Tumor-Infiltrating Lymphocytes Refine Outcomes in Triple-Negative Breast Cancer Treated with Anthracycline-Free Neoadjuvant Chemotherapy

PURPOSE

Stromal tumor-infiltrating lymphocytes (sTIL) are associated with pathologic complete response (pCR) and long-term outcomes for triple-negative breast cancer (TNBC) in the setting of anthracycline-based chemotherapy. The impact of sTILs on refining outcomes beyond prognostic information provided by pCR in anthracycline-free neoadjuvant chemotherapy (NAC) is not known.

EXPERIMENTAL DESIGN

This is a pooled analysis of two studies where patients with stage I (T>1 cm)-III TNBC received carboplatin (AUC 6) plus docetaxel (75 mg/m2; CbD) NAC. sTILs were evaluated centrally on pre-treatment hematoxylin and eosin slides using standard criteria. Cox regression analysis was used to examine the effect of variables on event-free survival (EFS) and overall survival (OS).

RESULTS

Among 474 patients, 44% had node-positive disease. Median sTILs were 5% (range, 1%-95%), and 32% of patients had ≥30% sTILs. pCR rate was 51%. On multivariable analysis, T stage (OR, 2.08; P = 0.007), nodal status (OR, 1.64; P = 0.035), and sTILs (OR, 1.10; P = 0.011) were associated with pCR. On multivariate analysis, nodal status (HR, 0.46; P = 0.008), pCR (HR, 0.20; P < 0.001), and sTILs (HR, 0.95; P = 0.049) were associated with OS. At 30% cut-point, sTILs stratified outcomes in stage III disease, with 5-year OS 86% versus 57% in ≥30% versus <30% sTILs (HR, 0.29; P = 0.014), and numeric trend in stage II, with 5-year OS 93% versus 89% in ≥30% versus <30% sTILs (HR, 0.55; P = 0.179). Among stage II-III patients with pCR, EFS was better in those with ≥30% sTILs (HR, 0.16; P, 0.047).

CONCLUSIONS

sTILs density was an independent predictor of OS beyond clinicopathologic features and pathologic response in patients with TNBC treated with anthracycline-free CbD chemotherapy. Notably, sTILs density stratified outcomes beyond tumor-node-metastasis (TNM) stage and pathologic response. These findings highlight the role of sTILs in patient selection and stratification for neo/adjuvant escalation and de-escalation strategies.

ctDNA and residual cancer burden are prognostic in triple-negative breast cancer patients with residual disease

Triple-negative breast cancer (TNBC) patients with residual disease (RD) after neoadjuvant systemic therapy (NAST) are at high risk for recurrence. Biomarkers to risk-stratify patients with RD could help individualize adjuvant therapy and inform future adjuvant therapy trials. We aim to investigate the impact of circulating tumor DNA (ctDNA) status and residual cancer burden (RCB) class on outcomes in TNBC patients with RD. We analyze end-of-treatment ctDNA status in 80 TNBC patients with residual disease who are enrolled in a prospective multisite registry. Among 80 patients, 33% are ctDNA positive (ctDNA+) and RCB class distribution is RCB-I = 26%, RCB-II = 49%, RCB-III = 18% and 7% unknown. ctDNA status is associated with RCB status, with 14%, 31%, and 57% of patients within RCB-I, -II, and -III classes demonstrating ctDNA+ status (P = 0.028). ctDNA+ status is associated with inferior 3-year EFS (48% vs. 82%, P < 0.001) and OS (50% vs. 86%, P = 0.002). ctDNA+ status predicts inferior 3-year EFS among RCB-II patients (65% vs. 87%, P = 0.044) and shows a trend for inferior EFS among RCB-III patients (13% vs. 40%, P = 0.081). On multivariate analysis accounting for T stage and nodal status, RCB class and ctDNA status independently predict EFS (HR = 5.16, P = 0.016 for RCB class; HR = 3.71, P = 0.020 for ctDNA status). End-of-treatment ctDNA is detectable in one-third of TNBC patients with residual disease after NAST. ctDNA status and RCB are independently prognostic in this setting.

Abstract P2-01-05: Impact of post-treatment ctDNA and residual cancer burden (RCB) on outcomes in patients with triple-negative breast cancer (TNBC) and residual disease

Introduction: Residual disease (RD) after neoadjuvant chemotherapy (NACT) is associated with high risk of recurrence in TNBC. RCB classification is prognostic in patients with RD. Recent studies show that post-NACT circulating cell-free tumor DNA (ctDNA) also provides prognostic information in patients with RD. Most TNBC patients with RD receive adjuvant therapy after surgery (chemotherapy and/or radiation), thus ctDNA status at completion of all adjuvant therapy (end of treatment, EOT) may be a better indicator of long-term prognosis. Furthermore, the impact of EOT ctDNA status on prognosis in context of RCB is of interest. Utilizing data from a prospective registry, the objective of this study was to investigate the impact of EOT ctDNA status and RCB class on outcomes in TNBC patients with RD. We hypothesized that RCB and EOT ctDNA status may provide complementary prognostic information. Methods: Study population included TNBC patients with RD post-NACT and available EOT plasma samples who were enrolled in an IRB-approved multisite prospective registry between 2011 and 2018. EOT samples were collected after completion (1-6 months) of all curative treatment (local and systemic). ctDNA was isolated and subjected to next generation sequencing (QIAseq 275-gene Human Comprehensive Cancer Panel on an Illumina NextSeq 550). Samples demonstrating pathogenic/likely pathogenic variant(s) with 3-40% allelic frequencies were considered ctDNA positive. Variants with allelic frequencies ≥40% were included in ctDNA positive status only if not present in ClinVar8/dbSNP9 as a known germline variant. The impact of EOT ctDNA status and RCB on event-free survival (EFS) and overall survival (OS) were estimated according to the Kaplan-Meier method and compared among groups by log-rank test, followed by Cox regression analysis. Results: For 47 TNBC patients with RD and available EOT plasma sample, the median age was 47 years, and 43% had node-positive disease at diagnosis. RCB class distribution was as follows: RCB I=28%, RCB II=49%, RCB III=15%, RCB unknown=8%. 45% of patients received adjuvant chemotherapy (59% with RCB II-III received adjuvant chemotherapy), and 68% received adjuvant radiation. EOT ctDNA was positive in 34% (16/47) of patients and was associated with higher T stage (p=0.012), TNM stage (p=0.033) and trend toward higher RCB class (p=0.078). ctDNA positivity rates in RCB I, II and III classes were 23%, 30% and 71%, respectively. Among all patients, 3-year EFS and OS were 71% and 73%, respectively. Table 1 provides 3-year EFS and OS by ctDNA status in all patients and by RCB class. ctDNA positive status was associated with inferior EFS and OS. Conclusion: EOT ctDNA positivity was noted in one-third of TNBC patients with residual disease and was highly prognostic, with almost half of patients with ctDNA positivity suffering an EFS event by 3 years. Patients with RCB III had very poor outcome (3-year EFS ≤20%) regardless of ctDNA status. However, in RCB classes I/II, ctDNA provided further prognostic utility, as ctDNA negative patients with RCB I/II had excellent outcomes (3-year EFS &gt;90%). These findings should be confirmed in other studies and provide insights into the role of ctDNA for patient stratification/selection in residual disease adjuvant therapy intensification trials for TNBC.

3-year EFS3-year OSAll patients: ctDNA positive vs ctDNA negative56% vs 78%, HR 3.02 (95% CI: 1.01-9.01), p=0.03856% vs 82%, HR 3.05 (95% CI: 1.02-9.13), p=0.037RCB I/II: ctDNA positive vs ctDNA negative73% vs 92%, HR 4.38, p=0.07873% vs 92%, HR 3.03, p=0.159RCB III: ctDNA positive vs ctDNA negative0% vs 20%, HR 1.67, p=0.5610% vs 20%, HR 1.30, p=0.765

Citation Format: Priyanka Sharma, Shane R Stecklein, Bruce F Kimler, Rachel Yoder, Kelsey Schwensen, Joshua M Staley, Qamar J Khan, Anne P O'Dea, Lauren E Nye, Manana Elia, Jaimie Heldstab, Trisha Home, Stephen Hyter, Kamilla Isakova, Harsh B Pathak, Andrew K Godwin. Impact of post-treatment ctDNA and residual cancer burden (RCB) on outcomes in patients with triple-negative breast cancer (TNBC) and residual disease [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 P2-01-05.

Abstract P4-10-03: Immunogenicity of SARS-CoV-2 vaccination in subjects on active treatment for breast cancer

Background: Infection with SARS-CoV-2 has led to a global pandemic and has significantly impacted the care of cancer patients. Breast cancer patients receiving active systemic therapy need protection against COVID19 but the efficacy of vaccines in this population is unknown. Although specific biomarkers associated with protection from SARS-CoV-2 infection have yet to be identified, measurement of serum antibody activity is generally accepted as a surrogate of in vivo humoral response to vaccine. This study evaluates the efficiency and durability of binding antibodies to SARS-CoV-2 spike (S) protein in response to COVID19 vaccine in breast cancer patients receiving systemic treatment. Methods: Breast cancer patients, who were unvaccinated, partially or fully vaccinated with Pfizer-BioNTech BNT162b2 (PF), Moderna mRNA-1273 (Mod) or Johnson & Johnson AD26.COV2.S (J&J) were enrolled in this prospective longitudinal study. Eligible patients were on systemic treatment with cytotoxic chemotherapy, chemotherapy plus a checkpoint inhibitor (CPI), CPI alone or a CDK 4/6 inhibitor. Longitudinal blood samples are being collected at baseline, prior to vaccination in unvaccinated patients (T0), 2 weeks after the first vaccine dose and before the second dose for the mRNA vaccines (T1), 1 month (T2), 3 months (T3), 6 months (T4) and 12 month post vaccination. For J&J, there was no T1 timepoint. Roche Elecsys® Anti-SARS-CoV-2 S receptor binding domain (RBD) antibody immunoassay was used to measure antibody titers (range 0.4 to 250 U/mL). Cut points of &lt;0.8 U/mL = negative, ≥0.8 U/mL = seropositive, were based on validated product specifications. Results: Of the 84 breast cancer patients enrolled, 9 had documented COVID infection at baseline and were excluded from analysis. Mean age was 58 years; 99% were female, 85% were Caucasian, 49% had early stage disease and 51% had metastatic breast cancer. 67% were receiving cytotoxic chemotherapy, 20% a CKD 4/6 inhibitor, 13% a CPI with or without chemotherapy. 61.2% were vaccinated with PF, 34.3% with Mod and 4.5% with J&J vaccines. Seropositivity rate for the entire group was 10% at T0, 78% at T1, 98% at T2 and 100% at T3. Seropositivity rates of all cohorts at different timepoints are shown in the table. Mean titers for all patients were 12.6 U/mL at T0, 102.3 U/mL at T1, 204.4 U/mL at T2 and 214.6 U/mL at T3 timepoints. Similar incremental increase in antibody levels was observed in all cohorts (Table). Conclusions: 78% of the patients with breast cancer on active systemic treatment were seropositive after the first dose of COVID19 vaccine and 98% after the second dose. The antibody response was maintained at 3 months, with 100% seropositivity rate. 6-month antibody response will be available at the time of presentation. Durability of antibody response at 6 and 12 months will help determine the timing of additional vaccine booster doses in this population. Importantly, this study has found that active treatment with chemotherapy, immunotherapy or CDK4/6 inhibitor therapy does not impact antibody response to SARS-CoV-2 vaccination in patients with breast cancer. Table: Seropositivity rate and mean Anti-S protein antibody levels by cohort at each time point. T0= baseline, T1=after first vaccine dose (mRNA vaccines), T2= 4 weeks after 2 doses of mRNA vaccine or after single dose of J&J vaccine, T3=3 months after the first dose of vaccine.

N% Seropositive (&gt;0.8 U/mL)Mean Antibody Levels (U/mL)T0T1T2T3T0T1T2T3All subjects7510789810012.6102.3204.4214.6Chemotherapy50577961003.3105.6200.0250CDK 4/6 inhibitors15257510010013.786.8234.7205.8CPI + Chemotherapy82583100NA*62.8121.4177.5NA*CPI therapy20100100NA*0.46.82250NA*CPI=Checkpoint Inhibitors; *Timepoint for longitudinal samples not reached

Citation Format: Cory Bivona, Kevin Li, Priyanka Sharma, Jianghua He, Grace Martin, Andrew K Godwin, Anthony Rooney, Stephen Williamson, Gary Doolittle, Weijing Sun, Bruce F Kimler, Anne P O'Dea, Lauren E Nye, Joseph P McGuirk, Ziyan Pessetto, Lisa Haney, Nicole Balmaceda, Laura Mitchell, Karissa Finke, Maggie Nelson, Dinesh Pal Mudaranthakam, Natalie Streeter, Stephanie Lafaver, Jaimie Heldstab, Qamar J Khan. Immunogenicity of SARS-CoV-2 vaccination in subjects on active treatment for breast cancer [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 P4-10-03.

Abstract P2-11-17: Feasibility of microbiome analysis from random periareolar fine needle aspiration in premenopausal women at increased risk for breast cancer

Background: Nearly 10% of breast cancers (BC) are diagnosed in premenopausal woman under age 45 and of childbearing potential. Women considering future childbearing are typically excluded from BC prevention trials and are ineligible for standard of care chemoprevention. More biomarkers are needed to support BC prevention trials in this young cohort. Women of childbearing potential are encouraged to supplement diet with minimum of 300mg of EPA + DHA omega-3 fatty acids (FA) per day. EPA and DHA are thought to have a favorable effect on the gut microbiome implicated in cancer development. Few studies have characterized the breast microbiome by core biopsy or surgical sample but to our knowledge no studies have explored the feasibility of breast microbiome collection using the less invasive technique Random Periareolar Fine Needle Aspiration (RPFNA). In a pilot study, we demonstrated feasibility of recruiting premenopausal women considering future pregnancy to a BC prevention trial with a 6-month intervention of omega-3 FA supplementation (19-A-1921-SABCS). RPFNA was used to collect breast tissue for biomarker analysis, which is a mildly invasive technique used for repeated sample collection in BC prevention trials. Objectives: 1) To determine the feasibility of characterizing breast microbiome from specimens collected by RPFNA in premenopausal woman at high risk for BC, 2) To identify changes in the breast and stool microbiome with omega-3 FA supplementation in this population. Methods: Ten women between the ages of 21 and 40 who were considering future pregnancy and at high risk for BC were enrolled to a pilot study and took Omega-3-Acid Ethyl Ester (total of 750mg DHA and 930mg EPA) daily for 6 months. Tissue collection with RPFNA of breast as well as blood, urine and stool were completed at baseline and off-study visit. RPFNA samples from the first 2 passes at each site of breast (4 sites total) were collected for microbiome and placed in a 2mL tube with 0.5 – 1cc of PBS and flash frozen and stored at -80C. DNA was isolated from RPFNA samples using QIAamp DNA Mini Kit (51304). Microbiome profiling analysis was performed by Veracet using 16S V4 rRNA gene sequencing on the Illumina MiSeq platform. Wilcoxon signed rank test was used to compare paired samples. Results: Of the 10 women enrolled, median age was 33 years (range 22-37). 90% (9 of 10) returned for off-study visit. Of the 9 women who completed the off-study visit, 2 elected to not undergo off-study RPFNA. There were 16 total stool samples and 17 total RPFNA samples for microbiome evaluation. There were 6 paired (baseline and off-study) stool and 7 paired RPFNA samples. Mean DNA concentration from RPFNA samples was 10.36ng/µl (range 0.62 – 74.10). From all samples, 52.1% of operational taxonomic units (OTUs) were classified at the genus level. Breast samples were sequenced to a depth of mean 27,767 reads (range 5,745 – 125,445) and stool to a depth of mean 119,296 reads (range 72,979 – 188,867). The alpha diversity metric of OTU richness was 1069 (breast) and 438 (stool). Shannon diversity was 4.51 (breast) and 3.89 (stool). Mean OTU richness for baseline and off-study RPFNA samples were 1098 and 1028 respectively (V = 25, p value = 0.076). Mean OTU richness for baseline and off-study stool samples were 440 and 437 respectively (V = 15, p value = 0.40). Conclusion: We demonstrated feasibility of analyzing breast microbiome from an RPFNA specimen. Additional investigation with modifications to technique and/or sample population is. needed to achieve adequate sequencing depth for characterization of breast microbiome. Lower depth of sequencing in breast samples is thought to reflect differences in microbial DNA quantity. We were unable to assess change in microbiome composition in breast or stool samples with omega-3 fatty acid supplementation due to small sample size.

Citation Format: Lauren E Nye, Jennifer R Klemp, Kandy R Powers, Anne P O'Dea, Amy L Kreutzjans, Trina Metheny, Teresa A Phillips, Susan E Carlson, Bruce F Kimler, Carol J Fabian. Feasibility of microbiome analysis from random periareolar fine needle aspiration in premenopausal women at increased risk for breast cancer [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 P2-11-17.

Abstract PS7-44: Energetics and lifestyle in inherited syndromes (ELLIE'S study)

Background: US women have a 1 in 8 lifetime chance of developing breast cancer (BC), with an estimated 10% resulting from a hereditary BC gene mutation. Individuals with mutations in genes such as BRCA1 and BRCA2 have an increased risk of breast and ovarian cancer, as well as other types of cancers. At present, there are more than a dozen other hereditary cancer related genetic mutations that have an associated moderate to high risk of developing cancer. Along with an ability to identify and characterize risk in individuals with a hereditary cancer mutation, there is a need to study modifiable factors such as dietary intake and physical activity in relation to an individual’s risk for cancer.

Obesity and poor physical fitness are independently associated with an increased risk of BC and recurrence. There is a paucity of data on the impact of BMI, obesity, and physical activity on primary and recurrent BC in genetic mutation carriers. Women with a moderate penetrance gene mutation are at a high risk for BC and yet are likely to have an impact from modifiable risk factors. The impact of obesity, diet, and physical activity on BC risk and outcomes needs to be further characterized in genetic mutation carriers.

Methods: A short REDCap electronic survey was disseminated on social media and through our advocate partner Facing our Risk of Cancer Empowered (FORCE). Eligible participants include males or females, ≥18 years with a hereditary cancer genetic mutation. The survey includes questions regarding personal health, weight, height, metabolic risk factors, reproductive history as well as personal and/or family history of cancer and gene mutation status. In addition, includes a standardized assessment for diet (14-Item Mediterranean Diet Tool) and physical activity (IPAQ and modifiable PAQ). The first 1000 participants are compensated for their time with a $10 e-card. The survey is available in English and Spanish. The Spanish version was developed in collaboration with JUNTOS Kansas City.

Objectives: To establish a cohort and describe obesity rates, physical activity, metabolic factors, and nutrition in a cohort of individuals that have an increased risk of cancer due to a hereditary cancer genetic mutation.

Results: A total of N = 1,117 surveys have been completed as of June 30, 2020. Of them, 61.2% were removed from final analysis due to incomplete surveys, internet bots, and multiple single-user entries. A total N = 443 surveys have been verified and included in this analysis. Demographics: 98.6% female (n= 437), 94.4% white (n = 418) and median age 46 (range 19 – 77 yrs). Mutations represented in the cohort include: BRCA2 (39.0%), BRCA1 (29.1%), CHEK2 (13.1%), and ATM (5.9%) and &lt; 5%: PALB2, RAD51D, and TP53. Median BMI 24.9 ± 6.06 stdv. BMI 25 to &lt; 30: 26.4% (n = 117). BMI 30 or &gt; 30: 23.47% (n = 104). 61.3% responders are currently trying to lose weight. Attempts at weight loss: No attempts: n = 60 (13.5%), at least 1: n = 55 (12.4%), 2-5: n = 211 (47.6%), 6 or more: n = 117 (26.4%). Limitations to exercise include motivation (26.9%), time (23.5%), not liking exercise (15.6%), and lack of gym memberships (12.4%). 74.9% (n = 332) responded that they are interested in participating in future studies. The Spanish survey was made available 3/3/2020, no responses to date.

Conclusion: Individuals harboring a hereditary cancer genetic mutation are interested and willing to participate in research focused on lifestyle modifications and association with cancer risk. Rates of being overweight or obese are high and many have made multiple attempts at weight loss and find common barriers to exercise. Social media is a feasible platform to recruit to a lifestyle research project in a rare population. Additional steps to limit internet trolls, bots, and repetitive responses are necessary but did not impede recruitment. Further effort and collaboration are needed to expand the survey to underrepresented minorities.

Citation Format: Lauren E Nye, Kendra Cruz, Sue Friedman, Diane Rose, Christie Befort, Debra K Sullivan, Jill M Hamilton-Reeves, Lisa M Harlan-Williams, Fariba Behbod, Jo Wick, Melinda Irwin, Jennifer Klemp. Energetics and lifestyle in inherited syndromes (ELLIE'S study) [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 PS7-44.

Abstract P1-14-01: Feasibility study of moderate dose omega 3 fatty acid supplementation in premenopausal women at high risk for breast cancer considering future pregnancy

Background: 11% of women developing breast cancer are pre-menopausal women of childbearing potential under the age of 45. Pregnancy and breast feeding provide long term protection for breast cancer when they occur at an early age. The reasons for protection are poorly understood but likely involve both changes in the immune microenvironment and ductal and lobular epithelial differentiation. This pilot study is addressing a potential prevention strategy in a population otherwise excluded from breast cancer prevention trials and not eligible for standard of care chemoprevention.

Methods: Eligible individuals included pre-menopausal women ages 21-40 that were considering future pregnancy and are at high risk for breast cancer based on family history, prior precancerous biopsy, or 5-year Gail model risk estimate of ≥ 1.7% or 10-year Tyrer-Cuzick risk of 2x population risk as listed in the model. Participants were enrolled and baseline tissue collection included random periareolar fine-needle aspiration (RPFNA) of breast, as well as collection of blood, urine and stool. Women were asked to take two capsules of Omega-3-Acid Ethyl Esters daily (a total of 750 mg DHA and 930 mg EPA) for six months. Post-intervention visit included repeat tissue collection. If women were pregnant at time of post-intervention visit, RPFNA was not done. Baseline and post-intervention DHA Food Frequency Questionnaire (FFQ) and the BCPT Questionnaire were administered. The intervention length was shortened for some participants due to the study ending.

Objectives: 1) To determine feasibility of a breast cancer prevention intervention study in this cohort of pre-menopausal women at high risk for breast cancer and considering future pregnancy, 2) measure compliance with the omega-3 fatty acid supplement in this population, 3) identify novel biomarkers modulated by moderate dose omega-3 fatty acids in this population.

Results: Ten women were successfully enrolled at an average rate of 1.5/month from a single center high risk breast clinic. Of the ten women enrolled, median age was 33 years (range 22-37, ±5.04 stdev), 70% married, 80% Non-Hispanic White, 10% of Ashkenazi Jewish descent and 40% reported having a genetic mutation. Feasibility was achieved with 80% (8 out of 10) of participants returning for post-intervention visit. Reasons given for discontinuation of study were (n=1) side effect from supplement (bloating) and (n=1) scheduling conflicts. Of the eight women who completed the off study visit, two chose not to undergo the off study RPFNA due to discomfort with initial procedure or time commitment. Self-reported pill count showed an average of three missed pills/month. Grade 1 related adverse events reported included odor, nausea and flatulence. Post-intervention, more participants reported diarrhea, vaginal discharge and bleeding, weight gain, general aches and dizziness on BCPT items compared to baseline. Change in benign breast tissue biomarkers will be reported including breast tissue cytomorphology, Ki67, fatty acid analysis and selected gene expression.

Conclusion: It is feasible to recruit premenopausal women considering future pregnancy to a breast cancer prevention trial with a minimally invasive sampling procedure. Results from this trial will inform a larger randomized prevention trial.

Citation Format: Lauren E Nye, Jennifer R Klemp, Kandy R Powers, Anne P O'Dea, Kendra A Cruz, Amy L Kreutzjans, Trina Metheny, Teresa A Phillips, Susan E Carlson, Bruce F Kimler, Carol J Fabian. Feasibility study of moderate dose omega 3 fatty acid supplementation in premenopausal women at high risk for breast cancer considering future pregnancy [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 P1-14-01.