Abstract P2-01-11: SentimagIC: A non-inferiority trial comparing super paramagnetic iron oxide vs. Tc99 and blue dye in the detection of axillary sentinel nodes in patients with early stage breast cancer

Background: Sentinel lymph node biopsy (SLNB), performed using radioisotope tracer with or without blue dye, is a highly accurate method for staging the axilla in early breast cancer. A radioisotope tracer with or without blue dye is the most commonly used technique for SLNB. Superparamagnetic iron oxide mapping agents detected by a handheld magnetic probe have been explored to overcome the disadvantages of the standard technique which include the short half-life, availability, handling and disposal issues for radioisotope, and the risk of allergic reactions to blue dye. Iron oxide mapping agents have been shown to be non-inferior to the standard technique in European studies. The SentimagIC trial was designed to establish the non-inferiority of a new formulation of the magnetic tracer, SiennaXP, to the combination of radioisotope and blue dye and was required to support a US regulatory submission.

Methods: Between January and December 2015, 160 patients with clinically node negative early stage breast cancer were recruited from six centers in the United States. Subjects received radioisotope injection then an intraoperative subareolar injection of SiennaXP and isosulfan blue dye prior to SLNB being performed. The sentinel node identification rate was compared between SiennaXP and the standard technique to evaluate concordance and non-inferiority.

Results: 147 procedures were completed in 147 subjects. A total of 369 histologically confirmed nodes were excised. The nodal detection rate was 94.3% (348/369) with SiennaXP and 93.5% (345/369) with the standard technique (difference 0.8%, 95% binomial confidence interval lower bound -2.1%). The per-subject detection rate was 99.3% (145/146) with SiennaXP and 98.6% (144/146) with the standard technique (one subject excluded due to not contributing any analyzable nodes). There were 22 subjects with positive SLNs, of whom 21 (95.4%) were detected by both SiennaXP and the standard tracers. In one subject, a positive node was not identified by any tracer, but was removed as clinically suspicious. The number of nodes excised per subject was 2.4 for both SiennaXP and for the standard combined technique.

Conclusion: This study showed SiennaXP is non-inferior to the standard dual technique of radioisotope and blue dye for axillary sentinel lymph node detection in early stage breast cancer and this provides a potential alternative to radioisotope and blue dye.

Citation Format: Alvarado M, Bold R, Gittleman M, Beitsch P, Blair S, Harmer Q, Kivilaid K, Teshome M, Thompson A, Mittendorf E, Hunt K. SentimagIC: A non-inferiority trial comparing super paramagnetic iron oxide vs. Tc99 and blue dye in the detection of axillary sentinel nodes in patients with early stage breast cancer [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 P2-01-11.

A remarkable new species of Sicophion Gauld, 1979 (Hymenoptera: Ichneumonidae) from Peru, with a key to the species

The small Neotropical genus Sicophion currently comprises two described species. The genus is recorded for the first time in Peru and S. yana sp. n. is described. A key to species is also presented.

Abstract P2-09-26: Women without significant claus model breast cancer risks may warrant breast MRI when a pathogenic/likely-pathogenic variant (PV/LPV) is detected in a hereditary cancer moderate risk gene

Background: Hereditary cancer gene panel testing can assess breast cancer risk for women with significant family histories. The Claus risk model is another method to determine which women qualify for annual breast MRIs based on family history, and can be used for those with BRCA negative status or for those who do not qualify for BRCA testing. In July 2014, Kaiser Permanente Southern California, a large integrated health plan, began using hereditary cancer panels comprised of moderate and high-risk breast cancer genes (GeneDx). At the time of implementation, no clinical management guidelines existed for patients with PV/LPV in moderate risk genes. In March 2015, the National Comprehensive Cancer Network (NCCN) amended the Genetic/Familial High Risk Assessment Breast and Ovarian guidelines to include breast cancer surveillance for patients with PV/LPV in moderate risk genes including ATM, CHEK2 and PALB2.

Objective: To determine if the identification of PV/LPV in moderate risk genes versus Claus model calculation increases the number of women warranting breast MRI in a managed care setting.

Methods: We performed a retrospective query of our gene panel results from 6/2014 to 5/2015 to identify patients with ATM, CHEK2 and PALB2 PV/LPV. Personal and family histories were obtained from the test requisitions. Patients with personal histories of breast cancer were excluded from analysis. We calculated the lifetime breast cancer risk using the Claus model for all eligible female patients with a moderate risk gene PV/LPV. To calculate the risk, the Claus model included family history of breast cancer in first and second-degree relatives. A lifetime breast cancer risk of >20% indicates "high" risk.

Results: A total of 19 female patients without breast cancer had a PV/LPV detected in a moderate risk gene (ATM, CHEK2, and PALB2. Claus model calculation was feasible in 12 patients. Of these 12, 4 had a PV/LPV in ATM, 6 in CHEK2 and 2 in PALB2. Only one out of these 12 women was identified with >20% risk of breast cancer based on the Claus model, and was recommended a breast MRI.

A review of electronic medical records (EMR) notes to date (June 1, 2015) revealed that breast MRI was recommended for 10 of the 12 patients above, and completed in 6. MRI identified a suspicious breast lesion in one patient. Follow-up tests and lumpectomy revealed atypical ductal hyperplasia and she will be followed with annual MRI and mammogram. The remaining 2 of12 women had no mention of MRI in their EMR, and will be flagged for follow-up to determine MRI status.

Conclusions: Eleven out of 12 women with a PV/LVP in a moderate risk gene would not have been identified as having an increased breast cancer risk by the Claus model. In our small sample, utilization of a High/Moderate Risk Gene Panel identified more patients potentially warranting enhanced breast cancer surveillance with annual breast MRI than the Claus model. This finding suggests that the use of hereditary cancer gene panel testing may impact the medical management of women with a familial risk for breast cancer. Larger studies with outcome data are needed to determine optimal surveillance guidelines.

Citation Format: Alvarado M, Tiller GE, Kershberg H, Solomon SR, Mullineaux L, Haque R. Women without significant claus model breast cancer risks may warrant breast MRI when a pathogenic/likely-pathogenic variant (PV/LPV) is detected in a hereditary cancer moderate risk gene. [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 P2-09-26.

Abstract S3-06: Treatment outcomes in patients with invasive breast cancer treated with neoadjuvant systemic therapy and breast MR imaging: Results of a secondary analysis of TBCRC 017

Background:Neoadjuvant chemotherapy (NCT) is used frequently to downstage locally advanced tumors and facilitate breast conservation. However, we have previously reported that achievement of radiographic complete response (rCR) or pathologic complete response (pCR) does not impact choice of surgery for many patients. This secondary analysis reports treatment outcomes across 9 NCI comprehensive cancer centers in women receiving both NCT and breast MR imaging to assess whether treatment outcomes among women receiving NCT differs according to choice of locoregional treatment.

Methods:1077 women from 9 institutions were retrospectively identified as having undergone NCT with MR imaging obtained both before and after systemic treatment. Systemic treatment regimen was not prespecified, but receipt of at least 80% of all planned cycles was required prior to final MR imaging. We performed a univariate analysis as well as a multivariable Cox proportional hazard regression to identify covariates associated with overall survival (OS), disease-free survival (DFS) and time to recurrence (TTR). rCR was defined as no residual enhancement on post-treatment breast MRI.

Results:1077 patients diagnosed and treated with NCT for stage I-III invasive breast cancer from January 1, 2002 to June 16, 2014 were analyzed for all endpoints. Median follow-up was 4.2 years, (range 0.1 to 13 years). Median age of the cohort was 50 years, (range 19-87 years). 473 (43.9%) had ER(+) and/or PR(+)/HER2(-) disease, 348 (32.3%) had HER2(+) disease, and 256 (23.8%) had ER(-)/PR(-)/HER2(-) (triple negative) disease. Mastectomy or breast conserving therapy (BCT) was recorded as the definitive surgery in 675 (62.7%) and 402 (37.3%) of patients, respectively. Radiation receipt was confirmed in 84.1% of BCT and 68.3% of mastectomy patients. Overall there were 134 recurrences, 168 disease events and 89 deaths. Among patients with pCR, there were 7/161 (7.2%) recurrences in those undergoing mastectomy and 6/143 (5.1%) in those undergoing lumpectomy (p=0.81). Among patients who achieved an rCR, there were recurrences in 5% of those undergoing mastectomy and 2.9% in those undergoing lumpectomy (p=0.53). In multivariable analysis of the entire cohort, only clinical stage, ER status and pCR remained independently associated with DFS. Notably, subset analysis showed that lumpectomy was independently associated with improved TTR (HR 0.40; 95% CI 0.17-0.97) in the triple negative group only, but this did not translate into improved DFS with lumpectomy in this group. Radiographic CR as determined by breast MRI accurately predicted presence or absence of pCR in 74% of cases, but was not independently associated with DFS, OS or TTP.

Conclusions:Among a contemporary cohort of women receiving neoadjuvant systemic therapy and breast MR imaging at 9 NCI designated cancer centers, type of surgery did not impact DFS, OS or TTP. The only exception was found in the triple negative group in which the lumpectomy group had a more favorable TTP compared to the mastectomy group. These findings provide additional evidence that in women who are appropriate candidates for lumpectomy after NCT, BCT does not compromise long-term cancer outcomes.

Citation Format: De Los Santos J, Hyslop T, Alvarado M, Forero A, Golshan M, Hieken T, Horton J, Hudis C, McGuire K, Meric-Bernstam F, Nanda R, Zagar T, Hwang S. Treatment outcomes in patients with invasive breast cancer treated with neoadjuvant systemic therapy and breast MR imaging: Results of a secondary analysis of TBCRC 017. [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 S3-06.

Abstract P2-13-03: Complications following total skin-sparing mastectomy and expander-implant reconstruction: Effects of radiation therapy on the stages of reconstruction

BACKGROUND

With increasing numbers of patients requiring post-mastectomy radiation therapy (PMRT), many patients undergoing total-skin sparing mastectomy (TSSM) and immediate two-staged expander-implant (TE-I) reconstruction will receive radiation therapy (XRT) during the course of their reconstruction. Additionally, many patients undergoing TSSM for recurrent cancer have a history of prior lumpectomy and XRT. While the increased risk of reconstructive complications in the setting of XRT has been well-documented, few studies have looked at the impact of XRT on the stages of TE-I reconstruction.

METHODS

All patients undergoing TSSM and immediate two-staged TE-I reconstruction between 2006 and 2013 were identified from a prospectively maintained database. The incidences of TE-I loss and severe infection requiring admission for IV antibiotics were assessed in the subsets of patients with a prior history of XRT and those who received PMRT. Complications were divided into those following the first stage of reconstruction (TSSM and TE placement) and those following the second stage (TE-I exchange).

RESULTS

A total of 218 TSSM and TE-I reconstruction cases were included in the analysis, 85 (39%) with prior XRT and 133 (61%) with PMRT, all of whom who received PMRT prior to TE-I exchange. Mean follow-up time was 2.5 years. Nearly all cases of prior XRT occurred in patients who developed a local recurrence and then underwent TSSM; mean time from prior XRT to TSSM was 7 years (range: 2 months to 22 years). Patients with prior XRT were much more likely to develop complications following the first stage of reconstruction than after the second stage (TE-I loss: 15% vs. 4%, p = 0.02; infection: 20% vs. 8%, p = 0.02). Patients who received PMRT had low rates of complications following the first stage of reconstruction, when they had not yet received any radiation exposure (TE-I loss: 3%; infection: 8%). However, rates increased significantly following TE-I exchange, with an 18% TE-I loss and 30% rate of infection, which was nearly 4-fold higher than patients with a prior history of XRT.

CONCLUSIONS

Patients with prior XRT are at significantly increased risk of reconstructive complications following the first stage of TE-I reconstruction after TSSM, even with a remote history of XRT. However, if these patients are able to successfully maintain their reconstruction through tissue expansion, their risk of complications at the second stage is comparable to patients without radiation exposure and significantly lower than patients receiving PMRT. Careful patient selection and appropriate pre-operative counseling for TSSM and TE-I reconstruction is critical to optimize outcomes and set appropriate expectations.

Citation Format: Sears M, Warren Peled A, Wang F, Foster RD, Alvarado M, Wong J, Ewing CA, Esserman LJ, Sbitany H, Fowble B. Complications following total skin-sparing mastectomy and expander-implant reconstruction: Effects of radiation therapy on the stages of reconstruction. [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 P2-13-03.

Abstract P2-09-04: Implementation of next generation cancer gene panel testing in a large HMO

Background: Next generation cancer gene panel testing is fairly new in clinical practice. Little is known about the diagnostic yield of multigene cancer panel testing in community based hospitals.

Objective: To describe characteristics of a diverse cohort who underwent high/moderate risk multigene panel testing for either a personal or a family history of cancer in a large health plan, and report the proportion of pathogenic/likely pathogenic variants (PV/LPV) and variants of unknown clinical significance (VUS) by race/ethnicity.

Methods: Subjects included all 586 female patients who were referred for genetic counseling and underwent multigene panel testing between July 2014 and January 2015. Based on a literature review, the custom-designed high/moderate risk gene panel included 20 cancer susceptibility genes (described below). All tests were performed by the same commercial laboratory (GeneDx).

Results: Of the 586 women, 78 (13.3%) tested positive PV/LPV316 (53.9%) tested negative; and 192 (32.8%) carried one or more VUS. Age at testing ranged from 22-81 years (median 50 years). More women with PV/LPV results tended to be obese than those who tested negative (39.7% vs. 31.2%), and had greater comorbidity (Charlson Index of >3, 35.9% vs. 33.2%).

Of 586 women, 305 (52.0%) had a cancer diagnosis, mainly first primary breast cancer (n=290, 95.1%), while some also had a second primary breast cancer (n=67, 11.4%). Of the 305 women with cancer, 131 (42.9%) were diagnosed prior to the multigene testing implementation (1987-2013), while 174 (57.1%) were diagnosed after implementation.

The cohort was diverse in terms of race/ethnicity: Western/Northern European (31.2%), Latina/Caribbean (30.0%), Asian (14.8%), African-American (7.2%), Ashkenazi Jewish (6.3%), Native American (5.9%), and other (14.9%) (percent exceeds 100% due to mixed race/ethnicity). Of the 192 women who carried a VUS, 60.4% were Western/Northern European, and 46.4% were Latina/Caribbean. Pathogenic or likely pathogenic mutations were higher in Latina /Caribbean women (37.2%), followed by Western/Northern European (26.7%), and African (10.3%). We identified a total of 84 pathogenic mutations among the 78 women with PV/LPV in the following genes: BRCA1 (n=22), BRCA2 (n=17), MUTYH (n=16; all heterozygous), CHEK2 (n=9), ATM (n=4), PALB2 (n=4), PMS2 (n=3), MLH1 (n=2), VHL (n=2), and one mutation in each of the following genes: APC, CDH1, PTEN, TP53, and STK11. VUS were detected in 192 patients (32.7%) of the 586 tested. VUS in ATM (n=57), APC (n=32) and CHEK2 (n=25) comprised 59.4% of all VUS detected.

Discussion: The large percent of VUS was surprising, given that our panel included only high/moderate risk cancer genes. The over-representation of BRCA1/2 among all mutations (45.1%) likely reflected a greater proportion of patients referred for genetic counseling with a personal and/or family breast cancer history. Given that 35% of our positive results were dominant-acting pathogenic or suspected pathogenic mutations, our results suggest that multigene cancer panel testing is an appropriate method for detecting germline mutations in a high-risk cohort in a managed care setting.

Citation Format: Haque R, Alvarado M, Ahmed SA, Chung J, Tiller GE. Implementation of next generation cancer gene panel testing in a large HMO. [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 P2-09-04.

Abstract P3-01-10: Sentinel lymph node biopsy after neoadjuvant chemotherapy for patients with clinically node-positive breast cancer: A single institution retrospective evaluation

Background: In patients with clinically node-negative breast cancer sentinel lymph node biopsy (SLNB) offers accurate staging information with considerably less morbidity than a full axillary lymph node dissection (ALND). However, for clinically node-positive (cN1) patients who undergo neoadjuvant chemotherapy SLNB is thought to have a high false-negative rate and not suitable for this population. We sought to evaluate the false-negative rate (FNR) of SLNB following chemotherapy in patients initially presenting with cN1 breast cancer at a single institution.

Methods: Patients undergoing neoadjuvant chemotherapy diagnosed with cN1 breast cancer between October 2004 and February 2014 were identified from the University of California, San Francisco cancer registry. All patients underwent single agent mapping with Tc99 and SLNB followed by completion axillary lymph node dissection (ALND). Pathologic complete response, number of sentinel nodes removed and FNR were calculated.

Results: Of the 80 patients who underwent SLNB and ALND, 43 had residual metastatic disease in the nodes producing a nodal pCR of 46.25% (95%CI. 35.0%-57.8%). In 14 patients, cancer was not identified in the SLNs but was discovered in the lymph nodes retrieved by ALND, resulting in an overall FNR of 32.6% (95% CI, 19.1%-48.5%). 49 patients had only 1 SLN removed. Of the patients with only 1 SLN removed, a false-negative SLN was identified in 9 of the 21 patients with a positive node for a FNR of 42.9% (95% CI, 21.8%-66.0%). Of the patient with more than 1 SLN removed, 5 of 18 patients with a positive node had a false-negative SLN yielding a FNR of 27.8% (95% CI, 9.7%-53.5%). Only 14 patients had more than two SLNs excised.

Conclusion: Recent studies including the French GANEA 2 and ACOSOG Z1071 trials demonstrated a significant decrease in FNR when more than 1 SLN was excised. In this retrospective study however a single SLN was sampled from most patients. The FNR from this study was more than three times the generally accepted threshold of 10%. This substantial FNR further supports the need to remove more than 1 SLN during surgery in order to accurately assess nodal disease. Furthermore the implementation of a dual mapping technique would likely facilitate this process.

Citation Format: Gallant E, Ewing C, Wong J, Esserman L, Alvarado M. Sentinel lymph node biopsy after neoadjuvant chemotherapy for patients with clinically node-positive breast cancer: A single institution retrospective evaluation. [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 P3-01-10.

Barriers and facilitators to physical activity amongst overweight and obese women in an Afro-Caribbean population: A qualitative study

Background

The proportion of obese women is nearly twice the proportion of obese men in Barbados, and physical inactivity may be a partial determinant. Using qualitative interviews and ‘semi-structured’ participant observation, the aim of this study was to identify modifiable barriers to physical activity and to explore the factors that facilitate physical activity amongst overweight and obese women in this low-resourced setting.

Methods

Seventeen women aged 25 to 35 years with a BMI ≥25, purposefully sampled from a population-based cross-sectional study conducted in Barbados, were recruited in 2014 to participate in in-depth semi-structured interviews. Twelve of these women participated in one or more additional participant observation sessions in which the researcher joined and observed a routine activity chosen by the participant. More than 50 hours of participant observation data collection were accumulated and documented in field notes. Thematic content analysis was performed on transcribed interviews and field notes using the software Dedoose.

Results

Social, structural and individual barriers to physical activity were identified. Social factors related to gender norms and expectations. Women tended to be active with their female friends rather than partners or male peers, and reported peer support but also alienation. Being active also competed with family responsibilities and expectations. Structural barriers included few opportunities for active commuting, limited indoor space for exercise in the home, and low perceived access to convenient and affordable exercise classes. Several successful strategies associated with sustained activity were observed, including walking and highly social, low-cost exercise groups. Individual barriers related to healthy living strategies included perceptions about chronic disease and viewing physical activity as a possible strategy for desired weight loss but less effective than dieting.

Conclusions

It is important to understand why women face barriers to physical activity, particularly in low-resourced settings, and to investigate how this could be addressed. This study highlights the role that gender norms and health beliefs play in shaping experiences of physical activity. In addition, structural barriers reflect a mix of resource-scarce and resource-rich factors which are likely to be seen in a wide variety of developing contexts.

Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries.

METHODS

We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions.

FINDINGS

Global life expectancy for both sexes increased from 65.3 years (UI 65.0-65.6) in 1990, to 71.5 years (UI 71.0-71.9) in 2013, while the number of deaths increased from 47.5 million (UI 46.8-48.2) to 54.9 million (UI 53.6-56.3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased. For women aged 25-39 years and older than 75 years and for men aged 20-49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10.7%, from 4.3 million deaths in 1990 to 4.8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100,000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions.

INTERPRETATION

For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.

FUNDING

Bill & Melinda Gates Foundation.

Abstract P3-14-12: Risk factors for local regional recurrence in patients undergoing breast conserving surgery following neoadjuvant chemotherapy and validation of the MD Anderson prognostic index

Background: Breast conserving surgery (BCS) is a primary goal of neoadjuvant chemotherapy (NAC) in patients with locally advanced breast cancer, especially with recent improvements in tumor response. Patient selection for BCS following NAC may be different than classic local regional recurrence (LRR) risk factors. Here we investigate risk factors for LRR and attempt to validate the MD Anderson Prognostic Index (MDAPI) for LRR in a single institution series.

Methods: Data were analyzed for 178 consecutive patients treated at one institution who underwent NAC followed by BCS and whole breast radiotherapy between the years 1999 and 2011. Using univariate and multivariate analysis, multiple clinicopathologic factors were investigated, as well as the subgroups of the MDAPI. Chi-square tests were used to compare the LRR-free survival rates between subgroups.

Results: The median follow-up was 70.33 months and the 5-year LRR-free survival was 93.18%. Multivariate analysis demonstrated that clinical stage and pathologic stage were both statistically significant for LRR-free survival, while pattern of residual disease was of borderline statistical significance. The MDAPI was not significantly associated with LRR-free survival (MDAPI low 93.80%, Intermediate 88.23%, High 88.89%).

Five-Year Local Regional Recurrence -Free Survival According to Clinicopathologic Factors # Patients5yr LRR-Free SurvivalPathologic Stage p = 0.03301580.0%14292.5%27692.5%3994.6%pCR38100%Clinical Stage p = 0.0291580.0%213796.3%33883.8%MDAPI Score P = 0.506Low (0 or 1)12993.80%Int (2)3488.23%High (3)988.89%*MDAPI Score Factors  cN Stage P = 0.305cN0-N116593.3%cN2-N31070%LVI P = 0.453No-LVI15793.5%Yes-LVI2390.9%pT>2cm P = 0.158Residual Tumor Morphology P = 0.055Multifocal Resid Tumor5996.5%Solitary Mass6690.6%No Resid Tumor5394.3%*These factors make up the MDA Prognostic Index

Conclusion: Overall the 5-year LRR-free survival was high at 93.18%, which compares favorably to similar neoadjuvant patient cohorts who receive mastectomy instead of BCS. Our analysis indicates clinical stage and pathologic stage are significant in predicting LRR. Of the four predictive factors utilized by the MDAPI, only multifocal residual disease showed weak predictive power (p = 0.055) in our population; however, it correlated with higher LRR-free survival, the opposite of its indication in the MDAPI. The MDAPI was not useful in our patient population; the risk groups did not significantly correlate with LRR-free survival. This may be secondary to low total number of recurrence events and also the small number of patients in the MDAPI-high group (9 patients had an MDAPI score of 3, and none had a score of 4). As further data emerge regarding biology of tumors and recurrence, it may be a combination of molecular profiling and residual cancer burden that is a better predictor for LRR.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-12.

Late maternal hypothyroidism alters the expression of Camk4 in neocortical subplate neurons: a comparison with Nurr1 labeling

Maternal thyroid hormones (THs) are essential for normal offspring's neurodevelopment even after onset of fetal thyroid function. This is particularly relevant for preterm children who are deprived of maternal THs following birth, are at risk of suffering hypothyroxinemia, and develop attention-deficit/hyperactivity disorder. Expression of neocortical Ca(2+)/calmodulin kinase IV (Camk4), a genomic target of thyroid hormone, and nuclear receptor-related 1 protein (Nurr1), a postnatal marker of cortical subplate (SP) cells, was studied in euthyroid fetuses and in pups born to dams thyroidectomized in late gestation (LMH group, a model of prematurity), and compared with control and developmentally hypothyroid pups (C and MMI groups, respectively). In LMH pups, the extinction of heavy Camk4 expression in an SP was 1-2 days delayed postnatally compared with C pups. The heavy Camk4 and Nurr1 expression in the SP was prolonged in MMI pups, whereas heavy Camk4 and Nurr1 expression in layer VIb remains at P60. The abnormal expression of Camk4 in the cortical SP and in layer VIb might cause altered cortical connectivity affecting neocortical function.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex.

METHODS

We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions.

FINDINGS

In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted.

INTERPRETATION

Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.

FUNDING

Bill & Melinda Gates Foundation.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex.

METHODS

We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions.

FINDINGS

In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted.

INTERPRETATION

Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.

FUNDING

Bill & Melinda Gates Foundation.

Abstract P4-14-04: Total skin-sparing mastectomy in BRCA mutation carriers

BACKGROUND: Total skin-sparing mastectomy (TSSM) with preservation of the nipple-areolar complex skin has become increasingly accepted as an oncologically safe procedure for both prophylactic and therapeutic indications. The goal of this study was to evaluate the oncologic outcomes after TSSM in BRCA mutation carriers.

METHODS: We identified 53 BRCA-positive patients who underwent bilateral TSSM for prophylactic (27 patients) or therapeutic (26 patients) indications from 2001 to 2011. Cases were age-matched (for prophylactic cases) or age- and stage-matched (for therapeutic cases) with non-BRCA-positive patients who underwent bilateral TSSM during this time period. Outcomes included tumor involvement of the resected nipple tissue, the development of new breast cancers in patients who underwent bilateral risk-reducing TSSM, and the development of any local-regional recurrence in patients who underwent therapeutic TSSM.

RESULTS: Outcomes from 212 TSSM procedures in 53 cases and 53 controls were analyzed. In patients undergoing TSSM for prophylactic indications, in situ cancer was found in 1 (1.9%) of the nipple specimens in the BRCA-positive patients vs. 2 specimens (3.7%) in the non-BRCA-positive cohort (p = 1). At a mean follow-up of 56 months, no new cancers developed in the BRCA-positive or the non-BRCA-positive cohorts. In patients undergoing TSSM for therapeutic indications, in situ or invasive cancer was found in 0 of the nipple specimens in the BRCA-positive patients vs. 2 specimens (3.9%) in the non-BRCA-positive cohort (p = 0.49). At a mean follow-up of 33 months, there were no local-regional recurrences in the BRCA-positive cohort.

CONCLUSIONS: TSSM is an oncologically safe procedure in BRCA-positive patients, as is evidenced by the low rates of tumor involvement of the nipple tissue and local-regional recurrence after therapeutic mastectomy. In BRCA-positive patients undergoing TSSM as a risk-reducing strategy, five-year follow-up demonstrates no increased risk for the development of new breast cancers; longer-term follow-up is anticipated to further confirm its safety.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-04.

Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs).

METHODS

Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis.

FINDINGS

Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350,000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient -0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa.

INTERPRETATION

Rates of YLDs per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world.

FUNDING

Bill & Melinda Gates Foundation.

Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time.

METHODS

We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights.

FINDINGS

Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions.

INTERPRETATION

Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results.

FUNDING

Bill & Melinda Gates Foundation.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex.

METHODS

We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions.

FINDINGS

In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted.

INTERPRETATION

Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.

FUNDING

Bill & Melinda Gates Foundation.

Abstract P4-16-07: Selective use of post-mastectomy radiation therapy in the neoadjuvant setting

Background: Neoadjuvant chemotherapy, once reserved for locally advanced breast cancer, has become more common in Stage II disease. While one of its proven benefits is an increase in the frequency of breast conserving surgery, many women will undergo mastectomy despite an excellent clinical response. Indications for post-mastectomy radiation (PMRT) following neoadjuvant therapy are not well defined. Some studies have suggested that certain subgroups of women (young age, triple negative disease) with negative nodes or 1–3 positive nodes after chemotherapy have a significant risk of local-regional failure without PMRT. We conducted a single-institution retrospective study of women undergoing neoadjuvant chemotherapy and mastectomy without PMRT to assess clinical outcomes among this cohort.

Methods: 101 women with initial stage I-III disease (20% stage I, 72% stage II, 8% stage III) received neoadjuvant chemotherapy (doxorubicin-based +/− taxane) followed by mastectomy without PMRT between 2005 and 2011. Mean age was 49 years (range 22–81 years). 16% were BRCA+. 66 patients (65%) had clinically negative axillary nodes at presentation, 34% had N1 disease and 1% had N2 disease. Subtype by IHC was 61% luminal A, 11% luminal B (ER+, Her2+), 20% triple negative and 8% ER−, Her2+. At the time of surgery, 81% were node negative and 19% had 1–3 positive nodes. Pathologic complete response (pCR) (breast + axilla) occurred in 28%. Median follow-up was 34 months (range 5.5–84.5 months).

Results: There were 2 (2%) local-regional failures (1 axillary recurrence at 52 months after mastectomy and 1 chest wall recurrence at 10 months). Both of these recurrences were in patients with negative nodes and luminal A tumors; patients had 2.2 and 2.5 cm of residual invasive cancer, respectively, and negative margins at mastectomy. There were no local-regional failures in women with triple negative cancers, those with 1–3 positive nodes, or patients younger than 40. Additionally, there were no failures in women with a pCR, including those with initial stage IIIA-B disease.

Conclusions: Among carefully selected patients fulfilling low risk criteria for local-regional recurrence, PMRT following neoadjuvant chemotherapy may be omitted without compromising local-regional control.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-16-07.

Abstract P3-08-06: Triple Negative Breast Cancer and BRCA Status: Implications for Genetic Counseling

BACKGROUND: Controversy exists whether women newly diagnosed with triple negative breast cancer (TNBC) should be referred to genetic counseling as they may be more likely to be BRCA carriers. However, prior studies included small numbers of carriers and their results have had limited influence on practice guidelines. The objective of this study was to determine the association of breast cancer molecular subtype and BRCA status in a large group of medically insured women.

METHODS: We examined a cohort of 2,105 women with breast cancer history tested for BRCA mutations in a large California health plan from 1997–2011. BRCA test results were recorded in the health plan's clinical genetics registry. Of the 2,105 breast cancer patients, 249 were BRCA mutation carriers (143 BRCA1 carriers, and 106 BRCA2 carriers). We conducted data linkages of all patients with the health plan's NCI-SEER affiliated tumor registry and identified ER, PR, and HER2. HER2 status was also captured from pathology reports using natural language processing. ER, PR, and HER2 status were assessed by immunohistochemical or FISH techniques. Patients were classified into four main biologic subtypes: triple negative (ER−/PR−/HER2−); luminal A (ER+ and/or PR+/HER2−); luminal B (ER+ and/or PR+/HER2+); and HER2-enriched (HER2+/ER−). We examined the association between molecular subtypes (collapsed into TNBC vs. non TNBC categories) and BRCA1/2 mutation status using contingency table analyses. P-values (two-sided) were estimated using chi-square analysis. Multivariable logistic regression was used to estimated adjusted odds ratios (OR) and 95% confidence intervals.

RESULTS: TNBC subtype was strongly associated with BRCA status (P < 0.0001). Women with TNBC tumors were five-fold more likely to be BRCA carriers than women who had non-TNBC breast tumors (OR = 5.6, 95% CI: 4.1–7.5). Specifically, the association of TNBC with BRCA1 was more robust (OR = 12.2, 95% CI: 8.3–17.9). Adjusting for age and stage of breast cancer diagnosis and race/ethnicity did not materially modify the association between TNBC and BRCA1 status. TNBC was not associated with BRCA2 status (OR = 1.6, 95% CI: 0.9–2.7).

C-ha-ras enhances the neoplastic transformation of human breast epithelial-cells treated with chemical carcinogens

The present study was carried out with the purpose of analyzing the additive effect of c-Ha-ras oncogene on tumorigenesis in human breast epithelial cells (HBEC) treated with chemical carcinogens. A human breast epithelial cell (HBEC) line, MCF-10F, previously treated with dimethylbenz(a) anthracene (DMBA) and benzo(a)pyrene (BP) was used in these studies. The MCF-10F cells, DMBA and/or BP-transformed cells originated from the clones D3-1 and BP1 which were transfected with the plasmid pH06T1 containing the human T24 mutated c-Ha-ras oncogene and termed MCF-10F-Tras, D3-1-Tras and BP1-Tras, respectively. Whereas the c-Ha-ras transfected cells presented altered morphology, increased anchorage independent growth in agar-methocel, invasiveness and tumorigenicity, the MCF-10F cells, the clones D3 and BP1 were not tumorigenic. Importantly, whereas MCF-10F-Tras was slightly tumorigenic, the D3-1-Tras and BP1-Tras transfected cells were 100% tumorigenic in the SCID mice; and the tumors thus obtained were poorly differentiated carcinomas. DNA fingerprinting confirmed that the tumors derived originated from the cell lineage used. It was concluded that c-Ha ras induces an additive effect on the expression of tumorigenesis in human breast epithelial cell line MCF-10F treated with chemical carcinogens. Our work provide a model for analyzing the role of c-Ha-ras in human breast cancer.