ovarian cancer were ineligible. All women had to have been informed that they carried a deleterious BRCA1/2 mutation at least 1 year prior to completing the interview. The objectives of this study are: 1)to examine the rate of uptake of prophylactic surgeries; 2)identify acculturation and attitudinal factors related to decisions made and 3)examine relationships between primary language, receipt of genetic counseling (GC) and in which language it was provided and uptake of prophylactic surgeries. We plan to enroll 100 participants.

Results: As of 6/11/2017, 86 telephone interviews have been conducted. We anticipate that all 100 interviews will be completed by July 2017. 51.2% (44/86) of participants completed the interview in Spanish. Our population was diverse in terms of country of origin: 50.0% (43/86) were born in the US, 22.1% (19/86) in Mexico, 11.6% (10/86) in Puerto Rico, 4.6% (4/86) in El Salvador, 3.5% (3/86) in Ecuador and 8.1% (7/86) in other countries of Latin America. 30% (26/86) of the participants reported an annual household income inferior to $50.000. Only 26.7% (23/86) of women reported having a graduate degree. Approximately one quarter of participants were unemployed at the time of study participation (26.7%, 23/86). 34.9% (30/86) were unaffected and 62.8% (54/86) were affected with BC. 73.3% (63/86) of participants reported having received formal GC, of which only 28.6% (18/63) was conducted in Spanish. 66.3% (57/86) of women opted to undergo BSO and 58.1% (50/86) underwent prophylactic mastectomy. Being born outside the US and currently working were associated with higher uptake of BSO. Multivariate analysis will be performed once all interviews have been completed.

Conclusions: To our knowledge this is the largest study that evaluates uptake of prophylactic measures in Latinas known to be BRCA1/2 carriers. Our study included a heterogeneous group of participants in terms of country of origin, income and level of education including English knowledge. It was conducted across various academic and community centers in the country. The uptake of prophylactic surgeries among Latinas with germline BRCA mutations seems to be slightly lower than what has been reported in non-Hispanic whites (71-74%) but higher than in African Americans (32-50%). Results and factors associated with decision making will be updated once the total number of participants is enrolled.

Citation Format: Lynce F, Serrano A, Friedman S, Nahleh Z, Dutil J, Campos C, Ricker C, Rodriguez P, Duron Y, Isaacs C, Graves K. UPTAKE study - Uptake of preventive surgeries among Latinas with BRCA1/2 mutations [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 P6-10-05.

Abstract PD6-03: Distribution of microsatellite instability, tumor mutational load, and PD-L1 status in molecularly profiled invasive breast cancer

Background: Recent data indicate a promising response to immune check point blockade (ICB) in patients with breast cancer. Pembrolizumab, a humanized monoclonal antibody against programmed death 1 (PD-1) receptor and one of several ICB agents in development, was given an FDA approval for all MSI (microsatellite instability)-high solid tumors. MSI incidence in breast cancer is not fully elucidated. Other biomarkers being explored in possible relationship to ICB activity include PD-1 ligand (PD-L1) status and tumor mutational load (TML). In this study, we aimed to explore the incidence of these biomarkers in invasive breast cancers.

Methods: A retrospective data analysis of patients profiled by commercial next-generation sequencing (NGS) at Caris Life Sciences was performed. MSI results were either high, stable, or equivocal. MSI was calculated by comparing repeat-insertions or deletions across over 7,000 microsatellite sequences in the patient sample to the hg19 reference genome. Samples with repeat variances in more than 45 microsatellites were classified as MSI-High PD-L1 expression was evaluated using immunohistochemical analysis (IHC), with clone SP-142 (Roche Diagnostics). A sample was considered positive if there was &gt;5% membranous staining of tumor cells. Tumor mutational load was calculated as a total number of non-synonymous somatic mutations identified per megabase of the genome coding area with high being greater than or equal to 17.

Results: A total of 9,627 breast cancer cases were queried from the Caris Life Sciences database. The mean age (±SD) was 56.8 ± 12.4 years (range 20-90). The tumor distribution was 60.7% hormone receptor (HR) positive (ER and/or PR) and HER2 negative, 9.5% HER2 positive (with HR negative or positive), and 29.8% triple negative (negative for ER, PR and HER2). Of all cases, there were 5,203 tested for PD-L1 status, 354 (6.8%, 95% CI 6.2-7.5%) were positive. Of 1,440 tumors tested for MSI status, 15 (1.04%, 95% CI 0.58-1.71%) were either high (8) or equivocal (7), the rest were MSI-low. Tumor mutational load (TML) was available on 1,766 tumors, of which 55 (3.1%, 95% CI 2.4-4.0%) were high. Seven out of the 8 MSI-high tumors were also TML-high. Four out of the 8 MSI-high breast cancers were triple negative.

Conclusion: In this large dataset of molecularly profiled breast cancer, MSI was observed in about 1% of the breast tumors tested. Overall, modest positivity of TML, PD-L1, and MSI of all invasive breast cancers was observed. The percentage of patients that had at least one of these biomarkers that may confer responsiveness to ICB is planned and will be further stratified by subtype. MSI-high breast cancers mostly overlapped with those that were TML-high. Future research is needed to show the clinical utility of these biomarkers in response to ICB. Updated data will be presented.

Citation Format: Obeid E, Ellerbrock A, Handorf E, Goldstein L, Gatalica Z, Arguello D, Swain SM, Isaacs C, Vacirca J, Tan A, Schwartzberg L. Distribution of microsatellite instability, tumor mutational load, and PD-L1 status in molecularly profiled invasive 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 PD6-03.

Connectivity of diagnostic technologies: improving surveillance and accelerating tuberculosis elimination

In regard to tuberculosis (TB) and other major global epidemics, the use of new diagnostic tests is increasing dramatically, including in resource-limited countries. Although there has never been as much digital information generated, this data source has not been exploited to its full potential. In this opinion paper, we discuss lessons learned from the global scale-up of these laboratory devices and the pathway to tapping the potential of laboratory-generated information in the field of TB by using connectivity. Responding to the demand for connectivity, innovative third-party players have proposed solutions that have been widely adopted by field users of the Xpert(®) MTB/RIF assay. The experience associated with the utilisation of these systems, which facilitate the monitoring of wide laboratory networks, stressed the need for a more global and comprehensive approach to diagnostic connectivity. In addition to facilitating the reporting of test results, the mobility of digital information allows the sharing of information generated in programme settings. When they become easily accessible, these data can be used to improve patient care, disease surveillance and drug discovery. They should therefore be considered as a public health good. We list several examples of concrete initiatives that should allow data sources to be combined to improve the understanding of the epidemic, support the operational response and, finally, accelerate TB elimination. With the many opportunities that the pooling of data associated with the TB epidemic can provide, pooling of this information at an international level has become an absolute priority.

Abstract P6-11-04: The evaluation of ganitumab/metformin plus standard neoadjuvant therapy in high-risk breast cancer: Results from the I-SPY 2 trial

Background: I-SPY 2 is a multicenter, phase 2 trial using response-adaptive randomization within biomarker subtypes to evaluate novel agents when added to standard neoadjuvant therapy for women with high-risk stage II/III breast cancer - investigational agent(I) +paclitaxel(T) qwk, doxorubicin & cyclophosphamide(AC) q2-3 wk x 4 vs. T/AC (control arm). The primary endpoint is pathologic complete response (pCR) at surgery. The goal is to identify/graduate regimens that have ≥85% Bayesian predictive probability of success (statistical significance) in a 300-patient phase 3 neoadjuvant trial defined by hormone-receptor (HR) & HER2 status & MammaPrint (MP). Regimens may also leave the trial for futility (&lt; 10% probability of success) or following accrual of maximum sample size (10%&lt; probability of success &lt;85%). We report the results for experimental arm Ganitumab, a type I insulin-like growth factor receptor (IGF1R) inhibitor. IGF1R inhibitors are known to induce insulin resistance and all patients assigned to Ganitumab received metformin.

Methods: Women with tumors ≥2.5cm were eligible for screening. MP low/HR+ and HER2+ tumors were ineligible for randomization. Hemoglobin A1C≥ 8.0% were ineligible. MRI scans (baseline, 3 cycles after start of therapy, at completion of weekly T and prior to surgery) were used in a longitudinal statistical model to improve the efficiency of adaptive randomization. Ganitumab was given at 12mg/kg q2 weeks and metformin at 850mg PO BID, while receiving ganitumab. Analysis was intention to treat with patients who switched to non-protocol therapy counted as non-pCRs. Ganitumab/metformin was open only to HER2- patients, and eligible for graduation in 3 of 10 pre-defined signatures: HER2-, HR+HER2- and HR-HER2-.

Results: Ganitumab/metformin did not meet the criteria for graduation in the 3 signatures tested. When the maximum sample size was reached, accrual to this arm stopped. Ganitumab/metformin was assigned to 106 patients; there were 128 controls. We report probabilities of superiority for Ganitumab/metformin over control and Bayesian predictive probabilities of success in a neoadjuvant phase 3 trial equally randomized between Ganitumab/metformin and control, for each of the 3 biomarker signatures, using the final pathological response data from all patients. Safety data will be presented.

SignatureEstimated pCR Rate (95% probability interval)Probability Ganitumab/ Metformin Is Superior to ControlPredictive Probability of Success in Phase 3 Ganitumab/ Metformin N = 106Control N = 128  All HER2-22% (13%-31%)16% (10%-23%)89%33%HR+/HER2-14% (4%-24%)12% (4%-19%)66%21%HR-/HER2-32% (17%-46%)21% (11%-32%)91%51%

Conclusion: The I-SPY 2 adaptive randomization study estimates the probability that investigational regimens will be successful in a phase 3 neoadjuvant trial. The value of I-SPY 2 is to give insight about the performance of an investigational agent's likelihood of achieving pCR. For Ganitumab/metformin, no subtype came close to the efficacy threshold of 85% likelihood of success in phase 3, and this regimen does not appear to impact upfront reduction of tumor burden. Our data do not support its continued development for the neoadjuvant treatment of breast cancer.

Citation Format: Yee D, Paoloni M, van't Veer L, Sanil A, Yau C, Forero A, Chien AJ, Wallace AM, Moulder S, Albain KS, Kaplan HG, Elias AD, Haley BB, Boughey JC, Kemmer KA, Korde LA, Isaacs C, Minton S, Nanda R, DeMichele A, Lang JE, Buxton MB, Hylton NM, Symmans WF, Lyandres J, Hogarth M, Perlmutter J, Esserman LJ, Berry DA. The evaluation of ganitumab/metformin plus standard neoadjuvant therapy in high-risk breast cancer: Results from the I-SPY 2 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 P6-11-04.

Abstract P6-11-02: Efficacy of Hsp90 inhibitor ganetespib plus standard neoadjuvant therapy in high-risk breast cancer: Results from the I-SPY 2 trial

Background:Pathologic complete response(pCR) after neoadjuvant therapy is an established prognostic biomarker for high-risk breast cancer(BC). Improving pCR rates may identify new therapies that improve survival. I-SPY 2 uses response-adaptive randomization within biomarker subtypes to evaluate novel agents when added to standard neoadjuvant therapy for women with high-risk stage II/III breast cancer; the goal is to identify regimens that have ≥85% Bayesian predictive probability of success (statistical significance) in a 300-patient phase 3 neoadjuvant trial defined by hormone-receptor (HR), HER2 status and MammaPrint (MP). We report the results for Ganetespib, a selective inhibitor of Hsp90 that induces the degradation/deactivation of key drivers of tumor initiation, progression, angiogenesis, and metastasis.Ganetespib + taxanes previously have resulted in a superior therapeutic response compared to monotherapy in multiple solid tumor models including BC.

Methods:Women with tumors ≥2.5cm were eligible for screening and participation. MP low/HR+ tumors were ineligible for randomization. QTcF &gt;470msec and HbA1C &gt;8.0% were ineligible. MRI scans (baseline, +3 cycles, following weekly paclitaxel, T, and pre-surgery) were used in a longitudinal statistical model to improve the efficiency of adaptive randomization. Ganetespib was given with weekly T at 150 mg/m2 IV weekly (3 weeks on, 1 off). Patients were premedicated (dexamethasone 10mg and diphenhydramine HCl 25-50 mg, or therapeutic equivalents). Analysis was intention to treat with patients who switched to non-protocol therapy counted as non-pCRs. The Ganetespib regimen was open only to HER2- patients, and eligible for graduation in 3 of 10 pre-defined signatures: HER2-, HR+/HER2- and HR-/HER2-.

Results:Ganetespib did not meet the criteria for graduation in the 3 signatures tested. When the maximum sample size was reached, accrual stopped. Ganetespib was assigned to 93 patients; there were 140 controls. We report probabilities of superiority for Ganetespib over control and Bayesian predictive probabilities of success in a neoadjuvant phase 3 trial equally randomized between Ganetespib and control, for the 3 biomarker signatures, using the final pCR data from all patients. Safety data will be presented.

SignatureEstimated pCR Rate (95% probability interval)Probability Ganetespib Is Superior to ControlPredictive Probability of Ganetespib Success in a Phase 3 Trial Ganetespib N = 93Control N = 140  All HER2-26% (16%-37%)18% (8%-28%)91%47%HR+/HER2-15% (4%-27%)14% (4%-24%)60%19%HR-/HER2-38% (23%-53%)22% (9%-35%)96%72%

Conclusion:The I-SPY 2 adaptive randomization model efficiently evaluates investigational agents in the setting of neoadjuvant BC. The value of I-SPY 2 is that it provides insight as to the regimen's likelihood of success in a phase 3 neoadjuvant study. Although no signature reached the efficacy threshold of 85% likelihood of success in phase 3, we observed the most impact in HR-/HER2- patients, with a 16% improvement in pCR rate. While our data do not support the continued development of Ganetespib alone for neoadjuvant BC, combinations with Ganetespib, which could potentiate its effect, may be worth pursuing in I-SPY 2 or similar trials.

Citation Format: Forero A, Yee D, Buxton MB, Symmans WF, Chien AJ, Boughey JC, Elias AD, DeMichele A, Moulder S, Minton S, Kaplan HG, Albain KS, Wallace AM, Haley BB, Isaacs C, Korde LA, Nanda R, Lang JE, Kemmer KA, Hylton NM, Paoloni M, van't Veer L, Lyandres J, Perlmutter J, Hogarth M, Yau C, Sanil A, Berry DA, Esserman LJ. Efficacy of Hsp90 inhibitor ganetespib plus standard neoadjuvant therapy in high-risk breast cancer: Results from the I-SPY 2 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 P6-11-02.

Abstract OT2-01-09: PALINA: A phase II safety study of palbociclib in combination with letrozole in African American women with hormone receptor positive HER2 negative advanced breast cancer

Background:Insufficient data exist to describe the hematological safety of palbociclib in African American women (AAW) who are known to have a high incidence of benign ethnic neutropenia (BEN). The studies that led to the FDA approval of palbociclib (PALOMA 1 and 3) only included participants with baseline absolute neutrophil count (ANC) of ≥1500/mm3. The standard lower limit of ANC of 1500/mm3 for initiation of treatment in those with BEN has been previously challenged. In this current study, we propose to lower the ANC cutoff for enrollment to 1000/mm3.

Trial design: PALINA is a phase II study evaluating the hematological safety of palbociclib with letrozole in 35 AAW with hormone receptor (HR) positive HER2 negative advanced breast cancer and ANC ≥1000/mm3. Patients enrolled will receive palbociclib 125mg daily for 21 days followed by 7 days off and letrozole 2.5mg daily. For patients enrolled with baseline ANC between 1000-1499/mm3, initial dose of palbociclib will be 100mg daily for 21 days followed by 7 days off. Presence of Duffy Null Polymorphism (SNP rs2814778) as a predictive marker for neutrophil count will be assessed at baseline. Metabolite and exosomal signature (proteins and RNA) of drug resistance will be evaluated at different time points.

Main eligibility criteria: Self-identified Black, African or AAW of ≥ 18 years of age with proven diagnosis of advanced HR-positive, HER2-negative breast cancer; ECOG performance status 0-2; ANC ≥ 1,000/mm3 and no prior receipt of CDK4/6 inhibitors.

Specific aims: The primary endpoint is the proportion of patients who complete planned oncologic therapy without the development of a hematological event defined as episodes of febrile neutropenia and treatment discontinuation due to neutropenia. Additional endpoints include: number of patients who required dose delays or dose reductions in palbociclib attributed to neutropenia; rate of grade 3/4 neutropenia; clinical benefit rate at 24 weeks; correlations between metabolite and exosomal signature with disease response; correlations between baseline ANC prior to cancer diagnosis and the Duffy Null polymorphism with hematological safety.

Statistical methods: The study is designed to assess the rate of completion of planned therapy in the absence of a hematological event defined as episodes of febrile neutropenia and treatment discontinuation due to neutropenia. Simon's two-stage design with a maximum of 35 patients is used. The null hypothesis that the true completion rate is 60% will be tested against a one-sided alternative. This design yields a type I error rate of 0.05 and power of 80% when the true completion rate is 80%.

Present accrual and target accrual: The Institutional Review Board at Georgetown University Medical Center (GUMC) has approved the study. Enrollment of the first patient is expected in July 2016 with a total of 35 patients planned to be recruited. The recruitment sites are MedStar Georgetown University Hospital and other hospitals of the Georgetown MedStar Cancer Network, Hackensack University Medical Center and University of Alabama at Birmingham. This trial is funded by an ASPIRE Breast Cancer Research Award from Pfizer.

Citation Format: Lynce F, Shajahan-Haq A, Cai L, Graham D, Gallagher C, Mohebtash M, Kamugisha L, Novielli N, Castle J, Forero A, Isaacs C. PALINA: A phase II safety study of palbociclib in combination with letrozole in African American women with hormone receptor positive HER2 negative advanced breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-01-09.

Abstract PD8-04: Racial differences in the molecular landscape of breast cancer

Background:African Americans (AA) have a higher mortality associated with breast cancer (BC) when compared to Caucasians (CC).This has been attributed to diverse factors that include access to care, reproductive factors and different somatic genomic profiles. We aimed to compare the racial mutational landscape of 565 BC samples.

Methods:DNA from formalin-fixed paraffin-embedded samples was sequenced using the Illumina NextSeq (Agilent SureSelect XT, 592 gene selected based on COSMIC database) and MiSeq (TruSeq, 47 gene) for mutation and gene amplification analyses. Protein expression was evaluated by Immunohistochemistry (IHC). The exome aggregation consortium database was assessed for known ethnicity associations.

Results:Tumor samples from 118 AA and 447 CC female patients were included in this analysis. AA were younger (median age 56 vs58y, p0.005) and had higher proportion of triple negative BC (TNBC) (32% vs17%, p0.001). 50.3% of the samples were obtained from primary tumors and the remainder from metastatic sites. This was similar in AA and CC (48.8% vs51.8% primary tumors, pNS). The two genes with highest mutation prevalence were TP53 and PIK3CA. AA had fewer PIK3CA mutations (14.7% vs28.2%, p0.03). Within HR+/HER2+ and HR+/HER2- subtypes there was a similar trend in the number of PIK3CA mutations but it was no longer significant. The remainder mutation analysis did not differ between races. In terms of protein expression there were significant differences in the androgen receptor(AR), RRM1, EGFR and TS expression (table). AR positivity defined as ≥10% was less frequent in AA (40.0% vs60.4%, p0.0001 and when adjusted for age, p0.005) and associated with PIK3CA mutations in both AA and CC (p0.01 and p0.007). AR expression in TNBC was positive in 17.8% of CC and 5.4% of AA (pNS). Copy number variation (CNV) data assessed by NextGen revealed significantly higher gene copy number in AA compared to CC in CCND1 (16% vs4%, p0.04), FGF19 (16% vs1.3%, p0.01) and FGF4 (16% vs3%, p0.02). When only TNBC was considered, RRM1, TOPO1 and TUBB3 expression was significantly higher in AA than CC (table) and there were no differences in the mutational analyses. Evaluation of other BC subtypes (HER2, HR positive) is currently underway.

Conclusions:In this large cohort of AA who underwent genomic profiling there were relatively few differences in the mutation analysis compared to CC. The only significant difference seen was the lower number of PIK3CA mutations in AA, which had been previously reported in a cohort of 105 AA from the TCGA data (Keenan et al. JCO 2015). Protein expression by IHC revealed lower expression of AR in AA, even after adjustment for age, which could have therapeutic implications. Some of the racial differences found in the molecular landscape of BC including PIK3CA mutations, AR, EGFR expression and CNV may contribute to a more aggressive tumor biology in AA.

Protein expression by IHCBCTNBCAA %CC %pAA %CC %pHER2/neu912ns00nsAR40600.005180.07ER44620.0000nsPR35460.0900nsEGFR30160.036050nsERCC133460.063626nsMGMT6163ns6571nsPD-150340.066548nsPD-L106ns011nsPGP76ns1015nsPTEN5658ns4247nsRRM139270.0459270.01TLE350590.104357nsTOP2A7164ns86470.08TOPO16358ns69460.03TS44300.016349nsTUBB355410.0677510.03

Citation Format: Lynce F, Xiu J, Nunes MR, Swain SM, Gatalica Z, Isaacs C, Pohlmann P. Racial differences in the molecular landscape of breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD8-04.

Abstract P4-13-12: Everolimus plus trastuzumab and vinorelbine for trastuzumab-resistant, taxane-pretreated, HER2+ advanced breast cancer: Overall survival results from BOLERO-3

Background

PI3K/AKT/mTOR pathway activation due to PTEN loss may lead to trastuzumab (TRAS) resistance. mTOR inhibition has been shown to restore TRAS sensitivity in PTEN-deficient tumors. This provided the rationale for the BOLERO-3 trial which evaluated the combination of everolimus (EVE), an mTOR inhibitor, plus TRAS and a taxane in HER2+ advanced breast cancer (ABC). The addition of EVE to TRAS plus vinorelbine (VNB) led to a statistically significant prolongation of 1.2 months in median progression free survival (PFS) vs TRAS plus VNB in patients with TRAS-resistant and taxane-pretreated, HER2+ ABC (7.0 months vs 5.78 months; hazard ratio, 0.78; p=0.0067). The final overall survival (OS) analysis from this study is presented here.

Materials and methods

BOLERO-3 is a randomized, double-blind, placebo-controlled, phase 3 trial. Women with HER2+ ABC progressing on prior TRAS and taxane therapy were randomized (1:1) to receive either daily EVE (5 mg) or PBO plus weekly TRAS (2 mg/kg) and VNB (25 mg/m2), in 3-week cycles, stratified by previous lapatinib use. The primary endpoint was PFS by local investigator assessment. Overall survival was a key secondary endpoint.

Results

Overall, 569 patients were enrolled; 284 patients received EVE and 285 patients received PBO. As of April 1, 2015, after a median follow-up of 44.7 months, 388 deaths had occurred, 191 (67.3%) in the EVE arm and 197 (69.1%) in the PBO arm. The median OS in the EVE arm vs PBO arm was 23.5 months vs 24.1 months (HR = 0.96; 95% CI, 0.79-1.17; p = 0.3392). In the HR+ subgroup, the median OS with EVE was 23.5 months (vs 25.5 months with PBO; HR = 1.03; 95% CI, 0.79-1.35); in the HR subgroup, the median OS with EVE was 22.9 months (vs 23.1 months with PBO; HR = 0.86; 95% CI, 0.64-1.17). AEs leading to treatment discontinuation were reported in 81 (28.9%) vs 46 (16.3%) patients in the EVE vs PBO arms. Serious adverse events (SAEs) were reported in 122 (43.6%) vs 58 (20.6%) patients in the EVE vs PBO arms. Overall, 14 on-treatment deaths were observed, 7 (2.5%) in the EVE arm and 7 (2.5%) in the PBO arm; on-treatment deaths due to AEs were balanced between treatment arms (0.7% in each treatment arm). Types of post-progression therapies were balanced across both treatment arms.

Conclusions

In BOLERO-3, EVE showed a statistically significant prolongation of PFS. OS was similar in both treatment arms. The safety profile of EVE was comparable to that observed previously with EVE in breast cancer. (Funded by Novartis; BOLERO-3 ClinicalTrials.gov number, NCT01007942.)

Citation Format: Isaacs C, O'Regan R, Xu B, Masuda N, Arena F, Yap Y-S, Papai Z, Lang I, Armstrong A, Lerzo G, White M, Shen K, Zhang Y, Jappe A, Pacaud LB, Taran T, Ozguroglu M. Everolimus plus trastuzumab and vinorelbine for trastuzumab-resistant, taxane-pretreated, HER2+ advanced breast cancer: Overall survival results from BOLERO-3. [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 P4-13-12.

Abstract P5-10-01: Patient advocates as partners in breast cancer research at Georgetown University Lombardi Comprehensive Cancer Center

The integration of patient advocate input into biomedical research grant proposals is a relatively new phenomenon and represents a paradigm shift for basic, translational and clinical researchers seeking funding for their proposed studies. In 2011, the Lombardi Comprehensive Cancer Center (LCCC) at Georgetown University (GU) established the Georgetown Breast Cancer Advocates (GBCA) to facilitate collaboration between researchers and advocates. The mission of GBCA is to ensure research is patient-centered, innovative, evidence-based, and accessible. Working with researchers and clinicians at GU-LCCC early in proposal development, the members of the GBCA evaluate the feasibility of research, emphasizing the need for bench-to-bedside studies, the importance of quality of life, health care disparities and a reduction in breast cancer mortality. This integrated and early approach has resulted in GU-LCCC researchers being awarded a PCORI Grant, a DOD Idea Expansion Award, and a prestigious NIH U01 award.

The GBCA consists of survivors and community stakeholders from diverse ethnic, racial, and age groups. It ranges from women at high risk for breast cancer to both short- and long-term survivors of various sub-types of breast cancer and those with recurrent disease. Several advocates were trained by the National Breast Cancer Coalition's scientific education program, Project LEAD, and others participate in the Susan G. Komen for the Cure Advocates in Science Program. Members have served as consumer reviewers for the DOD's Breast Cancer Research Program at both the peer review and programmatic review levels, and as patient representatives on American Society of Clinical Oncology (ASCO) clinical practice guideline panels. GU-LCCC researchers and oncologists serve as advisors for the group.

This poster describes the evolution and work of the GBCA and how the group has influenced breast cancer research at GU-LCCC. GBCA works with researchers in the pre-award phase, providing input to investigators regarding methodologies to increase participant recruitment, retention, and adherence to research protocols. The advocates also provide input on study designs and patient education strategies. Through their contributions, the advocates have become an integral and respected part of the breast cancer research community at GU-LCCC.

Citation Format: Brundage S, Charles Chisholm D, Holloway JN, Lucas W, Salamone J, Winarsky S, London M, Greenwood N, Stahl S, Carbine N, Goyes R, Price E, Ernst E, Leventhal K-G, Isaacs C, Clarke R, Shajahan-Haq AN. Patient advocates as partners in breast cancer research at Georgetown University Lombardi Comprehensive Cancer Center. [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 P5-10-01.

Abstract P3-15-03: Safety analysis of BOLERO-3: A phase 3 trial of daily everolimus (EVE) vs placebo (PBO), both with weekly trastuzumab (TRAS) and vinorelbine in trastuzumab-resistant, advanced breast cancer

Background: Activation of the PI3K/mTOR pathway is thought to be involved in resistance to TRAS. BOLERO-3 is a randomized phase 3, double-blind, placebo-controlled, international, clinical trial evaluating the addition of the mTOR inhibitor EVE (5 mg/day) to TRAS plus vinorelbine (25 mg/m2) in patients with HER2+ advanced breast cancer resistant to TRAS and who were previously treated with a taxane. A total of 569 adult women were randomized 1:1 to receive EVE (n = 284) or PBO (n = 285). Study treatment represented the 2nd, 3rd, or 4th line of chemotherapy-containing regimen for 83% of patients in the metastatic setting. The primary endpoint, progression-free survival based on local radiologic assessment, was significantly longer in the EVE arm versus PBO (HR = 0.78; P = .0067) at a median follow-up of 20 months.

Methods: Study drugs were continued until disease progression or unacceptable toxicity. Incidences of adverse events (AEs) were monitored continuously. Dose modifications and discontinuations were recorded.

Results: The median duration of exposure to study treatment was similar across treatment groups: 24.8 weeks for EVE, 25.1 weeks for TRAS, and 24.0 weeks for vinorelbine (EVE arm); and 22.9 weeks for PBO, 24.0 weeks for TRAS, and 23.1 weeks for vinorelbine (PBO arm). The AEs were consistent with known drug-safety profiles. Class-effect AEs with mTOR inhibitors (including stomatitis, rash, noninfectious pneumonitis, and hyperglycemia) were higher in the EVE arm and were mainly grade 1/2. Grade 3 class-effect AEs each occurred in &lt;15% of patients (stomatitis [13%], hyperglycemia [2%], and noninfectious pneumonitis [&lt;1%]). Grade 4 noninfectious pneumonitis (&lt;1%) was uncommon; there were no grade 4 events of stomatitis or hyperglycemia, and no grade 3/4 events of rash. The incidence and grade of hematologic AEs were increased in the EVE arm vs the PBO arm, including all grade neutropenia (81% vs 70%), anemia (49% vs 29%), febrile neutropenia (17% vs 4%) and thrombocytopenia (14% vs 2%); grade 3/4 hematologic AEs included neutropenia (grade 3: 35% vs 32%; grade 4: 38% vs 30%), anemia (grade 3: 17% vs 6%; grade 4: 2% vs &lt;1%), febrile neutropenia (grade 3: 11% vs 3%; grade 4: 5% vs 1%), and thrombocytopenia (grade 3: 3% vs &lt;1%; grade 4: 1% vs 0). The incidences and grades of changes in liver enzymes and hyperlipidemia were similar between arms. Serious AEs were reported in 42% of patients in the EVE arm and 20% of patients in the PBO arm (26% and 6% were attributed to study treatments, respectively). A higher percentage of patients discontinued treatment because of AEs in the EVE arm versus PBO (10% vs 5%). In all, 83% of patients required at least 1 EVE dose interruption and/or reduction; 96% of these were attributed to AEs. There were fewer deaths in the EVE arm (37%) compared with PBO (41%).

Conclusions: The safety of the combination of EVE, TRAS, and vinorelbine was considered manageable in this heavily pretreated patient population. Overall, the results from BOLERO-3 demonstrate that EVE can be combined with TRAS and chemotherapy to improve efficacy in TRAS-resistant HER2+ advanced breast cancer previously treated with a taxane.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-15-03.

Abstract OT1-1-12: SAFE-HEaRt: A pilot study assessing the cardiac SAFEty of HER2 targeted therapy in patients with HER2 positive breast cancer and reduced left ventricular function

Background: Substantial benefit of trastuzumab is associated with cardiac side effects, mostly asymptomatic. According to current FDA approved package insert, patients should not receive trastuzumab or newer HER2 targeted therapies if there is evidence of cardiomyopathy.

Trial design: SAFE-HEaRt is a pilot study evaluating the cardiac safety of trastuzumab, pertuzumab and ado-trastuzumab emtansine in 30 patients with HER2 positive breast cancer (BC) and mild LV dysfunction (LVEF≥40% and &lt;50%) while on optimized cardiac therapy with B-Blockers and ACE inhibitors. Left ventricular ejection fraction (LVEF) and myocardial strain will be assessed at baseline, week 6,12,18 and then every 12 weeks. Troponin I (cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) will be collected at the same time points.

Main Eligibility criteria: Patients diagnosed with stage I-IV HER2 positive BC; LVEF≥40% and &lt;50% prior to or while receiving non-lapatinib HER2 targeted therapy.

Specific aims: The primary endpoint is the proportion of patients who complete planned oncologic therapy without the development of a cardiac event (presence of symptoms attributable to heart failure (HF) confirmed by a cardiologist, cardiac arrhythmia requiring pharmacological or electrical treatment, myocardial infarction, sudden cardiac death or death due to myocardial infarct, arrhythmia or HF) or asymptomatic worsening of cardiac function (i.e. asymptomatic decline in LVEF &gt;10% points from baseline and/or LVEF&lt;35% corroborated by a confirmatory echocardiogram in 2-4 weeks).

Additional endpoints include: Median time to development of an event; absolute changes in LVEF during HER2 targeted therapy; HER2 therapy holds attributed to cardiotoxicity; correlation of myocardial strain and serum biomarkers with cardiac events and asymptomatic worsening of cardiac function.

Statistical methods: A two-stage design is used to test if the completion rate of planned oncologic therapy will be at least 30% versus less than 10% with 80% power at a significance level of 5%. At the first stage, 15 patients will be entered. If one or more patients complete therapy in the absence of a cardiac event, then additional 15 patients will be enrolled in the second stage. Early stopping rules are incorporated for safety based on cardiac death and symptomatic HF. Safety monitoring plan consists of an internal cardiac review panel and a Data Safety Monitoring Board (DSMB) that includes an external cardiologist expert.

Present accrual and target accrual: The Institutional Review Board has approved the study. Enrollment of the first patient is expected in July 2013 with a total of 30 patients planned to be recruited. The initial recruitment sites are MedStar Washington Hospital Center and MedStar Georgetown University Hospital. This trial is partially supported by Genentech and funded by a Conquer Cancer Foundation of ASCO Young Investigator Award, supported by The Breast Cancer Research Foundation. Any opinions, findings, and conclusions expressed in this material are those of the author(s) and do not necessarily reflect those of the American Society of Clinical Oncology, the Conquer Cancer Foundation, or The Breast Cancer Research Foundation.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-1-12.

Abstract P4-12-19: BOLERO-3: Everolimus plus trastuzumab and vinorelbine in Asian patients with HER2-positive metastatic breast cancer

Background: Resistance to trastuzumab may occur through activation of the PI3K/Akt/mTOR signaling pathway, the inhibition of which may restore trastuzumab sensitivity. BOLERO-3, a phase 3, double-blind, international trial involving 569 patients with trastuzumab-resistant, HER2-positive (HER2+), advanced breast cancer pretreated with a taxane, recently reported that adding everolimus (EVE; an mTOR inhibitor) to vinorelbine and trastuzumab significantly improved progression-free survival (PFS) vs placebo (PBO) plus vinorelbine and trastuzumab (hazard ratio [HR] = 0.78; log-rank P = .0067). As EVE pharmacokinetics and, therefore, clinical effects may be different in Asian patients, we analyzed the efficacy and safety data from BOLERO-3 for the Asian population.

Methods: Eligible women with trastuzumab-resistant, HER2+, advanced breast cancer who received prior taxane therapy were randomized (1:1) to EVE (5 mg/day) or matching PBO in combination with weekly vinorelbine (25 mg/m2) and trastuzumab (2 mg/kg after 4-mg/kg loading dose). The primary endpoint was PFS by investigator. Secondary endpoints included safety.

Results: Among 569 patients enrolled in this study, 166 (29%) patients were Asian; 88 and 78 were assigned to EVE or PBO arms, respectively. In this subpopulation, adding EVE to vinorelbine and trastuzumab prolonged median PFS compared with the PBO arm (8.3 vs 6.8 months, respectively; HR = 0.83; 95% confidence interval, 0.59 - 1.18). In general, the incidence of all grade adverse events was similar for Asian versus non-Asian patients in the EVE arm (stomatitis, 71% vs 59%; pneumonitis, 7% vs 5%; and infections, 58% vs 70%) and the PBO arm (stomatitis, 31% vs 26%; pneumonitis, 1% vs 4%; and infections, 48% vs 49%). Serious adverse events had a low incidence and included febrile neutropenia (9.1%), neutropenia (2.3%), stomatitis (2.3%), anemia (2.3%), and cataract (2.3%) as the most common among Asian patients in the EVE arm. The incidence of serious pneumonitis was low: Asian (1.1%) versus non-Asian patients (0%) in the EVE arm and 0% versus 1.5%, respectively, in the PBO arm.

Conclusions: Asian patients in the BOLERO-3 trial treated with EVE plus vinorelbine and trastuzumab showed PFS benefits similar to the overall population and had a comparable manageable safety profile. Thus, EVE in combination with vinorelbine and trastuzumab may be considered as a new therapeutic option for Asian women with trastuzumab-resistant, HER2+, advanced breast cancer progressing after taxane-based therapies.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-19.

Abstract P4-12-18: BOLERO-3: Quality-of-life maintained in patients with metastatic breast cancer treated with everolimus plus trastuzumab plus vinorelbine

Background: Activation of the PI3K/mTOR pathway is implicated in resistance to trastuzumab. Accordingly, the BOLERO-3 study evaluated the efficacy of adding everolimus (EVE), an mTOR inhibitor, to vinorelbine and trastuzumab. At the final progression-free survival (PFS) analysis, EVE significantly improved PFS vs PBO (hazard ratio [HR] = 0.78; log-rank P = .0067) but EVE-treated patients had higher rate of grade 3/4 toxicity. To further qualify the benefit:risk of adding EVE to trastuzumab-based therapy, per-protocol, patient-reported, health-related quality-of-life (HRQoL) data were analyzed.

Methods: BOLERO-3 is a randomized phase 3, double-blind, placebo-controlled, international multicenter trial. Taxane-pretreated patients (N = 569) with trastuzumab-resistant, HER2+, advanced breast cancer were randomized (1:1) to treatment with EVE or placebo (PBO) plus vinorelbine and trastuzumab. The European Organisation for Research and Treatment of Cancer (EORTC) quality-of-life questionnaire C30 (QLQ-C30) (including the breast cancer-specific BR23 module) was administered at baseline and every 6 weeks thereafter until progression. The QLQ-C30 consists of 30 items combined into 15 subscales, including Global Health Status and functional subscales, where higher scores (range, 0 to 100) indicate better HRQoL. Time to definitive deterioration (TTD) based on a 10% decrease from baseline for GHS and for the physical, emotional, and social function subscales was determined using the Kaplan-Meier method. Treatment arms were compared using a 2-sided log-rank test stratified by prior use of lapatinib.

Results: Overall, there was no significant difference in median TDD of HRQoL between treatment arms. The median TTD in global health status score was 8.3 months for EVE (95% confidence interval [CI], 6.9-11.5) vs 7.3 months for PBO (95% CI, 5.6-10.4; P = .8386). The median TTD in the physical, emotional, and social function subscale scores showed no significant difference between arms. For example, median TTD in the physical function subscale score was 12.0 months (95% CI, 8.3-14.1) for EVE vs 12.5 months (95% CI, 8.3-20.9) for PBO (P = .4251), and median TTD in the emotional function subscale score was 15.2 months (95% CI, 9.2-17.3) for EVE vs 12.5 months (95% CI, 9.7-16.4) for PBO (P = .8140).

Conclusions: These analyses demonstrate that, despite increased frequency of adverse events observed with the addition of EVE to the standard treatment of vinorelbine and trastuzumab, overall and functional HRQoL scores were not negatively impacted in patients with trastuzumab-resistant, HER2+, advanced breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-18.

Abstract P2-12-03: BRCA1/2 testing in an urban population of black women (BW)

Background: Current indications for BRCA1/2 testing do not vary by race or ethnicity except for Ashkenazi Jewish individuals. Uptake of BRCA1/2 testing is low in BW, despite the presence of risk factors for BRCA1/2 mutations such as diagnosis of breast cancer (BC) at a young age and triple negative breast cancer (TNBC). The prevalence of BRCA1/2 mutations in BW is not well defined.

Aims: To determine the prevalence and predictors of deleterious BRCA1/2 mutations and variants of uncertain significance (VUS) in an urban population of BW, to describe preventive measures taken by BW with deleterious BRCA1/2 mutations and to describe the timing of genetic testing in BW with BC.

Methods: We performed a retrospective study of all BW, defined as women who self-identified as black, African or African-American, who underwent genetic risk evaluation at two hospitals in Washington DC from 2006-2012. We collected data on age, insurance, BRCA1/2 test results, preventive measures taken after receipt of test results, oncologic history and family history (FH), defined as a first or second degree relative with BC diagnosed at age ≤ 50 and/or a first or second degree relative with ovarian cancer (OC) diagnosed at any age.

Results: 211 BW received genetic counseling during this time period, 85.8% at MedStar Washington Hospital Center, and 14.2% at MedStar Georgetown University Hospital. 73% were affected (148 BC, 6 OC). Among those with BC, 14.2% had TNBC. Median age was 48 years (range 24-83). BRCA1/2 testing was performed in 70.1% (119 BC, 6 OC, 23 unaffected). Deleterious BRCA1/2 mutations were identified in 12.2% (18/148) of BW (10 BRCA1, 8 BRCA2). VUS were identified in 9.5% (14/148) of BW (3 BRCA1, 11 BRCA2). 15.2% of BW tested in 2006-2009 had VUS compared to 4.9% of BW tested in 2010-2012. 64% of VUS have been reclassified, all as benign polymorphisms except for one. BRACAnalysis Large Rearrangement Test (BART) was performed in 20.9% but did not identify any mutations. Deleterious BRCA1/2 mutations were identified in 28.5% of BW with TNBC who underwent BRCA1/2 testing, with higher prevalence among those diagnosed at younger ages (≤ age 50: 45.5%, ≤ age 60: 40%). Deleterious BRCA1/2 mutations were identified in 75% of BW with TNBC diagnosed ≤ age 50 and a positive FH. Following receipt of test results, 28% of BW found to have deleterious BRCA1/2 mutations underwent prophylactic oophorectomy and 33% underwent prophylactic mastectomy within the study time period. BRCA1/2 counseling was performed prior to definitive breast surgery in 40.5% of BW affected with BC. 11.1% of BW with BRCA1/2 mutations were underinsured and received testing under grant support.

Conclusions: In this retrospective study of a large population of BW who underwent genetic risk evaluation, the prevalence of deleterious BRCA1/2 mutations was 12.2%. A very high prevalence was seen in BW with TNBC, particularly in the presence of a FH. As expected, identification of VUS decreased over time. Inadequate insurance coverage remains a barrier to genetic testing among BW. (Supported by the Familial Cancer Registry at LCCC P30 CA51008-17).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-12-03.

Germline genetic variants in ABCB1, ABCC1 and ALDH1A1, and risk of hematological and gastrointestinal toxicities in a SWOG Phase III trial S0221 for breast cancer

Hematological and gastrointestinal toxicities are common among patients treated with cyclophosphamide and doxorubicin for breast cancer. To examine whether single-nucleotide polymorphisms (SNPs) in key pharmacokinetic genes were associated with risk of hematological or gastrointestinal toxicity, we analyzed 78 SNPs in ABCB1, ABCC1 and ALDH1A1 in 882 breast cancer patients enrolled in the SWOG trial S0221 and treated with cyclophosphamide and doxorubicin. A two-SNP haplotype in ALDH1A1 was associated with an increased risk of grade 3 and 4 hematological toxicity (odds ratio=1.44, 95% confidence interval=1.16-1.78), which remained significant after correction for multiple comparisons. In addition, four SNPs in ABCC1 were associated with gastrointestinal toxicity. Our findings provide evidence that SNPs in pharmacokinetic genes may have an impact on the development of chemotherapy-related toxicities. This is a necessary first step toward building a clinical tool that will help assess risk of adverse outcomes before undergoing chemotherapy.

A peer-led decision support intervention improves decision outcomes in black women with breast cancer

Previous reports suggest that Black breast cancer patients receive less patient-centered cancer care than their White counterparts. Interventions to improve patient-centered care (PCC) in Black breast cancer patients are lacking. Seventy-six women with histologically confirmed breast cancer were recruited from the Washington, DC area. After a baseline telephone interview, women received an in-person decision support educational session led by a trained survivor coach. The coach used a culturally appropriate guidebook and decision-making model-TALK Back!(©) A follow-up assessment assessed participants' acceptability of the intervention and intermediate outcomes. After the intervention, participants reported increased: self-efficacy in communicating with providers (70 %) and self-efficacy in making treatment decisions (70 %). Compared to baseline scores, post-intervention communication with providers significantly increased (p= .000). This is the first outcome report of an intervention to facilitate PCC in Black breast cancer patients. Testing this intervention using RCTs or similar designs will be important next steps.

Abstract P1-09-04: Down-regulation of trefoil protein 1(TFF1) in normal breast tissue of postmenopausal women at increased risk for breast cancer on exemestane

Background: Aromatase inhibitors (AI) are effective for breast cancer risk reduction in postmenopausal women. TFF1, also known as pS2, is an estrogen response gene present in normal mammary tissue with increased expression in estrogen receptor positive breast cancer. Previous studies have demonstrated down-regulation of TFF1 and Ki-67, a marker of proliferation, in postmenopausal women with locally advanced breast cancer who receive neoadjuvant AIs. TFF1 and proliferating cell nuclear antigen (PCNA) may serve as biomarkers of effect of AIs in women at increased risk for breast cancer.

Methods: We conducted a single-arm phase II trial of exemestane in women at increased risk for breast cancer and examined the impact on TFF1 and PCNA. Postmenopausal women at increased risk for invasive breast cancer by clinical or histological criteria received 25mg of exemestane daily for 2 years. Subjects were required to have stopped any hormonal medication ≥ 3 months prior to enrollment. Image guided breast biopsies targeting dense breast tissue were performed at baseline and at 12 months. Core specimens were obtained under local anesthesia at each time point from the same area of the breast. One core biopsy sample was formalin-fixed, paraffin-embedded and examined for pathologic abnormalities, as well as TFF1 and PCNA. TFF1 was assessed by intensity of stain (0 to 3+) and percent of cells with any staining; PCNA was assessed by percent of cells staining within the tissue section. The pathologist (B.K.) was blinded to the time of biopsy. Change in intensity and % positive cells were evaluated by paired t-test.

Results: Thirty four subjects underwent both baseline & 12 month breast biopsies. Eight biopsies at baseline and 5 biopsies at 12 months did not contain any ductal or lobular tissue and were not analyzed. Twenty-two subjects had evaluable breast tissue at both time points for TFF1 analysis and 23 subjects for PCNA analysis. No high risk lesions or invasive cancers were identified. Of the baseline specimens, 95.5% were positive for TFF1: 59.1% (13 of 22) were scored as 3+(intense), 31.8% (7 of 22) were 2+(moderate) and 4.5% (1 of 22) were 1+(low). Percent of cells staining for TFF1 ranged from 0 to 20% (median = 1%). After 1 year on exemestane TFF1 intensity decreased in 17 subjects (77.3%), 4 had no change and 1 increased. Mean TFF1 change was −1.32 (95% CI −1.87 to −0.76; p &lt; 0.001). The change in % positive cells for PCNA ranged from −15 to +30% (median = 0%).

Discussion: Assessing tissue biomarkers with repeat core needle biopsies in a phase II prevention trial in high risk women is feasible. Since prevention agents are not universally protective, determining biomarkers of effect may allow tailored therapy. TFF1 is a biologically plausible biomarker of AI activity that was down-regulated in 77% of breast tissue following exemestane therapy. This is the first study to evaluate this tissue marker in the prevention setting. Further study is needed to correlate with other biomarkers of interest, e.g. change in mammographic density, serum hormone levels and clinical outcomes.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-09-04.

Association of PHB 1630 C>T and MTHFR 677 C>T polymorphisms with breast and ovarian cancer risk in BRCA1/2 mutation carriers: results from a multicenter study

BACKGROUND

The variable penetrance of breast cancer in BRCA1/2 mutation carriers suggests that other genetic or environmental factors modify breast cancer risk. Two genes of special interest are prohibitin (PHB) and methylene-tetrahydrofolate reductase (MTHFR), both of which are important either directly or indirectly in maintaining genomic integrity.

METHODS

To evaluate the potential role of genetic variants within PHB and MTHFR in breast and ovarian cancer risk, 4102 BRCA1 and 2093 BRCA2 mutation carriers, and 6211 BRCA1 and 2902 BRCA2 carriers from the Consortium of Investigators of Modifiers of BRCA1 and BRCA2 (CIMBA) were genotyped for the PHB 1630 C>T (rs6917) polymorphism and the MTHFR 677 C>T (rs1801133) polymorphism, respectively.

RESULTS

There was no evidence of association between the PHB 1630 C>T and MTHFR 677 C>T polymorphisms with either disease for BRCA1 or BRCA2 mutation carriers when breast and ovarian cancer associations were evaluated separately. Analysis that evaluated associations for breast and ovarian cancer simultaneously showed some evidence that BRCA1 mutation carriers who had the rare homozygote genotype (TT) of the PHB 1630 C>T polymorphism were at increased risk of both breast and ovarian cancer (HR 1.50, 95%CI 1.10-2.04 and HR 2.16, 95%CI 1.24-3.76, respectively). However, there was no evidence of association under a multiplicative model for the effect of each minor allele.

CONCLUSION

The PHB 1630TT genotype may modify breast and ovarian cancer risks in BRCA1 mutation carriers. This association need to be evaluated in larger series of BRCA1 mutation carriers.

P3-11-01: Effects of Exemestane Therapy on the Lipid Profile of Postmenopausal Women with an Elevated Risk of Developing Invasive Breast Cancer

Background: Aromatase inhibitors are effective for breast cancer prevention in postmenopausal women. In the recent MAP.3 study, exemestane significantly reduced invasive breast cancer in postmenopausal women with an elevated risk of developing breast cancer. At 35 months follow up there was no increase risk in cardiovascular events in this study; however, the effects of exemestane use on lipid profiles and cardiovascular health are still unclear.

Methods: We conducted a single-arm phase II trial of exemestane in women at increased risk for breast cancer and examined the impact of exemestane on lipid profiles. Postmenopausal women at high risk for invasive breast cancer (e.g., Gail Model risk ≥ 1.7, a history of lobular neoplasia, atypical ductal hyperplasia, DCIS, or stage I/II breast cancer, or BRCA 1/2 mutation) were given exemestane (25 mg orally daily) for 2 years. Fasting serum total cholesterol, HDL, LDL, triglycerides, and homocysteine were collected at baseline, 3, 12, and 24 months after initiation of exemestane therapy. Apolipoprotein A and B were collected at baseline, 3 and 12 months. Wilcoxon sign ranked test was used to analyze if changes from baseline values differed from zero. The Hochberg p-value adjustment was used to account for multiple hypothesis tests.

Results: Of the 42 women enrolled in the study, 6 dropped out prior to completing 1 year and 1 dropped out prior to completing 2 years of exemestane therapy. Thirty-one women have completed 2 years of exemestane therapy and the remaining 4 are expected to complete 2 years of therapy by January 2012. On average, participants were 58.5 years old, mostly Caucasian (n = 37; 84.1%), and had a BMI of 29.2 kg/m2. A majority (n = 19) of participants were on lipid-lowering medications (14 were taking a statin) or taking fish oil supplements (n =5) prior to starting on the trial and 1 was started on a statin approximately 10 months after starting the trial. There were no significant differences in mean lipid values for each of the 4 assessment points or in the mean change from baseline at 3, 12, and 24 months between patients who were taking lipid-lowering medications and those were not. In unadjusted analyses, change in HDL from baseline was significantly different from zero and decreased from baseline at 3, 12 and 24 months (−8.0 mg/dL, −8.5 mg/dL, and −9.9 mg/dL; All p-values ≤ .001 before and after applying the Hochberg adjustment). Total cholesterol also significantly decreased from baseline at 3 months (−13.6 mg/dL, p = .002) but was no longer significant at 12 and 24 months (−9.6 mg/dL and −11.4 mg/dL, respectively; p-values = .07). The rest of the lipid panel did not significantly change during follow-up.

Discussion: In agreement with previous studies, we found that exemestane causes a significant decrease in HDL and total cholesterol, while leaving the rest of the lipid panel unchanged. Prior studies excluded patients on lipid-lowering medication; half of our participants were taking lipid-lowering medication. It is notable that both women off and on lipid-lowering medication had decreases in HDL. Additional studies are needed to elucidate long-term cardiovascular outcomes in this high risk but otherwise healthy population.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-11-01.

Patterns of fatal machine rollovers in Canadian agriculture

Introduction

Our objectives were to examine the activities and circumstances associated with agricultural machine-related rollover fatalities.

Methods

We identified agricultural machine rollover fatalities recorded by the Canadian Agricultural Injury Surveillance Program (CAISP) in 1990–2005. We determined sideways and backwards rollovers by year, age and sex of the victims, agricultural season, machine type, and the activity, circumstances and location of the injury event.

Results

The annual rate of rollover fatalities in Canada was 9.1 per 100 000 farm operations. Rollover fatalities decreased to 30% of baseline over the 16-year study period (p = .004). Fatal rollovers most often occurred among men aged 50–69 years and 60–79 years for sideways and backwards rollovers, respectively.

Discussion

Sideways rollovers occur when driving across an incline or at the edge of a ditch bordering a roadway or field. Backwards rollovers occur when driving up an incline, towing or extracting stuck machines, pulling stumps or trees, and towing implements or logs. Primary prevention programs for rollover injuries should target these identified patterns of injury.

Patterns of fatal machine rollovers in Canadian agriculture

INTRODUCTION

Our objectives were to examine the activities and circumstances associated with agricultural machine-related rollover fatalities.

METHODS

We identified agricultural machine rollover fatalities recorded by the Canadian Agricultural Injury Surveillance Program (CAISP) in 1990-2005. We determined sideways and backwards rollovers by year, age and sex of the victims, agricultural season, machine type, and the activity, circumstances and location of the injury event.

RESULTS

The annual rate of rollover fatalities in Canada was 9.1 per 100,000 farm operations. Rollover fatalities decreased to 30% of baseline over the 16-year study period (p = .004). Fatal rollovers most often occurred among men aged 50-69 years and 60-79 years for sideways and backwards rollovers, respectively.

DISCUSSION

Sideways rollovers occur when driving across an incline or at the edge of a ditch bordering a roadway or field. Backwards rollovers occur when driving up an incline, towing or extracting stuck machines, pulling stumps or trees, and towing implements or logs. Primary prevention programs for rollover injuries should target these identified patterns of injury.

Evaluation of the XRCC1 gene as a phenotypic modifier in BRCA1/2 mutation carriers. Results from the consortium of investigators of modifiers of BRCA1/BRCA2

BACKGROUND

Single-nucleotide polymorphisms (SNPs) in genes involved in DNA repair are good candidates to be tested as phenotypic modifiers for carriers of mutations in the high-risk susceptibility genes BRCA1 and BRCA2. The base excision repair (BER) pathway could be particularly interesting given the relation of synthetic lethality that exists between one of the components of the pathway, PARP1, and both BRCA1 and BRCA2. In this study, we have evaluated the XRCC1 gene that participates in the BER pathway, as phenotypic modifier of BRCA1 and BRCA2.

METHODS

Three common SNPs in the gene, c.-77C>T (rs3213245) p.Arg280His (rs25489) and p.Gln399Arg (rs25487) were analysed in a series of 701 BRCA1 and 576 BRCA2 mutation carriers.

RESULTS

An association was observed between p.Arg280His-rs25489 and breast cancer risk for BRCA2 mutation carriers, with rare homozygotes at increased risk relative to common homozygotes (hazard ratio: 22.3, 95% confidence interval: 14.3-34, P<0.001). This association was further tested in a second series of 4480 BRCA1 and 3016 BRCA2 mutation carriers from the Consortium of Investigators of Modifiers of BRCA1 and BRCA2.

CONCLUSIONS AND INTERPRETATION

No evidence of association was found when the larger series was analysed which lead us to conclude that none of the three SNPs are significant modifiers of breast cancer risk for mutation carriers.

Germline mutations in CDH1 are infrequent in women with early-onset or familial lobular breast cancers

BACKGROUND

Germline mutations in CDH1 are associated with hereditary diffuse gastric cancer; lobular breast cancer also occurs excessively in families with such condition.

METHOD

To determine if CDH1 is a susceptibility gene for lobular breast cancer in women without a family history of diffuse gastric cancer, germline DNA was analysed for the presence of CDH1 mutations in 318 women with lobular breast cancer who were diagnosed before the age of 45 years or had a family history of breast cancer and were not known, or known not, to be carriers of germline mutations in BRCA1 or BRCA2. Cases were ascertained through breast cancer registries and high-risk cancer genetic clinics (Breast Cancer Family Registry, the kConFab and a consortium of breast cancer genetics clinics in the United States and Spain). Additionally, Multiplex Ligation-dependent Probe Amplification was performed for 134 cases to detect large deletions.

RESULTS

No truncating mutations and no large deletions were detected. Six non-synonymous variants were found in seven families. Four (4/318 or 1.3%) are considered to be potentially pathogenic through in vitro and in silico analysis.

CONCLUSION

Potentially pathogenic germline CDH1 mutations in women with early-onset or familial lobular breast cancer are at most infrequent.

Abstract P1-07-03: Effect of Exemestane on Mammographic Density in Postmenopausal Women at Risk for Breast Cancer

Background: A reduction in mammographic density(MD) has been associated with the reduction in breast cancer risk among those taking tamoxifen. Aromatase inhibitors (AIs) show promise for breast cancer prevention in postmenopausal women. We are conducting a phase II trial of exemestane in women at increased risk for breast cancer. The primary endpoint for this study is change in MD.

Methods: Subjects were screened and enrolled at two sites: Center for Cancer Research, National Cancer Institute and Lombardi Comprehensive Cancer Center, Georgetown University Hospital. Eligible participants are at increased risk for breast cancer by virtue of: Gail model risk ≥1. 7% over 5 years; high risk pathological lesion (e.g. lobular neoplasia, ductal carcinoma in situ); known BRCA1/2 deleterious mutation or prior stage I/II breast cancer at least 2 years from breast cancer treatment and not treated with AIs. Women were excluded if AP spine T-score was &lt;-2.5 (osteoporosis). Study participants received exemestane 25 mg, calcium carbonate 1200 mg and vitamin D 400 IU daily for two years. Mammograms were conducted at baseline, 1 and 2 years. MD was calculated using the semi-automated Cumulus software. The cranio-caudal view of one breast was selected for analysis. For patients who had had no prior surgery or radiation, the side with greater density at baseline was selected. For patients who had undergone significant breast surgery or radiation, mammograms of the unaffected side were selected. Percent MD was determined by one investigator (C.B.) who read each image twice and was masked to the subject's time on exemestane. The mean change in paired images was tested for a mean change of zero using the Wilcoxon signed rank test. As of June 2010, 42 women have enrolled in the trial and we have analyzed change in MD at one year in the first 22 subjects.

Results:For the 22 subjects included in this analysis 15 were eligible due to a high risk pathological lesion, 4 by Gail Model and 3 by prior breast cancers. 18 had film screen mammograms at baseline and 12 months, 4 had film screen mammograms at baseline and digital mammogram at 12 months. Mammographic density declined 7% (p=0.0006, 95% CI −11% to −3%) at one year. The change in MD ranged from −26% to +14% and the standard deviation was 9%. In regard to the four subjects who had film screen mammograms at baseline and digital at follow up, the baseline percent dense areas were slightly higher than average but this did not reach statistical significance (p=0.32 by the Wilcoxon rank sum test). The 12 month MD comparison was similar to the 18 subjects with film images (p=0.90).

Conclusions: Exemestane use was associated with a statistically significant decrease in MD at one year. Prior evaluations of AI therapy in high risk women have not shown a significant decline in MD, however time on treatment was shorter and other third generation AIs were used. Although the number of subjects is small, MD did not differ significantly between film screen and digital mammograms. We will further evaluate change in MD in the entire cohort at 1 and 2 years and between film screen and digital mammography. Phase III trials are on-going to evaluate the effect of exemestane on breast cancer prevention.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-07-03.

Variants in the BRCA1/Fanconi-Anemia Repair Pathway and Taxane-Induced Neuropathy in SWOG S0221

Background: Taxane-induced peripheral neuropathy is a dose-limiting side effect that leads to suboptimal cancer treatment and diminished quality of life. The mode of taxane neurotoxicity is unclear, but may be through stabilization of microtubules and induction of spindle checkpoint, leading to cell cycle arrest at G2/M. Fanconi Anemia (FA) genes, including FANCD2, and FANCA, appear to be involved in G2/M phase checkpoint maintenance as well as spindle checkpoint in response to internal and external signals, such as taxane treatment. Thus, we hypothesized that variants in FA genes could impact severity of taxane-induced neuropathies.Methods: Using DNA extracted from blood collected from 893 breast cancer patients participating in a trial evaluating metronomic dosing of cyclophosphamide, doxorubicin and paclitaxel (S0221), we genotyped for single nucleotide polymorphisms (SNPs) that represent all of the variability across FANCA (44 SNPs) and FANCD2 (24 SNPs) in all race/ethnicity groups, as well as a panel of ancestry informative markers to control for potential population stratification, using Illumina GoldenGate platform. SNPs with minor allele frequency (MAF) less than 0.10 and those out of Hardy Weinberg Equilibrium (HWE) proportions (p&lt;0.001) were removed from analyses. Ordinal regression was used to test for allelic and haplotypic association with grade 3 or 4 toxicities relative to 0, 1, and 2 toxicities, adjusting for age, genetic admixture index and treatment arm. To adjust for multiple testing, permutation analyses were performed on both single SNP and haplotype models.Results: Eighteen SNPs in FANCD2 and 38 SNPs in FANCA passed MAF and HWE proportion requirements. For FANCD2, 4 SNPs spanning 67.5 Kb (rs7648104, rs2272125 [coding SNP], rs6786638 and rs644215), were significantly associated with taxane-induced neuropathy (p&lt;0.001) after controlling for multiple testing, with each SNP resulting in approximately a twofold increase in odds of severe taxane-induced neuropathy. Haplotype estimation showed that all 18 SNPs comprise a single haplotype. Two major (&gt;1% frequency) haplotypes were found. The frequencies of the risk haplotype in cases (patients with grade 3 or 4 neuropathy) and controls (patients with ≤ grade 2 neuropathy) were 0.25 and 0.15, respectively. Ordinal regression analyses were highly significant (p&lt;0.0005); patients with at least one copy of the risk haplotype had more than a twofold increased risk of grade 3 or 4 taxane-induced neuropathy (OR=2.2, 95% CI 1.44, 3.44). For FANCA, no SNPs or haplotypes were significantly associated with grade 3 or 4 neurotoxicity, either prior to or after correction for multiple testing.Conclusions: These results indicate that the Fanconi-Anemia pathway may be important for neurological sensitivity to taxanes, and that genotypic markers might be able to be used to identify patients at increased risk for severe taxane-induced neuropathy. Further studies will elucidate potential associations with survival outcomes.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2001.

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

9544

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.

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A prospective multi-center ovarian cancer screening study in women at increased risk

5510

Background: No proven ovarian cancer (OC) screening strategy exists for women who are at increased risk for the disease. A risk of ovarian cancer algorithm (ROCA) using serial CA125 values has previously shown greater positive predictive value (PPV) and sensitivity than a single CA125 in screening women at general population risk. We hypothesized that using ROCA would yield a reasonable PPV for ovarian cancer screening in a cohort at increased risk. Methods: Between 7/2001 and 9/2006, 25 sites (14 Cancer Genetics Network, 3 ovarian SPOREs, 1 EDRN, 7 others) prospectively enrolled patients. Inclusion criteria included: among self, 1° or 2° relatives in same lineage either (i) BRCA1/2 mutation, or (ii) two of OC or early onset (age = 50) breast cancer (BC), or (iii) Ashkenazi ethnicity and 1 of OC or BC. A previous diagnosis of OC excluded subjects. Subjects underwent CA125 every 3 months and the risk of having ovarian cancer based on the CA125 profile was recalculated after each test. ROCA referred subjects with risk > 1% to ultrasound (US), and risk > 10% additionally to a gynecologic oncologist. Objectives included PPV for study indicated surgery, sensitivity, and compliance. Sample size was chosen to observe 8 OC endpoints with a power of 80% to rule out PPV = 10% if the true PPV = 20%. Results: 2,343 high risk women enrolled, with 6,284 women years of screening and 19,549 CA125s obtained. There were 628 (10%/yr) referrals to US with 414 US performed. 38 women underwent study indicated surgeries. 9 OCs were identified during screening, 3 were prevalent (1 early, 2 late stage), and 6 were incident (5/6 = 83% early, 1 late). 3 of the 6 incident cases were found on prophylatic oophorectomy in early stage. ROCA detected 2 in early stage of remaining 3 incident cases, and 3 of 3 prevalent cases. The PPV was 5/38 = 13% (95% CI 4.4%, 28%) and sensitivity was 5/6 = 83%, CI (36%, 99%). There was high compliance with CA125 testing throughout study, with 84%, 85%, 85%, 82% subjects returning within 1 month of schedule for first 4 tests. Conclusions: Frequent CA125 testing using ROCA results in an acceptable PPV and high compliance in a cohort of women at increased risk for OC. A definitive screening study (= 30 incident cases) using ROCA with serial CA125 and possibly additional markers is required to define sensitivity for early stage OC.

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Circulating tumor cells (CTC): Assessment of treatment efficacy in metastatic breast cancer (MBC)

10535

Background: Preliminary data in MBC suggest that ≥5 CTC/7.5 mL blood is associated with worse progression free survival (PFS) and overall survival (OS), and that the persistence of ≥5 CTC/7.5 mL blood after the initiation of therapy predicts for treatment failure (NEJM 2004. 351:781.). We are conducting a prospective clinical research study to validate the prognostic and predictive significance of this serum biomarker in MBC. Methods: Serial CTC levels are obtained in patients starting a new systemic treatment regimen for progressive, radiographically measurable MBC. 10 mL samples of peripheral blood are collected before the start of treatment and then at 3–4 week intervals. All subjects are followed prospectively for PFS and OS, and they are offered the opportunity to continue CTC testing upon disease progression. CTC enumeration is performed on a 7.5 mL blood volume using the CellSearch technology (Veridex, LLC; Warren, NJ). Epithelial cells are immunomagnetically separated and fluorescently labeled, and nucleated (DAPI+) cells with the EpCAM+, cytokeratin 8/18/19+, and CD45- phenotype are counted as CTC. Clinical outcomes are based on radiographic studies and physical examination in accordance with RECIST criteria. Results: 46 of 100 subjects have been accrued, and 33 have completed at least one radiographic staging evaluation with a median follow up of 7 mos (range 2–18 mos). Treatment for the 33 evaluable patients includes chemotherapy (27%), endocrine therapy (46%), and combination therapy with a biologic agent (27%). At baseline, 85% (28/33) had at least 1 CTC/7.5 mL (range 1–78), and 27% (9/33) had ≥5 CTC/7.5 mL. Median PFS was 2.57 months and 6.77 months for subjects with ≥5 vs <5 CTC/7.5 mL at baseline, respectively (p=0.02). Conclusions: The current data validate the observation that baseline CTC levels correlate with PFS in patients with MBC and measurable disease. Patient accrual and data analysis are ongoing to confirm that persistent CTC levels ≥5/7.5 mL correlate with a lack of treatment efficacy and therefore are a reliable surrogate marker of disease responsiveness and PFS.

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A phase II study of weekly gemcitabine and docetaxel in first and second line metastatic breast cancer

10668

Background: Combination chemotherapy for metastatic breast cancer has generally been demonstrated to be associated with a higher response rate than single agent therapy, however such therapy is often accompanied by increased toxicity. Thus there is a need to develop well-tolerated combination chemotherapy regimens. Gemcitabine and docetaxel are both active agents in the treatment of this disease, and are effective and well tolerated when administered on a weekly basis. The purpose of this study was to evaluate the therapeutic efficacy and toxicity of weekly gemcitabine and docetaxel as first or second line treatment of metastatic breast cancer (MBC). Methods: Patients with measurable MBC who had received no more than 1 prior chemotherapy regimen in the metastatic setting were treated with gemcitabine 800 mg/m2 and docetaxel 30 mg/m2 on days 1 and 8 every 21 days without growth factor support. Results: Thirty-one patients were enrolled. Twenty-nine patients were evaluable for toxicity and 25 for efficacy. Median age was 55 (range 30 to 79). Visceral disease was the dominant site in 74% of patients. Doxorubicin and paclitaxel were previously administered in 74% and 48% of patients respectively. The overall response rate was 56% (complete response in 1 patient and partial responses in 13 patients). Stable disease was evident in 10 additional patients (38.4%). The progression free survival was 35 weeks (range 9 to 101 weeks) and the median overall survival was 17 months. Treatment was well tolerated with the majority of toxicities being grade 1 or 2 (85%). The only grade 3 (G3) or 4 (G4) toxicities observed were neutropenia in 14 participants (G3 41%; G4 7%), anemia in 4 (13%), G3 elevated transaminases in 3 (10%), G3 thrombocytopenia in 1 (3%), G3 flu-like symptoms in 2 (7%) and G3 edema in 1 (3%). Conclusions: The regimen of gemcitabine 800 mg/m2 and docetaxel 30 mg/m2 given two weeks out of three for MBC showed excellent overall response of 56% with very good tolerability. The findings from our trial compare well to the response rates of 36% to 79% seen in prior phase II trials utilizing higher doses of this combination chemotherapy.

[Table: see text]