Characteristics of cardiac rehabilitation programs in Latin America and the Caribbean, and estimation of capacity and needs in the region

Background

Cardiac rehabilitation (CR) is an established model of cardiovascular (CV) prevention that has proven benefits. Availability, characteristics and need of CR programs in Latin-American and Caribbean (LAC) countries remains poorly characterized. This study aims to establish the availability, capacity, density and aspects of CR delivery in LAC.

Methods

A cross-sectional survey was administered to CR programs in 24 LAC. Local CV organizations and societies identified CR programs. Characteristics of individual CR program were reviewed including: funding sources, core components, healthcare providers, and dose (number of sessions per weeks X total number of weeks) of CR. National CR capacity (median number of patients a program could serve per year X number of programs per country), density (Ischemic Heart Disease [IHD] incidence per year/ national capacity), need (IHD incidence per year- national capacity) and occupancy (median number patients program served per year/national capacity) were computed based on survey responses.

Results

At least one CR program was identified per LAC country (total 255 programs across 24 countries). Data was collected in 20 of the 24 countries. Responses were received from 139/255 programs (median program response rate=55%; Table 1). Over 50% (n=73) of programs were funded by multiple sources (government, hospital/clinic, private health insurance); Self-payment was reported by 63% programs, in which 24 (33.8%) patients paid over 50% of the cost. Guideline-indicated conditions were accepted in 77% or more programs. Physiotherapists (n=106, 76.3%), cardiologists (n=105, 75.5%) and dietitians (n=79, 56.8%) were the most common healthcare providers on CR teams. Regionally, programs offered 9 (IQR = 8–10) core components (patient education, exercise prescription and initial assessment delivered by nearly all programs). Median CR was 36 (IQR = 24–56) sessions/patient. Twenty-seven (20.9%) programs offered alternative CR models (e.g., home or community-based and hybrid models). Median national capacity was 500 CR spots/country (IQR= 200–2300). Regional density was 1 CR spot per 24 incident IHD patients per year. Greatest need in absolute terms for CR was observed in Brazil, Dominican Republic and Mexico (all with >150,000 spots needed per year to manage incident IHD patients; Table 1). Occupancy ranged from over 100% in Colombia to 15% in Chile (median=60%, IQR = 32%–81%), Table 1.

Conclusion

In LAC countries, there is very limited capacity to meet the need for CR. Nature of CR services varied regionally.

Funding Acknowledgement

Type of funding source: None

Minibeam radiation therapy: A micro- and nano-dosimetry Monte Carlo study

PURPOSE

Minibeam radiation therapy (MBRT) is an innovative strategy based on a distinct dose delivery method that is administered using a series of narrow (submillimetric) parallel beams. To shed light on the biological effects of MBRT irradiation, we explored the micro- and nanodosimetric characteristics of three promising MBRT modalities (photon, electron, and proton) using Monte Carlo (MC) calculations.

METHODS

Irradiation with proton (100 MeV), electron (300 MeV), and photon (effective energy of 69 keV) minibeams were simulated using Geant4 MC code and the Geant4-DNA extension, which allows the simulation of energy transfer points with nanometric accuracy. As the target of the simulations, cells containing spherical nuclei with or without a detailed description of the DNA (deoxyribonucleic acid) geometry were placed at different depths in peak and valley regions in a water phantom. The energy deposition and number of events in the cell nuclei were recorded in the microdosimetry study, and the number of DNA breaks and their complexity were determined in the nanodosimetric study, where a multi-scale simulation approach was used for the latter. For DNA damage assessment, an adapted DBSCAN clustering algorithm was used. To compare the photon MBRT (xMBRT), electron MBRT (eMBRT), and proton MBRT (pMBRT) approaches, we considered the treatment of a brain tumor located at a depth of 75 mm.

RESULTS

Both mean energy deposition at micrometric scale and DNA damage in the "valley" cell nuclei were very low as compared with these parameters in the peak region at all depths for xMBRT and at depths of 0 to 30 mm and 0 to 50 mm for eMBRT and pMBRT, respectively. Only the charged minibeams were favorable for tumor control by producing similar effects in peak and valley cells after 70 mm. At the micrometer scale, the energy deposited per event pointed to a potential advantage of proton beams for tumor control, as more aggressive events could be expected at the end of their tracks. At the nanometer scale, all three MBRT modalities produced direct clustered DNA breaks, although the majority of damage (>93%) was composed of isolated single strand breaks. The pMBRT led to a significant increase in the proportion of clustered single strand breaks and double-strand breaks at the end of its range as compared to the entrance (7% at 75 mm vs 3% at 10 mm) in contrast to eMBRT and xMBRT. In the latter cases, the proportions of complex breaks remained constant, irrespective of the depth and region (peak or valley).

CONCLUSIONS

Enhanced normal tissue sparing can be expected with these three MBRT techniques. Among the three modalities, pMBRT offers an additional gain for radioresistant tumors, as it resulted in a higher number of complex DNA damage clusters in the tumor region. These results can aid understanding of the biological mechanisms of MBRT.

Shiga Toxin-Producing Escherichia coli O157, England and Wales, 1983-2012

Although incidence remained constant, outbreaks from contaminated meat and milk declined and those from petting farms and schools and nurseries increased.

We evaluated clinical Shiga toxin–producing Escherichia coli O157 infections in England and Wales during 1983–2012 to describe changes in microbiological and surveillance methods. A strain replacement event was captured; phage type (PT) 2 decreased to account for just 3% of cases by 2012, whereas PT8 and PT21/28 strains concurrently emerged, constituting almost two thirds of cases by 2012. Despite interventions to control and reduce transmission, incidence remained constant. However, sources of infection changed over time; outbreaks caused by contaminated meat and milk declined, suggesting that interventions aimed at reducing meat cross-contamination were effective. Petting farm and school and nursery outbreaks increased, suggesting the emergence of other modes of transmission and potentially contributing to the sustained incidence over time. Studies assessing interventions and consideration of policies and guidance should be undertaken to reduce Shiga toxin–producing E. coli O157 infections in England and Wales in line with the latest epidemiologic findings.

Abstract OT2-03-02: DI study: Decision impact of the NanoString® Technologies Prosigna™ in early breast cancers

Backgrounds: More than a decade of research, clinical studies, and peer reviewed publications support the value of molecular subtyping based on gene expression analyses to assess prognosis and treatment options for patients with early-stage breast cancer. Therefore, genomic assays are now being introduced to supplement the conventional diagnostic tools. Prosigna is a standardized test that measures the expression levels of 50 classifier genes in formalin-fixed, paraffin-embedded (FFPE) breast tumor tissue samples and provide a subtype classification based on the fundamental biology of individual patient's tumor (referred to as molecular subtyping), as well as a prognostic score (referred to as risk of recurrence (ROR) score) that predicts the probability of cancer recurrence over 10 years.

The primary objective of this study is to assess the extent to which Prosigna affects the medical oncologist's treatment recommendations regarding adjuvant chemotherapy and actual treatments received for patients with early-stage breast cancer. Changes will include hormonal therapy alone, hormonal therapy plus chemotherapy, and changes in types of chemotherapy if chemotherapy was recommended before and after the test. Secondary objectives will be to elicit information on investigators' confidence in the recommendations before and after the test, and by cancer recurrence risk groups, rate of chemotherapy related adverse events stratified by administration of chemotherapy, and patients' decisional conflict status, anxiety levels, and functional status before and after Prosigna results.

Multicentric prospective study. Prosigna will be performed on operative piece for all consecutively postmenopausal women matching the inclusion criteria and having signed an informed consent. Data on patient demographics, disease status, intended cancer-specific postoperative management before and after the test, tests results, investigators and patients' confidence in the treatment and in the test, will be recorded in the inclusion visit, after the tests results and 6 month post-assay.

Inclusion criteria: Postmenopausal patients with resected node-negative, estrogen-receptor-positive, HER2-negative (by the local laboratory) early-stage invasive breast cancer (T1-T2, N0, pN0 (i+), pN1 (micrometastatic), M0), able to give consent, eligible for treatment of breast cancer with adjuvant chemotherapy and with ECOG performance status of 0 or 1.

Statistical methods: The clinical and demographic characteristics of the study sample will be described using mean, median, standard deviation, and range for continuous/ordinal variables and frequency and proportion for categorical variables. Bivariate plots and crosstabs will be performed to inspect bivariate associations between variables. The proportion of patients for whom the physicians' choice of treatment changed from baseline to follow-up will be calculated along with the 95% confidence interval. The change in investigator confidence in treatment recommendations before and after Prosigna results were known will be analyzed by calculating the mean and 95% CI for the question regarding whether a physician is more confidence in treatment recommendation after ordering Prosigna.

47 patients have been included on 200 scheduled.

Citation Format: Lerebours F, Hequet D, Guinebretière J-M, Roulot A, Callens C, Gentien D, Penault-LLorca F, Zilberman S, Salmon R, Foa C, Berseneff H, Huchon C, Katz G, MacDonald M, Morel P, Bieche I, Dubot C, Rouzier R. DI study: Decision impact of the NanoString® Technologies Prosigna™ in early breast cancers. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT2-03-02.

The standard tangential fields used for breast irradiation do not allow optimal coverage and dose distribution in axillary levels I-II and the sentinel node area

BACKGROUND

Recent data from ACOSOG Z0011 and NSABP B32 trials suggested no need for axillary lymph node dissection (ALND) in patients with micrometastatic involvement of the sentinel lymph node (SLN). The low rate of axillary recurrence was attributed to the axilla coverage by the tangential fields (TgFs) irradiation and systemic therapy. This study aimed to evaluate dose distribution and coverage of the axilla levels I-II and the SLN area.

PATIENTS AND METHODS

One hundred and nine patients were analyzed according to three groups: group 1 (50 Gy; n = 18), group 2 (60 Gy; n = 34) and group 3 (66 Gy; n = 57). Patients were treated using the standard (STgF; n = 22) or high (HTgF; n = 87) TgF.

RESULTS

The median doses delivered to level I using HTgF versus STgF were 33 and 20 Gy (P = 0.0001). The mean dose delivered to the SLN area was only 28 Gy. Additionally, the SLN area was totally included in the HTgF in 1 out of 12 patients who had intraoperative clip placement in the SNL area.

CONCLUSIONS

TgFs provide a limited coverage of the axilla and the SNLB area. This information should be considered when only TgFs are planned to target the axilla in patients with a positive SLN without ALND. Standardization of locoregional radiotherapy in this situation is urgently needed.

Use of antiviral drugs to reduce household transmission of pandemic (H1N1) 2009, United Kingdom

TOC Summary: Early treatment of primary case-patients and prophylaxis of household contacts provides effective protection.

The United Kingdom implemented a containment strategy for pandemic (H1N1) 2009 through administering antiviral agents (AVs) to patients and their close contacts. This observational household cohort study describes the effect of AVs on household transmission. We followed 285 confirmed primary cases in 259 households with 761 contacts. At 2 weeks, the confirmed secondary attack rate (SAR) was 8.1% (62/761) and significantly higher in persons <16 years of age than in those >50 years of age (18.9% vs. 1.2%, p<0.001). Early (<48 hours) treatment of primary case-patients reduced SAR (4.5% vs. 10.6%, p = 0.003). The SAR in child contacts was 33.3% (10/30) when the primary contact was a woman and 2.9% (1/34) when the primary contact was a man (p = 0.010). Of 53 confirmed secondary case-patients, 45 had not received AV prophylaxis. The effectiveness of AV prophylaxis in preventing infection was 92%.

Seroprevalence of hepatitis E virus in the UK farming population

Hepatitis E is a zoonosis that can be acquired by the consumption of contaminated food or water, or via person-to-person spread. However, little is known about the transmission of hepatitis E virus (HEV) in the UK. We investigated the epidemiology of indigenous hepatitis E infection using the PHLS Farm Cohort, a sentinel group with a history of close contact with a range of domestic animals. Ten of the 413 subjects tested were positive for hepatitis E IgG antibodies (2.4%). Seroprevalence peaked in those aged 51 to 60 years (relative risk 3.3, 95% CI: 1.0-10.5). Male participants (relative risk 3.6, 95% CI: 0.6-21.2) and those from farms in the Hereford area of the United Kingdom (relative risk 2.7, 95% CI: 0.8-8.4), an area of mixed livestock farming, were more likely to have serological evidence of previous HEVs exposure, although these findings were not statistically significant. Exposure to pigs, or water from a private supply, was not identified as a significant risk factor. The results of this study suggest that UK farming populations are exposed to HEV, but the predominant route of transmission remains elusive.

Evidence of person-to-person transmission of oseltamivir-resistant pandemic influenza A(H1N1) 2009 virus in a hematology unit

We describe the first confirmed person-to-person transmission of oseltamivir-resistant pandemic influenza A(H1N1) 2009 virus that occurred in a hematology unit in the United Kingdom. Eleven cases of (H1N1) 2009 virus infection were identified, of which, ten were related as shown by sequence analysis of the hemagglutinin and neuraminidase genes. H275Y analysis demonstrated that 8 of 10 case patients had oseltamivir-resistant virus, with 4 of 8 case patients infected by direct transmission of resistant virus. Zanamivir should be considered as first-line therapy for influenza in patients with lymphopenic hematological conditions and uptake of influenza vaccination encouraged to further reduce the number of susceptible individuals.

Abstract P5-14-12: Management of Phyllodes Breast Tumours: A Review of 165 Cases

Aim:The aim of our study was to examine the treatment and outcome of 165 patients with phyllodes tumours and to review the options for surgical management.

Patients and Methods: This is a retrospective study of 165 patients who presented to the Institut Curie between January 1994 and November 2008 for benign, borderline or malignant phyllodes tumours. Results: The median follow-up was 12.65 months [range 0 to 149.8]. The median age at diagnosis was 44 years [range 17 to 79]. One hundred and sixty patients (97%) had breast conserving treatment, of whom 3 patients (1. 8%) had oncoplastic breast surgery. Younger women had a significantly higher chance of having a benign phyllodes tumor (p = 0.0001) or a tumour of small size (&lt; 0.0001). Histological examination showed 114 benign (69%), 37 borderline (22%) and 14 malignant tumours (9%).

The median tumour size was 30 mm [range 5 to 150]. The tumour margins were considered incomplete (&lt; 10 mm) in 46 out of 165 cases (28%) with 52% revision surgery. Only the tumour grade was a significant risk factor for incomplete tumour margins (p = 0.005). Fifteen patients developed local recurrence (10%) and two, metastases. In univariate analysis, the histological grade (p = 0.008) and tumour size (p=0.02) were significative risk factors for local recurrence with an accentuated risk for borderline tumours and tumours of large size. Similar results were obtained using multivariate analysis (p=0.07)

Conclusion: The mainstay of treatment for phyllodes tumours remains excision with a safe surgical margin, taking advantage breast conserving surgery where amenable. For borderline or malignant phyllodes tumours or in cases of local tumour recurrence, mastectomy and immediate breast reconstruction may become the preferred option.Genetic analysis will potentially supplement classical histological examination in order to improve our management of these tumours. The role of adjuvant treatments is unproven and must be considered on a case-by-case basis.

Assessing the role of contact tracing in a suspected H7N2 influenza A outbreak in humans in Wales

Background

The detailed analysis of an outbreak database has been undertaken to examine the role of contact tracing in controlling an outbreak of possible avian influenza in humans. The outbreak, initiating from the purchase of infected domestic poultry, occurred in North Wales during May and June 2007. During this outbreak, extensive contact tracing was carried out. Following contact tracing, cases and contacts believed to be at risk of infection were given treatment/prophylaxis.

Methods

We analyse the database of cases and their contacts identified for the purposes of contact tracing in relation to both the contact tracing burden and effectiveness. We investigate the distribution of numbers of contacts identified, and use network structure to explore the speed with which treatment/prophylaxis was made available and to estimate the risk of transmission in different settings.

Results

Fourteen cases of suspected H7N2 influenza A in humans were associated with a confirmed outbreak among poultry in May-June 2007. The contact tracing dataset consisted of 254 individuals (cases and contacts, of both poultry and humans) who were linked through a network of social contacts. Of these, 102 individuals were given treatment or prophylaxis. Considerable differences between individuals' contact patterns were observed. Home and workplace encounters were more likely to result in transmission than encounters in other settings. After an initial delay, while the outbreak proceeded undetected, contact tracing rapidly caught up with the cases and was effective in reducing the time between onset of symptoms and treatment/prophylaxis.

Conclusions

Contact tracing was used to link together the individuals involved in this outbreak in a social network, allowing the identification of the most likely paths of transmission and the risks of different types of interactions to be assessed. The outbreak highlights the substantial time and cost involved in contact tracing, even for an outbreak affecting few individuals. However, when sufficient resources are available, contact tracing enables cases to be identified before they result in further transmission and thus possibly assists in preventing an outbreak of a novel virus.

Pandemic Influenza A (H1N1) 2009 and mortality in the United Kingdom: risk factors for death, April 2009 to March 2010

Binary file ES_Abstracts_Final_ECDC.txt matches

Pandemic Influenza A (H1N1) 2009 and mortality in the United Kingdom: risk factors for death, April 2009 to March 2010

This paper describes the epidemiology of fatal pandemic influenza A(H1N1) cases in the United Kingdom (UK) since April 2009 and in particular risk factors associated with death. A fatal case was defined as a UK resident who died between 27 April 2009 and 12 March 2010, in whom pandemic influenza A(H1N1) infection was confirmed by laboratory or recorded on death certificate. Case fatality ratios (CFR) were calculated using the estimated cumulative number of clinical cases as the denominator. The relative risk of death was estimated by comparing the population mortality rate in each risk group, with those not in a risk group. Across the UK, 440 fatal cases were identified. In England, fatal cases were mainly seen in young adults (median age 43 years, 85% under 65 years), unlike for seasonal influenza. The majority (77%) of cases for whom data were available (n=308) had underlying risk factors for severe disease. The CFR in those aged 65 years or over was nine per 1,000 (range 3 - 26) compared to 0.4 (range 0.2 to 0.9) for those aged six months to 64 years. In the age group between six month and 64 years, the relative risk for fatal illness for those in a risk group was 18. The population attributable fractions in this age group were highest for chronic neurological disease (24%), immunosuppression (16%) and respiratory disease (15%). The results highlight the importance of early targeted effective intervention programmes.

Single Circulating Tumor Cell Detection and Overall Survival in Non Metastatic Breast Cancer

Background: Circulation of cancer cells in the blood is a necessary step of hematogeneous metastasis while circulating tumor cells (CTC) have been reported to have a low metastatic efficiency in preclinical animal models. After a median follow-up of 18 months, we previously reported that CTC detection influences the distant metastasis-free survival (DMFS) in non-metastatic breast cancer (BC) patients (pts) treated by neoadjuvant chemotherapy (NACT) in a multicenter prospective trial. Updated results are presented here, focusing on overall survival (OS) and predictors of metastatic relapse.Methods: In 115 localized BC pts, CTC were prospectively screened (CellSearch) before and after NACT (REMAGUS02). We analyzed their outcome after a median follow-up of 36 months.Results: At baseline, 23% of pts were CTC-positive, but only 10% had more than 1 CTC per 7.5ml of blood. At an individual level, CTC detection before chemotherapy, used as a test to predict metastatic relapse, exhibited a global accuracy of 77%, higher than that of tumor grade (54%), tumor size (57%), lymph node invasion (40%), triple negative phenotype (76%) and pathological complete response (27%). Multivariate analyses for OS and DMFS showed that CTC detection before chemotherapy was a strong independent prognostic factor for both DMFS (p=0.01, RR=5.0, 95%CI[1.4-17]) and OS (p=0.007, RR=9, 95%CI[1.8-45]), along with tumor size and triple-negative phenotype, while post-chemotherapy CTC detection had a lower significance for both endpoints (p=0.07 and p=0.09 respectively).Conclusion: Biologically, the metastatic efficiency of CTC could be higher than previously thought. Clinically, besides confirming our previously reported results, this study shows that CTC detection may become the main prognostic factor in BC pts treated with NACT. Implementing this technique in everyday management might help to identify high-risk pts in whom innovative strategies should be investigated.Supported by PHRC AOM/2OO2/02117, Pfizer inc., Roche, sanofi-aventis.ISRCTN10059974

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3017.

Tumour Aromatase Expression, a Prognostic for Local Control in Young Breast Cancer Patients after Breast-Conserving Treatment?

Introduction: To determine whether the levels of expression of 17 candidate genes were associated with locoregional control after breast conserving treatments of early-stage breast cancers in young, premenopausal women.Methods: Gene expression was measured using RT-PCR in the breast tumors of a series of 53 young (≤40 years), premenopausal patients. All treatments consisted in primary breast conserving surgery followed by whole-breast radiotherapy (+/- regional lymph nodes) with or without systemic treatments (chemotherapy +/- hormone-therapy). The median follow-up was 10 years.Results: The 10-year locoregional recurrence rate was 70% (95% CI 57%-87%). In univariate analysis, no clinical/pathological prognostic factors were found to be significantly associated with a decreased loco-regional control. Expression of three genes was found to be significantly associated with an increased loco-regional recurrence rate: low estrogen receptor beta, low aromatase, high GATA3. Two others were associated with only a trend (p&lt;0.10): low HER1 and SKP2. In multivariate analysis only the absence of aromatase was significantly associated with an increased loco-regional recurrence rate (p=0.003, Relative Risk=0.49 95% CI [0.29-0.82]).Conclusions: Recent data give credit to the fact that breast cancer in young women is a distinct biological entity driven by special oncogenic pathways. Our results highlight the role of estrogen signalling pathways (mainly CYP19/aromatase, GATA3 and ERβ) in the risk of locoregional recurrence of breast cancer in young women. Confirmation in larger prospective studies are needed.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6035.

Distant Metastasis Free Survival (DMFS) in Breast Cancer Patients with Micrometastases (pN1mi) in the Sentinel Lymph Node (SLN): Results in 582 Positive-SLN Patients in a Single Institution

Background:The risk of developing distant metastases (DM) in pN1mi and isolated tumor cells (pN0i+) patients remains under question. Does occult axillary node metastases is an additional factor for using an adjuvant systemic therapy (AST) in early breast cancer ?Patients and Methods:Among 2695 patients operated on from 2000 to 2006 for SLN, 582 patients had a positive SNB: 307 were pN1, 154 pN1mi and 121 pN0i+ (6th AJCC-classification). All patients underwent an immediate or delayed Axillary Lymph Node Dissection (ALND). We report the results for DMFS [median follow-up of 56 months (2-105)].We used Kaplan-Meier method and Cox regression for multivariate analysis.Results:ALND were positive in pN1, pN1mi and pN0i+ patients respectively in 127 (41,3%), 20 (13%) and 14 (11.6%) of these patients. On univariate and multivariate analysis, positive ALND, mitotic index, pathologic tumor size were significantly related to the DMFS; on multivariate analysis, the type of axillary lymph node metastases was an additional significative factor. There was not relationship between pN0i+ and the development of DM. Surprisingly, patients with pN1mi had a 2.8 higher risk for developing DM than pN1 patients. pN1 patients receive more AST than pN1mi (75% and 22%), however AST was not prognostic (p=0.49).Conclusion:In our series, patients with pN1mi were associated with a worse prognosis related to DMFS compared to pN1. Use of AST and/or biological primary tumor characteristics could explain this paradoxical result. Longer follow-up and larger series are needed to determine the prognostic significance of axillary occult metastases.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 308.

Transcriptomic Profiles and Circulating Tumor Cell Detection in Primary Breast Cancer

Background: We have previously demonstrated that circulating tumor cells (CTC) detection by the CellSearch system is strongly associated with metastatic outcome in non-metastatic breast cancer (BC) treated by neoadjuvant chemotherapy (NACT) [Pierga, Clin Cancer Res 2008]. Transcriptomic analysis of primary tumors may uncover molecular phenotypes associated with CTC detection.Methods: Both CTC detection in blood at diagnosis and transcriptomic analysis of the primary tumor have been performed prospectively in 58 non-metastatic BC patients (pts) treated by NACT in a phase II trial (REMAGUS02). We searched for an association between CTC detection and (i) intrinsic molecular subtypes, (ii) stemness signature, (iii) other published signatures, and (iv) expression of molecular markers involved in CTC detection. CTC-associated genes were also studied (v).Results: (i) CTC detection was not statistically associated with an intrinsic molecular subtype: 29% in basal-like (n=5/17pts), 33% in HER2+ (3/9pts), 13% in luminal A (2/13pts), 20% in luminal B (2/10pts) and 29% in normal-like (2/7pts) BC. (ii) No association was found between CTC detection and the stemness signature. (iv) CTC detection was also not related to the “stemness profile”; it was independent of EpCAM, CK8 and CK18 transcriptomic expression. Other results (iii, v) will be disclosed at the meeting.Conclusion: Our study is the first to compare tumor gene expression profiles and blood dissemination of cancer cells in early BC pts. In these pts, CTC detection by the CellSearch system does not depend on intrinsic molecular subtypes, contrary to a published report based on in vitro-grown cells lines [Sieuwerts, J Natl Cancer Inst 2009]. Being independent from molecular prognostic factors, CTC detection is likely to play a critical role in early BC management.Supported by PHRC AOM/2OO2/02117, Pfizer inc., Roche, sanofi-aventis.ISRCTN10059974

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3005.

Management of side effects of aromatase inhibitors (AIs) during adjuvant therapy for postmenopausal women with HR+ breast cancer: Analysis of French practices

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Background: Aromatase inhibitors (AIs) are widely used as adjuvant therapy for HR+ breast cancer. Most frequently reported side effects are joint pain, osteoporosis and lipid disorders. Our aim was to describe how physicians in their clinical practice manage these side effects at initiation of treatment and during follow-up. Methods: Multicentric survey conducted in October 2008 by Internet among a sample of 293 physicians specialized in breast cancer management prescribing adjuvant AIs in post-menopausal women with HR+ breast cancer Results: At initiation of AI treatment, 97 % of the physicians interviewed declared informing their patients of the possible occurrence of joint pain; corresponding figures were 81 % for the increased risk of osteoporotic fractures, 66 % for lipid disorders, 59 % for asthenia, and only 16% for cognitive disorders. At initiation, 71% of the physicians assess fracture history, 83 % prescribe BMD, and 60 % lipid tests. Co-prescription of drugs in association with AIs from the onset of treatment is uncommon (24% of physicians interviewed), vitamin D and calcium being the most frequent prescription (19%); prescription of bisphosphonates was less frequently declared (10%). During the course of treatment, 90% of physicians assess BMD at least once, 41% repeat BMD two years after and 41% adapt monitoring of BMD according to the initial result. Lipid tests are monitored every six months by 29% of physicians, and every year by 29%. In case of joint pain, the initial therapeutic management includes: prescription of an analgesic and/or an anti-inflammatory for 66% of physicians, change of AI for 28%; the switch for tamoxifene is mentioned by only 1%. As a second step in case of failure of the initial measures, adjuvant treatment is modified by 70 % of physicians: change of AI by 50 %, switch for tamoxifene by 20 %. Conclusions: The possible side effects of aromatase inhibitors are taken into account by physicians from the initiation of treatment. They perform themselves the monitoring of the patient during follow-up, including the search for side effects. Bone-joint adverse events are managed by oncologists while the care of lipid disorders is transferred to the primary care physician.

No significant financial relationships to disclose.

Are ipsilateral breast tumour invasive recurrences in young (< or =40 years) women more aggressive than their primary tumours?

The characteristics of ipsilateral breast tumour recurrences (IBTRs) relative to those of their primary tumours (PTs) remain scarcely studied. Of 70 young (⩽40 years) premenopausal women with IBTRs, we studied a series of 63 with paired histological data. Median follow-up since IBTR was 10 years. Rates of histological types, grades or hormonal receptors were not significantly different in PTs and in IBTRs. The concordance between IBTRs and their PTs was good for histological types. IBTRs with conserved histological types tended to occur more locally, but not significantly sooner than others. These IBTRs had good concordance for hormone receptors. In discordant cases there were as many losses as appearances of the receptors. The concordance was weak for grades, with equivalent numbers of IBTRs graded lower as higher than their PTs. The 10-year overall survival rate was 70%. Neither the conservation of histological type, location, nor of the two combined were associated with deaths. Early (<2 years) IBTRs, tended to be associated with poorer survival (HR=2.24 (0.92–5.41); P=0.08). IBTRs did not display features of higher aggressiveness than PTs. Neither clinical nor histological definition of a true recurrence could be established other than the conservation of the histological type.

Breast cancer liver metastases (BCLM): What may be the role of surgery combined with chemotherapy?

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Background: Despite recent treatment improvements, the prognosis of BCLM is still poor. Hepatic resection (HR) has been associated with better outcome in selected patients, but its place in multimodality treatment of BCLM remains controversial. This study aimed to examine the outcome of a large cohort of patients selected for HR of BCLM and to define prognostic factors of survival, in a way to better define the place of surgery. Methods: A standardized questionnaire reviewing the main diagnostic and treatment modalities of primary tumor, liver metastases, response to medical therapies, type of surgical procedures, postoperative outcome, and survival following surgery, was sent to all contributing centers. Results: 460 patients treated with liver resection for BCLM from 1980 to 2000, were collected from 31 hepatobiliary surgery centers. Mean age was 51.8 years. Primary tumor, mainly adenocarcinoma, was treated by resection combined with chemotherapy and/or radiotherapy in most cases. Diagnosis of BCLM was made after an average of 54 months from the treatment of the primary tumor. BCLM were unique in 56% and associated to limited extrahepatic disease in 18.5% of patients. After initial treatment by systemic therapy (70% of patients), HR achieved a R0 resection in 82% of patients and was combined to extrahepatic resection for distant metastases in 9% of patients. Postoperative mortality (= 2 months) was 0.2%. Median survival was 45.4 months after HR, with an overall survival of 41% and 22% at 5 and 10 years, respectively. Disease-free survival rates were 14% and 10%, respectively. Four predictive factors were independently associated to an unfavourable outcome: tumor progression on chemotherapy before surgery (p = 0.0006, RR = 2.9), disease-free interval < 12 months after treatment of the primary tumor (p = 0.0003, RR = 2.1), extrahepatic metastases (p = 0.0002, RR = 1.9) and R2 liver resection (p < 0.0001, RR = 3.0). Conclusions: Inclusion of HR in the multimodality treatment of BCLM is safe and associated with a hope of long term survival (22% at 10 years). Surgery should be discussed on a multidisciplinary basis, particularly when potentially radical, in patients well controlled by chemotherapy with a long disease-free interval, and in the absence of extrahepatic disease.

No significant financial relationships to disclose.

Facteurs pronostiques du mélanome malin de l’uvée

INTRODUCTION

We conducted a retrospective study on the clinical factors influencing the local and general prognosis of patients treated for uveal melanoma with a preliminary analysis of the prognostic value of monosomy 3.

PATIENTS

and method: The patients sent to Curie Institute for uveal melanoma have a complete initial clinical evaluation, conservative management by radiotherapy or enucleation, and local and general long-term follow-up. Over the last 5 years, the status of chromosome 3 has been assessed by FISH in the tumors of enucleated patients. Findings concerning the initial workup, treatment, and follow-up are recorded prospectively. We conducted a retrospective study with multivariate analysis of the clinical factors influencing local recurrence, ocular conservation metastasis, and survival and studied the effect of monosomy 3.

RESULTS

A total of 2241 patients were registered with a median follow-up of 72 months. Of these patients, 92.8% had conservative management with iodine 125 brachytherapy or proton beam therapy and 7.2% of the patients had enucleation (n=160). Tumors from 120 patients were studied for the status of chromosome 3 by FISH. The overall survival rate was 76.3% and the metastatic rate was 19.5%. The clinical factors influencing survival were the size and location of the tumor, age of the patient, gender, and initial treatment. The factors influencing the metastatic risk were the same plus retinal detachment and local recurrence. Monosomy 3 was a significant risk factor for metastatic disease.

DISCUSSION

This study found the usual risk factors with the difference that location on the equator seems to be of worse prognosis than ciliary body involvement for survival and metastasis. In addition, the initial retinal detachment appears to be a risk factor for local recurrence and metastasis. At present, the evaluation of chromosome 3 is available for enucleated tumors but it could probably be done on needle biopsy performed during conservative management as well.

CONCLUSION

This study confirms previous results on the prognostic factors of uveal melanoma and on the value of monosomy 3. The increasingly precise identification of a group of high-risk patients should allow us to propose adjuvant therapy and to adapt follow-up.

Outbreak of verotoxin producing E.coli O157 infections involving over forty schools in south Wales, September 2005

By 3 October 2005, 157 cases of infection had been reported in an outbreak of verotoxin producing Escherichia coli (VTEC) O157 in south Wales in the United Kingdom

The population impact of MRSA in a country: the national survey of MRSA in Wales, 1997

Continuous data collection on all new isolates of MRSA via CoSurv has taken place in Wales since January 1996. In order to audit this data collection, and to address some of the issues that it does not include, a survey of MRSA was carried out. Questionnaires were completed by infection control teams. Rates were calculated using hospital throughput denominators. Results from the one-day prevalence survey, the two-week incidence survey, and the follow-up survey carried out on new MRSA patients identified in the incidence survey, are presented. Results were found to be broadly similar to those collected via routine surveillance. MRSA was found frequently and disproportionately in the elderly, with higher rates in male than female patients. The highest incidence of total and invasive MRSA was in males aged 75 and over (total: 12.5/1000 finished consultant episodes; invasive: 2.8/1000). Although there was a large community reservoir of MRSA, most appeared to have been acquired in hospital, since most patients had a history of hospitalization, often with multiple hospital admissions. Community-based isolates from cases with no hospital history tended to have been from ulcers. Prevalence and incidence of MRSA was relatively low compared with hospital throughput (mean prevalence: 2.4/100 occupied beds; mean incidence: 3.6/1000 finished consultant episodes), there was also quite large variation between sites, even when screening samples were removed. Patients with MRSA had strikingly long stays before isolation of the organism (prevalence survey: 39 days; incidence survey: 31 days) and highest incidence occurred in elderly care wards. The outcome survey showed that approximately half of the patients were treated with some type of antimicrobial therapy for MRSA. Decontamination therapy was associated with clearance of MRSA only when controlling for sex of the patient. The majority of patients were discharged still with MRSA, mostly to their own homes. The survey emphasizes the need to continue surveillance to detect any changes, to allow guidelines based on evidence to be developed and to monitor the effectiveness of such guidelines.