Abstract P2-14-01: The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 TRIAL

Background: In women with breast cancer receiving neoadjuvant chemotherapy, residual cancer burden (RCB) predicts distant recurrence and survival. In those with high risk tumors, locoregional recurrence (LRR) remains a concern, and has been associated with type of local therapy received. We evaluated the impact of local therapy on LRR in the ISPY-2 TRIAL.

Methods: Data were analyzed in Stata 14.2, using Chi2 test, log rank test, and a Cox proportional hazards model. RCB was considered a categorical variable (0/1 versus 2/3), as described in prior publications. Breast surgery categories were lumpectomy +/- radiotherapy, or mastectomy +/- radiotherapy. Axillary surgery was defined as sentinel lymph node (SLN) surgery (≤6 nodes removed) or axillary dissection (>6 nodes).

Results: Follow up data from the I-SPY2 TRIAL were available for 630 patients (median follow up 2.76 yrs, range 0.4-7.2). Type of local therapy was significantly associated with clinical stage at presentation, with stage III patients most frequently undergoing mastectomy + radiation (p<0.001). Women with higher RCB were more likely to undergo mastectomy than those with lower RCB (61.3% vs 48.8% mastectomy rate, p=0.002), and more likely to receive adjuvant radiotherapy (62.0% vs 53.9%, p=0.048). There was no association between clinical stage, type of surgery, or radiotherapy and LRR (Table). Higher RCB was significantly associated with LRR, with 3 year locoregional recurrence free rate of 95.1% in RCB 0/1 versus 89.9% in RCB 2/3 (p=0.003).

In a Cox model adjusting for clinical stage, tumor subtype, surgical therapy, RCB status, nodal radiation, and age, significant predictors for LRR were tumor subtype and RCB status. Hazard ratio (HR) for LRR in those with RCB 0/1 was 0.39 compared to those with RCB 2/3 (95% CI 0.17-0.87, p=0.021). There was no difference in LRR between breast conservation and mastectomy; within the breast conservation group, those who had lumpectomy alone had higher hazard of LRR compared to those having lumpectomy + radiation (HR 3.1, 95% CI 1.1-9.2, p=0.043).

Conclusions: Extent of surgical therapy was not associated with local tumor control, regardless of advanced tumor stage at presentation. Rather, tumor biology and response to therapy were the best predictors of LRR. These data highlight the opportunity to minimize the morbidity of extensive surgical therapy for patients with excellent response to systemic therapy.

LRR rates by clinical features and treatment status FrequencyLRR RateP valueClinical Stage  0.5I240 (47.5%)5.8% II185 (36.6%)8.7% III80 (15.8%)6.3% Tumor Subtype  0.014ER+PR+Her2-161 (26.4%)3.1% ER+PR-Her2-56 (9.2%)3.6% Her2+176 (28.9%)6.3% Triple negative216 (35.5%)11.1% Local therapy  0.169Lumpectomy85 (13.5%)11.8% Lumpectomy with radiation198 (31.4%)5.6% Mastectomy173 (27.5%)5.2% Mastectomy with radiation174 (27.6%)8.6% Axillary surgery  0.23None5 (0.8%)20% SLN329 (52.2%)5.8% ALND296 (47%)8.5% Axillary radiation  0.535Yes42 (6.7%)9.5% No588 (93.3%)7.0% Axillary management  0.2No surgery or radiation5 (0.8%)20.0% SLN312 (50%)5.3% SLN+Axillary radiation17 (2.7%)8.3% ALND271 (43%)10.3% ALND+Axillary radiation25 (4%)5.4% RCB  0.0020/1293 (50.1%)3.8% 2/3292 (49.9%)10.3% 

Citation Format: Silverstein J, Suleiman L, Yau C, Price ER, Singhrao R, Yee D, DeMichele A, Isaacs C, Albain KS, Chien AJ, Forero-Torres A, Wallace AM, Pusztai L, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Leyland-Jones B, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, I-SPY 2 TRIAL Consortium, Berry DA, Asare SM, Esserman LJ, Boughey JC, Mukhtar RA. The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 TRIAL [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-01.

Abstract P2-07-03: Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden

Background: Patients achieving a pathologic complete response (pCR) following neoadjuvant therapy have significantly improved event-free survival relative to those who do not; and pCR is an FDA-accepted endpoint to support accelerated approval of novel agents/combinations in the neoadjuvant treatment of high risk early stage breast cancer. Previous studies have shown that recurrence risk increased with increasing burden of residual disease (as assessed by the RCB index). As well, these studies suggest that patients with minimum residual disease (RCB-I class) also have favorable outcomes (comparable to those achieving a pCR) within high risk tumor subtypes. In this study, we assess whether integrating RCB with MRI functional tumor volume (FTV), which in itself is prognostic, can improve prediction of distant recurrence free survival (DRFS); and identify a subset of patients with minimal residual disease with comparable DRFS as those who achieved a pCR. Imaging tools can then be used to identify the subset that will do well early and guide the timing of surgical therapy.

Method: We performed a pooled analysis of 596 patients from the I-SPY2 TRIAL with RCB, pre-surgical MRI FTV data and known follow-up (median 2.5 years). We first assessed whether FTV predicts residual disease (pCR or pCR/RCB-I) using ROC analysis. We applied a power transformation to normalize the pre-surgical FTV distribution; and assessed its association with DRFS using a bi-variate Cox proportional hazard model adjusting for HR/HER2 subtype. We also fitted a bivariate Cox model of RCB index adjusting for subtype; and assessed whether adding pre-surgical FTV to this model further improves association with DRFS using a likelihood ratio (LR) test. For the Cox modeling, penalized splines approximation of the transformed FTV and RCB index with 2 degrees of freedom was used to allow for non-linear effects of FTV and RCB on DRFS.

Result: Pre-surgical MRI FTV is significantly associated with DRFS (Wald p<0.00001), and more effective at predicting pCR/RCB-I than predicting pCR alone (AUC: 0.72 vs. 0.65). Larger pre-surgical FTV remains associated with worse DRFS adjusting for subtype (Wald p <0.00001). The RCB index is also significantly associated with DRFS adjusting for subtype (Wald p<0.00001). Adding FTV to a model containing RCB and subtype further improves association with DRFS (LR p=0.0007). RCB-I patients have excellent DRFS (94% at 3 years compared to 95% in the pCR group). Efforts are underway to identify an optimal threshold for dichotomizing pre-surgical FTV and FTV change measures for use in combination with pCR/RCB-I class to generate integrated RCB (iRCB) groups as a composite predictor of DRFS.

Conclusion: Pre-surgical MRI FTV is effective at predicting minimal residual disease (RCB0/I) in the I-SPY 2 TRIAL. Despite the association between FTV and RCB, FTV appears to provide independent added prognostic value (to RCB and subtype), suggesting that integrating MRI volume measures and RCB into a composite predictor may improve DRFS prediction.

Citation Format: Hylton NM, Symmans WF, Yau C, Li W, Hatzis C, Isaacs C, Albain KS, Chen Y-Y, Krings G, Wei S, Harada S, Datnow B, Fadare O, Klein M, Pambuccian S, Chen B, Adamson K, Sams S, Mhawech-Fauceglia P, Magliocco A, Feldman M, Rendi M, Sattar H, Zeck J, Ocal I, Tawfik O, Grasso LeBeau L, Sahoo S, Vinh T, Yang S, Adams A, Chien AJ, Ferero-Torres A, Stringer-Reasor E, Wallace A, Boughey JC, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, Haugen PK, van't Veer LJ, Perlmutter J, Melisko ME, Wilson A, Peterson G, Asare AL, Buxton MB, Paoloni M, Clennell JL, Hirst GL, Singhrao R, Steeg K, Matthews JB, Sanil A, Berry SM, Abe H, Wolverton D, Crane EP, Ward KA, Nelson M, Niell BL, Oh K, Brandt KR, Bang DH, Ojeda-Fournier H, Eghtedari M, Sheth PA, Bernreuter WK, Umphrey H, Rosen MA, Dogan B, Yang W, Joe B, I-SPY 2 TRIAL Consortium, Yee D, Pusztai L, DeMichele A, Asare SM, Berry DA, Esserman LJ. Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-07-03.

Abstract P4-08-12: Comparative analyses of the prognostic value of oncotype and mammaprint using the National Cancer Database

INTRODUCTION: Majority of the approximately 40,610 deaths from metastatic breast cancer in the US each year occur in women with hormone receptor positive breast cancer who recur after treatment for early stage disease. Genomic analysis is increasingly used to personalize breast cancer treatment for women with early breast cancer resulting in AJCC 8 modification of TNM staging. The 70-gene Mammaprint was developed using both ER- and ER+ breast tissue samples, while the 21-gene Oncotype DX (ODX) assay was developed using only ER+ breast tissue. Previous studies found that the two genomic assays gave discordant testing results.

OBJECTIVE: To compare the performance of Mammaprint and Oncotype DX in assigning prognosis in early stage hormone receptor positive breast cancer.

METHOD: A retrospective cohort of women diagnosed with early stage, hormone receptor positive breast cancer who received ODX or Mammaprint was established using the National Cancer Data Base (NCDB), 2010-2014. Using the propensity score matching method, we defined two groups of patients with similar clinical and demographic characteristics; one group received ODX and another received Mammaprint. The groups were matched by clinicopathologic and demographic factors. We examined the association between ODX or Mammaprint and overall survival using Log-rank test and Cox models in the two groups separately. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated as strength of association. The prognostic values were evaluated using c-index (i.e. area under ROC curve).

RESULTS: Of 320,276 eligible patients with breast cancer, 41.5% received ODX and 1.3% received Mammaprint testing. The use of ODX increased from 34.3% in 2010 to 45.2% in 2014, while the use of Mammaprint increased from 0.5% in 2010 to 2.0% in 2014. After propensity score matching, we identified 3319 patients who received ODX and matched to 3319 patients who received Mammaprint. Compared to patients with a low risk Mammaprint score (n=1915), patients with a high risk Mammaprint score (n=1404) had 4.53-fold increased risk of dying (95% CI 2.79-7.36). The c-index for Mammaprint was 0.683. Relative to patients with a low ODX recurrence score (n=1927), the HR for intermediate ODX score was 1.23 (95% CI 0.76-1.98) and the HR for high ODX score was 3.62 (95% CI 2.21-5.94). The c-index for ODX was 0.601. In patients with ODX testing, 28.2% received chemotherapy. In patients with Mammaprint testing, 42.4% received chemotherapy. Based on MINDACT's modification of Adjuvant!Online, 49.2% patients were assigned to the clinical high risk group, including 22.3% to the clinical high risk/genomic low risk (C-high/G-low) subgroup and 26.9% to the C-high/G-high subgroup. The percentage of patients receiving chemotherapy with C-low/G-low, C-low/G-high, C-high/G-low, and C-high/G-high were 4.3%, 70.4%, 32.2%, and 84.9%, respectively.

CONCLUSION: The findings from our preliminary study suggest that Mammaprint may achieve better separation of high risk from low risk patients. However, it is possible that having more genes in multigene assays would better capture the heterogeneity of hormone receptor positive breast cancer and guide choice of optimal systemic therapy to reduce risk of metastases.

Citation Format: Ibraheem AF, Olopade O, Huo D. Comparative analyses of the prognostic value of oncotype and mammaprint using the National Cancer Database [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-12.

Abstract P3-07-05: Not presented

This abstract was not presented at the conference.

Citation Format: Hardeman A, Grushko T, Clayton W, Hurley I, Khramtsova G, Parker J, Perou C, Olopade O. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-07-05.

Prevalence and Spectrum of Breast Cancer Inherited Mutations in Uganda and Cameroon Women

Background: Breast cancer among indigenous Africans is characterized by higher prevalence of triple-negative disease and poor prognosis. A previous study in Nigeria reported a strikingly high prevalence of deleterious germline mutations in BRCA1 and BRCA2 among Nigerian women with breast cancer. It is unknown if this is true in other sub-Saharan African countries. Aim: The objective of this study is to determine the frequency of germline mutations among an unselected sample of women in Africa. Methods: We conducted a case-control study of breast cancer in Uganda and Cameroon to investigate genetic and nongenetic risk factors for breast cancer. Breast cancer cases were enrolled in two tertiary hospitals in the two countries, unselected for age at diagnosis and family history. Controls who were free of breast cancer were enrolled in the same hospitals and matched to cases on age. A 24-gene sequencing panel was used to test germline mutations in cases and controls. Results: There were 176 cases and 177 controls with a mean age at diagnosis of 46.2 years for cases and mean age at interview of 46.7 years for controls. Among cases, 18.2% carried a pathogenic mutation in a breast cancer gene: 6.3% in BRCA1, 6.3% in BRCA2, 1.7% in ATM, 1.1% in PALB2, 0.6% in BARD1, 0.6% in CDH1, 0.6% in TP53, and 1.2% in any of 17 other genes. Among controls, 2.3% carried a pathogenic mutation in one of the 24 susceptibility genes. Cases were 9.6-fold more likely to carry a mutation compared with controls (odds ratio=9.61, 95% confidence interval: 3.28-38.1; P < 0.001). The mean age of breast cancer cases with pathogenic BRCA1 mutations was 38.3 years compared with 46.7 years among other cases without such mutations ( P = 0.03). There was a trend that cases with a positive family history had higher chance of carrying a mutation (33.3%) than cases without (17.1%), but few cases reported a positive family history. Conclusion: Our findings confirm the earlier report of a high proportion of deleterious mutations in BRCA1 and BRCA2 among breast cancer patients in sub-Saharan Africa. As most of these women present with advanced breast cancer, there is an urgent need to improve access to genomic testing and life saving cancer medicines including chemotherapy and clinical trials of novel agents like PARP inhibitors. Given the high burden of inherited breast cancer, genetic risk assessment should be integrated into cancer control plans in sub-Saharan Africa.

Abstract P4-02-10: Breast cancer surveillance in high-risk women with dynamic contrast-enhanced magnetic resonance imaging every 6 months: Results from a single institution study

Purpose: To develop a novel approach for early detection of breast cancer and examine molecular features of screen detected cancers in prospectively ascertained high-risk women undergoing semi-annual dynamic contrast-enhanced breast magnetic resonance imaging (DCE-MRI) for women at high genetic risk.

Background: Women with a personal or family history of breast cancer and genetic mutation carriers of BRCA1 and BRCA2 have a higher than normal risk of breast cancer. An intensified screening surveillance regimen is an early detection strategy in high-risk women. The American Cancer Society recommends annual DCE-MRI in addition to annual mammogram based off several pivotal screening studies that demonstrated improved sensitivity and cancer detection rates and decreased interval cancer rates with the addition of annual DCE-MRI. Questions remain regarding the optimal screening modality and interval regimen in these high-risk women.

Methods: Between 2004 and 2016, we assembled a prospective cohort of high-risk women undergoing semi-annual DCE-MRI and annual mammography. To be eligible, women had a lifetime breast cancer risk &gt;20% and/or tested positive for a pathogenic mutation using a cancer gene panel including BRCA1, BRCA2, CDH1, PALB2, CHEK2 and other cancer susceptibility genes in the DNA repair pathway. Somatic mutation events in screen-detected tumors were investigated using UW-OncoPlex cancer gene panel using DNA extracted from FFPE shavings.

Results: 295 women were recruited to the study; 44% of the study participants had pathogenic mutations in BRCA1 or BRCA2 genes. At a median follow-up of 3.3 years (range 0-12 years), 3 DCIS and 13 early stage invasive breast cancers were detected, of which 14 occurred in subjects with identifiable pathogenic mutations (11 BRCA1, 2 BRCA2, 1 CDH1). The incidence rate is 1.3% in all subjects, but 3.5 % per year in BRCA1 carriers. DCE-MRI identified all 13 invasive cancers at a mean size of 0.61 cm (range 0.1-1.0 cm); none had lymph node metastasis. No interval cancers occurred. In addition, 7 of the breast cancers were detected on DCE-MRI imaging obtained at the 6 months screening interval; they would be interval cancers if only annual screening were implemented. There was very little DNA for somatic mutation testing in the majority of cases. However, as expected, there was heterogeneity in the spectrum of mutations but the most commonly somatically mutated gene in the early cancers was TP53.

Conclusions: DCE-MRI every 6 months performed well for early detection of invasive breast cancer in high-risk women, accomplishing the ultimate goal of breast cancer screening—detecting node-negative, invasive tumors less than 1 cm. Semi-annual DCE-MRI performed especially well in BRCA1 mutation carriers at risk for the most aggressive subtype of breast cancer. Further interventional studies evaluating this novel screening approach are warranted to personalize breast cancer risk assessment and prevention.

Citation Format: Whitaker K, Guindalini R, Abe H, Sheeth D, Huo D, Hong S, Churpek J, Verp M, Obeid E, Zheng Y, Amico A, Yoshimatsu T, Olopade O. Breast cancer surveillance in high-risk women with dynamic contrast-enhanced magnetic resonance imaging every 6 months: Results from a single institution study [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 P4-02-10.

Should Minors Be Offered BRCA1/2 Testing for Hereditary Breast Cancer? Opinions of Parents Who Have Undergone BRCA1/2 Testing

Background: Professional societies recommend against the genetic testing of minors for hereditary cancer syndromes that present in adulthood. Yet, many adolescent specialists indicate that they would consider BRCA1/2 testing of minor children. We conducted interviews with parents who have had BRCA1/2 testing, to evaluate their opinions regarding the genetic testing of minors for BRCA1/2. Methods: 244 parents, including 67 BRCA1/2 mutation carriers (MCs), 140 parents with uninformative negative results (UN), 14 with true negative results (TN) & 23 with a variant of uncertain significance (VUS), from two cancer risk assessment programs completed semi-structured interviews. We used multiple logistic regressions to evaluate the associations among biomedical factors, demographic factors and support of testing minors. Wald tests and likelihood ratio tests were used to assess statistical significance for binary covariates and nominal covariates. Results: 38% of parents supported testing minors for BRCA1/2 in response to a dichotomous (Y/N) question. Support was greatest among parents with TN (64%) and UN (40%) results and lower among MCs (31%) and parents with a VUS (26%). In a multivariable analysis, support was greatest among parents who tested negative (p=0.02), were of minority race (p=0.06) and among fathers (&lt;0.01). Responses to open-ended questions suggest that 27% of parents unconditionally support testing of minors, and 25% support testing only in certain situations. Psychological risks, a lack of medical necessity and the insufficient maturity of minors, were frequent concerns of those opposed. The potential to positively impact minors' health behaviors was the most reported reason for supporting testing. Conclusions: Up to 52% of parents who have undergone BRCA1/2 testing support pediatric testing for BRCA1/2. Given willingness among general and pediatric practitioners and interest among parents, further research is necessary to formally evaluate the risks and benefits of providing genetic testing to minors for adult-onset hereditary cancer syndromes in order to inform clinical practice and public policy that will ensure optimal psychosocial and medical outcomes for all members of families at risk for hereditary cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4071.

The Effect of Preoperative MRI on Mastectomy Rates in Breast Cancer Patients

Background: Currently, there are two primary surgical options for the treatment of early stage breast cancer: modified radical mastectomy and breast conserving surgery (BCS) with post-surgical radiation. Numerous studies have shown that there is no survival difference between the two surgical treatments, however, in recent years, there is data to suggest that mastectomy rates have been on the rise. While many factors undoubtedly influence surgical management decisions in breast cancer patients, the effect of routine use of preoperative breast MRI may be a contributor to the rise in mastectomy rates. Methods: Breast cancer patients who were treated surgically and received a preoperative MRI were identified using a database from the University of Chicago Department of Radiology, which contains information on over 4200 patients who have received breast MRI since 2002. These patients were cross-referenced with data from the University of Chicago Cancer Registry, which contains information regarding type of surgical treatment, surgeon, stage of cancer at time of diagnosis and surgical stage for all breast cancer patients treated at the University of Chicago Hospitals from 2000-2007. Annual mastectomy rates from 2000-2007 were calculated and compared using Pearson's Chi Square test. Annual mastectomy rates were stratified by mean age at diagnosis and stage of disease. Mastectomy rates prior to routine use of preoperative MRI (2000-2002) and after routine use of preoperative MRI (2005-2007) were calculated for breast cancer patients under 45 and over 45 years of age and rates were compared using Fisher's exact test. Results: A total of 1,404 patients received surgical treatment for a new diagnosis of breast cancer between 2000 and 2007 at the University of Chicago Hospitals. Results to date indicate that mastectomy rates across all years are not significantly different (p = 0.315). Results also indicate that the mean age at diagnosis of patients who receive mastectomy as the initial surgical treatment for their breast cancer is higher than those who receive BCS from 2000-2002, but is lower than those who receive BCS from 2003-2007. In addition, breast cancer patients under the age of 45 have higher rates of mastectomy since the routine use of preoperative MRI which trends toward statistical significance (p = 0.0598). Conclusion: These preliminary results indicate that overall mastectomy rates at the University of Chicago Hospitals are not increasing in concordance with the increased use of preoperative MRI testing, but that younger breast cancer patients may have higher rates of mastectomy in the MRI era.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4019.

Concordance in Hormone Receptor Status between First and Second Breast Cancers

Background: Women with breast cancer are more likely to have second breast cancer. It is uncertain on the biologic relationship between the two tumor lesions. Whether the second cancer represents an independent second primary versus recurrent or metastatic disease has implications in both cancer treatment and understanding of carcinogenesis. This study was conducted to evaluate the concordance of estrogen receptor (ER) and progesterone receptor (PR) status, and examine factors that influence the concordance. This study also examined whether there is a difference in the proportion of hormone receptor positivity between two breast cancers.Methods: 37,362 patients with diagnoses of two breast cancers between 1990 and 2006 were identified through 17 cancer registries of the Surveillance, Epidemiology, and End Results program. Logistic regressions were used to assess the association in hormone receptor status between two cancers. Odds ratios (OR) and 95% confidence interval (CI) were used to indicate the strength of association. Conditional logistic regressions were used to examine the change in proportion of hormone receptor positivity.Results: The two breast cancers were contralateral in 79% of patients and ipsilateral in 21% of patients. There was a strong association in ER status between two tumors, with OR of 17.8 (CI: 14.2-22.3) for ipsilateral pairs and 8.85 (CI: 8.08-9.69) for bilateral pairs. The strength of association in ER status depended on lag interval between first and second tumor. In patients with ipsilateral cancers, the OR was 170 for synchronous tumors (&lt;1 month) and 6.6 for metachronous cases separated by 5 years or longer. In patients with contralateral cancers, the corresponding OR was 31.5 and 4.12. The strength of association also depended on age at diagnosis. In patients with contralateral cancers, the OR was 11.7 and 7.03 for patients with first breast cancer diagnosed before and after 50 years old, respectively. There was also a strong association in PR status between two tumors, with OR of 8.39 (CI: 6.95-10.1) for ipsilateral pairs and 4.84 (CI: 4.48-5.24) for bilateral pairs. The ER positive proportion in second tumors occurred within 1 year was similar to that of first tumors. However, compared with the first tumors, the odds of ER positivity was decreased by 47% and 21%, respectively, in second ipsilateral and contralateral breast cancers occurred 1-5 years after first tumors.Conclusions: Hormone receptor status of the primary breast cancer is strongly predictive of that of the second breast cancer, occurred either in the same or in contralateral breast, and the predictive value was very good even after 5 years. These findings suggest that two breast cancers of the same patient arise in a common predisposing milieu, which is probably predetermined by genetic makeup and/or environmental exposures in early life. The second cancer occurred after 1-5 years was more likely to be hormone receptor negative compared with the first cancer, suggesting that treatment for the first cancer, possibly tamoxifen, can modify the expression of subsequent breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4144.

Association of Proliferating Macrophages with High Grade, Hormone Receptor Negative Breast Cancer

Macrophages, a key cell in the inflammatory cascade, have been associated with poor prognosis in cancers, including breast cancer. Tumor associated macrophages (TAM) have also been shown to play a role in invasion and metastases. In this study, we investigated the role of a subset of macrophages known as proliferating macrophages (promacs) in breast cancer. We examined the relationship between promacs and clinico-pathologic characteristics such as tumor size, grade, lymph node metastasis, hormone receptor status, molecular subtype, and survival. This study was conducted at two independent institutions (University of California, San Francisco and University of Chicago) using two independent cohorts of patients with breast cancer. Formalin-fixed, paraffin-embedded sections and/or tissue microarrays were double-stained with anti-CD68 (a macrophage marker) and anti-PCNA (a proliferation marker) antibodies. The number of total macrophages as well as promacs per high power field were counted. Molecular subtypes were determined from gene expression array analyses. Outcomes were available for a subset of the cases and Kaplan Meier survival curves were generated.Tumor tissue from two different cohorts of patients with breast cancer were stained and analyzed at two independent institutions. In both studies, promac density was significantly correlated with higher grade, hormone-receptor negative tumors, and a basal-like subtype. In contrast there was no correlation between numbers of promacs and tumor size, stage, or number of involved lymph nodes. The presence of increased promacs was a significant predictor of survival in these treated patients. Proliferating macrophages are more abundant in high grade tumors, and predict a worse outcome, independent of stage and grade. These findings, corroborated at two independent institutions, suggest that the presence of promacs is associated with tumor progression and increased promac density may serve as a prognostic indicator for poor outcomes. Novel therapies that are able to target and halt the activity of promacs may be a promising strategy for the treatment of promac rich tumors.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3042.

Genetic Risks for Breast Cancer in African American Women: Analysis of Candidate Single Nucleotide Polymorphisms from Association Studies

Background: African American breast cancer patients present with more aggressive disease than Caucasian women. They are also more likely to experience earlier onset of illness and tumors that are resistant to current treatment options due to their high grade and negative hormone receptor status. These attributes are correlated with greater mortality. The different frequencies of these indicators in African American and Caucasian patients have been associated with genetic susceptibility and genetically driven progression of breast cancer. However, these studies have focused on well-known breast cancer genes, not the low-penetrance mutations identified by genome-wide association studies (GWAS).Aims: This pilot case-control replication study investigated both the overall and attribute-based breast cancer risk of African American women associated with three single nucleotide polymorphisms (SNPs) selected through previously published association studies, including a genome-wide association study by Gold et al. (2008), and predicted high odds ratios and high minor allele frequencies in the African American population compared to the original study populations. We hypothesized that rs2180341 and rs7776136, located in 6q22.33 and associated with risk in a GWAS of Ashkenazi Jewish familial breast cancer cases, would contribute to overall risk in a case-control cohort of African American women. We also hypothesized that rs3741378, a SNP in SIPA1 previously associated with hormone-receptor negative tumors, would contribute to this outcome in the same cohort. These SNPs were additionally studied for relevance to other clinical outcomes.Methods: Two hundred and eighteen cases and 105 controls from the University of Chicago Cancer Risk Clinic were genotyped for these three SNPs using SNaPshot multiplex. Clinical information, including age of diagnosis, family history, hormone receptor status, survival, and tumor grade and stage, was also collected. Statistical analysis was performed using Pearson's χ2 test, Fisher's exact test, logistic regression and supplementary tests in Stata.Results: Unlike other populations, the African American population showed allelic odds ratios of approximately 1.0 for all SNPs tested, indicating no statistically significant association between these SNPs and breast cancer risk. We also found no association with age of diagnosis, hormone receptor status, tumor stage and grade. However, the minor allele of rs2180341 was associated with decreased survival in patients with a hazard ratio of 3.991 (p=0.044, 95% CI: 1.038-15.337) for the homozygous minor allele genotype.Conclusion: This pilot study represents one of the first forays into the translation of breast cancer GWAS results to populations of African ancestry. Based on our preliminary findings, future studies on a larger cohort of breast cancer cases of African ancestry will be needed to identify risk factors that may be particular to this patient population.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3068.

Lifestyle modifications including complementary and alternative medicine and quality of life among women at high risk for breast cancer

e20583

Background: Breast cancer (BC) patients commonly employ lifestyle modifications (LM) such as complementary and alternative medicine (CAM), but limited information exists among women who are high risk for BC (HRBC). This study's aims were to estimate the prevalence of LM use among HRBC patients, describe communication patterns, and determine correlations with quality of life (QoL) measures. Methods: Women enrolled in a multi-modality screening study for HRBC patients (≥20% lifetime risk) were distributed a questionnaire asking about the use of CAM therapies and other LM, timing of use, reasons, costs, and communication patterns. QoL measures included the Short-Form 36 (SF-36) and Beck Depression Inventory (BDI). Demographic variables and those instruments with significant correlations (p<0.05) were included in a multivariate model. Results: A total of 173 HRBC patients are enrolled on this study and 123 have completed the survey. General characteristics of these women include a median age of 45 years, 91% Caucasian, 30% have a gene mutation (e.g. BRCA1/2), and 33% have had breast and/or ovarian cancer. Ninety-nine percent reported a lifetime prevalence of LM and CAM, and nearly half of subjects (48%) did so for cancer-related reasons. The most popular LM were exercise (83%), massage (68%), yoga (44%), vitamin E (38%), and chiropractic medicine (36%). The most common cancer-related changes were low fat diet (15%), exercise (11%), and meditation (10%). Half of subjects (48%) did not discuss any of these LM with their physicians, and the most common reason was their physician did not ask. In the multivariate model for cancer-related LM, subjects having a history of BC or ovarian cancer were 6.2 times (p<0.001) more likely to use LM and CAM. Subjects with a below average SF-36 general health subscale score were 3.4 times (p<0.05) more likely to pursue non-biologically based CAM, and those with an elevated BDI (score>9) were 6.2 times (p<0.05) less likely to pursue dietary changes. Conclusions: LM including CAM are highly prevalent among women at HRBC. Oncologists should inquire about LM and CAM use and explore reasons for this including QoL.

No significant financial relationships to disclose.

Parent perceptions of offspring responses to parental communication of BRCA1/2 test results

1511

Background: Many BRCA1/2 mutation carriers report sharing their genetic test results with their minor children. The impact of this communication on offspring remains unknown. Methods: 163 parents who had BRCA1/2 testing completed qualitative interviews regarding their experiences with communication of their genetic test results to offspring. Descriptive responses were coded and response proportions utilized to summarize results. We used multiple regressions fit by GEE to test associations with disclosure. We controlled for parent mutation status in each regression. Results: 163 parents (52 BRCA1/2 mutation carriers) reported on 323 offspring 5 to 25 years old at the time of parent genetic testing. 107 (66%) parents reported disclosing to at least one offspring. Child age (p < 0.001) and parent cancer history (p = 0.004) were positively associated with disclosure. Parents without a BRCA1/2 mutation were more likely to communicate test results than parents with a mutation (p = 0.007). Among parents who disclosed, few (14%) reported they perceived their offspring to have had an initial negative affective or behavioral response. Others (13%) reported offspring concern for self and family. Reports of initial negative responses and concern were more frequent among parents with a mutation or a variant of uncertain significance. Many parents reported that the communication had no significant impact (39%) or a positive impact (36%) on their offspring. Conclusions: Many parents report sharing BRCA1/2 test results with their offspring. Parent self-reports suggest that they do not perceive most offspring to experience adverse reactions to this communication. Self-reports suggest that offspring learning of a BRCA1/2 mutation or a variant of uncertain significance may be more susceptible to initial negative reactions. Further research is necessary to explore psychosocial and behavioral responses to learning of hereditary risk during childhood and adolescence, and to inform the development of interventions to optimize adaptive response.

No significant financial relationships to disclose.

Telephone disclosure of BRCA1/2 test results? Experience and opinions of genetic counselors and consumers

1510

Background: BRCA1/2 test results have historically been disclosed in person (IPD) by a certified genetic counselor (GC). Greater consumer demand and access to BRCA1/2 testing, and greater prevalence and acceptance of telemedicine, have interested providers in conducting BRCA1/2 testing and disclosing results by telephone (TD) and internet. GC and consumer experiences and opinions about TD have not been well described. Methods: To determine experience, opinions and interest in TD of BRCA1/2 test results we conducted semi-structured interviews with 194 GC recruited via NSGC Cancer Special Interest Group and with 30 consumers (to date) less than 9 months post IPD of BRCA1/2 test results at two cancer centers. Descriptive statistics characterize GC and consumer experiences and opinions. Results: 98% GC had provided TD; 46% rarely. Most frequent reasons for TD: perceived consumer hardship of IPD (n = 190); consumer preference (n = 49) and medical benefit (n = 30). GC comfort with TD varied by test result (true negative [TN] 77%, indeterminate [IND] 49%; mutation carriers [MC] 37%; variant of unknown significance [VUS] 33%). GC cited consumer convenience (n = 132), medical (n = 71) and psychological benefit (n = 42), and greater GC counseling capacity (n = 33) as TD advantages. No nonverbal communication (n = 161), poorer communication/understanding (n = 67), and difficulty explaining complex results (n = 41) were disadvantages GC most frequently reported. 46% post-IPD consumers reported interest in TD; interest varied by test result (VUS 67%; IND, 63%; TN 57%; MC 25%). Consumers’ perceived advantages: convenience (n = 22) and medical benefit (n = 9); and disadvantage to TD; lack of visual and personal connection with GC (n = 18). Conclusions: Results of the ongoing study suggest many consumers of BRCA1/2 testing are interested in, and nearly all GC have conducted, TD. GC and consumers share perceptions of TD convenience, and of challenges of lack of visual cues, however, GC comfort with, and consumer preference for, TD vary differently by test result. Given consumer and provider interest, longitudinal study of TD impact on knowledge, risk perception, communication, and health behaviors, and their mediators will be critical to develop policy and procedures optimizing adaptive responses to TD.

No significant financial relationships to disclose.

The role of VEGFR-2 genetic variation in breast cancer progression

Abstract #904

Background: Substantial laboratory and clinical data have demonstrated the critical role of angiogenesis in breast tumor progression. A significant correlation between vascular endothelial growth factor receptor-2 (VEGFR-2) expression and cell proliferation has been described in invasive breast carcinomas, suggesting that VEGF stimulates mammary cell growth through VEGFR-2. We sought to examine whether variability in VEGFR-2 expression and activation in tumors might be due to individual genetic variations, which may also play a role in response to anti-angiogenic therapy. To our knowledge, no study has correlated genetic variation in VEGFR-2 to expression and activity in primary breast tumors.&#x2028; Methods: DNA from 42 primary breast tumors was extracted from fresh frozen tissue. The core promoter, 5'-untranslated region (UTR), 3'-UTR, exons and intron-exon boundary regions of VEGFR-2 were sequenced for all tumors. Tissue microarrays were constructed, and tumor and paired normal breast tissue were stained with anti-VEGFR-2 antibody (Calbiochem). Microvessel density (MVD) was determined by immunohistochemical staining using a primary antibody against platelet endothelial cell adhesion molecule (anti-CD34, Novocastra). Semiquantitative analysis was performed independently by two pathologists. VEGFR-2 expression was correlated with genotype and MVD using the Mann-Whitney test. VEGFR-2 expression in normal and tumor tissue was compared using the Wilcoxon signed-rank test.&#x2028; Results: Two-thirds of tumors were from self-reported African Americans (AA), and the majority were ER positive. Twenty-three different single nucleotide polymorphisms (SNPs) were identified; ten were previously reported in dbSNP. Three of these SNPs were common (minor allele frequency &gt;10%): one was located in the core promoter region and the other two were located in exons 7 and 11 (both non-synonymous SNPs). Using PolyPhen prediction software (http://genetics.bwh.harvard.edu/pph/), the two non-synonymous SNPs were predicted to affect protein function. Of the 23 different SNPs identified, 11 were only seen in tumors from AA and 3 were only observed in tumors from Caucasians. Thirty-six of the 42 tumors (86%) had at least one SNP. VEGFR-2 expression in tumor was significantly higher than in paired normal tissue (p=0.0002). VEGFR-2 expression was significantly lower in tumors with the AA genotype of the 4032 A/G core promoter SNP as compared to those with the AG and GG genotypes combined (p=0.02). VEGFR-2 expression was significantly associated with MVD in tumor tissues (p=0.04).&#x2028; Discussion: Our preliminary study suggests an association between genetic variations in the VEGFR-2 gene and protein expression in tumor tissue. Future work will examine the spectrum of these genetic variations in diverse populations and their potential role in predicting response to anti-angiogenic therapy.&#x2028; This study was funded by the University of Chicago Breast SPORE NCI P50 CA125183.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 904.

Rapid progression of prostate cancer in men with a BRCA2 mutation

Men with BRCA2 mutations have been found to be at increased risk of developing prostate cancer. There is a recent report that BRCA2 carriers with prostate cancer have poorer survival than noncarrier prostate cancer patients. In this study, we compared survival of men with a BRCA2 mutation and prostate cancer with that of men with a BRCA1 mutation and prostate cancer. We obtained the age at diagnosis, age at death or current age from 182 men with prostate cancer from families with a BRCA2 mutation and from 119 men with prostate cancer from families with a BRCA1 mutation. The median survival from diagnosis was 4.0 years for men with a BRCA2 mutation vs 8.0 years for men with a BRCA1 mutation, and the difference was highly significant (P<0.01). It may be important to develop targeted chemotherapies to treat prostate cancer in men with a BRCA2 mutation.

Breast cancer risk after bilateral prophylactic oophorectomy in BRCA1 mutation carriers

BACKGROUND

The availability of genetic testing for inherited mutations in the BRCA1 gene provides potentially valuable information to women at high risk of breast or ovarian cancer; however, carriers of BRCA1 mutations have few clinical management options to reduce their cancer risk. Decreases in ovarian hormone exposure following bilateral prophylactic oophorectomy (i.e., surgical removal of the ovaries) may alter cancer risk in BRCA1 mutation carriers. This study was undertaken to evaluate whether bilateral prophylactic oophorectomy is associated with a reduction in breast cancer risk in BRCA1 mutation carriers.

METHODS

We studied a cohort of women with disease-associated germline BRCA1 mutations who were assembled from five North American centers. Surgery subjects (n = 43) included women with BRCA1 mutations who underwent bilateral prophylactic oophorectomy but had no history of breast or ovarian cancer and had not had a prophylactic mastectomy. Control subjects included women with BRCA1 mutations who had no history of oophorectomy and no history of breast or ovarian cancer (n = 79). Control subjects were matched to the surgery subjects according to center and year of birth.

RESULTS

We found a statistically significant reduction in breast cancer risk after bilateral prophylactic oophorectomy, with an adjusted hazard ratio (HR) of 0.53 (95% confidence interval [CI] = 0.33-0.84). This risk reduction was even greater in women who were followed 5-10 (HR = 0. 28; 95% CI = 0.08-0.94) or at least 10 (HR = 0.33; 95% CI = 0.12-0.91) years after surgery. Use of hormone replacement therapy did not negate the reduction in breast cancer risk after surgery.

CONCLUSIONS

Bilateral prophylactic oophorectomy is associated with a reduced breast cancer risk in women who carry a BRCA1 mutation. The likely mechanism is reduction of ovarian hormone exposure. These findings have implications for the management of breast cancer risk in women who carry BRCA1 mutations.

Predisposition testing for inherited breast cancer

Predisposition testing (i.e., genetic testing that provides information about a person's susceptibility to disease) is now available for several inherited forms of cancer. Individuals who are found to have an altered gene (e.g., a germ-line mutation in a cancer susceptibility gene) have a higher risk of developing cancer than those who do not carry an altered gene. Therefore, predisposition testing can be a powerful clinical tool for assessing a person's risk for developing cancer. All health care providers, particularly cancer care providers, should be knowledgeable about cancer predisposition testing options. This article provides an overview of predisposition testing for inherited breast cancer, including general facts about testing, potential risks and benefits, specific genetic counseling issues, and molecular details of known breast cancer susceptibility genes.

Increased p16 levels correlate with pRb alterations in human urothelial cells

The CDKN2 (MTS1) gene is located at 9p21; its product, p16, inhibits the cyclin D/CDK4 complex that phosphorylates pRb, thus negatively regulating cell cycle progression [M. Serrano et al., Nature (Lond.), 366: 704, 1994; A. Kamb et al., Science (Washington DC), 264: 436, 1994; T. Nobori et al., Nature (Lond.), 368: 753, 1994]. CDKN2 mutations are more common in cultured human uroepithelial cells (HUC) than in uncultured bladder cancers. We examined the status of CDKN2/p16 in early and late passage (P) cultures of HUC. HUC immortalization was not accompanied by p16 loss, even in cells with a hemizygous 9p21-pter deletion, but late passage cultures with a p16 loss showed decreased generation time. Thus, the data do not indicate that CDKN2 is a candidate for a chromosome 9 senescence gene but suggest that p16 loss may confer a growth advantage in vitro. Significant differences in p16 levels were observed among HUC cell lines, but no CDKN2 mutations were detected. However, an inverse correlation between elevated p16 and loss of pRb function was observed (P < 10(-4)). Ten samples with normal pRb showed low or undetectable p16 levels, while seven samples with known pRb alterations showed abundant p16 but nevertheless grew vigorously in culture. These results support the hypothesis that p16 mediated cell cycle inhibition, as well as p16 regulation, occurs via pRb dependent pathway(s).

Clinical, morphologic, and cytogenetic characteristics of patients with lymphoid malignancies characterized by both t(14;18)(q32;q21) and t(8;14)(q24;q32) or t(8;22)(q24;q11)

Six patients with an aggressive leukemia/lymphoma disorder had a t(14;18) as well as either a t(8;14) (three patients) or a t(8;22) (three patients). Leukemia cells from all three patients with the t(8;22) had a mature B cell phenotype (Smlg + and TdT-), whereas two of three patients with the t(8;14) had a pre-B phenotype and were Smlg-. None of the patients with the t(8;22) had a prior history of follicular lymphoma, whereas two of the three patients with the t(8;14) had had a follicular lymphoma. The clinical, cytogenetic, and morphologic characteristics of these six patients along with eight previously reported cases with both the t(14;18) and the t(8;14), the t(8;22) or the t(2;8) are discussed.