Value of ultrasound in assessing response to neoadjuvant chemotherapy in breast cancer

AIM

To analyse the utility of ultrasound in assessing response to neoadjuvant chemotherapy (NAC) and predicting residual cancer burden (RCB) index and pathological complete response (pCR) MATERIALS AND METHODS: This was a retrospective study with 417 patients over 7 years. The difference in longest diameter (LD) of the index lesion from baseline to end, baseline to mid, and mid to end was evaluated with respect to RCB class using logistic regression and ordered logistic regression.

RESULTS

Change in LD measurements from baseline to end, baseline to mid, and mid to end of chemotherapy as a predictor of RCB class show a negative relationship with a statistically significant association. This would suggest that a smaller change in LD measurements would be associated with an eventual higher RCB class. Change in LD measurements from baseline to end and baseline to mid chemotherapy as a predictor of pCR class show a negative relationship with a statistically significant association (p<0.05). This similarly indicates an inversely proportional relationship between changes in LD measurements and RCB class 0 for baseline to end and baseline to mid.

CONCLUSION

This study has shown significance in reducing LD measurements on ultrasound as a predictor of PCR and RCB class. This adds weight to the current practice of using ultrasound at the start, mid and end of chemotherapy cycles to monitor NACT responses.

'I know it's not normal but it's normal to me, and that's all that matters': experiences of young adults conceived through egg donation, sperm donation, and surrogacy

STUDY QUESTION

What are thoughts and feelings of young adults born following egg donation, sperm donation, and surrogacy?

SUMMARY ANSWER

Young adults felt either unconcerned or positive about the method of their conception.

WHAT IS KNOWN ALREADY

Much of what we know about adults born to heterosexual couples following anonymous donation has come from samples of donor conceived people who had found out about their origins during adulthood. There have been no studies of how young adults born through surrogacy feel about their conception and towards their surrogate.

STUDY DESIGN, SIZE, DURATION

Thirty-five young adults were interviewed as part of the seventh phase of a larger multi-method, multi-informant longitudinal study of assisted conception families in the UK. Adults were conceived using either egg donation, sperm donation, gestational surrogacy, or genetic surrogacy and were raised in households headed by heterosexual couples.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants had a mean age of 20 years and were born following traditional surrogacy (n = 10), gestational surrogacy (n = 5), egg donation (n = 11), or sperm donation (n = 9). All young adults born following sperm donation and most (n = 10) born from egg donation had an anonymous donor. In all surrogacy arrangements, the parents had met the surrogate prior to treatment. The majority of young adults were told about their conception by the age of 4 years. Participants were interviewed over the internet using a semi-structured interview. Interviews were transcribed verbatim and analysed using qualitative content analysis to understand young adults' thoughts and experiences related to their conception and whether they were interested in meeting their donor or surrogate.

MAIN RESULTS AND THE ROLE OF CHANCE

Fourteen (40%) young adults felt their conception made them feel special or unique, with the remainder feeling either neutral or unconcerned (n = 21, 60%). A higher proportion of young adults conceived using egg donation (n = 8, 73%) felt unique/special compared to young adults born following sperm donation and surrogacy. For 10 of the young adults, their feelings about their conception had changed over time, with most becoming more positive (n = 9, 26%). For most young adults (n = 22, 63%), conception was rarely or infrequently discussed with others. However, when it was, these conversations were largely conducted with ease. Most (n = 25, 71%) did not know other individuals born through the same method of conception as themselves, and the vast majority (n = 34, 97%) were not members of any support groups. For the 25 young adults not in contact with their donor or surrogate, 11 wished to meet them, 8 did not want to have contact, and 6 were unsure. Young adults in contact with their donor or surrogate had varying levels of closeness to them. Only one young adult had searched for the identity of their donor.

LIMITATIONS, REASONS FOR CAUTION

Of the 47 young adults invited to participate in the present study, 35 agreed to take part resulting in a response rate of 74%. It is therefore not known how those who did not take part felt about their conception. Given that the families reported here had been taking part in this longitudinal study from when the target child was aged 1 year, they may have been more likely to discuss the child's conception than other families. The study also utilized self-report measures, which may have been prone to social desirability, with donor conceived young adults wanting to present their experiences in a positive light.

WIDER IMPLICATIONS OF THE FINDINGS

The findings suggest that young adults born through surrogacy and donor conception do not feel negatively about their birth and this may be a consequence of the young age at which they found out about their conception. Although some young adults said they wished to meet their donor, this did not necessarily mean they were actively searching for them.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Wellcome Trust [grant number 208013/Z/17/Z]. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Results of the c-TRAK TN trial: a clinical trial utilising ctDNA mutation tracking to detect molecular residual disease and trigger intervention in patients with moderate- and high-risk early-stage triple-negative breast cancer

BACKGROUND

Post-treatment detection of circulating tumour DNA (ctDNA) in early-stage triple-negative breast cancer (TNBC) patients predicts high risk of relapse. c-TRAK TN assessed the utility of prospective ctDNA surveillance in TNBC and the activity of pembrolizumab in patients with ctDNA detected [ctDNA positive (ctDNA+)].

PATIENTS AND METHODS

c-TRAK TN, a multicentre phase II trial, with integrated prospective ctDNA surveillance by digital PCR, enrolled patients with early-stage TNBC and residual disease following neoadjuvant chemotherapy, or stage II/III with adjuvant chemotherapy. ctDNA surveillance comprised three-monthly blood sampling to 12 months (18 months if samples were missed due to coronavirus disease), and ctDNA+ patients were randomised 2 : 1 to intervention : observation. ctDNA results were blinded unless patients were allocated to intervention, when staging scans were done and those free of recurrence were offered pembrolizumab. A protocol amendment (16 September 2020) closed the observation group; all subsequent ctDNA+ patients were allocated to intervention. Co-primary endpoints were (i) ctDNA detection rate and (ii) sustained ctDNA clearance rate on pembrolizumab (NCT03145961).

RESULTS

Two hundred and eight patients registered between 30 January 2018 and 06 December 2019, 185 had tumour sequenced, 171 (92.4%) had trackable mutations, and 161 entered ctDNA surveillance. Rate of ctDNA detection by 12 months was 27.3% (44/161, 95% confidence interval 20.6% to 34.9%). Seven patients relapsed without prior ctDNA detection. Forty-five patients entered the therapeutic component (intervention n = 31; observation n = 14; one observation patient was re-allocated to intervention following protocol amendment). Of patients allocated to intervention, 72% (23/32) had metastases on staging at the time of ctDNA+, and 4 patients declined pembrolizumab. Of the five patients who commenced pembrolizumab, none achieved sustained ctDNA clearance.

CONCLUSIONS

c-TRAK TN is the first prospective study to assess whether ctDNA assays have clinical utility in guiding therapy in TNBC. Patients had a high rate of metastatic disease on ctDNA detection. Findings have implications for future trial design, emphasising the importance of commencing ctDNA testing early, with more sensitive and/or frequent ctDNA testing regimes.

FOxTROT2: innovative trial design to evaluate the role of neoadjuvant chemotherapy for treating locally advanced colon cancer in older adults or those with frailty

Treating older adults with cancer is increasingly important in modern oncology practice. However, we currently lack the high-quality evidence needed to guide optimal management of this heterogeneous group. Principally, historic under-recruitment of older adults to clinical trials limits our understanding of how existing evidence can be applied to this group. Such uncertainty is particularly prevalent in the management of colon cancer (CC). With CC being most common in older adults, many patients also suffer from frailty, which is recognised as being strongly associated with poor clinical outcomes. Conducting clinical trials in older adults presents several major challenges, many of which impact the clinical relevance of results to a real-world population. When considering this heterogeneous group, it may be difficult to define the target population, recruit participants effectively, choose an appropriate trial design, and ensure participants remain engaged with the trial during follow-up. Furthermore, after overcoming these challenges, clinical trials tend to enrol highly selected patient cohorts that comprise only the fittest older patients, which are not representative of the wider population. FOxTROT1 was the first phase III randomised controlled trial to illustrate the benefit of neoadjuvant chemotherapy (NAC) in the treatment of CC. Patients receiving NAC had greater 2-year disease-free survival compared to those proceeding straight to surgery. Outcomes for older adults in FOxTROT1 were similarly impressive when compared to their younger counterparts. Yet, this group inevitably represents a fitter subgroup of the older patient population. FOxTROT2 has been designed to investigate NAC in a full range of older adults with CC, including those with frailty. In this review, we describe the key challenges to conducting a robust clinical trial in this heterogeneous patient group, highlight our strategies for overcoming these challenges in FOxTROT2, and explain how we hope to provide clarity on the optimal treatment of CC in older adults.

Technological readiness and implementation of genomic-driven precision medicine for complex diseases

The fields of human genetics and genomics have generated considerable knowledge about the mechanistic basis of many diseases. Genomic approaches to diagnosis, prognostication, prevention and treatment - genomic-driven precision medicine (GDPM) - may help optimize medical practice. Here, we provide a comprehensive review of GDPM of complex diseases across major medical specialties. We focus on technological readiness: how rapidly a test can be implemented into health care. Although these areas of medicine are diverse, key similarities exist across almost all areas. Many medical areas have, within their standards of care, at least one GDPM test for a genetic variant of strong effect that aids the identification/diagnosis of a more homogeneous subset within a larger disease group or identifies a subset with different therapeutic requirements. However, for almost all complex diseases, the majority of patients do not carry established single-gene mutations with large effects. Thus, research is underway that seeks to determine the polygenic basis of many complex diseases. Nevertheless, most complex diseases are caused by the interplay of genetic, behavioural and environmental risk factors, which will likely necessitate models for prediction and diagnosis that incorporate genetic and non-genetic data.

Survival in breast cancer patients with a delayed DIEP flap breast reconstruction after adjustment for socioeconomic status and comorbidity

Purpose

Overall survival in breast cancer patients receiving a delayed deep inferior epigastric perforator (DIEP) flap breast reconstruction is better than in those without delayed breast reconstruction. This study aimed at determining the impact of socioeconomic status (SES) and comorbidity on these observations.

Materials and methods

This matched cohort study included all consecutive women undergoing a delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013. Controls had not received any delayed breast reconstruction and were relapse-free after a corresponding follow-up interval. Matching was by year of and age at mastectomy, tumour stage and lymph node status. Charlson Comorbidity Index (CCI) and socioeconomic data were obtained from national registers. Associations with breast cancer-specific (BCSS) and overall survival (OS) were investigated by Kaplan-Meier survival estimates and Cox proportional hazard regression analysis.

Results

Women in the DIEP group (N = 254) more often continued education after primary school (88.6% versus 82.6%, P = 0.026), belonged to the high-income group (76.0% versus 63.1%, P < 0.001), were in a partnership (57.1% versus 55.7%, P = 0.024) and healthier (median CCI 1.00 (range 0–13) versus 2.00 (range 0–16), P = 0.021) than the control group (N = 729). After adjustment for tumour and treatment factors, SES and comorbidity, OS remained significantly better for the DIEP group than the control group (HR 2.27, 95% CI 1.44–3.55).

Conclusion

Women with a delayed DIEP flap reconstruction are a subgroup of higher socioeconomic status and better health. Higher survival estimates for the DIEP group persisted after adjusting for those differences, suggesting the presence of further unmeasured covariates.

•

Women with a delayed DIEP flap reconstruction have a higher socioeconomic status.

•

They also have less comorbidity than women with no delayed reconstruction.

•

Superior survival in DIEP patients is not eliminated by adjustments for such differences.

•

Unmeasured selection to the reconstructive process may explain observed survival differences.

CYP2D6 genotype predicts tamoxifen discontinuation and drug response: a secondary analysis of the KARISMA trial

BACKGROUND

Guidelines regarding whether tamoxifen should be prescribed based on women's cytochrome P450 2D6 (CYP2D6) genotypes are conflicting and have caused confusion. This study aims to investigate if CYP2D6 metabolizer status is associated with tamoxifen-related endocrine symptoms, tamoxifen discontinuation, and mammographic density change.

PATIENTS AND METHODS

We used data from 1440 healthy women who participated the KARISMA dose determination trial. Endocrine symptoms were measured using a modified Functional Assessment of Cancer Therapy - Endocrine Symptoms (FACT-ES) questionnaire. Change in mammographic density was measured and used as a proxy for tamoxifen response. Participants were genotyped and categorized as poor, intermediate, normal, or ultrarapid CYP2D6 metabolizers.

RESULTS

The median endoxifen level per mg oral tamoxifen among poor, intermediate, normal and ultrarapid CYP2D6 metabolizers were 0.18 ng/ml, 0.38 ng/ml, 0.56 ng/ml and 0.67 ng/ml, respectively. Ultrarapid CYP2D6 metabolizers were more likely than other groups to report a clinically relevant change in cold sweats, hot flash, mood swings, being irritable, as well as the overall modified FACT-ES score, after taking tamoxifen. The 6-month tamoxifen discontinuation rates among poor, intermediate, normal, and ultrarapid CYP2D6 metabolizers were 25.7%, 23.6%, 28.6%, and 44.4%, respectively. Among those who continued and finished the 6-month tamoxifen intervention, the mean change in dense area among poor, intermediate, normal, and ultrarapid CYP2D6 metabolizers were -0.8 cm², -4.5 cm², -4.1 cm², and -8.0 cm² respectively.

CONCLUSIONS

Poor CYP2D6 metabolizers are likely to experience an impaired response to tamoxifen, measured through mammographic density reduction. In contrast, ultrarapid CYP2D6 metabolizers are at risk for exaggerated response with pronounced adverse effects that may lead to treatment discontinuation.

559 IDENTIFYING PATIENTS WITH MOOD DISORDER FOLLOWING ADMISSION WITH HIP FRACTURE WITH A VIEW TO STARTING TREATMENT & PROVIDE ADVICE

Introduction

The signs of depression in the elderly often go unnoticed. The MDT at RSCH observed that low mood could negatively impact on patient’s recovery, affecting pain thresholds and leading to poor engagement with rehabilitation. Proactive identification and management of mood disorder is an important part of CGA, but not routinely performed. The aim of this QI project is to improve identification and management of mood disorder in patients over 65 years admitted to RSCH with hip fractures by introducing a standardised assessment tool to guide appropriate interventions.

Method

Notes of patients with hip fracture admitted over a four-month period were retrospectively reviewed to establish if patients were screened for low mood. A mood screening tool, Cornell Score, was chosen and implemented by OT’s and junior doctors over a four-month period. Those identified with depression or probable depression were issued verbal advice, an information leaflet and follow-up arranged.

Results

Ninety-eight patients were included in the retrospective cohort; There was no indication that mood was considered or assessed at any point during admission. During the four-month prospective period, 86 patients (96%) were screened for low mood; 9% had major depression and 16% probable depression. Feedback from our occupational therapists and doctors was positive, with the tool being easy to use in patients with or without cognitive impairment. Much of the assessment could be incorporated into initial assessment or in gaining collateral history. Anecdotally, considering patients psychological well-being had a positive impact on inpatient therapy sessions guided the MDT in supporting the patient appropriately.

Conclusion

Implementation of a standardised and validated mood screening tool enabled us to identify that a quarter (25%) of the patients had, or probably had depression. This allowed us to intervene with simple measures such as verbal advice and an information leaflet and consider pharmacological intervention where appropriate.

Strategies to Improve Recruitment to a De-escalation Trial: A Mixed-Methods Study of the OPTIMA Prelim Trial in Early Breast Cancer

AIMS

De-escalation trials are challenging and sometimes may fail due to poor recruitment. The OPTIMA Prelim randomised controlled trial (ISRCTN42400492) randomised patients with early stage breast cancer to chemotherapy versus 'test-directed' chemotherapy, with a possible outcome of no chemotherapy, which could confer less treatment relative to routine practice. Despite encountering challenges, OPTIMA Prelim reached its recruitment target ahead of schedule. This study reports the root causes of recruitment challenges and the strategies used to successfully overcome them.

MATERIALS AND METHODS

A mixed-methods recruitment intervention (QuinteT Recruitment Intervention) was used to investigate the recruitment difficulties and feedback findings to inform interventions and optimise ongoing recruitment. Quantitative site-level recruitment data, audio-recorded recruitment appointments (n = 46), qualitative interviews (n = 22) with trialists/recruiting staff (oncologists/nurses) and patient-facing documentation were analysed using descriptive, thematic and conversation analyses. Findings were triangulated to inform a 'plan of action' to optimise recruitment.

RESULTS

Despite best intentions, oncologists' routine practices complicated recruitment. Discomfort about deviating from the usual practice of recommending chemotherapy according to tumour clinicopathological features meant that not all eligible patients were approached. Audio-recorded recruitment appointments revealed how routine practices undermined recruitment. A tendency to justify chemotherapy provision before presenting the randomised controlled trial and subtly indicating that chemotherapy would be more/less beneficial undermined equipoise and made it difficult for patients to engage with OPTIMA Prelim. To tackle these challenges, individual and group recruiter feedback focussed on communication issues and vignettes of eligible patients were discussed to address discomforts around approaching patients. 'Tips' documents concerning structuring discussions and conveying equipoise were disseminated across sites, together with revisions to the Patient Information Sheet.

CONCLUSIONS

This is the first study illuminating the tension between oncologists' routine practices and recruitment to de-escalation trials. Although time and resources are required, these challenges can be addressed through specific feedback and training as the trial is underway.

Abstract P1-09-04: Association between a breast cancer polygenic risk score and contralateral breast cancer risk

Background

Breast cancer patients are at significant risk of a second contralateral, breast cancer (CBC). Identification of women at high or low CBC risk could improve patient management decisions. Previous research has shown that breast cancer-associated single nucleotide polymorphisms (SNPs) summarized in a polygenic risk score (PRS) predict the risk of a first breast cancer with an odds ratio (OR) per 1 SD of 1.55 (95% confidence interval (95%CI)=1.52-1.58) (77-SNP PRS). The aim of this study was to evaluate the association between a recently developed PRS and CBC risk.

Methods

We identified 19 studies from the Breast Cancer Association Consortium (BCAC) with follow-up information on participating patients and at least 10 patients diagnosed with CBC. This included 38,228 females of European ancestry diagnosed with first invasive breast cancer since 1990. Genotyping was done using the iCOGS array or OncoArray, with genotypes for SNPs not on the arrays estimated by imputation. We used a 313-SNP PRS, optimized for prediction of overall (first) breast cancer in the BCAC dataset. Metachronous CBC risk by PRS was quantified using univariable and multivariable Cox regression analyses stratified by country and adjusted for multiple patient, tumor, and treatment characteristics. We assessed PRS interaction with age, family history, adjuvant systemic therapy, and ER-status.

Results

Median time to develop a CBC (N=1,046) after a first breast cancer was 5.8 years (range 0.3-21.9). Higher PRS was associated with increased CBC risk: hazard ratio (HR) per 1 SD=1.31 (95%CI=1.23-1.39). Patients in the highest and lowest 5% of the PRS had 1.95 fold and 0.67 fold risks of CBC, respectively, compared with patients in the middle quintile. Adjustments for age, year of diagnosis, family history, tumor size, nodal status, ER-status, or treatment (chemotherapy, endocrine therapy, radiotherapy) did not substantially alter these results. We found an interaction with age at first breast cancer diagnosis (Pinteraction=.002); the PRS was associated with an increased CBC risk for patients aged ≥40 years (HR=1.37, 95%CI=1.28-1.47), but not for patients &lt;40 years (HR=1.06, 95%CI=0.93-1.21).

Conclusion

The PRS is predictive for the development of CBC in patients ≥40 years at first breast cancer diagnosis. For this group, the PRS could be incorporated in CBC risk prediction models to help define high and low risk patients, and hence optimize screening and treatment strategies.

Citation Format: Kramer I, Hooning MJ, Breast Cancer Association Consortium (BCAC), Mavaddat N, Canisius S, Keeman R, van den Broek AJ, Steyerberg E, Hauptmann M, Pharoah PD, Easton DF, Hall P, Schmidt MK. Association between a breast cancer polygenic risk score and contralateral breast cancer risk [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 P1-09-04.

Abstract PD4-06: A clinical model for assessing the individual breast cancer risk in mammography screening

Background. Mammography screening reduces breast cancer mortality, but is suboptimal for the breast cancers that are not detected by the screening. These women are identified as symptomatic interval cancers with more aggressive tumors and worse pronosis. To efficiently screen for breast cancer the individual breast cancer risk should be determined. We describe a model that is suited for bi-annual screening programs and estimates the 2-year risk of breast cancer. The risk model could be used at most mammography screening units without adding substantial cost.

Methods. The study was based on the population based prospective KARMA cohort including 70,877 participants. Mammograms were collected up to five years following baseline mammogram. A prediction model was developed using mammographic features (density, microcalcifications and masses), use of hormone replacement therapy (HRT), family history of breast cancer, menopausal status, and body mass index. Relative risks were calculated using conditional logistic regression and 2-year absolute risks were calculated

Results. Comparing women at highest and lowest mammographic density yielded a 5-fold higher risk of breast cancer for women at highest density. When adding microcalcifications and masses to the model, high-risk women had a nearly 9-fold higher risk of breast cancer compared to those at lowest risk. In the full model, taking HRT use, family history of breast cancer and menopausal status into consideration, area under the curve (AUC) reached 0.73.

We calculated the absolute 2-year risk of breast cancer based on national incidence and mortality rates. We also stratified women into risk groups using the NICE guidelines adapted to 2-year risks. The 20% women with moderate or high breast cancer risk were 7.6 times more likely to develop breast cancer compared to the general risk. Also 18% of the women showed 4 times reduced risk compared to the average population.

Conclusions. This risk model can improve mammography screening by identifying women that are in need of additional examination procedures. There is also a substantial proportion of women with low breast cancer risk who will have little benefit from screening.

Citation Format: Eriksson M, Czene K, Pawitan Y, Hall P. A clinical model for assessing the individual breast cancer risk in mammography screening [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 PD4-06.

Discharged but not dissatisfied: outcomes and satisfaction of patients discharged from the Edinburgh Trauma Triage Clinic

Aims

The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led ‘virtual’ triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC.

Patients and Methods

A total of 628 patients who had sustained these injuries over a one-year period were identified. There were 337 patients in the pre-TTC group and 289 in the post-TTC group. The Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) or Foot and Ankle Disability Index (FADI), EuroQol-5D (EQ-5D), visual analogue scale (VAS) pain score, satisfaction rates, and return to work/sport were assessed six months post-injury. The development of late complications was excluded by an electronic record evaluation at three years post-injury. A cost analysis was performed.

Results

Outcomes were as good or better post-TTC, compared with pre-TTC scores. At three years, the pre-TTC group required a total of 496 fracture clinic appointments compared with 61 in the post-TTC group. Mean cost per patient was nearly fourfold less after the commencement of the TTC.

Conclusion

Management of minor fractures through the Edinburgh TTC results in clinical outcomes that are comparable with the previous system of routine face-to-face consultation. Outpatient workload for these injures was reduced by 88%. Cite this article: Bone Joint J 2018;100-B:959–65.

Risk of recurrence and death in patients with breast cancer after delayed deep inferior epigastric perforator flap reconstruction

Background

Postmastectomy reconstruction using a deep inferior epigastric perforator (DIEP) flap is increasingly being performed in patients with breast cancer. The procedure induces extensive tissue trauma, and it has been hypothesized that the release of growth factors, angiogenic agonists and immunomodulating factors may reactivate dormant micrometastasis. The aim of the present study was to estimate the risk of breast cancer recurrence in patients undergoing DIEP flap reconstruction compared with that in patients treated with mastectomy alone.

Methods

Each patient who underwent delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013, was compared with up to four controls with breast cancer who did not receive a DIEP flap. The control patients were selected using incidence density matching with respect to age, tumour and nodal status, neoadjuvant therapy and year of mastectomy. The primary endpoint was breast cancer‐specific survival. Survival analysis was carried out using Kaplan–Meier survival estimates and Cox proportional hazard regression analysis.

Results

The analysis included 250 patients who had 254 DIEP flap reconstructions and 729 control patients. Median follow‐up was 89 and 75 months respectively (P = 0·053). Breast cancer recurrence developed in 50 patients (19·7 per cent) in the DIEP group and 174 (23·9 per cent) in the control group (P = 0·171). The 5‐year breast cancer‐specific survival rate was 92·0 per cent for patients with a DIEP flap and 87·9 per cent in controls (P = 0·032). Corresponding values for 5‐year overall survival were 91·6 and 84·7 per cent (P < 0·001). After adjustment for tumour and patient characteristics and treatment, patients without DIEP flap reconstruction had significantly lower overall but not breast cancer‐specific survival.

Conclusion

The present findings do not support the hypothesis that patients with breast cancer undergoing DIEP flap reconstruction have a higher rate of breast cancer recurrence than those who have mastectomy alone.

Deep inferior epigastric perforator is safe

J 5 — A Data Processing System for Medical Information

A system for medical information has been developed. The system is a general and flexible one which without reprogramming or new programs can accept any alphabetic and/or numeric information. Coded concepts and natural language can be read, stored, decoded and written out. Medical records or parts of records (diagnosis, operations, therapy, laboratory tests, symptoms etc.) can be retrieved and selected. The system can process simple statistics but even make linear pattern recognition analysis.

The system described has been used for in-patients, outpatients and individuals in health examinations.

The use of computers in hospitals, health examinations or health care systems is a problem of storing information in a general and flexible form. This problem has been solved, and now it is possible to add new routines like booking and follow-up-systems.

J 5 — A Data Processing System for Medical Information

A system for medical information has been developed. The system is a general and flexible one which without reprogramming or new programs can accept any alphabetic and/or numeric information. Coded concepts and natural language can be read, stored, decoded and written out. Medical records or parts of records (diagnosis, operations, therapy, laboratory tests, symptoms etc.) can be retrieved and selected. The system can process simple statistics but even make linear pattern recognition analysis.

The system described has been used for in-patients, outpatients and individuals in health examinations.

The use of computers in hospitals, health examinations or health care systems is a problem of storing information in a general and flexible form. This problem has been solved, and now it is possible to add new routines like booking and follow-up-systems. •

Abstract P4-08-01: Not presented

This abstract was not presented at the symposium.

Decision-Making in Medical Research and Clinical Practice: Theory and Methodology of Laboratory Data Evaluation by Predictors, Indicators and Indices

A method designed to aid clinical decision-making is described. Predictors and Indicators are criteria that reflect the likelihood of disease and health, based on a retrospective analysis of the frequencies of diseases or diagnoses associated with symptoms, signs, and tests (SST’s). The approach is primarily based upon the SST’s of an individual and how these vary over time. This differs from traditional approaches which operate primarily from a disease-or diagnostic-oriented perspective. Such approaches are, therefore, useful in areas of medical research, education, and paraclinical service units, but have a limited value for patient-care. Static and dynamic health indices aid clinical decision-making by summarizing the SST-oriented Predictor and Indicator evaluations into individualized indices that can be monitored over time.

The methodology of employing this approach for the evaluation of laboratory data is presented. The application of these techniques to a battery of laboratory tests will be presented in the near future.

Abstract P4-13-14: Risk of recurrence and death in breast cancer patients after delayed deep inferior epigastric perforator flap reconstruction

PURPOSE

Post-mastectomy reconstruction using the deep inferior epigastric perforator (DIEP) flap is increasingly performed in breast cancer patients. The procedure induces large tissue trauma and it has been hypothesized that the release of growth factors, angiogenic agonists and immunomodulating factors may reactivate dormant micrometastasis. The aim of our study was to contrast the risk of breast cancer recurrence in patients undergoing DIEP reconstruction to patients treated with mastectomy alone.

PATIENTS AND METHODS

We conducted a retrospective nested case-control study. Cases were defined as breast cancer patients operated with delayed DIEP reconstruction at Karolinska University Hospital, Sweden, between 1999-2013. Three controls, defined as breast cancer patients operated with conventional mastectomy without delayed reconstruction, were matched to each case based on age, tumour stage and year of mastectomy. The primary endpoint was breast cancer-specific survival. Survival analysis was carried out by Kaplan–Meier survival estimates and Cox proportional hazard regression analysis.

RESULTS

In all, 254 cases and 729 controls were included and had a median follow up of 134 and 122 months, respectively (p=0.004). Breast cancer recurrence occurred in 50 (19.7%) cases and 174 (23.9%) controls, respectively (p=0.171). Ten-year breast cancer-specific survival was 90.7% for cases and 85.2% in controls (p=0.067). The corresponding figures for 10-year overall survival was 89.6% and 80.0%, respectively (p&lt;0.001). Higher tumor stage and positive axillary lymph nodes, but not DIEP reconstruction, were independent risk factors for death due to breast cancer.

CONCLUSION

Our findings did not support the hypothesis that breast cancer patients undergoing DIEP reconstruction would have a higher rate of breast cancer recurrence than patients undergoing mastectomy alone.

Citation Format: Adam H, Docherty Skogh A-C, Edsander Nord Å, Schultz I, Gahm J, Hall P, Frisell J, Halle M, de Boniface J. Risk of recurrence and death in breast cancer patients after delayed deep inferior epigastric perforator flap reconstruction [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 P4-13-14.

Abstract P6-12-24: Risk and predictors of psoriasis in breast cancer patients: A Swedish population based cohort study

Background The risk of psoriasis in breast cancer patients is largely unknown, as available evidence is limited to case findings. We systematically examined the incidence and risk factors of psoriasis in breast cancer patients.

Methods Using Cox regression models, a Swedish nationwide cohort of 56,235 breast cancer patients (2001-2012) was compared to 280,854 age-matched reference individuals from the general population to estimate the incidence and hazard ratio (HR) of psoriasis. We also calculated HRs for psoriasis according to treatment, genetic and lifestyle factors in a regional cohort of 8,987 patients.

Results In the nationwide cohort, 599 breast cancer patients were diagnosed with psoriasis during 307,684 person-years (median: 5.1 years) compared to 2,795 cases in the matched individuals during 1,666,038 person-years. Breast cancer patients were at an increased risk of psoriasis (HR=1.17; 95% CI=1.07-1.28) and its most common subtype (psoriasis vulgaris; HR=1.33; 95% CI =1.17-1.52). The risk of psoriasis vulgaris was long-term increased up to 12 years after diagnosis. Treatment specific analyses indicated an increased risk of psoriasis in patients treated with radiotherapy (HR=2.44; 95% CI=1.44-4.12) and mastectomy (HR=1.54, 95% CI=1.03-2.31). Apart from treatment-specific effects, we identified genetic predisposition, obesity and smoking as independent risk factors for psoriasis in breast cancer patients.

Table 1. Hazard ratios for psoriasis according to treatment characteristics   HR (95% CI) Total No.No. of CasesModel 1Model 2Endocrine therapy    No1533271.00 (REF)1.00 (REF)Yes71001210.90 (0.59-1.36)0.80 (0.52-1.24)Chemotherapy    No55441021.00 (REF)1.00 (REF)Yes3070460.82 (0.57-1.19)0.70 (0.47-1.04)Radiotherapy    No2061231.00 (REF)1.00 (REF)Yes65741251.78 (1.14-2.78)2.44 (1.44-4.12)Surgery    Lumpectomy5203941.00 (REF)1.00 (REF)Mastectomy3459550.96 (0.69-1.34)1.54 (1.03-2.31)Model 1: adjusted for age and calendar period of breast cancer diagnosis. Model 2: model 1 plus all the treatment factors.

Table 2. Hazard ratios of psoriasis according to genetic and life style factors   HR (95% CI) Total No.No. of casesModel 1Model 2PRS score    Tertile 11440131.00 (REF)1.00 (REF)Tertile 21442362.74 (1.45-5.17)2.83 (1.50-5.34)Tertile 31483402.94 (1.57-5.49)2.98 (1.59-5.58)BMI    &lt;25 kg/m22331401.00 (REF)1.00 (REF)25-30 kg/m21434281.18 (0.73-1.92)1.15 (0.71-1.87)&gt;30 kg/m2536192.29 (1.32-3.98)2.10 (1.20-3.68)Physical activity per week    0 hours762211.00 (REF)1.00 (REF)0-2 hours1645360.77 (0.45-1.33)0.77 (0.44-1.32)&gt;2 hours1910300.56 (0.32-0.98)0.59 (0.33-1.03)Regular smoker    No1773261.00 (REF)1.00 (REF)Yes2546621.65 (1.04-2.61)1.59 (1.00-2.52)Genetic predisposition for psoriasis was defined by a polygenic risk score (PRS) including 35 SNPs for psoriasis susceptibility. Model 1: adjusted for age and calendar period of breast cancer diagnosis. Model 2: all of the risk factors were put into the model, including treatment.

Conclusions The incidence of psoriasis is elevated among breast cancer patients, with treatment, lifestyle and genetic factors defining the individual risk profile. Our findings underline the complex etiology of psoriasis in breast cancer patients and may help to assess individual risk of psoriasis after a breast cancer diagnosis.

Citation Format: Yang H, Brand JS, Li J, Ludvigsson JF, Ugalde-Morales E, Chiesa F, Hall P, Czene K. Risk and predictors of psoriasis in breast cancer patients: A Swedish population based cohort 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 P6-12-24.

Abstract P3-09-03: Not presented

This abstract was not presented at the symposium.

Application of Indicators, Predictors and Diagnostic Indices in Coagulation Disorders

A theoretical model for the evaluation of binary and continuous diagnostic variables by indicators and predictors was recently described by Sebag and Hall [5]. The application of the new method for the evaluation of a self-administered questionnaire was described by Wahlberg et al. [6, 7]. In the present study the model is applied to material from two clinical tests :

1. Three blood coagulation laboratory tests for the diagnosis of von Willebrand’s disease (continuous variables) ;

2. Six blood coagulation laboratory tests performed in healthy males, aged 40, from Edinburgh and Stockholm, for the evaluation of risk factors in ischemic heart disease (continuous variables).

The diagnostic power of the laboratory variables is calculated by indicators and predictors. The total diagnostic capacity of all variables is expressed by a laboratory or summation index.

The material from the coagulation tests shows that it was possible to separate healthy individuals from diseased ones. By laboratory indices calculated for six coagulation variables, the Stockholm and Edinburgh populations were found to have different blood coagulation patterns.

Application of Indicators, Predictors and Diagnostic Indices in Coagulation Disorders

A recently described theoretical model for the evaluation of binary and continuous diagnostic variables by indicators and predictors, is in the present study applied to a self-administered-questionnaire for obtaining a medical history of different blood coagulation disturbanoies (binary variables).

The diagnostic power of each question is calculated by indicators and predictors. The total diagnostic capacity of the questionnaire is expressed by an anamnestic or summation index.

The questionnaire was shown to be able to separate healthy individuals from diseased ones. A rank order of the diagnostic capacity of the questions, built upon indicators and predictors, is presented.

Final efficacy and updated safety results of the randomized phase III BEATRICE trial evaluating adjuvant bevacizumab-containing therapy in triple-negative early breast cancer

Background

The purpose of this analysis was to assess the long-term impact of adding bevacizumab to adjuvant chemotherapy for early triple-negative breast cancer (TNBC).

Methods

Patients eligible for the open-label randomized phase III BEATRICE trial had centrally confirmed triple-negative operable primary invasive breast cancer (pT1a-pT3). Investigators selected anthracycline- and/or taxane-based chemotherapy for each patient. After definitive surgery, patients were randomized 1:1 to receive ≥4 cycles of chemotherapy alone or with 1 year of bevacizumab (5 mg/kg/week equivalent). Stratification factors were nodal status, selected chemotherapy, hormone receptor status, and type of surgery. The primary end point was invasive disease-free survival (IDFS; previously reported). Secondary outcome measures included overall survival (OS) and safety.

Results

After 56 months' median follow-up, 293 of 2591 randomized patients had died. There was no statistically significant difference in OS between treatment arms in either the total population (hazard ratio 0.93, 95% confidence interval [CI] 0.74-1.17; P = 0.52) or pre-specified subgroups. The 5-year OS rate was 88% (95% CI 86-90%) in both treatment arms. Updated IDFS results were consistent with the primary IDFS analysis. Five-year IDFS rates were 77% (95% CI 75-79%) with chemotherapy alone versus 80% (95% CI 77-82%) with bevacizumab. From 18 months after first study dose to study end, new grade ≥3 adverse events occurred in 4.6% and 4.5% of patients in the two arms, respectively.

Conclusion

Final OS results showed no significant benefit from bevacizumab therapy for early TNBC. Late-onset toxicities were rare in both groups. Five-year OS and IDFS rates suggest that the prognosis for patients with TNBC is better than previously thought.

ClinicalTrials.gov

NCT00528567.

The relationship between free-stream coherent structures and near-wall streaks at high Reynolds numbers

The present work is based on our recent discovery of a new class of exact coherent structures generated near the edge of quite general boundary layer flows. The structures are referred to as free-stream coherent structures and were found using a large Reynolds number asymptotic approach to describe equilibrium solutions of the Navier-Stokes equations. In this paper, first we present results for a new family of free-stream coherent structures existing at relatively large wavenumbers. The new results are consistent with our earlier theoretical result that such structures can generate larger amplitude wall streaks if and only if the local spanwise wavenumber is sufficiently small. In a Blasius boundary layer, the local wavenumber increases in the streamwise direction so the wall streaks can typically exist only over a finite interval. However, here it is shown that they can interact with wall curvature to produce exponentially growing Görtler vortices through the receptivity process by a novel nonparallel mechanism. The theoretical predictions found are confirmed by a hybrid numerical approach. In contrast with previous receptivity investigations, it is shown that the amplitude of the induced vortex is larger than the structures in the free-stream which generate it.This article is part of the themed issue 'Toward the development of high-fidelity models of wall turbulence at large Reynolds number'.

Abstract P2-07-03: Insulin and breast cancer risk: Novel insights from mammographic density analyses

Background: Insulin has been suspected to influence breast cancer risk because of its mitogenic effects and impact on sex hormone levels. Epidemiological studies investigating breast cancer occurrence in insulin-treated patients with diabetes have produced conflicting results, but were often underpowered and lacked adequate control for important confounders.

Purpose: To investigate the impact of insulin treatment on mammographic density (MD) as intermediate phenotype for breast cancer risk, and to further explore causation by analyzing associations with a polygenic risk score (PRS) incorporating 18 single nucleotide polymorphisms (SNPs) associated with fasting insulin levels.

Design: We conducted a matched cohort study within a Swedish screening-based cohort including insulin-treated type 1 (T1D, N=122) and type 2 (T2D, N=237) diabetes patients and up to 5 non-diabetic women matched on birth year (N=1,780). Associations between diabetes status and duration of insulin use with volumetric mammographic density were analyzed using general linear models adjusting for a comprehensive set of potential confounders. PRS analyses were performed in an independent sample of non-diabetic women (N=9,437) from the same cohort.

Results: In multivariable analyses, T1D patients had higher percent (11.2 vs. 8.8%; P&lt;0.001) and absolute dense volumes (66.6 vs. 60.8 cm3; P=0.09) and a lower absolute non-dense volume (513.2 vs. 617.7 cm3; P&lt;0.001) compared to age-matched non-diabetics. Percent- and absolute dense volumes increased with increasing T1D duration, while no such trend was observed for the absolute non-dense volume. Similar associations but of smaller magnitude, were found in insulin-treated T2D patients. Genetically predicted higher fasting insulin levels among non-diabetes women were associated with increased percent and absolute dense volumes (% change per sd increase in PRS = 0.8 (0.0-1.6) and 0.9 (0.1-1.8) respectively), but no difference in absolute non-dense volume.

Conclusions: Our results demonstrate higher mammographic density among insulin-treated diabetes patients, and genetic analyses support an effect of insulin on volumetric mammographic density. Further studies into how the observed MD differences translate into breast cancer risk are warranted.

Citation Format: Borgquist S, Rosendahl AH, Czene K, Bhoo-Pathy N, Dorkhan M, Hall P, Brand JS. Insulin and breast cancer risk: Novel insights from mammographic density analyses [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-07-03.

Abstract OT3-06-01: KARISMA, The karma intervention study. - A tamoxifen dose determination trial

Background: Breast cancer incidence is increasing throughout the world. Despite remarkable risk reducing effects demonstrated in preventive randomised endocrine trials; primary preventive strategies are scarcely part of clinical routine. Putative reasons for reluctance may be inadequate tools for identification of women at high risk of breast cancer and reluctance to prescribe pharmaceuticals with considerable side effects in the preventive setting.

Trial Design: A randomized, double blinded, six-armed placebo controlled dose determination study to investigate the optimal dose of tamoxifen with the most favorable side effect spectra. To reduce the number of participants, costs and to shorten the trial period; change in mammographic density will be used as clinical outcome. After randomization and baseline mammography, women will be treated with placebo, 1mg, 2.5mg, 5mg, 10mg or 20mg of tamoxifen for six months where after a subsequent mammogram is performed.

Eligibility criteria: 1) Attending the national Swedish mammography screening program, 2) Having a measurable mammographic density, i.e. ≥4.5 % density (volumetric) measured by Volpara.

Specific aims: The primary aim is to identify the minimum dose of tamoxifen non-inferior in its ability to reduce mammographic density and with fewer side effects compared to 20 mg of tamoxifen. Secondarily, to study the associations between different doses of tamoxifen and changes in circulating levels of a number of proteins, lipids, hormones, and tamoxifen metabolites, including the impact of polymorphisms in the CYP2D6 gene. A translational aim is to study molecular changes in the healthy breast tissue as a result of tamoxifen exposure.

Statistical Methods: Previous studies have shown that ∼ 50% of women treated with 20mg of tamoxifen have a reduction in density and respond to therapy. We therefore use the median density decrease in women treated with 20mg tamoxifen as the predefined response threshold. The primary efficacy endpoint is thus the proportion of responders that reaches this threshold. We will test for non-inferiority after treatment with placebo, 1mg, 2.5mg, 5mg, and 10mg compared to the group of women treated with 20mg tamoxifen. Per definition 50% of the women in the 20mg group are responders. The non-inferiority margin is defined to be 16.7 percentage points; that is the fraction of responders is not less than one third of the treated individuals (50% minus 16.7% = 33.3%).The null hypothesis is thus that the proportion of responders in women treated with placebo, 1mg, 2.5mg, 5mg, and 10mg is 33.3% or higher. Power calculations have determined a need of 1200 participants corresponding to 200 participants in each treatment arm.

Present accrual and target accrual: The trial will start recruiting as of September 2016. Eligible women are identified from the Swedish mammographic screening cohort, i.e. women age 40-74 years invited for biennial screening.

Contact information for people with a specific interest in the trial:

Signe.Borgquist@med.lu.se & Per.Hall@ki.se.

Citation Format: Borgquist S, Eriksson M, Czene K, Hall P. KARISMA, The karma intervention study. - A tamoxifen dose determination trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-06-01.

Abstract P2-06-06: A clinical model for assessment of the individual breast cancer risk

Background. Most mammography screening programs are not individualized. To efficiently screen for breast cancer the individual risk of the disease should be determined. We describe a model that estimate the 2-year risk of breast cancer and could be used at most mammography screening units without adding substantial cost.

Methods. The study was based on the population based prospective Karma cohort including 70,877 participants. Mammograms were collected up to three years following baseline mammogram. A prediction protocol was developed using mammographic features (density, microcalcifications and masses), use of hormone replacement therapy (HRT), family history of breast cancer, menopausal status, age, and body mass index. Relative risks were calculated using conditional logistic regression. Absolute risks were calculated using the iCARE protocol.

Results. Comparing women at highest and lowest mammographic density yielded a 5-fold higher risk of breast cancer for women at highest density. When adding microcalcifications and masses to the model, high-risk women had a nearly 9-fold higher risk of breast cancer compared to those at lowest risk. The difference in microcalcifications and masses between left and right breast was a better predictor of breast cancer than number of microcalcifications and masses in the breasts.

When calculating the absolute 2-year risk of breast cancer we stratified women using the NICE guidelines for 10-year risk divided by 5 (Table 1). The mean absolute 2-year risk of breast cancer in the different risk categories was 0.12%, 0.33%, 0.83% and 1.95% for women at low, moderate, general, and high risk. In most countries with established mammography screening programs approximately 5 women in a 1000 are diagnosed with breast cancer at regular screening. We managed to identify a low risk group of approximately 10% of all women where 1 woman in a 1000 will be diagnosed with breast cancer, contrasting the 2% of all women at highest risk where 20 women out of a 1000 will be diagnosed with breast cancer within 2 years of last negative screen (Table 1).

In the full model, taking HRT use, family history of breast cancer and menopausal status into consideration, area under the curve (AUC) reached 0.71.

Conclusions. Our model includes three mammographic features that could easily be derived from clinically available software. By adding information on some few established risk factors it is possible to improve clinical care by identifying women in need of additional examination procedures. At the same time there is a substantial proportion of women that will have very little benefit from mammography screening due to their low risk of breast cancer.

Table 1. Absolute 2-year risk of breast cancer in women stratified in to risk categories based on the NICE guidelinesAbsolute 2-year risk (risk group)Percent women at riskMean absolute 2-year risk2Stratified 2-year risk0-0.15 (low)10.30.121.0 (reference)0.15-&lt;0.6 (general)64.80.332.750.6-&lt;1.6 (moderate)22.90.826.83≥1.6 (high)2.01.9516.2

Citation Format: Eriksson M, Czene K, Pawitan Y, Leifland K, Darabi H, Hall P. A clinical model for assessment of the individual breast cancer risk [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-06-06.