Meeting highlights: International Consensus Panel on the Treatment of Primary Breast Cancer

When May Adjuvant Radiotherapy be Avoided in Operable Breast Cancer?

Randomised trials in which the omission of radiotherapy has been tested after breast-conserving surgery, with or without adjuvant systemic therapy, show a significant four- to five-fold reduction in local recurrence. As yet, no subgroup of women managed by breast-conserving surgery has been identified from whom radiotherapy can be withheld. Few randomised data have been published on the effect of omission of radiotherapy on local control, quality of life and costs, particularly in older women for whom the risk of local recurrence is generally lower. Ongoing trials are evaluating the role of radiotherapy in this population of low risk, older women. Adjuvant radiotherapy after breast-conserving surgery or mastectomy significantly reduces the incidence of local recurrence. In women who have had a mastectomy at high risk of recurrence (> 20% risk of recurrence at 10 years), adjuvant radiotherapy improves survival if combined with adjuvant systemic therapy. Among women with T3 tumours, and those with four or more involved axillary nodes treated by mastectomy, postoperative radiotherapy is the standard of care. For women at intermediate risk of recurrence (i.e. <15% 10-year risk of recurrence after surgery and systemic therapy alone), with one to three involved nodes or node negative with other risk factors, the role of radiotherapy is unclear. Clinical trials to assess the role of postmastectomy radiotherapy (PMRT) in this setting are needed. For pT1-2, pNO tumours without other risk factors, there is no evidence at present that PMRT is needed.

Surface-enhanced laser desorption/ionization time of flight mass spectrometry protein profiling identifies ubiquitin and ferritin light chain as prognostic biomarkers in node-negative breast cancer tumors

Novel prognostic biomarkers are imperatively needed to help direct treatment decisions by typing subgroups of node-negative breast cancer patients. The current study has used a proteomic approach of SELDI-TOF-MS screening to identify differentially cytosolic expressed proteins with a prognostic impact in 30 node-negative breast cancer patients with no relapse versus 30 patients with metastatic relapse. The data analysis took into account 73 peaks, among which 2 proved, by means of univariate Cox regression, to have a good cumulative prognostic-informative power. Repeated random sampling (n = 500) was performed to ensure the reliability of the peaks. Optimized thresholds were then computed to use both peaks as risk factors and, adding them to the St. Gallen ones, improve the prognostic classification of node-negative breast cancer patients. Identification of ubiquitin and ferritin light chain (FLC), corresponding to the two peaks of interest, was obtained using ProteinChip LDI-Qq-TOF-MS. Differential expression of the two proteins was further confirmed by Western blotting analyses and immunohistochemistry. SELDI-TOF-MS protein profiling clearly showed that a high level of cytosolic ubiquitin and/or a low level of FLC were associated with a good prognosis in breast cancer.

Estrogen-regulated proteins cathepsin D and pS2 in breast carcinoma

In addition to classical prognostic/predictive factors, significant biological markers have been identified to provide potentially relevant information regarding natural or clinical course of breast cancer. Steroid receptor status of the primary breast cancer have been proven to be a predictor of response to endocrine therapy since up to 80 % of patients with steroid receptor-positive tumors respond to endocrine treatment. In order to improve the predictive value of steroid receptor status, attention has been paid to estrogen-regulated proteins, including pS2 and cathepsin D among others that may be indicators of a functional signal transduction pathway through which tumor cells respond to estrogen stimulation. It has been shown that pS2 protein may be constitutive product as well as estrogen-regulated product in breast carcinoma. pS2 appears to be positively correlated with ER, associated with a good prognosis and a predictor of response to endocrine treatment of primary and metastatic breast cancer. The expression cathepsin D may be both constitutive and overexpressed as a result of estrogen-induced transcription. It was believed that the main role of cathepsin D was to degrade protein, but many other biological functions of cathepsin D were recognized. Cathepsin D level in primary breast cancer has been demonstrated as an independent marker of poor prognosis associated with increased risk for metastasis and shorter survival times. Our recent results show direct correlation of cathepsin D positivity with pS2 expression. Additionally, we found that cathepsin D is statistically significantly associated with pS2 both in node-negative and node-positive patients bearing tumors smaller than 2 cm. .

Serum c-erbB-2 protein is a useful marker for monitoring tumor recurrence of the breast

C-erbB-2 oncogene protein (ErbB-2/HER-2) overexpression is a prognostic marker of breast carcinoma. The purpose of this study was to evaluate serum ErbB-2 for monitoring tumor recurrence of operable breast carcinoma patients. The subjects were 86 breast carcinoma patients with stage I-IIIB. Sera were collected at preoperative and postoperative periods from 1996 to 2000. The cutoff value was set at 5.4 ng/ml for preoperative patients and at 6.5 ng/ml for postoperative patients. Twenty-nine patients (34%) had higher preoperative serum ErbB-2 levels (>or=5.4 ng/ml). A higher preoperative serum ErbB-2 was associated with higher clinical stage, larger tumor size, nodal metastasis, higher histologic grade and lymphatic invasion, but not with vascular invasion, hormonal receptor status or other tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen 15-3 (CA15-3). As of April 2005, 27 patients (31%) had recurrence and 18 (62%) of them had a higher preoperative serum ErbB-2. Seventeen patients died of tumor progression. The recurrence-free survival rates at 7 years after breast surgery were 84% in 57 patients with a normal preoperative serum ErbB-2 and 41% in 29 patients with a higher preoperative serum ErbB-2 (p < 0.0001). The overall survival rates at 7 years were 93% and 55% (p < 0.0001), respectively. A multivariate analysis revealed that preoperative serum ErbB-2 was an independent prognostic factor for recurrence-free survival and overall survival in breast carcinoma patients. The specificities and sensitivities of postoperative tumor markers (CEA, CA15-3 and ErbB-2) were 91%, 100% and 85%, and 40%, 30% and 70%, respectively. Serum ErbB-2 is a preoperative prognostic marker and may be useful for monitoring tumor recurrence of the breast.

Cost-effectiveness of new guidelines for adjuvant systemic therapy for patients with primary breast cancer

BACKGROUND

In this study, the potential impact of a new national guideline for adjuvant systemic therapy in breast cancer (introduced in The Netherlands in 1998) was assessed, as well as the modifications of this guideline, issued in 2001. Both the change in total number of patients eligible for adjuvant therapy, as well as the cost-effectiveness of the changed clinical management of these patients were analysed.

PATIENTS AND METHODS

Percentages of patients who would be eligible for adjuvant therapy in 1994, 1998 and 2001 were estimated, based on clinical data from 127 patients, who were operated on in 1994. Ten-year overall survival rates were used as a measure of effectiveness, based on the two most recent EBCTCG meta-analyses. Actual resource costs were calculated. With a decision analytic model, the incremental cost-effectiveness ratios (1998 versus 1994, and 2001 versus 1998) were calculated.

RESULTS

The introduction of the 1998 guideline resulted in a relative increase of 80% in the total number of patients eligible for adjuvant therapy, compared with 1994 (from 40% to 72% of all patients with primary breast cancer). With an estimated absolute increase of 10-year overall survival of 2%, the 1998 guideline was found to have an expected incremental cost-effectiveness ratio of about 4837 per life-year gained.

CONCLUSIONS

Introduction of the new guideline considerably affected the number of patients eligible for adjuvant systemic therapy for breast cancer. The associated incremental cost-effectiveness ratio is well within the range of values that are generally considered acceptable.

Treatment for Breast Cancer in Patients with Alzheimer's Disease

OBJECTIVES

To report use of breast cancer treatment (surgery, radiation, and chemotherapy) by patients with Alzheimer's disease (AD).

DESIGN

Retrospective cohort study.

SETTING

Surveillance, Epidemiology, and End Results (SEER) is a population-based cancer registry covering 14% of the U.S. population.

PARTICIPANTS

Fifty thousand four hundred sixty breast cancer patients aged 65 and older, of whom 1,935 (3.8%) had a diagnosis of AD before or up to 6 months after cancer diagnosis.

MEASUREMENTS

Diagnosis of AD was taken from International Classification of Diseases, Ninth Revision, diagnostic codes accompanying Medicare billing claims between 1992 and 1999. The SEER program reported surgery and radiation. Chemotherapy was taken from Medicare billing records.

RESULTS

Subjects with AD were diagnosed with breast cancer at later stages, when tumors were larger and the likelihood of lymph node involvement had increased. Patients with AD had a lower likelihood of surgery (odds ratio (OR)=0.60, 95% confidence interval (CI)=0.46-0.81), radiation (OR=0.31, 95% CI=0.23-0.41), and chemotherapy (OR=0.44, 95% CI=0.34-0.58) than those without AD.

CONCLUSION

Overall, AD patients receive less treatment for breast cancer than do comparable female Medicare beneficiaries. Chemotherapy and radiation are administered less frequently to women with AD than to other comparable patients. It is unclear whether suboptimal medical care has an effect on their survival. Further research on the effect of screening and treatment decision-making for these patients is warranted.

Physicians' Assessments of Adjuvant Tamoxifen's Effectiveness in Older Patients with Primary Breast Cancer

OBJECTIVES

To examine physicians' assessments of tamoxifen effectiveness in breast cancer patients, identify predictors of these assessments, and estimate the relationship between these assessments and receipt of tamoxifen prescription.

DESIGN

A cohort of breast cancer patients aged 65 and older at diagnosis and their physicians were surveyed using mailed questionnaires and telephone interviews.

SETTING

Community and academic hospitals in Rhode Island; North Carolina; Minnesota; and Los Angeles, California between 1996 and 1998.

PARTICIPANTS

Physicians completed treatment recommendation forms for 496 of 865 Stage Ic to IIIa breast cancer patients.

MEASUREMENTS

Visual scales measured physicians' assessments of the risk that individual patients would have a breast cancer recurrence or die of breast cancer with, and without, tamoxifen therapy.

RESULTS

The mean risk ratio+/-standard deviation comparing risk of recurrence without tamoxifen with the risk with tamoxifen was 1.8+/-1.0 and for breast cancer mortality was 1.8+/-1.2. Only estrogen-receptor status and enrollment site emerged as significant predictors of recurrence and mortality risk ratios in regression models. Patients for whom the physician estimated that the recurrence or mortality risk doubled without tamoxifen were more likely to receive a tamoxifen prescription than patients for whom the physician estimated that tamoxifen would have no effect (odds ratio (OR)=1.4, 95% confidence interval (CI)=0.98-2.1 for recurrence risk, OR=1.8; 95% CI=1.2-2.6 for mortality risk).

CONCLUSION

Estrogen receptor status most strongly influenced physicians' assessments of tamoxifen's effectiveness in individual patients; this effectiveness was not found to be associated with advancing patient age. Estrogen receptor status and enrollment site were related to receipt of tamoxifen prescription, but advancing age was not after accounting for physician's individualized assessment of tamoxifen's effectiveness. These findings suggest that an evidence-based approach for hormonal therapy has been widely adopted for care of older patients with breast cancer.

[Combined flow cytometry determination of S-phase fraction and DNA ploidy is an independent prognostic factor in node-negative invasive breast carcinoma: review of a series of 271 patients with stage I and II breast cancer]

PURPOSE

To assess the significance of S-phase fraction (SPF) and DNA ploidy evaluated by DNA flow cytometry as prognostic markers in stage I or II breast cancer.

PATIENTS AND METHODS

A series of 271 patients, treated by surgery, radiotherapy+/-systemic therapy was analysed (median follow up: 64 months). Standardized flow cytometry cell preparation from frozen samples and consensus rules for data interpretation were followed. Three SPF classes were defined on the basis of tertiles after adjustment for ploidy. Four groups were defined based on combinations of DNA ploidy (DIP: diploid; ANEUP: aneuploid) and SPF: DIP and low SPF (DL, N=37), DIP and medium or high SPF (DMH, N=76), ANEUP and low SPF (AL, N=24), ANEUP and medium or high SPF (AMH, N=68). Local control rate (LCR), disease-free survival (DFS), metastasis-free survival (MFS), and overall survival (OS) were correlated with DNA ploidy, SPF, DL to AMH groups, T and N stages, SBR grading, age, and hormonal status on univariate and multivariate analysis (Cox model).

RESULTS

On univariate analysis, DFS and LCR were higher for DIP tumours. High SPF values were associated with shorter DFS. LCR, MFS, DFS, and OS rates were significantly different with an increasingly poorer prognosis from DL to AMH. On multivariate analysis, groups DL to AMH, histological node involvement and T stage were independently associated with MFS, and DFS. In N- patients, DL to AMH remained independent for MFS and DFS. For SBR III tumours, MFS and OS were significantly different in DL to AMH groups. These results strongly support the use of combined evaluation of DNA ploidy and SPF as independent parameters in clinical trials for N- stage I and II breast cancer.

Relationship between the expression of cyclooxygenase 2 and MDR1/P-glycoprotein in invasive breast cancers and their prognostic significance

INTRODUCTION

Recent reports suggest that expression of the cyclooxygenase 2 (COX-2) enzyme may up-regulate expression of MDR1/P-glycoprotein (MDR1/P-gp), an exponent of resistance to cytostatic drugs. The present study aimed at examining the relationship between the expression of COX-2 and of MDR1/P-gp in a group of breast cancer cases.

METHODS

Immunohistochemical reactions were performed using monoclonal antibodies against COX-2 and MDR1/P-gp on samples originating from 104 cases of primary invasive breast cancer.

RESULTS

COX-2-positive cases were shown to demonstrate higher expression of MDR1/P-gp (P < 0.0001). The studies also demonstrate that COX-2 expression was typical for cases of a higher grade (P = 0.01), a shorter overall survival time (P < 0.0001) and a shorter progression-free time (P < 0.0001). In the case of MDR1/P-gp, its higher expression characterised cases of a higher grade (P < 0001), with lymph node involvement (P < 0001), and shorter overall survival (P < 0.0001) and progression-free time (P < 0.0001).

CONCLUSION

Our studies confirmed the unfavourable prognostic significance of COX-2 and MDR1/P-gp. We also document a relationship between COX-2 and MDR1/P-gp, which suggests that COX-2 inhibitors should be investigated in trials as a treatment supplementary to chemotherapy of breast cancers.

Combined flow cytometry determination of S-phase fraction and DNA ploidy is an independent prognostic factor in node-negative invasive breast carcinoma: analysis of a series of 271 patients with stage I and II breast cancer

PURPOSE

To assess the significance of S-phase fraction (SPF) and DNA ploidy evaluated by DNA flow cytometry as prognostic markers in stage I or II breast cancer.

PATIENTS AND METHODS

A series of 271 patients, treated by surgery, radiotherapy +/- systemic therapy was analyzed (median follow up: 64 months). Standardized flow cytometry cell preparation from frozen samples and consensus rules for data interpretation were followed. Three SPF classes were defined on the basis of tertiles after adjustment for ploidy. Four groups were defined based on combinations of DNA ploidy (DIP: diploid; ANEUP: aneuploid) and SPF: DIP and low SPF (DL, n=37), DIP and medium or high SPF (DMH, n=76), ANEUP and low SPF (AL, n=24), ANEUP and medium or high SPF (AMH, n=68). Local control rate (LCR), disease-free survival (DFS), metastasis-free survival (MFS), and overall survival (OS) were correlated with DNA ploidy, SPF, DL to AMH groups, T and N stages, SBR grading, age, and hormonal status on univariate and multivariate analysis (Cox model).

RESULTS

On univariate analysis, DFS and LCR were higher for DIP tumours. High SPF values were associated with shorter DFS. LCR, MFS, DFS, and OS rates were significantly different with an increasingly poorer prognosis from DL to AMH. On multivariate analysis, groups DL to AMH, histological node involvement and T stage were independently associated with MFS, and DFS. In N- patients, DL to AMH remained independent for MFS and DFS. For SBR III tumours, MFS and OS were significantly different in DL to AMH groups. These results strongly support the use of combined evaluation of DNA ploidy and SPF as independent parameters in clinical trials for N- stage I and II breast cancer.

Bringing Molecular Prognosis and Prediction to the Clinic

In the past 30 years, important advances have been made in the knowledge of breast cancer biology and in the treatment of the disease. However, the translation of these advances into clinical practice has been slow. With the advent of molecular-based medicine, it is hoped that the bridge between the bench and the bedside will continue to be shortened. Because breast cancer is a heterogeneous disease with wide-ranging subsets of patients who have different prognoses and who respond differently to treatments, the identification of patients who need treatment and the definition of the best therapy for an individual have become the priorities in breast cancer care. This article will review the crucial role of prognostic and predictive factors in achieving these goals. A critical review of classical and newer individual molecular markers, such as hormone receptors, HER2, urokinase-type plasminogen activator and plasminogen activator inhibitor 1, cyclin E, topoisomerase II, and p53, was performed, and the preliminary results obtained using the new gene expression profiling technology are described along with their potential clinical implications.

Size of breast cancer metastases in axillary lymph nodes: clinical relevance of minimal lymph node involvement

BACKGROUND

Overt ipsilateral axillary lymph node metastases of breast cancer are the most significant prognostic indicators for women who have undergone surgery, yet the clinical relevance of minimal involvement (isolated tumor cells and micrometastases) of these nodes is uncertain.

PATIENTS AND METHODS

We evaluated biologic features, adjuvant treatment recommendations, and prognosis for 1,959 consecutive patients with pT1-3, pN0, minimal lymph node involvement (pN1mi or pN0i+), or pN1a (single positive node) and M0, who were operated on and counseled for medical therapy from April 1997 to December 2000.

RESULTS

Patients with pN1a and pN1mi/pN0i+, when compared with patients with pN0 disease, were more often prescribed anthracycline-containing chemotherapy (39.1% v 33.2% v 6.1%, respectively; P < .0001) and were less likely to receive endocrine therapy alone (9.8% v 19.4% v 41.9%, respectively; P < .0001). At the multivariate analysis, a statistically significant difference in disease-free survival (DFS) and in the risk of distant metastases was observed for patients with pN1a versus pN0 disease (hazard ratio [HR] = 2.04; 95% CI, 1.46 to 2.86; P < .0001 for DFS; HR = 2.32; 95% CI, 1.42 to 3.80; P = .0007 for distant metastases) and for patients with pN1mi/pN0i+ versus pN0 disease (HR = 1.58; 95% CI, 1.01 to 2.47; P = .047 for DFS; HR = 1.94; 95% CI, 1.04 to 3.64; P = .037 for distant metastases).

CONCLUSION

Even minimal involvement of a single axillary node in breast cancer significantly correlates with worse prognosis compared with no axillary node involvement. Further studies are required before widespread modification of clinical practice.

Compliance and toxicity of adjuvant CMF in elderly breast cancer patients: a single-center experience

Background

Few data are available on compliance and safety of adjuvant chemotherapy when indicated in elderly breast cancer patients; CMF (cyclophosphamide, methotrexate, fluorouracil) can be reasonably considered the most widely accepted standard of treatment.

Methods

We retrospectively reviewed compliance and safety of adjuvant CMF in patients older than 60. The treatment was indicated if patients had no severe comorbidity, a high-risk of recurrence, and were younger than 75. Toxicity was coded by NCI-CTC. Toxicity and compliance were compared between two age subgroups (<65, ≥ 65) by Fisher exact test and exact Wilcoxon rank-sum test.

Results

From March 1991 to March 2002, 180 patients were identified, 100 older than 60 and younger than 65, and 80 aged 65 or older. Febrile neutropenia was more frequent among older patients (p = 0.05). Leukopenia, neutropenia, nausea, cardiac toxicity and thrombophlebitis tended to be more frequent or severe among elderlies, while mucositis tended to be more evident among younger patients, all not significantly. Almost one half (47%) of the older patients receiving concomitant radiotherapy experienced grade 3–4 haematological toxicity. Compliance was similar in the two groups, with 6 cycles administered in 86% and 79%, day-8 chemotherapy omitted at least once in 36% and 39%, dose reduction in 27% and 38%, prolonged treatment duration (≥ 29 weeks) in 10% and 11% and need of G-CSF in 9% and 18%, among younger and older patients, respectively.

Conclusion

Our data show that, in a highly selected population of patients 65 or more years old, CMF is as feasible as in patients older than 60 and younger than 65, but with a relevant burden of toxicity. We suggest that prospective trials in elderly patients testing less toxic treatment schemes are mandatory before indicating adjuvant chemotherapy to all elderly patients with significant risk of breast cancer recurrence.

Assessment of the quality of breast cancer care: a single institutional study from Saudi Arabia

OBJECTIVE

To evaluate the quality of operable breast cancer care in a tertiary care institution.

DESIGN

A retrospective analysis of all breast cancer patients seen in our institution between 1995 and 2000. Data were abstracted from the charts of these patients. Indicators were based on an international consensus conference and other publications.

SETTING

A tertiary care health care institution.

MAIN MEASURES

We evaluated the charts and calculated the percentage for which the internationally accepted quality care indicators were followed during the continuum of care. We also reviewed the histopathological reports to evaluate conformation with the accepted indicators.

RESULTS

Charts of 75 patients (four exclusions, three metastatic, and one male), diagnosed to have breast cancer during the study period were reviewed. Only 28 (37%) patients had triple assessment before a definitive surgical procedure. Pre-operative staging including a CT and bone scan was performed in 58 (77.3%). Among the 50 patients who had definite surgical intervention, the majority had mastectomy (44/50, 88%) whereas axillary dissection was performed in 46 (46/50, 92%). Estrogen and progesterone receptor status was reported in only four (4/50, 8%) and the exact tumor size in 24 (24/50, 48%) of the histopathological reports. Adjuvant chemotherapy was used in accordance with the international standards but radiotherapy was under-utilized.

CONCLUSION

Our study demonstrated that the quality of breast cancer care in this institution was below the accepted international standards. This study may be used to make interventions for improvement of quality in similar institutions all over the kingdom.

Axillary recurrence rate in breast cancer patients with negative sentinel lymph node (SLN) or SLN micrometastases: prospective analysis of 150 patients after SLN biopsy

OBJECTIVE

To assess the axillary recurrence rate in breast cancer patients with negative sentinel lymph node (SLN) or SLN micrometastases (>0.2 mm to <or=2.0 mm) after breast surgery and SLN procedure without formal axillary lymph node dissection (ALND).

SUMMARY BACKGROUND DATA

Under controlled study conditions, the SLN procedure proved to be a reliable method for the evaluation of the axillary nodal status in patients with early-stage invasive breast cancer. Axillary dissection of levels I and II can thus be omitted if the SLN is free of macrometastases. The prognostic value and potential therapeutic consequences of SLN micrometastases, however, remain a matter of great debate. We present the follow-up data of our prospective SLN study, particularly focusing on the axillary recurrence rate in patients with negative SLN and SLN micrometastases.

METHODS

In this prospective study, 236 SLN procedures were performed in 234 patients with early-stage breast cancer between April 1998 and September 2002. The SLN were marked and identified with 99m technetium-labeled colloid and blue dye (Isosulfanblue 1%). The excised SLNs were examined by step sectioning and stained with hematoxylin and eosin and immunohistochemistry (cytokeratin antibodies Lu-5 or CK 22). Only patients with SLN macrometastases received formal ALND of levels I and II, while patients with negative SLN or SLN micrometastases did not undergo further axillary surgery.

RESULTS

The SLN identification rate was 95% (224/236). SLN macrometastases were found in 33% (74/224) and micrometastases (>0.2 mm to <or=2 mm) in 12% (27/224) of patients. Adjuvant therapy did not differ between the group of SLN-negative patients and those with SLN micrometastases. After a median follow-up of 42 months (range 12-64 months), 99% (222/224) of evaluable patients were reassessed. While 1 patient with a negative SLN developed axillary recurrence (0.7%, 1/122), all 27 patients with SLN micrometastases were disease-free at the last follow-up control.

CONCLUSIONS

Axillary recurrences in patients with negative SLN or SLN micrometastases did not occur more frequently after SLN biopsy alone compared with results from the recent literature regarding breast cancer patients undergoing formal ALND. Based on a median follow-up of 42 months-one of the longest so far in the literature-the present investigation does not provide evidence that the presence of SLN micrometastases leads to axillary recurrence or distant disease and supports the theory that formal ALND may be omitted in these patients.

Expression of the ELAV-like protein HuR is associated with higher tumor grade and increased cyclooxygenase-2 expression in human breast carcinoma

PURPOSE

The human ELAV (embryonic lethal abnormal vision)-like protein HuR stabilizes a certain group of cellular mRNAs that contain AU-rich elements in their 3'-untranslated region. Cell culture studies have shown that the mRNA of cyclooxygenase (COX)-2 can be stabilized by HuR.

EXPERIMENTAL DESIGN

To investigate a possible contribution of dysregulation of mRNA stability to the progression of cancer and to overexpression of COX-2, we studied expression of HuR in 208 primary breast carcinomas by immunohistochemistry.

RESULTS

There were two different staining patterns of HuR in tumor tissue of breast carcinomas: nuclear expression was seen in 61% of cases; and an additional cytoplasmic expression was seen in 30% of cases. Expression of HuR was significantly associated with increased COX-2 expression; this association was particularly significant for cytoplasmic HuR expression (P < 0.0005). We further observed a significant association of cytoplasmic (P = 0.002) or nuclear HuR (P = 0.027) expression with increased tumor grade. Only 13% of the grade 1 carcinomas showed cytoplasmic expression of HuR, compared with 46% of the grade 3 carcinomas. There was no significant correlation between HuR expression and other clinicopathological parameters such as histological type, tumor size, or nodal status as well as patient survival.

CONCLUSIONS

Our results suggest that overexpression of HuR in tumor tissue may be part of a regulatory pathway that controls the mRNA stability of several important targets in tumor biology, such as COX-2. Based on our results, additional studies are necessary to investigate whether HuR might be a potential target for molecular tumor therapy.

Genomic and proteomic approaches for studying human cancer: prospects for true patient-tailored therapy

Global gene expression analysis is beginning to move from the laboratories of basic investigators to large-scale clinical trials. The potential of this technology to improve diagnosis and tailored treatment of human disease may soon be realised, now that several comprehensive studies have demonstrated the utility of gene expression profiles for the classification of tumours into distinct, clinically relevant subtypes and the prediction of clinical outcomes. In addition, new data from the emerging proteomics platforms add another layer of molecular information to the study of human disease, as scientists attempt to catalogue a complete inventory of the proteins encoded by the genome and to establish a 'biosignature' profile of human health and disease. As a result, it is anticipated that, together, these technologies will facilitate the comprehensive study of genes, gene products and signalling pathways so that the objective of personalized molecular medicine can be achieved. This paper will review the studies that best demonstrate how genomics and proteomics technologies can be used to improve cancer diagnosis and treatment it will specifically highlight the important work being incorporated into clinical trials.

Analysis of axillary coverage during tangential radiation therapy to the breast

PURPOSE

To evaluate the percent of the prescribed radiation dose to the breast delivered to the axillary tissue and to evaluate the volume of the axilla receiving 95% of the prescribed dose with normal and with high tangential fields.

METHODS AND MATERIALS

Computed tomographic scan images with 5-mm sections were retrospectively analyzed for 35 patients who had undergone three-dimensional (3D) planning for whole-breast radiation. The axillary nodal region was identified and divided into Levels I to III and Rotter's nodes (RN). Digitally reconstructed radiographs were created, and two plans were developed: (a) the standard clinical opposed tangential irradiation fields and (b) the high-tangential irradiation fields. Axillary coverage was examined by use of dose-volume histograms (DVH), and the average coverage for the four nodal groups was obtained.

RESULTS

The data show that with the standard tangential irradiation fields, the average dose delivered to Levels I, II, III, and RN is 66% (standard deviation, or SD = 13%), 44% (SD = 18%), 31% (SD = 20%), and 70% (SD = 19%) of the prescribed dose, respectively. The coverage increases to 86% (SD = 9%), 71% (SD = 19%), 73% (SD = 17%), and 94% (SD = 8%) of the prescribed dose, respectively, for Levels I, II, III, and RN when the high tangential irradiation fields are used. 51% of Level I, 26% of Level II, and 15% of Level III receive 95% of the prescribed dose with normal tangents. The volume increases to 79%, 51%, and 49% of Levels I, II, and III, respectively, with high tangents.

CONCLUSION

The tangential fields designed to treat only the breast do not adequately cover the axillary region and, therefore, cannot be relied upon for prophylactic therapy of the axilla. The high tangential irradiation fields increase the dosages received by the axillary region, but the average dosages received by the lower axillary regions are still less than 90% of the prescribed dose.

Biopathologic profile of breast cancer core biopsy: is it always a valid method?

For breast cancer management biopathologic profile and particularly the expression of estrogen receptor (ER) and progesterone receptor (PR) is considered essential. In advanced cases, core biopsy results are the only data available. To evaluate reliability of data, results of ER, PR, MIB1, p53 and c-erbB2 on core biopsy were compared with those on surgical specimens. Results showed a statistically significant concordance for ER and PR in pT1 but not in pT2 tumors, possibly due to breast cancer heterogeneity. MIB1 results were worse with no significant concordance even for pT1 group. There was statistically significant concordance in pT1 and pT2 groups for p53 and c-erbB 2, probably due to the high number of negative cases for these markers. We recommend more core biopsies for larger tumors since core biopsy has a high probability for giving unreliable data in these cases. In conclusion, this study showed that core biopsy has a high probability for not very reliable data in bigger tumors where the results obtained might be the only data available. A higher number of core biopsy is recommended in those cases.

Young age: an independent risk factor for disease-free survival in women with operable breast cancer

Background

The incidence of breast cancer in young women (age < 35) is low. The biology of the disease in this age group is poorly understood, and there are conflicting data regarding the prognosis for these women compared to older patients.

Methods

We retrospectively analyzed 2040 consecutive primary invasive breast cancer patients who underwent surgical procedures at our institution between 1990 and 1999. The younger age group was defined as patients aged <35 years at the time of diagnosis. The clinicopathological characteristics and treatment outcomes were compared between younger and older age groups.

Results

A total of 256 (12.5%) patients were aged <35. There was a significantly higher incidence of nuclear grade 3 and medullary histological-type tumors in younger patients compared to older patients. Axillary lymph node status, T stage, histological grade, c-erbB2 expression and estrogen receptor status did not differ significantly between the two age groups. Younger patients had a greater probability of recurrence and death at all time periods. Although there was no significant difference in disease-free survival between the two age groups in lymph node-negative patients, the younger group showed worse prognosis among lymph node-positive patients (p < 0.001). In multivariate analysis, young age remained a significant predictor of recurrence (p = 0.010).

Conclusion

Young age (<35) is an independent risk factor for relapse in operable breast cancer patients.

Minimal and small size invasive breast cancer with no axillary lymph node involvement: the need for tailored adjuvant therapies

BACKGROUND

Prognosis of patients with node-negative disease and tumor size <1 cm is a matter of controversy. While data exist to clearly correlate small tumor size to better prognosis, the fact that very small breast cancers may express biological markers of dire prognosis leads many to ignore small tumor size during treatment decision-making.

PATIENTS AND METHODS

Data from 425 patients classified as having node-negative pT1mic, pT1a or pT1b after surgery (from April 1997 to December 2001) at the European Institute of Oncology, were analyzed to be described as disease-free according to prognostic variables including: Ki-67 (<20% versus > or =20% of the cells), ER (absent versus positive > or =1% of the cells), PgR (absent versus positive > or =1% of the cells), grade, overexpression or amplification of HER2/neu, presence of peritumoral vascular invasion and age (by decade). The median follow-up for this cohort of patients was 43 months.

RESULTS

No local or distant relapse was observed for patients with pT1mic breast cancer; 4-year disease-free survival for pT1a and pT1b was 97.0% and 97.6%, respectively. In both univariate and multivariate analyses the most relevant prognostic factor for this low-risk population was Ki-67 labeling. The 4-year disease-free survival was 99.2% for tumors with low Ki-67 and 93.3% for tumors with high Ki-67 (> or =20%) labeling. The hazard ratio (HR) for patients with high Ki-67 was 12.9 (95% CI 1.5-112.0, P=0.02).

CONCLUSIONS

Within the first 4 years, microinvasive breast cancer parallels ductal carcinoma in situ (DCIS) rather than invasive carcinoma. Costs and benefits of adjuvant therapy should be accurately weighted in these patients. Patients with pT1a and pT1b, node-negative disease have a limited but substantial risk of recurrence and therefore adjuvant therapy, according to endocrine responsiveness of the tumor and patient preference, should continue to be offered as a reasonable treatment option.

Accuracy of typing and grading invasive mammary carcinomas on core needle biopsy compared with the excisional specimen

INTRODUCTION

Breast core needle biopsy (CNB) allows evaluation of histological, prognostic, and predictive factors in invasive mammary carcinomas (IMC). We tested the CNB accuracy on typing and grading of invasive breast carcinomas.

MATERIALS AND METHODS

A histological review of 120 CNBs and their related surgical specimens was carried out in a double-blind fashion. Tumor type and grade were assigned according to the World Health Organization classification and the Nottingham grading system.

RESULTS

The sum of CNB fragment lengths varied from 4 mm to 38 mm (mean 16.7 mm), and tumor sample size varied from 1 mm to 26 mm (mean 11.1 mm). Histological type matched surgical specimen evaluation in 80 of 120 cases (66.6%). Of the cases, 17 (14.2%) were changed to a different prognostic category. Histological grade comparison was accurate in 56 of 95 cases (59.0%, kappa=0.35). Histological grade components (tubule formation, nuclear grade, and mitotic index) agreed, respectively, in 54.7%, 58.9%, and 62.1% (kappa index 0.30, 0.36, and 0.28).

DISCUSSION

Typing IMC on CNB can be routinely assessed based on good correlation with surgical specimens, especially considering prognostic categories for IMC. Grading IMC based on CNB is not as accurate, and its evaluation should be delayed until the surgical specimen examination. Tumor heterogeneity seems to be the most important factor for disagreement.

Compliance With Consensus Recommendations for Systemic Therapy Is Associated With Improved Survival of Women With Node-Negative Breast Cancer

Purpose

The impact of consensus recommendations for systemic therapy on outcome of disease is unclear. We evaluated if compliance with guidelines for systemic adjuvant treatment is associated with improved survival of women with node-negative breast cancer.

Patients and Methods

The study population included women diagnosed with invasive node-negative breast cancer in Québec, Canada, in 1988 to 1989, 1991 to 1992, and 1993 to 1994. Information was collected by chart review, linkage with administrative databases, and queries to attending physicians. Guidelines from the 1992 St Gallen conference were used as standard of care. Survival was estimated by Kaplan-Meier and Cox proportional hazards analyses.

Results

Among 1,541 women, 358 died before December 1999. Median follow-up was 6.8 years. Seven-year event-free and overall survivals were 66% and 81%, respectively. Survival was 88%, 84%, and 74% in women at minimal, moderate, or high risk of recurrence. Virtually all women at minimal risk were treated according to the consensus (98.4% of 370). In comparison, adjusted hazard ratios of death were 1.0 (95% CI, 0.6 to 1.7) and 2.3 (95% CI, 1.3 to 4.0) among women at moderate risk treated according to the consensus or not, respectively. Among women at high risk, adjusted hazard ratios of death were 2.0 (95% CI, 1.4 to 2.8) and 2.7 (95% CI, 1.9 to 3.9), respectively. Both risk category (P < .0005) and compliance with guidelines (P < .0005) were independent significant predictors of survival.

Conclusion

Treatment according to consensus recommendations is associated with improved survival of women with breast cancer in the community. Promoting the adoption of guidelines for treatment is an effective strategy for disease control.

Thymidine labeling index: prognostic role in breast cancer

The aim of this study is to evaluate the prognostic role of thymidine labeling index in patients with breast cancer. Cellular proliferation rates in 155 breast cancer specimens were investigated by 3H-thymidine labeling index (3H-TLI). Median age was 47 years (range: 23-76). At presentation, 11 patients (7.1%) had stage I disease, 76 (49%) had stage II, 64 (41.3%) had stage III disease, and 4 (2.6%) had metastatic involvement. Patients were placed in 2 groups based on their proliferative indices. The cut-off level was assigned as the median TLI value of the whole group. Correlations between proliferative activity of the tumors based on 3H-TLI levels and various previously established prognostic factors, as well as the influence of proliferative activity on survival as a clinical outcome, were analyzed. The mean and median TLI values for the whole group of patients were 4.36 +/- 4.96% and 2.76% (range: 0-23.6), respectively. There was a significant association of nuclear grade with TLI (P = 0.04). Patients who were alive with no sign of disease at the final follow-up examination had a significantly lower median TLI rate than those who were either alive with disease or those who had eventually died with disease progression (3.7% versus 1.9%, respectively; P = 0.04). Patients with locally advanced disease (N2 + N3 involvement) had a significantly higher median TLI rate than those with local nodal involvement (N1) (3.4% versus 1.7%, respectively, P = 0.026). Furthermore, TLI levels showed a significant association with overall survival in patients with node-negative disease (P = 0.02). Based on the results of this study, it can be concluded that TLI plays a significant prognostic role in a subset of patients with node-negative breast cancer. Furthermore, TLI appears to have a predictive value for the clinical outcome of patients with breast cancer. These findings may justify a more aggressive therapeutic approach in patients with high TLI levels. Further large-scale, prospective studies are required before a definite conclusion can be reached.reached.

“Good Old” clinical markers have similar power in breast cancer prognosis as microarray gene expression profilers

We compared the power of gene expression measurements with that of conventional prognostic markers, i.e., clinical, histopathological, and cell biological parameters, for predicting distant metastases in breast cancer patients using both established prognostic indices (e.g., the Nottingham Prognostic Index (NPI)) and novel combinations of conventional markers. We used publicly available data on 97 patients, and the performance of metastasis prediction was represented by receiver operating characteristic (ROC) areas and Kaplan-Meier plots. The gene expression profiler did not perform noticeably better than indices constructed from the clinical variables, e.g., the well established NPI. When analysing separately subgroups, according to the oestrogen receptor (ER) status both approaches could predict clinical outcome more easily for the ER-positive than for the ER-negative cohort. Given the time it may take before microarray processing is used worldwide, particularly due to the costs and the lack of standards, it is important to pursue research using conventional markers. Our analysis suggests that it might be possible to improve the combination of different conventional prognostic markers into one prognostic index.

Variability in axillary lymph node dissection for breast cancer

BACKGROUND

The axillary nodal status may influence the prognosis and the choice of adjuvant treatment of individual breast cancer patients. The variation in number of reported axillary lymph nodes and its effect on the axillary nodal stage were studied and the implications are discussed.

METHODS

Between 1994 and 1997, a total of 4,806 axillary dissections for invasive breast cancers in 4,715 patients were performed in hospitals in the North-Netherlands. The factors associated with the number of reported nodes and the relation of this number with the nodal status and the number of positive nodes were studied.

RESULTS

The number of reported nodes varied significantly between pathology laboratories, the median number of nodes ranged from 9 to 15, respectively. The individual hospitals explained even more variability in the number of nodes than pathology laboratories (range in median number 8-15, P < 0.0001). The number of reported nodes increased gradually during the study period. A decreasing trend was observed with older patient age. A higher number of reported nodes was associated with a markedly increased chance of finding tumor positive nodes, especially more than three nodes. The frequency of node positivity increased from 28% if less than six nodes to 54% if >/=20 nodes were examined, the percentage of tumors with >/=4 positive nodes increased from 4 to 31%. Multivariate analysis confirmed these results.

CONCLUSIONS

This population-based study showed a large variation in the number of reported lymph nodes between hospitals. A more extensive surgical dissection or histopathological examination of the specimen generally resulted in a higher number of positive nodes. Although the impact of misclassification on adjuvant treatment will have varied, the impact with regard to adjuvant regional radiotherapy may have been considerable.

The urokinase plasminogen activator system: a rich source of tumour markers for the individualised management of patients with cancer

The urokinase plasminogen activator (uPA) system consists of the serine protease uPA, the glycolipid-anchored receptor, uPAR, and the 2 serpin inhibitors, plasminogen activator inhibitor-1 (PAI-1) and plasminogen activator inhibitor-2 (PAI-2). Recent findings suggest that uPA, uPAR and PAI-1 play a critical role in cancer invasion and metastasis. Consistent with their role in cancer dissemination, high levels of uPA, PAI-1 and uPAR in multiple cancer types correlate with adverse patient outcome. The prognostic value of uPA/PAI-1 in axillary node-negative breast cancer patients was recently validated using both a prospective randomised trial and a pooled analysis. Assay of uPA and PAI-1 may thus help identify low-risk node-negative patients for whom adjuvant chemotherapy is unnecessary. Finally, emerging data suggest that high levels of uPA and PAI-1 in breast cancer are associated with a preferential response to adjuvant chemotherapy but relative resistance to hormone therapy. The measurement of uPA components, especially in breast cancer, thus has the potential to help with individualised patient management.

Molecular profiling of breast cancer: clinical implications

Breast cancers are routinely subcategorised on the basis of clinical stage, cellular morphology and immunohistochemical analysis of a small number of markers. The recent development of gene expression microarray and related technologies provides an opportunity to perform more detailed profiling of the disease. It is anticipated that the molecular classification arising from such studies will be more powerful than its pathological predecessor at confining treatment to those patients who are most likely to benefit. It is likely that this will result in a much less frequent use of adjuvant chemotherapy. Furthermore, of those who do receive it, a higher proportion will benefit. If adopted, this will offer considerable patient benefits in terms of reducing unnecessary toxicity and have major health economic implications.

Conservative surgery in breast cancer. Significance of resection margins

We approached the issue of surgical margins in the conservative treatment of breast cancer by examining the literature germane to four precise questions: At what distance from the macroscopic margin of the tumour should the resection margin be? To what extent do histologically clear resection margins indicate complete local control of the disease? To what extent do histologically involved margins indicate persistence of disease? and Does the local recurrence rate correlate with the status of the resection margin? We propose categorizing margin involvement into five groups (absent, focal, minimal, moderate and extensive involvement) according to strict histological criteria, and assigning increasingly aggressive subsequent treatments according to the extent of any margin involvement.

Percutaneous stereotactic en bloc excision of nonpalpable breast carcinoma: a step in the direction of supraconservative surgery

Recently, the advanced breast biopsy instrumentation (ABBI) system has been introduced as an alternative to conventional breast biopsy techniques. This study was prospectively conducted to evaluate the potential of the ABBI method in locoregional management of a consecutive series of patients with nonpalpable mammographically detected breast carcinomas. Sixty-one consecutive patients underwent an ABBI procedure as a first step before possible surgery for nonpalpable breast lesions that would in any case require complete excision. For the 27 patients in whom the ABBI biopsy revealed malignancy further surgery was recommended, including re-excision of the biopsy site and axillary dissection in cases of infiltrating carcinoma. We calculated the probabilities that the ABBI specimen would have tumor-free margins and that a definitely complete excision had been achieved as a function of the mammographic or pathological diameter of the cancer. For cancer with a pathological diameter less than 10 mm measured on the ABBI specimen, the probability (92%) of obtaining complete resection was significantly better than for larger lesions (P=0.01, Fisher's exact test). Although the therapeutic perspectives for the ABBI method are limited at present, we suggest that this approach is a first step in the direction of a surgical strategy that is better adapted to the pathological characteristics peculiar to these small tumors, whose incidence is increasing.

The role of biological markers as predictors of response to preoperative chemotherapy in large primary breast cancer

The aim of this prospective study was to evaluate biological markers, their correlation with response and outcome, and the change in these markers under the influence of preoperative chemotherapy (PCT) in patients with a large primary breast cancer. One hundred and thirty-five women were treated with PCT, followed by locoregional therapy and adjuvant treatment. Estrogen receptor (ER), progesterone receptor (PgR), HER-2, p53, and cathepsin D were determined by immunohistochemistry (IHC) before and after PCT. The overall response (OR) was 70% and the pathologic complete response (pCR) was 13%. Forty-four percent of the patients could be offered breast-conserving surgery (BCS). At a median follow-up of 50 mo the overall survival is 82% and the disease-free survival is 70%. No local recurrence (LR) has developed following BCS. Invasive ductal carcinoma (IDC) was more frequently ER-negative and HER-2-positive than invasive lobular carcinoma (ILC). P53-negative and ER-negative patients seemed to be more chemosensitive compared to p53-positive patients (74% vs 53%) and ER-positive patients (75% vs 65%), but this difference did not reach statistical significance. A trend toward higher complete pathologic remission rate was seen for ER-negative patients (p = 0.0609). PgR, HER-2, and cathepsin D were not related to response. The pattern of biological markers did not change with PCT, making repeated determination useless.

Surgical treatment for invasive lobular carcinoma of the breast

The management and outcome of 131 women with infiltrating lobular carcinoma treated in the Belfast City Hospital between October 1987 and February 1999 were reviewed. Two patients had primary hormonal treatment and were excluded from the statistical analysis, and 129 patients were followed up. Fifty-four patients (41%) had initial breast conservation surgery, which was followed by re-excision of margins in eight patients (14.8%) and completion total mastectomy in 26 patients (48.1%). The breast conservation surgery group, 28 patients (21.7%), was compared with the total mastectomy group, 101 patients (78.2%), after a median follow-up period of 90 months (range 24-160 months). The overall survival was 68.7%. Survival analysis was performed using Kaplan-Meier and Cox regression which showed that lymph node involvement and tumour grade were the only variables affecting survival (P<0.0001, and 0.01, respectively). The type of surgery performed did not affect survival (P=0.42). The total number of patients who developed local recurrence was 17 patients (13.1%, 12 patients in the breast conservation surgery group and five patients in the total mastectomy group, P<0.0001). Kaplan-Meier analysis of local recurrence showed that the type of surgery (P<0.0001), patient age (P=0.02), tumour grade (P=0.002), adjuvant radiotherapy (P=0.013), chemotherapy (P=0.031) and hormonal treatment (P=0.003) significantly affected local recurrence. Cox regression analysis showed that the only factor significantly affecting local recurrence was the type of surgery performed (P=0.02). Patients who underwent mastectomy had less local recurrence than those who had breast conservation surgery. Local recurrence after breast conservation surgery is high, even with clear surgical margins and post-operative radiotherapy. The authors believe that total mastectomy for infiltrating lobular carcinoma is a safer option to control local disease, especially in younger patients and those with high-grade tumours. Overall survival is not affected by the type of surgical treatment. Local recurrence can be a late event and a long-term follow-up is recommended.

Estudio epidemiológico del grupo GEICAM sobre el cáncer de mama en España (1990-1993): proyecto «El Álamo»

BACKGROUND AND OBJECTIVE

The aim of the El Alamo project was to define the demographic and clinic characteristics, treatment and evolution of women with invasive breast cancer diagnosed in hospitals of the GEICAM group (Spanish Breast Cancer Research Group) between 1990 and 1993.

PATIENTS AND METHOD

Data from 4,532 patients were included. Forms were completed according to the medical history of patients, and collected in the GEICAM scientific office, where they were added to a data base.

RESULTS

32 hospitals from 19 provinces and 11 regional communities participated in the study. Mean age of the 4,532 patients was 56.72 years, 1,428 (31.5%) were premenopausal and 2,988 (65.9%) were postmenopausal. Stage II tumors were most frequent (55.5%). Among patients with stage I, II and III at diagnosis, surgery was the first treatment in most (90.7%), radical mastectomy being the most frequent procedure performed (79.7%). 70.4% of 1941 patients with positive axillary node and 37.4% of 1,806 patients without axillary affection received adjuvant chemotherapy with or without hormone therapy.

CONCLUSIONS

El Alamo project represents the largest data base on breast cancer in Spain and the results are similar to those observed in other countries such as the USA.

Prognostic predictor with multiple fuzzy neural models using expression profiles from DNA microarray for metastases of breast cancer

Gene expression profiling data from DNA microarray were analyzed using the fuzzy neural network (FNN) modeling method for predicting the distant metastases of breast cancer. The best model consisting of five genes was able to predict metastases of breast cancer with 94% accuracy. Furthermore, 100% accuracy was achieved by majoritarian decision using only 25 genes from five noninferior models which were constructed independently. From the constructed model, gene expression rules, which may cause distant metastases, were explicitly extracted and 60% of the metastases cases could be explained by this rule. The FNN modeling method described in this paper enables precise extraction of significant biological markers affecting prognosis without prior knowledge.

Phase II trial combining docetaxel and doxorubicin as neoadjuvant chemotherapy in patients with operable breast cancer

BACKGROUND

This study was conducted to assess the antitumour activity of docetaxel in combination with doxorubicin for neoadjuvant therapy of patients with breast cancer.

PATIENTS AND METHODS

Forty-eight women were treated with intravenous doxorubicin 50 mg/m(2) over 15 min followed by a 1-h infusion of docetaxel 75 mg/m(2) every 3 weeks for six cycles. Dexamethasone or prednisolone premedication was allowed. Granulocyte colony-stimulating factor was not allowed as primary prophylaxis. The primary end point was the pathologically documented complete response rate (pathological response).

RESULTS

The mean relative dose intensity calculated for four or more cycles was 0.99 for doxorubicin and 0.99 for docetaxel. Overall, the pathological response rate was 13%. There were 11 complete and 29 partial clinical responses for an overall response rate of 85% [95% confidence interval (CI) 75% to 95%] in the evaluable population (n = 47). Disease-free and overall survival rates were 85% (95% CI 71% to 94%) and 96% (95% CI 85% to 99%), respectively, after a median follow-up of 36.6 months. Grade 3/4 neutropenia was observed in 65% of patients and 17% reported grade 4 febrile neutropenia.

CONCLUSIONS

Docetaxel and doxorubicin is an effective and well-tolerated combination in the neoadjuvant therapy of breast cancer. Future controlled trials are warranted to investigate the best schedules and to correlate response with biological factors.

Conservation therapy in T1-T2 breast cancer: past, current issues, and future challenges and opportunities

PURPOSE

To assess the significance of patient age, race, tumor-related prognostic parameters, status of surgical excision margins, and irradiation boost on incidence of ipsilateral breast relapse, and to review current issues in the management of T1-T2 breast cancer patients with conservation therapy.

MATERIALS AND METHODS

Records of 1037 patients with histologically confirmed stage T1 and 308 patients with T2 carcinoma of the breast treated with breast conservation therapy from January 1970 through December 1997 were prospectively registered and evaluated. The mean follow-up for surviving patients was 6.6 years (range, 4-30 years), with a minimum follow up of 4 years for all patients.

RESULTS

There were 78 ipsilateral breast relapses (IBRs); the actuarial 10-year incidence of IBR was 7% for T1 and 11% for T2 tumors. In patients 40 years of age or younger, four of 24 (17%) with extensive intraductal component developed an ipsilateral breast relapse, compared with six of 80 (8%) without extensive intraductal component, in contrast to eight of 159 (5%) and 33 of 776 (4%) in postmenopausal patients with or without extensive intraductal component, respectively. In patients with T2 tumors, two of eight (25%) women 40 years or younger with extensive intraductal component, and seven of 50 (14%) without extensive intraductal component developed ipsilateral breast relapse. The corresponding values for the patients older than 40 years were five of 48 (10%) and 13 of 202 (6%), respectively. The incidences of ipsilateral breast relapses, correlated with status of surgical margins after re-excision in T1 tumors, were one of 30 (3.3%) for positive, no relapses in 40 patients with close margins, 16 of 438 (3.6%) for negative, and 18 of 196 (9%) for undetermined margins. In the patients with T2 tumors, ipsilateral breast relapses occurred in two of 16 patients (12.5%) with positive margins, one of 16 (6%) with close, seven of 105 (6.6%)with negative, and four of 68 (5.9%) with undetermined margins (differences not statistically significant). In patients with T1 tumors, negative margins, the 10-year relapse rate was the same (8%) in 559 to whom a boost was administered and in 66 without a boost. In patients with positive margins, the relapse rate was 4% in 215 receiving a boost (18-20 Gy) and 33% (two of six) without a boost. In patients with T2 tumors and negative margins, the rate of ipsilateral breast relapses in 16 patients to whom no boost was given was 12%, as opposed to 10% in 143 patients who received a boost. However, with T2 tumors and close or positive margins, the IBR rate at 10 years was 12% in 81 given a boost, in contrast to 40% (2 of 5) without a boost. In T1 tumors, the breast failure rate was two of 53 (3.7%) in women < or = 40 years receiving chemotherapy and eight of 51 (15.6%) without chemotherapy. For T2 tumors, the corresponding values were seven of 39 (17%) and two of 19 (10.5%), respectively. In women 40 years or younger with T1 tumors receiving hormones or not, the ipsilateral breast relapse rate was two of 19 (10.5%) and eight of 85 (9.4%), respectively; in the older than 40 years group, the corresponding values were six of 377 (1.6%) and 35 of 558 (6.2%). In the patients with T2 tumors, ipsilateral breast relapse rates were not statistically different in the various groups. On multivariate analysis, only age and adjuvant therapy were significant factors predictive of ipsilateral breast relapse.

CONCLUSIONS

Surgical excision margins status following adequate doses of radiation therapy was not a predictor of ipsilateral breast relapse. In patients younger than 40 years of age with extensive intraductal component, a somewhat higher breast relapse rate was noted but not enough to preclude breast conservation therapy. A boost of irradiation did not have a significant impact in the incidence of ipsilateral breast relapse in patients with negative margins, but it was of benefit to those with close or positive margins. Close attention to surgical margin status and delivery of higher doses of irradiation to the tumor excision site in patients with close or positive surgical margins will decrease the probability of breast relapses.

Clinical significance and outcome of one or two rib lesions on bone scans in breast cancer patients without known metastases

The presence of one or two rib lesions on bone scans of post-treatment breast cancer patients without known metastases often makes clinical decision making problematic. The aim of this study was to identify skeletal metastasis predictors that might help the management of these patients. We recruited post-treatment breast cancer patients without overt metastases whose bone scans showed (1) one or two rib hot spots, or (2) one rib lesion and a concurrent bone abnormality. Their clinical and serial scintigraphic data were collected, reviewed and evaluated for correlations. After their first abnormal bone scans, 23 patients (11 of the 77 patients initially with one rib lesion (incidence, 14.3%), three of the 27 patients with two rib lesions (incidence, 11.1%), and nine of the 11 patients with one rib lesion plus a concurrent bone abnormality (incidence, 81.8%)) developed multiple bone metastases within 2 years of the initial rib lesions in all but one case. Univariate analyses revealed that a concurrent bone lesion other than the rib, direct tumour invasion to the chest wall or skin, and 10 or more lymph nodes involved were associated with increased risks of bone metastases whereas longer persistence of the rib lesions was associated with a lower risk. Multivariate proportional hazard analyses indicated that patients with a concurrent bone lesion other than the rib (relative risk (RR)=39.65; 95% confidence interval (CI)=8.13-193.28), 10 or more lymph nodes involved (RR=13.49; 95% CI=2.09-86.91), and no radiotherapy (RR=7.59; 95% CI=2.11-27.39) were more likely to have bone metastases, while those with longer persistence of the rib lesions (RR=0.92; 95% CI=0.84-0.98) and longer time interval between surgery and the rib lesion detection (RR=0.96; 95% CI=0.94-0.99) were less likely. We have identified clinical features applicable to risk stratification. High incidence of bone metastases was noted in patients with one rib lesion and a concurrent bone abnormality. Regular follow-up for 2 years after detection of rib lesions is recommended, especially for those with risk factors.

Ubiquitin-immunoreactive degradation products of cytokeratin 8/18 correlate with aggressive breast cancer

Decreased amounts of cytokeratin (CK) 8/18 in the cytoplasm of breast cancer cells correlate with a poor prognosis. Although such decreases have been attributed to suppressed gene expression, accelerated protein degradation may also be responsible. In order to investigate whether selective degradation via the ubiquitin (Ub)-dependent proteasome pathway occurs in breast cancer, one- and two-dimensional (1-D and 2-D) immunoblot analysis was performed on cancerous and normal breast tissue from 50 breast cancer patients using the anti-Ub monoclonal antibodies (mAbs) KM691 and KM690. On 1-D gel electrophoresis, one broad band or two bands were detected at about 43 kDa; these were detected only in cancer tissue. Immunoreactive bands at 43 kDa were significantly associated with aggressive morphology (P = 0.011), nuclear p53 accumulation (P = 0.015) and overexpression of Her2 / neu protein (P = 0.012). On 2-D gel electrophoresis, these bands were fractionated into a group of several spots that formed a staircase pattern at 40-45 kDa. Partial amino acid sequencing analysis demonstrated that these Ub-immunoreactive spots corresponded to CK8 and CK18; however, since they did not have an amino-terminal domain, and were located at lower molecular weight positions than intact CK8 and CK18 on the 2-D gel, they were regarded as degradation products. CK18 degradation was confirmed by confocal microscopy as loss of the frame-like network that forms the luminal structure. These results indicate that CK 8/18 degradation products are detected specifically in breast cancer and may determine its aggressiveness.

Undertreatment strongly decreases prognosis of breast cancer in elderly women

PURPOSE

No consensus exists on therapy of elderly cancer patients. Treatments are influenced by unclear standards and are usually less aggressive. This study aims to evaluate determinants and effect of treatment choice on breast cancer prognosis among elderly patients.

PATIENTS AND METHODS

We reviewed clinical files of 407 breast cancer patients aged >/= 80 years recorded at the Geneva Cancer Registry between 1989 and 1999. Patient and tumor characteristics, general health status, comorbidity, treatment, and cause of death were considered. We evaluated determinants of treatment by logistic regression and effect of treatment on mortality by Cox model, accounting for prognostic factors.

RESULTS

Age was independently linked to the type of treatment. Overall, 12% of women (n = 48) had no treatment, 32% (n = 132) received tamoxifen only, 7% (n = 28) had breast-conserving surgery only, 33% (n = 133) had mastectomy, 14% (n = 57) had breast-conserving surgery plus adjuvant therapy, and 2% (n = 9) received miscellaneous treatments. Five-year specific breast cancer survival was 46%, 51%, 82%, and 90% for women with no treatment, tamoxifen alone, mastectomy, and breast-conserving surgery plus adjuvant treatment, respectively. Compared with the nontreated group, the adjusted hazard ratio of breast cancer mortality was 0.4 (95% CI, 0.2 to 0.7) for tamoxifen alone, 0.4 (95% CI, 0.1 to 1.4) for breast-conserving surgery alone, 0.2 (95% CI, 0.1 to 0.7) for mastectomy, and 0.1 (95% CI, 0.03 to 0.4) for breast-conserving surgery plus adjuvant treatment.

CONCLUSION

Half of elderly patients with breast cancer are undertreated, with strongly decreased specific survival as a consequence. Treatments need to be adapted to the patient's health status, but also should offer the best chance of cure.

A Pilot Study of Dose Intense Doxorubicin and Cyclophosphamide Followed by Infusional Paclitaxel in High-Risk Primary Breast Cancer

We conducted a pilot study of dose dense doxorubicin and cyclophosphamide (AC) combination chemotherapy followed by infusional paclitaxel (T) in primary breast cancer to determine its safety and feasibility. Twenty-two subjects (10 with stage II and > or = 4 positive lymph nodes, and 12 with stage III disease) were treated with AC (A 60 mg/m2 and C 2000 mg/m2) with filgrastim every 14 days for three cycles followed by infusional paclitaxel (140 mg/m2 over 96 h) every 14 days for three cycles. Mean overall cycle length was 15.3 days and mean duration of therapy was 92 days. Dose reductions of C or T were required in 7/132 (5.3%) cycles for mucositis, diarrhea, or failure to recover platelets by day 15. Ninety-five percent of subjects had grade 4 neutropenia and 1 subject had a platelet nadir of < 20,000. Actual delivered dose intensity (DI) over six cycles was: A 27 mg/m2 per week; C 892 mg/m2 per week; T 64 mg/m2 per week (90.6, 89.2, and 91.4% of planned DI, respectively). Average total dose administered was: A 180 mg/m2; C 5880 mg/m2; T 403 mg/m2 (100, 98, and 96% of planned total doses, respectively). Clinical response rate in 10 subjects receiving neoadjuvant therapy was 100% (4 complete response, 6 partial response). Four subjects had a pathologic complete response (three subjects without evidence of malignancy and one subject with ductal carcinoma in situ.) Administration of dose dense AC followed by infusional paclitaxel in 14-day cycles is feasible and this regimen is active in breast cancer.

Routine mammography is associated with earlier stage disease and greater eligibility for breast conservation in breast carcinoma patients age 40 years and older

BACKGROUND

Reduction in breast carcinoma mortality is a major benefit of screening mammography and has been demonstrated in multiple randomized clinical trials and service screening programs. Another benefit from screening is that it allows the patient a wider choice of treatment options, particularly the possibility of conservation surgery. The current study analyzed the impact of mammography in the staging and treatment of breast carcinoma.

METHODS

A total of 1591 women aged > or = 40 years were treated for breast carcinoma between July 1995 and October 2001. Three subgroups were defined and compared. Group 1 had 192 patients with no previous mammography, Group 2 was comprised of 695 patients who underwent mammography on average less often than once yearly, and Group 3 was comprised of 704 patients who on average underwent mammography once yearly or more often.

RESULTS

The difference in tumor stage was found to be statistically significant between the groups (P < 0.0001). In Group 1, 15% of the patients had ductal carcinoma in situ (DCIS) compared with 21% of patients in Group 2 and 26% of patients in Group 3. In addition, 32% of patients in Group 1 had T1 tumors, whereas 50% of patients in Group 2 and 56% of patients in Group 3 had T1 tumors. The tumor size was < or = 1 cm in 8% of the patients in Group 1 compared with 20-23% of patients in Groups 2 and 3 (P = 0.0092). Breast conservation was an option for 41% of the patients in Group 1 but mastectomy was recommended in another 41% of patients. However, in Groups 2 and 3, 61% of patients were offered breast conservation and mastectomy was recommended to 28% (P < 0.0001).

CONCLUSIONS

In the current study, women age > or = 40 years with breast carcinoma who underwent mammography at least once yearly were diagnosed with DCIS more often compared with patients who underwent mammography less frequently or those who had no prior mammography. Women who underwent mammographic screening were found to have smaller tumors, which resulted in a majority of these patients being able to consider breast conservation as an alternative to mastectomy.

Evidence-based indications for postmastectomy irradiation

The ASCO guidelines panel found that PMRT reduces the risks of both local-regional recurrence and distant recurrence, and improves survival rates for patients with invasive breast cancer with involved axillary lymph nodes receiving systemic therapy. The benefits of PMRT, however, vary with regards to particular patient subsets (such as those defined by the number of involved axillary nodes). The panel agreed that PMRT is indicated routinely for patients with four or more positive axillary nodes, tumors larger than 5 cm in size, or locally advanced cancers. There was insufficient evidence for the panel to make recommendations or suggestions for the use of PMRT for patients with T1-2 tumors with one to three positive axillary nodes or for all patients receiving neoadjuvant systemic therapy. Physicians and patients are encouraged to participate in randomized trials exploring such issues, such as the ongoing intergroup study for patients with one to three positive axillary nodes.

Treatment outcome after radiotherapy alone for patients with Stage I-II nasopharyngeal carcinoma

BACKGROUND

The objective of this study was to review the long-term treatment outcome of patients with American Joint Committee on Cancer (AJCC) 1997 Stage I-II nasopharyngeal carcinoma (NPC) who were treated with radiotherapy alone.

METHODS

One hundred forty-one patients with NPC had AJCC 1997 Stage I-II disease (Stage I NPC, 50 patients; Stage II NPC, 91 patients) after restaging and were treated with radiotherapy alone between September 1989 and August 1991. Fifty-seven patients had lymph node disease, and the median greatest lymph node dimension was 3 cm. The median dose to the nasopharynx was 65 grays. The median follow-up was 82 months (range, 4-141 months).

RESULTS

Patients who had Stage I disease had an excellent outcome after radiotherapy. The 10-year disease specific survival, recurrence free survival (RFS), local RFS, lymph node RFS, and distant metastasis free survival rates were 98%, 94%, 96%, 98%, and 98%, respectively. Patients who had Stage II disease had a worse outcome compared with patients who had Stage I disease: The corresponding 10-year survival rates were 60%, 51%, 78%, 93%, and 64%. The differences all were significant except for lymph node control. Among patients who had Stage II disease, those with T1-T2N1 NPC appeared to have a worse outcome compared with patients who had T2N0 NPC. No significant differences in survival rates were found with respect to lymph node size or status for patients with T1-T2N1 disease.

CONCLUSIONS

When patients with NPC had their disease staged according to the AJCC 1997 classification system, patients with Stage I disease had an excellent outcome after they were treated with radiotherapy alone. Patients with Stage II disease, especially those with T1-T2N1 disease, had a relatively worse outcome, and more aggressive therapy, such as combined-modality treatment, may be indicated for those patients.

Elevated expression of cyclooxygenase-2 is a negative prognostic factor for disease free survival and overall survival in patients with breast carcinoma

BACKGROUND

Cyclooxygenases regulate the production of prostaglandins and play a role in tumor development and progression. The authors investigated the prognostic impact of expression of the cyclooxygenase (COX) isoforms, COX-1 and COX-2, on disease-free survival and progression-free survival in patients with primary breast carcinoma as well as the association between COX expression and other clinicopathologic parameters.

METHODS

In this study COX isoform expression was determined by immunohistochemistry in a cohort of 221 patients with primary breast carcinoma.

RESULTS

Expression of COX-2 was detected in 36% of breast carcinoma samples and was associated significantly with several clinicopathologic parameters, including positive lymph node status (P < 0.0005), larger tumor size (P < 0.0005), poor differentiation (P < 0.0005), vascular invasion (P = 0.03), and negative estrogen receptor status (P = 0.04). In contrast, COX-1 was expressed in 45% of tumors and was associated with smaller tumor size (P = 0.02) and with negative lymph node status (P = 0.01). In a univariate survival analysis, a significant association was observed between elevated COX-2 expression and decreases in disease-free survival (P = 0.0007) and overall survival (P = 0.02). In a multivariate analysis, expression of COX-2 was of borderline significance for disease-free survival (relative risk, 1.90; 95% confidence interval, 1.00-3.59), adjusting for tumor size, histologic grade, number of positive lymph nodes, and patient age. Elevated expression of COX-1 in tumor tissue had no statistically significant influence on patient prognosis.

CONCLUSIONS

The current data suggest that increased expression of COX-2 may play a role in the progression of primary breast carcinoma. It remains to be investigated whether treatment with selective inhibitors of COX-2 may be an additional therapeutic option for patients with breast carcinoma.

Virtual reality intervention for older women with breast cancer

This study examined the effects of a virtual reality distraction intervention on chemotherapy-related symptom distress levels in 16 women aged 50 and older. A cross-over design was used to answer the following research questions: (1) Is virtual reality an effective distraction intervention for reducing chemotherapy-related symptom distress levels in older women with breast cancer? (2) Does virtual reality have a lasting effect? Chemotherapy treatments are intensive and difficult to endure. One way to cope with chemotherapy-related symptom distress is through the use of distraction. For this study, a head-mounted display (Sony PC Glasstron PLM - S700) was used to display encompassing images and block competing stimuli during chemotherapy infusions. The Symptom Distress Scale (SDS), Revised Piper Fatigue Scale (PFS), and the State Anxiety Inventory (SAI) were used to measure symptom distress. For two matched chemotherapy treatments, one pre-test and two post-test measures were employed. Participants were randomly assigned to receive the VR distraction intervention during one chemotherapy treatment and received no distraction intervention (control condition) during an alternate chemotherapy treatment. Analysis using paired t-tests demonstrated a significant decrease in the SAI (p = 0.10) scores immediately following chemotherapy treatments when participants used VR. No significant changes were found in SDS or PFS values. There was a consistent trend toward improved symptoms on all measures 48 h following completion of chemotherapy. Evaluation of the intervention indicated that women thought the head mounted device was easy to use, they experienced no cybersickness, and 100% would use VR again.