The effect of self-management techniques on relevant outcomes in chronic low back pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Among many treatment approaches for chronic low back pain (CLBP), self-management techniques are becoming increasingly important. The aim of this paper was to (a) provide an overview of existing digital self-help interventions for CLBP and (b) examine the effect of these interventions in reducing pain intensity, pain catastrophizing and pain disability.

DATABASES AND DATA TREATMENT

Following the PRISMA guideline, a systematic literature search was conducted in the MEDLINE, EMBASE, PsychInfo, CINAHL and Cochrane databases. We included randomized controlled trials from the last 10 years that examined the impact of digital self-management interventions on at least one of the three outcomes in adult patients with CLBP (duration ≥3 months). The meta-analysis was based on random-effects models. Standardized tools were used to assess the risk of bias (RoB) for each study and the quality of evidence for each outcome.

RESULTS

We included 12 studies (n = 1545). A small but robust and statistically significant pooled effect was found on pain intensity (g = 0.24; 95% CI [0.09, 0.40], k = 12) and pain disability (g = 0.43; 95% CI [0.27, 0.59], k = 11). The effect on pain catastrophizing was not significant (g = 0.38; 95% CI [-0.31, 1.06], k = 4). The overall effect size including all three outcomes was g = 0.33 (95% CI [0.21, 0.44], k = 27). The RoB of the included studies was mixed. The quality of evidence was moderate or high.

CONCLUSION

In summary, we were able to substantiate recent evidence that digital self-management interventions are effective in the treatment of CLBP. Given the heterogeneity of interventions, further research should aim to investigate which patients benefit most from which approach.

SIGNIFICANCE

This meta-analysis examines the effect of digital self-management techniques in patients with CLBP. The results add to the evidence that digital interventions can help patients reduce their pain intensity and disability. A minority of studies point towards the possibility that digital interventions can reduce pain catastrophizing. Future research should further explore which patients benefit most from these kinds of interventions.

Invoking Self-Related and Social Thoughts Impacts Online Information Sharing

Online sharing impacts which information is widely available and influential in society. Yet, systematically influencing sharing behavior remains difficult. Past research highlights two factors associated with sharing: the social and self-relevance of the to-be-shared content. Based on this prior neuroimaging work and theory, we developed a manipulation in the form of short prompts that are attached to media content (here health news articles). These prompts encourage readers to think about how sharing the content may help them to fulfill motivations to present themselves positively (self-relevance) or connect positively to others (social relevance). Fifty-three young adults completed this pre-registered experiment while undergoing fMRI scanning. Ninety six health news articles were randomly assigned to three within-subject conditions that encouraged self-related or social thinking, or a control. Invoking self-related or social thoughts about health-related news (vs. control) 1) causally increased brain activity in a priori regions of interest chosen for their roles in processing social and self-relevance and 2) causally impacted self-reported sharing intentions. This study provides evidence corroborating prior reverse inferences regarding the neural correlates of sharing. It further highlights the feasibility and utility of targeting neuropsychological processes to systematically facilitate online information spread.

Abstract 353: Phenotypic Switching Of Vascular Smooth Muscle Cells Is Regulated By ApoE And A Potential Therapeutic Target In Popliteal Aneurysms

Introduction: Popliteal artery aneurysm (PAA) is an individually highly fatal disease, causing ischemia and eventual major amputation, mainly in 50-70-year-old males. It is the most frequent peripheral artery aneurysm and correct treatment is challenging for clinicians, since both open and endovascular repair have only modest success rates, depending on the clinical presentation. In comparison to other aneurysm entities, little is known about its specific pathogenesis.

Material and Methods: 26 Human PAA and popliteal artery samples were analyzed by immunohistochemistry, mRNA and miRNA expression analysis and targeted proteomics (OLink platform) to identify key features of the disease and crucial pathways involved. Additionally, a primary cell culture of PAA specimen was established for in-vitro vascular smooth muscle cell (VSMC) modulation.

Results: VSMCs lose their contractile phenotype along with significant inflammatory and proteolytic changes in the vessel wall architecture. Extensive tissue remodeling with high cell turnover rates (as indicated by Ki67+ cells) compared to non-diseased popliteal artery is a unique feature in comparison to AAA. This correlates with highly abundant co-expression of the apolipoproteins E and CI with Ki67 in VSMCs in double immune-fluorescent stains. Stimulation of VSMCs with external APOE or APOCI alters proliferation rates and significantly changes a subset of contractile markers proteins upon gene expression analysis. These findings are emphasized by a specific case of a solely mechanically induced PAA in a young male.

Conclusion: Pathogenesis of PAA shows similar histologic features than AAA, yet differs in key pathways involved. Increased cell turnover in the aneurysm neck area suggests evaluation of alternative treatment strategies, i.e., targeting key processes of pathogenesis such as angiogenesis and cell turnover.

Mast cell‐deficient mice Mcpt5Cre/Dicer fl/fl redefine the role of mast cells in experimental bullous pemphigoid

Background

Bullous pemphigoid (BP) is the most frequent autoimmune blistering disease of the skin affecting the elderly. BP is immunopathologically characterized by autoantibodies against BP180 and BP230. With the growing evidence of cell‐mediated autoimmunity in the pathogenesis of BP, it still remains unclear whether mast cells (MCs) are involved, due to conflicting data obtained from Kit‐dependent MC‐deficient mouse models.

Objectives

To clarify the role of MCs in experimental BP; the dynamics in cutaneous MC numbers, associated immune cells and the development of disease in Kit‐independent MC‐deficient mouse model.

Methods

Employing a recently established murine adult passive transfer model of BP induced by the transfer of pathogenic immunoglobulin G (IgG), lesional skin biopsies were investigated histologically and immunohistochemically for the time‐dependent MC accumulation and dermal infiltration.

Results

The numbers of cutaneous MCs increased following the induction of BP, in part, maintained by MC proliferation. Numbers of T cells, neutrophils and eosinophils in the skin also increased after BP induction, with eosinophils showing a preferential co‐localization with MCs. Furthermore, clinical disease manifestation in MC‐deficient Mcpt5Cre/Dicer^fl/fl mice remained unchanged compared to MC‐sufficient Dicer^fl/fl mice. The composition of the immune cell infiltration including as T cells, neutrophils and eosinophils was largely unaffected by the absence of MCs.

Conclusion

MCs do not play a pivotal role in the pathogenesis of passive IgG‐transfer mediated BP model. Their increase in number may be a bystander effect following tissue injury. We therefore suggest caution regarding the selection of MCs as sole targets for the development of novel drugs for BP.

A Comprehensive Multi-Analyte Method for Hair Analysis: Substance-Specific Quantification Ranges and Tool for Task-Oriented Data Evaluation

The aim of the present study was to quantify a large number of analytes including opioids, stimulants, benzodiazepines, z-drugs, antidepressants and neuroleptics within a single sample workup followed by a single analytical measurement. Expected drug concentrations in hair are strongly substance dependent. Therefore, three different calibration ranges were implemented: 0.5 to 600 pg/mg (group 1), 10 to 12,000 pg/mg (group 2) and 50 to 60,000 pg/mg (group 3). In order to avoid saturation effects, different strategies were applied for selected transitions including the use of parent mass ions containing one or two 13C-isotopes and detuning of the declustering potential and/or collision energy. Drugs were extracted from pulverized hair by a two-step extraction protocol and measured by liquid chromatrography--tandem mass spectrometry (LC--MS-MS) using Scheduled MRM™ Algorithm Pro. In total, 275 MRM transitions including 43 deuterated standards were measured. The method has been fully validated according to international guidelines. A MultiQuant™ software based tool for task-oriented data evaluation was established, which allows extracting selected information from the measured data sets. The matrix effects and recoveries were within the allowed ranges for the majority of the analytes. The lower limits of quantification (LLOQs) were for ∼72% of the analytes in the low-pg/mg range (0.5-5 pg/mg) and for ∼24% of the analytes between 10 and 50 pg/mg. These LLOQs considered cut-offs by the Society of Hair Testing (SoHT), if recommended. The herein established multi-analyte approach meets the specific requirements of forensic hair testing and can be used for the rapid and robust measurement of a wide range of psychoactive substances. The analyte-specific wide concentration ranges open up a wide field of applications.

Combined analysis of gut microbiota, diet and PNPLA3 polymorphism in biopsy-proven non-alcoholic fatty liver disease

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is a global health burden. Risk factors for disease severity include older age, increased body mass index (BMI), diabetes, genetic variants, dietary factors and gut microbiota alterations. However, the interdependence of these factors and their individual impact on disease severity remain unknown.

METHODS

In this cross-sectional study, we performed 16S gene sequencing using fecal samples, collected dietary intake, PNPLA3 gene variants and clinical and liver histology parameters in a well-described cohort of 180 NAFLD patients. Principal component analyses were used for dimensionality reduction of dietary and microbiota data. Simple and multiple stepwise ordinal regression analyses were performed.

RESULTS

Complete data were available for 57 NAFLD patients. In the simple regression analysis, features associated with the metabolic syndrome had the highest importance regarding liver disease severity. In the multiple regression analysis, BMI was the most important factor associated with the fibrosis stage (OR per kg/m² : 1.23, 95% CI 1.10-1.37, P < .001). The PNPLA3 risk allele had the strongest association with the histological grade of steatosis (OR 5.32, 95% CI 1.56-18.11, P = .007), followed by specific dietary patterns. Low abundances of Faecalibacterium, Bacteroides and Prevotella and high abundances of Gemmiger were associated with the degree of inflammation, ballooning and stages of fibrosis, even after taking other cofactors into account.

CONCLUSIONS

BMI had the strongest association with histological fibrosis, but PNPLA3 gene variants, gut bacterial features and dietary factors were all associated with different histology features, which underscore the multifactorial pathogenesis of NAFLD.

RNA Sequencing and Somatic Mutation Status of Adrenocortical Tumors: Novel Pathogenetic Insights

CONTEXT

Pathogenesis of autonomous steroid secretion and adrenocortical tumorigenesis remains partially obscure.

OBJECTIVE

To investigate the relationship between transcriptome profile and genetic background in a large series of adrenocortical tumors and identify new potential pathogenetic mechanisms.

DESIGN

Cross-sectional study.

SETTING

University Hospitals of the European Network for the Study of Adrenal Tumors (ENSAT).

PATIENTS

We collected snap-frozen tissue from patients with adrenocortical tumors (n = 59) with known genetic background: 26 adenomas with Cushing syndrome (CS- cortisol-producing adenoma [CPA]), 17 adenomas with mild autonomous cortisol secretion (MACS-CPAs), 9 endocrine-inactive adenomas (EIAs), and 7 adrenocortical carcinomas (ACCs).

INTERVENTION

Ribonucleic acid (RNA) sequencing.

MAIN OUTCOME MEASURES

Gene expression, long noncoding RNA (lncRNA) expression, and gene fusions. Correlation with genetic background defined by targeted Sanger sequencing, targeted panel- or whole-exome sequencing.

RESULTS

Transcriptome analysis identified 2 major clusters for adenomas: Cluster 1 (n = 32) mainly consisting of MACS-CPAs with CTNNB1 or without identified driver mutations (46.9% of cases) and 8/9 EIAs; Cluster 2 (n = 18) that comprised CP-CPAs with or without identified driver mutation in 83.3% of cases (including all CS-CPAs with PRKACA mutation). Two CS-CPAs, 1 with CTNNB1 and 1 with GNAS mutation, clustered separately and relatively close to ACC. lncRNA analysis well differentiate adenomas from ACCs. Novel gene fusions were found, including AKAP13-PDE8A in one CS-CPA sample with no driver mutation.

CONCLUSIONS

MACS-CPAs and EIAs showed a similar transcriptome profile, independently of the genetic background, whereas most CS-CPAs clustered together. Still unrevealed molecular alterations in the cAMP/PKA or Wnt/beta catenin pathways might be involved in the pathogenesis of adrenocortical tumors.

Health news sharing is reflected in distributed reward-related brain activity

Neuroimaging has identified individual brain regions, but not yet whole-brain patterns, that correlate with the population impact of health messaging. We used neuroimaging to measure whole-brain responses to health news articles across two studies. Beyond activity in core reward value-related regions (ventral striatum, ventromedial prefrontal cortex), our approach leveraged whole-brain responses to each article, quantifying expression of a distributed pattern meta-analytically associated with reward valuation. The results indicated that expression of this whole-brain pattern was associated with population-level sharing of these articles beyond previously identified brain regions and self-report variables. Further, the efficacy of the meta-analytic pattern was not reducible to patterns within core reward value-related regions but rather depended on larger-scale patterns. Overall, this work shows that a reward-related pattern of whole-brain activity is related to health information sharing, advancing neuroscience models of the mechanisms underlying the spread of health information through a population.

Brain Activity Tracks Population Information Sharing by Capturing Consensus Judgments of Value

Information that is shared widely can profoundly shape society. Evidence from neuroimaging suggests that activity in the ventromedial prefrontal cortex (vmPFC), a core region of the brain's valuation system tracks with this sharing. However, the mechanisms linking vmPFC responses in individuals to population behavior are still unclear. We used a multilevel brain-as-predictor approach to address this gap, finding that individual differences in how closely vmPFC activity corresponded with population news article sharing related to how closely its activity tracked with social consensus about article value. Moreover, how closely vmPFC activity corresponded with population behavior was linked to daily life news experience: frequent news readers tended to show high vmPFC across all articles, whereas infrequent readers showed high vmPFC only to articles that were more broadly valued and heavily shared. Using functional connectivity analyses, we found that superior tracking of consensus value was related to decreased connectivity of vmPFC with a dorsolateral PFC region associated with controlled processing. Taken together, our results demonstrate variability in the brain's capacity to track crowd wisdom about information value, and suggest (lower levels of) stimulus experience and vmPFC-dlPFC connectivity as psychological and neural sources of this variability.

Prediction of advanced fibrosis in non-alcoholic fatty liver disease using gut microbiota-based approaches compared with simple non-invasive tools

Liver fibrosis is the major determinant of liver related complications in patients with non-alcoholic fatty liver disease (NAFLD). A gut microbiota signature has been explored to predict advanced fibrosis in NAFLD patients. The aim of this study was to validate and compare the diagnostic performance of gut microbiota-based approaches to simple non-invasive tools for the prediction of advanced fibrosis in NAFLD. 16S rRNA gene sequencing was performed in a cohort of 83 biopsy-proven NAFLD patients and 13 patients with non-invasively diagnosed NAFLD-cirrhosis. Random Forest models based on clinical data and sequencing results were compared with transient elastography, the NAFLD fibrosis score (NFS) and FIB-4 index. A Random Forest model containing clinical features and bacterial taxa achieved an area under the curve (AUC) of 0.87 which was only marginally superior to a model without microbiota features (AUC 0.85). The model that aimed to validate a published algorithm achieved an AUC of 0.71. AUC’s for NFS and FIB-4 index were 0.86 and 0.85. Transient elastography performed best with an AUC of 0.93. Gut microbiota signatures might help to predict advanced fibrosis in NAFLD. However, transient elastography achieved the best diagnostic performance for the detection of NAFLD patients at risk for disease progression.

Prognostic factors for and pattern of lymph-node involvement in patients with operable cervical cancer

PURPOSE

Lymph node metastases significantly worsen the prognosis in cervical carcinoma. Risk factors-pathological and patient related-could select patients at high risk for lymph node involvement.

METHODS

This retrospective analysis was performed by analyzing data from patients with cervical carcinoma treated between 2000 and 2017 at the Department of Obstetrics and Gynecology of the University Hospital Ulm.

RESULTS

In total, 261 patients with cervical carcinoma (International Federation of Gynecology and Obstetrics (FIGO) stage IA-IIB) and lymphadenectomy with at least 10 removed lymph nodes were available for analysis. Overall, 86 (33.0%) patients had lymph node metastases; 73 patients had pelvic lymph node metastases only and 13 patients had both pelvic and paraaortic lymph node metastases. Lymph node metastases were found most often in the region of the external iliac artery and obturator fossa, with 57.0% and 54.7% of all 86 node-positive patients, respectively. Univariable analyses showed that presence of lymph node metastases was significantly associated with both preoperative FIGO stage (p = 0.001) and final pathological tumor stage (p < 0.001), status of resection margin (p = 0.002), lymphovascular space invasion (LVSI), (p < 0.001) and vascular space invasion, (p < 0.001). In a multivariable logistic regression model with presence of lymph node metastases (yes/no) as binary response variable, only LVSI (p < 0.001) and body mass index (BMI), (p = 0.035) remained as significant independent predictors of lymph node involvement. Subgroup analyses showed that LVSI was a significant predictive factor for lymph node involvement in patients with a preoperatively assessed FIGO stage < IIB (p < 0.001), but not for patients with a preoperatively assessed FIGO stage ≥ IIB (p = 0.122).

CONCLUSIONS

The risk factor LVSI should play an important role in deciding whether an individualized therapy concept is based on escalating or deescalating treatment. In future, the sentinel concept could reduce morbidity and at the same time provide an important prognostic assessment for a subset of cervical cancer patients.

Cognitive regulation of ventromedial prefrontal activity evokes lasting change in the perceived self-relevance of persuasive messaging

Persuasive messages can change people's thoughts, feelings, and actions, but these effects depend on how people think about and appraise the meaning of these messages. Drawing from research on the cognitive control of emotion, we used neuroimaging to investigate neural mechanisms underlying cognitive regulation of the affective and persuasive impact of advertisements communicating the risks of binge drinking, a significant public health problem. Using cognitive control to up-regulate (vs. down-regulate) responses to the ads increased: negative affect related to consequences of excessive drinking, perceived ad effectiveness, and ratings of ad self-relevance made after a one-hour delay. Neurally, these effects of cognitive control were mediated by goal-congruent modulation of ventromedial prefrontal cortex and distributed brain patterns associated with negative emotion and subjective valuation. These findings suggest that people can leverage cognitive control resources to deliberately shape responses to persuasive appeals, and identify mechanisms of emotional reactivity and integrative valuation that underlie this ability. Specifically, brain valuation pattern expression mediated the effect of cognitive goals on perceived message self-relevance, suggesting a role for the brain's valuation system in shaping responses to persuasive appeals in a manner that persists over time.

MicroRNA expression correlates with disease recurrence and overall survival in oral squamous cell carcinoma

OBJECTIVES

Locoregional disease recurrence and metastatic events are the leading causes of death and the most important prognostic factors in patients with head and neck squamous cell carcinoma (HNSCC). A major goal of oncology is the identification of clinical and molecular parameters to evaluate the individual risk of recurrence. MicroRNAs (miRNAs) have been shown to correlate well with tumor size and differentiation. Therefore, they are candidate biomarkers for estimating clinical outcomes.

MATERIALS AND METHODS

In this study, the expression levels of distinct miRNAs extracted from formalin-fixed, paraffin-embedded (FFPE) samples of oral squamous cell carcinoma were compared.

RESULTS

Statistical analysis revealed significant correlations between distinct miRNAs and disease recurrence (miR-99*, miR-194*; p < 0.05) and overall survival (miR-99*; p < 0.05). The results were then validated via data from The Cancer Genome Atlas (TCGA).

CONCLUSIONS

Our data show that miR-99* and miR-194* can possibly serve as biomarkers for clinical outcome in HNSCC. These findings may help to identify high-risk patients, who could profit from a more individualized treatment and follow-up.

Rare compound heterozygous variants in PNKP identified by whole exome sequencing in a German patient with ataxia-oculomotor apraxia 4 and pilocytic astrocytoma

Ataxia-oculomotor apraxia type 4 (AOA4) is a rare autosomal recessive neurologic disorder. The phenotype is characterized by ataxia, oculomotor apraxia, peripheral neuropathy and dystonia. AOA4 is caused by biallelic pathogenic variants in the PNKP gene encoding a polynucleotide kinase 3'-phosphatase with an important function in DNA-damage repair. By whole exome sequencing, we identified 2 variants within the PNKP gene in a 27-year-old German woman with a clinical AOA phenotype combined with a cerebellar pilocytic astrocytoma diagnosed at 23 years of age. One variant, a duplication in exon 14 resulting in the frameshift c.1253_1269dup p.(Thr424fs*49), has previously been described as pathogenic, for example, in cases of AOA4. The second variant, representing a nonsense mutation in exon 17, c.1545C>G p.(Tyr515*), has not yet been described and is predicted to cause a loss of the 7 C-terminal amino acids. This is the first description of AOA4 in a patient with central European descent. Furthermore, the occurrence of a pilocytic astrocytoma has not been described before in an AOA4 patient. Our data demonstrate compound heterozygous PNKP germline variants in a German patient with AOA4 and provide evidence for a possible link with tumor predisposition. Localization of the 2 variants in human PNKP NP_009185.2. NM_007254.3:c.1253_1269dup p.(Thr424fs*49) is predicted to cause a frameshift within the kinase domain, NM_007254.3:c.1545C>G p.(Tyr515*) is predicted to cause loss of 2 C-terminal amino acids of the kinase domain and 5 additional C-terminal amino acids.

Microbiome Influences Prenatal and Adult Microglia in a Sex-Specific Manner

Microglia are embryonically seeded macrophages that contribute to brain development, homeostasis, and pathologies. It is thus essential to decipher how microglial properties are temporally regulated by intrinsic and extrinsic factors, such as sexual identity and the microbiome. Here, we found that microglia undergo differentiation phases, discernable by transcriptomic signatures and chromatin accessibility landscapes, which can diverge in adult males and females. Remarkably, the absence of microbiome in germ-free mice had a time and sexually dimorphic impact both prenatally and postnatally: microglia were more profoundly perturbed in male embryos and female adults. Antibiotic treatment of adult mice triggered sexually biased microglial responses revealing both acute and long-term effects of microbiota depletion. Finally, human fetal microglia exhibited significant overlap with the murine transcriptomic signature. Our study shows that microglia respond to environmental challenges in a sex- and time-dependent manner from prenatal stages, with major implications for our understanding of microglial contributions to health and disease.

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Microglia undergo sequential phases of differentiation during development

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The maternal microbiome influences microglial properties during prenatal stages

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The absence of the microbiome has a sex- and time-specific impact on microglia

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Microbiome depletions have acute and long-term effects on microglial properties

Adverse events of group psychotherapy in the in-patient setting - results of a naturalistic trial

OBJECTIVE

Adverse events of psychotherapy have often been neglected in research. In this study, potential adverse events of group psychotherapies in a psychiatric hospital were systematically assessed, explored for predictors and linked to treatment outcome.

METHOD

A naturalistic trial was conducted in 180 in-patients attending different group psychotherapies. Adverse events were assessed using three different measures: (i) weekly reporting of unwanted treatment reactions, (ii) mood changes in response to every single group session and (iii) premature group termination.

RESULTS

Different measures of adverse events were weakly associated. Deterioration of mood state and/or unwanted treatment reactions were experienced by 60-65% of all patients. Reports of unwanted treatment reactions decreased over time and were negatively associated with symptom improvement. However, mood state deterioration was constant and unrelated to treatment outcome. The rate of premature group termination was 34%. Significant predictors of adverse events included patient characteristics as well as disadvantageous group conditions.

CONCLUSIONS

For the majority of patients, group psychotherapy in the in-patient setting is associated with adverse events. Changes over time and a strong correlation with general symptom severity must be considered in the assessment and interpretation of adverse events. Predictors should be considered as potential risk factors in future research.

Abstract P2-05-02: Active surveillance with a combination of tumor marker CA27.29 and detection of circulating tumor cells two year after primary diagnosis strongly predicts subsequent prognosis

Introduction

The prognosis of patients with early breast cancer is commonly estimated by prognostic factors obtained at the time of the initial diagnosis. However, patients and physicians alike are seeking for factors evaluating the prognosis years thereafter during follow-up. The identification of a patient group with an unfavourable prognosis could lead to secondary treatment intervention, potentially improving outcome. Aim of the study was to assess the added prognostic value of circulating tumor cells (CTCs) and CA27.29 beyond established predictors.

Materials and Methods

Patients of the phase III SUCCESS-A study were included into this analysis (n=1005). SUCCESS-A is a chemotherapy study for high risk patients with a comprehensive translational research program, which included the determination of CTCs and CA27.29 two years after the initial diagnosis. A Cox regression model with disease-free survival (DFS) as outcome and well-established predictors (age, BMI, pT, pN, histology, grading, ER, PR, Her2neu) was compared with an extended Cox model with the well-established predictors and additionally CTC (&gt;0 versus 0) two years after randomization, and CA27.29 (in U/mL) measured after chemotherapy and again two years after randomization using a likelihood ratio test. In case of significance, the extended model was applied to predict for each patient the risk of disease recurrence within the next 12 months (0 to 100%). Cross-validated AUC, sensitivity and specificity values were determined to assess clinical usefulness of risk prediction.

Results

The markers CA27.29 and CTC were both significantly associated with subsequent prognosis (p &lt; 0.000001). The detection of CTCs increased the risk of subsequent DFS events (HR=2.14, 95%CI: 1.31-3.48), while CA27.29 after two years increased the risk for DFS events with a HR of 1.12 per U/mL increase (95%CI: 1.09-1.15). The combination of the two markers significantly empowered the prognostic relevance, with a HR of 6.64 for patients with CTCs and an elevated CA27.29 by 10 U/mL compared to patients without CTCs and without CA27.29 elevation. The mean risk of disease recurrence in the third year after randomization was 2.38%. Discrimination of patients with and without disease recurrence based on risk prediction from the extended Cox model (AUC: 0.80) was better than discrimination based on the clinical model without the markers CTC and CA27.29 (AUC: 0.64). Sensitivity with regard to decision thresholds 1%, 2%, 3%, and 4% predicted risk was 0.89, 0.77, 0.65, and 0.55, respectively. The corresponding specificity was 0.42, 0.69, 0.81, and 0.88.

Discussion

Both CTCs and CA29.27 values determined 2 years after primary diagnosis are clinically relevant predictors of subsequent prognosis for those patients. This study extends evidence for active surveillance of breast cancer survivors. Identifying a group of women with a high recurrence risk after two years could be the basis for the development of secondary adjuvant treatment.

Citation Format: Janni W, Rack B, Häberle L, Friedl TWP, Tesch H, Lorenz R, Jäger B, Fehm T, Müller V, Schneeweiß A, Lichtenegger W, Blohmer J, Beckmann MW, Scholz C, Pantel K, Trapp E, Fasching PA. Active surveillance with a combination of tumor marker CA27.29 and detection of circulating tumor cells two year after primary diagnosis strongly predicts subsequent prognosis [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-02.

Constructed wetlands may lower inorganic nutrient inputs but enhance DOC loadings into a drinking water reservoir in North Wales

The objective of this study was to monitor a newly constructed wetland (CW) in north Wales, UK, to assess whether it contributes to an improvement in water quality (nutrient removal) of a nearby drinking water reservoir. Inflow and outflow of the Free Water Surface (FWS) CW were monitored on a weekly basis and over a period of 6 months. Physicochemical parameters including pH, conductivity and dissolved oxygen (DO) were measured, as well as nutrients and dissolved organic and inorganic carbon (DOC, DIC) concentration. The CW was seen to contribute to water quality improvement; results show that nutrient removal took place within weeks after construction. It was found that 72 % of initial nitrate (N03 (-)), 53 % of initial phosphate (PO4 (3-)) and 35 % of initial biological oxygen demand (BOD) were removed, calculated as a total over the whole sampling period. From our study, it can be concluded that while inorganic nutrients do decline in CWs, the DOC outputs increases. This may suggest that CWs represent a source for DOC. To assess the carbon in- and output a C budget was calculated.

Toxicity Assessment of a Phase III Study Evaluating FEC-Doc and FEC-Doc Combined with Gemcitabine as an Adjuvant Treatment for High-Risk Early Breast Cancer: the SUCCESS-A Trial

Introduction: This paper aims to evaluate the toxicity profile of additive gemcitabine to adjuvant taxane-based chemotherapy in breast cancer patients. Methods: Patients enrolled in this open-label randomized controlled Phase III study were treated with 3 cycles of epirubicin-fluorouracil-cyclophosphamide (FEC) chemotherapy followed by 3 cycles of docetaxel with those receiving 3 cycles of FEC followed by 3 cycles of gemcitabine-docetaxel (FEC-DG). 3690 patients were evaluated according to National Cancer Institute (NCI) toxicity criteria (CTCAE). The study medications were assessed by the occurrence of grade 3-4 adverse events, dose reductions, postponements of treatment cycles and granulocyte colony-stimulating factor (G-CSF) support. Results: No differences in neutropenia or febrile neutropenia were demonstrated. However, thrombocytopenia was significantly increased with FEC-DG treatment (2.0 vs. 0.5 %, p < 0.001), as was leukopenia (64.1 vs. 58.5 %, p < 0.001). With FEC-DG significantly more G-CSF support in cycles 4 to 6 (FEC-DG: 57.8 %, FEC-D: 36.3 %, p < 0.001) was provided. Transaminase elevation was significantly more common with FEC-DG (SGPT: 6.3 %, SGOT: 2 %), whereas neuropathy (1.2 %), arthralgia (1.6 %) and bone pain (2.6 %) were more common using FEC-D. Dose reductions > 20 % (4 vs. 2.4 %) and postponement of treatment cycles (0.9 vs. 0.4 %) were significantly more frequent in the FEC-DG arm. Eight deaths occurred during treatment in the FEC-DG arm and four in the FEC-D arm. Conclusion: The addition of gemcitabine increased hematological toxicity and was associated with more dose reductions and postponements of treatment cycles.

Randomised phase III trial of FEC120 vs EC-docetaxel in patients with high-risk node-positive primary breast cancer: final survival analysis of the ADEBAR study

BACKGROUND

Taxane-containing adjuvant chemotherapy has been established as standard treatment in node-positive breast cancer. This study compared efficacy and tolerability of epirubicin (E)/cyclophosphamide (C) followed by docetaxel (Doc) with a dose-dense 5-fluorouracil (F)+E+ C regimen.

METHODS

The ADEBAR study was a randomised phase III trial for women with primary invasive breast cancer and ⩾4 metastatic axillary lymph nodes (n=1364). Treatment consisted of four 21-day cycles of E plus C, followed by four 21-day cycles of Doc (EC-Doc), or six 28-day cycles of E plus F plus C (FEC120).

RESULTS

Disease-free survival (DFS) was similar in the two treatment arms as shown by multivariate Cox regression adjusted for other prognostic factors (EC-Doc vs FEC120, hazard ratio (HR): 1.087; 95% confidence interval (CI): 0.878-1.346, P=0.444). In addition, there was no significant difference in overall survival (OS) between the two groups (HR: 0.974; 95% CI: 0.750-1.264, P=0.841). Haematologic toxicity was more common in FEC120 recipients; non-haematologic toxicities occurred more frequently in the EC-Doc arm. The serious adverse event rate was significantly higher in the FEC120 group (29.7% vs 22.5%).

CONCLUSIONS

EC-Doc provides a feasible and effective alternative therapy option to FEC120 with a different safety profile in this high-risk breast cancer cohort.

Abstract P1-12-03: Short term quality of life with epirubicin-fluorouracil-cyclophosphamid (FEC) and sequential epirubicin/cyclophosphamid-docetaxel (EC-DOC) chemotherapy in patients with primary breast cancer – Results from the prospective multi-center randomized Adebar trial

Background:

The grade of recommendation for adjuvant dose-dense chemotherapy in patients with high risk primary breast cancer is heterogeneous among international guidelines. Understanding the impact on quality of life (QOL) by adjuvant dose dense chemotherapy in comparison to standard adjuvant chemotherapy is thereby a crucial factor, especially if the benefit is potentially low. This study aims to assess the impact on QOL by adjuvant dose dense chemotherapy in the prospective randomized multi-center ADEBAR trial.

Methods:

QOL was assessed at baseline (t1), before cycle 4 FEC (Epirubicin 60mg/m2 i.v. d 1 + 8, 5-Fluoruracil 500mg/m2 i.v. d 1 + 8, Cyclophosphamide 75mg/m2 p.o. d 1–14, q4w x 6) and cycle 5 EC-DOC (Epirubicin 90mg/m2 plus Cyclophosphamide 600mg/m2 q3w x 4, sequentially followed by Docetaxel 100mg/m2 q3w x 4) (t2), 4 weeks after chemotherapy (t3), 6 weeks after radiation (t4) and 1 year after baseline (t5) using the European Organization for Research and Treatment for Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) and the Breast Cancer-Specific Module (QLQ-BR23). A multivariate mixed model was fitted to test for differences between the two treatment arms. Primary endpoint was global QOL, secondary endpoints physical functioning, nausea&vomiting, fatigue and systemic therapy side effects. A minimum clinically meaningful difference was considered to be 10 points.

Results:

1306 patients were recruited between 3/2002 and 5/2005 675 were assigned to the FEC and 688 to the EC-DOC arm. Compliance to QOL assessment was 74% at baseline and 58% four weeks after therapy, but dropped to 11% after one year follow up. After the beginning of treatment global QOL dropped in both arm by 3 to 4 points. In the EC-DOC arm QOL dropped further at t3 by 7 points and stayed stable in the FEC arm. 6 weeks after radiation QOL exceeded baseline in both arms by 6 to 8 points. The differences between treatment arms were strongest at t3 (54.1 vs. 49.7) but did not reach clinical relevance at any point in time. Physical functioning, nausea vomiting, fatigue and systemic therapy side effects followed with some minor exceptions similar patterns, but showed higher amplitudes.

Conclusion:

In conclusion we could not detect a statistically significant difference between the two treatment arms in QOL parameters, indicating that dose dense adjuvant chemotherapy did not impact QOL at a clinically relevant level compared to standard adjuvant chemotherapy.

Citation Format: Schwentner L, Harbeck N, Singer S, Eichler M, Rack B, Forstbauer H, Wischnik A, Scholz C, Fink V, Huober J, Friedl T, Weissenbacher T, Härtl K, Kiechle M, Janni W. Short term quality of life with epirubicin-fluorouracil-cyclophosphamid (FEC) and sequential epirubicin/cyclophosphamid-docetaxel (EC-DOC) chemotherapy in patients with primary breast cancer – Results from the prospective multi-center randomized Adebar trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-12-03.