Real-Life Implementation of Treatment Guidelines for Adjuvant Chemotherapy in Invasive Breast Cancer: Retrospective Analysis of a Large Single Centre 10-Year Database

Background and objective: Decision to administer adjuvant chemotherapy to N-/M- invasive breast cancer (IBC) patients remains a clinical challenge. Several patient-related factors, such as age, tumor size and grade, or hormone receptor (HR) and HER2 status are incorporated in treatment guidelines. Recommendations have become more complex with time and availability of additional tests. Using the breast cancer database developed at Institut Paoli Calmettes (IPC) from 1999 onwards, our objective was to analyze the importance of key patient-related factors in chemotherapy decision and their evolution over time.Methods: Using our database containing 5854 N-/M- IBC patients, descriptive statistics and classification tree analysis (CART) examined the following factors: age (cut-off 40y), tumor size (cut-off 20 mm), SBR histologic grade, HR positivity, perivascular infiltration (PVI). At IPC, HER2 became clinical routine from 2000 onwards, and cut-off for tumor size was reduced to 15 mm after 2005.Consequently, a second cohort comprised of patients diagnosed between 2000 and 2005 with homogeneous diagnosis and management practices was analysed.Results: SBR-1 and SBR-2 represented 32% and 46% of all cases (n=5854) resp., and SBR-3 22%. Distribution of patients for the other factors of interest was: tumor size > 20 mm for 27%, HR+ for 80%, age >= 40 yr for 91%, PVI+ for 24%. Adjuvant chemotherapy was administered to 1597 patients (27,3%). The optimal tree model based on pruning and 10-fold cross-validation correctly predicted 83.5% of decision, with 93% sensibility and 61% specificity. SBR was the most important t decision factor, allowing to improve the prediction rate from 72.7% to 76.4%. The next factors were date of diagnosis, then size for SBR 1-2, and age for SBR3. Adjuvant chemotherapy was more frequent after 2000 than before: 34.2% vs 8.9% resp. for SBR1-2, and 83.2% vs 39.3% resp.for SBR3. In the 2000-2005 cohort (n=1658, SBR1=37%, SBR2=40%, SBR3=23%), chemotherapy was chosen for 754 patients (45.5%). The optimal tree model based on pruning and 10-fold cross-validation correctly predicted 79.3% of cases with 82.8% sensibility and 76.4% specificity. SBR was again the primary decision factor, improving the prediction rate from 55.5% to 75.0%. For SBR1-2 chemotherapy was used in 35% of patients, and tumor size, PVI and age were the next decision factors. For the SBR-3, grade was the only relevant decision factor in the algorithm, leading to chemotherapy in 82% of patients.Conclusion: Hierarchy of factors driving chemotherapy decision is remarkably stable over time. Tumor grade, a major indicator of proliferation, remains the most contributive factor for adjuvant chemotherapy in N-/M- IBC, despite the progressive availability of new pathologic indicators over time. Considering the variability of tumor grading by histology across centers, and the limited informative power of intermediate SBR-2 grade, improvement in tumor grading may provide a simple approach to refine currently validated treatment algorithms and allow for a more individualized treatment strategy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2089.

Electronic tracking system and wandering in Alzheimer's disease: a case study

INTRODUCTION

Wandering is a behavioural disorder, which occurs in Alzheimer's disease or other dementia. People who wander are at risk of physical harm and untimely death. Moreover, wandering behaviour causes a lot of stress to the caregivers. In the last few years, different geolocation devices have been developed in order to minimise risk and manage unsafe wandering. These detection systems rarely meet patients and caregivers' needs because they are not involved in the devices building process.

AIM

The aim is to explore the needs and perceptions of wandering persons and their caregivers towards existing tracking devices as well as their acceptability and usability. This paper reports a dyad case.

MATERIALS

The tracking system tested is presented as a mobile Global Positioning System (GPS) receiver-shaped, including function of telephony and data transfer via GSM/GPRS.

METHOD

Dyad patient/caregiver expressed their needs and perceptions towards tracking devices and gave their impressions about the functioning of the tested device at the end of the test.

RESULTS

The patient focused on the device's shape which he found too voluminous and unaesthetic, and was unable to give an opinion about the device's functioning. The spouse highlighted malfunctions and usage difficulties, which made the device not appropriate to her needs.

CONCLUSION

Involving end-users in the co-design of new technologies is necessary for building tailored devices. Moreover, in this area of dementia care, the person-centred approach is essential to a tailored wandering management.

Allogeneic stem cell immunotherapy for advanced metastatic breast cancer

e12012

Background: Despite continuous progress, advanced breast cancer (ABC) remains an incurable disease. Immunotherapy using allogeneic stem cell transplantation (ASCT) has been proven successful in malignant hematological diseases. We have investigated ASCT as a possible way of improving tumor control in ABC. Methods: Between 1998 and 2008, 21 ABC pts underwent ASCT after the same reduced intensity conditioning (RIC) based on fludarabine, busulfan and ATG or low dose irradiation from a HLA-identical sibling. Results: Pre-treatment characteristics of pts receiving ASCT were the following: ER or PR +, 79%; HER-2+, 27%; liver metastasis, 48%; adjuvant chemotherapy, 90%; median number of metastatic sites, 2 (1–4); 95% have received anthracyclines and/or taxanes; 71% have received endocrine therapy; 48% received more than 2 lines of cytotoxics; median age at transplant was 39 years (range 22–57). At time of transplant, 48% pts had progressive disease (PD), and 52% pts had a stable disease (SD). All pts engrafted and none died from transplant related mortality. While outcome was uniformly poor for pts with PD (no response and no surviving pt at 2 years), pts with SD achieved a 36% response rate (p = 0.09) and a 55% (CI95%, 28–79%) overall survival (OS) probability at 2 years (p = 0.001). To better assess the impact of ASCT, we looked for control group. During the same period, a total of 93 pts were searched for a HLA match sibling: 41 pts had an identified donor while 52 had no donor (group A). Of those 41 pts with a donor, 21 proceeded to transplant (group C) and 20 did not (group B). Reasons for not proceeding to transplant when a donor was found were: disease progression: 12 pts; patient decision: 6 pts; referring MD decision: 2pts. Progression-free survivals (PFS) were assessed from the first day of the last therapy immediately preceding HLA typing. Median PFS were 7.4 (CI95%, 6.2–12.4), 5.7 (CI95%, 4.6–12.8), and 18.2 (CI95%, 12.9–30.7) months for groups A, B, and C, respectively and were strikingly different between the 3 groups (p = 0.014). OS were not different. Conclusions: ASCT can be safely performed in ABC and may provide an outcome advantage to selected pts deserving further investigations.

No significant financial relationships to disclose.

Sentinel lymphadenectomy for the staging of clinical axillary node-negative breast cancer before neoadjuvant chemotherapy

e11575

Background: Several authors reported sentinel lymph node biopsy after neoadjuvant chemotherapy. Nevertheless, the ideal time of sentinel lymph node biopsy is still a matter of debate. Methods: We evaluated the feasibility and the accuracy of sentinel lymph node biopsy before neoadjuvant chemotherapy using a combined procedure (blue dye and radio-labelled detection) in a homogeneous cohort study with clinically axillary node-negative breast cancer. Study candidates were patients referred to the Institut Paoli-Calmettes Cancer Center (Marseille, France) for the treatment of invasive breast cancer. Patients were included in the study if they had tumor more than 3 cm in diameter without palpable axillary lymph node for which a neoadjuvant chemotherapy was indicated in order to enhance the likelihood of breast conservation. An axillary lymph node dissection was performed after completion of neoadjuvant chemotherapy. Results: From September 2005 to September 2007, thirty-one women with T2 or T3 invasive breast cancer without palpable axillary lymph node underwent sentinel lymph node biopsy before neoadjuvant chemotherapy and an axillary lymph node dissection after neoadjuvant chemotherapy. Among the 20 women who had metastatic sentinel lymph node biopsy (65%), 4 (20%) had additional metastatic node on axillary lymph node dissection. By contrast, all the 11 women who had no metastatic sentinel lymph node biopsy had no involved nodes in the axillary lymph node dissection. The sentinel lymph node biopsy identification rate before neoadjuvant chemotherapy was 100% with any false negative. Conclusions: Sentinel lymph node biopsy before neoadjuvant chemotherapy is a feasible and an accurate diagnostic tool to predict the pre-therapeutic axilla status. These findings suggest that axillary lymph node dissection may be avoided in patients with a negative sentinel lymph node biopsy performed before neoadjuvant chemotherapy.

No significant financial relationships to disclose.

Sentinel lymphadenectomy for the staging of clinical axillary node-negative breast cancer before neoadjuvant chemotherapy

e11604

Background: Several authors reported sentinel lymph node biopsy after neoadjuvant chemotherapy. Nevertheless, the ideal time of sentinel lymph node biopsy is still a matter of debate. Methods: We evaluated the feasibility and the accuracy of sentinel lymph node biopsy before neoadjuvant chemotherapy using a combined procedure (blue dye and radio-labelled detection) in a homogeneous cohort study with clinically axillary node-negative breast cancer. Study candidates were patients referred to the Institut Paoli-Calmettes Cancer Center (Marseille, France) for the treatment of invasive breast cancer. Patients were included in the study if they had tumor more than 3 cm in diameter without palpable axillary lymph node for which a neoadjuvant chemotherapy was indicated in order to enhance the likelihood of breast conservation. An axillary lymph node dissection was performed after completion of neoadjuvant chemotherapy. Results: From September 2005 to September 2007, thirty-one women with T2 or T3 invasive breast cancer without palpable axillary lymph node underwent sentinel lymph node biopsy before neoadjuvant chemotherapy and an axillary lymph node dissection after neoadjuvant chemotherapy. Among the 20 women who had metastatic sentinel lymph node biopsy (65%), 4 (20%) had additional metastatic node on axillary lymph node dissection. By contrast, all the 11 women who had no metastatic sentinel lymph node biopsy had no involved nodes in the axillary lymph node dissection. The sentinel lymph node biopsy identification rate before neoadjuvant chemotherapy was 100% with any false negative. Conclusions: Sentinel lymph node biopsy before neoadjuvant chemotherapy is a feasible and an accurate diagnostic tool to predict the pre-therapeutic axilla status. These findings suggest that axillary lymph node dissection may be avoided in patients with a negative sentinel lymph node biopsy performed before neoadjuvant chemotherapy.

No significant financial relationships to disclose.

GATA3, P53, Ki67 and vascular peritumoral invasion are strongly predictive of hormonal resistance in luminal breast cancer

Abstract #5068

Background: Breast cancers are traditionally divided into hormone receptor positive and negative cases that guide patient management. The two luminal subtypes in gene expression profiling , A and B, are defined by high expression of ER, GATA3, and FOXA1. There is a little doubt that ER status is a strong predictor of response to endocrine therapy. Prognostic immunohistochemical biomarkers for ER-positive breast cancer include progesterone (PR) and androgen (AR) receptors, proteins related to proliferation or apoptotic resistance. The aim of this study was to identify the best predictors of success of hormonal therapy among immunohistochemical and classical factors.
 Methods: We studied 10 markers in a consecutive series of 832 cases of breast carcinoma treated at the Paoli-Calmettes Institute from 1990 to 2002 and deposited onto tissue-micro arrays (TMA): luminal-related ER, PR, AR, FOXA1, and GATA3 factors, proliferation-related KI67 and CCND1, ERBB2, anti-apoptotic BCL2, and p53. We also measured the vascular peritumoral invasion (VPI) size, Grade and lymph nodes involvement (N). On these series 145 cases had been profiled on Affymetrix microarrays. The patients had been treated with adjuvant chemotherapy and/or hormonal therapy . The 132 events observed and taken into account were metastases (MF).
 Results: Of the 67 luminal A cases of this series 63 were ER-positive, 98% were FOXA1-positive; only half of them expressed the five luminal-related markers. In 584 ER-positive patients, 200 did not receive adjuvant hormonal therapy with a highly significant difference in MF with those who received Tamoxifen (p=0.017). For the 240 cases who received hormonal therapy, the factors associated to the MF in multivariate analysis were:
 
 A prognostic score can be established summing the impact of each four parameters with a significant Logrank test : p= 0.0003.
 
 Discussion: A panel of three antibodies (Ki67, P53 and GATA3), associated with VPI can significantly improve the traditional prognosticators in predicting outcome for ER-positive breast cancer patients receiving hormonal therapy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5068.