Obesity and the outcome of young breast cancer patients in the UK: the POSH study

BACKGROUND

Obese breast cancer patients have a poorer prognosis than non-obese patients. We examined data from a large prospective cohort study to explore the associations of obesity with tumour pathology, treatment and outcome in young British breast cancer patients receiving modern oncological treatments.

PATIENTS AND METHODS

A total of 2956 patients aged ≤40 at breast cancer diagnosis were recruited from 126 UK hospitals from 2001 to 2007. Height and weight were measured at registration. Tumour pathology and treatment details were collected. Follow-up data were collected at 6, 12 months, and annually.

RESULTS

A total of 2843 eligible patients (96.2%) had a body mass index (BMI) recorded: 1526 (53.7%) were under/healthy-weight (U/H, BMI <25 kg/m(2)), 784 (27.6%) were overweight (ov, BMI ≥25 to <30), and 533 (18.7%) were obese (ob, BMI ≥30). The median tumour size was significantly higher in obese and overweight patients than U/H patients (Ob 26 mm versus U/H 20 mm, P < 0.001; Ov 24 mm versus U/H 20 mm, P < 0.001). Obese and overweight patients had significantly more grade 3 tumours (63.9% versus 59.0%, P = 0.048; Ov 63.6% versus U/H 59.0% P = 0.034) and node-positive tumours (Ob 54.6% versus U/H 49.0%, P = 0.027; Ov 54.2% versus U/H 49%, P = 0.019) than U/H patients. Obese patients had more ER/PR/HER2-negative tumours than healthy-weight patients (25.0% versus 18.3%, P = 0.001). Eight-year overall survival (OS) and distant disease-free interval (DDFI) were significantly lower in obese patients than healthy-weight patients [OS: hazard ratio (HR) 1.65, P < 0.001; DDFI: HR 1.44, P < 0.001]. Multivariable analyses adjusting for tumour grade, size, nodal, and HER2 status indicated that obesity was a significant independent predictor of OS and DDFI in patients with ER-positive disease.

CONCLUSIONS

Young obese breast cancer patients present with adverse tumour characteristics. Despite adjustment for this, obesity still independently predicts DDFI and OS.

P2-12-03: A Prospective Study of the Prognostic Implications of Being a BRCA1 Carrier for Young Onset Breast Cancer Patients

Background

BRCA1 gene carriers frequently develop triple negative breast cancer (TNBC) at young ages. Retrospective studies have reached conflicting conclusions about the prognostic implications of breast cancer diagnosed on a background of a constitutional BRCA1 gene mutation. Many studies have the disadvantages of retrospective design and small numbers or both. The Prospective study of Outcomes in Sporadic versus Hereditary breast cancer (POSH) recruited 3024 patients diagnosed before 41 years of age and treated for breast cancer in the UK between 2000 and 2007 (protocol published: Eccles et al BMC Cancer 2008).

Aim: To investigate the effect of family history and BRCA1 gene mutation status on breast cancer survival in women aged younger than 41 years at diagnosis.

Methods: Cases in which the primary tumour pathology report was not available (2.8% of total) were excluded from this analysis. A completed family history questionnaire was available for 2907 cases (99% of total). The primary end point for this analysis was the development of distant metastases from breast cancer. All patients were younger than the starting age for screening in the UK except for known gene carriers of which there were only 8 in total, the remainder of identified gene carriers were tested after cancer diagnosis or as part of this study. Over 90% of patients received adjuvant or neoadjuvant chemotherapy with over 90% of these receiving an anthracycline based regimen. Kaplan Meier survival analysis and log rank test were used to assess survival differences.

Results: 2937 patients were included in the analysis. Mean and median age at diagnosis was 36 years and the cohort was followed prospectively for a mean and median follow up time of 50 months. Overall distant disease free survival in the whole cohort was only 75% at 5 years. The effect of family history on presentation was explored. Patients who reported a first or second degree relative with breast cancer presented with smaller tumours (20mm compared to 22.5mm, p= 0.006) but no difference in axillary nodal status (p=0.2605). Survival was however significantly better comparing the 499 patients who reported a family history of breast cancer compared with the rest of the cohort (p=0.0164). 539 patients had been tested for mutations in the BRCA1/2 genes and 176 high risk gene BRCA1/BRCA2 carriers were identified. We compared 118 patients with a known BRCA1 gene mutation (almost all diagnosed after the cancer) to the 465 patients with confirmed TNBC (p=0.0118). Survival was significantly better in the BRCA1 carriers (p=0.0118). After excluding 29 gene carriers whose primary tumour showed any of ER, HER2 or PR as positive, the same improved survival trend was seen although significant at the 10% level (p=0.07).

Conclusion: This prospective study indicates that BRCA1 gene carriers clearly do not have a worse prognosis when compared to triple negative breast cancers or young onset breast cancer overall and these early follow up data indicate an improved outlook in gene carriers.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-03.

UK guidance document: treatment of metastatic breast cancer

Although there have been major improvements in the management of breast cancer, with a rapidly falling death rate despite an increasing incidence of the disease, metastatic breast cancer remains common and the cause of death in nearly 12 000 women annually in the UK. Numerous treatment options are available that either target the tumour or reduce the complications of the disease. Clinical decision making depends on knowledge of the extent and biology of the disease and available drug options, an understanding of the functional status, and also the wishes and expectations of the individual patient. In addition, the organisation of services and support of the patient are essential components of high-quality care. The National Institute for Health and Clinical Excellence (NICE) has produced guidelines for the treatment of advanced breast cancer, which in some areas have perhaps failed to appreciate the complexity of patient management. This guidance document aims to provide succinct practical advice on the treatment of metastatic breast cancer, highlight some limitations of the NICE guidelines, and provide suggestions for management where available data are limited.

A case controlled, cross-sectional survey of joint and muscle aches, pains and stiffness in women with primary breast cancer

Abstract #1116

Background: The long term consequences of treatment for breast cancer are becoming increasingly important as both the incidence rises and survival improves. Joint and muscle aches, pains and stiffness are some of the most commonly described problems amongst women treated for breast cancer, yet there is little primary research focusing on this issue. Inevitably some of these symptoms will be caused by ageing, however there is some evidence to suggest that they are specific to or exacerbated by primary breast cancer treatment (Felson and Cummings, 2005). Clinical observations suggest that there may be specific patterns of pain with specific breast cancer treatments. No previous research has compared the prevalence and patterns of these symptoms to those in women of a similar age without cancer.&#x2028; Aims: 1.To determine the prevalence of joint and muscle aches, pains and stiffness in women after treatment for primary breast cancer and to compare with age matched controls.&#x2028; 2.To explore the patterns of these symptoms in different parts of the body.&#x2028; Methods: We recruited 247 women with breast cancer following primary breast cancer treatment and 272 without breast cancer attending for mammographic screening and benign breast clinics. They completed the Nordic musculoskeletal pain questionnaire, the Brief Pain Inventory (BPI) and the SF-36 general health questionnaire. Medical and demographic details were collected as well as information about factors which might affect these symptoms, such as menopausal status and weight.&#x2028; Results: Current pain was reported by 143(62%) women in the breast cancer group as opposed to 125(49%) in the non cancer group (p=.005). Current pain was significantly worse in the breast cancer group at a mean of 4.2 on a ten point scale (BPI) compared to 3.4 in women without breast cancer(p=.006), although interference to daily activities as a result of pain was not significantly increased. The hands (p=.02) and upper back (p=.003) were more likely to be reported as a site of pain in women with breast cancer, while neck pain was more common in women without breast cancer (p=.04). Hands (p=.02) and upper back pain (p=.008) also significantly affected women's activities in the last 12 months. Although pain in the feet was not reported as more common in women with breast cancer it was more likely to affect activity in the last 12 months (p=.01).&#x2028; Discussion: This study provides evidence that joint pains are more prevalent and more severe in women with breast cancer than women of the same age without breast cancer. Patterns of pain showed specificity to the hands and upper back, which were also worse than in women without breast cancer. The fact that women reported that foot pain was more likely to affect their activity suggests that although it was not more common, it was more troublesome in women with breast cancer. Further analyses will explore the impact of symptoms on quality of life.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1116.

Management of spinal cord and cauda equina compression secondary to epidural metastatic disease in adults with malignant germ cell tumours

AIM

To review the management and clinical outcome of 10 patients, presenting to a single centre with symptoms and signs of spinal cord or cauda equina compression secondary to epidural metastatic disease from a testicular germ cell cancer.

METHODS

Clinical data regarding presenting history, physical examination, staging investigations, treatment and clinical outcome were retrospectively obtained from patient records.

RESULTS

Eight patients exhibited neurological deficits at the time of initial presentation of germ cell cancer or as a first manifestation of relapse following dog leg irradiation. Four of these cases were managed with chemotherapy alone, with excellent neurological recovery, whilst four underwent decompressive laminectomy--in three cases prior to referral and in one case after commencing chemotherapy. Five of the eight patients relapsed. Four required further chemotherapy (high dose in two cases). The remaining patient underwent thoracic surgery, with resection of teratoma differentiated. Six of the eight patients are currently alive and disease free. Two patients had chemorefractory disease and died, though one was treated in the pre-cisplatin era. Two patients presented with cord compression as a feature of disease relapse following chemotherapy, and were managed with radiotherapy alone in an attempt to achieve local disease control and limit neurological dysfunction. However, both subsequently died with progressive disease.

CONCLUSION

Epidural spinal cord or cauda equina compression is a rare complication of metastatic germ cell cancer, which can be successfully managed in chemo-naive patients with good neurological outcome.

Orchidectomy after chemotherapy for patients with metastatic testicular germ cell cancer

OBJECTIVE

To evaluate the contribution of routine orchidectomy in the management of patients who present with advanced, metastatic, testicular germ cell cancer and who are treated with initial chemotherapy.

PATIENTS AND METHODS

Sixty consecutive patients presenting with metastatic testicular germ cell cancer and treated with initial chemotherapy followed by orchidectomy were identified. The results from a clinical and pathological review of these patients are presented. The pathological findings at orchidectomy were compared with the pathological findings from metastatic masses resected after chemotherapy, and are reviewed with the clinical outcome.

RESULTS

Of the 60 orchidectomy specimens after chemotherapy, 24 (40%) contained significant histological abnormalities comprising residual invasive germ cell cancer, intratubular germ cell neoplasia and/or mature teratoma. The remaining 36 (60%) orchidectomy specimens contained fibrous scarring with or with no necrosis. Six (10%) orchidectomy specimens contained residual invasive germ cell cancer, three nonseminomatous germ cell cancer (NSGCT) and three seminoma. The patients with residual invasive NSGCT present within the testis had evidence of residual invasive NSGCT within extragonadal masses resected after chemotherapy; all three have relapsed and died from chemorefractory progressive disease.

CONCLUSION

Orchidectomy after chemotherapy is recommended in all patients undergoing primary chemotherapy, as a significant proportion (40%) are left with histological abnormalities that predispose to subsequent relapse. Persistence of invasive NSGCT at the site of the primary tumour after chemotherapy is associated with persistence of invasive disease at other metastatic sites and is a poor prognostic finding.

Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group

BACKGROUND

The effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved postoperative life expectancy, or at least one that is not diminished by the surgery. Because colorectal cancer is a major cause of morbidity and mortality in elderly people, we have examined how the outcomes of surgery in elderly patients differ from those in younger patients.

METHODS

We did a systematic review of published and aggregate data provided by investigators. Studies were identified by computerised and manual searches of published and unpublished reports, scanning references, and contacting investigators. Within each study, outcomes for patients aged 65-74 years, 75-84 years, and 85+ years were expressed in relation to those aged less than 65 years.

FINDINGS

From 28 independent studies, and a total of 34,194 patients, we found that elderly patients had an increased frequency of comorbid conditions, were more likely to present with later-stage disease and undergo emergency surgery, and less likely to have curative surgery than younger patients. The incidence of postoperative morbidity and mortality increased progressively with advancing age. Overall survival was reduced in elderly patients, but for cancer specific survival age-related differences were much less striking.

INTERPRETATION

The relation between age and outcomes from colorectal cancer surgery is complex and may be confounded by differences in stage at presentation, tumour site, pre-existing comorbidities, and type of treatment received. However, selected elderly patients benefit from surgery since a large proportion survive for 2 or more years, irrespective of their age.

Enteropathy-type intestinal T-cell lymphoma: clinical features and treatment of 31 patients in a single center

PURPOSE

We report the clinical features and treatment of 31 patients with a diagnosis of enteropathy-type intestinal T-cell lymphoma treated at the Wessex Regional Medical Oncology Unit in Southampton between 1979 and 1996 (23 men, eight women).

PATIENTS AND METHODS

Patients were identified from our lymphoma database. Details of history, physical examination, staging investigations, treatment, and outcome were taken from patient records.

RESULTS

Twelve patients (35%) had a documented clinical history of adult-onset celiac disease, and a further three had histologic features consistent with celiac disease in resected areas of the small bowel not infiltrated with lymphoma. After diagnosis, 24 (77%) of the 31 patients were treated with chemotherapy; the remaining seven had surgical treatment alone. More than half were unable to complete their planned chemotherapy courses, often because of poor nutritional status; 12 patients required enteral or parenteral feeding. A response to initial chemotherapy was observed in 14 patients (complete response, n = 10; partial response, n = 4). Observed complications of treatment were gastrointestinal bleeding, small-bowel perforation, and the development of enterocolic fistulae. Relapses occurred 1 to 60 months from diagnosis in 79% of those who responded to initial therapy. Of the total 31 patients, 26 (84%) have died, all from progressive disease or from complications of the disease and/or its treatment. The actuarial 1- and 5-year survival rates are 38.7% and 19.7%, respectively, with 1- and 5-year failure-free survival rates of 19.4% and 3.2%, respectively.

CONCLUSION

The prognosis for these patients is poor. This, in part, reflects late diagnosis and poor performance status at the time of presentation. The role of salvage treatments and high-dose chemotherapy at relapse is not clear. However, it is encouraging that there are five long-term survivors in our patient population.

Lymphadenopathy due to amyloid deposition in non-Hodgkin's lymphoma

BACKGROUND

Amyloidosis is a rare complication of non-Hodgkin's lymphoma. Most of the reported patients have had systemic amyloidosis and have died as a result of complications of this disease.

MATERIALS AND METHODS

The clinical cases of two patients with lymphoplasmacytic non-Hodgkin's lymphoma who presented with lymphadenopathy due to localised amyloid deposition are reviewed. Immunohistochemical studies were performed on the amyloid deposits and adjacent lymphoma.

RESULTS

The amyloid deposits in both patients were derived from monoclonal light chains of the same isotype as those expressed by the lymphoma cells and were localised to areas adjacent to the lymphoma despite the presence of circulating light chains. Both patients had an indolent clinical course and treatment appeared to have little influence on the amyloid deposition.

CONCLUSIONS

Non-Hodgkin's lymphoma may be associated with localised amyloidosis secondary to local production and deposition of amyloid from monoclonal light chains synthesised by the lymphoma cells. This is a rare cause of lymphadenopathy which does not respond to treatment of the underlying lymphoma.

PACE BOM chemotherapy: a 12-week regimen for advanced Hodgkin's disease

BACKGROUND

This study was designed to evaluate the efficacy and toxicity of a 12-week alternating weekly chemotherapy regimen for advanced Hodgkin's disease. Consolidative irradiation of residual masses was used in selected cases.

PATIENTS AND METHODS

Eighty-three patients with newly diagnosed advanced Hodgkin's disease (bulky stage IIA, stage IIB-IVB) or with progressive disease after extended field radiotherapy for early stage disease were included in this study. The patients were treated for 12 weeks with PACE BOM comprising oral prednisolone together with intravenous doxorubicin, cyclophosphamide and etoposide alternating weekly with intravenous bleomycin, vincristine and methotrexate. Limited field adjuvant radiotherapy was also given to 21 patients with localised persistent radiological abnormalities visible on chest X-ray after chemotherapy. The study end points were overall survival, failure free survival (FFS) and toxicity, particularly with respect to reproductive function.

RESULTS

With a median post treatment follow up of 52 months the actuarial 5-year overall survival is 90% (confidence interval 81%-95%) and FFS is 64% (52%-74%). This treatment was well tolerated and fertility was maintained in a high proportion of young adults.

CONCLUSIONS

The brief duration PACE BOM regimen with or without radiotherapy appears to be comparable in efficacy to other doxorubicin containing regimens, with a favourable toxicity profile. Randomised clinical trials are now needed to evaluate the role of this and comparable initial treatment approaches to advanced Hodgkin's disease.

Primary pure teratoma of the testis

PURPOSE

Despite its histologically benign appearance, primary pure teratoma of the testis is believed to have metastatic potential and behave similarly to other nonseminomatous germ cell tumors. We present our experience with the natural history and management of pure teratoma.

MATERIALS AND METHODS

We reviewed the histological findings and clinical history of 15 patients with primary pure teratoma who were treated during a 15-year period, accounting for 4.2% of all nonseminomatous germ cell tumors treated during the same period. Fourteen patients were available for followup and are included in this report.

RESULTS

In 8 patients the tumor was composed entirely of mature teratoma and in 6 immature elements were also present, although this finding was not associated with an increased frequency of metastatic disease. Carcinoma in situ was found adjacent to the tumor in 12 cases. Of 10 patients with stage I disease at presentation who were entered on a surveillance program only 2 have had relapse. The remaining 4 patients had metastatic disease at presentation and, thus, metastatic disease occurred in a total of 6 of the 14 patients (43%) with a median followup of 46 months (range 5 to 197). Metastatic disease was confined to the retroperitoneum in all 6 patients and only 2 patients had elevated serum marker levels. Five patients were treated with primary chemotherapy followed by resection of a residual mass and in all cases teratoma was identified in the resected mass. One patient underwent surgical excision of a retroperitoneal mass, which contained teratoma and yolk sac tumor, followed by chemotherapy. All patients are alive without evidence of progressive disease.

CONCLUSIONS

In patients with primary pure teratoma of the testis metastatic disease may develop and the metastases may contain other subtypes of nonseminomatous germ cell tumors in addition to teratoma. There is probably a reduced frequency of relapse, which should be considered when advising patients with stage I disease, but otherwise management should be the same as for other testicular nonseminomatous germ cell tumors and the prognosis should be excellent.

Orchiectomy after chemotherapy in patients with metastatic testicular cancer. Is it indicated?

BACKGROUND

A small proportion of patients with testicular germ cell tumors present with widely metastatic disease and are treated initially with chemotherapy. Little is known about the efficacy of systemic chemotherapy in eradicating the primary testicular germ cell cancer; however, there is concern that the testis may act as a sanctuary site for germ cell cancer in these patients, and orchiectomy, is, therefore, recommended after chemotherapy.

METHODS

The results from a clinical and pathologic review of 24 patients who underwent delayed orchiectomy after chemotherapy are presented. The testicular pathologic findings are correlated with those in extragonadal masses and also with a blinded review of postchemotherapy testicular ultrasound scans.

RESULTS

The most common testicular pathological finding was a dense fibrous scar that was found in all patients. Three patients had persistent testicular germ cell cancer, six had mature teratoma, and one had carcinoma in situ. There was a strong concordance between the major testicular pathologic findings and those in the resected extragonadal masses. All three patients with persistent testicular germ cell cancer subsequently had disease progression in the extragonadal sites. Testicular ultrasound examination did not distinguish accurately between residual tumor or scar in the testis.

CONCLUSION

Persistence of the primary testicular germ cell cancer is most likely due to the same heterogeneous response to chemotherapy observed in different metastatic sites. Because current imaging techniques cannot identify accurately those patients with residual testicular germ cell cancer or related testicular abnormalities that may predispose to subsequent relapse, orchiectomy after chemotherapy remains appropriate.

A complicated case of metastatic teratoma. Growing teratoma syndrome and cerebral metastasis

All patients presenting with metastatic teratoma should be regarded as potentially curable and this case demonstrates the multiple treatment modalities which are often needed in the management of such patients. Increasing experience with cisplatin based combination chemotherapy has led to the development of prognostic factors which are used to determine the intensity of treatment given to individual patients. Surgical intervention plays a very important role in the management of residual disease at the completion of chemotherapy. Recognition of the growing teratoma syndrome and the importance of early surgical excision is illustrated by this case. Isolated CNS relapse may occur because the CNS may act as a sanctuary site in patients receiving systemic chemotherapy, but does not preclude long term disease free survival.