P810Novel scoring system for takotsubo syndrome

Background

Scoring systems for risk stratification in takotsubo syndrome (TTS) are lacking.

Purpose

The present study aimed to develop a score to predict the overall mortality in TTS.

Methods

TTS patient were enrolled from a multicenter registry. Parameters known to be associated with adverse outcomes in TTS were identified based on current literature. A multivariable analysis including these parameters was conducted and those which were found to be significantly associated with mortality were considered in the scoring system. For each patient, the prognostic score was derived by summing the respective points of each prognostic factor. Based on cut-off values, patients were categorized into four groups including low, intermediate, high, and very high risk.

Results

A total of 1160 patients (90.8% females; mean age 66.5±13.0 years) were included in the present study. Regarding triggering factors, an emotional trigger was identified in 32.6% of TTS patients while 32.1% had preceding physical activities, medical conditions, or procedures and 5.7% had preceding neurologic disorders. The remaining patients (29.7%) had no identifiable triggering factors. According to the results from multivariable analysis, points were assigned to each parameter that was independently associated with long-term mortality: 15 points for neurologic trigger, 10 points for the other physical trigger, 8 points for Age >70 years, 7 points for male sex, 7 points for left ventricular ejection fraction ≤45%, 6 points for diabetes mellitus, 5 points for heart rate >94 bpm on admission, 5 points for systolic blood pressure >140 mmHg on admission, and 2 points for no identifiable trigger. Based on the total points, patients were categorized into four prognostic groups: low-risk ≤15 points (43.5%), intermediate-risk 16–22 points (28.0%), high-risk 23–29 points (18.0%), and very high-risk >29 points (10.5%).

Conclusion

This novel score for risk stratification in TTS only requires easy-obtainable variables to clinicians even in the acute phase and could identify low to very high risk of overall mortality. Thus, it could potentially serve as a useful clinical tool to predict prognosis in patients with TTS.

The impact of adjuvant radiotherapy on the survival of primary breast cancer patients: a retrospective multicenter cohort study of 8935 subjects

BACKGROUND

Radiotherapy (RT) is proven to be an important backbone for adjuvant therapy in randomized, controlled trials, but it is unclear if these effects are provable in a daily routine cohort of breast cancer patients. This study sought to answer the following questions in a daily routine cohort of breast cancer patients: 1. Does guideline-adherent RT improve primary breast cancer patient survival? 2. Is breast-conserving surgery (BCS) followed by RT equal to a mastectomy (MA) with regard to outcome parameters? 3. Does adjuvant RT compensate for an incomplete tumor resection (R1)?

PATIENTS AND METHODS

In this retrospective, multicenter cohort study, we investigated data from 8935 primary breast cancer patients recruited from 17 participating certified breast cancer centers in Germany between 1992 and 2008. Guideline adherence based on internationally validated guidelines.

RESULTS

The patients who received guideline-adherent RT for primary breast cancer were associated with significantly improved survival parameters [recurrence-free survival (RFS): P < 0.001; overall survival (OS): P < 0.001] compared with patients who did not receive guideline-adherent adjuvant RT. Furthermore, the results demonstrated that there were no significant differences in RFS and OS between BCS followed by RT and MA [RFS: P = 0.293; OS: P = 0.104]. Adjuvant RT did not improve the outcome of patients receiving nonguideline-adherent incomplete tumor resection via BCS (R1); these patients showed a significantly impaired RFS [P < 0.001] and OS [P < 0.001] compared with patients who underwent guideline-adherent complete tumor resection via BCS (R0). In addition, non-guideline-adherent RT after MA (overtherapy) did not significantly influence survival [RFS: P = 0.838; OS: P = 0.613].

CONCLUSION

Our study confirms the importance of guideline-adherent adjuvant RT. It shows highly significant associations between RFS or OS and guideline adherent RT. Nevertheless, inadequate (R1-) surgical resection in a daily routine cohort of patients increases the risk of local recurrence and appears not to be compensated by the following RT.

Abstract P5-14-03: The impact of adjuvant radiotherapy on survival in primary breast caner: What is the role of guideline adherence in radiotherapy – A retrospective multi-center cohort study of 8935

Introduction:

Breast cancer remains the most common malignancy in women in industrialized countries. Over the last decades improved adjuvant therapy strategies were the key for a favorable prognosis in patients. Among these, radiotherapy is one of the important backbones in adjuvant therapy strategies. This study tries to answer the following questions:

1. Does guideline adherent radiotherapy improve survival in primary breast cancer patients?

2. Is breast conserving surgery followed by RT equal to mastectomy in outcome parameters?

3. Is there a difference in survival between patients receiving BCT followed by RT with non guideline conform incomplete tumor resection (R1)? Does adjuvant RT compensate incomplete resection of the tumor?

Material and Methods:

In this German retrospective multi-center cohort study called BRENDA (breast cancer care under evidence based guidelines) we investigate data of 8.935 primary breast cancer patients recruited from 17 participating breast cancer centers in Germany (all certified breast cancer centers by the German Cancer Society). Guideline adherence is established in all adjuvant treatment modalities based on internationally validated guidelines.

Results:

Patients who received guideline adherent RT in primary breast cancer were associated with significantly improved survival parameters [RFS: p &lt; 0.001; HR = 0.28 (95% CI: (0.24 – 0.33)] [OAS: p &lt; 0.001; HR = 0.26 (95% CI: 0.19 – 0.36)] compared to patients who did not receive guideline adherent adjuvant RT. Compared to other adjuvant treatment modalities (surgery/chemotherapy/endocrine therapy) guideline violations concerning radiotherapy and chemotherapy have the most important impact on survival parameters. Furthermore, the results of Fisher et al. and Veronesi et al. were confirmed by demonstrating that BCT followed by RT is equal to mastectomy [RFS: p = 0.293; HR = 1.20 (95% CI:0.85-1.70)] [OAS: p = 0.104; HR = 1.31 (95% CI: 0.95-1.81)]. Adjuvant RT could not improve the outcome in patients with non-guideline conform incomplete tumor resection via BCT (R1) showing a significantly impaired RFS [p&lt;0.001; HR = 2.87 (95% CI: 2.00-4.12)] and OAS [p&lt;0.001; HR = 2.06 (95% CI: 1.43-2.98)] compared to guideline conform complete tumor resection via BCT (R0). Additionally, non guideline adherent RT after mastectomy (only T1/T2) (overtherapy) did not influence survival significantly [RFS: p = 0.838; HR = 1.07 (95% CI: 0.57-1.98)] [OAS: p = 0.613; HR = 1.18 (95% CI: 0.63-2.20)].

Discussion:

Guideline adherent adjuvant RT is associated with an improvement of survival parameters in primary breast cancer. Patients undergoing guideline conform BCT (R0) followed by RT present an equal outcome as patients undergoing mastectomy. However adjuvant RT can not compensate an inadequate tumor resection via BCT and RT overtherapy after mastectomy does not improve survival parameters.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-14-03.

Ayurveda: between religion, spirituality, and medicine

Ayurveda is playing a growing part in Europe. Questions regarding the role of religion and spirituality within Ayurveda are discussed widely. Yet, there is little data on the influence of religious and spiritual aspects on its European diffusion. Methods. A survey was conducted with a new questionnaire. It was analysed by calculating frequency variables and testing differences in distributions with the χ (2)-Test. Principal Component Analyses with Varimax Rotation were performed. Results. 140 questionnaires were analysed. Researchers found that individual religious and spiritual backgrounds influence attitudes and expectations towards Ayurveda. Statistical relationships were found between religious/spiritual backgrounds and decisions to offer/access Ayurveda. Accessing Ayurveda did not exclude the simultaneous use of modern medicine and CAM. From the majority's perspective Ayurveda is simultaneously a science, medicine, and a spiritual approach. Conclusion. Ayurveda seems to be able to satisfy the individual needs of therapists and patients, despite worldview differences. Ayurvedic concepts are based on anthropologic assumptions including different levels of existence in healing approaches. Thereby, Ayurveda can be seen in accordance with the prerequisites for a Whole Medical System. As a result of this, intimate and individual therapist-patient relationships can emerge. Larger surveys involving bigger participant numbers with fully validated questionnaires are warranted to support these results.

Comparing the outcome between multicentric and multifocal breast cancer: what is the impact on survival, and is there a role for guideline-adherent adjuvant therapy? A retrospective multicenter cohort study of 8,935 patients

Multifocal (MF) and multicentric (MC) breast cancers have been comprehensively studied, and their outcomes have been compared with unifocal (UF) tumors. We attempted to answer the following questions: (1) Does MF/MC presentation influence the outcome concerning BC mortality?, (2) Is there an impact of guideline-adherent adjuvant treatment in these BC subtypes?, and (3)What is the influence of guideline violations concerning surgery (breast-conserving surgery versus mastectomy) on the survival of MF/MC BC patients? Between 1992 and 2008, we retrospectively analyzed 8,935 breast cancer patients from 17 participating breast cancer centers within the BRENDA study group. Of 8,935 breast cancer patients, 7,073 (79.2 %) had UF tumors, 1,398 (15.6 %) had MF tumors, and 464 (5.2 %) had MC tumors. RFS was significantly worse for MF/MC BC patients compared to patients with UF tumors (MF p = 0.007; MC p = 0.019). OAS was significantly worse for MC patients but not for MF patients compared to patients with UF tumors (MF p = 0.321; MC p = 0.001). Guideline adherence was significantly lower in patients with MF (n = 580; 41.5 %) and MC (n = 204; 44.0 %) compared to patients with UF (n = 3,871; 54.7 %) (p < 0.001) tumors. Guideline violations were associated with a highly significant deterioration in survival throughout all subgroups except for MC, with respect to RFS and OAS. For 100 %-guideline-adherent patients, we could not find any significant differences in RFS and OAS after adjusting by nodal status, grade, and tumor size. Furthermore, we could not find any significant differences in RFS and OAS in patients with MF or MC stratified by breast-conserving therapy (BCT lumpectomy and radiation therapy) and mastectomy. There is a strong association between improved RFS and OAS in patients with MF/MZ BC. There are no significant differences in RFS and OAS for patients with breast-conserving therapy or mastectomy.

Guideline Compliant Irradiation Following Breast Conserving Surgery or Mastectomy Improves Recurrence Free Survival

Purpose: Two pivotal studies by Veronesi and Fisher have established the concept of breast conserving surgery for small breast cancers stage T1 or with size less than 4 cm respectively. The aim of this retrospective study was to validate the current practice of BCS in an unselected cohort of patients within the network of 16 regional breast cancer centres in germany and to quantify the detrimental effect of guideline non-compliant locoregional therapy on recurrence free survival.Methods: 4507 patients who received primary therapy between 1992 and 2005 were recorded. Data on surgery, axillary dissection and postoperative irradiation were used to categorize patients according to adherence to guidelines. The effect of guideline compliant locoregional therapy on recurrence free survival was calculated.Results: Out of 3579 patients (79.4%) who were treated by BCS 3036 (84.8%) received postoperative irradiation as mandated by the guideline. A total of 928 (20.6%) patients underwent mastectomy, out of these a fraction of 344 patients received postoperative irradiation as required by the guideline. No significant difference in recurrence free survival was found between patients who underwent BCS plus postoperative irradiation and those patients who underwent mastectomy (T1: HR=1.08 (95%-CI: 0.70-1.67), p=0.281; T2: HR=1.21 (95%-CI: 0.61 - 2.39), p=0.577). Guideline compliant locoregional therapy resulted in a significant improvement in RFS as shown for patients receiving guideline compliant BCS plus irradiation or guideline compliant mastectomy without irradiation versus patients with any type of non-compliant locoregional therapy (HR=3.53, 95%-CI: 2.97-4.18, p&lt;0.001).Conclusion: Our findings support current clinical practice of BCS in small tumors as initially indicated and also in tumors of stage T2. Violations of guidelines for locoregional therapy were clearly associated with a poorer prognosis.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4106.

Influence of Treatment Conforming to Guidelines on Recurrence Free Survival (RFS) and Overall Survival (OS) in Triple Negative Breast Cancer

Introduction: The triple negative(TN) breast cancer subtype (ER neg, PR neg, HER 2 neg) represents about 10 to 15% 0f all breast cancer types. It characterizes an aggressive phenotype with significantly worsened RFS, OS as well as specific clinical and pathological properties. The aim of this study was: 1.To assess the efficacy of guideline conforming conventional chemotherapy, local recurrence rate, distant recurrence rate, as well as overall survival. 2.To ask for subgroups that show the greatest benefit from conventional chemotherapy and 3. to ask for impact of guidelines violation on RFS and OA.Patients and methods: 3658 breast cancer Patients that were first diagnosed between the years 2000 and 2005 were analyzed in a multicentric retrospective study. A total of 371 (10,1%) were triple negative. Results: Median age was 62 years(26-101) TN: 60years.(28-97). 13,8% of all included patients are triple negative. 90,3% of all TN patients are at intermediate/high risk according to Nottingham risk classification. 76,5 have G3 tumors. The 5 year DFS is 74,8% (95%CI 68,8% - 80,8%) and for none TN 86,5%(95%CI 84,6% - 88,4%) (logrankp&lt;0,0001). The 5 year OS is 75,8%(95%CI:69,9%- 81,8%) and for none TN 86%(95%CI:84,1%-87,9%). (logrank p &lt; 0,0001). The essential parameters for RFS and OS were guidelines conforming surgery and radiation therapy, when chemotherapy conforming to guidelines was provided. The 5 year RFS for TN patients undergoing a 100% guideline according adjuvant therapy is 86.1%(95%CI:78.9%-93.4%), with 1-2 violations 76.0% (95%CI:69.0%-83.1%) and with ≥3 violations 50.6%(95%CI:20.1%-81.1%) (logrank p&lt;0.0001). In total a 66,8% of all TN patients were not treated according to guidelines (ranking of violations: Chemotherapy, radiation therapy, surgery). 18% had 2 or more violations. Summary: The Results show a significant improvement of outcomes in TN breast cancer patients when treatment is conducted in accordance to guidelines. There are subgroups of TN breast cancer patients that profit from therapy according to guidelines. The leading guideline violation was noted for radiation therapy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2101.

Impact of study participation on survival of early-stage breast cancer patients: Results from the BRENDA study, a multicenter clinical cohort on quality of breast cancer care

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Background: Over the past two decades significant progress in treatment of early breast cancer has been accomplished through well designed, clinical trials (CTs). It has been hypothesized that trial participation could also be beneficial for the individual breast cancer patient. The BRENDA study group has been analysing quality of care provided by one university based and 16 regional breast cancer centers in south germany. In this study we investigated the impact of study participation on survival in an unselected clinical cohort of early stage breast cancer patients. Methods: The study population includes 5,966 patients who received primary therapy for early breast cancer between 1992 and 2005. Influence on survival by study participation was calculated by Cox proportional hazard analyses. Model adjustments include prognostic factors, type of treatment, age, risk group and time period. Guideline compliant treatment was assessed based on the St Gallen expert consensus recommendations and the German national S3 Guidelines. Results: A total of 738 patients (12%) received adjuvant (n = 552) or neoadjuvant (n = 186) systemic therapy within one out of 42 registered prospective multicenter phase II or III clinical trials. For patients not receiving neoadjuvant systemic therapy trial participation was associated with improved overall and disease free survival (hazard ratio [HR] = 0.75, 95% confidence interval [CI] 0.57–0.99, HR = 0.78, CI 0.63 - 0.97, respectively). The calculated effect was of similar magnitude after additional adjustment for co-existing morbidity of patients. Descriptional analysis revealed that guideline violations for locoregional or systemic treatment were more frequently found in patients receiving adjuvant treatment outside CTs. No significant effect on survival was calculated for 183 patients receiving neoadjuvant systemic therapy within CT protocols. Conclusions: In our study population participation in prospective clinical trials for adjuvant systemic therapy was associated with improved survival irrespective of treatment actually given. Intrinsic mechanisms within the framework of clinical trials can improve quality of breast cancer patient care.

No significant financial relationships to disclose.

Outcome analysis of 189 consecutive cancer patients referred to the intensive care unit as emergencies during a 2-year period

The referral of critically ill cancer patients to an intensive care unit (ICU) is a matter of controversial debate. This study was conducted by an interdisciplinary clinical group to evaluate the outcome of ICU treatment in cancer patients according to their characteristics at the time of referral. A retrospective analysis was used to identify relevant subgroups among 189 consecutive cancer patients referred as emergencies to one of four ICUs during a 2-year period. Reasons for ICU referral were pneumonia (29.6%), sepsis (27.0%), fungal infection (11.1%), another infection (9.5%), gastrointestinal emergency (16.9%), treatment-related organ toxicity (6.9%), or other, non-infectious complications (43.9%). Vasopressor support was required in 50.3%, mechanical ventilation in 49.7%, and haemodialysis/-filtration in 26.5% of the patients. Overall, 41.3% died during ICU treatment, 12.2% died after transfer from ICU to a non-ICU ward, and 35.4% were discharged alive. Sepsis, mechanical ventilation, vasopressor support, renal replacement therapy and neutropenia were independent risk factors for fatal outcome, but no single risk factor unequivocally predicted death. All patients with fungal infection who required vasopressor support and either had sepsis (n=13) or needed mechanical ventilation (n=14) died during ICU treatment, while all non-septic patients. who did not require mechanical ventilation, were younger than 74 years of age and had a non-infectious underlying complication (n=29), survived. This analysis may help to early identify relevant subgroups of cancer patients with different prognoses under ICU treatment. A prospective study to confirm the predictive usefulness of this approach is needed. Cancer patients should not be excluded from referral to the intensive care unit in an emergency solely due to their underlying malignant disease or a single unfavourable prognostic factor.

Weekly intravenous recombinant humanized anti-P185HER2 monoclonal antibody (herceptin) plus docetaxel in patients with metastatic breast cancer: a pilot study

BACKGROUND

In patients with HER2-positive metastatic breast cancer (MBC), combined treatment of herceptin (H) and chemotherapy (CT) improves time to progression, response rates and survival compared with CT alone.

MATERIALS AND METHODS

We evaluated the safety and efficacy of weekly Docetaxel combined with weekly H as treatment in HER2 overexpressing MBC.

RESULTS

Preliminary toxicity data from 12 patients and 76 cycles of D and 80 cycles of H were analysed. No G3/4 toxicity was observed. The most frequent non-hematologic toxicities were fatigue (2 patients G2, 2 patients G1), dyspepsia (1 patients G2, 3 patients G1), diarrhea (1 patient G2, 3 patients G1), and nausea (1 patient G2, 3 patients G1). Six partial responses have been observed in 12 patients (ORR 50%).

CONCLUSIONS

The combination of weekly Docetaxel and Herceptin is well tolerated with significant anti-tumor activity.