[What do clinicians do with the results of the systematic staging imaging at the time of the breast cancer diagnosis?]

INTRODUCTION

Asymptomatic distant metastasis is often looked for at the time of initial diagnosis of early breast cancer. However, there is no consensus on when to perform it and on the consequences on the treatment.

PATIENTS AND METHODS

One hundred and twenty-three asymptomatic women receiving systemic neoadjuvant (32 patients) or adjuvant treatment (91 patients) for breast cancer at the Oscar-Lambret center in September 2011 were considered. The staging imaging was a PET scan for 59 patients (pts), a CT scan and a bone scan for 59 patients and both for 5 patients. The result for each procedure was considered normal, abnormal but typically benign or potentially malignant. In this case, another imaging technique was carried out to confirm the suspected diagnosis. The patient was considered metastatic if the results of two different procedures were concordant and eventually in case of response to chemotherapy.

RESULTS

Nine pts were considered metastatic (9/125=7%). They were stage 1: 1, stage 2: 4 and stage 3: 4. The staging by CT, abdomen and pelvis scan coupled with bone scintigraphy discriminated five metastatic patients with overdiagnosis of 33 benign lesions and the need of 20 additional confirmatory tests. Similarly, the PET staging, more expensive, only discriminated two metastatic patients and 15 benign lesions requiring 20 confirmatory tests.

CONCLUSION

These results support the international recommendations to make a staging from stage IIIA. The CT, abdominal and pelvic scan coupled with bone scintigraphy should be considered as a gold standard in breast cancer staging.

A retrospective case series of 103 consecutive patients with leptomeningeal metastasis and breast cancer

Approximately 2-5 % of patients with breast cancer (BC) develop leptomeningeal metastasis (LM). 103 consecutive patients with BC were diagnosed with LM and initially treated with intra-CSF liposomal cytarabine from 2007 to 2011 at a single institution. Correlations were determined with respect to patient characteristics and BC subtype with regard to overall survival (OS). At LM diagnosis, 61 % of patients had a 0-2 performance status (PS), the remaining 39 % were severely neurologically impaired. Regardless of PS, all patients received intra-cerebrospinal fluid (CSF) liposomal cytarabine as first-line treatment. Systemic treatment and radiotherapy were also given in 58 and 17 % of patients respectively as clinically appropriate. Second- (intra-CSF thiotepa) and third-line (intra-CSF methotrexate) treatment was administered in 24 and 6 patients respectively. Median OS was 3.8 months (range 1 day-2.8 years). In multivariate analysis, an initial combined treatment, a second-line treatment with intra-CSF thiotepa, an initial clinical response, and a non-'ER/PR/HER2 negative' BC were significantly associated with a better OS. Median OS in this heterogeneous retrospective case series was similar to that of previously observed BC patients treated with intra-CSF methotrexate suggesting intra-CSF liposomal cytarabine is a reasonable first choice therapy of BC-related LM.

Association of PHB 1630 C>T and MTHFR 677 C>T polymorphisms with breast and ovarian cancer risk in BRCA1/2 mutation carriers: results from a multicenter study

BACKGROUND

The variable penetrance of breast cancer in BRCA1/2 mutation carriers suggests that other genetic or environmental factors modify breast cancer risk. Two genes of special interest are prohibitin (PHB) and methylene-tetrahydrofolate reductase (MTHFR), both of which are important either directly or indirectly in maintaining genomic integrity.

METHODS

To evaluate the potential role of genetic variants within PHB and MTHFR in breast and ovarian cancer risk, 4102 BRCA1 and 2093 BRCA2 mutation carriers, and 6211 BRCA1 and 2902 BRCA2 carriers from the Consortium of Investigators of Modifiers of BRCA1 and BRCA2 (CIMBA) were genotyped for the PHB 1630 C>T (rs6917) polymorphism and the MTHFR 677 C>T (rs1801133) polymorphism, respectively.

RESULTS

There was no evidence of association between the PHB 1630 C>T and MTHFR 677 C>T polymorphisms with either disease for BRCA1 or BRCA2 mutation carriers when breast and ovarian cancer associations were evaluated separately. Analysis that evaluated associations for breast and ovarian cancer simultaneously showed some evidence that BRCA1 mutation carriers who had the rare homozygote genotype (TT) of the PHB 1630 C>T polymorphism were at increased risk of both breast and ovarian cancer (HR 1.50, 95%CI 1.10-2.04 and HR 2.16, 95%CI 1.24-3.76, respectively). However, there was no evidence of association under a multiplicative model for the effect of each minor allele.

CONCLUSION

The PHB 1630TT genotype may modify breast and ovarian cancer risks in BRCA1 mutation carriers. This association need to be evaluated in larger series of BRCA1 mutation carriers.

Familial transmission of information dealing with BRCA1/2 mutations in hereditary breast and ovarian cancer

Abstract #1104

Background: A mutation of the BRCA1/2 genes is implicated in 5 to 10% of the breast and ovarian cancer cases. In France, when such a genetic mutation is discovered in a family, the consulting persons are expected to transmit themselves this medical information to their relatives. Indeed, for legal reasons, physicians are not allowed to contact them personally. An important gap has been observed however between the number of persons who are potentially concerned by this genetic information and the number of persons actually consulting. We then wondered about (1) the actual transmission of genetic information to relatives, (2) possible reasons for the non-transmission of this information, (3) the rate of concerned consulting relatives and (4) presumed reasons for not consulting when informed.
 Methods: This sample includes 31 target consultants (index cases) of mutated families who received the result of the genetic test between January 2003 and June 2005. Data were gathered in two successive steps: some were first referring to consultants' medical files, then we called these target consultants asking them standardized questions about their relatives. Final analyses concern 264 relatives complying with our selection criteria.
 Results: According to information gathered thanks to medical files and calls to target consultants, most of the relatives (73.1 %) are informed that a deleterious mutation is present in the family. Women are more often informed (80.7 %) than men (63.2 %). The non-informational motives are on the one hand mainly social and emotional distance and, on the other hand, the stressful content of this information. It would be disclosed through family by the women who are alive and carry the mutation. Moreover, a minority of the presumed informed women (39.7 %) have attended the oncogenetic consultation. This rate represents 32 % of all concerned women. Almost no man has consulted. We can just assume the motives for short-term absence of consultation. They seem to be especially linked to relatives' disinterest towards genetic information. The studied characteristics just allow us to point out the closeness with a mutated relative as a determinant factor of consultation.
 Discussion: This study brings two main results linked to relatives' information and consultation when a breast and ovarian cancer genetic risk has been identified in the family. On the first hand, it confirms that familial transmission of the medical information is pretty good. On the other hand, despite the good communication among family members, the rate of consultation remains low in informed women. According to these findings, efforts have to be made to give better explanations about the goals of oncogenetic consultation as well as enhancing the quality of information transmission in mutated families. These improvements could raise consultation rates and then increase the efficiency of screening and preventive measures.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1104.

[Role of MRI in the presurgical work-up of breast cancer: appropriate utilization of MRI as a complement to mammography and ultrasound]

The role of MRI for presurgical local staging of breast cancers amenable to conservative treatment has been the subject of multiple publications and tends to become a "validated" indication in routine practice. The purpose of the paper is to review the advantages and limitations of this imaging modality that is part of a comprehensive management that must be validated by clinical data especially with regards to local recurrence and survival. Knowledge of these elements combined with more precise indications should result in improved patient management while avoiding overtreatment or unnecessary anxiety-producing examinations.

[Follow-up of patients treated for localized invasive breast carcinoma]

The follow-up of patients treated for invasive breast carcinoma remains a major challenge because of breast cancer prevalence and the frequent patient's preferences for a regular follow-up. Concerning this last point, there is a lack of studies about the consequences of a systematic follow-up. Few decades ago, regular and systematic follow-up was considered as a dogma. In 1994, it was seriously questioned by two randomised Italian trials: they did not find any benefit in terms of survival and quality of life in patients who had a regular search of asymptomatic metastasis. Follow-up strategy after early breast cancer is still an unexplored field, despite higher performance of investigation tests and development of new treatments strategies that allowed a significant decrease of recurrences and increase of cancer care. Currently, the international guidelines deeply recommend a regular physical examination and mammography. But a systematic search for non-symptomatic metastases is unnecessary. We now need a coordination between practitioners to avoid useless tests, and to respond to patients' will.

Comparison of physicians' and cancer prone women's attitudes about breast/ovarian prophylactic surgery. Results from two national surveys

Prophylactic surgery is a major issue for breast/ovarian cancer prone women. Bio-clinical data to help in the decision-making are not sufficient. In this context of uncertainty, physicians' and women's attitudes to prophylactic surgery is information of great value. The physicians' attitudes were assessed by a randomised national sample of practitioners involved in breast and ovarian cancer management. The patients' attitudes were appraised with a pre-consultation self- administered questionnaire presented during a one-year period to all women in five cancer genetic clinics chosen, for their representative geographical locations and their activity level. Consent to prophylactic surgery is higher among physicians than among patients (p < 0.0001). Acceptability of mastectomy is lower than that of oophorectomy in both patients and physicians (p < 0.0001 in both groups). In addition, age at which the intervention is proposed to be performed is a key determinant for both mastectomy and oophorectomy acceptability, in both physicians and patients (p < 0.001 for each comparison). Particularly, the age of 40 years seems to be a critical threshold for the acceptability of prophylactic oophorectomy. In contrast, respondents' age at the time of the survey has no significant effect on the acceptability rate. The higher acceptability rate of prophylactic oophorectomy compared to that of mastectomy observed in the physicians' survey is paradoxical because a more substantial medical impact on life expectancy was expected from the latter. Our results indicate that assumed reduced mortality is not the main criterion steering acceptability. It was anticipated that prophylactic mastectomy should be rarely performed in France.

Multicenter phase II-III study of oxaliplatin plus cyclophosphamide vs. cisplatin plus cyclophosphamide in chemonaive advanced ovarian cancer patients

PURPOSE

A phase II-III randomised study to compare safety and efficacy of an oxaliplatin/cyclophosphamide (OXAC) combination, vs. the reference combination of cisplatin/cyclophosphamide (CPC), in untreated advanced ovarian cancer patients.

PATIENTS AND METHODS

182 patients were enrolled, of whom 177 were treated: 86 with OXAC (130 mg/m2 oxaliplatin two-hour intravenous (i.v.) infusion, 1,000 mg/m2 cyclophosphamide two-hour i.v. infusion), and 91 with CPC (100 mg/m2 cisplatin one-hour i.v. infusion. 1,000 mg/m2 cyclophosphamide two-hour i.v. infusion). Treatment cycles were repeated every three weeks (maximum of six cycles).

RESULTS

The main toxicities, which were significantly less severe in the OXAC arm, were myelosuppression and vomiting, including (OXAC vs CPC, % patients): grade 3-4 leukopenia (37% vs. 56%), and anaemia (7% vs. 32%), with blood transfusions in 8% vs. 21%. In the OXAC arm, 64% of surgically assessable patients and 33% of clinically assessable patients achieved an objective response. In the CPC arm, 67% patients achieved a surgical response and 42% achieved an objective clinical response. In the OXAC and CPC arms, median progression free-survival was 13.0 and 13.3 months, and overall survival was 36.0 and 25.1 months respectively, without statistically significant difference.

CONCLUSION

The activity and time-related parameters of the OXAC and CPC combinations in advanced ovarian cancer patients, are comparable. Combined with the better safety profile of the oxaliplatin-containing regimen, this confirms the interest of oxaliplatin combined with active new agents in this indication.

[Evidence-based medicine: towards evidence-based radiology]

PURPOSE

To present evidence-based medicine (EBM), a concept that has been emerging over the decade, and to propose a reflexion about the role of radiologists in this new paradigm of medical practice. Clinical decision making. This new paradigm proposes the use of the best evidence and patient's participation in making medical decisions with de-emphasizing of intuition and empirical medicine. Application to a practice policy. EBM imposes new skills for physicians: clinical practice guideline is a witness of its importance. The main objective of EBM is to assist practitioners in their decision making process, but limits of this new concept must be known when it is used to control health-care resources or practice policies. Towards evidence-based radiology. What is the place for radiologists (diagnosis or interventional) in this new very popular paradigm?

Clinical evidence for topotecan-paclitaxel non--cross-resistance in ovarian cancer

PURPOSE

A large, randomized study comparing the efficacy and safety of topotecan versus paclitaxel in patients with relapsed epithelial ovarian cancer showed that these two compounds have similar activity. In this study, a number of patients crossed over to the alternative drug as third-line therapy, ie, from paclitaxel to topotecan and vice versa. We therefore were able to assess the degree of non-cross-resistance between these two compounds.

PATIENTS AND METHODS

Patients who had progressed after one platinum-based regimen were randomized to either topotecan (1.5 mg/m(2)/d) x 5 every 21 days (n = 112) or paclitaxel (175 mg/m(2) over 3 hours) every 21 days (n = 114). A total of 110 patients received cross-over therapy with the alternative drug (61 topotecan, 49 paclitaxel) as third-line therapy.

RESULTS

Response rates to third-line cross-over therapy were 13.1% (8 of 61 topotecan) and 10.2% (5 of 49 paclitaxel; P =.638). Seven patients who responded to third-line topotecan and four patients who responded to paclitaxel had failed to respond to their second-line treatment. Median time to progression (from the start of third-line therapy) was 9 weeks in both groups, and median survival was 40 and 48 weeks for patients who were receiving topotecan or paclitaxel, respectively. The principal toxicity was myelosuppression; grade 4 neutropenia was more frequent with topotecan (81.4% of patients) than with paclitaxel (22.9% of patients).

CONCLUSION

Topotecan and paclitaxel have similar activity as second-line therapies with regard to response rates and progression-free and overall survival. We demonstrated that the two drugs have a degree of non-cross-resistance. Thus, there is a good rationale for incorporating these drugs into future first-line regimens.

[Patient choice for cancer treatment: towards a shared-decision model?]

The process of medical decision implies the elaboration of a choice between alternatives. Who has the choice? The doctor? The patient? Both? That depends on the particular characteristics of the patient and of the tumour, but also of the characteristics of the doctor and of his approach of medical discipline. For that reason, we planned first to remind some principles. In our analysis, the patient-doctor's relationship ties with environment, culture and habits. Philosophical principles, moral, and models of the relation between patient and doctor concern first part. In the second part, these ideas are compared with our routine practice: surveys about patients' needs, the obstacles for complete information and participation, studies on patients' preferences. The authors' analysis is that we are going inescapably towards shared decision-making taking into account the patients preferences. This evolution is not only tied with ethical principles, but with medical reason, i.e. the variability of patients' preferences led to tailor the treatment to the individual patient especially when benefit is limited. Of course, the applicability of a shared model depends on the particular situation of the patient and of his demand. It is all the easier as the consequences of the treatment are well known the riks tiny and distant. In the classical paternalistic model, there is no choice for the patient because the doctor(s) give the treatment. In the ideal model of the shared decision, doctor and patient progress together towards medical decision, in this case, the patient is not alone facing a choice, and in all cases, he is never alone.

Tamoxifen adjuvant treatment duration in early breast cancer: initial results of a randomized study comparing short-term treatment with long-term treatment. Fédération Nationale des Centres de Lutte Contre le Cancer Breast Group

PURPOSE

In 1986, The Fédération Nationale desCentres de Lutte Contre le Cancer Breast Group initiated a multicenter randomized trial to assess the usefulness of long-term adjuvant tamoxifen treatment. Short-term adjuvant tamoxifen treatment was to be compared with life long adjuvant tamoxifen treatment.

PATIENTS AND METHODS

Patients who were disease-free after 2 to 3 years of adjuvant tamoxifen treatment were eligible for the trial. From September 1986 to May 1995, 3,793 patients were randomized from France, Belgium, and Argentina. A total of 1,882 patients stopped tamoxifen (short-term group), and 1,911 patients were to continue tamoxifen for life (long-term group) at the same dose as previously prescribed. The protocol was modified in February 1997, limiting tamoxifen treatment to 10 years after randomization, thus giving a comparison between a 2- to 3-year treatment and a 12- to 13-year treatment. To date, the median duration of tamoxifen treatment is 30 months in the short-term group, and 70 months in the long-term group.

RESULTS

Overall, longer tamoxifen treatment induced a 23% reduction in relapse rates, leading to a 7-year disease-free survival rate of 78%, compared with 72% in the shorter-treatment group. In contrast, overall survival did not differ between the two groups, with a 79% overall survival rate in both groups. This improvement in disease-free survival could be observed in node-positive patients (P: =.001); however, it was not found in node-negative patients. Prolonged tamoxifen treatment corresponded to a significant increase in disease-free survival in estrogen receptor-positive patients (P: =.03) as well as in estrogen receptor-negative patients (P: =.05). Furthermore, longer treatment reduced contralateral breast cancers and did not increase the number of endometrial cancers.

CONCLUSION

Although no survival advantage was noted, patients did benefit from longer tamoxifen treatment over 3 years and had significantly better disease-free survival compared with patients who stopped hormonal treatment. Long-term follow-up is needed to assess these results. Most patients in the long-term group are still receiving treatment. Comparison of results as time passes will enable conclusions to be made on the value of long-term treatment over 5 years compared with 2 to 3 years.

[Predictive value of abdominopelvic scan for optimal surgery of ovarian carcinoma]

BACKGROUND

Some patients undergo laparoscopy without optimal debulking surgery as initial treatment for advanced ovarian carcinoma. The amount of residual tumor following primary surgery is an important prognosis factor. Neoadjuvant chemotherapy is a new therapeutic approach. Secondary, optimal surgery could be done in better conditions.

PURPOSE

To access the ability of preoperative abdominopelvic CT to predict success of debulking surgery for ovarian carcinoma: less than 1cm of residual tumor size after initial surgery.

MATERIALS AND METHODS

We reviewed 39 patients (two stage Ic, 1 stage IIc, 22 stage III and 14 stage IV) operated on for ovarian carcinoma between January 1992 and December 1997. Surgical criteria of inability to perform optimal surgical cytoreduction were compared with abdominopelvic CT done the month before. CT scans were prospectively assessed by radiologist A and retrospectively (3 months to 6 years delay) reviewed separately by radiologists A and B without surgical data.

RESULTS

Nineteen patients underwent optimal debulking surgery: 13 no residual tumor and 6 with residual lesions under 1cm. The interreader (0.73) and intrareader (0.9) agreement, worked out by Kappa coefficient, was judged good to very good. The sensitivity of CT was 91% with a specificity of 95%.

CONCLUSION

These results allowed us to determine which CT criteria were accurate and reproducible to be a helpful for therapeutic choice and to avoid laparotomy without optimal surgery.

Evaluation of toxicity and efficacy of 186Re-hydroxyethylidene diphosphonate in patients with painful bone metastases of prostate or breast cancer

Twenty-eight patients (12 men with prostate cancer, 16 women with breast cancer) were included in a phase II trial to evaluate the efficacy of 186Re-hydroxyethylidene diphosphonate (HEDP) on pain from bone metastasis and the toxicity of this agent.

METHODS

After intravenous administration of 1295 MBq 186Re-HEDP, the efficacy was evaluated by means of a daily log.

RESULTS

We observed an objective response in 67% of prostate cancer patients and in 36% of breast cancer patients. The mean duration of response was 45 d for prostate cancer patients and 24 d for breast cancer patients. No major adverse effects were observed. Marrow toxicity did not exceed grade 2 for white blood cells and grade 3 for platelets using National Cancer Institute criteria.

CONCLUSION

186Re-HEDP provides safe symptomatic relief of pain in prostate cancer patients. The benefit of this treatment is less clear in breast cancer patients. Further studies should be conducted to evaluate treatment by 186Re-HEDP at an earlier stage of the disease.

Disclosure to the family of breast/ovarian cancer genetic test results: patient's willingness and associated factors

Informed probands are key actors for disclosing genetic information to their relatives when a mutation has been identified in the family. The objectives were to study women's attitudes towards the family disclosure of positive breast cancer genetic testing results and to determine the predictive factors of the diffusion patterns observed. A national multi-center cross-sectional survey was carried out at five French cancer genetic clinics during a 1-year period. Self-administered questionnaires were completed after the consultation by 84.5% (398/471) of women attending breast cancer genetic clinics for the first time. Among the 383 respondents who had at least one living first-degree relative to inform, 8.6% would inform none, 33.2% would inform at least one of them, and 58.2% would inform all of them. The sibship would be the most frequently informed blood relatives, sisters in 86.9% and brothers in 79% compared with mother in 71.4%, children in 70.4%, and father in 64.9%. Women of the family would be more frequently informed than men (P < 0.05). After multivariate adjustment, age, the fact to be affected by cancer, the number of daughters, and the emotional disturbance due to cancer in a close relationship were the main determinants (P < 0.05) of the diffusion patterns observed. The first step of the relatives' attendance to genetic counseling and the proband's willingness to disclose breast cancer genetic tests results was high in this study and was clearly dependent on the women's personal and emotional characteristics.

Surgical staging of early invasive epithelial ovarian tumors

Early stage epithelial ovarian carcinoma is defined pathologically as a tumor strictly limited to one or both ovaries without any extra-ovarian disease (i.e., Stage IA or B of the International Federation of Gynecology and Obstetrics (FIGO) classification). This diagnosis can be obtained only after an exhaustive surgical staging procedure, performed as soon as the diagnosis of epithelial invasive ovarian carcinoma is established. This staging surgery currently encompasses a peritoneal cytology, the thorough inspection of all the visceral and parietal peritoneal surfaces with biopsy of any abnormality, total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO), random peritoneal biopsies, omentectomy, appendectomy and bilateral pelvic and para-aortic lymphadenectomies, up to the left renal vein. The results of this staging procedure and its indications are discussed. In all of the cases, the radical removal of the pathologic adnexa is indicated, along with the complete peritoneal and retroperitoneal staging. While fertility-sparing surgery (avoiding hysterectomy and contralateral adnexectomy, if possible) seems to be safe for young women, a TAH + BSO is the rule for the others. Adjuvant chemotherapy can be omitted in well-differentiated tumors with a negative staging operation, but currently it remains indicated in all other cases. Indeed, the ultimate goal in early stage ovarian carcinoma is to not impair by inadequate management the high chance of a cure.

[Predictive value of preoperative abdominopelvic CT for optimal cytoreduction surgery in ovarian carcinoma]

Some patients underwent laparoscopy without optimal debulking surgery as initial treatment for advanced ovarian carcinoma. The amount of residual tumor following primary surgery was an important prognosis factor. Neoadjuvant chemotherapy is a new therapeutic approach. Secondary, optimal surgery could be done in better conditions. The purpose was to access the ability of preoperative abdominopelvic CT to predict success of debulking surgery for ovarian carcinoma: less than 1 cm of residual tumor size after initial surgery. We reviewed 39 patients (2 stages Ic, 1 stage IIc, 22 stages III and 14 stages IV) operated on for ovarian carcinoma between January 1992 and December 1997. Surgical criteria of inability to perform optimal surgical cytoreduction were compared with abdominopelvic CT done the month before. CT scans were prospectively assessed by radiologist A and retrospectively (3 months to 6 years delay) rewiewed separately by radiologists A and B without surgical data. Nineteen patients underwent optimal debulking surgery: 13 no residual tumor and 6 with residual lesions under 1 cm. The interreader (0.73) and intrareader (0.9) agreement, worked out by Kappa coefficient, was juged good to very good. The sensitivity of CT was 91% with a specificity of 95%. These results allowed us to determine wich CT criteria were accurate and reproducible to be a helpfull for therapeutic choice and to avoid laparotomy without optimal surgery.

A multicenter phase II study with triptorelin (sustained-release LHRH agonist) in advanced or recurrent endometrial carcinoma: a French anticancer federation study

The objective of this phase II multicenter study was to assess the efficacy and tolerance of triptorelin (a sustained-release LHRH agonist) in advanced or recurrent endometrial cancer. A total of 101 monthly intramuscular injections were administered to 24 eligible patients (median number/patient = 3; range 1-12). Mainly due to progression, only 16 patients received 3 or more injections. Among the 23 evaluable patients, 1 complete and 1 partial response (response rate of 8.7%) and 5 disease stabilizations were observed, often of long duration, but never in an irradiated area or after progestogens treatment failure. Median survival for eligible patients was 7.2 months (range: 1-36 months). Only grade 1 toxicities possibly related to the treatment were observed in 4 patients. In conclusion, triptorelin was safe, well tolerated, and easily manageable, and the very low toxicity did not impair the quality of life in these patients with a very poor prognosis. Although the response rate was disappointing, several patients showed early evidence of efficacy which may be of long duration. Response rates range between 0 and 45% in different published studies. Additional studies with stricter inclusion criteria and a larger sample size are necessary to better evaluate the role of LHRH agonists in endometrial adenocarcinomas.

Results of a European Organization for Research and Treatment of Cancer/Early Clinical Studies Group phase II trial of first-line irinotecan in patients with advanced or recurrent squamous cell carcinoma of the cervix

PURPOSE

To determine the efficacy and tolerability of irinotecan (CPT-11) in advanced or recurrent cervical carcinoma.

PATIENTS AND METHODS

Eligible patients had histologically confirmed, inoperable, progressive, metastatic or recurrent squamous cell cervical carcinoma and had received no radiotherapy in the preceding 3 months and had never received chemotherapy. The initial irinotecan dosage of 350 mg/m(2) every 3 weeks was modifiable according to toxicity. Treatment continued for six cycles after complete response, or until disease progression or excessive toxicity after partial response, or for three additional cycles in the case of stable disease. Patients were stratified into group A (>/= one measurable lesion in a previously unirradiated area, with or without progressive disease in irradiated fields) or group B (measurable new lesion[s] in an irradiated field).

RESULTS

Fifty-one of 55 enrolled patients were eligible for inclusion (median age, 47 years; range, 30 to 71 years). The response rate was 15.7% (95% confidence interval [CI], 7.0% to 28.6%) overall, 23.5% (95% CI, 10.7% to 41.2%) for group A (complete response, 2.9%), and zero for group B. The median time to progression and median survival were 4.0 and 8.2 months for group A and 2.5 and 4.2 months for group B, respectively. The major grade 3/4 toxicities for groups A and B were diarrhea (24.3% and 55.5%, respectively) and neutropenia (24.3% and 33.3%, respectively). There were four toxicity-related deaths, three in group B. Patients with no prior external pelvic irradiation experienced fewer grade 3 and 4 adverse events.

CONCLUSION

Irinotecan is effective in treating cervical squamous cell carcinoma if disease is located in an unirradiated area. Because of toxicity, a reduced dose is advised for patients previously treated with external pelvic irradiation.

Novel indications for BRCA1 screening using individual clinical and morphological features

Since there is a lack of common family profile among BRCA1-gene carriers, and since the risk of being a mutation carrier is not limited to women with a family history of breast or ovarian cancer, multivariate statistical analysis using the logistic-regression model was carried out, to discriminate between sporadic cases and BRCA1-breast cancers (BRCA1-BCs), especially when information about the family history of breast/ovarian cancer and ethnicity are irrelevant or unavailable, in order to offer specific medical treatment to this population. We examined 32 BRCA1-BCs selected at cancer genetic clinics and 200 consecutive controls without family history of breast cancer for age at onset and current morphological parameters. Following the multivariate analysis, 3 parameters only, namely, early age at cancer onset [odds ratio (OR) for each year = 1.16; p < 0.0001], estrogen-receptor negativity (OR = 5.7; p = 0.01) and poor differentiation (OR = 5; p = 0.03) were found significant factors for predicting BRCA1-carrier status. The expected impact in BRCA1 screening of our model was estimated using data on 5700 breast-cancer cases from a hospital-based registry. Only 50 and 15% of tumours with early age at onset below 35 years present one or the other 2 discriminant parameters respectively. Consequently, whereas the probability of finding a BRCA1 mutation is rated low (6.2%) when the sole criterion of early onset up to the age of 35 years is used, based on our model, in the sub-group of women with a tumor that is both estrogen-receptor-negative and poorly differentiated the mutation-detection rate is predicted to be above the 10% chance level recommended by the ASCO guidelines. This sub-group of women, representing about 1% of all breast-cancer cases in Western countries, consequently deserves to be tested.

Cancer genetic clinics: why do women who already have cancer attend?

Cancer patients attend oncogenetic clinics so that the existence of a genetic risk can be checked and the relatives informed. The aim of this study was to describe the expectations of cancer patients about genetic counselling and their beliefs about the aetiology of their disease. A survey based on self-administered questionnaires before and after the consultation was carried out on 115 women with breast/ovarian cancer who attended one of the six French participating clinics. In 59 cases (51%), the consultees' expectations focused on the preventive options available and in 86 cases (75%) on their offspring; 87 (76%) found the consultation informative. On average, the women rated heredity and diet as lower risk factors (P < 0.05) after the consultation than before. Heredity, stress and the environment were thought to be more decisive than diet, smoking and alcohol. 34 patients who seemed unlikely to have a genetic risk in the consultant's opinion thought heredity to be less relevant (P < 0.05) after the consultation than before. At the time of the survey, cancer patients accounted for at least half of the consultees attending oncogenetic clinics in France. They need to have the clinical specificities of their disease and its medical management explained. They attend mainly for their offspring's sake, whereas healthy clients attend for their own sake.

[Information for patients with cancer of the colon: results of a survey of gastroenterologists, surgeons, and oncologists of the North region]

This regional survey was aimed to detect hypothetical variations in attitudes among truth telling in colon cancer by an anonymous questionnaire sent to the 290 gastroenterologists, surgeons and oncologists of the Northern France area. The answers were assessed as always (A), often (O), rarely and never. Diagnosis was revealed to the patient (whether or not he asked the question) or to his spouse in 83%, 40% and 93% of the cases, respectively. The diagnosis of diffuse metastasis was revealed (A + O) to the patient or to his spouse in 23% and 95% of the cases, respectively. Only 3% of the physicians told (A + O) the patient that his condition was incurable while this aspect was A + O revealed to the patient's spouse in 34% of the cases. Most of the time, the diagnosis of colon cancer was revealed by oncologists rather than by surgeons or gastroenterologists. Conversely the full truth was more commonly told to the family by surgeons and gastroenterologists than by oncologists. We found variation in attitudes towards truth telling in colon cancer which depend on the physician's specialty. It seems to us that the magnitude of the full truth told to the patient or his family in Northern France area, is somewhat intermediate between the attitude of doctors in Northern Europe and in Latin Mediterranean or Eastern Europe countries.

Time elapsing from cancer diagnosis and anxiety in women attending cancer genetic clinics

The aim of this study was to investigate the effects of cancer genetic consultations on feelings of anxiety in women with breast/ovarian cancer. Among the 138 women attending six French clinics during a one-year period, 115 (83.3%) answered pre- and post-consultation questionnaires. The state anxiety score (Spielberger's STAI) was lower (paired t-test, p<0.001) after the consultation (34.7 9.4) than before (38.8 10.5). The time elapsing since cancer diagnosis (r=-0.28, p=0.007) was the main predictor of the decrease in anxiety. The patients consulting earlier after their cancer was diagnosed were more anxious before the consultation than those consulting later: whereas their anxiety states after the consultation were similar. The consultation effectively decreased the anxiety observed and the anxiety felt by cancer patients before the consultation may constitute an anticipatory stress response that should be investigated.

[Dupuytren's contracture and diabetes mellitus]

The literature suggests that the frequency of Dupuytren's disease is ten times greater in diabetes than in the general population. We have studied 42 diabetic patients with a contracture of the palmar fascia. Dupuytren's contracture can be considered a complication of diabetes and of the local neurovascular changes since both are often associated. The contracture is usually not severe in diabetes, is nodular in form, and usually crushes the palmar surface of the long and ring fingers. It is usually well tolerated by the patients and surgery is rarely indicated, particularly in view of the advanced age of many patients. In caring for patients with Dupuytren's disease, surgeons should also rule out the presence of diabetes with appropriate test.

Germline BRCA1 mutations in patients from 84 families with breast and/or ovarian cancers in northern France

The BRCA1 gene modification is responsible for an autosomal dominant syndrome of inherited early onset breast and/or ovarian cancer. This gene is estimated to account for almost half of inherited breast cancers and three quarters of inherited breast/ovarian cancers. This suggests that about 1 in every 500 women may carry the BRCA1 mutation. The BRCA1 was isolated by positional cloning in 1994. More than 100 different mutations have been found in the germline of affected individuals. Using systematic sequencing, we looked at BRCA1 germline mutations in 84 patients treated at the Centre Oscar Lambret for breast and/or ovarian cancer who belonged to high-risk families. We found 39 mutations: 22 true mutations inducing modifications of the BRCA1 protein (BRCA1+), six mutations with unknown consequences on the BRCA1 protein, and eleven mutations corresponding to polymorphisms that had been described previously. All the BRCA1+ cases had a HPG3 tumour. The median age of discovery and the receptor positivity percentage are lower in hereditary breast cancer than in the standard population of the breast cancers treated in our centre. Conversely, most of the BRCA1+ patients are without node involvement. This shows that BRCA1 mutations are not always related to parameters thought to indicate a bad prognosis.

[Comparative study of tumor evaluation with computerized tomography and surgery in ovarian cancer]

PURPOSE

To evaluate the results of an abdomino-pelvic scan in cancers of the ovary in comparison with surgery.

MATERIAL AND METHODS

We reviewed the observations concerning patients operated on for malignant tumors of the ovary between January 1992 and April 1995 in our anti-cancer center. We selected 32 patients who had had both a complete surgical abdominal exploration (laparotomy or laparoscopy) and an abdominal pelvic scan in the preceding months. We divided the abdomen into 33 areas and compared the scan of each with the surgical findings. Two cancer radiologists, including one gynecology specialist, studied the imaging separately. Neither knew the results of the surgical observations.

RESULTS

Imaging findings varied with localization tumor size and presence or not of ascites radiologists. For certain localization, detection of lesions was difficult for both readers (pancreas, spleen, stomach), for others, recognition improved with experience (bowel, diaphragm, colon).

CONCLUSION

The clinician must be aware of the variability of ovarian cancer assessment by CT scan, particularly if imaging alone is being used to guide treatment.

[Germ-line mutation of BRCA1 in patients with breast and/or ovarian cancer in high risk families in Northern France]

The BRCA1 gene modification is responsible for an autosomal dominant syndrome of inherited early onset breast and/or ovarian cancer. This gene is estimated to account for almost half of inherited breast cancers and three quarters of inherited breast/ovarian cancers. This suggests that about 1 out of 500 women may carry BRCA1 mutation. The BRCA1 gene was isolated by positional cloning in 1994. More than 100 different mutations have been found in the germline of affected individuals. We looked by systematic sequencing at BRCA1 germline mutations in 36 patients treated at the Centre Oscar-Lambret for breast and/or ovarian cancer and that belonged to high risk families. We have found 24 mutations: 9 true mutations inducing modifications of the BRCA1 protein (BRCA1+), 5 mutations with unknown consequences on the BRCA1 protein and 10 mutations corresponding to polymorphisms that had been previously described. All the BRCA1+ cases had a HPG3 tumor. The median age of discovery and the receptor positivity percentage are lower in hereditary breast cancer than in the standard population of the breast cancers treated in our center. Consequently, BRCA1 mutations are associated to parameters thought to be of bad prognosis.

[Paraneoplastic superior vena cava thrombosis disclosing an ovarian tumor]

We report the case of a patient who was admitted in hospital for evaluation of a superior vena cava thrombosis. The patient exhibited an activated protein C resistance due to an arginine-506 mutation in factor V. Thoracic CT-scan showed a non-compressive complete superior vena cava thrombosis. Other investigations revealed a pleural effusion associated with an ovarian tumor. Pathological data of pleural biopsies showed a papillar carcinoma. Ovarian neoplasia revealed by a paraneoplasic syndrome was diagnosed. Treatment associated cyclophosphamide and carboplatin with anti-K-vitamin was administrated, with a complete remission and disappearance of superior vena cava thrombosis at 27 months of evolution. At this date, we observed a local pelvis recurrence which was treated with paclitaxel associated with surgery.

Attitudes towards cancer predictive testing and transmission of information to the family

Before the organisation of breast cancer predictive testing in France, consultands' attitudes towards this kind of testing and towards passing on information about the family cancer risk to their relatives were investigated. This survey was carried out from January 1994 to January 1995 at six specialised cancer genetic clinics located in different parts of France Female consultands who were first degree relatives of cancer patients and who had at least one case of breast cancer in their family, affecting either themselves or a first degree relative or both, participated in this study. Among the 248 eligible consultands attending the clinics during the study period, 84.3% answered a post-consultation questionnaire. Among the 209 respondents, 40.7% (n = 85) were cancer patients and 59.3% (n = 124) were healthy consultands. A high consensus in favour of genetic testing was noted, since 87.7% of the sample stated that they would ask for breast cancer gene testing if this test became available. The underlying assumption of 96.6% of the women was that their health surveillance would be improved after a positive test. A high awareness of the anxiety that would be generated in a family after a positive result was observed and found to be associated (p < 0.05) with the anxiety and depressive profiles of the patients. Half of the healthy respondents said they would not change their attitude towards screening if the results of predictive testing turned out to be negative. Only 13.7% of the 161 patients who stated that the oncogeneticists asked them to contact their relatives firmly refused to do so, mainly because of difficult family relationships.

[Attitudes towards screening and prevention of breast and ovarian cancers with hereditary predisposition. Survey by female gynecologists in the north of France]

Search for mutations of BRCA1 in women at hereditary risk for cancer is now possible. We asked the female gynaecologists of our county (north of France) their opinion about the search of a mutation of BRCA1 if they had a familial risk of breast cancer. Our aim was to obtain the opinion of informed women about their willingness to do the test for themselves and about the consequences they should accept. One hundred and eighty-three women received a questionnaire by post. The response rate was 56.3%. Twenty-four percent of the responders had a first degree relative with breast cancer. Most of the responders (87.4%; IC 95%: 81-93.8) would ask for the search of a mutation of BRCA1. The percentage of women who would accept the test is smaller for the women who have a first degree relative with breast cancer (72.0% vs 92.3%; P = 0.02). The reasons given to do the test were a better screening or prevention (69.7%) and the knowledge of a personal risk (49.4%). For breast cancer, 93.2% (95% CI: 88.4-98) would accept a screening protocol, 30.1% (CI: 21.3-38.9) would accept a prophylactic bilateral mastectomy. For ovarian cancer, 93.2% (CI: 88.4-98) would accept the screening, 52.4% (CI: 42.8-62) would accept a prophylactic ovariectomy. In conclusion, most of the informed women would ask for the test and the surgical options for reducing the risk of cancer are not absolutely rejected. Of course, only future studies will state precisely the choice of truly implicated women.

Cancer genetics clinics: target population and consultees' expectations

The aim of this study was to determine in healthy consultees attending cancer genetics clinics their risk status, their pathways leading to the clinics, their expectations and perception of cancer risk. In 1994, the consultees at six French centres completed a questionnaire before their first oncogenetic consultation. The oncogeneticists subsequently filled in a standardised form giving their risk assessment. Among the 206 healthy consultees, 91.3% were women, 92.2% had at least one cancer-affected first-degree relative and 73% had a "cancer family risk" as assessed by the oncogeneticist. Sixty-nine per cent of the consultees were referred to the clinics by a physician, 10.4% by their family and 18.8% on their own initiative: 83.5% of the sample perceived their family risk of cancer as being high and this belief was confirmed in 74.3% of the cases studied by the oncogeneticist. The families of self-referred consultees were less often at risk than those of consultees referred by a physician or by their family (P = 0.012). The majority (78%) expected to be informed about cancer prevention and screening, and this expectation depended on the consultee's level of education (P = 0.001). This study shows that medical pathways are more effective than the media as a means of reaching the members of the general population who are genuinely at risk, and shows that fuller information about prevention needs to be provided at cancer genetic consultations.

[Breast neoplasms: information in question(s). A survey of patients and physicians at a cancer treatment center]

OBJECTIVE

The aim of this study was to know the wishes of our patients for information and to compare them with the point of view of our colleagues in a cancer center.

METHODS

We gave 100 consecutive new patients with breast cancer a questionnaire about their needs. The same questionnaire was given in duplicate to all our colleagues in the cancer center (n = 53) asking: 1) their own needs of information if they had breast cancer 2) how they thought the patients would answer.

RESULTS

Seventy-five percent of the patients and 81% of the doctors returned the questionnaire (28 were men and 15 women; 81% were involved in the management of breast cancer). On one hand, concerning information about the disease and about the treatment, there was no difference between the needs expressed by patients of doctors (as patients). As expected, the two groups wanted to be well informed. On the other hand, there was always a statistically significant difference between the needs expressed by patients and the opinion of doctors who systematically underestimated them. Concerning information to the family, 21% of doctors and only 4% of patients didn't want any information to be given to their family. Interestingly, 67% of the patients thought the decision had to be taken together with the doctor and 56% of the doctors (as patients) wished the decision to be taken by the doctor.

CONCLUSION

Patients and physicians if they were patients, expressed the same high level need of information, but the patients needs seemed underestimated by the majority of doctors.

Plasma insulin-like growth factor-1 (IGF-1) concentrations in human breast cancer

Insulin-like growth factor-1 (IGF-1) is capable of stimulating breast cancer cell growth in vitro and the presence of IGF-1 receptors has been demonstrated in primary breast cancers. We determined plasma IGF-1 in a primary breast cancer population and in a control population. Radioimmunoassays were performed either directly on plasma, IGF-1 (NE), or after an acid-ethanol extraction of the plasma, IGF-1 (E). We demonstrated an inverse correlation between age and IGF-1: for this reason, only results obtained in females of the same age range (> 35 years) were compared. Median concentrations of IGF-1 were significantly higher in primary breast cancers [IGF-1 (E) = 152 ng/ml, IGF-1 (NE) = 26 ng/ml, n = 44] than in controls [IGF-1 (E) = 115 ng/ml, IGF-1 (NE) = 20 ng/ml, n = 92]. To our knowledge such a growth factor increase has never been described in breast cancer. We conclude that IGF-1 could be an important factor involved in the development of breast cancer and that treatment reducing IGF-1 levels could be beneficial for patients.

Absence of germline mutations of exons 5 to 8 of the P53 gene in 26 breast cancer families from the north of France

We looked for germline mutations of exons 5 to 8 of the P53 gene in 27 female patients from 26 families originating from the north of France who had breast cancer and at least one first degree relative also affected with breast cancer. Detection of the mutations was made by single strand conformation polymorphism analysis. No mutation was found in any patient, confirming that germline mutations of the P53 gene are very rare in familial breast cancer (apart from Li Fraumeni families).