P2-17-01: Influence of Delayed Zoledronic Acid Initiation on Disease-Free Survival in Postmenopausal Women with Endocrine Receptor-Positive Early Breast Cancer Receiving Adjuvant Letrozole: Exploratory Analyses from the ZO-FAST Trial

Introduction: Bisphosphonates (BPs) combined with adjuvant endocrine therapy have been shown to prevent aromatase inhibitor-associated bone loss (AIBL) and improve outcomes in recent clinical trials in patients with hormone receptor-positive (HR+) early breast cancer (EBC). Accelerated bone turnover (a common phenomenon during AIBL) has been associated with increased risk of bone metastasis in EBC (Lipton A, et al. St. Gallen 2009. abs #244), but little is known about the effect of BPs on the disease course in women with EBC and progressing AIBL. We have previously demonstrated that adding ZOL to adjuvant therapy significantly improved bone mineral density (BMD) and prolonged disease-free survival (DFS) vs delayed ZOL (de Boer R, et al. SABCS 2010. P5-11-01). We report here the prognostic factors for DFS and the effect of ZOL initiation in the delayed ZOL (DZOL) arm of the ZO-FAST trial at 5 years’ median follow-up.

Methods: The ZO-FAST trial randomized postmenopausal women with HR+ EBC initiating letrozole (LET; 2.5 mg qd x 5 years) with a BMD T-score ≥ −2 (N=1,065) to immediate (IMZOL; 4 mg q 6 months) or DZOL (initiated for post-baseline T-score < −2, or nontraumatic/asymptomatic fractures). The primary endpoint was change in BMD at 12 months; patients were followed for disease recurrence and overall survival for 5 years (secondary endpoints). Exploratory Cox regression analyses were performed to identify prognostic factors for DFS in the DZOL arm.

Results: At 60-months follow-up, IMZOL significantly reduced the risk of a DFS event by 34% vs DZOL (42 vs 62 events; ∼80% distant recurrences and 20% local; hazard ratio [HR]=0.66; 95% confidence interval [CI], 0.44−0.97; P=.034) in the intent-to-treat population (N=1,065; n=532 IMZOL; n=533 DZOL). In exploratory analyses of the DZOL arm (n=535; safety population), patients who initiated DZOL treatment (n=144) had significantly improved DFS (10 events; HR=0.462; 95% CI, 0.23−0.94; P=.033) compared with DZOL arm patients who never initiated ZOL (53 events; n=391). Other significant prognostic factors for DFS events in the DZOL arm were age ≥65 years at study entry (HR=1.949; 95% CI, 1.09−3.47; P=.024 vs age <65 years) and cancer T-stage ≥2 (HR=2.155; 95% CI, 1.03−4.51; P=.042 vs T-stage <2).

Conclusions: Exploratory analyses of the ZO-FAST database revealed significant DFS benefits from initiation of ZOL treatment for postbaseline fractures or T-scores < −2, suggesting that ZOL (even if initiated late) can positively influence the disease course in patients with AIBL. Together with other studies showing DFS benefits from ZOL in patients with complete ovarian suppression/postmenopausal status (Coleman RE, et al. SABCS 2010. abs #S4-5; Gnant M, et al. NEJM 2009;360:679–691), these data suggest that treating (and ideally, preventing) AIBL may also improve DFS in patients with HR+ EBC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-17-01.

S1-3: Long-Term Survival Outcomes among Postmenopausal Women with Hormone Receptor-Positive Early Breast Cancer Receiving Adjuvant Letrozole and Zoledronic Acid: 5-Year Follow-Up of ZO-FAST

Introduction: Recent clinical trials suggest potential anticancer activity for bisphosphonates combined with adjuvant endocrine therapy in patients with hormone receptor-positive (HR+) early breast cancer (EBC). Data from the interim analysis of AZURE suggest that the benefits of adding zoledronic acid (ZOL) may be greatest in patients with low estrogen levels (Coleman RE, et al. SABCS 2010). In ZO-FAST, we have previously demonstrated that adding ZOL to adjuvant therapy significantly improved bone mineral density (BMD) and prolonged disease-free survival (DFS) vs delayed ZOL (de Boer R, et al. SABCS 2010). We report here the effect of time since menopause at breast cancer diagnosis (ie, baseline menopausal status) on DFS benefits with ZOL.

Methods: Postmenopausal women with HR+ EBC receiving letrozole (LET; 2.5 mg qd x 5 yr) with a BMD T-score ≥-2 (N=1065) were randomized to ZOL (4 mg q6mo): immediate (IMZOL) or delayed (DZOL; initiated for postbaseline T-score <-2 or nontraumatic/asymptomatic fracture). Patients were followed for disease recurrence and overall survival (OS) for 5 years. Patients were eligible for the study if they had established menopause at the time of diagnosis, or if they became menopausal because of chemotherapy or ovarian suppression (ie, recently postmenopausal). The effect of baseline menopausal status on DFS was examined in Cox regression analyses.

Results: At 60 months’ follow-up in the overall population (N=1065), IMZOL significantly reduced the risk of a DFS event by 34% vs DZOL (hazard ratio [HR]=0.66; 95% confidence interval [CI], 0.44−0.97; P=.034). In exploratory analyses of women who were postmenopausal for >5 years or >60 years old at study entry (n=670), IMZOL improved DFS (HR=0.63; 95% CI, 0.39−1.01; P=.052) and significantly prolonged OS (HR=0.50; 95% CI, 0.27−0.92; P=.022) vs DZOL. Additional subgroup analyses including patterns of breast cancer recurrence will be presented. During 5 years of treatment, osteonecrosis of the jaw (ONJ) was reported in 4/669 patients (0.6%) who received ZOL, and there was no increase in renal adverse events (AEs) in the ZOL-treated patients. Overall, AEs were consistent with the known safety profiles of both study drugs.

Conclusions: Long-term follow-up in ZO-FAST confirms the overall survival benefits of adding ZOL (4 mg q6mo) to adjuvant LET therapy for EBC. However, subset analyses suggest that women with established postmenopausal status may benefit from ZOL therapy more than others. These results are consistent with observations in the AZURE trial, and support potentially greater ZOL benefits in a low-estrogen environment. Additional studies are needed to fully define the patient populations most likely to benefit from adjuvant ZOL in this setting.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr S1-3.

P4-16-04: An Open-Label, Phase IIa, Non-Randomized Study of Radium-223 in Breast Cancer Patients with Bone Dominant Disease No Longer Considered Suitable for Endocrine Therapy

Background

Radium-223 (Alpharadin™) is a 1st-in-class alpha-pharmaceutical. It targets bone metastases (mets) with high-energy alpha-radiation of extremely short range that spares bone marrow. These characteristics generate highly localized radiation zones that may inhibit tumor progression and induce pain relief. Radium-223 has a profound effect on markers of bone metabolism and has shown a survival advantage over standard of care in pts with castration-resistant prostate cancer. The study's main objective was to investigate whether multiple IV injections (inj) of radium-223 have any clinically relevant effect on bone markers in metastatic breast cancer (MBC) pts with bone dominant disease (BDD).

Methods: Study included MBC pts with BDD who had progressed (based on imaging or other clinically relevant information) on endocrine therapy and were no longer considered suitable for endocrine therapy. In this open-label, multicenter, single-arm, phase IIa study (EudraCT #2009-012189-30), 23 pts were scheduled to receive 4 IV inj of radium-223 50 kBq/kg every 4 wk. Bone markers were assessed at baseline, prior to every treatment, and thereafter at each follow-up visit. Primary efficacy endpoint was change in urine levels of NTX (uNTX) and bALP at 16 wk. Functional imaging with FDG-PET was performed in 20 pts at baseline and wk 8 and 16. Symptomatic response was assessed using validated questionnaires.

Results: Histologic types were ductal carcinoma (n=12), lobular carcinoma (n=7), and others (n=2). Median interval from diagnosis of breast cancer to 1st relapse was 3 (1, 11) years. All except 1 pt received endocrine therapies, and adjuvant chemotherapy was given to approximately 60%. 21 of 23 pts were treated concurrently with bisphosphonates. 15 of 23 pts received all 4 inj of radium-223; 4/23 received 3 inj; and 4/23 received 2 inj. Pts who received <4 inj had disease progression (bone and visceral mets [n=3], visceral mets [n=3]) or withdrawn consent (n=1) and were not eligible to continue radium-223. One pt died before 4th inj due to atrial fibrillation. Median age was 58 (41, 83) years. Median uNTX levels were reduced by 20% (from 36 to 29 ***nmo1BCE/mmo1 creatinine; P=0.03) and 5% (from 36 to 23 ***nmo1BCE/mmo1 creatinine; P=NS) at wk 8 and 16 respectively; 17/23 and 9/13 pts (for whom data were available) had a decrease in uNTX at wk 8 and 16 respectively. Median bALP levels were reduced by 33% (from 22.1 to 12.1 ng/mL; P=0.0001) at wk 8 and 33% (from 22.1 to 10.4 ng/mL; P=0.04) at wk 16. Bone-ALP levels were reduced in 20/22 pts at wk 8 and in 10/12 pts (for whom data were available) at wk 16. Radium-223 was found to be safe and well tolerated. 3 pts had serious AEs, none related to study drug; 1 of them died due to disease progression. Functional imaging results, additional bone marker data, and pt-reported outcomes are being analyzed.

Conclusions: Radium-223 consistently reduced uNTX and bALP during the 16-wk treatment period, results observed in addition to bisphosphonate use. Results show radium-223 targets the areas of increased bone metabolism caused by bone mets. Radium-223 found to be safe and well tolerated, confirming highly tolerable SE profile seen in other studies.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-16-04.

Search for the rare decays K(L)→π0π0μ+μ- and K(L)→π0π0X0→π0π0μ+μ-

The KTeV E799 experiment has conducted a search for the rare decays, K(L)→π(0)π(0)μ(+)μ(-) and K(L)→π(0)π(0)X(0)→π(0)π(0)μ(+)μ(-), where the X(0) is a possible new neutral boson that was reported by the HyperCP experiment with a mass of (214.3 ± 0.5) MeV/c(2). We find no evidence for either decay. We obtain upper limits of Br(K(L)→π(0)π(0)X(0)→π(0)π(0)μ(+)μ(-)) < 1.0 × 10(-10) and Br(K(L)→π(0)π(0)μ(+)μ(-)) < 9.2 × 10(-11) at the 90% confidence level. This result rules out the pseudoscalar X(0) as an explanation of the HyperCP result under the scenario that the dsX(0) coupling is completely real.

The treatment of early breast cancer in women over the age of 70

One third of all breast cancers are diagnosed in women aged 70 or over. Older women are a heterogeneous population who are under-represented in clinical trials, and as a result uncertainty can exist as to what represents optimal treatment. This minireview, from an international authorship, summarises the existing evidence surrounding the management of early breast cancer in women aged 70 and over. The use of primary surgery and endocrine therapy, and adjuvant chemotherapy, radiotherapy, endocrine therapy and trastuzumab are discussed. Reference is made to ongoing clinical trials in this area and areas of controversy are highlighted.

Disability, distress and unemployment in neurology outpatients with symptoms 'unexplained by organic disease'

OBJECTIVES

To determine the disability, distress and employment status of new neurology outpatients with physical symptoms unexplained by organic disease and to compare them with patients with symptoms explained by organic disease.

METHODS

As part of a cohort study (the Scottish Neurological Symptoms Study) neurologists rated the extent to which each new patient's symptoms were explained by organic disease. Patients whose symptoms were rated as 'not at all' or only 'somewhat' explained by disease were considered cases, and those whose symptoms were 'largely' or 'completely' explained by disease were considered controls. All patients completed self-ratings of disability, health status (Medical Outcomes Study Short Form 12-Item Scale (SF-12)) and emotional distress (Hospital Anxiety and Depression Scale) and also reported their employment and state financial benefit status.

RESULTS

3781 patients were recruited: 1144 (30%) cases and 2637 (70%) controls. Cases had worse physical health status (SF-12 score 42 vs 44; difference in means 1.7 (95% CI -2.5 to 0.9)) and worse mental health status (SF-12 score 43 vs 47; difference in means -3.5 (95% CI -4.3 to to 2.7)). Unemployment was similar in cases and controls (50% vs 50%) but cases were more likely not to be working for health reasons (54% vs 37% of the 50% not working; OR 2.0 (95% CI 1.6 to 2.4)) and also more likely to be receiving disability-related state financial benefits (27% vs 22%; (OR 1.3, 95% CI 1.1 to 1.6)).

CONCLUSIONS

New neurology patients with symptoms unexplained by organic disease have more disability-, distress- and disability-related state financial benefits than patients with symptoms explained by disease.

Wicking assay for the rapid detection of Rift Valley fever viral antigens in mosquitoes (Diptera: Culicidae)

Rift Valley fever virus (RVFV) causes outbreaks of severe disease in domestic ungulates as well as humans in Africa. There is a logical concern that RVFV could be introduced into the Americas and cause significant health and economic damage based on the precedent of the introduction and spread of West Nile virus (WNV). Unfortunately, there are currently no licensed diagnostic assays available for RVFV in the Americas. In this work, we report on the ability of a novel dipstick assay, VectorTest RVFV antigen assay, modeled on the VecTest assay for WNV, to detect a RVFV-infected female within a pool of mosquitoes. The dipsticks provided results in <20 min, were easy to use, and did not require a laboratory with containment facilities. Although readily able to detect a mosquito with a disseminated RVFV infection, it only occasionally detected RVFV in a mosquito with a nondisseminated infection, and therefore may fail to detect some pools that actually contain one or more positive mosquitoes. The RVFV dipstick assay was highly specific and did not react with samples to which had been added yellow fever, West Nile, Venezuelan equine encephalitis, sandfly fever Naples, sandfly fever Sicilian, or sandfly fever Toscana viruses. The RVFV assay can provide a rapid, safe, easy-to-use assay to alert public health personnel to the presence of RVFV in mosquitoes. Results from this assay will allow a rapid threat assessment and the focusing of vector control measures in high-risk areas.

Ovarian germ cell malignancy: a heterogeneous tumour requiring supra-regional management

BACKGROUND

Malignant ovarian germ cell tumours (GCT) are rare tumours with clinical and histological heterogeneity. Risk adapted treatment of these tumours is advocated.

METHODS

We reviewed patients with malignant ovarian GCT managed by a single specialist during 1991-2009 at our institution. Clinicopathological features that may predict behaviour of the disease and disease outcomes were assessed.

RESULTS

Thirty-four patients with a median follow-up time of 5.7 years were identified. The 10-year estimated survival rates were up to 80%; 8/13 patients with Stage I disease were recommended active surveillance, of whom three relapsed and, one with an immature teratoma died.

CONCLUSIONS

Ovarian GCT are potentially curable but appear to have a worse prognosis than their testicular counterparts. To improve expertise in the management of these complex tumours and optimise future management, a supra-regional service modeled on that used in the management of gestational trophoblastic disease is proposed.

Aging and bone

Bones provide mechanical and protective function, while also serving as housing for marrow and a site for regulation of calcium ion homeostasis. The properties of bones do not remain constant with age; rather, they change throughout life, in some cases improving in function, but in others, function deteriorates. Here we review the modifications in the mechanical function and shape of bones, the bone cells, the matrix they produce, and the mineral that is deposited on this matrix, while presenting recent theories about the factors leading to these changes.

Systems mapping workshops and their role in understanding medication errors in healthcare

Systems mapping workshops have been applied to the problem of medication errors in healthcare. The workshops were designed using experiential group work principles. They involved a range of stakeholders from within the health service as well as those who supply the health sector, including designers who may be able to enhance the safety of products and systems used in healthcare. Research has shown that the method encourages stakeholder participation, provides robust results within a limited time and enhances understanding across specialist interest groups. Additional, creative design workshops that considered the same topic showed significant promise in developing concepts from which potential solutions could be developed further.

Which factors should be taken into account in perimenopausal women with early breast cancer who may become eligible for an aromatase inhibitor? Recommendations of an expert panel

Menopausal status is a major consideration in adjuvant breast cancer therapy. The variable onset and duration of the menopausal transition and the poor predictive value of bleeding patterns and hormone levels mean many women fall naturally into a "perimenopausal" category. Women becoming amenorrhoeic during cytotoxic or endocrine treatment are also of uncertain status since ovarian function may resume even in older patients after several months without menses. The recent St. Gallen panel acknowledged that aromatase inhibitors (AIs) should form part of standard endocrine therapy for postmenopausal women with receptor-positive tumours. Among perimenopausal women at sufficiently high risk of recurrence, there may also be a case for adjuvant AIs either up-front or after tamoxifen. Such treatment should be initiated only after careful consideration of the patient's age, menstrual history and the effects of tamoxifen (which may make hormone levels an unreliable guide to ovarian function). In treatment-naïve women whose postmenopausal status cannot be confirmed by reliable, serial hormone measurements, treatment should start with tamoxifen. Serial monitoring of hormone levels may enable an AI to be started if postmenopausal status is confirmed. In women with treatment-induced amenorrhoea, any decision to start an AI requires baseline hormone levels consistent with postmenopausal status; and continuation of treatment requires that hormone levels remain postmenopausal during regular monitoring.

A conditioning technique applicable to elementary school classrooms

A procedure was developed for use in a public school classroom where only one of the children needed treatment, sophisticated apparatus was not feasible, personnel were untrained in conditioning techniques, and where disruption had to be minimized. Candy reinforcers were contingent upon working behavior. The total candy earned in the session was divided equally among the class. Portable radio control apparatus was adopted to give feedback to the child when he was displaying the desired working behavior. An increase in working behavior and a decrease in talking aloud and out-of-seat behavior was observed for each of the four subjects. When the feedback apparatus was removed, the desired behavior was maintained through candy reinforcement alone in all four subjects.

Efficacy of zoledronic acid in postmenopausal women with early breast cancer receiving adjuvant letrozole: 36-month results of the ZO-FAST Study

BACKGROUND

Aromatase inhibitors (AIs) are accepted as adjuvant therapy for postmenopausal women (PMW) with hormone-responsive early breast cancer (EBC) with superior efficacy to tamoxifen. However, increased bone loss is associated with AIs.

PATIENTS AND METHODS

PMW with EBC receiving letrozole (2.5 mg/day for 5 years) were randomly assigned to immediate zoledronic acid (ZOL; 4 mg every 6 months) or delayed ZOL (initiated only for fracture or high risk thereof).

RESULTS

Patients (N = 1065) had a median age of 58 years; 54% had received prior adjuvant chemotherapy. At 36 months, mean change in L2-L4 bone mineral density (BMD) was +4.39% for immediate versus -4.9% for delayed ZOL (P < 0.0001). Between-group differences were 5.27% at 12 months, 7.94% at 24 months, and 9.29% at 36 months (P < 0.0001 for all). At 36 months, the immediate-ZOL group had a significant 41% relative risk reduction for disease-free survival (DFS) events (P = 0.0314). Adverse events are consistent with the known safety profiles of the study drugs.

CONCLUSIONS

At 36 months, immediate ZOL was more effective in preserving BMD during letrozole therapy. Immediate versus delayed ZOL led to significantly improved DFS. Benefits are observed in the context of a favorable, well-established safety profile for letrozole and ZOL.