Abstract P3-08-07: Distinct biological signatures describe differences in BRCA mutated subgroups

Background: BRCA mutated (BRCA+) breast cancers are expected to have increased activation of Homologous Recombination Deficiency (HRD) and altered DNA damage repair pathways when compared to BRCA wildtype (BRCA-). To better understand differences in these populations, biological patterns and immune responses to BRCA+ breast cancers were evaluated. The primary aim of our study was to use novel gene expression tools to assess early stage breast cancers with and without germline BRCA mutations, and within distinct BRCA+ subgroups.

Methods: We identified 124 early stage untreated breast cancers with and without BRCA mutations (n = 62 and 62, respectively). Our BRCA- group was matched by hormone receptor (HR) status, age, and stage to the BRCA+ group. The NanoString Breast Cancer 360 panel was applied to RNA isolated from 80 breast tumors (BRCA+ = 39; BRCA- = 41). The BRCA+ group had a BRCA1+ subgroup (n=17) and a BRCA2+ subgroup (n=22).

Results: There was a significant increase in two BC360 signatures in both the BRCA1+ and BRCA2+ tumors compared with the BRCA- population: Prosigna™Risk of Recurrence (ROR) score [BRCA1+: HR: 1.142 (95% CI 1.019, 1.279), p=0.02; BRCA2+: HR: 1.321 (95% CI 1.190, 1.466), p<0.001] and HRD [BRCA1+: HR: 3.576 (95% CI 2.174, 5.880), p=0.02; BRCA2+: HR: 1.801 (95% CI 1.142, 2.840), p<0.001]. BRCA1+ tumors had lower expression of ESR1 [p=0.03], PGR [p=0.02], ER signaling [p<0.001], and differentiation [p=0.005]; while BRCA2+ tumors had lower expression of stroma markers [p=0.02] and inflammatory chemokines [p=0.001]. The two BRCA+ subgroups had distinct molecular subtype correlation trends that were highly significant. BRCA1+ tumors were positively associated with a basal subtype [p<0.001], whereas this association was not significant for BRCA2+ tumors. BRCA2+ tumors were associated with an increase in luminal B subtype [p=0.05]. All BRCA+ tumors had a decrease in luminal A subtype correlation [BRCA1+: p<0.001; BRCA2+: p=0.002]. In addition to the BC360 signatures, a differential analysis of all genes in the BC360 panel revealed more single gene differences in BRCA2+ than BRCA1+ tumors when compared to BRCA- tumors.

Conclusions: In early stage BRCA+ breast cancer, tumors have higher ROR and increased HRD signature scores compared to BRCA- tumors. Furthermore, BRCA1+ and BRCA2+ tumors have both signature and single gene expression differences when compared to BRCA- tumors, indicating distinct subgroup-related biology. The greater correlation of BRCA1+ tumors with basal-like biology and BRCA2+ tumors with aggressive hormonal biology confirms these trends. Distinctions in hormone receptor signaling, DNA-damage pathways, and microenvironment/inflammatory features between BRCA1 and BRCA2 associated cancers suggest a need for different prevention and therapeutic strategies for each of these breast cancer subtypes. The unique biological patterns identified here should be further evaluated as predictive or prognostic tools that could be translated into clinical care for early stage BRCA+ patients.

Citation Format: Force J, Plichta J, Stashko I, Kimmick G, Westbrook K, Sammons S, Hwang S, Hyslop T, Kauff N, Castellar E, Nair S, Weinhold K, Davis S, Mashadi-Hossein A, Brauer HA, Marcom PK. Distinct biological signatures describe differences in BRCA mutated subgroups [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-08-07.

Guselkumab for the Treatment of Moderate-to-Severe Plaque Psoriasis During Induction Phase: A Systematic Review and Network Meta-Analysis

Background:

Guselkumab is an interleukin-23 inhibitor indicated for treatment of moderate-to-severe plaque psoriasis.

Objective:

The objective was to determine the relative efficacy and safety of guselkumab compared to other biologics.

Methods:

A systematic review was performed to identify randomized controlled trials (RCTs). Bayesian network meta-analyses (NMAs) were conducted using meta-regression analyses that adjusted for cross-trial differences and risk differences. The primary outcome was Psoriasis Area and Severity Index (PASI) 90 response. Other efficacy and safety outcomes were considered. Several meta-regressions were performed to account for variations in patient and study characteristics: baseline risk adjustment (ie, control group response), prior biologic use, duration of psoriasis, weight, age, race, and baseline PASI/dermatology life quality index scores. The best-fitting model using predefined criteria was selected.

Results:

Forty-five RCTs were identified. Patient and study characteristics differed between RCTs as reflected in variations in control group response. Both the baseline risk-adjusted NMA and the risk-difference NMA fit the data best and suggested guselkumab has one of the highest PASI 90 responses. Pairwise comparisons from the baseline risk-adjusted PASI 90 NMA suggested guselkumab has comparable efficacy with ixekizumab (relative risk [RR]: 0.999, 95% credible intervals [CrIs]: 0.89-1.13) and brodalumab (RR: 1.04, 95% CrIs: 0.91-1.17) and superior efficacy versus all other treatments in the network (RR range, 1.20 to 43.22). Guselkumab was superior or comparable to other therapies for other efficacy outcomes and had a more favorable safety profile than most.

Conclusions:

Guselkumab has one of the highest PASI 90 responses among psoriasis treatments; similar findings were observed for other efficacy outcomes. Guselkumab has a favorable benefit–risk balance compared to moderate-to-severe psoriasis therapies.

Unique Partnership to Roll Out Cancer Awareness and Screening Program for High-Risk Population in Maharashtra

Background and context: India is one of the few countries to have National Cancer Control Program and emphasis is given on tobacco related cancers because of high prevalence of such practices in India. As per the Global Adult survey 2016 around 30% of Indian population consume tobacco in any other form. Bus drivers, conductors and support staff of two leading public transport companies will be targeted by Indian Cancer Society as they are among high risk population with huge percentage of employees addicted with tobacco. Through this unique partnership, Indian Cancer Society (ICS) will promote tobacco deaddiction, cancer awareness and early detection of cancer among their staff. Aim: ICS is aiming at reaching out to around 1.20 Lakh bus drivers, conductors and support staff through this project in the span of 2 years. Strategy/Tactics: Cancer awareness will be created among targeted as well as general population by means of posters, banners, IEC leaflets. Depot managers will be sensitized about cancer, ill effects of tobacco consumption and importance of early detection. All eligible employees will be screened for commonest cancers in India like oral, breast, cervical and prostate. Tobacco deaddiction activities like support group meetings, experience sharing activities, role plays etc. will be organized for employees to facilitate tobacco deaddiction. Program/Policy process: Baseline survey was conducted for the sample size of 1000 employees in the month of March 2018 to assess their knowledge, attitude and practices related to tobacco addiction and cancer awareness. BCC and IEC activities will be planned based on the findings of baseline survey. Customized cancer screening packages will be developed based on the age and risk profile of employees. Support group meetings will be organized for employees with tobacco addiction. Outcomes: In the tenure of 2 years, cancer awareness will be created among 1.20 Lakh bus drivers, conductors and support staff. 75%–80% of these population will undergo cancer screening. General population residing in 30 districts of Maharashtra will be reached out through the cancer awareness drive organized at bus depots. Burden on the health system of these two transport companies will be reduced due to improved knowledge and health practices among their staff. Conclusion: With mandatory CSR, the private sector is keen on focusing on diseases with measurable outcome. Partnerships between government and NGOs can provide opportunities for private sector to collaborate; to reduce the burden of cancer through awareness and facilitate early detection thus improving chance of cure. This PPP model will provide structured quality cancer screening facility to identified high risk population and will facilitate early cancer detection. Best practices will be imbibed and tobacco deaddiction activities will be sustained beyond the project period.

An Eye Opener: Lessons Learnt in Retinoblastoma Awareness and Screening Program

Background: Retinoblastoma is most common intraocular malignancy of infancy. Globally screening is recommended for ‘at risk’ children. Despite knowing this, Indian Cancer Society undertook general screening at behest of a corporate donor. Scenario in India is challenging as children at rural, urban slums are not routinely screened for any of eye disease. ICS implemented the pilot project among underprivileged children with primary aim of spreading awareness and improve the ocular health. Though expected outcome was zero retinoblastoma suspect cases; based on past projects it was expected that other eye conditions like squint, cataract etc. would be identified in a few. Aim: To screen 4500 children below 4 years of age at Indian rural and suburban slum areas. To create awareness about retinoblastoma and other eye conditions in community. Methods: Locations were identified where literacy, awareness, immunization coverage were low. Partners were selected a team of experts (ocular oncologists, pediatric ophthalmologists, optometrists, paramedical staff) were deployed for implementation. For awareness, all parents coming for the immunization, Aaganwadis and preschools etc. were given a talk on the importance of child eye screening and various disease which can be detected and prevented through simple eye examination. Special community level programs planned to create awareness about retinoblastoma and early childhood eye screening. Brochures and pamphlets were to be given in the vernacular language of the region. Screening for retinoblastoma was planned in 2 phases, those found to have positive red reflex in stage 1 are subjected to dilation, after obtaining consent from the parents. Proformas were filled in and treatment was given as per the pediatric eye disease identified. Results: In 5 months 2450 children were screened, at tribal area and in suburban slum areas. Awareness sessions were conducted for 348 mothers in batches at the tribal area and similarly for mothers and teachers at Anganwadi, schools. None of the parents/teachers were aware about cancer of eye. A thorough eye check-up was done based on the suggestions of the American Association of Pediatric eye diseases and special attention was given to tests such as Bruckners test. Number of children suspected of retinoblastoma was nil, however, 6% children were found to have other eye conditions such as congenital cataract, corneal opacity, refractive errors, squints and ptosis in the tribal area and project is ongoing in suburban area. Treatment was given as per the protocol for same. Conclusion: Screening for retinoblastoma for not at risk children is not recommended. Main aim for implementing retinoblastoma awareness program is to integrate it with immunization or nutritional program in India. This would ensure standardized ocular care. Challenges are numerous, such as lack of infrastructure, poor literacy rates, low income levels. Yet, innovative strategies are needed for better impact of awareness programs.

Navigating Muddy Waters: Clearing Waves While Keeping Ourselves Afloat

Background and context: As the oldest cancer-related nongovernmental organization in Malaysia, the National Cancer Society of Malaysia regularly receives proposals for collaborations. While many are mutually beneficial, some are “risky”. Examples include partnerships with fast food companies, health supplements which benefits are vastly exaggerated, or fundraisers being held at bars or pubs. While these campaigns are accepted norms within the region, they might not conform to the standards of more mature markets. As we are expected to promote these activities or products on our digital media accounts, we risk overcrowding our pages, or being perceived as endorsing a product or behavior. Aim: Keeping donors happy while maintaining credibility Strategy/Tactics: The current strategy for NCSM's digital outreach is to focus on education/awareness instead of marketing. Also, we match the campaign's values with that of NCSM when deciding whether to promote it. When promoting a campaign, we stay neutral or personalise the donation. Above all, we play “devil's advocate”, focus on the impact of the funds raised, and stay firm on our decision. Program/Policy process: Out of 12 social media posts each week, no more than 2 is on marketing campaigns. Donors, instead of the product, are featured in a personalised “Why I Give” post. At times, we also prioritize well-meaning campaigns over others. For fundraisers held in bars/pubs, we ask for compromises (e.g., to ban smoking in the area for a short time, or that we do not promote the alcohol manufacturer). We are also proactive in checking the promotional content and insist that the donor remove any unproven information. Outcomes: NCSM's Facebook page grew organically (without ad buys) from 4000 in 2016 to 15,000 in 2017. We have about 60 new followers each week, negligible “unfollows” even on marketing-heavy times, and a minimum reach of 15,000 people. Education content is more popular (2300 reach per post versus 400); the same trend is observed for personalised versus product-based posts (3700 vs 400). To date, we have good relationships with our donors, and have not received comments on any partnerships. What was learned: It's intention, and not visual or monetary value, that counts: our audiences are more appreciative of quality content, even if marketing/product posts might look better. Also, staff and survivors can sense sincere donors, which makes a difference in our promotional efforts (positive versus matter-of-fact tones). Well-meaning donors do adhere to our promotion guidelines, and do agree to not being promoted. In addition, featuring donors is a great way to publicise an activity without mentioning the product. Most importantly, being able to justify collaborations within the organization protects its integrity and credibility.

Aneurysm of Anterior Inferior Cerebellar Artery-posterior Inferior Cerebellar Artery Variant

Aneurysms arising from anterior inferior cerebellar artery-posterior inferior cerebellar artery (AICA-PICA) variant are extremely rare. They usually present with subarachnoid hemorrhage. This is probably the second case report of a large thrombosed AICA-PICA variant aneurysm presenting as a cerebellopontine angle mass lesion with cranial nerve palsy, managed successfully by surgical clipping.

Squamous cell carcinoma of the upper aerodigestive tract in exclusive smokers, chewers, and those with no habits

BACKGROUND

Tobacco consumption is the major risk factor for developing head and neck squamous cell cancer (SCC). The site of development of HNSCC may depend on the way the tobacco is consumed. While laryngeal cancers are more common among smokers, oral cancers are more common among tobacco chewers. Since the use of smokeless tobacco is increasing, it is important to know whether this difference is restricted only to site wise distribution or it has other clinical and pathological implications.

PATIENTS AND METHODS

We analyzed a prospectively collected dataset of HNSCC patients other than nasopharyngeal cancers attending our outpatient department at a single unit of the head and neck services at Tata Memorial Hospital, Mumbai, India, between January 2010 and September 2011. There were 747 eligible patients and were divided into three groups: Those with chewing as the only habit (chewers), those with smoking as the only habit (smokers), and those with no habits. Patients with regular use of alcohol were excluded from the study. The clinical and pathological parameters were analyzed.

RESULTS

Of the 747 patients, the tobacco chewers formed 69.3% followed by smokers (19.5%) and patients with no habits (11.1%). Majority of smokers were men (98%). Site distribution revealed patients with chewing as the only habit had oral cancers (most commonly gingivobuccal complex cancers) as the most common site and those with smoking as the only habit had larynx as the most common site. In patients with no habits, oral tongue was found to be the most common site. No statistically significant pathological differences were observed in between these groups in patients who underwent surgery (n = 366) at the initial modality of treatment.

CONCLUSIONS

There is a direct relationship between the form of tobacco use and site of appearance of HNSCC. However, there are no differences in clinical or pathological parameters between HNSCC caused by tobacco chewing or tobacco smoking.

Immunoscore to provide prognostic information in low- (T1-3N1) and high-risk (T4 or N2) subsets of stage III colon carcinoma patients treated with adjuvant FOLFOX in a phase III trial (NCCTG N0147; Alliance)

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Background: A consensus interpretation of the IDEA colon cancer study results suggested that risk categories based on T/N stage grouping be used to guide decision-making for duration (3 vs 6 months) of adjuvant FOLFOX or CapeOX chemotherapy. Given the prognostic potential of immune biomarkers, we examined the immunoscore and individual T and B lymphocyte markers in low and high risk T/N subsets of stage III colon carcinoma patients (N=600) treated with adjuvant FOLFOX. Methods: Immunoscore (CD3+, CD8+) and individual T-cell and CD20+ B-cell immunostain densities in central tumor (CT) and invasive margin (IM) of FFPE sections were quantified by image analysis. A predetermined immunoscore categorization was used [high (2-4) vs low (0-1)]. Individual markers were analyzed by backwards selection wherein CD3+ IM was most robust for prognosis and an optimized cutoff was then determined. Associations with disease-free survival (DFS) were analyzed by multivariable Cox regression adjusting for age, T/N stage, sidedness, KRAS/BRAF, and DNA mismatch repair. Results: In low and high risk T/N patient subsets, the immunoscore and CD3+ IM were each significantly discriminant for prognosis. Among low risk (T1-3N1) patients, a high vs low immunoscore was associated with a 91% vs 77% 3-year DFS [HR 0.57, 95% confidence interval (CI) 0.34-0.95, adjusted (adj) P= 0.026]. Among high risk (T4 or N2) patients, a high vs low immunoscore was associated with a 68% vs 54% 3-year DFS (HR 0.64, 95% CI 0.42-0.98, Padj= 0.034]. Similarly, a high vs low intratumoral CD3+ density at the invasive margin (IM) was significantly associated with prognosis in low risk [HR 0.37, 95% CI 0.21- 0.66), Padj< 0.0003] and in high risk [HR 0.47, 95% CI, 0.27- 0.80), Padj< 0.0028] patient subsets. Conclusions: Immunoscore and CD3+ IM were shown to prognostically stratify FOLFOX-treated patients within both low and high risk T/N subsets. These data underscore limitations of the T/N risk classification for adjuvant treatment decisions in stage III patients, and demonstrate the ability of T-cell markers to enhance prognostication to guide clinical decision-making.