Abstract P6-01-27: Utilization of the Oncotype Dx Assay for Young Patients with Early Stage, Hormone-Receptor Positive, HER2-Negative Breast Cancer in an Integrated Health System

Background: Oncotype Dx (ODX) is one of the most widely used prognostic multigene expression assays for early-stage, hormone receptor-positive (HR+), HER2-negative (HER2-) breast cancer. Previous studies demonstrated reduction in chemotherapy in patients with a low ODX Recurrence Score (RS). Over recent years, utilization of this tool has increased in young breast cancer (YBC) patients (age≤40 years), a population often underrepresented in randomized clinical trials. The purpose of this retrospective study was to assess the utilization of this assay over time in an integrated health system and whether ODX RS results altered clinical practice. Methods: YBC patients with T1-T2N0 HR+HER2- breast cancer were retrospectively evaluated. Descriptive analysis examined the association between tumor characteristics, year of diagnosis, ODX testing, treatment, and recurrence outcomes. ODX risk categories were defined as: low risk 0-15; intermediate risk 16-25; high risk > 25. Recurrence was determined by the date of confirmation on pathology or imaging. Bivariate analysis compared characteristics between groups using Fisher exact tests for categorical variables and t-tests and nonparametric tests for continuous variables. Results: From 2008-2018, 1,436 Stage I-III YBC patients were diagnosed with invasive breast cancer, and 455 met eligibility criteria for ODX testing. Median follow-time (interquartile range, IQR) was 4.9 (2.8, 7.9) years for the 255 women who were tested and 5.7 (3.5, 8.7) years for the 200 women who were not tested (p< 0.05). Prior to 2018, 52.1% of patients were tested; after 2017, ODX testing rate increased to 88%. Overall, there were 255 patients who underwent ODX testing (55.9%). The median age (IQR) of patients who had an ODX test was 38.0 (35.0, 39.0). Of 225 tested patients, 42.0% (n=107) were White, 6.3% (n=16) Black, 33.7% (n=86) Asian/Pacific Islander, 15.7% (n=40) Hispanic, and 2.3% (n=6) identified as Other. There was no overall difference in testing based on ethnicity (p=0.42). More patients with grade 1 versus grade 3 disease were tested, 61.5% vs 45.2% (p=0.02 from overall Fisher exact test). Adjuvant chemotherapy was administered to 61.0% (122/200) patients who were not tested, whereas 38.4% (98/255) of those tested received chemotherapy (p< 0.001). In tested patients, 6% of low-risk (RS 0-15), 37% of intermediate risk (RS 16-25), and 92% of high risk (RS >25) patient received adjuvant chemotherapy. Among patients with T2 lesions, a higher proportion not tested (90.8% [59/65]) received adjuvant chemotherapy compared with those not tested (57.1% [40/70]). There were no differences in recurrence based on ODX testing, 11.0% (22/200) not tested vs. 9.4% (24/255) tested (p=0.26). Conclusions: Utilization of ODX testing increased after 2017. A significantly lower proportion of women who underwent ODX testing received chemotherapy, compared with women not tested for ODX. A higher percent of women with T2 cancer received chemotherapy if testing was not completed, which may reflect a greater fear of recurrence in younger patients. Further investigation is needed to better understand this potential risk of overtreatment in the YBC population.

Citation Format: Ashley Aller, Jeanne A. Darbinian, Raymond Liu, Gillian Kuehner, Alison Savitz, Patience Odele, Laurel Habel, Brooke Vuong. Utilization of the Oncotype Dx Assay for Young Patients with Early Stage, Hormone-Receptor Positive, HER2-Negative Breast Cancer in an Integrated Health System [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 P6-01-27.

Abstract 1446: Genetic risk factors for the development of multiple primary cancers

Introduction: Individuals with one cancer are at greater risk of new primary cancers than the general population. While several hereditary cancer syndromes are known, genetic risk factors for multiple primary cancers in an individual are not well understood. Identification of susceptibility variants to multiple primary tumors could enhance screening for subsequent cancers among those at highest risk.

Methods: We conducted a pan-cancer genome-wide association study (GWAS) of multiple primary cancers among participants from 2 prospective cohorts: Kaiser Permanente and the UK Biobank. The primary GWAS within cohorts used logistic regression to estimate associations for diagnosis with ≥2 invasive or in situ primary cancers other than non-melanoma skin (N=11,773, 8,928 invasive only) compared to cancer-free controls (N=420,101). Case-case analyses were conducted to distinguish associations with multiple cancers from single-cancer (N=90,576) susceptibility signals. Regression models were adjusted for age, sex, first 10 genetic ancestry principal components, and array. Cohort-specific GWAS results were meta-analyzed. We highlight genome-wide significant (p<5×10-8) results with consistent effect direction across the 2 studies.

Results: We identified 8 variants associated with multiple primary cancers.

Discussion: To our knowledge, rs192703567 has no previous cancer associations. Three identified variants are in known cancer predisposition genes (rs2293607 in TERC, rs6983267 in CASC8, rs35850753 in TP53). Three variants (rs34379047, rs612611, and rs9419958) are previously associated with multiple cancers, 2 (rs2293607 and rs6983267) with cancer pleiotropy, and 2 (rs283732 and rs35850753) with individual cancers. Most variants from the cancer-free control analyses had consistent effects in the single-cancer case-case analyses, suggesting pleiotropic mechanisms. Our preliminary findings offer insight into genetic risk factors associated with developing multiple primary cancers.

Multiple vs. none Multiple invasive vs. none Multiple vs. single Multiple invasive vs. single Chr Position rsID A1 A2 Gene OR P OR P OR P OR P 3 169482335 rs2293607 T C TERC 1.11 1.0×10-9 1.10 2.2×10-7 1.06 2.0×10-3 1.05 0.01 8 128281644 rs283732 C T Intergenic 1.09 2.3×10-7 1.11 9.2×10-9 1.06 3.8×10-4 1.09 3.9×10-5 8 128413305 rs6983267 G T CASC8 POU5F1B CCAT2 PCAT1 1.08 4.1×10-7 1.09 2.9×10-8 1.00 0.83 1.02 0.34 10 105644473 rs34379047 T A OBFC1 1.16 8.5×10-12 1.19 6.0×10-11 1.19 2.3×10-4 1.10 4.0×10-4 10 105675946 rs9419958 T C STN1 1.14 1.8×10-11 1.16 4.5×10-11 1.08 3.1×10-4 1.09 2.8×10-4 11 69307463 rs612611 G A Intergenic 1.11 3.7×10-8 1.10 5.3×10-6 1.06 9.6×10-4 1.05 0.02 17 7578671 rs35850753 T C TP53 1.27 4.9×10-7 1.34 1.6×10-8 1.16 2.8×10-3 1.24 8.8×10-5 22 40738280 rs192703567 C T Intergenic 1.37 5.2×10-8 1.37 1.8×10-6 1.43 4.9×10-9 1.43 2.8×10-7 Chr=Chromosome; A1=Effect allele; A2=Other allele; OR=Odds ratio.

Citation Format: Jovia L. Nierenberg, Linda Kachuri, Taylor B. Cavazos, Rebecca E. Graff, Thomas J. Hoffmann, Jie Zhang, Stacey Alexeeff, Laurel Habel, Douglas Corley, Stephen Van Den Eeden, Elad Ziv, Lori C. Sakoda, John S. Witte. Genetic risk factors for the development of multiple primary cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1446.

Abstract P5-02-02: Second harmonic generation in combination with nuclear morphometry in the evaluation of DCIS

Purpose/Objective: Collagen is a major extracellular matrix (ECM) constituent in normal breast and is extensively remodeled in breast carcinoma. Therefore, features of remodeled collagen in the stroma adjacent to ductal carcinoma in situ (DCIS) could indicate cancer progression. The major objective of this study is to identify potential tumor-associated collagen signatures unique to DCIS that will allow us to predict progression based on the collagen texture and nuclear morphology. In this present study, we develop two image analysis pipelines (SHG Texture Extraction and H&E Nuclear Morphology Extractor) to quantify 1) stromal changes, 2) collagen signatures and 3) nuclear morphology from normal breast to DCIS in order to predict local breast cancer recurrence.

Method: We used second harmonic generation (SHG) images and H&E to analyze collagen features and to study nuclear morphology using a data set of 336 patients (from which 310 normal and 327 DCIS regions were imaged). The 336 patients were a subset of patients with pure DCIS taken from a case-control study. Clinical-pathologic factors were associated with risk of subsequent ipsilateral cancer (DCIS or invasive). The SHG framework consisted of collagen segmentation using 1) adaptive thresholding and 2) morphological operations. The H&E framework consisted of nuclear segmentation using adaptive thresholding and a maker-controlled watershed algorithm; and nuclear feature extractions including intensity, texture and morphology. Overall, the SHG framework segments collagen regions and computes textural features specifically at collagen regions. Furthermore, the H&E framework segments nuclei and computes nuclei morphology and textural features. These features were used in L1-regularized logistic regression to construct classification models to discriminate normal vs DCIS regions; and to distinguish regions from DCIS patients with vs. without local recurrences.

Results: In first experiment, we performed L1-regularized logistic regression to construct a classification model to discriminate normal vs DCIS regions. Our results suggest that using only SHG collagen features, this logistic model selected 19 significant features to build a classification model that achieved area under curve (AUC) 90% and accuracy 83% using 5-Fold cross validation. When H&E nuclei features are used, the logistic model selected 88 significant features and achieved AUC 91% and accuracy 86%. By combined both SHG and H&E features, the model achieved classification AUC 93% and accuracy 88%. By using L1-regularized logistic model with combined significant SHG and H&E features, we achieved AUC 59% with an accuracy of 61% for DCIS and recurrent DCIS regions.

Conclusions: Our study suggests that SHG and nuclear morphology features extracted from H&E can improve the classification of normal and DCIS regions. Overall, these results suggest that second harmonic generation and H&E nuclear morphology analysis could aid in the assessment of prognosis and risk of progression to invasive breast cancer.

Citation Format: Park CC, Irshad H, Ziaee S, Martin-Tuite P, Habel L, Weaver VM, Schnitt SJ, Beck AH. Second harmonic generation in combination with nuclear morphometry in the evaluation of DCIS [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 P5-02-02.

Abstract P1-15-01: Adjuvant trastuzumab +/- anthracycline and cardiotoxicity in a community cohort of 962 HER2+ breast cancers from 2005-2011: Comparison of incidence by risk factors and by diagnostic codes vs clinical chart review

Background: Prospective clinical trials using clinical criteria and observational studies using diagnostic codes from electronic health records have reported seemingly contradictory cardiotoxicity risk for adjuvant trastuzumab (T). Accurate estimates of individualized patient specific cardiotoxicity risk are essential for treatment decisions in early HER2+ breast cancer (BC).

Methods: 1,109 consecutive non-metastatic HER2+ invasive BC's diagnosed 5/1/2005 to 12/31/2011 at Kaiser Permanente Northern California receiving adjuvant T were reviewed for symptomatic congestive heart failure (SxCHF), baseline and post-T cardiac ejection fraction (EF), anthracycline (A) use, and CHF risk factors (RF) including age, race, hypertension (HTN), diabetes (DM), obesity, smoking. Records of patients with CHF ICD9 codes or an EF drop to <50% were reviewed by a RN, a cardiologist, and an oncologist. Primary outcomes were SxCHF (NYHA Class II or higher), EF fall to <50%, and < 38 weeks of T (75% of prescribed).

Results: Median age of 962 eligible patients was 54 years (range 24-95). 305 (31.7%) were > 60 years old. During a median follow-up of 4.1 years, 4.6% of patients had CHF ICD9 codes, but only 2.5% had SxCHF or cardiac death confirmed by clinical review. At 1 year, cumulative incidence of an EF fall to <50% was 5.7% with T alone and 17.7% with T+ A. A total of 15.3% finished <38 weeks of T, 9.4% with T alone and 20.6% with T+A. The overall 2- and 5-year cumulative incidence of SxCHF/cardiac death was low: 1.3% and 2.7% with T alone and 2.2% and 3.1% with T + A. These rates were lower than reports based solely on diagnostic or billing codes, and varied substantially by RF (see table). The rates were similar to those predicted by the NSABP B-31 Cardiac Risk Score. Clinical heart failure based on diagnostic codes was not confirmed at chart review 48% of the time. Results from multivariable analyses will be presented.

Predictors of Trastuzumab Cardiotoxicity  Cumulative Incidence (%)PredictorsNFall EF to<50%Symptomatic CHF  1-year2-year5-yearAll96212.01.82.8Anthracycline50517.72.23.1Non-anthracycline4575.71.32.7Age<6065711.71.11.1Age 60-6922212.61.43.8Age 70-797112.77.111.0Baseline EF 50-55%9230.78.88.8HTN dx39212.63.44.7BMI 30+31516.32.64.5DM Dx10315.55.06.9Smoking (ever)33314.23.76.1HTN and BMI 30+18215.53.96.0HTN, BMI 30+, DM5016.08.212.2Age<50, BMI<30, No HTN/DM2197.30.00.0Age>60, 2+ RF(HTN, DM, BMI 30+)10114.95.08.9

Conclusions: Risk of clinically confirmed CHF/cardiac death was substantially lower than risk based on ICD codes alone. Risk was consistent with prior clinical trials and differed substantially by age, baseline EF, use of A, and other CHF risk factors. Greatest risk was with age of 70+, borderline baseline EF, and comorbidities known to increase CHF risk. Quite low risk (1.1% at 5 years) was seen in patients under 60 years old.

Citation Format: Fehrenbacher L, Capra A, Krishnaswami A, Quesenberry C, Habel L. Adjuvant trastuzumab +/- anthracycline and cardiotoxicity in a community cohort of 962 HER2+ breast cancers from 2005-2011: Comparison of incidence by risk factors and by diagnostic codes vs clinical chart review. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-15-01.

Abstract A05: Menopausal vasomotor symptoms and mammographic density in the Study of Women's Health Across the Nation

Background: Declines in endogenous estrogen during menopause have been linked to the onset of menopausal vasomotor symptoms (VMS) and to reduced breast cancer risk. Percent mammographic density (PMD) is viewed as a marker for breast cancer susceptibility. Establishing a relationship between VMS and PMD may justify future prospective investigations of VMS and breast cancer risk.

Methods: We investigated this association in the Study of Women's Health Across the Nation (SWAN) Mammgraphic Density Substudy (N=833). Women were pre- or perimenopausal at enrollment and followed through menopause. VMS were assessed at annual SWAN visits. PMD was ascertained from routine screening mammograms. A linear mixed effects model was used to evaluate the longitudinal association between VMS and PMD.

Results: Women contributed a total of 4,748 mammograms (2-10 per woman) over a median 5.4 years. We observed no overall association between VMS and PMD. When stratified by menopausal status, VMS was associated with lower PMD among perimenopausal women (β = -1.29%, 95%CI -2.58, -0.001) and those with unknown menopausal status due to hormone use during the study period (β = -3.62%, 95%CI -7.17, -0.07). VMS was not associated with absolute dense area in any analyses. Among women who transitioned to postmenopausal, VMS was not associated with change in PMD across the menopausal transition.

Conclusion: Although our findings do not suggest a strong association between VMS and PMD, we observed a significant effect among perimenopausal women and those using hormones during menopause.. Further prospective studies are needed to establish a relationship between VMS and breast cancer risk, and to ascertain the extent to which this relationship may be mediated by PMD.

Citation Format: Vicki Hart, Susan Sturgeon, Nicholas Reich, Lynnette Leidy Sievert, Sybil Crawford, Ellen Gold, Laurel Habel, Katherine W. Reeves. Menopausal vasomotor symptoms and mammographic density in the Study of Women's Health Across the Nation. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A05.

Proteinuria testing among patients with diabetes mellitus is associated with bladder cancer diagnosis: potential for unmeasured confounding in studies of pioglitazone and bladder cancer

BACKGROUND

The observed association between pioglitazone and bladder cancer could be causal or because of bias in the design of prior studies. We hypothesize that proteinuria testing may lead to detection bias if routine test results for proteinuria lead to a full urinalysis.

METHODS

We reanalyzed patients with diabetes mellitus within Kaiser Permanente Northern California. Logistic and Cox regression adjusted for age, sex, race, and smoking were used to assess the association of proteinuria testing with pioglitazone use, subsequent full urinalysis, and diagnosis with bladder cancer.

RESULTS

Patients treated with pioglitazone were more likely than others with diabetes to undergo testing for proteinuria (p < 0.001). The odds of positive tests for proteinuria were higher among pioglitazone-treated patients (OR = 1.41, 95%CI 1.36-1.46). A positive proteinuria test was associated with increased odds of completing a urinalysis in the following 6 months (OR = 1.78, 95%CI 1.73-1.85). Negative and positive proteinuria test results were inversely (hazard ratio (HR) 0.63, 95%CI 0.52-0.75) and positively associated (HR 2.45, 95%CI 2.12-2.82) with bladder cancer risk, respectively. Adjustment for negative and positive proteinuria testing reduced the magnitude of association between pioglitazone and bladder cancer by only 5 to 10% (ever-exposed HR: from 1.06 to 1.01 and >4 years exposure HR: from 1.38 to 1.28).

CONCLUSIONS

Proteinuria testing may be a confounder in studies of pioglitazone and bladder cancer but does not fully explain the association between pioglitazone and bladder cancer in this cohort. Optimal adjustment for proteinuria testing likely requires knowledge of the test result.

Abstract P2-11-08: IHC 2+ FISH (-) breast cancer (BC): Patient characteristics and outcomes: A comparison to HER2 IHC 0, 1+ and HER2 + BC diagnosed 2000-2006

Background: HER2 IHC 2+ results are equivocal and lead to FISH testing. FISH(+) results lead to HER2(+) treatment often with trastuzumab. FISH(-) results lead to treatment without trastuzumab. We examined the characteristics and breast cancer-specific mortality of HER2 2+ FISH (-) BC in consecutive patients in a large health care delivery system. Methods: Using the KPNC cancer registry and electronic medical record, we identified 13,845 consecutive stage I-III BC patients diagnosed between 1/2000 and 12/2006 not treated with adjuvant trastuzumab. Patient demographics, disease stage, IHC and FISH results, and breast cancer mortality were obtained. IHC and FISH testing were performed in a single central laboratory. Results: After excluding any adjuvant trastuzumab, 10,760 (78%) patients had HER2 IHC scores of 0,1+, 1,533 (11%) were IHC2+/FISH (-), and 1,552 (11%) were IHC3+ or FISH (+). Compared to patients with IHC 0,1+ tumors, those with IHC2+FISH (-) tumors were younger (mean age 61 vs 62 years, p = 0.03) and more often node+ (36% vs 30%, p = &lt;0.0001); their tumors were more often poorly differentiated (29% vs 22%, p = &lt;0.0001),) and T2 vs T1 (31% vs 24%, p = &lt;0.0001), and less frequently T1ab (20% vs 29%, p = &lt;0.0001), ER+ (81% vs 85%, p = 0.0003), or PR+ (70% vs 74%, p = &lt;0.0002). Among the ER+ patients, the 10-year BC-specific mortality was higher for those with IHC2+/FISH (-) than IHC 0, 1+ tumors (11.4% vs 8.9%, p = 0.0014). Within disease stages, there were trends but no statistical difference in BC-specific mortality. IHC3+/FISH (+) ER+ patients had greater differences in the above characteristics and significant increased mortality among middle, and higher stages. In multivariable analysis adjusting for age, tumor size, differentiation, hormonal therapy and chemotherapy, risk of BC death among ER+ patients was similar for IHC2+FISH (-) and IHC 0,1+ disease; but risk was higher for IHC3+/FISH (+) disease. Table 1: 10-year breast cancer (BC) survival of women with stage I-III ER-positive BC by HER2 subtype, 2000-2006.

10-year BC survival of stage I-III ER+ patients by IHC FISH statusHER2 SubtypeNo of PatientsBC Deathsat Risk%BC Survival95% CILogRank P-valueIHC 0,1+9,1616212,45491.190.4-91.8-IHC2+FISH(-)1,24811222388.686.3-90.60.0014IHC3+ and/or FISH(+)93512523783.680.6-86.2&lt;0.0001

Conclusions: In ER+ patients, those with IHC2+FISH (-) tumors have prognostic characteristics that are intermediate between those with IHC 0,1+ and IHC3+/FISH(+) tumors. Compared to IHC 0,1+ disease, they are at increased risk of BC mortality overall but not within stages.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-11-08.

Abstract 3650: PAM50 breast cancer subtyping and risk of recurrence in a population-based cohort

BACKGROUND The PAM50 gene expression signature for identifying intrinsic subtypes of breast cancer has been shown to add significant clinical information beyond standard molecular biomarkers (ER, PR, Her2). Previous studies with the PAM50 have focused primarily on retrospective clinical trials in which the drug regimens and enrollment criteria are relatively homogenous. We assess the prognostic significance of subtyping within the community setting using therapies appropriate at the time of diagnosis.

METHODS Two prospective studies of breast cancer survivors, Life After Cancer Epidemiology (LACE) and Pathways, were subtyped by the PAM50 using quantitative RT-PCR. LACE participants were diagnosed from 1997-2000 with tumors ≥1 cm; while Pathways enrolled subjects at time of diagnosis (2006-2008) with tumors ≥0.5 cm. Both studies included AJCC stages I-III. LACE participants were enrolled on average 2 years post-diagnosis, such that early recurrences were excluded. In addition, women in Pathways were diagnosed after 2006 when Herceptin treatment was available. Formalin-fixed, paraffin-embedded tumor blocks were centrally reviewed by a pathologist and 1mm directed punches of invasive cancer were taken for RNA extraction and expression profiling. A published algorithm was used for subtyping and provided a continuous gene expression score for proliferation, ESR1/ER, PGR/PR, and ERBB2/Her2 (Bastien et al, BMC Med Genomics. 2012 Oct 4;5:44). Subtype classification was correlated with disease-free survival, estimated using Kaplan-Meier plots and log-rank testing. Multivariable delayed entry Cox regression analyses determined the prognostic significance of subtypes in the context of standard clinical indicators of survival.

RESULTS The PAM50 subtype distribution for the cohort was Luminal A (52%), Luminal B (20%), HER2-E (14%), Basal-like (10%), and Normal-like (4%). Approximately 7% of Luminal tumors (A and B) were called ER negative by immunohistochemistry (IHC). Luminal A tumors were more likely to be PR positive (82%) compared to those classified as Luminal B (61%). Only 2% of Luminal B tumors were low proliferation. The HER2-E subtype contained 66% clinically Her2+ tumors and the Basal-like tumors were 90% triple negative. In univariate analyses, women with non-Luminal A subtypes were all at higher risk of recurrence. Controlling for tumor size and positive nodes, those with Basal-like subtype still had a significantly higher risk of recurrence (HR=2.34, 95% CI 1.37, 3.98).

CONCLUSIONS There are proportionally more Luminal A patients within the population-based studies compared to clinical trials that have focused on higher risk patients. The PAM50 subtype remains a significant prognostic indicator of recurrence in the context of standard therapies used in community practice today.

Citation Format: Philip Bernard, Erin Weltzien, Inge Stijleman, Candyce H. Kroenke, Carole Davis, Marilyn L. Kwan, Charles Quesenberry, Adrienne Castillo, Laurel Habel, Rachel Factor, Larry Kushi, Carol Sweeney, Bette Caan. PAM50 breast cancer subtyping and risk of recurrence in a population-based cohort. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3650. doi:10.1158/1538-7445.AM2013-3650

Abstract 131: Race and breast cancer prognosis by PAM50 subtype in the LACE and Pathways studies

Background: African-Americans have poorer breast cancer (BC) prognosis, and Asians and Hispanics have better prognosis, compared with Whites. The Black-White difference is unexplained and has been attributed to diagnosis with less treatable tumor subtypes in African-Americans. However, little research has examined whether race-survival differences exist by breast cancer subtype. Therefore, we examined associations between race and BC survival by PAM50 breast cancer subtypes (luminal A, luminal B, basal-like, HER2 enriched) in a prospective cohort of 1,282 breast cancer survivors from the Life After Cancer Epidemiology and Pathways cohorts.

Methods: Self-reported race was obtained at study entry from mailed questionnaires. 1 mm punches were obtained from areas of representative tumor in formalin-fixed, paraffin-embedded tumor blocks. Expression of the PAM50 genes for molecular subtype was determined by RT-PCR of extracted RNA. After a median 6.3 years of follow-up (range 0.3-15.5 years), 213 deaths, with 118 from breast cancer, were reported. Delayed entry Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) of BC mortality, controlling for time from diagnosis to enrollment, socioeconomic status, BC severity, BC subtype, treatment, and other known prognostic factors. Logistic regression was used to evaluate associations between race and subtype. Survival analyses stratified by subtype were adjusted for age, time from diagnosis to enrollment, BC severity, and BC treatment.

Results: Consistent with previous research, adjusted for stage and breast cancer treatment, BC mortality was significantly higher in African-Americans (HR=2.90, 95% CI: 1.74-4.86) and lower in Latinas and Asians (HR=0.51, 95% CI: 0.26-0.99), compared with Whites. In addition, compared with Whites, African-Americans had a lower likelihood of the luminal A (OR=0.61, 95% CI: 0.38-0.98) and luminal B (OR=0.43, 95% CI: 0.23-0.82) subtypes and a greater likelihood of the less treatable basal subtype (OR=2.93, 95% CI: 1.94-4.44). Asians were less likely to be diagnosed with the basal subtype (OR=0.41, 95% CI: 0.23-0.71) and somewhat more likely to be diagnosed with the HER2-enriched subtype (OR=1.47, 95% CI: 0.97-2.21). Stratified by subtype, African-Americans had poorer prognosis among those with luminal A (HR=2.64, 95% CI: 0.93-7.49), luminal B (HR=2.20, 95% CI: 0.43-11.26), basal-like (HR=1.66, 95% CI: 0.78-3.54), and HER2 enriched (HR=3.25, 95% CI: 1.04-10.15) subtypes than Whites.

Conclusion: African-Americans had worse breast cancer survival than other racial/ethnic groups and had less treatable types of breast cancer. However, breast cancer mortality was higher in African-Americans across tumor subtypes, suggesting that the Black-White survival difference may not be attributable to differential diagnosis by subtype.

Citation Format: Candyce Kroenke, Marilyn Kwan, Philip Bernard, Adrienne Castillo, Carole Davis, Rachel Factor, Laurel Habel, Larry Kushi, Charles Quesenberry, Kaylynn Shakespear, Inge Stijleman, Carol Sweeney, Erin Weltzien, Bette Caan. Race and breast cancer prognosis by PAM50 subtype in the LACE and Pathways studies. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 131. doi:10.1158/1538-7445.AM2013-131

Abstract P3-07-05: Bisphosphonate use after primary breast cancer and risk of contralateral breast cancer using pharmacy data

Background: It is not clear if bisphosphonates (BP) are associated with improved breast cancer prognosis in women with early breast cancer. Clinical trials have reported mixed results, yet BPs may be most beneficial in patients with low estrogen levels. However, BPs and risk of second (contralateral) breast cancer has been minimally studied. We examined the association of oral BP use (ever/never and duration) on risk of contralateral breast cancer (CBC) in 17,224 women with early stage breast cancer treated with tamoxifen.

Materials and Methods: A cohort was assembled of women diagnosed with their first primary breast cancer (Stage 0, I, II) from 1996 to 2007 on tamoxifen and followed through 31 December 2009 at Kaiser Permanente Northern and Southern California. Demographic, tumor, pharmacy, and cancer treatment information was extracted from electronic medical records and SEER-affiliated cancer registries at each site. Second (contralateral) tumors were identified from the cancer registries. Detailed information on oral BP use (before and after initial breast cancer diagnosis) was obtained from pharmacy databases. A record of &gt;90 days supply was considered the minimum exposure. Initiation and duration of post-diagnosis use was categorized as 1) non-use (≤90 days supply) and use (&gt;90 days supply) and 2) non-use (≤90 days supply), 91 days–&lt;1 year supply, 1-&lt;2 years supply, and ≥2 years supply. Delayed entry Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) with BP use modeled as a time-varying covariate. Women were followed through CBC, health plan disenrollment, death, or end of study, whichever occurred first. We adjusted for age, stage and year of diagnosis; race/ethnicity; income; comorbidity; tumor factors; primary and adjuvant cancer treatments; previous BP use, and study site.

Results: Over a mean (SD) follow-up of 6.4 (6.3) years, 586 women (3.4%) were diagnosed with CBC after their initial breast cancer diagnosis. Around 19.2% (n = 3303) of the cohort used a BP post-initial breast cancer diagnosis (&gt;93% alendronate). To minimize confounding by indication, all models were adjusted for prior use of BPs before breast cancer diagnosis (n = 1047, 6.1%) and excluded women with prior 5-year history of osteopenia, osteoporosis, and fractures (n = 1808, 10.5%). Compared to non-users, ever use (&gt;90 days supply) was associated with a modestly lower CBC risk (HR = 0.80; 95% CI: 0.61, 1.16). However, stratified analyses by age at breast cancer diagnosis (&lt;50 years vs. ≥50 years) suggested lower risk among older women (HR = 0.80; 95% CI: 0.57, 1.12) compared with younger women (HR = 1.00; 95% CI: 0.39, 2.52). Increasing duration of use was not associated with CBC risk compared to non-use and possibly reflective of some residual confounding by indication: &lt;1 year (HR = 0.56; 95% CI: 0.30, 1.02), 1-&lt;2 years (HR = 0.99; 95% CI: 0.56, 1.72), ≥2 years (HR = 0.91; 95% CI: 0.58, 1.42).

Discussion: While we found modestly lower CBC risk with BP use after diagnosis of primary breast cancer, the protective effects were perhaps confined to older women compared with younger women. Next steps include adding BMD to further explore confounding by indication and examining BP use and breast cancer recurrence and mortality.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-07-05.

Smoking and survival after breast cancer diagnosis: a prospective observational study and systematic review

The association of smoking with outcomes following breast cancer prognosis is not well understood. In a cohort study called Life After Cancer Epidemiology (LACE), 2,265 women diagnosed with breast cancer were followed for a median of 12 years. We used multivariable proportional-hazards models to determine whether smoking, assessed approximately two years post-diagnosis, was associated with risk of death among these women. We also undertook a systematic review of all cohort studies to date that have examined the association between smoking and breast cancer mortality. Compared with never smokers, women who were current smokers had a twofold higher rate of dying from breast cancer [hazard ratio (HR) = 2.01, 95 % confidence interval (CI) 1.27-3.18] and an approximately fourfold higher rate of dying from competing (non-breast cancer) causes (HR = 3.84, 95 % CI 2.50-5.89). Among seven studies that met the inclusion criteria in the systematic review, three studies and our own reported significantly increased risk of breast cancer death with current smoking. We found little evidence of an association between former smoking and breast cancer mortality (HR = 1.24, 95 % CI 0.94-1.64). Consistent with findings from our prospective observational study, the systematic review of seven additional studies indicates positive association of current smoking with breast cancer mortality, but weak association with former smoking. Women who smoke following breast cancer diagnosis and treatment are at higher risk of death both from breast cancer and other causes.

Racial and ethnic differences in adjuvant hormonal therapy use

BACKGROUND

In the United States, 5-year breast cancer survival is highest among Asian American women, followed by non-Hispanic white, Hispanic, and African American women. Breast cancer treatment disparities may play a role. We examined racial/ethnic differences in adjuvant hormonal therapy use among women aged 18-64 years, diagnosed with hormone receptor-positive breast cancer, using data collected by the Northern California Breast Cancer Family Registry (NC-BCFR), and explored changes in use over time.

METHODS

Odds ratios (OR) comparing self-reported ever-use by race/ethnicity (African American, Hispanic, non-Hispanic white vs. Asian American) were estimated using multivariable adjusted logistic regression. Analyses were stratified by recruitment phase (phase I, diagnosed January 1995-September 1998, phase II, diagnosed October 1998-April 2003) and genetic susceptibility, as cases with increased genetic susceptibility were oversampled.

RESULTS

Among 1385 women (731 phase I, 654 phase II), no significant racial/ethnic differences in use were observed among phase I or phase II cases. However, among phase I cases with no susceptibility indicators, African American and non-Hispanic white women were less likely than Asian American women to use hormonal therapy (OR 0.20, 95% confidence interval [CI]0.06-0.60; OR 0.40, CI 0.17-0.94, respectively). No racial/ethnic differences in use were observed among women with 1+ susceptibility indicators from either recruitment phase.

CONCLUSIONS

Racial/ethnic differences in adjuvant hormonal therapy use were limited to earlier diagnosis years (phase I) and were attenuated over time. Findings should be confirmed in other populations but indicate that in this population, treatment disparities between African American and Asian American women narrowed over time as adjuvant hormonal treatments became more commonly prescribed.

Abstract 4643: Epstein-Barr virus infection (EBV) and expression of B-cell oncogenic markers in HIV+ diffuse large B-cell lymphoma (DLBCL)

Background: Lymphomagenicity of EBV in the setting of HIV infection has been widely accepted. However, the underlying carcinogenic mechanism of EBV is largely unknown and warrants further study. We sought to investigate the hypothesis that EBV infection is associated with expression of specific B-cell oncogenic markers in HIV+ DLBCL.

Methods: HIV+ DLBCL cases diagnosed between 1996-2007 within the Kaiser Permanente California Health Plan were identified. Archived tumor specimens were retrieved and H&E slides were reviewed to identify representative tumor blocks for tissue microarray (TMA) construction. Immunohistochemistry staining was performed on TMA cores to analyze the expression of selected B-cell oncogenic markers in the following categories: (1) mutagenic molecule (that induce mutation/translocation), (2) cell cycle promoter, (3) B-cell activator and (4) anti-apoptotic protein. Percent of DLBCL cells with visible marker staining was scored on a scale from 0-4 (0-9%, 10-24%, 25-49%, 50-74% and ≥75%). EBV infection was determined by in situ hybridization of EBV encoded RNA and was considered positive if ≥10% of the DLBCL cells had detectable EBV. Correlations between EBV and marker expression were examined using Spearman's correlation coefficient.

Results: We identified 194 HIV+ DLBCL cases. Of these, 117 lacked sufficient tissue; another 7 had undetermined EBV status; and 70 were included in the study. Marker expressions are shown in the table:

Incidence and Demographic and Tumor Characteristics of HER2-Positive Invasive Breast Cancer in a Large, Unselected Population, 2000-2006

BACKGROUND: Most HER2 data have been generated from populations of invasive breast cancer (IBC) patients with selected patient and tumor characteristics (clinical trials, referral centers). The average age of women in US adjuvant trastuzumab trials was 49. Pre 2000, clinical trials of adjuvant chemotherapy included 25-40% HER2+ cases. We used an unselected population of women with IBC to estimate the age-specific incidence rates of HER2+ IBC and compare patient and tumor characteristics of HER2+ and HER2- disease.METHODS: Among female members of Kaiser Permanente Northern California (KPNC) 20 years or older (n=1.22 million), we identified all those diagnosed with a new primary IBC in 2000-2006 (n=16,975). During this period, all IBCs were routinely tested for HER2 by KPNC's regional IHC laboratory (center of excellence for HercepTest, CLIA licensed and CAP certified) and those that were IHC 2+ were sent for FISH testing; IHC 3+ or IHC 2+/FISH+ (ratio ≥ 2.0) were considered HER2+. Demographic and tumor characteristics were derived from the KPNC tumor registry. *Complete HER2 testing available for 94% of IBCs.RESULTS: Incidence of HER2+ IBC increased less dramatically with age and peaked 20 years earlier than incidence of all IBC (Table 1). Among those with IBC, the percent that were HER2+ decreased with age. Of all HER2+ IBCs, 69% were ≥50 years old and 42% were ≥60 years old.Incidence of all IBC and incidence of HER2+ diseaseAge GroupPerson-YrsNo. of IBCsIBC rate/100KHER2+ IBCs*%HER2+HER2+IBC rate/100K20-39288153371024.6416424.75.6940-4917402132680154.0049819.728.6250-5915535284354280.2759914.538.5660-699677624280442.2649412.351.0570-796676013318497.002718.740.5980+3666531633445.381429.638.73ALL817729016975207.59216813.626.51 The percent of tumors that were HER2+ increased with stage (local=11%, regional=18%, distant =25%), tumor differentiation (well =2%, moderate =12%, poor=26%, undifferentiated=30%), and generally with size (&lt;0.5cm=17%, 0.5-0.9cm=7%, 1-1.9 cm=10%, 2-4.9 cm=17%, &gt;5 cm=20%). ER- and PR- tumors were more likely to be HER2+ (of all ER- tumors, 29% were HER2+; of all PR- tumors, 25% were HER2+; of all ER+ tumors, 10% were HER2+; of all PR+ tumors, 9% were HER2+). Among all IBC patients, percent of disease that was HER2+ was highest for Asians (20%) and lowest for Caucasians (12%).CONCLUSION: In a large, unselected, population of invasive breast cancer patients, the incidence of HER2+ disease was highest among women aged 60-69 years. Among breast cancer patients, HER2+ disease was highest in Asians. The percent HER2+ was 13.6% for all breast cancer patients in this population based cohort and highest (24.7%) in the 20-39 year age group.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3058.

HER2 Amplification, Polysomy Status and Breast Cancer Survival in a Large Kaiser Permanente Case-Control Study: Assessment of HER2 by Quantitative Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) and Fluorescence In Situ Hybridization (FISH)

BackgroundPolysomy 17 is found in breast cancer and may complicate interpretation of HER2 results. HER2 status by FISH and quantitative RT-PCR were determined in a case-control study that quantitated HER2 mRNA levels in polysomy 17 patients and that examined breast cancer survival in tamoxifen (TAM) treated and untreated patients.MethodsA Kaiser Permanente nested case-control study was performed in node-negative breast cancer patients diagnosed from 1985-94 who were not treated with chemotherapy. Cases died of breast cancer prior to 2002; up to three controls were matched for each case, with a total of 568 unique patients. HER2 was measured by quantitative RT-PCR by Oncotype DX; pre-defined cutoffs ≥11.5 expression units (positive), ≥10.7 to &lt;11.5 expression units (equivocal), and &lt;10.7 expression units (negative) (each unit represents ∼2-fold change in expression). HER2 and polysomy were assessed by FISH (Vysis, Abbott); ratio &gt; 2.2 (positive), 1.8 to 2.2 (equivocal), &lt;1.8 (negative). Chromosome 17 polysomy was defined as a CEP 17 signal ≥3. Conditional logistic regression explored the association between the HER2/Polysomy subgroups and risk of breast cancer death.ResultsMedian age at dx was 59 yrs, 30.9% were TAM treated and median time to death was 59 months. 12% (67/568) of patients were HER2 positive by RT-PCR and 11% (60/568) were HER2 positive by FISH. By ASCO/CAP guidelines, concordance for HER2 by central FISH and central RT-PCR was 97% (95% CI: 96%, 99%). HER2 positivity by either method was weakly prognostic; HER2 positive patients had increased odds of dying from breast cancer compared to HER2 negative patients (by FISH (OR=1.95, 95% CI=1.19-3.19) and RT-PCR (OR=1.72, 95% CI=1.04-2.84)). Similar results were obtained in TAM-treated and untreated groups separately. Seventy-one (12.5%) patients showed polysomy 17. 33% of FISH positive patients were polysomy 17 (20/60) and 19 of the 20 were RT-PCR HER2 positive (Table). The majority of FISH negative polysomy 17 cases were RT-PCR HER2 negative (32/49) but rare cases (4/49) were RT-PCR HER2 positive. Compared to chromosome 17 eusomic patients, HER2 positive patients with polysomy 17 had 2.77 (95% CI: 1.21, 6.33) times the odds of dying from breast cancer; HER2 positive, chromosome 17 eusomic patients had 1.78 (95% CI: 0.97, 3.25) times the odds; and HER2 negative, polysomy 17 patients had 1.50 (95% CI: 0.83, 2.72) times the odds.Incidence of Polysomy 17 by HER2 Status (FISH and RT-PCR)HER2Central FISH positiveCentral FISH equivocalCentral FISH negativeTotal RT-PCRRT-PCR positive19/55 (35%)1/1 (100%)4/11 (36%)24/67 (36%)RT-PCR equivocal0/4 (0%)1/5 (20%)13/79 (17%)14/88 (16%)RT-PCR negative1/1 (100%)0/4 (0%)32/408 (8%)33/413 (8%)Total FISH20/60 (33%)2/10 (20%)49/498 (10%)71/568 (13%) ConclusionHER2 amplification with polysomy was common. FISH negative polysomy 17 cases were rarely RT-PCR HER2 positive. While differences were not statistically significant, HER2+/polysomy 17 patients tended to have the worst prognosis, followed by HER2+/eusomic, HER2-/polysomy 17, and HER2 negative eusomic pts whether HER2 status was measured by FISH or RT-PCR.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6004.

Race, ethnicity, sex and temporal differences in Barrett's oesophagus diagnosis: a large community-based study, 1994-2006

OBJECTIVE

To evaluate the demographics and incidence of Barrett's oesophagus diagnosis using community-based data.

DESIGN

Observational study.

SETTING

Kaiser Permanente, Northern California healthcare membership, 1994-2006.

PATIENTS

Members with an electronic diagnosis of Barrett's oesophagus.

MAIN OUTCOME MEASURES

Incidence and prevalence of a new Barrett's oesophagus diagnosis by race, sex, age and calendar year.

RESULTS

4205 persons met the study definition for a diagnosis of Barrett's oesophagus. The annual incidence in 2006 was highest among non-Hispanic whites (39/100,000 race-specific member-years, 95% confidence interval (95% CI) 35 to 43), with lower rates among Hispanics (22/100,000, 95% CI 16 to 29), Asians (16/100,000, 95% CI 11 to 22), and blacks (6/100,000, 95% CI 2 to 12). The annual incidence was higher among men than women (31 vs 17/100,000, respectively, year 2006; p<0.01). The incidence increased with age from 2 per 100,000 for persons aged 21-30 years, to a peak of 31 per 100,000 member-years for persons aged 61-70 years (year 2006). There was no increase in the incidence of new diagnoses until the last two observation years, which coincided with changes in data collection methods and may be due to bias. The overall prevalence among active members increased almost linearly to 131/100,000 member-years by 2006.

CONCLUSIONS

The demographic distributions of Barrett's oesophagus differ markedly by race, age and sex and were comparable to those for oesophageal adenocarcinoma. Thus, demographic disparities in oesophageal adenocarcinoma risk may arise partly from the risk of having Barrett's oesophagus, rather than from differing risks of progression from Barrett's oesophagus to cancer. There has been an almost linear increase in the prevalence of diagnosed disease.

Hemochromatosis gene status as a risk factor for Barrett's esophagus

Conditions causing high iron levels, such as hemochromatosis, are proposed risk factors for esophageal adenocarcinoma. Although this hypothesis is supported by animal models, no human data currently exist. We conducted a case-control study of persons with a new Barrett's esophagus diagnosis (cases), persons with gastroesophageal reflux disease (GERD) (without Barrett's esophagus), and population controls. Subjects completed detailed examinations and assays for hemochromatosis mutations and serum iron stores. We evaluated 317 cases, 306 GERD patients, and 308 population controls. There was no significant association between Barrett's esophagus and any hemochromatosis gene defect (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 0.95-1.84), a moderate or severe mutation (OR = 1.54, 95% CI: 0.94-2.52), or a severe mutation (C282Y homozygote or C282Y/H63D heterozygote; OR = 0.77, 95% CI: 0.24-2.48) compared with the population controls. As expected, gene defects were associated with increased iron stores. We can conclude from our findings that Barrett's esophagus was not associated with hemochromatosis gene defects, although we cannot exclude small effects.

Iron intake and body iron stores as risk factors for Barrett's esophagus: a community-based study

OBJECTIVE

High iron stores are a proposed modifiable risk factor for esophageal adenocarcinoma, but minimal human data exist. We evaluated whether iron intake and iron stores were associated with Barrett's esophagus, a metaplastic change that is a strong risk factor for esophageal adenocarcinoma.

METHODS

We conducted a case-control study within the Kaiser Permanente Northern California population. We identified all persons with a new diagnosis of Barrett's esophagus (cases); they were matched to persons with GERD (without Barrett's esophagus) and to population controls. Subjects completed examinations, dietary questionnaires, and testing for serum iron stores (ferritin and transferrin saturation). Analyses used unconditional logistic regression.

RESULTS

We evaluated 319 cases, 312 GERD patients, and 313 population controls. Compared with population controls, Barrett's esophagus patients had lower dietary iron intakes (4th vs 1st quartiles, odds ratio [OR]= 0.37, 95% confidence interval [CI] 0.17-0.80), similar total iron intakes (including supplement use), and lower iron stores (4th vs 1st quartiles, ferritin OR = 0.24, 95% CI 0.14-0.40;% transferrin saturation OR = 0.66, 95% CI 0.41-1.04; P value trend <0.01 and 0.03, respectively). Similar associations were observed in comparisons with GERD controls and among subjects without clear sources of blood loss on endoscopy.

CONCLUSIONS

Patients with Barrett's esophagus had lower dietary iron intakes and lower serum iron stores than controls in our population. These findings do not provide support for the current hypothesis that high iron stores or a high iron intake are risk factors for Barrett's esophagus, a potential early event in the carcinogenic sequence for esophageal adenocarcinoma.

Helicobacter pylori and gastroesophageal reflux disease: a case-control study

BACKGROUND

Gastric colonization with Helicobacter pylori is a proposed protective factor against gastroesophageal reflux disease (GERD), but little population-based data exist and other data conflict.

METHODS

We conducted a case-control study within the membership of a large integrated health-care system that compared GERD-free subjects with two groups: subjects with a physician-assigned GERD diagnosis and randomly selected members with self-described weekly GERD symptoms. Subjects completed interviews, GERD questionnaires, and antibody testing for H. pylori and its cagA protein.

RESULTS

Serologic data were available for 301 physician-assigned GERD patients, 81 general membership subjects with GERD symptoms, and 175 general membership subjects without GERD symptoms. Physician-assigned GERD patients were less likely to have H. pylori antibodies than GERD-free member controls (odds ratio (OR) = 0.27, 95% confidence interval (CI) 0.15-0.47); there was also an inverse association between H. pylori and GERD symptom severity (OR = 0.18, 95% CI 0.08-0.41; severe or very severe symptoms) and GERD frequency (OR = 0.18, 95% CI 0.09-0.38; for symptoms at least weekly). The association was stronger among persons with erosive GERD and was similar between H. pylori-positive subjects with and without cagA. There was no association among persons who were cagA positive, but H. pylori negative. Similar findings were found in analyses of the general membership with self-described GERD symptoms.

CONCLUSIONS

H. pylori antibody status was inversely associated with a GERD diagnosis and GERD symptoms compared with a general membership population.

Helicobacter pylori infection and the risk of Barrett's oesophagus: a community-based study

OBJECTIVE

Gastric colonisation with the Helicobacter pylori bacterium is a proposed protective factor against oesophageal adenocarcinoma, but its point of action is unknown. Its associations with Barrett's oesophagus, a metaplastic change that is a probable early event in the carcinogenesis of oesophageal adenocarcinoma, were evaluated

METHODS

A case-control study was carried out in the Kaiser Permanente Northern California population, a large health services delivery organisation. Persons with a new Barrett's oesophagus diagnosis (cases) were matched to subjects with gastro-oesophageal reflux disease (GORD) without Barrett's oesophagus and to population controls. Subjects completed direct in-person interviews and antibody testing for H pylori and its CagA (cytotoxin-associated gene product A) protein.

RESULTS

Serological data were available on 318 Barrett's oesophagus cases, 312 GORD patients and 299 population controls. Patients with Barrett's oesophagus were substantially less likely to have antibodies for H pylori (OR = 0.42, 95% CI 0.26 to 0.70) than population controls; this inverse association was stronger among those with lower body mass indexes (BMIs < 25, OR = 0.03, 95% CI 0.00 to 0.20) and those with CagA+ strains (OR = 0.08, 95% CI 0.02 to 0.35). The associations were diminished after adjustment for GORD symptoms. The H pylori status was not an independent risk factor for Barrett's oesophagus compared with the GORD controls.

CONCLUSIONS

Helicobacter pylori infection and CagA+ status were inversely associated with a new diagnosis of Barrett's oesophagus. The findings are consistent with the hypothesis that H pylori colonisation protects against Barrett's oesophagus and that the association may be at least partially mediated through GORD.

Conjugated equine estrogen and risk of benign proliferative breast disease: a randomized controlled trial

BACKGROUND

Estrogens stimulate proliferation of breast epithelium and may therefore increase the risk of benign proliferative breast disease, a condition that is associated with increased risk of breast cancer. We tested the effect of conjugated equine estrogen (CEE) on risk of benign proliferative breast disease in the Women's Health Initiative (WHI) randomized controlled trial.

METHODS

In the WHI CEE trial, 10,739 postmenopausal women were randomly assigned to 0.625 mg/d of CEE or to placebo. Baseline and annual breast examinations and mammograms were required. We identified women in the trial who reported breast biopsies that were free of cancer, obtained the associated histological sections, and subjected them to standardized central review. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). All statistical tests were two-sided.

RESULTS

A total of 232 incident cases of benign proliferative breast disease were ascertained during follow-up (average duration, 6.9 years), with 155 in the CEE group and 77 in the placebo group. Use of CEE was associated with a more than two-fold increase in the risk of benign proliferative breast disease (HR = 2.11, 95% CI = 1.58 to 2.81). For benign proliferative breast disease without atypia, the HR was 2.34 (95% CI = 1.71 to 3.20), whereas for atypical hyperplasia, it was 1.12 (95% CI = 0.53 to 2.40). Risk varied little by levels of baseline characteristics.

CONCLUSION

Use of 0.625 mg/d of CEE was associated with a statistically significant increased risk of benign proliferative breast disease.

Post-diagnosis weight gain and breast cancer recurrence in women with early stage breast cancer

PURPOSE

To examine whether weight gain after diagnosis of breast cancer affects the risk of breast cancer recurrence.

PATIENT AND METHODS

Patients included 3215 women diagnosed with early stage breast cancer (Stage I >1 cm., II, and IIIA) who were enrolled either in an observational cohort of breast cancer survivors or were part of the comparison group of a dietary intervention trial to prevent breast cancer recurrence. We computed weight change from 1 year prior to diagnosis to study enrollment. Delayed entry Cox proportional hazards models were used to evaluate associations of categories of weight change with time to recurrence, controlling for known prognostic factors.

RESULTS

Neither moderate (5-10%) nor large (> 10%) weight gain (HR 0.8, 95% CI, 0.6-1.1; HR 0.9, 95% CI, 0.7-1.2, respectively) after breast cancer diagnosis was associated with an increased risk of breast cancer recurrence in the early years post-diagnosis (median time of 73.7 months from diagnosis).

CONCLUSION

Our research provides evidence that weight gain commonly seen in the first several years following a breast cancer diagnosis does not increase a woman's risk for breast cancer recurrence in the first 5-7 years post-diagnosis. However, this research does not address the effects of weight gain on overall survival or on the risk of other new cancers, other prognostic outcomes of concern to the breast cancer survivor.

Risk of subsequent cancer following invasive or in situ squamous cell skin cancer

PURPOSE

Determine the risk of subsequent cancer following squamous cell skin cancer.

METHODS

Using computerized surgical pathology records and membership data from a health maintenance organization, we retrospectively identified 822 individuals with primary squamous cell skin cancer (SCSC) and 3662 comparison subjects matched for age, sex, race, residence area, and length of membership. Patients were included in the study if they had no prior history of cancer, and received at least one multiphasic health checkup and questionnaire (MHC). Patients were followed for subsequent invasive cancer up to 24 years, with a mean follow-up time of 7.8 years.

RESULTS

SCSC patients had a significantly greater risk [adjusted for body mass index (BMI) and education] for subsequent cancer overall (excluding non-melanoma skin cancer) [risk ratio (RR) = 1.4, 95% confidence interval (CI) = 1.2-1.6], and for basal cell skin cancer (RR = 13.8, 95% CI = 8.8-21.9), digestive (RR = 1.6, 95% CI = 1.1-2.4), and genitourinary cancers (RR = 1.5, 95% CI = 1.0-2.0). An increased, but not statistically significant, adjusted risk (RR > or = 1.4) was also observed for lip, oral cavity, and pharynx cancer (RR = 3.9, 95% CI = 0.6-25.0); non-cutaneous squamous cell cancer (RR = 1.9, 95% CI = 0.9-4.4); and respiratory and intrathoracic cancer (RR = 1.4, 95% CI = 0.8-2.6). The addition of alcohol consumption, combined occupational exposure, marital status, and smoking history to the multivariate model did not materially change any significant positive associations with SCSC.

CONCLUSIONS

Our results suggest that patients diagnosed with SCSC may be at an increased risk of subsequent cancer at many sites, although several estimated risk estimates were within the limits of chance given no true association.

Chemistry and anti-herpes simplex virus type 1 evaluation of cycloSal-nucleotides of acyclic nucleoside analogues

The synthesis of different cycloSal-phosphotriesters of the acyclic nucleoside analogues acyclovir (ACV), penciclovir (PCV) and T-penciclovir (T-PCV) as potential new lipophilic, membrane-soluble pronucleotides is described. The introduction of the cycloSal moiety was achieved by using reactive cyclic chlorophosphane reagents. In addition to the cycloSal-PCV monophosphate (MP) phosphotriesters, a second derivative bearing an acetyl group at the second primary alcohol function was prepared. In hydrolysis studies the cycloSal-ACVMPs showed the expected range of hydrolytic stability dependent on the substituent in the masking group (8-17 h). In contrast, the cycloSal-PCVMP derivatives exhibited a 11- to 15-fold increase in hydrolytic lability as compared to the corresponding cycloSal-ACVMP derivatives. We demonstrated that the free primary alcohol group is responsible for this rate acceleration because cycloSal-OAc-PCVMP, in which the hydroxyl group was blocked by acetylation, did not show the aforementioned acceleration. Unexpectedly, the hydrolysis product was not PCVMP but according to NMR and mass spectrometry it was cycloPCVMP (cPCVMP). The title compounds were evaluated in vitro for their ability to inhibit herpes simplex virus type 1 (HSV-1) and thymidine kinase-negative (TK-) HSV-1 replication in Vero cells. The cycloSal-ACVMP compounds exhibited high antiviral activity in HSV-1-infected cells. More importantly, one derivative retained all activity from the wild-type virus strain in HSV-1/TK(-)-infected Vero cells. The PCV derivatives were markedly less active. The reason for the failure of the cycloSal-PCVMPs seems to be due to the formation of cPCVMP instead of the desired PCVMP.

Relationship of maternal substance abuse to subsequent sudden infant death syndrome in offspring

To assess the possible relationship between maternal drug use during pregnancy and subsequent sudden infant death syndrome (SIDS), we identified 1760 cases of SIDS from a population of more than 1.2 million infants (1.45/1000) born in New York City between 1979 and 1989. The SIDS rate in drug-exposed infants was 5.83 per 1000 infants, compared with 1.39 per 1000 infants who were not drug exposed. With control for known associated high-risk variables, the risk ratio for SIDS in each individual drug group (methadone, 3.6; heroin, 2.3; methadone and heroin, 3.2; cocaine, 1.6; cocaine and methadone or heroin, 1.1) was higher than in the non-drug-exposed group. Higher rates of SIDS were found in infants exposed to opiates alone than in cocaine-exposed infants, but increasing rates of SIDS in cocaine-exposed infants toward the end of the decade suggested that "crack" cocaine may be linked to these increasing rates. Declines in the overall rate of SIDS during the decade were observed for both the drug-exposed (11.28 to 4.09 per 1000) and the nonexposed groups (1.70 to 1.05 per 1000). Differences in rates of SIDS between major racial-ethnic groups in nonexposed infants were not apparent if the mothers used drugs during pregnancy. Seasonal variation and distribution of ages at time of SIDS death did not differ between the drug-exposed group and the nonexposed group, suggesting that drug-associated SIDS may provide clues as to the cause or causes of SIDS.

Transmission of human immunodeficiency virus type 1 by dry-heated clotting factor concentrates. Transfusion Safety Study Group

The Transfusion Safety Study monitored susceptible persons for human immunodeficiency virus type 1 (HIV-1) infections transmitted by plasma products and blood components. Through December, 1988, 6 subjects without antibody to HIV-1 (anti-HIV-1) became seropositive after receiving dry-heated factor VIII concentrate. The preparations implicated in 3 cases were derived entirely from anti-HIV-1-screened donors. In all instances, HIV-1 infection could be explained by concentrates heated at 60 degrees C for 24-30 h. Limiting consideration to concentrates and components administered after study entry showed that 4 of the seroconversions occurred among 122 subjects given 10 million units of factor VIII concentrates. No seroconversions occurred among 84 subjects given 5 million units of factor IX concentrates, or 83 who received components from over 26,000 unpaid donations. Serologic surveillance of anti-HIV-1-negative subjects provides important information, and should be routine in the management of persons receiving clotting factor concentrates.

Trends in reporting of maternal drug abuse and infant mortality among drug-exposed infants in New York City

New York City trends in maternal drug abuse during pregnancy and in mortality rates for infants with in utero drug exposure are reported; causes of death among drug-exposed infants are studied, as is the association between maternal drug abuse and other factors that contribute to infant mortality (e.g., low birthweight, lack of prenatal care). Data for this study are derived from the linked files of New York City birth and infant death certificates. Reports of infants born to drug abusing mothers increased from 6.7 per 1000 live births in 1981 to 20.3 per 1000 live births in 1987, with abuse of cocaine accounting for most of the rise. When standardized for race and ethnicity, the mortality rate for drug-exposed infants born from 1978 through 1986 was 35.9, or 2.4 times that for infants in New York City in general. Drug-exposed infants were over three times as likely as infants in the general population to be of low birthweight. The association of both opiates and cocaine with increased mortality and low birthweight was similar. Death rates from SIDS and AIDS were especially higher for drug-exposed infants than for those in the general population, and were similar for opiate- and cocaine-exposed infants. The impact of drug abuse on infant mortality rates in selected low socioeconomic health districts is discussed.