Survival among patients with untreated metastatic breast cancer: "What if I do nothing?"

PURPOSE

We sought to assess survival outcomes of patients with de novo metastatic breast cancer (dnMBC) who did not receive treatment irrespective of the reason.

METHODS

Adults with dnMBC were selected from the NCDB (2010-2016) and stratified based on receipt of treatment (treated = received at least one treatment and untreated = received no treatments). Overall survival (OS) was estimated using the Kaplan-Meier method, and groups were compared. Cox proportional hazards models were used to identify factors associated with OS.

RESULTS

Of the 53,240 patients with dnMBC, 92.1% received at least one treatment (treated), and 7.9% had no documented treatments, irrespective of the reason (untreated). Untreated patients were more likely to be older (median 68 y vs 61 y, p < 0.001), have higher comorbidity scores (p < 0.001), have triple-negative disease (17.8% vs 12.6%), and a higher disease burden (≥ 2 metastatic sites: 38.2% untreated vs 29.2% treated, p < 0.001). The median unadjusted OS in the untreated subgroup was 2.5 mo versus 36.4 mo in the treated subgroup (p < 0.001). After adjustment, variables associated with a worse OS in the untreated cohort included older age, higher comorbidity scores, higher tumor grade, and triple-negative (vs HR + /HER2-) subtype (all p < 0.05), while the number of metastatic sites was not associated with survival.

CONCLUSIONS

Patients with dnMBC who do not receive treatment are more likely to be older, present with comorbid conditions, and have clinically aggressive disease. Similar to those who do receive treatment, survival in an untreated population is associated with select patient and disease characteristics. However, the prognosis for untreated dnMBC is dismal.

Anatomy Versus Biology: What Guides Chemotherapy Decisions in Older Patients With Breast Cancer?

INTRODUCTION

With the increasing utilization of genomic assays, such as the Oncotype DX recurrence score (RS), the relevance of anatomic staging has been questioned for select older patients with breast cancer. We sought to evaluate differences in chemotherapy receipt and/or survival among older patients based on RS and sentinel lymph node biopsy (SLNB) receipt/result.

METHODS

Patients aged ≥ 65 diagnosed with pT1-2/cN0/M0 hormone-receptor-positive (HR+)/HER2-breast cancer (2010-2019) were selected from the National Cancer Database. Logistic regression was used to identify factors associated with chemotherapy receipt. Cox proportional hazards models were used to estimate the association of RS/SLNB group with overall survival. A cost-benefit study was also performed.

RESULTS

Of the 75,428 patients included, the majority had an intermediate RS (58.2% versus 27.9% low, 13.8% high) and were SLNB- (85.1% versus 11.6% SLNB+, 3.3% none). Chemotherapy was recommended for 13,442 patients (17.8%). After adjustment, chemotherapy receipt was more likely with higher RS and SLNB+. After adjustment, SLNB receipt/result was only associated with overall survival among those with an intermediate RS. However, returning to the OR for SLNB is not cost-effective.

CONCLUSIONS

SLNB receipt/result was associated with survival for those with an intermediate RS, but not a low or high RS, suggesting that an SLNB may indeed be unnecessary for select older patients with breast cancer.

Prognostic Tools for Older Women with Breast Cancer: A Systematic Review

Background: Breast cancer is the most common cancer in women, and older patients comprise an increasing proportion of patients with this disease. The older breast cancer population is heterogenous with unique factors affecting clinical decision making. While many models have been developed and tested for breast cancer patients of all ages, tools specifically developed for older patients with breast cancer have not been recently reviewed. We systematically reviewed prognostic models developed and/or validated for older patients with breast cancer. Methods: We conducted a systematic search in 3 electronic databases. We identified original studies that were published prior to 8 November 2022 and presented the development and/or validation of models based mainly on clinico-pathological factors to predict response to treatment, recurrence, and/or mortality in older patients with breast cancer. The PROBAST was used to assess the ROB and applicability of each included tool. Results: We screened titles and abstracts of 7316 records. This generated 126 studies for a full text review. We identified 17 eligible articles, all of which presented tool development. The models were developed between 1996 and 2022, mostly using national registry data. The prognostic models were mainly developed in the United States (n = 7; 41%). For the derivation cohorts, the median sample size was 213 (interquartile range, 81-845). For the 17 included modes, the median number of predictive factors was 7 (4.5-10). Conclusions: There have been several studies focused on developing prognostic tools specifically for older patients with breast cancer, and the predictions made by these tools vary widely to include response to treatment, recurrence, and mortality. While external validation was rare, we found that it was typically concordant with interval validation results. Studies that were not validated or only internally validated still require external validation. However, most of the models presented in this review represent promising tools for clinical application in the care of older patients with breast cancer.

Abstract P6-05-51: Best Quality of Care from a Distance (BQual-D): Maintaining high quality care for hormone receptor positive (HR+) metastatic breast cancer (MBC) during the COVID pandemic, patient participation and satisfaction with the program

Background During the COVID pandemic, we designed and implemented a program, called BQual-D, to maintain high quality care for patients with HR+, HER2 negative MBC who were taking oral anti-cancer therapy and needed to shelter at home. This program augmented available clinical resources with (1) trained nurse coaches to manage side effects, improve adherence, monitor for cancer progression and screen for psychological distress via telehealth, and (2) a care coordinator to arrange blood testing at local labs to facilitate timely medication dose adjustments. BQual-D served patients from August 2020 through April 2021. Here, we describe survey results assessing patient (pt) satisfaction with BQual-D. Methods Pt’s satisfaction surveys included questions rated on a Likert scale (1 “strongly disagree” to 5 “strongly agree”) with questions regarding the following: satisfaction with the quality of the nurse coaching calls; perception that the nurse coach listened to what they were trying to convey; whether or not their needs were met by the nurse coaching calls; whether they felt that they received adequate explanation regarding the nurse coaching calls; whether they would recommend the nurse coaching calls to a friend; perception of whether or not the nurse coach was negative or critical towards them; whether or not they would do it over (i.e., if they would return to the nurse coaching calls); whether or not they felt that the nurse coach was friendly or warm toward them; they were able to more effectively deal with care and symptoms; they felt free to express themselves; they were able to focus on what was of real concern to them; the nurse seemed to understand what they were thinking and feeling. Patients were also asked how much the calls helped with their care and symptoms. Descriptive statistics are reported (i.e., frequencies and means). Results 84 pts were screened and contacted for the BQual-D program. Of the 64 pts who responded, 52 (81.3%) were interested and enrolled in BQual-D; 12 (18.8%) declined. Among those who enrolled, 1 voluntarily withdrew, and 7 withdrew due to change in treatment. Participants had a mean age of 65 (range 36 – 88 yrs) and the following racial distribution - Caucasian/White (38, 73.1%), Black or African American (12, 23.1%), American Indian (1, 1.9%) and American Indian or Alaskan Native (1, 1.9%). Satisfaction surveys were received from 32 (50%) pts. Results of surveys regarding patient satisfaction with the nurse coach were generally positive. Pts agreed or strongly agreed that they were satisfied with the quality of the nurse coaching calls (94%), the nurse coach listened to what they were trying to convey (94%), their needs were met by the nurse coaching calls (91%), they understood the purpose of the call (90%), and they would recommend the nurse coaching calls to a friend (88%). The majority (74%) agreed or strongly agreed that they were able to more effectively deal with their care and symptoms after the nurse coach calls. When asked how much the calls helped their care and symptoms, 61% indicated that they made things a lot better, 19% indicated that they made things somewhat better, 16% indicated that they made no difference. One patient indicated that the calls made things somewhat worse. Conclusions During the COVID pandemic, when sheltering at home was encouraged, patient satisfaction with BQual-D, which provided additional health resources (nurse coaches, care coordinator) to support pts on oral therapy for HR+ MBC, was high. Resources needed to implement BQual-D should be explored as a way of providing additional support for pts to minimize the requirement for in-person visits. Funding: Supported by a grant from Pfizer.

Citation Format: Gretchen Kimmick, Smrithi Divakaran, Heather Moore, Cynthia Rose, Pamela Gentry, Michael Willis, Susan Dent, Sarah L. Sammons, Jeremy Force, Kelly Westbrook, Carey Anders, Rebecca Shelby. Best Quality of Care from a Distance (BQual-D): Maintaining high quality care for hormone receptor positive (HR+) metastatic breast cancer (MBC) during the COVID pandemic, patient participation and satisfaction with the program. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-51.

Infrastructure to Support Accrual of Older Adults to National Cancer Institute Clinical Trials

As part of ongoing efforts to meaningfully improve recruitment, enrollment, and accrual of older adults into cancer clinical trials, the National Cancer Institute (NCI) sponsored a workshop with experts across the country entitled Engaging Older Adults in the NCI Clinical Trials Network: Challenges and Opportunities. Three working groups, including Study Design, Infrastructure, and Stakeholders, were formed, who worked together to offer synergistic improvements in the system. Here, we summarize the workshop discussions of the Infrastructure Working Group, whose goal was to address infrastructural challenges, identify underlying resources, and offer solutions to facilitate accrual of older adults into cancer clinical trials. Based on preconference work and workshop discussions, four key recommendations to strengthen NCI infrastructure were proposed: 1) further centralize resources and expertise; 2) provide training for clinical research staff; (3) develop common data elements; and 4) evaluate what works and does not work. These recommendations provide a strategy to improve the infrastructure to enroll more older adults in cancer clinical trials.

A Novel Staging System for De Novo Metastatic Breast Cancer Refines Prognostic Estimates

OBJECTIVE

We aim to identify prognostic groups within a de novo metastatic cohort, incorporating both anatomic and biologic factors.

BACKGROUND

Staging for breast cancer now includes anatomic and biologic factors, although the guidelines for stage IV disease do not account for how these factors may influence outcomes.

METHODS

Adults with de novo metastatic breast cancer were selected from the National Cancer DataBase (2010-2013). Recursive partitioning analysis was used to group patients with similar overall survival (OS) based on clinical T/N stage, tumor grade, ER, PR, HER2, number of metastatic sites, and presence of bone-only metastases. Categories were created by amalgamating homogeneous groups based on 3-year OS rates (stage IVA: >50%, stage IVB: 30%-50%, stage IVC: <30%).

RESULTS

16,187 patients were identified; median follow-up was 32 months. 65.2% had 1 site of distant metastasis, and 42.9% had bone-only metastases. Recursive partitioning analysis identified the number of metastatic sites (1 vs >1) as the first stratification point, and ER status as the second stratification point for both resulting groups. Additional divisions were made based on HER2 status, PR status, cT stage, tumor grade, and presence of bone-only metastases. After bootstrapping, significant differences in 3-year OS were noted between the 3 groups [stage IVB vs IVA: HR 1.58 (95% confidence interval 1.50-1.67), stage IVC vs IVA: HR 3.54 (95% confidence interval 3.33-3.77)].

CONCLUSIONS

Both anatomic and biologic factors yielded reliable and reproducible prognostic estimates among patients with metastatic disease. These findings support formal stratification of de novo stage IV breast cancer into 3 distinct prognosis groups.

Abstract P4-10-06: Best quality care from a distance (BQual-D): Maintaining high quality care for hormone receptor positive (HR+) metastatic breast cancer (MBC) during the COVID pandemic, description of the program and provider satisfaction

Background: During the COVID pandemic, we designed and implemented a program, called BQual-D, to maintain high quality care for patients with HR+, HER2 negative MBC who were taking oral anti-cancer therapy and needed to shelter at home. This program augmented available clinical resources with (1) trained nurse coaches to manage side effects, improve adherence, monitor for cancer progression and screen for psychological distress via telehealth, and (2) a care coordinator to arrange blood testing at local labs to facilitate timely medication dose adjustments. BQual-D served patients from August, 2020 through April of 2021. Here, we describe survey results assessing provider satisfaction with BQual-D. Methods: Surveys assessing provider satisfaction were distributed in December, 2020 (Survey#1) and in April, 2021 (Survey#2). Provider demographics were collected with Survey#1. Eight questions assessed satisfaction with different aspects of the BQual-D program, including content of the nurse coach notes, communication with the program, timeliness of communication, frequency of notes, ease of reading the notes, ease of referring patients, and turnaround time for labs, which were rated on a Likert scale of 1 (strongly dissatisfied) to 10 (strongly satisfied), with an additional response choice of 0 (unable to assess). Providers were also asked if BQual-D led to changes in patient management (yes/no), the degree to which BQual-D supported the medical management of the patient (from 1=not at all to 7=significantly), the influence of BQual-D on patient wellbeing (positive effects, no change, negative effects), and the overall quality of care delivered by the program (from 1=excellent to 4=poor). Finally, we asked providers if they would continue to recommend their patients to BQual-D (yes, in the same way as the program has been deployed; yes but with improvements; or no). Results are described by frequencies and means. Results: Nineteen providers responded to Survey#1. Providers were physicians (31.6%), advanced practice providers (31.6%), nurses (31.6%) and a clinical pharmacist (5.3%). Respondents were 89.5% female, 94.7% White, and had a mean age of 44 years and mean 11 years in practice. Providers rated the quality of care provided by the BQual-D program as excellent (44%) or good (57%), all providers surveyed indicated that they would continue to recommend the program to patients, and 95% of providers indicated that the program had a positive effect on patients’ well-being. Half of the respondents indicated that BQual-D resulted in changes in or addition to patient management and 90% indicated that BQual-D significantly supported medical management. Providers were strongly satisfied (scores of 8-10 on the Likert scale) with overall communication with the BQual-D team (74%) and timeliness of communications (79%). Providers were also strongly satisfied with the content (68.4%), frequency (74%), and ease of reading (68%) program notes. Seven providers completed Survey#2, in which providers rated the overall quality of the program as excellent (57%) or good (43%); 86% indicated that they would continue to recommend the program to patients, and 86% indicated that the program had a positive effect on patients’ well-being. Conclusions: During the COVID pandemic, when sheltering at home was encouraged, provider satisfaction with BQual-D, which provided additional health resources (nurse coaches, care coordinator) to support patients on oral therapy for HR+ MBC, was high. Resources needed to implement BQual-D should be explored as a way of providing additional support for patients and providers in order to minimize the requirement for in-person visits. Funding: Supported by a grant from Pfizer.

Citation Format: Gretchen Kimmick, Smrithi Davakaran, Heather Moore, Cynthia Rose, Pamela Gentry, Michael Willis, Susan Dent, Sarah Sammons, Jeremy Force, Kelly Westbrook, Carey Anders, Rebecca Shelby. Best quality care from a distance (BQual-D): Maintaining high quality care for hormone receptor positive (HR+) metastatic breast cancer (MBC) during the COVID pandemic, description of the program and provider satisfaction [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-10-06.

The phase II MutHER study of neratinib alone and in combination with fulvestrant in HER2 mutated, non-amplified metastatic breast cancer

PURPOSE

HER2 mutations (HER2^mut) induce endocrine resistance in estrogen receptor positive (ER+) breast cancer.

EXPERIMENTAL DESIGN

In this single arm multi-cohort phase II trial, we evaluated the efficacy of neratinib plus fulvestrant in patients with ER+/HER2^mut, HER2-non-amplified metastatic breast cancer (MBC) in the fulvestrant-treated (n=24) or fulvestrant-naïve cohort (n=11). Patients with ER-negative/HER2^mut MBC received neratinib monotherapy in an exploratory ER- cohort (n=5).

RESULTS

The clinical benefit rate (CBR: 95% CI) was 38% (18-62%), 30% (7-65%), and 25% (1-81%) in the fulvestrant-treated, fulvestrant-naïve, and ER- cohort, respectively. Adding trastuzumab at progression in 5 patients resulted in 3 partial responses and 1 stable disease {greater than or equal to}24 weeks. CBR appeared positively associated with lobular histology and negatively associated with HER2 L755 alterations. Acquired HER2^mut were detected in 5 of 23 patients at progression.

CONCLUSION

Neratinib and fulvestrant is active for ER+/HER2^mut MBC. Our data supports further evaluation of dual HER2 blockade for the treatment of HER2^mut MBC.

DEVELOPMENT, FEASIBILITY, AND ACCEPTABILITY OF A BEHAVIORAL WEIGHT AND SYMPTOM MANAGEMENT INTERVENTION FOR BREAST CANCER SURVIVORS AND INTIMATE PARTNERS

BACKGROUND

Weight gain is common for breast cancer survivors and associated with disease progression, recurrence, and mortality. Traditional behavioral programs fail to address symptoms (i.e., pain, fatigue, distress) experienced by breast cancer survivors that may interfere with weight loss and fail to capitalize on the concordance in weight-related health behaviors of couples. This study aimed to develop and examine the feasibility and acceptability of a behavioral weight and symptom management intervention for breast cancer survivors and their intimate partners.

MATERIALS AND METHODS

Interviews were conducted with N=14 couples with overweight/obesity to develop the intervention. Intervention feasibility and acceptability were examined through a single-arm pilot trial (N=12 couples). Patterns of change in intervention targets were examined for survivors and partners.

RESULTS

Themes derived from interviews were used to develop the 12-session couple-based intervention, which included components from traditional behavioral weight management interventions, appetite awareness training, and cognitive and behavioral symptom management protocols. Couples also worked together to set goals, create plans for health behavior change, and adjust systemic and relationship barriers to weight loss. Examples were tailored to the experiences and symptom management needs of breast cancer survivors and partners. The intervention demonstrated feasibility (attrition: 8%; session completion: 88%) and acceptability (satisfaction). Survivors and partners experienced reductions in weight and improvements in physical activity, eating behaviors, emotional distress, and self-efficacy. Survivors evidenced improvements in fatigue and pain.

CONCLUSIONS

A behavioral weight and symptom management intervention for breast cancer survivors and partners is feasible, acceptable, and is potentially efficacious.

Abstract CT026: A phase II trial of neratinib (NER) or NER plus fulvestrant (FUL) (N+F) in HER2 mutant, non-amplified (HER2mut) metastatic breast cancer (MBC): Part II of MutHER

Introduction: The irreversible pan-HER inhibitor NER showed modest single agent activity for HER2mut MBC in Part I of MutHER trial. In Part II, we hypothesized that (1) N+F would improve activity in estrogen receptor positive (ER+) HER2mut MBC due to ER-HER2 crosstalk and (2) dual HER2 blockade by adding trastuzumab at disease progression (PD) could overcome resistance.

Methods: Pts with ER+HER2mut MBC were enrolled to 2 cohorts (FUL treated or naive) to receive N+F with diarrhea prophylaxis. ER- pts received NER in an exploratory ER- cohort. Trastuzumab was added at PD if approved by insurance. Simon's Minimax 2-stage phase II design with the primary endpoint of clinical benefit rate (CBR: rates of complete/partial response [CR/PR] plus stable disease [SD] &gt;24 weeks [wks]), with anticipated vs null hypothesis being CBR of 55% vs 35% (FUL treated) or 65% vs 40% (FUL naïve) with 80% power, 1 sided 0.05 alpha, was used. Secondary endpoints included progression free survival (PFS) and adverse events (AEs). Serial blood samples were analyzed for circulating tumor DNA (ctDNA) by Guardant360 for concomitant mutations, HER2mut variant allele frequency (VAF) dynamics, and resistance mechanisms.

Results: Between Sep. 2015 and Oct. 2020, 40 pts with HER2mut MBC were enrolled, completing the 1st stage of each ER+ cohort. 35 pts (21 FUL treated, 10 FUL naïve, 4 ER-) were evaluable for response, with median age 63 (35-82) years, 3 (0-12) prior MBC regimen, lobular BC in 13 (37%) and visceral mets in 32 (91%) pts. 21 (68%) ER+ pts had prior CDK4/6 inhibitor. All but 1 pt has come off study due to PD. Table 1 shows the efficacy by cohort. Further enrollment is closed per protocol. Adding trastuzumab at PD induced CB in 4 (3 PR, 1 SD≥24 wks) of 5 pts (1 ER-, 4 ER+), with PFS 28 (95% CI 18~NA) wks. Common AEs across cohorts were diarrhea (G3 21%) and fatigue (G3 5%). No G4 AEs.

ctDNA HER2mut was detected in 72% (23/32) baseline (BL) samples tested. In pts with paired samples, HER2mut VAF decreased at C1D15/C2D1 from BL in 75% (15/20) and rose in 89% (16/18) at PD. Acquired HER2mut, including the T798I gatekeeper mutation, were detected in 2 pts at PD. Mutations in TP53 (53%), PIK3CA (43%), and CDH1 (35%) were common, but none significantly associated with PFS in all or ER+ pts.

Conclusions: NER, or N+F, is active for HER2mut MBC with good tolerability. Adding trastuzumab at PD induced further response, supporting dual HER2 blockade for HER2mut MBC.

Table 1.EfficacyCohortFUL treatedFUL naïveER-Best Response, n evaluablen = 21n = 10n = 4CR, n100PR, n431SD (≥ 24 wks), n300SD (&lt; 24 wks), n1030PD, n343CBR, n with CB/total n evaluable, % (95% CI)8 of 20*, 40% (19~64%)3 of 10, 30% (7~65%)1 of 4, 25% (0.6~81%)mPFS (95% CI), wks, ITT (n)24 (16~31) wks, (n = 24)20 (8~NA) wks, (n = 11)8.5 (8~NA) wks, (n = 5)*20 of 21 pts are evaluable for CBR in the FUL treated Cohort as 1 pt had SD as best response and treatment is still ongoing. ITT (intent to treat) population is used for mPFS estimate.

Citation Format: Cynthia X. Ma, Jingqin Luo, Rachel A. Freedman, Timothy Pluard, Julie Nangia, Janice Lu, Frances Valdez-Albini, Melody Cobleigh, Jason Jones, Nancy U. Lin, Eric Winer, P. Kelly Marcom, Shana Thomas, Jill Anderson, Brittney Haas, Kimberly M. Hamann, Richard Bryce, Alshad S. Lalani, Lisa Carey, Matthew Goetz, Feng Gao, Gretchen Kimmick, Mark Pegram, Matthew J. Ellis, Ron Bose. A phase II trial of neratinib (NER) or NER plus fulvestrant (FUL) (N+F) in HER2 mutant, non-amplified (HER2mut) metastatic breast cancer (MBC): Part II of MutHER [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT026.

Abstract PS10-48: Cardiovascular (CV) risk profile in patients with estrogen receptor (ER) positive HER2 negative advanced breast cancer (ABC): A retrospective cohort study (CAREB)

Background: CDK 4/6 inhibitors in patients (pts) with HR+/HER2- ABC has led to significant improvements in clinical outcomes, however our understanding of the impact of these treatments on CV health is unknown. Gains in overall survival should not be offset by increased CV morbidity and mortality; a particular concern given the shared risk factors for both breast cancer and CV disease. Objective: The aim of this study was to describe patient characteristics, treatment patterns and cardiovascular risk factors and disease in pts with ABC treated with endocrine therapy (ET) or ET + CDK 4/6 inhibitor. Methods: We retrospectively studied pts with HR+/HER2- ABC who were receiving first line endocrine therapy. Post-menopausal (PM) women, pre-menopausal women on ovarian suppression (OS), and men were included. Two cohorts were included: Group A - treated with ET alone (2012-2014; prior to US approval of CDK 4/6 inhibitors) and Group B - treated with ET+ CDK 4/6 inhibitor (2015-2017). The following data was extracted from Duke University Health System’s electronic medical record (EPIC) and entered into a REDCap database: demographics, baseline cardiovascular risk factors, and co-morbidities. Pt characteristics are summarized using medians and interquartile ranges for continuous variables and categorical descriptions are summarized using frequencies and percentages. Results: In total 103 patients were included with 57 in Group A (ET alone) and 46 in Group B (ET + CDK 4/6 inhibitor). Median age was 62.0 and 63.5 years in Group A and B, respectively. Fifty-three (93%) of pts in Group A were PM women compared to 37 (80%) PM women and 1 (3%) male in Group B. The groups seemed to be similar in terms of race (white 70% vs 72%), baseline body mass index (28.2 vs 27.6), baseline systolic blood pressure (132.0 vs 135.5) and diastolic blood pressure (79.0 vs 77.5). Similarly, the groups seemed to be similar in baseline hypertension (68% vs 62%); diabetes (23% vs 24%); Hemoglobin A1c (7.2% vs 6.4%) or family history of CV disease (56% vs 55%), Group A versus Group B, respectively. There were slightly more current/past smokers in Group B than Group A (48% vs 35%) and more pts in Group A with a history of hyperlipidemia relative to Group B (52% vs 31%). Conclusions: In this retrospective descriptive cohort study there seemed to be no differences in demographics or baseline CV risk factors between the ET and ET + CDK 4/6 inhibitor cohorts with the exception of more baseline hyperlipidemia in the ET cohort. This might suggest that baseline CV risk factors did not dissuade practioners from prescribing ET + CDK 4/6 inhibitor therapy. We plan to expand our cohort to collect information on type and duration of ET and CDK 4/6 inhibitors, reason for treatment discontinuation, and CV events (eg heart failure, arrhythmias, stroke, myocardial infarction), to better understand the impact that cardiovascular risk factors have on outcomes in breast cancer patients taking ET+ CDk 4/6 inhibitor. Table 1: Demographics and CV risk factors in ABC patients treated with ET or ET + CDK4/6 inhibitor

Median (IQR) unless otherwise indicatedGroup A ET (n=57)Group B ET+ CDK 4/6 inhibitor (n=46)Age median (range)62.0 (27-84)63.5 (30-82)Menopausal status, n (%) Post menopausal Premenopausal + OS Male53 (93) 4 (7) 037 (80) 8 (17) 1 (3)Race, n (%) White Other40 (70) 17 (30)33 (72) 13 (28)Type of Insurance, n (%) Private Medicare Medicare and Private Medicaid Medicaid and Medicare Vererans Sponsored Self-Pay Unknown19 (33) 14 (25) 16 (28) 1 (2) 4 (7) 0 3 (5) 019 (41) 4 (9) 15 (33) 1 (2) 4 (9) 1 (2) 0 2 (4)BMI (kg/m2)28.2 (24.9, 30.6)27.6 (24.4, 34.5)Baseline BP (mmHg) Systolic Diastolic132.0 (118.0, 145.0) 79.0 (73.0, 84.0)135.5 (124.0, 149.0) 77.5 (72.0, 84.0)HgbA1c (%)7.2 (6.4, 7.4)6.4 (5.4, 6.4)CVRF, n (%) Hypertension Diabetes FH CVD Current/past smokers Hyperlipidemia36 (68) 13 (23) 28 (56) 20 (35) 29 (52)28 (62) 11 (24) 22 (55) 22 (48) 14 (31)OS = ovarian suppression; BMI = body mass index; BP = blood pressure; HgbA1c = hemoglobin A1c; CVRF = cardiovascular risk factors; FH = family history; CVD = cardiovascular disease; IQR = Interquartile range

Citation Format: Susan Dent, Gloria Broadwater, Terry Hyslop, Kevin Oeffinger, Michel Khouri, Sanjeev Balu, Gretchen Kimmick. Cardiovascular (CV) risk profile in patients with estrogen receptor (ER) positive HER2 negative advanced breast cancer (ABC): A retrospective cohort study (CAREB) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS10-48.

The Evolving Complexity of Treating Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor-2 (HER2)-Negative Breast Cancer: Special Considerations in Older Breast Cancer Patients-Part II: Metastatic Disease

Breast cancer is a disease of aging, and the incidence of breast cancer is projected to increase dramatically as the global population ages. The majority of breast cancers that occur in older adults are hormone-receptor positive, human epidermal growth factor receptor-2 (HER2)-negative phenotypes, with favorable tumor biology; yet, because of underrepresentation in clinical trials, less evidence is available to guide the complex care for this population. Providing care for older patients with metastatic breast cancer, with coexisting medical conditions, increased risk of treatment toxicity, and frailty, remains a clinical challenge in oncology. In this review, we provide an overview of the current evidence from clinical trials and subanalyses of older adults with hormone receptor-positive, HER2-negative metastatic breast cancer, highlighting data on the safety and efficacy of oral therapies, including endocrine therapy alone or in combination with cyclin-dependent kinase (CDK) 4/6 inhibitors, phosphatidylinositol 3-kinase (PI3K) inhibitors, and mammalian target of rapamycin (mTOR) inhibitors. In addition, we note the significant underrepresentation of older and frail adults in these studies. Current and future directions in research for this special population, in order to address significant knowledge gaps, include the need to improve long-term adherence to hormonal and targeted therapy, prospective clinical trials that capture clinical and biological aging endpoints, and the need for a multidisciplinary approach with integration of geriatric and oncology principles.

Overall health at diagnosis predicts the risk of complications within the first year after breast cancer diagnosis

PURPOSE

Breast cancer patients with overall poor health are at a greater risk of both complications during treatment and mortality from competing causes. We sought to determine the association of pre-existing comorbidities on treatment-related complications and overall survival.

METHODS

We identified women ages 40-90 years old from our institutional registry with stage I-II invasive breast cancer from 2005 to 2014. Recursive partitioning was used to stratify women based on pre-existing comorbidities as low, moderate, or high risk of treatment-associated complications. Cox proportional hazards model was constructed to estimate the association of risk with overall survival.

RESULTS

2077 women were studied. Mean age was 60 (IQR 51-68). Over half (54%) had ≥ 1 comorbid condition, and 29% experienced at least one adverse medical event within 1 year of diagnosis. Risk categories included low (no comorbidities or hypertension), moderate (combinations of comorbidities excluding congestive heart failure), and high (congestive heart failure in isolation or in combination with other conditions). High-risk women had a lower 10-year OS compared to moderate- or low-risk women (89% vs 90% vs 96%, log-rank p < 0.001). After adjustment, being at moderate (HR 2.20, 95% CI 1.30-3.72, p = 0.003) or high risk (HR 5.07, 95% CI 1.66-15.52, p = 0.004) of adverse sequelae was associated with reduced OS compared to those at low risk of these adverse medical events.

CONCLUSIONS

Following breast cancer diagnosis, overall poor health was associated with a greater risk of mortality and complications within the first year of treatment, which was driven by a pre-existing diagnosis of congestive heart failure.

Improving health engagement and lifestyle management for breast cancer survivors with diabetes

Breast cancer survivors with type 2 diabetes are at high risk for cancer recurrence, serious health complications, more severe symptoms, psychological distress, and premature death relative to breast cancer survivors without diabetes. Maintaining glycemic control is critical for decreasing symptoms and preventing serious health problems. Many breast cancer survivors with type 2 diabetes have difficulty maintaining diabetes self-management behaviors and achieving glycemic control. Both cancer and diabetes-related symptoms (e.g., physical symptoms and psychological distress) are often barriers to engaging in diabetes self-management strategies. This study evaluates a novel diabetes coping skills training (DCST) intervention for improving breast cancer survivors' abilities to manage symptoms and adhere to recommended diabetes self-management behaviors. The telephone-based DCST protocol integrates three key theory-based strategies: coping skills training for managing symptoms, adherence skills training, and healthy lifestyle skills training. A randomized clinical trial will test the DCST intervention plus diabetes education by comparing it to diabetes education alone. Symptoms, distress, diabetes self-management behaviors, and self-efficacy will be assessed at baseline and 3, 6, and 12 months. Glycosylated hemoglobin (HbA1c) will be assessed at baseline, 6, and 12 months. This study addresses a critical gap in the care of breast cancer survivors by evaluating a novel behavioral intervention to improve the management of symptoms, adherence, and glycemic control in breast cancer survivors with type 2 diabetes. Special considerations for this medically underserved population are also provided. The findings of this study could lead to significant improvements in clinical care and beneficial outcomes for breast cancer survivors. Trials registration: ClinicalTrials.gov, NCT02970344, registered 11/22/2016.

Abstract P3-08-10: Characterization of oncotype DX recurrence score and chemotherapy utilization patterns in young women (≤40) with early stage ER+/HER-, lymph node negative breast cancer

Background: Meta-analyses have demonstrated that young women ≤40 (YW) derive the most benefit from chemotherapy (EBCTCG, Lancet. 1998). Oncotype DX was designed to determine the benefit of chemotherapy in women with ER+/HER2-, node-negative (LN-) breast cancer based on recurrence score (RS). TAILORx reported clinically meaningful benefits in freedom-from-distant recurrence in women &lt;50 with the addition of chemotherapy to endocrine therapy when RS was 16-25. Recent TAILORx analyses suggest that women &lt;40 with an intermediate (int) RS do not derive chemotherapy benefit, though YW comprised &lt;4% of the trial population [1]. Defining the optimal adjuvant treatment strategy for this population of YW remains a clinical challenge. We sought to determine national patterns of RS utilization in association with receipt of chemotherapy and to characterize the association of RS with tumor characteristics and demographics among YW with early stage ER+, LN- breast cancer.

Methods: Using the National Cancer Data Base (NCDB), we identified individuals age &lt;75, diagnosed 2010-2015 with stage I-II, ER+/HER2-, LN- breast cancer with known RS. Cohorts were defined as low (0-10), int (11-25), and high (&gt;25) RS. Age categories were classified as ≤40, 41-50, and &gt;50. Chi-square tests or Fisher’s exact tests were used to compare categorical variables. Logistic regression was used to estimate the association of RS score and age group with adjuvant chemotherapy use, after adjustment for known covariates. Kaplan-Meier curves were used to visualize unadjusted overall survival (OS), and Cox proportional hazards models were used to estimate adjusted OS.

Results: 120,051 women were identified, of whom 4,781 were ≤40 years, 24,846 were 41-50, and 90,424 were &gt;50. By age group, 20% of YW had a high RS compared to 12% of women age 41-50 and 15% of women &gt;50 (p&lt;0.001). Among YW, black women were more likely than white women to have a high RS; 29% vs. 19% (p&lt;0.001). RS was strongly associated with receipt of chemotherapy in YW (86% of high RS vs. 33% of int RS vs. 7% of low RS, p&lt;0.001). Chemotherapy was omitted in 55% of YW with RS 16-25. YW in multivariate analysis with a low or int RS were more likely than women 41-50 or &gt;50 to receive chemotherapy (p&lt;0.001). Receipt of chemotherapy for YW with an int RS was associated with younger chronologic age (p&lt;0.001), ductal histology (p=0.02), high grade (p&lt;0.001), and higher pathologic T-stage (p&lt;0.001). Among YW, the unadjusted 5-year OS (95% CI) was as follows: low RS= 100% (0.99-1), int RS= 100% (1-1), high RS= 93% (0.90-0.96). Chemotherapy did not influence 5 year OS in YW with an int RS. In univariate analysis, a high RS was associated with a worse 5-year OS in YW (log-rank p&lt;0.001). After adjustment for race and chemotherapy receipt, high vs. low RS was associated with an increased risk of death (HR=5.86, 95% CI 1.19-28.82, p=0.03) in YW.

Conclusions: High RS is more common in YW (≤40) than those age 41-50 or &gt;50, and is associated with worse OS. YW with an int or low RS are more likely to receive chemotherapy despite unclear benefit. Chemotherapy was omitted in over half of YW with RS of 16-25, highlighting the uncertainty in clinical practice which will remain until further studies inform optimal systemic treatment specific to YW.

1. Sparano, J.A., et al., Clinical and Genomic Risk to Guide the Use of Adjuvant Therapy for Breast Cancer. New England Journal of Medicine, 2019. 380(25): p. 2395-2405.

Citation Format: Sarah Sammons, Yi Ren, Jeremy Force, Oluwadamilola M. Fayanju, Laura H. Rosenberger, Jennifer K. Plichta, Gretchen Kimmick, Kelly Westbrook, Susan Dent, Carey Anders, Samantha M. Thomas, Terry Hyslop, E. S. Hwang, P. K. Marcom, Rachel A. Greenup. Characterization of oncotype DX recurrence score and chemotherapy utilization patterns in young women (≤40) with early stage ER+/HER-, lymph node negative breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-10.

Abstract P5-14-17: Musculoskeletal side effects over time and association with adherence in women taking neoadjuvant letrozole for estrogen receptor positive DCIS: CALGB 40903 (Alliance)

Background: Side effects of and adherence to aromatase inhibitors in women with ductal carcinoma in situ are not well described. Methods: Postmenopausal women in a prospective phase II study of neoadjuvant letrozole for estrogen receptor positive DCIS completed questionnaires on side effects [Menopause Specific Quality of Life Questionnaire (MENQOL), Brief Pain Inventory-short form (BPI-SF), Arthritis Impact Measurement Scales (AIMS2)], well-being (FACT-G), and adherence [Medication-Taking questionnaire] at baseline, 1, 3 and 6 months (mo), and study completion. We used descriptive statistics and paired t-tests to compare 1, 3 and 6 mo results to baseline. Hierarchical linear mixed modeling, controlling for baseline symptom or well-being level, was used to examine effect of symptoms and well-being on intentional and nonintentional nonadherence, based on the Medication-Taking Questionnaire. Results: Included were 84 women, mean age 63 (39-83) years. In univariate analyses, compared to baseline, menopausal symptoms increased [physical (p=0.001 at 3, p&lt;0.001 at 6 mo); vasomotor (p&lt;0.001 at 1, 3, 6 mo), psychosocial (p=0.006 at 6 mo) and sexual (p=0.01 at 6 mo)]. Joint pain and stiffness increased [BPI-SF pain subscale (p=0.048 at 3, p=0.01 at 6 mo); AIMS2 joint pain subscale (p=0.03 at 1, p&lt;0.001 at 3 and 6 mo); AIMS2 stiffness subscale (p=0.004 at 3, p=0.01 at 6 mo)]. Intentional and nonintentional adherence did not significantly change over time (p&gt;0.05). Lower emotional (p=0.049) and functional (p=0.002) well-being by FACT-G and higher joint pain (p=0.03) by AIMS2 were associated with higher nonintentional nonadherence; higher physical side effects of menopause (p=0.001) by MENQOL were associated with lower intentional nonadherence. Conclusions: Among women taking letrozole for DCIS, menopausal symptoms and joint pain/stiffness increased over time with most differences noted at 3 and 6 mo. Lower well-being and higher symptom levels were associated with higher nonintentional nonadherence. NCT01439711.U10CA180821, U10CA180882, UG1CA189823, Breast Cancer Research Foundation, https://acknowledgments.alliancefound.org.

Citation Format: Gretchen Kimmick, Amylou C Dueck, Rebecca Shelby, Michelle Naughton, Abigail Caudle, Briant Fruth, E. Shelley Hwang. Musculoskeletal side effects over time and association with adherence in women taking neoadjuvant letrozole for estrogen receptor positive DCIS: CALGB 40903 (Alliance) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-14-17.

A feasible and acceptable multicultural psychosocial intervention targeting symptom management in the context of advanced breast cancer

OBJECTIVE

Advanced breast cancer patients around the world experience high symptom burden (ie, distress, pain, and fatigue) and are in need of psychosocial interventions that target symptom management. This study examined the feasibility, acceptability, and engagement of a psychosocial intervention that uses cognitive-behavioral strategies along with mindfulness and values-based activity to enhance patients' ability to manage symptoms of advanced disease in a cross-cultural setting (United States and Singapore). Pre-treatment to post-treatment outcomes for distress, pain, and fatigue were compared between intervention recipients and waitlisted controls.

METHODS

A pilot randomized controlled trial included women with advanced breast cancer (N = 85) that were recruited in the United States and Singapore. Participants either received the four session intervention or be put on waitlist. Descriptive statistics and effect size of symptom change were calculated.

RESULTS

The psychosocial intervention was found to be feasible as indicated through successful trial accrual, low study attrition (15% ), and high intervention adherence (77% completed all sessions). Acceptability (ie, program satisfaction and cultural sensitivity) and engagement to the study intervention (ie, practice of skills taught) were also high. Anxiety, depression, and fatigue scores remained stable or improved among intervention participants while the same symptoms worsened in the control group. In general, effect sizes are larger in the US sample compared with the Singapore sample.

CONCLUSIONS

The cognitive-behavioral, mindfulness, and values-based intervention is feasible, acceptable, and engaging for advanced breast cancer patients in a cross-cultural setting and has potential for efficacy. Further larger-scaled study of intervention efficacy is warranted.

Investigating confounders of the association between survival and adjuvant radiation therapy after breast conserving surgery in a sample of elderly breast Cancer patients in Appalachia

Background

To explain the association between adjuvant radiation therapy after breast conserving surgery (BCS RT) and overall survival (OS) by quantifying bias due to confounding in a sample of elderly breast cancer beneficiaries in a multi-state region of Appalachia.

Methods

We used Medicare claims linked registry data for fee-for-service beneficiaries with AJCC stage I-III, treated with BCS, and diagnosed from 2006 to 2008 in Appalachian counties of Kentucky, Ohio, North Carolina, and Pennsylvania. Confounders of BCS RT included age, rurality, regional SES, access to radiation facilities, marital status, Charlson comorbidity, Medicaid dual status, institutionalization, tumor characteristics, and surgical facility characteristics. Adjusted percent change in expected survival by BCS RT was examined using Accelerated Failure Time (AFT) models. Confounding bias was assessed by comparing effects between adjusted and partially adjusted associations using a fully specified structural model.

Results

The final sample had 2675 beneficiaries with mean age of 75, with 81% 5-year survival from diagnosis. Unadjusted percentage increase in expected survival was 2.75 times greater in the RT group vs. non-RT group, with 5-year survival of 85% vs 60%; fully adjusted percentage increase was 1.70 times greater, with 5-year rates of 83% vs 71%. Quantification of incremental confounding showed age accounted for 71% of the effect reduction, followed by tumor features (12%), comorbidity (10%), dual status(10%), and institutionalization (8%). Adjusting for age and tumor features only resulted in only 4% bias from fully adjusted percent change (70% change vs 66%).

Conclusion

Quantification of confounding aids in determining covariates to adjust for and in interpreting raw associations. Substantial confounding was present (60% of total association), with age accounting for the largest share (71%); adjusting for age plus tumor features corrected for most of the confounding (4% bias). The direct effect of BCS RT on OS accounted for 40% of the total association.

Patient-reported outcomes in the Translational Breast Cancer Research Consortium

Members of the Translational Breast Cancer Research Consortium conducted an expert-driven literature review to identify a list of domains and to evaluate potential measures of these domains for inclusion in a list of preferred measures. Measures were included if they were easily available, free of charge, and had acceptable psychometrics based on published peer-reviewed analyses. A total of 22 domains and 52 measures were identified during the selection process. Taken together, these measures form a reliable and validated list of measurement tools that are easily available and used in multiple cancer trials to assess patient-reported outcomes in relevant patients.

Abstract P3-08-07: Distinct biological signatures describe differences in BRCA mutated subgroups

Background: BRCA mutated (BRCA+) breast cancers are expected to have increased activation of Homologous Recombination Deficiency (HRD) and altered DNA damage repair pathways when compared to BRCA wildtype (BRCA-). To better understand differences in these populations, biological patterns and immune responses to BRCA+ breast cancers were evaluated. The primary aim of our study was to use novel gene expression tools to assess early stage breast cancers with and without germline BRCA mutations, and within distinct BRCA+ subgroups.

Methods: We identified 124 early stage untreated breast cancers with and without BRCA mutations (n = 62 and 62, respectively). Our BRCA- group was matched by hormone receptor (HR) status, age, and stage to the BRCA+ group. The NanoString Breast Cancer 360 panel was applied to RNA isolated from 80 breast tumors (BRCA+ = 39; BRCA- = 41). The BRCA+ group had a BRCA1+ subgroup (n=17) and a BRCA2+ subgroup (n=22).

Results: There was a significant increase in two BC360 signatures in both the BRCA1+ and BRCA2+ tumors compared with the BRCA- population: Prosigna™Risk of Recurrence (ROR) score [BRCA1+: HR: 1.142 (95% CI 1.019, 1.279), p=0.02; BRCA2+: HR: 1.321 (95% CI 1.190, 1.466), p&lt;0.001] and HRD [BRCA1+: HR: 3.576 (95% CI 2.174, 5.880), p=0.02; BRCA2+: HR: 1.801 (95% CI 1.142, 2.840), p&lt;0.001]. BRCA1+ tumors had lower expression of ESR1 [p=0.03], PGR [p=0.02], ER signaling [p&lt;0.001], and differentiation [p=0.005]; while BRCA2+ tumors had lower expression of stroma markers [p=0.02] and inflammatory chemokines [p=0.001]. The two BRCA+ subgroups had distinct molecular subtype correlation trends that were highly significant. BRCA1+ tumors were positively associated with a basal subtype [p&lt;0.001], whereas this association was not significant for BRCA2+ tumors. BRCA2+ tumors were associated with an increase in luminal B subtype [p=0.05]. All BRCA+ tumors had a decrease in luminal A subtype correlation [BRCA1+: p&lt;0.001; BRCA2+: p=0.002]. In addition to the BC360 signatures, a differential analysis of all genes in the BC360 panel revealed more single gene differences in BRCA2+ than BRCA1+ tumors when compared to BRCA- tumors.

Conclusions: In early stage BRCA+ breast cancer, tumors have higher ROR and increased HRD signature scores compared to BRCA- tumors. Furthermore, BRCA1+ and BRCA2+ tumors have both signature and single gene expression differences when compared to BRCA- tumors, indicating distinct subgroup-related biology. The greater correlation of BRCA1+ tumors with basal-like biology and BRCA2+ tumors with aggressive hormonal biology confirms these trends. Distinctions in hormone receptor signaling, DNA-damage pathways, and microenvironment/inflammatory features between BRCA1 and BRCA2 associated cancers suggest a need for different prevention and therapeutic strategies for each of these breast cancer subtypes. The unique biological patterns identified here should be further evaluated as predictive or prognostic tools that could be translated into clinical care for early stage BRCA+ patients.

Citation Format: Force J, Plichta J, Stashko I, Kimmick G, Westbrook K, Sammons S, Hwang S, Hyslop T, Kauff N, Castellar E, Nair S, Weinhold K, Davis S, Mashadi-Hossein A, Brauer HA, Marcom PK. Distinct biological signatures describe differences in BRCA mutated subgroups [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 P3-08-07.

Testing a behavioral intervention to improve adherence to adjuvant endocrine therapy (AET)

Adjuvant endocrine therapy (AET) is used to prevent recurrence and reduce mortality for women with hormone receptor positive breast cancer. Poor adherence to AET is a significant problem and contributes to increased medical costs and mortality. A variety of problematic symptoms associated with AET are related to non-adherence and early discontinuation of treatment. The goal of this study is to test a novel, telephone-based coping skills training that teaches patients adherence skills and techniques for coping with problematic symptoms (CST-AET). Adherence to AET will be assessed in real-time for 18 months using wireless smart pill bottles. Symptom interference (i.e., pain, vasomotor symptoms, sleep problems, vaginal dryness) and cost-effectiveness of the intervention protocol will be examined as secondary outcomes. Participants (N = 400) will be recruited from a tertiary care medical center or community clinics in medically underserved or rural areas. Participants will be randomized to receive CST-AET or a general health education intervention (comparison condition). CST-AET includes ten nurse-delivered calls delivered over 6 months. CST-AET provides systematic training in coping skills for managing symptoms that interfere with adherence. Interactive voice messaging provides reinforcement for skills use and adherence that is tailored based on real-time adherence data from the wireless smart pill bottles. Given the high rates of non-adherence and recent recommendations that women remain on AET for 10 years, we describe a timely trial. If effective, the CST-AET protocol may not only reduce the burden of AET use but also lead to cost-effective changes in clinical care and improve breast cancer outcomes. Trials registration: ClinicalTrials.gov, NCT02707471, registered 3/3/2016.

Age and the Risk of Paclitaxel-Induced Neuropathy in Women with Early-Stage Breast Cancer (Alliance A151411): Results from 1,881 Patients from Cancer and Leukemia Group B (CALGB) 40101

PURPOSE

A few previous studies report a direct relationship between older age and chemotherapy-induced neuropathy. This study further evaluated this adverse event's age-based risk.

METHODS

CALGB 40101 investigated adjuvant paclitaxel (80 mg/m² once per week or 175 mg/m² every 2 weeks) in patients with breast cancer and served as a platform for the current study that investigated age-based differences in neuropathy. Grade 2 or worse neuropathy, as per Common Terminology Criteria for Adverse Events version 4, was the primary endpoint; patients were assessed at baseline, every 6 months for 2 years, and then annually for 15 years.

RESULTS

Among these 1,881 patients, 230 were 65 years of age or older, 556 were 55-64 years, and 1,095 were younger than 55; 1,226 neuropathy events (commonly grade 1 or 2) were reported in 65% of the cohort. The number of grade 2 or worse events was 63 (27%), 155 (28%), and 266 (24%) within respective age groups (p = .14). In univariate analysis, only motor neuropathy had a higher age-based incidence: 19 (8%), 43 (8%), and 60 (5%), respectively (p = .04); in multivariate analyses, this association was no longer statistically significant. Other endpoints, such as time to onset of neuropathy (time from trial enrollment to neuropathy development) and time to improvement (time from maximal grade sensory neuropathy to a one-category improvement), showed no statistically significant age-based differences. In contrast, obesity was associated with neuropathy, and every 2-week paclitaxel was associated with trends toward neuropathy.

CONCLUSION

Although paclitaxel-induced neuropathy is common, older age is not an independent risk factor. Clinical trial identification number. NCT00041119 (CALGB 40101).

IMPLICATIONS FOR PRACTICE

Age alone is not an independent risk factor for paclitaxel-induced neuropathy.

Functional Decline and Resilience in Older Women Receiving Adjuvant Chemotherapy for Breast Cancer

OBJECTIVES

To analyze self-reported changes in physical function in older women with breast cancer receiving adjuvant chemotherapy.

DESIGN

Secondary analysis of the Cancer and Leukemia Group B (CALGB) 49907 prospective randomized clinical trial.

SETTING

CALGB institutions in the United States.

PARTICIPANTS

Women aged 65 and older with Stage I to III breast cancer enrolled in CALGB 49907 who had physical function data from before and after receipt of adjuvant chemotherapy (N=256; mean age 71.5, range 65-85).

MEASUREMENTS

Participants were administered the physical function subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire before chemotherapy, at the end of chemotherapy, and 12 months after chemotherapy initiation. Functional decline was defined as a more than 10-point decrease from baseline at each time point. Resilience was defined as return to within 10 points of baseline. Multivariable regression was used to examine pretreatment characteristics associated with physical function changes.

RESULTS

Of 42% of participants who had physical function decline from before to the end of chemotherapy, 47% recovered by 12 months (were resilient). Almost one-third experienced functional decline from before chemotherapy to 12 months later. Pretreatment fatigue was a risk factor for functional decline from before to the end of chemotherapy (P=.02). Risk factors for functional decline at 12 months included pretreatment dyspnea (P=.007) and being unmarried (P=.01).

CONCLUSION

Functional decline was common in older women receiving adjuvant chemotherapy for breast cancer in a clinical trial. Although half recovered their physical function, one-third had a clinically meaningful decline at 12 months. Strategies are needed to prevent functional decline in older adults receiving chemotherapy. J Am Geriatr Soc 67:920-927, 2019.

A randomized phase II trial of MOVING ON: An intervention to increase exercise outcome expectations among breast cancer survivors

OBJECTIVE

The objective of the study is to test theoretical intervention fidelity and feasibility of MOVING ON, a self-directed, home-based, randomized controlled trial to increase exercise outcome expectations (OEs) (what one expects to obtain or avoid as a result of a behavior or lack thereof), among breast cancer survivors.

METHOD

Stage Ia to IIb survivors (n = 60) were given the MOVING ON intervention or control booklet. Data were collected through online surveys and an accelerometer at baseline, 4, 8, and 12 weeks postintervention. Fidelity was measured by questions assessing participant perceptions of MOVING ON (score ≥2) and direction of intervention effects. Feasibility was measured by recruitment rate (target of 60 participants in 6 months), retention (total attrition <17%), and acquisition of accelerometer data (% ≥subjective exercise data obtained). Analyses consisted of descriptive statistics, mixed models, and content analysis.

RESULTS

Fidelity met a priori criteria (mean = 3.31, SD = 0.87). Outcome expectations increased 0.01 points, and weekly steps increased by 970 every 4 weeks in the intervention arm compared to the control arm. All effect sizes were small, ranging from 0.01 to 0.09. Target enrollment, achieved in 17 weeks, met a priori feasibility criteria. Retention (66%) and accelerometer data acquisition (60%) (compared to 73% of subjective exercise data) did not.

CONCLUSION

MOVING ON influenced OEs as intended and was well received by participants. A fully powered study, of this low-cost, easy-to-implement intervention, is warranted. Intervention and measurement strategies used in MOVING ON can be incorporated in any study targeting OEs as a mediator of exercise or collecting exercise data with an accelerometer.

Abstract P5-21-08: Tolerability of the combination of lapatinib and trastuzumab in older patients with HER2 positive metastatic breast cancer

Background: Older adults are less likely to be included in clinical trials leading to the approval of novel cancer treatments. The Institute of Medicine and ASCO have identified therapeutic phase II trials as a key research priority to increase the evidence base for older adults with cancer. While targeted therapies may represent a less toxic option for older patients, few trials have studied their tolerability and efficacy in older adults. Here, we present a phase II study (NCT01273610) of the combination of trastuzumab and lapatinib in older patients with HER2+ metastatic breast cancer (MBC), incorporating geriatric oncology principles in the study design.

Methods: Patients age ≥ 60 years with MBC and any number of prior chemotherapy (CT) lines received trastuzumab (either 4mg/kg loading dose followed by 2mg/kg weekly or 8mg/kg followed by 6mg/kg q/3 weeks) plus lapatinib 1000 mg/m2 daily in 21-day cycles. Patients completed a pre-treatment geriatric assessment including measures of function, comorbidity, cognition, nutrition, and psychosocial status. A toxicity risk score developed for older adults receiving cytotoxic CT was calculated for each patient (Hurria et al. JCO 2011 & 2016). Relationships between tolerability (dose reductions and grade (G) ≥ 3 toxicity attributed to treatment) and risk score analyzed using a log2 transformation were assessed using generalized linear models, Student's t tests, and Fisher's exact test. Response rate (RR) and progression free survival (PFS) were evaluated.

Results: 40 patients (mean age 72 [60-92]) were accrued from 04/11 to 05/15. 25% (n = 10) were ≥ 75 years of age. 65% of patients (n = 26) had HR+ tumors and 35% (n = 14) were receiving ≥ 3rd line treatment. Median number of cycles was 4 (0-28). RR was 23% (n = 9, 95% CI 11-38%; 1 complete, 8 partial). 23% (n = 9) achieved stable disease. PFS was 2.7 months (95% CI 2.5-12). Based on the toxicity risk score, 21% (n = 8), 54% (n = 21), and 26% (n = 10) were at low, intermediate, and high risk. 70% (n = 28) of patients had G ≥ 2 toxicities and 20% (n = 8) G ≥ 3 toxicities. G 2 and 3 diarrhea occurred in 28% (n = 11) and 5% (n = 2) respectively. 5% (n = 2) were hospitalized due to treatment-related toxicity. No G ≥ 3 cardiac toxicities were observed. 23% of patients (n = 9) had treatment delays, and 43% (n = 17) required a lapatinib dose reduction. The mean toxicity risk score was higher in patients who required dose reductions (Student's t: p = 0.02). No statistically significant relationship was found between toxicity risk scores and the presence of G ≥ 3 treatment toxicity (logistic regression: OR = 3.08, 95% CI [0.54, 21.2], p = 0.22).

Conclusions: Among older patients with MBC (79% at intermediate or high risk of G ≥ 3 cytotoxic CT toxicity), trastuzumab and lapatinib were well tolerated, with only 20% experiencing G3 toxicities. The toxicity risk score was not found to be significantly related with treatment toxicity, which may be explained by the very low incidence of G3 events. Patients with a low toxicity risk score were not likely to require a lapatinib dose reduction.

Citation Format: O'Connor T, Soto-Perez-de-Celis E, Blanchard S, Chapman A, Kimmick G, Muss H, Luu T, Waisman JR, Li D, Mortimer J, Yuan Y, Somlo G, Stewart D, Katheria V, Levi A, Hurria A. Tolerability of the combination of lapatinib and trastuzumab in older patients with HER2 positive metastatic 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 P5-21-08.

Protocol for Moving On: a randomized controlled trial to increase outcome expectations and exercise among breast cancer survivors

Aim

The aim of this study was to test the feasibility and fidelity of an intervention, Moving On, aimed to increase outcome expectations OEs (i.e. what one expects to obtain or avoid as a result of a behaviour) and exercise among breast cancer survivors.

Design

Randomized controlled trial.

Methods

Intervention arm participants will be given a theory-guided booklet that was co-created by the research team and three physically active breast cancer survivors who exercise to manage late and long-term treatment effects. Attention control arm participants will be given a similar booklet focused on diet. Participants will have 1 week to complete reading, writing and reflecting activities in the booklets. Study outcomes will be measured through online surveys; exercise will also be measured objectively with a Fitbit®. Four weeks postintervention, participants' thoughts about the usefulness, strengths and weakness of the intervention booklet will be assessed. OEs and exercise will be measured at baseline, 4-, 8- and 12-week postintervention.

Neratinib Efficacy and Circulating Tumor DNA Detection of HER2 Mutations in HER2 Nonamplified Metastatic Breast Cancer

Purpose: Based on promising preclinical data, we conducted a single-arm phase II trial to assess the clinical benefit rate (CBR) of neratinib, defined as complete/partial response (CR/PR) or stable disease (SD) ≥24 weeks, in HER2^mut nonamplified metastatic breast cancer (MBC). Secondary endpoints included progression-free survival (PFS), toxicity, and circulating tumor DNA (ctDNA) HER2^mut detection.Experimental Design: Tumor tissue positive for HER2^mut was required for eligibility. Neratinib was administered 240 mg daily with prophylactic loperamide. ctDNA sequencing was performed retrospectively for 54 patients (14 positive and 40 negative for tumor HER2^mut).Results: Nine of 381 tumors (2.4%) sequenced centrally harbored HER2^mut (lobular 7.8% vs. ductal 1.6%; P = 0.026). Thirteen additional HER2^mut cases were identified locally. Twenty-one of these 22 HER2^mut cases were estrogen receptor positive. Sixteen patients [median age 58 (31-74) years and three (2-10) prior metastatic regimens] received neratinib. The CBR was 31% [90% confidence interval (CI), 13%-55%], including one CR, one PR, and three SD ≥24 weeks. Median PFS was 16 (90% CI, 8-31) weeks. Diarrhea (grade 2, 44%; grade 3, 25%) was the most common adverse event. Baseline ctDNA sequencing identified the same HER2^mut in 11 of 14 tumor-positive cases (sensitivity, 79%; 90% CI, 53%-94%) and correctly assigned 32 of 32 informative negative cases (specificity, 100%; 90% CI, 91%-100%). In addition, ctDNA HER2^mut variant allele frequency decreased in nine of 11 paired samples at week 4, followed by an increase upon progression.Conclusions: Neratinib is active in HER2^mut, nonamplified MBC. ctDNA sequencing offers a noninvasive strategy to identify patients with HER2^mut cancers for clinical trial participation. Clin Cancer Res; 23(19); 5687-95. ©2017 AACR.

Abstract CT011: Circulating tumor DNA (ctDNA) sequencing for HER2 mutation (HER2mut) screening and response monitoring to neratinib in metastatic breast cancer (MBC)

Introduction: MutHER is a phase II trial that demonstrated the anti-tumor activity of the pan-HER inhibitor neratinib in HER2mut, non-amplified MBC. The major challenges to accrue to this trial were the large number of pts to screen for the 2-3% HER2mut population and the high rate (24%) of poor quality tumor DNA for sequencing. The goals of this ctDNA study were: 1) the concordance of HER2mut detected by ctDNA versus tumor testing; 2) the incidence of ctDNA HER2mut in HER2 non-amplified MBC; 3) changes in HER2mut variant allele frequency (VAF) on neratinib therapy.

Methods: A sample size of 30 negative (neg) controls was needed to ensure 90% confidence if ctDNA testing has &gt;90% specificity in detecting HER2mut. Thus, plasma from MBC pts obtained at screening for MutHER trial (Neg control: 40 pts without HER2mut on tumor testing; Positive (pos) control: 14 pts with known HER2mut who received neratinib) were subjected to Guardant360 ctDNA 70-gene panel sequencing (all exons of HER2 included). ctDNA from the 14 neratinib treated pts were also analyzed at week (wk) 4 and upon progression. ctDNA data from MBC pts clinically tested at Guardant Health were interrogated for HER2mut incidence.

Results: Among the 14 pts with tumor pos for HER2mut, ctDNA sequencing identified the same HER2mut in 11, discrepant HER2mut in 1, and neg in 2. The 2 pts with ctDNA neg for HER2mut had progressive disease (PD) and stable disease (SD &gt; 6 months) on neratinib, respectively. Among the 40 neg controls, 8 were not evaluable (no detectable ctDNA or assay unsuccessful) and all 32 successfully sequenced cases were neg for HER2mut. The sensitivity and specificity of ctDNA for HER2mut detection was 11/14 (79%, 90% CI: 53-94%) and 32/32 (100%, 90% CI: 91-100%), respectively. Among the 11 paired baseline and wk 4 samples, 9 (82%) had lower HER2mut VAFs at wk 4 than at baseline, with 1 complete response (CR), 1 partial response (PR), 5 SD, and 4 PD at wk 8 as best tumor response. Two pts had higher wk 4 ctDNA HER2mut VAFs and both had radiographic PD at wk 8. The absolute HER2mut VAF levels at wk 4 were significantly associated with TTP (Spearman rho=-0.69, p=0.02) and tumor size change (rho=0.67, p=0.05). The HER2mut VAFs were significantly higher at progression than wk 4 in all pts (p&lt;0.01). One pt acquired a new HER2mut T798I, which is analogous to the gate-keeper mutation EGFR T790M. The incidence of HER2mut without amplification in unselected consecutive MBC clinically tested by Guardant360 was 3% (48/1,584), with mutation pattern similar to published tumor testing data.

Conclusions: ctDNA sequencing is sensitive and highly specific in detecting HER2mut, offering a non-invasive method to identify pts for trials of HER2mut-targeted therapy. Decreased HER2mut VAFs at wk 4 was observed in 82% of cases, consistent with the on-target effect of neratinib. Increased HER2mut VAFs at wk 4 is a potential early marker of progression.

Citation Format: Cynthia Ma, Ron Bose, Feng Gao, Rachel Freedman, Melinda Telli, Gretchen Kimmick, Eric Winer, Michael Naughton, Matthew Goetz, Christy Russell, Debu Tripathy, Melody Cobleigh, Andres Forero, Timothy Pluard, Carey Anders, Shana Thomas, Jill Anderson, Caroline Bumb, Kimberly Banks, Richard Lanman, Richard Bryce, Alshad Lalani, John Pfeifer, Daniel Hays, Mark Pegram, Kimberly Blackwell, Philippe Bedard, Hussam Al-Kateb, Matthew Ellis. Circulating tumor DNA (ctDNA) sequencing for HER2 mutation (HER2mut) screening and response monitoring to neratinib in metastatic breast cancer (MBC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT011. doi:10.1158/1538-7445.AM2017-CT011

Personality, coping, and social support as predictors of long-term quality-of-life trajectories in older breast cancer survivors: CALGB protocol 369901 (Alliance)

BACKGROUND

To determine long-term quality-of-life (QOL) trajectories among breast cancer survivors aged 65+ (older) evaluating the effects of personality and social support.

METHODS

Older women (N = 1280) newly examined with invasive, nonmetastatic breast cancer completed baseline assessments. Follow-up data were collected 6 and 12 months later and then annually for up to 7 years (median 4.5 years). Quality of life was assessed using EORTC-QLQ-C30 emotional, physical, and cognitive scales. Optimism (Life Orientation Test), Coping (Brief COPE), and social support (Medical Outcomes Study) were assessed at baseline. Group-based trajectory modeling identified QOL trajectories; multinomial regression evaluated effects of predictors on trajectory groups. Age, education, systemic therapy, comorbidity, and reported precancer function (SF-12) were considered as controlling variables.

RESULTS

Three trajectories were identified for each QOL domain: "maintained high," "phase shift" (lower but parallel scores to "maintained high" group), and "accelerated decline" (lowest baseline scores and steepest decline). Accelerated decline in emotional, physical, and cognitive function was seen in 6.9%, 31.8%, and 7.6% of older survivors, respectively. Maladaptive coping and lower social support increased adjusted odds of being in the accelerated decline group for all QOL domains; lower optimism was only related to decline in emotional function. Chemotherapy was related to physical and cognitive but not emotional function trajectories.

CONCLUSIONS

Personality and social resources affect the course of long-term emotional well-being of older breast cancer survivors; treatment is more important for physical and cognitive than emotional function. Early identification of those vulnerable to deterioration could facilitate clinical and psychological support.

Abstract P2-04-19: Elucidating the tumor immune microenvironment phenotype in early stage untreated BRCA mutated breast cancer patients

Background: Increased stromal tumor infiltrating lymphocytes (TILs) are predictive and prognostic for improved outcomes from neoadjuvant or adjuvant chemotherapy in triple negative breast cancer. Increased tumor mutational burden may promote neoantigens causing immune system upregulation. Microsatellite instability in gastrointestinal cancer predicts for response to checkpoint inhibition and is associated with inherited cancer predisposition. The immune system response in BRCA mutated breast cancer has not been described. The purpose of this study is to assess tumor infiltrating immune cells in early stage breast cancer patients with and without BRCA gene mutations.

Methods: We retrospectively investigated 124 early stage breast cancer patients with BRCA mutations (n=62, BRCA+) and without BRCA mutations (n=62, BRCA WT). The %TILs was measured manually by H&E. Our control group consisted of age, stage, and receptor status matched early stage untreated breast cancer patients who were deemed BRCA WT by extended gene panel testing or were negative for BRCA 1/2 and had a posttest probability of harboring an autosomal dominant mutated gene of ≤ 1% using the Bayes-Mendel algorithm. We used a two-sample binomial arcsin approximation to detect a 20% difference in TILs between cohorts to attain 80% power with a one-side alpha of 0.05. Wilcoxon Rank-Sums test was used to compare differences in the central tendencies for continuous variables. We used the Nanostring PanCancer immune profiling panel to immunophenotype a portion of the BRCA+ and BRCA WT cohorts and used nSolver for quality control, normalization, and bioinformatics analyses.

Results: Here we report TILs from the first 21 patients of our study. Thirteen patients harbored BRCA mutations and eight patients did not. All patients were HER2 negative. Eight (61%) and four (50%) patients were hormone receptor positive (HR+) in the BRCA+ and BRCA WT cohorts, respectively. Median %TILs were not significantly different between the BRCA+ (15, range 0-70) and BRCA WT (17.5, range 5-60; p=0.7) groups. Median %TILs in the HR+/BRCA+ (12.5, range 0-50) and HR-/BRCA+ (15, range 5-70) cohorts were not statistically different when compared to HR+/BRCA WT (10, range 5-15; p=0.4) and HR-/BRCA WT (30, range 20-60; p=0.2) cohorts, respectively. There were 2 patients with lymphocyte predominant breast cancer (n=1, HR-/BRCA+; n=1, HR-/BRCA WT).

Conclusions: This is the first study to characterize TILs and a tumor immune microenvironment phenotype in early stage breast cancer patients with BRCA mutations. These results suggest harboring a BRCA mutation is not associated with increased TILs in early stage untreated breast cancer patients. This conclusion stayed true regardless of hormone receptor status. However, a trend of decreased TILs was seen in HR-/BRCA+ patients when compared to those with HR-/BRCA WT disease. Moreover, the median and range of TILs were higher in the HR+/BRCA+ group compared to the HR+/BRCA WT group. This suggests increased TILs may exist in some HR+ patients with a BRCA mutation. Further investigation of TILs and immune profiling of early stage untreated breast cancer patients with and without BRCA mutations is warranted.

Citation Format: Force J, Abbott S, Broadwater G, Kimmick G, Westbrook K, Hwang S, Kauff N, Stashko I, Weinhold K, Nair S, Hyslop T, Blackwell K, Castellar E, Marcom PK. Elucidating the tumor immune microenvironment phenotype in early stage untreated BRCA mutated breast cancer patients [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 P2-04-19.

Accrual of Older Patients With Breast Cancer to Alliance Systemic Therapy Trials Over Time: Protocol A151527

Purpose Despite increasing awareness of accrual challenges, it is unknown if accrual of older patients to breast cancer treatment trials is improving. Methods We examined accrual of older patients to Alliance for Clinical Trials in Oncology systemic therapy breast cancer trials during 1985-2012 and compared disease characteristics and reasons for therapy cessation for older (age ≥ 65 years and ≥ 70 years) versus younger (age < 65 years and < 70 years) participants. To examine accrual trends, we modeled age as a function of time, using logistic regression. Results Overall, 17% of study participants were ≥ 65 years of age. Approximately 15%, 24%, and 24% of participants in adjuvant, neoadjuvant, and metastatic trials were age ≥ 65 years, and 7%, 15%, and 13% were age ≥ 70 years, respectively. The odds of a patient age ≥ 65 years enrolling significantly increased over time for adjuvant trials (odds ratio [OR] per year, 1.04; 95% CI, 1.04 to 1.05) but decreased significantly for neoadjuvant and metastatic trials (OR, 0.62; 95% CI, 0.58 to 0.67 and OR, 0.98, 95% CI, 0.97 to 1.00). Similar trends were seen for those age ≥ 70 years but these were statistically significant for adjuvant and neoadjuvant trials only (OR, 1.05, 95% CI, 1.04 to 1.07; and OR, 0.57, 95% CI, 0.52 to 0.62). In general, those age ≥ 65 years ( v those < 65 years) in adjuvant studies had a higher mean number of lymph nodes involved and more hormone receptor-negative tumors, although tumor sizes were similar. Early protocol treatment cessation was also more frequent in those age ≥ 65 years (50%) versus < 65 years (35.9%) across trials. Conclusion Older patients with breast cancer remain largely underrepresented in cooperative group therapeutic trials. We observed some improvement in accrual to adjuvant trials but worsening of accrual for neoadjuvant/metastatic trials. Novel strategies to increase accrual of older patients are critical to meaningfully change the evidence base for this growing patient population.

Abstract P6-09-10: All-cause survival estimates compared to observed survival in older women with breast cancer in CALGB 49907 and 369901 (Alliance A151503)

Background: Older adults represent 50% or more of all newly diagnosed cancer patients annually; these patients have multiple morbidities, complicating treatment decision-making.. Discussions about the risks and benefits of cancer treatments might be improved by having data on estimated all-cause survival. ePrognosis (http://eprognosis.ucsf.edu/carey2.php) is an online tool validated in older adults without cancer. We compared survival estimates using ePrognosis to observed survival in a population of women with early stage breast cancer who volunteered for cooperative group studies.

Methods: Participants in CALGB 49907 (n=194) and 369901 (n=809) who were age 70+ were included (total n=1003). Both studies had comparable eligibility: primary, newly diagnosed, invasive, non-metastatic breast cancer. In 49907, eligibly also included PS 0-2; in 369901 there were no PS restrictions, but women who failed a screening cognitive exam were excluded. The Carey 2-year Index from ePrognosis was used to estimate all-cause 2-year survival, based on age, sex, and daily function. Function (needing help from another person to bath and shop for groceries, difficulty walking several blocks and pushing or pulling a heavy object) was derived from the EORTC QLC-30. The Carey index from ePrognosis generates scores from 1-10, with higher scores indicating higher probability of death. Kaplan-Meier methods were used to obtain point estimates and confidence intervals for the observed 2-yr survival. A two sided z-test was used to test the hypothesis that the observed survival rate is equivalent to the predicted survival rate.

Results: At two years from study entry, 921 women were alive; 56 had died, and 26 were lost to follow-up/withdrawn. The population was, on average, 76 years old (SD 4.8), primarily white (89.3%), and the majority had hormone receptor positive tumors (79.4%). In our population, the Carey 2-years index predicated survival was not significantly different than observed rates in the 0-2 points and underestimated the survival rates for patients who had 3-6 points and 7-10 points.

ePrognosis Prediction49907 & 369901 PatientsPointsPredicted Probability of SurvivalNNumber of DeathsObserved Probability of Overall Survival at 2 years (%, 95% CI)p-value0-295%5332595% (93-97%)0.7433-688%4272394% (92-96%)&lt;0.0017-1064%43881% (65-90%)0.017

Conclusions: In this population of older women with breast cancer, using a few readily available data items, ePrognosis provided accurate survival estimates for women with a low probability of death (0-2 points) and underestimated all-cause survival in women with an increased probability of death (3-10 points). Further studies are needed to assess the validity of this tool in samples of cancer patients with higher risks of 2-year mortality. Extended follow-up to validate the tools in predicting 5- and 10-year all-cause and non-cancer mortality risk will further contribute to decision making in older patients.

Citation Format: Kimmick G, Pitcher B, Mandelblatt J, Clapp J, Ballman K, Barginear M, Freedman R, Artz A, Klepin H, Lafky J, Hopkins J, Winer E, Hudis C, Muss H, Cohen H, Jatoi A, Hurria A. All-cause survival estimates compared to observed survival in older women with breast cancer in CALGB 49907 and 369901 (Alliance A151503). [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 P6-09-10.

What Predicts an Advanced-Stage Diagnosis of Breast Cancer? Sorting Out the Influence of Method of Detection, Access to Care, and Biologic Factors

BACKGROUND

Multiple studies have yielded important findings regarding the determinants of an advanced-stage diagnosis of breast cancer. We seek to advance this line of inquiry through a broadened conceptual framework and accompanying statistical modeling strategy that recognize the dual importance of access-to-care and biologic factors on stage.

METHODS

The Centers for Disease Control and Prevention-sponsored Breast and Prostate Cancer Data Quality and Patterns of Care Study yielded a seven-state, cancer registry-derived population-based sample of 9,142 women diagnosed with a first primary in situ or invasive breast cancer in 2004. The likelihood of advanced-stage cancer (American Joint Committee on Cancer IIIB, IIIC, or IV) was investigated through multivariable regression modeling, with base-case analyses using the method of instrumental variables (IV) to detect and correct for possible selection bias. The robustness of base-case findings was examined through extensive sensitivity analyses.

RESULTS

Advanced-stage disease was negatively associated with detection by mammography (P < 0.001) and with age < 50 (P < 0.001), and positively related to black race (P = 0.07), not being privately insured [Medicaid (P = 0.01), Medicare (P = 0.04), uninsured (P = 0.07)], being single (P = 0.06), body mass index > 40 (P = 0.001), a HER2 type tumor (P < 0.001), and tumor grade not well differentiated (P < 0.001). This IV model detected and adjusted for significant selection effects associated with method of detection (P = 0.02). Sensitivity analyses generally supported these base-case results.

CONCLUSIONS

Through our comprehensive modeling strategy and sensitivity analyses, we provide new estimates of the magnitude and robustness of the determinants of advanced-stage breast cancer.

IMPACT

Statistical approaches frequently used to address observational data biases in treatment-outcome studies can be applied similarly in analyses of the determinants of stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 25(4); 613-23. ©2016 AACR.

Medication taking behaviors among breast cancer patients on adjuvant endocrine therapy

PURPOSE

To explore how symptoms and psychosocial factors are related to intentional and unintentional non-adherent medication taking behaviors.

METHODS

Included were postmenopausal women with hormone receptor positive, stage I-IIIA breast cancer, who had completed surgery, chemotherapy, and radiation, and were taking endocrine therapy. Self-administered, standardized measures were completed during a routine clinic visit: Brief Fatigue Inventory, Brief Pain Inventory, Menopause Specific Quality of Life Questionnaire, Functional Assessment of Cancer Therapy General and Neurotoxicity scales, and Self-Efficacy for Appropriate Medication Use Scale. Regression analyses were performed to determine the degree to which demographic, medical, symptom, and psychosocial variables, explain intentional, such as changing one's doses or stopping medication, and unintentional, such as forgetting to take one's medication, non-adherent behaviors.

RESULTS

Participants were 112 women: mean age 64 (SD = 9) years; 81% white; mean time from surgery 40 (SD = 28) months; 49% received chemotherapy (39% including a taxane); mean time on endocrine therapy, 35 (SD = 29.6) months; 82% taking an aromatase inhibitor. Intentional and unintentional non-adherent behaviors were described in 33.9% and 58.9% of participants, respectively. Multivariate analysis showed that higher self-efficacy for taking medication was associated with lower levels of unintentional (p = 0.002) and intentional (p = 0.004) non-adherent behaviors. The presence of symptoms (p = 0.03) and lower self-efficacy for physician communication (p = 0.009) were associated with higher levels of intentional non-adherent behaviors.

CONCLUSIONS

These results suggest that women who report greater symptoms, lower self-efficacy for communicating with their physician, and lower self-efficacy for taking their medication are more likely to engage in both intentional and unintentional non-adherent behaviors.

Abstract P5-15-11: The distress screening tool: Initial experience with electronically curated patient reported measures

Background: In June 2013, our health system transitioned to an electronic medical record (EMR) which included collecting patient quality of life data at each clinic visit. We used the NCCN distress thermometer (DT), a short, simple to use, self-report measure which uses a 10-point scale from 0 (no distress) to 10 (extreme distress) as well as an associated problem checklist which queries the source(s) of their distress. Among our breast cancer clinic population, we studied the severity and sources of distress as well as whether the DT score was associated with stage at diagnosis and time interval since diagnosis.

Methods: Between October 1, 2013 and April 30, 2014, starting 3 months after implementation of a comprehensive EMR, all patients seen at our tertiary breast cancer clinic were asked to complete the DT survey at each clinic visit. DT data were collected and entered into the EMR at point of care. The DT tool was correlated with demographic and tumor information from our prospectively curated electronic datamart.

Results: We collected 7276 DT surveys from 3267 unique patients over seven months. Median age of the cohort was 60 years; 73% were white and 21% were black. Among those with available staging data and a diagnosis of breast cancer, stage distribution was 10% stage 0, 34% stage I, 37% stage II, 15% stage III and 4% stage IV. The median reported distress score was 1.0 (range 0-10) with score distribution shown in Figure 1. The most commonly reported source of stress was fatigue (8.0%) followed by pain (6.8%). For new patient appointments the most commonly reported sources were worry (9.5%) followed by nervousness (8.0%). There was no significant correlation between overall distress score and stage at diagnosis. Among patients who were seen more than once during the study interval, the DT score changed for 33.7% of patients. The lowest distress scores were reported among women &gt;3 years from initial diagnosis.

Conclusions: The transition to an integrated EMR system has allowed collection of analyzable patient reported data to inform medical and psychosocial intervention. Structured data collection at point of care allows for efficient identification of and management for the major sources of distress among patients during breast cancer treatment and survivorship.

Citation Format: Shelley Hwang, Steve Power, Ilona Stashko, Rachel Blitzblau, Rachel Greenup, Janet Horton, Kellly Westbrook, Kimberly Blackwell, Heather Sperling, Jeffrey Peppercorn, Gretchen Kimmick, Kelly Marcom. The distress screening tool: Initial experience with electronically curated patient reported measures [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-15-11.

Patterns of locoregional treatment for nonmetastatic breast cancer by patient and health system factors

BACKGROUND

The purpose of this study was to examine local definitive therapy for nonmetastatic breast cancer with the Patterns of Care Breast and Prostate Cancer (POCBP) study of the National Program of Cancer Registries (Centers for Disease Control and Prevention).

METHODS

POCBP medical record data were re-abstracted in 7 state/regional registry systems (Georgia, North Carolina, Kentucky, Louisiana, Wisconsin, Minnesota, and California) to verify data quality and assess treatment patterns in the population. National Comprehensive Cancer Network clinical practice treatment guidelines were aligned with American Joint Committee on Cancer staging at diagnosis to appraise care.

RESULTS

Six thousand five hundred five of 9142 patients with registry-confirmed breast cancer were coded as having primary disease with stage 0 to IIIA tumors and were included in the study. Approximately 88% received guideline-concordant locoregional treatment. However, this outcome varied by age group: 92% of women < age 50 versus 80% of women ≥ age 70 years old received guideline care (P < 0.01). Characteristics that best discriminated receipt (no/yes) of guideline-concordant care in receiver operating curve analyses were the receipt of breast-conserving surgery (BCS) versus mastectomy (C = 0.70), patient age (C = 0.62), a greater tumor stage (C = 0.60), public insurance (C = 0.58), and the presence of at least mild comorbidity (C = 0.55). Radiation therapy (RT) after BCS was the most omitted treatment component causing nonconcordance in the study population. In multivariate regression, the effects of the treatment facility, ductal carcinoma in situ, race, and comorbidity on nonconcordant care differed by age group.

CONCLUSIONS

Patterns of underuse of standard therapies for breast cancer vary by age group and BCS use, with which there is a risk of omission of RT.

Patient experience and attitudes toward addressing the cost of breast cancer care

BACKGROUND

The American Society of Clinical Oncology views patient-physician discussion of costs as a component of high-quality care. Few data exist on patients' views regarding how cost should be addressed in the clinic.

METHODS

We distributed a self-administered, anonymous, paper survey to consecutive patients with breast cancer presenting for a routine visit within 5 years of diagnosis at an academic cancer center. Survey questions addressed experience and preferences concerning discussions of cost and views on cost control. Results are primarily descriptive, with comparison among participants on the basis of disease stage, using chi-square and Fisher's exact tests. All p values are two-sided.

RESULTS

We surveyed 134 participants (response rate 86%). Median age was 61 years, and 28% had stage IV disease. Although 44% of participants reported at least a moderate level of financial distress, only 14% discussed costs with their doctor; 94% agreed doctors should talk to patients about costs of care. Regarding the impact of costs on decision making, 53% felt doctors should consider direct costs to the patient, but only 38% felt doctors should consider costs to society. Moreover, 88% reported concern about costs of care, but there was no consensus on how to control costs.

CONCLUSION

Most breast cancer patients want to discuss costs of care, but there is little consensus on the desired content or goal of these discussions. Further research is needed to define the role of cost discussions at the bedside and how they will contribute to the goal of high-quality and sustainable cancer care.

Frailty and adherence to adjuvant hormonal therapy in older women with breast cancer: CALGB protocol 369901

PURPOSE

Most patients with breast cancer age ≥ 65 years (ie, older patients) are eligible for adjuvant hormonal therapy, but use is not universal. We examined the influence of frailty on hormonal therapy noninitiation and discontinuation.

PATIENTS AND METHODS

A prospective cohort of 1,288 older women diagnosed with invasive, nonmetastatic breast cancer recruited from 78 sites from 2004 to 2011 were included (1,062 had estrogen receptor-positive tumors). Interviews were conducted at baseline, 6 months, and annually for up to 7 years to collect sociodemographic, health care, and psychosocial data. Hormonal initiation was defined from records and discontinuation from self-report. Baseline frailty was measured using a previously validated 35-item scale and grouped as prefrail or frail versus robust. Logistic regression and proportional hazards models were used to assess factors associated with noninitiation and discontinuation, respectively.

RESULTS

Most women (76.4%) were robust. Noninitiation of hormonal therapy was low (14%), but in prefrail or frail (v robust) women the odds of noninitiation were 1.63 times as high (95% CI, 1.11 to 2.40; P = .013) after covariate adjustment. Nonwhites (v whites) had higher odds of noninitiation (odds ratio, 1.71; 95% CI, 1.04 to 2.80; P = .033) after covariate adjustment. Among initiators, the 5-year continuation probability was 48.5%. After adjustment, the risk of discontinuation was higher with increasing age (P = .005) and lower for stage ≥ IIB (v stage I) disease (P = .003).

CONCLUSION

Frailty is associated with noninitiation of hormonal therapy, but it does not seem to be a major predictor of early discontinuation in older patients.

Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

Comparison of doxorubicin and cyclophosphamide versus single-agent paclitaxel as adjuvant therapy for breast cancer in women with 0 to 3 positive axillary nodes: CALGB 40101 (Alliance)

PURPOSE

Optimal adjuvant chemotherapy for early-stage breast cancer balances efficacy and toxicity. We sought to determine whether single-agent paclitaxel (T) was inferior to doxorubicin and cyclophosphamide (AC), when each was administered for four or six cycles of therapy, and whether it offered less toxicity.

PATIENTS AND METHODS

Patients with operable breast cancer with 0 to 3 positive nodes were enrolled onto the study to address the noninferiority of single-agent T to AC, defined as the one-sided 95% upper-bound CI (UCB) of hazard ratio (HR) of T versus AC less than 1.30 for the primary end point of relapse-free survival (RFS). As a 2 × 2 factorial design, duration of therapy was also addressed and was previously reported.

RESULTS

With 3,871 patients enrolled onto the trial, a median follow-up period of 6.1 years, and 437 RFS events, we achieved an HR of 1.26 (one sided 95% UCB, 1.48; favoring AC does not allow a conclusion of noninferiority of T with AC; UCB > 1.3). With 266 patient deaths, the HR for overall survival (OS) was 1.27 favoring AC (UCB, 1.56). The estimated absolute advantage of AC at 5 years is 3% for RFS (91 v 88%) and 1% for OS (95 v 94%). All nine treatment-related deaths were patients receiving AC and are included in the analyses of both RFS and OS. Hematologic toxicity was more common in patients treated with AC, and neuropathy was more common in patients treated with T.

CONCLUSION

This trial did not show noninferiority of T to AC, a conclusion that is unlikely to change with additional events and follow-up. T was less toxic than AC.

Breast cancer and aging: results of the U13 conference breast cancer panel

Breast cancer is predominantly a disease of older women, yet there is a knowledge gap due to the persisting misalignment between the age distribution of women with breast cancer and the age distribution of participants in clinical trials. The purpose of this report is to state the U13 conference breast cancer panel's recommendations regarding therapeutic clinical trials that will fill gaps in knowledge regarding the care of older patients with breast cancer. The U13 conference was a collaboration between the Cancer and Aging Research Group and the National Institute on Aging and the National Cancer Institute (NCI). Clinical trials should be developed for frail and vulnerable patients who would not enroll on the standard phase III trials, as well as efforts need to be made to increase enrollment of fit older patients on standard phase III trials. As a result of this conference, panel members are working with the NCI and cooperative groups to address these knowledge gaps. With the aging population and increasing incidence of breast cancer with age, it is essential to study the feasibility, toxicity, and efficacy of cancer therapy in this at-risk population.

Breast cancer screening, area deprivation, and later-stage breast cancer in Appalachia: does geography matter?

OBJECTIVE

To model the relationship of an area-based measure of a breast cancer screening and geographic area deprivation on the incidence of later stage breast cancer (LSBC) across a diverse region of Appalachia.

DATA SOURCE

Central cancer registry data (2006-2008) from three Appalachian states were linked to Medicare claims and census data.

STUDY DESIGN

Exploratory spatial analysis preceded the statistical model based on negative binomial regression to model predictors and effect modification by geographic subregions.

PRINCIPAL FINDINGS

Exploratory spatial analysis revealed geographically varying effects of area deprivation and screening on LSBC. In the negative binomial regression model, predictors of LSBC included receipt of screening, area deprivation, supply of mammography centers, and female population aged>75 years. The most deprived counties had a 3.31 times greater rate of LSBC compared to the least deprived. Effect of screening on LSBC was significantly stronger in northern Appalachia than elsewhere in the study region, found mostly for high-population counties.

CONCLUSIONS

Breast cancer screening and area deprivation are strongly associated with disparity in LBSC in Appalachia. The presence of geographically varying predictors of later stage tumors in Appalachia suggests the importance of place-based health care access and risk.

Comorbidity burden and guideline-concordant care for breast cancer

OBJECTIVES

To explore the relationship between level and type of comorbidity and guideline-concordant care for early-stage breast cancer.

DESIGN

Cross-sectional.

SETTING

National Program of Cancer Registry (NPCR) Breast and Prostate Cancer Patterns of Care study, which re-abstracted medical records from 2004 in seven cancer registries.

PARTICIPANTS

Individuals with stage 0-III breast cancer.

MEASUREMENTS

Multicomponent guideline-concordant management was modeled based on tumor size, node status, and hormone receptor status, according to consensus guidelines. Comorbid conditions and severity were measured using the Adult Comorbidity Evaluation Index (ACE-27). Multivariate logistic regression models determined factors associated with guideline-concordant care and included overall ACE-27 scores and 26 separate ACE comorbidity categories, age, race, stage, and source of payment.

RESULTS

The study sample included 6,439 women (mean age 58.7, range 20-99; 76% white; 44% with no comorbidity; 70% estrogen- or progesterone-receptor positive, or both; 31% human epidermal growth factor receptor 2 positive). Care was guideline concordant in 60%. Guideline concordance varied according to overall comorbidity burden (70% for none; 61% for minor; 58% for moderate, 43% for severe; P < .05). In multivariate analysis, the presence of hypertension (odds ratio (OR) = 1.15, 95% confidence interval (CI) = 1.01-1.30) predicted guideline concordance, whereas dementia (OR = 0.45, 95% CI = 0.24-0.82) predicted lack of guideline concordance. Older age (≥ 50) and black race were associated with less guideline concordance, regardless of comorbidity level.

CONCLUSION

When reporting survival outcomes in individuals with breast cancer with comorbidity, adherence to care guidelines should be among the covariates.

Abstract P2-16-13: Phase I dose escalation clinical trial of the PI3K inhibitor BKM120 and capecitabine (C) in metastatic breast cancer (MBC)

Background: PIK3CA is one of the most frequently mutated genes in human breast cancer, and the high expression of a PIK3CA-pathway signature is associated with the poor prognosis Luminal B and Basal-like expression subtypes. BKM120 is an oral pan-class I phosphatidylinositol-3-kinase (PI3K) inhibitor, which has shown activity in preclinical and early clinical testing, and synergy with both endocrine and chemotherapy. In this trial we sought to evaluate the safety and estimate the maximum tolerated dose (MTD) of the combination of BKM120 and C in patients (pts) with MBC.

Methods: In a 3+3 dose escalation design, we evaluated four cohorts of BKM 120 daily plus C BID x 14 days in 21 day cycles. Standard definitions for DLT and MTD were used and evaluated on the first cycle. Toxicity was graded by CTCAE version 4. Response was evaluated after 2 cycles by RECIST criteria. Pts with MBC appropriate for treatment with C who had &lt;4 prior chemotherapy regimens and normal organ, bone marrow and cardiac parameters were eligible.

Results: 21 pts (11 hormone receptor (HR)+, 3 HER2+, 9 HR/HER2-negative) were enrolled and treated. All were evaluable for toxicity and 14 for response to date. Median age was 54 (range 35-65). Median prior chemotherapy regimens for MBC was 2 (range 1-4). The following dose levels (DL) were evaluated: BKM120 50 mg/d + C 1000 mg/m2/BID x 14(DL 1-4 pts), BKM120 80 mg/d + C 1000 mg/m2/BID x 14 (DL2-3 pts), BKM120 100 mg/d + C 1000 mg/m2/BID x 14 (DL3-9 pts), BKM120 100 mg/d + C 1250 mg/m2/BID x 14 (DL4-5 pts). Most frequent adverse events (all grades) included: Nausea (12), mood disorders (11), PPE (9), diarrhea (8), fatigue (7), vomiting (5) mucositis (4), rash (4), photosensitivity (3), hyperglycemia (3). Grade 3 or higher AEs in any cycle were transaminitis (3) diarrhea (2) mood disorder (2), hyperglycemia, fatigue, photosensitivity, PPE (1 pt each). DLTs: grade 3 hyperglycemia (1/6 pts at DL3), and grade 3 mood disorder in 1/5 pts DL 4. Additionally 4 of 5 patients at DL 4 required dose reduction or delay prior to C3D1. Thus DL 4 exceeded the MTD and DL 3 was expanded for further safety evaluation. Antitumor activity was seen with best responses of 1 CR (at DL 3), 3 PR (DL1 and 4) and 7 SD.

PK analysis, assessment of tumor PIK3CA mutation status and intrinsic subtype by PAM50 is ongoing.

Conclusions: The combination of BKM120 100 mg po q day and C 1000 mg/m2 / BID x 14 d in 21 day cycles is tolerable and appears active. PK and biomarker analysis are ongoing. A phase II trial is planned.

Acknowledgements: This study was funded by Novartis Pharmaceuticals and by a grant from Susan G. Komen for the Cure (SAC 110044).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-13.

Abstract P1-09-10: Disparities in presentation of breast cancer in a geriatric population

Background: Although there are known to be disparities by socioeconomic status (SES) in breast cancer presentation, this has not been as well studied in the elderly. We examined older women in North Carolina (NC) using insurance status as an indicator of SES. Dual Medicaid/Medicare (dMM) status was used as a surrogate for low SES and Medicare only (M) as a surrogate for higher SES.

Methods: From the 1999-2002 NC Central Cancer Registry, we identified women age ≥65 years presenting with nonmetastatic breast cancer, having surgery within 60 days of diagnosis, no neoadjuvant therapy, and insured by Medicare only or dual Medicaid/Medicare. We used Chi-square tests to compare demographic and tumor characteristics, including: age, race, ACE comorbidity index, tumor size, lymph node status (LN), ER/PR status and HER2 status.

Results: We identified n = 3088 women with mean age 75 (SD 6.69) years, including 560 dMM and 2528 M insured women. We found that the dMM patients were older than M patients, with 57.7% ≥75 years, vs. 42.6% (p&lt;0.001) and mean age 76.9 vs. 74.5 years (p&lt;0.001), as well as composed of more African Americans, 34.6% vs. 6.6% (p&lt;0.001). The dMM group also had significantly more comorbidity, with ACE comorbidity index: none 21.4% vs. 40.0%, minimal 45.2% vs. 43.2%, moderate 15.5% vs. 9.8% and severe 17.9% vs. 6.9% (p&lt;0.001). The dMM patients were diagnosed more often with regional as compared to local disease, 26.3% vs. 19.7% (p&lt;0.001) and had larger tumors at diagnosis, mean 23.46mm vs. 18.50mm (p&lt;0.001). Additionally, the dMM patients were found to have more LN involvement: 0 LN in 73.4% vs. 80.0%, 1-3 LN in 19.6% vs. 15.5%, 4-9 LN in 5.7% vs. 3.5% and ≥ 10 LN in 1.3% vs. 1.1% (p = 0.004). We did not find significant differences in tumor histology, grade, ER/PR subtype or HER2 status.

Conclusions: We found that in a population of elderly breast cancer patients, lower SES as defined by Medicaid insurance status was associated with older age, African American race and more advanced comorbidity. These same patients presented with move advanced disease, characterized by larger tumors and more LN involvement.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-10.

Abstract S4-03: Exome sequencing reveals clinically actionable mutations in the pathogenesis and metastasis of triple negative breast cancer

Triple negative breast cancer (TNBC) represents a particularly aggressive and difficult to treat form of breast cancer. No specific genetic alterations have been described as characteristic of the disease, with the exception of association with BRCA1/2, EGFR, and KRAS mutations. In this study, we sought to define clinically actionable mutations in untreated metastatic tumors as well as compare the mutational status of metastatic samples with germ-line and primary tumors using whole exome sequencing.

We prospectively enrolled 38 patients with newly diagnosed metastatic TNBC and collected matched specimens of germ-line DNA, primary tumor and metastatic tumor. Median DFI from time of initial primary diagnosis to recurrence was 18 months (IQR = 1-24 months) and 9 patients presented with de novo metastatic disease. 34/38 patients went on to receive first-line treatment with nab-paclitaxel, carboplatin, and bevacizumab and ORR/PFS/OS are available.

Sites of TNBC metastatic tissue (n = 31) included: liver (10), chest wall (13), non-regional lymph nodes (4), and lung (4). 7 patients had inadequate metastatic tumor for sequencing. We performed whole-exome sequencing for all samples using the Agilent solution-based system of exon capture, which uses RNA baits to target all protein coding genes (CCDS database), as well as ∼700 human miRNAs from miRBase (v13). In all, we generated over 10 GB of sequencing data using high throughput sequencing on the Illumina platform.

We observed striking genetic heterogeneity among the metastatic and primary tumors. There was no single driver mutation that was common to the metastatic tumors indicating the diverse genetic pathways that contribute to metastasis. Early analysis suggests that mutations in APC and MTOR occur more frequently in metastatic tumors than in primary tumors. Nonsense mutations of ER were detected in both primary and metastatic tumors but not in germ-line DNA. EGFR and HER2 mutations were not found in any of the primary or metastatic TNBC samples.

This data provides the most comprehensive genetic portrait of metastatic and primary TNBC to date, and represents a significant first step in identifying the genetic causes of the disease, drivers of recurrence, and potential therapeutic targets. Full results, including the primary versus metastatic tumor mutational analysis will be presented.

This study was funded by a Susan G. Komen Grant SAC 100001.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S4-03.