Vitamin D and breast cancer

In addition to its role in calcium homeostasis and bone health, vitamin D has also been reported to have anticancer activities against many cancer types, including breast cancer. The discovery that breast epithelial cells possess the same enzymatic system as the kidney, allowing local manufacture of active vitamin D from circulating precursors, makes the effect of vitamin D in breast cancer biologically plausible. Preclinical and ecologic studies have suggested a role for vitamin D in breast cancer prevention. Inverse associations have also been shown between serum 25-hydroxyvitamin D level (25(OH)D) and breast cancer development, risk for breast cancer recurrence, and mortality in women with early-stage breast cancer. Clinical trials of vitamin D supplementation, however, have yielded inconsistent results. Regardless of whether or not vitamin D helps prevent breast cancer or its recurrence, vitamin D deficiency in the U.S. population is very common, and the adverse impact on bone health, a particular concern for breast cancer survivors, makes it important to understand vitamin D physiology and to recognize and treat vitamin D deficiency. In this review, we discuss vitamin D metabolism and its mechanism of action. We summarize the current evidence of the relationship between vitamin D and breast cancer, highlight ongoing research in this area, and discuss optimal dosing of vitamin D for breast cancer prevention.

PD06-07: COMPliance and Arthralgias in Clinical Therapy (COMPACT): Assessment of the Incidence and Severity of Arthralgia, Treatment Costs and Compliance within the First Year of Adjuvant Anastrozole Therapy

Introduction: Aromatase inhibitors (AI) are well established as adjuvant endocrine treatment for postmenopausal (PMP) women with HR+ early breast cancer (EBC). However, according to retrospective data, compliance to adjuvant endocrine therapy for EBC may drop to below 70% after one year and to as low as 50% by year 4. In clinical trials, AI are significantly more frequently associated with arthralgia than tamoxifen. Yet, prospective real world data on the effects of AI-associated arthralgia on patient compliance, patient outcomes as well as treatment costs of arthralgia are lacking.

Methods: COMPACT is an open, prospective, non-interventional study assessing the incidence and severity of arthralgia, treatment costs, and compliance within the first year of adjuvant anastrozole therapy in PMP women with HR+ EBC. The study is sponsored by AstraZeneca Germany and supported by three major German health insurance funds [GWQ ServicePlus AG, DAK, TK]. Patients on adjuvant treatment for 3–6 months were enrolled at 620 breast centres and practices throughout Germany and stratified by, a) initial adjuvant anastrozole therapy or, b) switch from tamoxifen to anastrozole. All patients receive regular standardized information about EBC from baseline to week 20 to support treatment compliance. Data on patient demographics, occurrence of and treatment of arthralgia, and quality of life will be collected at baseline, 3, 6 and 9 months. Primary endpoints are scaled data on arthralgia, assessed with a visual analogous scale (VAS) via patient questionnaire, and compliance to anastrozole in both strata, assessed by patient and investigator questionnaire. Secondary endpoints include the incidence of arthralgia, treatment costs, reasons for non-compliance, and the influence of arthralgia on clinical outcome. For a subgroup of patients data on arthralgia treatment and compliance will be validated with corresponding data of the participating health insurance funds.

Results: Between April 2009 and February 2011, 2313 patients were recruited, 2007 receiving upfront anastrozole and 306 patients on switch therapy. Preliminary baseline data for 2313 patients show the following patient characteristics: mean age 64.5 years, mean BMI 27.7. Only 16.8% of patients had received hormone replacement therapy prior to their cancer. 41.5% of patients had concomitant symptoms relating to skeleton or musculature, and 11.9% stated arthralgias existing prior to anastrozole treatment. 13.1% reported a worsening of pre-existing arthralgias or new arthralgia after starting on anastrozole treatment.

Conclusion: COMPACT aims to provide valid real world data on the incidence and severity of AI-associated arthralgia, treatment modalities and treatment costs. Our results will help to understand and better counsel patients about AI-associated arthralgia to improve adherence to AI-treatment, breast cancer outcomes, and therapy costs.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD06-07.

P4-09-16: Factors Affecting the Development of Axillary Lymph Node Metastases in T1a-T1b Breast Cancers

Background: The presence of axillary nodal metastases is a poor prognostic indicator in patients with breast cancer. In the majority of patients, axillary nodal involvement correlates with tumor size and most commonly in tumors greater that 1 cm. Many series report an incidence of axillary nodal metastases in 3–37% of patients with tumors less than or equal to 2 cm. The presence of axillary nodal metastases will often change the stage of the cancer and role of adjuvant systemic treatment; therefore, it is important to understand what features are associated with these small lymph node positive tumors. The purpose of this study is to identify characteristics of T1a and T1b breast cancers that present with axillary nodal metastasis. Methods: A retrospective review of a prospective database identified 878 patients with T1a and T1b breast cancer. Pathologic features including tumor grade, hormone receptor status, lymphatic and vascular invasion, Her-2 neu status, and tumor histology were examined in patients with and without axillary nodal metastases. Pearson's χ2 test along with stepwise linear regression analysis were used to determine which factors were associated with the development of axillary nodal metastases.

Results: There were 289 T1a lesions and 589 T1b lesions studied. Four independent variables were found to be associated with axillary nodal metastases in T1a-T1b breast cancer. As illustrated in Table 1, a significant difference was seen in nodal positivity among patients with ER negative tumors compared to those with ER positive tumors (p=.0000). An increased incidence of nodal positivity was also observed among patients with LVI compared with those without LVI (p= .0000). A significant difference was observed in nodal positivity among patients with perineural invasion compared to those without (p=.0006). An increased incidence of nodal positivity was also observed among T1a and T1b tumors with a higher histologic grade (p= 0409, p= .0001). Of note, when comparing T1a to T1b breast cancers, there was no significant difference found among the identified exposure variables of interest.

P5-14-03: Genomic Comparison of Paired Primary Breast Carcinomas and Macrometastatic Lymph Node Metastases Using Quantitative RT-PCR by Oncotype DX: Assessment of the Recurrence Score and Quantitative Single Genes

Background

NCCN guidelines now include consideration of the 21 gene RT-PCR assay in node negative, hormone sensitive breast cancers greater than 0.6 cm. Recent data suggests a potential role for testing of node positive(N1), hormone sensitive patients as well. Currently, no data exists on testing of metastatic lymph nodes. We sought to establish the feasibility of Oncotype DX® testing in the metastatic lymph nodes and, furthermore, to evaluate the genomic concordance between the primary tumor and the nodal deposit. These results may further our understanding of tumor heterogeneity and biological selectivity in the process of lymph node metastasis and ultimately systemic metastases.

Methods: We examined the formalin fixed paraffin embedded tumor tissues (FPET) from 100 breast cancer patients from our institution's pathology database with available paired primary tumor and macrometastic nodal deposits by Oncotype Dx® testing. Inclusion criteria included patients with macrometastatic lymph node disease, hormone receptor positive, HER2 negative primary breast cancer. The testing laboratory was blinded from the clinical outcomes data available on these patients. All FPET samples had H&E slides made which were reviewed by board certified surgical breast pathologists to determine if there was sufficient invasive tumor and to direct dissection of all lymph node samples. The Recurrence Scores and quantitative single gene values from the paired samples will be examined descriptively with scatterplots and Pearson correlation coefficients and reported at the meeting.

Results: All 100 paired specimens were sent for Oncotype DX testing. 24 samples were found during standard H&E review to not have sufficient tumor for the assay. Of the 176 samples created for RNA extraction 173 samples had sufficient RNA for the Oncotype DX assay: 85 lymph node and 88 primary breast carcinoma samples. Recurrence Scores and quantitative single gene values from the paired primary breast carcinoma and lymph node samples will be examined descriptively and reported at the meeting.

Conclusion: Previous comparisons of paired primary and metastatic samples have used immunohistochemistry and FISH which are susceptible to variability in preanalytic variability such as delay to fixation, choice of fixative and duration in fixative. This study, using quantitative RT-PCR, will be one of the largest comparisons of tumor biology in paired samples yet reported in the era of genomic subtyping and may have implications for systemic adjuvant treatment.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-03.

Results of ENCORE 301, a randomized, phase II, double-blind, placebo-controlled study of exemestane with or without entinostat in postmenopausal women with locally recurrent or metastatic estrogen receptor-positive (ER+) breast cancer progressing on a nonsteroidal aromatase inhibitor (AI)

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Background: Hormonal therapy, including AIs, is the mainstay of ER+ breast cancer (BC) treatment; however, both acquired and intrinsic resistance limits its clinical benefit. Entinostat is a novel, oral, class I selective histone deacetylase inhibitor that has been shown to inhibit growth factor signaling pathways that mediate AI resistance. This study was designed to evaluate the impact of the addition of entinostat to exemestane therapy on progression-free survival (PFS).

Methods: Postmenopausal women with ER+ advanced BC who had progressed on a non-steroidal AI were randomized to exemestane 25 mg daily + entinostat 5 mg or placebo weekly.

Results: A total of 130 women were enrolled (66 exemestane+placebo; 64 exemestane+entinostat). All but 1 patient had Stage IV disease, and 82% had measurable disease. All patients had received prior hormonal therapy (1 prior line 42%; >1 prior line 58%), and 62% had received prior chemotherapy (33% in the advanced BC setting). Analysis of the intent-to-treat population showed that PFS was significantly (defined prospectively as p <0.10) longer with exemestane+entinostat than with exemestane+placebo (4.28 versus 2.27 months, respectively; hazard ratio [HR] = 0.73; p=0.06). Entinostat combined with exemestane was well-tolerated with the most frequent adverse events (AEs) consisting of fatigue, gastrointestinal disturbances, and hematologic abnormalities. AEs with a ≥20% higher incidence with exemestane+entinostat than with exemestane+placebo were fatigue (46% versus 26%, respectively) and uncomplicated neutropenia (25% versus 0%, respectively). The serious AE rate was similar for exemestane+entinostat (13%) and exemestane+placebo (12%).

Conclusions: Exemestane+entinostat significantly prolonged the median PFS and reduced the risk of disease progression by 27% versus exemestane+placebo (HR = 0.73). In light of these positive data, a phase III evaluation of this combination is planned.

[Osteopathic medicine]

Osteopathy is originated in the 19th century in the United States. Andrew Taylor Still seek for an alternative medical system to the orthodox medicine largely empirical and advocating bloodletting, calomel, etc., all of which was resumed with terms like" heroic medicine". Osteopathy as other alternative medical practices (homeopathy, eclecticism, etc.) based on rational and metaphysical postulates as vitalism or the fact that man is a divinely ordained machine. Still's approach was essentially manual and based on manipulation of the joints. Today osteopaths challenge these dogmas and seek to agree their practice within scientific biomedical standards. Even if strong randomized clinical trials are lacking, several surveys report how osteopathy gained public notoriety. Several recent meta-analyses pinpoint the benefit of the spinal manipulative treatment and even if there is no evidence that such an approach is superior to other advocated therapies there is no evidence that these therapies are more effective than the first one. The major indications for such a treatment are cervical and low back pain, either chronic or acute. The quality of the relationship between the practitioner and patient together with the placebo effect are important components of a treatment effect. Osteopathic education is an important aspect and only higher education institutions, i.e. universities can achieve and maintain adequate standards. Materia medica and surgery represent the two major therapeutic mainstreams in medicine; osteopathy considered as manual medicine could be the third one.

Effects of Echinaforce® treatment on ex vivo-stimulated blood cells

The herb Echinacea purpurea, also called purple coneflower, is regarded as an immune modulator. This study examined changes in cytokine production in blood samples from 30 volunteers before and during 8-day oral administration with an ethanolic extract of fresh Echinacea purpurea (Echinaforce(®)). Daily blood samples were ex vivo stimulated by LPS/SEB or Zymosan and analysed for a series of cytokines and haematological and metabolic parameters. Treatment reduced the proinflammatory mediators TNF-α and IL-1β by up to 24% (p<0.05) and increased anti-inflammatory IL-10 levels by 13% (p<0.05) in comparison to baseline. This demonstrated a substantial overall anti-inflammatory effect of Echinaforce(®) for the whole group (n=28). Chemokines MCP-1 and IL-8 were upregulated by 15% in samples from subjects treated with Echinaforce(®) (p<0.05). An analysis of a subgroup of volunteers who showed low pre-treatment levels of the cytokines MCP-1, IL-8, IL-10 or IFN-γ (n=8) showed significant stimulation of these factors upon Echinaforce(®) treatment (30-49% increases; p<0.05), whereas the levels in subjects with higher pre-treatment levels remained unaffected. We chose the term "adapted immune-modulation" to describe this observation. Volunteers who reported high stress levels (n=7) and more than 2 colds per year experienced a significant transient increase in IFN-γ upon Echinaforce(®) treatment (>50%). Subjects with low cortisol levels (n=11) showed significant down-regulation of the acute-phase proteins IL1-β, IL-6, IL-12 and TNF-α by Echinaforce(®) (range, 13-25%), while subjects with higher cortisol levels showed no such down-regulation. This is the first ex vivo study to demonstrate adapted immune-modulation by an Echinacea preparation. While Echinaforce(®) did not affect leukocyte counts, we speculate that the underlying therapeutic mechanism is based on differential multi-level modulation of the responses of the different types of leukocytes. Echinaforce(®) thus regulates the production of chemokines and cytokines according to current immune status, such as responsiveness to exogenous stimuli, susceptibility to viral infection and exposure to stress.

First time proof of sage's tolerability and efficacy in menopausal women with hot flushes

BACKGROUND

This trial aimed to assess the tolerability and efficacy of a fresh sage preparation in treating hot flushes and other menopausal complaints. Sage (Salvia officinalis) has been traditionally used to treat sweating and menopausal hot flushes, as well as to alleviate associated menopausal symptoms and as a general tonic. However, no clinical studies substantiating the use of sage in menopause have been published previously.

METHODS

In an open, multicenter clinical trial conducted in eight practices in Switzerland, 71 patients (intent-to-treat population [ITT], n=69; with a mean age of 56.4±4.7 years, menopausal for at least 12 months, and with at least five flushes daily) were recruited and treated with a once-daily tablet of fresh sage leaves for 8 weeks after an introductory baseline week. Parameters for the evaluation of efficacy were the change in intensity and frequency of hot flushes, and total score of the mean number of intensity-rated hot flushes (TSIRHF) as determined by diary protocol over the 2-month treatment period. Other variables included assessment of the Menopause Rating Scale (MRS) by the treating physician at baseline and after 2 months of therapy.

RESULTS

In the ITT population there was a significant decrease in the TSIRHF by 50% within 4 weeks and by 64% within 8 weeks (P<0.0001). The mean total number of hot flushes per day decreased significantly each week from week 1 to 8. The mean number of mild, moderate, severe, and very severe flushes decreased by 46%, 62%, 79%, and 100% over 8 weeks, respectively. The MRS and its somato-vegetative, psychological, and urogenital subscales decreased significantly by 43%, 43%, 47%, and 20% respectively. The treatment was very well tolerated.

CONCLUSION

A fresh sage preparation demonstrated clinical value in the treatment of hot flushes and associated menopausal symptoms.

Outcome of Isolated Sternal Recurrence in Breast Cancer

Introduction: Metastatic breast cancer to sternum is rare and its natural history and prognosis are not fully understood. Metastasis to sternum is considered as stage IV, but may represent local extension from internal mammary nodes. Here we present a case series of 7 patients with metastatic breast cancer to sternum with and without internal mammary node involvement.Method: Seven patients were identified by 5 medical oncologists from New York area with busy breast cancer practices, from 1991 to 2008. Patients chart were reviewed and information regarding age, menopausal status, hormone receptor status, Her2/neu status, initial treatment, time to sternal recurrence and treatment of metastatic disease were obtained.Results: Out of 7 patients with stages I to III at diagnosis, 4 were premenopausal. Two patients had triple negative tumors, 3 were ER/PR positive and 2 were Her2 positive. All patients received loco-regional treatment of the primary site with surgery and/or radiation. Five patients received adjuvant or neoadjuvant chemotherapy. Median time to sternal recurrence was 3 years. Two patients had biopsy confirmed metastasis to internal mammary nodes at relapse. All patients with recurrence received either chemotherapy, radiation or hormonal therapy. One patient received autologous bone marrow transplant after sternal recurrence. All 7 patients are alive, 5 of them in remission and 2 patients with stable disease. Median DFS in 5 patients with CR was 7.8 years.Conclusion: Isolated sternal recurrence with/without internal mammary node involvement is relatively uncommon and is classified as stage IV. On our review of 7 cases, 5 remain in continuous remission at a median of 8 years from recurrence. The other two patients have stable disease. These sternal lesions could possibly represent loco-regional recurrence rather than systemic relapse. Hence, isolated sternal recurrence from breast cancer may need to be stratified separately in studies of stage IV disease.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3054.

Differences in Breast Cancer Subtypes among Asian-American Women with Invasive Breast Cancer in New York City

Background: Specific breast cancer (BC) subtypes conferring distinct phenotypic and prognostic outcomes have been defined by molecular gene expression arrays. A recent study suggested that differences in BC subtypes exist among ethnic subgroups of Asian women in California. It has also been reported that there are differences in clinical outcomes among Asians with BC in the US, with Filipinos having a worse prognosis compared with other Asians. We sought to determine whether differences in BC subtypes exist among Asians in New York.Methods: Using outpatient registration records from Weill Cornell Breast Center and St. Vincent's Medical Center in New York City, we identified patients who were diagnosed with stage I, II, or III invasive BC between 1997 and 2007 who were of Chinese, Filipino, Japanese or Korean ethnicity. We reviewed pathology records according to an IRB approved protocol and recorded patient data for age, stage, grade, estrogen receptor (ER), progesterone receptor (PR) status, and HER-2/neu at diagnosis. Immunohistochemical surrogates for the four molecularly defined breast cancer subtypes were used according to accepted definitions (Luminal A: ER+Her2-; Luminal B: ER+ Her2+; Her2/neu: Her2+ ER-; Basal-like: ER-PR-, Her2-) Using chi-square analysis, we explored the relationship between ethnicity and BC subtypes.Results: 346 Asian women were identified with invasive breast cancer. Among the Chinese subgroup, 67% were of the Luminal A subtype, 15.3% were Luminal B, 10% were the Her2/neu subtype and 8.5% were Basal-like. Filipinos had a higher proportion of Luminal B cancers compared to the other ethnic groups. Filipinos and Koreans had a higher proportion of the Her2+/ER- subtype compared to Chinese and Japanese (P=0.004 by chi-square test). When considering all Her2/neu positive cancers, Filipinos had a significantly higher proportion of HER-2/neu positivity (46%) compared to Chinese (25%), Japanese (14%) and Korean (29%) groups (P=0.002). Filipinos and Koreans had a higher proportion of ER negative cancers and Grade III cancers compared to Chinese and Japanese (P=0.001 for ER status and P=0.01 for grade). In our series, Korean subjects were significantly younger than the other three ethnic groups (P&lt;0.0001 by AVOVA test).Conclusions: Differences in BC subtypes exist among Asian women with invasive breast cancer in New York. Filipino women are significantly more likely to have HER-2/neu positive BC compared with Chinese, Japanese, and Korean women. Our results are supportive of results from a study in which differences in distribution of Her2/neu positive cancers among Asians in California were seen. Furthermore, these findings provide one explanation for the worse clinical outcome for Filipinos compared with other Asians that has been previously reported.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3067.

Echinacea/sage or chlorhexidine/lidocaine for treating acute sore throats: a randomized double-blind trial

Background

The aim of this trial was to assess the relative efficacy of a sage/echinacea spray and a chlorhexidine/lidocaine spray in the treatment of acute sore throats.

Methods

This was a multicenter, randomized, double-blind, double-dummy controlled trial carried out in eleven general practices in Switzerland. A total of 154 patients (133 analyzed in per protocol collective) at least 12 years old with acute sore throat present for not more than 72 hours prior to inclusion and with a throat score ≥6 participated in the study. They used either an echinacea/sage spray or a chlorhexidine/lidocaine spray with two puffs every 2 hours, in a double-dummy blinded manner, up to 10 times daily until they were symptom-free, for a maximum of 5 days. The main outcome measures was the comparison of response rates during the first three days. A response was defined as a decrease of at least 50% of the total symptoms compared to baseline.

Results

The echinacea/sage treatment exhibited similar efficacy to the chlorhexidine/lidocaine treatment in reducing sore throat symptoms during the first 3 days (P(x < Y) = .5083). Response rates after 3 days were 63.8% in the echinacea/sage group and 57.8% in the chlorhexidine/lidocaine group. For all secondary parameters, such as time to becoming symptom free, throat pain, and global assessments of efficacy by the physician and patient, no difference between the two treatments was seen. They were both very well tolerated.

Conclusion

An echinacea/sage preparation is as efficacious and well tolerated as a chlorhexidine/lidocaine spray in the treatment of acute sore throats.

Achieving symptomatic remission in out-patients with schizophrenia--a naturalistic study with quetiapine

OBJECTIVE

Symptomatic remission was defined as a score of mild or less on each of eight key schizophrenia symptoms on the Positive and Negative Syndrome Scale (PANSS-8). To evaluate the symptomatic remission criterion in clinical practice and to determine predictors for achieving symptomatic remission, a 12-week non-interventional study (NIS) with quetiapine was conducted in Germany.

METHOD

For the comparison of patients with and without symptomatic remission, sociodemographic and clinical variables of 693 patients were analyzed by logistic regression for their predictive value to achieve remission.

RESULTS

Four hundred and four patients (58.3%) achieved symptomatic remission after 12 weeks' treatment with quetiapine. Remission was significantly predicted by a low degree of PANSS-8 total score, PANSS single items blunted affect (N1), social withdrawal (N4), lack of spontaneity (N6), mannerism and posturing (G5), and low disease severity (CGI-S) at baseline. Predictors of non-remission were older age, diagnosis of schizophrenic residuum, multiple previous episodes, longer duration of current episode, presence of concomitant diseases, and alcohol abuse.

CONCLUSION

This study demonstrated that the majority of schizophrenia out-patients achieved symptomatic remission after 12 weeks treatment and confirms the importance of managing negative symptoms in order to achieve disease remission.