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Chen Y, Li H, Janowczyk A, Toro P, Corredor G, Whitney J, Lu C, Koyuncu CF, Mokhtari M, Buzzy C, Ganesan S, Feldman MD, Fu P, Corbin H, Harbhajanka A, Gilmore H, Goldstein LJ, Davidson NE, Desai S, Parmar V, Madabhushi A. Computational pathology improves risk stratification of a multi-gene assay for early stage ER+ breast cancer. NPJ Breast Cancer 2023; 9:40. [PMID: 37198173 PMCID: PMC10192429 DOI: 10.1038/s41523-023-00545-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/28/2023] [Indexed: 05/19/2023] Open
Abstract
Prognostic markers currently utilized in clinical practice for estrogen receptor-positive (ER+) and lymph node-negative (LN-) invasive breast cancer (IBC) patients include the Nottingham grading system and Oncotype Dx (ODx). However, these biomarkers are not always optimal and remain subject to inter-/intra-observer variability and high cost. In this study, we evaluated the association between computationally derived image features from H&E images and disease-free survival (DFS) in ER+ and LN- IBC. H&E images from a total of n = 321 patients with ER+ and LN- IBC from three cohorts were employed for this study (Training set: D1 (n = 116), Validation sets: D2 (n = 121) and D3 (n = 84)). A total of 343 features relating to nuclear morphology, mitotic activity, and tubule formation were computationally extracted from each slide image. A Cox regression model (IbRiS) was trained to identify significant predictors of DFS and predict a high/low-risk category using D1 and was validated on independent testing sets D2 and D3 as well as within each ODx risk category. IbRiS was significantly prognostic of DFS with a hazard ratio (HR) of 2.33 (95% confidence interval (95% CI) = 1.02-5.32, p = 0.045) on D2 and a HR of 2.94 (95% CI = 1.18-7.35, p = 0.0208) on D3. In addition, IbRiS yielded significant risk stratification within high ODx risk categories (D1 + D2: HR = 10.35, 95% CI = 1.20-89.18, p = 0.0106; D1: p = 0.0238; D2: p = 0.0389), potentially providing more granular risk stratification than offered by ODx alone.
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Grants
- R01 CA216579 NCI NIH HHS
- C06 RR012463 NCRR NIH HHS
- R43 EB028736 NIBIB NIH HHS
- U01 CA239055 NCI NIH HHS
- R01 CA249992 NCI NIH HHS
- UG1 CA233328 NCI NIH HHS
- R01 CA220581 NCI NIH HHS
- R01 CA202752 NCI NIH HHS
- R01 CA208236 NCI NIH HHS
- U01 CA248226 NCI NIH HHS
- I01 BX004121 BLRD VA
- R01 CA257612 NCI NIH HHS
- U54 CA254566 NCI NIH HHS
- Research reported in this study was supported by the National Cancer Institute under award numbers R01CA249992-01A1, R01CA202752-01A1, R01CA208236-01A1, R01CA216579-01A1, R01CA220581-01A1, R01CA257612-01A1, 1U01CA239055-01, 1U01CA248226-01, 1U54CA254566-01, National Heart, Lung and Blood Institute 1R01HL15127701A1, R01HL15807101A1, National Institute of Biomedical Imaging and Bioengineering 1R43EB028736-01, National Center for Research Resources under award number 1 C06 RR12463-01, VA Merit Review Award IBX004121A from the United States Department of Veterans Affairs Biomedical Laboratory Research and Development Service the Office of the Assistant Secretary of Defense for Health Affairs, through the Breast Cancer Research Program (W81XWH-19-1-0668), the Prostate Cancer Research Program (W81XWH-15-1-0558, W81XWH-20-1-0851), the Lung Cancer Research Program (W81XWH-18-1-0440, W81XWH-20-1-0595), the Peer Reviewed Cancer Research Program (W81XWH-18-1-0404, W81XWH-21-1-0345, W81XWH-21-1-0160), the Kidney Precision Medicine Project (KPMP) Glue Grant and sponsored research agreements from Bristol Myers-Squibb, Boehringer-Ingelheim, Eli-Lilly and Astrazeneca.
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Affiliation(s)
- Yuli Chen
- Shaanxi Normal University, School of Computer Science, Xi'an, China
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Haojia Li
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Andrew Janowczyk
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Precision Oncology Center, University of Lausanne, Lausanne, Switzerland
| | - Paula Toro
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Germán Corredor
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Jon Whitney
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Cheng Lu
- Shaanxi Normal University, School of Computer Science, Xi'an, China
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Can F Koyuncu
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Mojgan Mokhtari
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Christina Buzzy
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Shridar Ganesan
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Michael D Feldman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Haley Corbin
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Hannah Gilmore
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Nancy E Davidson
- Fred Hutchinson Cancer Research Center, University of Washington, and Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Sangeeta Desai
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Vani Parmar
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Anant Madabhushi
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
- Louis Stokes VA Medical Center, Cleveland, OH, USA.
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Li H, Bera K, Toro P, Fu P, Zhang Z, Lu C, Feldman M, Ganesan S, Goldstein LJ, Davidson NE, Glasgow A, Harbhajanka A, Gilmore H, Madabhushi A. Collagen fiber orientation disorder from H&E images is prognostic for early stage breast cancer: clinical trial validation. NPJ Breast Cancer 2021; 7:104. [PMID: 34362928 PMCID: PMC8346522 DOI: 10.1038/s41523-021-00310-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 06/25/2021] [Indexed: 02/06/2023] Open
Abstract
Collagen fiber organization has been found to be implicated in breast cancer prognosis. In this study, we evaluated whether computerized features of Collagen Fiber Orientation Disorder in Tumor-associated Stroma (CFOD-TS) on Hematoxylin & Eosin (H&E) slide images were prognostic of Disease Free Survival (DFS) in early stage Estrogen Receptor Positive (ER+) Invasive Breast Cancers (IBC). A Cox regression model named MCFOD-TS, was constructed using cohort St (N = 78) to predict DFS based on CFOD-TS features. The prognostic performance of MCFOD-TS was validated on cohort Sv (N = 219), a prospective clinical trial dataset (ECOG 2197). MCFOD-TS was prognostic of DFS in both St and Sv, independent of clinicopathological variables. Additionally, the molecular pathways regarding cell cycle regulation were identified as being significantly associated with MCFOD-TS derived risk scores. Our results also found that collagen fiber organization was more ordered in patients with short DFS. Our study provided a H&E image-based pipeline to derive a potential prognostic biomarker for early stage ER+ IBC without the need of special collagen staining or advanced microscopy techniques.
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Affiliation(s)
- Haojia Li
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, OH, USA.
| | - Kaustav Bera
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, OH, USA
| | - Paula Toro
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, OH, USA
| | - PingFu Fu
- Case Western Reserve University, Department of Population and Quantitative Health Sciences, School of Medicine, Cleveland, OH, USA
| | - Zelin Zhang
- Nanjing University of Information Science and Technology, Jiangsu Key Laboratory of Big Data Analysis Technique, Nanjing, China
| | - Cheng Lu
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, OH, USA
| | - Michael Feldman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shridar Ganesan
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Nancy E Davidson
- Fred Hutchinson Cancer Research Center, University of Washington, and Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Akisha Glasgow
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Hannah Gilmore
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Anant Madabhushi
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, OH, USA. .,Louis Stokes Cleveland Veterans Administration Medical Center, Cleveland, OH, USA.
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3
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Willson ML, Burke L, Ferguson T, Ghersi D, Nowak AK, Wilcken N. Taxanes for adjuvant treatment of early breast cancer. Cochrane Database Syst Rev 2019; 9:CD004421. [PMID: 31476253 PMCID: PMC6718224 DOI: 10.1002/14651858.cd004421.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Adjuvant chemotherapy improves survival in premenopausal and postmenopausal women with early breast cancer. Taxanes are highly active chemotherapy agents used in metastatic breast cancer. Review authors examined their role in early breast cancer. This review is an update of a Cochrane Review first published in 2007. OBJECTIVES To assess the effects of taxane-containing adjuvant chemotherapy regimens for treatment of women with operable early breast cancer. SEARCH METHODS For this review update, we searched the Specialised Register of the Cochrane Breast Cancer Group, MEDLINE, Embase, CENTRAL (2018, Issue 6), the WHO International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov on 16 July 2018, using key words such as 'early breast cancer' and 'taxanes'. We screened reference lists of other related literature reviews and articles, contacted trial authors, and applied no language restrictions. SELECTION CRITERIA Randomised trials comparing taxane-containing regimens versus non-taxane-containing regimens in women with operable breast cancer were included. Studies of women receiving neoadjuvant chemotherapy were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias and quality of the evidence using the GRADE approach. Hazard ratios (HRs) were derived for time-to-event outcomes, and meta-analysis was performed using a fixed-effect model. The primary outcome measure was overall survival (OS); disease-free survival (DFS) was a secondary outcome measure. Toxicity was represented as odds ratios (ORs), and quality of life (QoL) data were extracted when present. MAIN RESULTS This review included 29 studies (27 full-text publications and 2 abstracts or online theses). The updated analysis included 41,911 randomised women; the original review included 21,191 women. Taxane-containing regimens improved OS (HR 0.87, 95% confidence interval (CI) 0.83 to 0.92; high-certainty evidence; 27 studies; 39,180 women; 6501 deaths) and DFS (HR, 0.88, 95% CI 0.85 to 0.92; high-certainty evidence; 29 studies; 41,909 women; 10,271 reported events) compared to chemotherapy without a taxane. There was moderate to substantial heterogeneity across studies for OS and DFS (respectively).When a taxane-containing regimen was compared with the same regimen without a taxane, the beneficial effects of taxanes persisted for OS (HR 0.84, 95% CI 0.77 to 0.92; P < 0.001; 7 studies; 10,842 women) and for DFS (HR 0.84, 95% CI 0.78 to 0.90; P < 0.001; 7 studies; 10,842 women). When a taxane-containing regimen was compared with the same regimen with another drug or drugs that were substituted for the taxane, a beneficial effect was observed for OS and DFS with the taxane-containing regimen (OS: HR 0.80, 95% CI 0.74 to 0.86; P < 0.001; 13 studies; 16,196 women; DFS: HR 0.83, 95% CI 0.78 to 0.88; P < 0.001; 14 studies; 16,823 women). Preliminary subgroup analysis by lymph node status showed a survival benefit with taxane-containing regimens in studies of women with lymph node-positive disease only (HR 0.83, 95% CI 0.78 to 0.88; P < 0.001; 17 studies; 22,055 women) but less benefit in studies of women both with and without lymph node metastases or with no lymph node metastases. Taxane-containing regimens also improved DFS in women with lymph node-positive disease (HR 0.84, 95% CI 0.80 to 0.88; P < 0.001; 17 studies; 22,055 women), although the benefit was marginal in studies of women both with and without lymph node-positive disease (HR 0.95, 95% CI 0.88 to 1.02; 9 studies; 12,998 women) and was not apparent in studies of women with lymph node-negative disease (HR 0.99, 95% CI 0.86 to 1.14; 3 studies; 6856 women).Taxanes probably result in a small increase in risk of febrile neutropenia (odds ratio (OR) 1.55, 95% CI 0.96 to 2.49; moderate-certainty evidence; 24 studies; 33,763 women) and likely lead to a large increase in grade 3/4 neuropathy (OR 6.89, 95% CI 3.23 to 14.71; P < 0.001; moderate-certainty evidence; 22 studies; 31,033 women). Taxanes probably cause little or no difference in cardiotoxicity compared to regimens without a taxane (OR 0.87, 95% CI 0.56 to 1.33; moderate-certainty evidence; 23 studies; 32,894 women). Seven studies reported low-quality evidence for QoL; overall, taxanes may make little or no difference in QoL compared to chemotherapy without a taxane during the follow-up period; however, the duration of follow-up differed across studies. Only one study, which was conducted in Europe, provided cost-effectiveness data. AUTHORS' CONCLUSIONS This review of studies supports the use of taxane-containing adjuvant chemotherapy regimens, with improvement in overall survival and disease-free survival for women with operable early breast cancer. This benefit persisted when analyses strictly compared a taxane-containing regimen versus the same regimen without a taxane or the same regimen with another drug that was substituted for the taxane. Preliminary evidence suggests that taxanes are more effective for women with lymph node-positive disease than for those with lymph node-negative disease. Considerable heterogeneity across studies probably reflects the varying efficacy of the chemotherapy backbones of the comparator regimens used in these studies. This review update reports results that are remarkably consistent with those of the original review, and it is highly unlikely that this review will be updated, as new trials are assessing treatments based on more detailed breast cancer biology.
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Affiliation(s)
- Melina L Willson
- NHMRC Clinical Trials Centre, The University of SydneySystematic Reviews and Health Technology AssessmentsLocked Bag 77SydneyNSWAustralia1450
| | - Lucinda Burke
- Chris O'Brien LifehouseDepartment of Radiation OncologySydneyAustralia
| | - Thomas Ferguson
- Royal Perth HospitalDepartment of Medical OncologyWellington StPerthWAAustralia6010
| | - Davina Ghersi
- National Health and Medical Research CouncilResearch Policy and Translation16 Marcus Clarke StreetCanberraACTAustralia2601
- The University of SydneySydney Medical SchoolSydneyAustralia
| | - Anna K Nowak
- Sir Charles Gairdiner Hospital and University of Western AustraliaDepartment of Medical OncologyB Block, Hospital AvenueNedlandsPerthWAAustralia6099
| | - Nicholas Wilcken
- The University of SydneySydney Medical SchoolSydneyAustralia
- Crown Princess Mary Cancer CentreMedical OncologyWestmeadNSWAustralia2145
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4
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Qin YY, Li H, Guo XJ, Ye XF, Wei X, Zhou YH, Zhang XJ, Wang C, Qian W, Lu J, He J. Adjuvant chemotherapy, with or without taxanes, in early or operable breast cancer: a meta-analysis of 19 randomized trials with 30698 patients. PLoS One 2011; 6:e26946. [PMID: 22069477 PMCID: PMC3206064 DOI: 10.1371/journal.pone.0026946] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 10/06/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Taxanes have been extensively used as adjuvant chemotherapy for the treatment of early or operable breast cancer, particularly in high risk, node-negative breast cancer. Previous studies, however, have reported inconsistent findings regarding their clinical efficacy and safety. We investigated disease-free survival (DFS), overall survival (OS), and drug-related toxicities of taxanes by a systematic review and meta-analysis. METHODOLOGY AND PRINCIPAL FINDINGS We systematically searched PubMed, EMBASE, the Cochrane Center Register of Controlled Trials, proceedings of major meetings, and reference lists of articles for studies conducted between January 1980 and April 2011. Randomized controlled trials (RCTs) comparing chemotherapy with and without taxanes in the treatment of patients with early-stage or operable breast cancer were eligible for inclusion in our analysis. The primary endpoint was DFS. Nineteen RCTs including 30698 patients were identified, including 8426 recurrence events and 3803 deaths. Taxanes administration yielded a 17% reduction of hazard ratio (HR) for DFS (HR = 0.83, 95% CI 0.79-0.88, p<0.001) and a 17% reduction of HR for OS (HR = 0.83, 95% CI 0.77-0.90, p<0.001). For high risk, node-negative breast cancer, the pooled HR also favoured the taxane-based treatment arm over the taxane-free treatment arm (HR = 0.82, 95% CI 0.77-0.87, p = 0.022). A significantly increased rate of neutropenia, febrile neutropenia, fatigue, diarrhea, stomatitis, and oedema was observed in the taxane-based treatment arm. CONCLUSIONS/SIGNIFICANCE Adjuvant chemotherapy with taxanes could reduce the risk of cancer recurrence and death in patients with early or operable breast cancer, although the drug-related toxicities should be balanced. Furthermore, we also demonstrated that patients with high risk, node-negative breast cancer also benefited from taxanes therapy, a result that was not observed in previous studies.
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Affiliation(s)
- Ying-Yi Qin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
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5
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Láng I, Kahán Z, Pintér T, Dank M, Boér K, Pajkos G, Faluhelyi Z, Pikó B, Eckhardt S, Horváth Z. [Pharmaceutical therapy of breast cancer]. Magy Onkol 2010; 54:237-254. [PMID: 20870601 DOI: 10.1556/monkol.54.2010.3.5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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6
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Kelly CM, Hortobagyi GN. Adjuvant Chemotherapy in Early-Stage Breast Cancer: What, When, and for Whom? Surg Oncol Clin N Am 2010; 19:649-68. [DOI: 10.1016/j.soc.2010.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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7
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Kelly CM, Warner E, Tsoi DT, Verma S, Pritchard KI. Review of the clinical studies using the 21-gene assay. Oncologist 2010; 15:447-56. [PMID: 20421266 DOI: 10.1634/theoncologist.2009-0277] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
PURPOSE A major challenge in treating early-stage hormone receptor (HR)(+) breast cancer is selecting women who, after initial surgery, do not require chemotherapy. Better prognostic and predictive tests are needed. The 21-gene assay is the only widely commercially available gene signature that can be performed on formalin-fixed paraffin-embedded tissue. METHODS We conducted a review of the literature supporting the prognostic and predictive ability of the 21-gene assay in HR(+) node-negative and node-positive breast cancer patients in chemotherapy-/endocrine-treated and untreated populations. We considered: (a) How accurate is the recurrence score (RS) as a prognostic factor for distant recurrence? (b) How accurate is the RS as a predictive factor for benefit from systemic therapy? (c) How does the RS compare with other prognostic/predictive factors such as tumor size, tumor grade, patient age, and integrated decision aids such as Adjuvant! Online? (d) How do patients and physicians view the 21-gene assay? (e) What are the cost implications of the 21-gene assay? RESULTS The 21-gene assay: (a) provided accurate risk information; (b) predicted response to cyclophosphamide, methotrexate, and 5-fluorouracil and to cyclophosphamide, doxorubicin, and 5-fluorouracil chemotherapy; (c) added additional information to traditional biomarkers; (d) was viewed positively by both physicians and patients; and (e) fell within the cost-effectiveness values in North America. CONCLUSION This assay may be offered to patients with node-negative HR(+) breast cancer to assist in adjuvant treatment decisions. Data are accumulating to support the use of the 21-gene assay in HR(+) node-positive patients.
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Affiliation(s)
- Catherine M Kelly
- Division of Medical Oncology, Sunnybrook Odette Cancer Centre, The University of Toronto, Toronto, Ontario, Canada, M4N 3M5
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8
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Chilcott J, Jones ML, Wilkinson A. Docetaxel for the adjuvant treatment of early nodepositive breast cancer: a single technology appraisal. Health Technol Assess 2009. [DOI: 10.3310/hta13suppl1-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of docetaxel for the adjuvant treatment of early node-positive breast cancer based upon the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer’s scope restricts the intervention to docetaxel in combination with doxorubicin and cyclophosphamide (TAC), and the comparator to anthracycline-based chemotherapy. Based on the BCIRG 001 trial, the submitted evidence shows that TAC is associated with superior disease-free and overall survival at 5 years compared with the anthracycline-based regimen FAC. The absolute risk reduction in patients treated with TAC compared with those treated with FAC was 7% for disease-free survival and 6% for overall survival. However, TAC was associated with significantly greater toxicity than FAC. There is also evidence that docetaxel, in an unlicensed sequential regimen FEC100-T, is associated with superior diseasefree and overall survival at 5 years compared with FEC100. An economic model was developed by the manufacturer based on the BCIRG 001 trial. This generated central estimates of the cost per life-year gained and cost per quality-adjusted lifeyear (QALY) gained of TAC compared with FAC of £7900 and £9800 respectively. The manufacturer’s submission predicts a cost-effectiveness of £15,000–£20,000 per QALY gained for TAC compared with E-CMF (epirubicin in sequential therapy with cyclophosphamide, methotrexate, and fluorouracil), and estimates the cost-effectiveness of FEC100-T to be £8200 per QALY compared with FEC100. Taking into account a number of issues identified by the ERG this may generate higher estimates of cost-effectiveness, but these are unlikely to exceed £35,000 per QALY gained. Importantly, FAC is not commonly used in clinical practice in the UK and, therefore, the submitted evidence does not indicate whether TAC is superior to the anthracycline-based regimens that are in common use (FEC or E-CMF). The indirect comparisons presented suggest that the economic case for TAC in comparison to current UK practice may not be proven. The manufacturer’s submission failed to record evidence of three serious adverse events in patients receiving docetaxel with doxorubicin or to mention the concern of the European Medicines Agency regarding TAC’s long-term adverse events. The guidance issued by NICE in June 2006 as a result of the STA states that docetaxel, when given concurrently with doxorubicin and cyclophosphamide (the TAC regimen), is recommended as an option for the adjuvant treatment of women with early nodepositive breast cancer.
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Affiliation(s)
- J Chilcott
- School of Health and Related Research (ScHARR), University of Sheffield, UK
| | - M Lloyd Jones
- School of Health and Related Research (ScHARR), University of Sheffield, UK
| | - A Wilkinson
- School of Health and Related Research (ScHARR), University of Sheffield, UK
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9
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López-Tarruella S, Martín M. Recent advances in systemic therapy: advances in adjuvant systemic chemotherapy of early breast cancer. Breast Cancer Res 2009; 11:204. [PMID: 19344489 PMCID: PMC2688937 DOI: 10.1186/bcr2226] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Adjuvant treatment for early breast cancer is an evolving field. Since the advent of the initial cyclophosphamide, methotrexate and 5-fluorouracil (CMF) regimens, which reduced risk for recurrence and death, anthracyclines and subsequently taxanes were added to the cytotoxic armamentarium for use sequentially or in combination in the adjuvant setting. The efficacy and toxicity of each chemotherapy regimen must be viewed within the context of host co-morbidities and the specific biologic phenotype of the tumor. In the era of mammographic screening, small, node-negative breast cancer is the most frequent presentation of the disease. Patient selection for adjuvant chemotherapy has become a key issue. Traditional prognostic factors continue to be of value in determining the risk for relapse, but new and sophisticated genomic tools (such as Oncotype Dx® and Mammaprint®) are now available and may improve our ability to select patients. For those patients who do require adjuvant chemotherapy, the 'one size fits all' paradigm should never again feature in the treatment of early breast cancer, following the important insights yielded by biomarker research to identify those who will benefit the most from a particular drug. In this review we focus on some of the current controversies and potential future steps in adjuvant chemotherapy for treatment of early breast cancer.
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Affiliation(s)
- Sara López-Tarruella
- Medical Oncology Department, Clínico San Carlos Hospital, Madrid, Profesor Martín Lagos, Madrid, Spain
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Strother RM, Sweeney C. Lessons learned from development of docetaxel. Expert Opin Drug Metab Toxicol 2008; 4:1007-19. [DOI: 10.1517/17425255.4.7.1007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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Allred DC. Problems and Solutions in the Evaluation of Hormone Receptors in Breast Cancer. J Clin Oncol 2008; 26:2433-5. [DOI: 10.1200/jco.2007.15.7800] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- D. Craig Allred
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
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12
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Progress in the Treatment of Early and Advanced Breast Cancer. Breast Cancer 2007. [DOI: 10.1007/978-3-540-36781-9_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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13
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Abstract
BACKGROUND Adjuvant chemotherapy improves survival in pre- and post-menopausal women with early breast cancer. Taxanes are highly active chemotherapy agents in metastatic breast cancer. Their role in early breast cancer was examined in this review. OBJECTIVES To review the randomised evidence comparing taxane containing chemotherapy regimens with non-taxane containing chemotherapy regimens as adjuvant treatment of pre- or post-menopausal women with early breast cancer. SEARCH STRATEGY The Cochrane Breast Cancer Group Specialised Register was searched on 9th January 2007 using the codes for 'early breast cancer' and keywords for taxanes. Details of the search strategy used to create the register are described in the Group's module in The Cochrane Library. The reference lists of other related literature reviews and articles were also searched. SELECTION CRITERIA Randomised trials comparing taxane containing regimens with non-taxane containing regimens in women with operable breast cancer. Women receiving neoadjuvant chemotherapy were excluded. DATA COLLECTION AND ANALYSIS Data were collected from published trials and abstracts. Studies were assessed for eligibility and quality and the data extracted independently by two review authors. Hazard ratios (HR) were derived for time-to-event outcomes, and meta-analysis was performed using a fixed-effect model. The primary outcome measure was overall survival (OS); disease-free survival (DFS) was a secondary outcome measure. Toxicity and quality of life data were extracted when reported. MAIN RESULTS We identified 20 studies, 12 of these (7 full publications, 5 abstracts) had sufficient data published for inclusion (11 for OS and 11 for DFS) in the review. The weighted average median follow up was 60.4 months. All studies fulfilled quality criteria either adequately or well. Amongst 18,304 women with 2483 deaths, the HR for OS was 0.81 (95% CI 0.75 to 0.88, P < 0.00001) favouring taxane containing regimens. Amongst 19,943 women with 4800 events, the HR for DFS was 0.81 (95% CI 0.77 to 0.86, P < 0.00001) favouring taxane containing regimens. There was no statistical heterogeneity for either OS or DFS. AUTHORS' CONCLUSIONS This meta-analysis of studies supports the use of taxane containing adjuvant chemotherapy regimens with improvement of overall survival and disease-free survival for women with operable early breast cancer. The review did not identify a subgroup of patients where taxane containing treatment may have been more or less effective. Dosage and scheduling of the taxane drug is not clearly defined and we await results of the next generation of studies to determine the optimal use of taxanes in early breast cancer.
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Estévez LG, Muñoz M, Alvarez I, Fernández Y, García-Mata J, Ruiz-Borrego M, Tusquets I, Seguí MA, Rodríguez-Lescure A, Adrover E, Lluch A. Evidence-based use of taxanes in the adjuvant setting of breast cancer. A review of randomized phase III trials. Cancer Treat Rev 2007; 33:474-83. [PMID: 17561350 DOI: 10.1016/j.ctrv.2007.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Revised: 04/03/2007] [Accepted: 04/08/2007] [Indexed: 11/20/2022]
Abstract
Six major randomized clinical trials evaluating the role of taxanes in the adjuvant setting of breast cancer have demonstrated significant improvements in terms of efficacy in favour of the taxane treatment arm. In all cases, different anthracycline-based regimens were used as the control arm. Nevertheless, many clinicians are still not sufficiently convinced to incorporate the routine use of taxanes in the adjuvant treatment of breast cancer. There are two main objections, first the possible lack of effectiveness of chemotherapy in hormone-receptor positive tumors and second, some of the anthracycline-based control arms used in these trials were not the optimal ones. In this review, we have searched and analyzed all randomized studies that evaluated the role of taxanes in the adjuvant setting of breast cancer patients and have reported results in terms of efficacy or tolerance. The suitability of the control arm, the prospective definition of patient's subgroups and the statistical methodology were taking into account. The objective of this review was to analyze if, at this point in time, there is sufficient evidence to support the routine use of taxanes in the adjuvant setting of breast cancer, and if it is valid for all subgroups including hormone-receptor and Her2/neu positive breast cancer patients. Other objectives of this review were to define the optimal regimen for administration of taxanes, how the tolerability of taxanes may be improved and also, to investigate any potential differences in efficacy or tolerability between docetaxel and paclitaxel.
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Jones SE, Savin MA, Holmes FA, O'Shaughnessy JA, Blum JL, Vukelja S, McIntyre KJ, Pippen JE, Bordelon JH, Kirby R, Sandbach J, Hyman WJ, Khandelwal P, Negron AG, Richards DA, Anthony SP, Mennel RG, Boehm KA, Meyer WG, Asmar L. Phase III trial comparing doxorubicin plus cyclophosphamide with docetaxel plus cyclophosphamide as adjuvant therapy for operable breast cancer. J Clin Oncol 2006; 24:5381-7. [PMID: 17135639 DOI: 10.1200/jco.2006.06.5391] [Citation(s) in RCA: 380] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE The combination of doxorubicin and cyclophosphamide (AC) is a standard adjuvant chemotherapy regimen. Studies of docetaxel and cyclophosphamide (TC) in metastatic breast cancer (MBC) showed promise in MBC. In 1997, we initiated a randomized adjuvant trial of TC compared with standard-dose AC with a primary end point of disease-free survival (DFS). PATIENTS AND METHODS Patients were eligible if they had stage I to III operable invasive breast cancer with complete surgical excision of the primary tumor. Between June 1997 and December 1999, 1,016 patients were randomly assigned to four cycles of either standard-dose AC (60 and 600 mg/m2, respectively; n = 510) or TC (75 and 600 mg/m2, respectively; n = 506), administered intravenously every 3 weeks as adjuvant chemotherapy. Radiation therapy (as indicated) and tamoxifen, for patients with hormone receptor-positive disease, were administered after completion of chemotherapy. RESULTS Both treatment groups (TC and AC) were well balanced with respect to major prognostic factors. Patients were observed through 2005 for a median of 5.5 years. At 5 years, DFS rate was significantly superior for TC compared with AC (86% v 80%, respectively; hazard ratio [HR] = 0.67; 95% CI, 0.50 to 0.94; P = .015). Overall survival rates for TC and AC were 90% and 87%, respectively (HR = 0.76; 95% CI, 0.52 to 1.1; P = .13). More myalgia, arthralgia, edema, and febrile neutropenia occurred on the TC arm; more nausea and vomiting occurred on the AC arm as well as one incident of congestive heart failure. CONCLUSION At 5 years, TC was associated with a superior DFS and a different toxicity profile compared with AC.
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Affiliation(s)
- Stephen E Jones
- US Oncology Research, Inc, Texas Oncology, Dallas, TX 75246, USA.
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Harbeck N, Minckwitz GV. Adjuvant Chemotherapy in Primary Breast Cancer. Breast Care (Basel) 2006. [DOI: 10.1159/000094755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Bria E, Nistico C, Cuppone F, Carlini P, Ciccarese M, Milella M, Natoli G, Terzoli E, Cognetti F, Giannarelli D. Benefit of taxanes as adjuvant chemotherapy for early breast cancer. Cancer 2006; 106:2337-44. [PMID: 16649217 DOI: 10.1002/cncr.21886] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The magnitude of the survival benefit of taxanes as adjuvant chemotherapy for early breast cancer is still unclear. A pooled analysis of Phase III trials was performed to assess the advantages that adjuvant taxane chemotherapy has over standard chemotherapy. METHODS All Phase III trials were considered eligible. A pooled analysis was accomplished and event-based relative risk ratios (RR) with 95% confidence intervals (95% CI) were derived. The significant differences in disease-free survival (DFS) and overall survival (OS) were explored. Magnitude outcome measures were absolute benefits and the number of patients needed to treat. A heterogeneity test was applied as well. A sensitivity analysis in 6 subpopulations was also performed. RESULTS Nine trials designed to assess if paclitaxel or docetaxel improve survival (15,598 patients) were gathered. One of the 9 trials did not report OS results. Significant differences in favor of taxanes were seen in DFS in the overall (RR: 0.86; 95% CI, 0.81-0.90 [P<.00001]) and lymph node-positive population (RR: 0.84; 95% CI, 0.79-0.89 [P<.0001]), and in OS in the overall (RR: 0.87; 95% CI, 0.81-0.83 [P<.0001]) and lymph node-positive population (RR: 0.84; 95% CI, 0.77-0.92 [P<.0001]). The absolute benefits in DFS and OS in favor of taxanes ranged from 3.3% to 4.6% and from 2.0% to 2.8%, respectively. CONCLUSIONS Considering all the available Phase III trials, taxane-based adjuvant chemotherapy for early breast cancer seems to add a significant benefit in both DFS and OS over standard chemotherapy. The lack of significant heterogeneity in the sensitivity analysis underscores the homogeneous effect across all trials.
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Affiliation(s)
- Emilio Bria
- Department of Medical Oncology, Regina Elena National Cancer Institute, Rome, Italy.
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Abstract
Adjuvant hormonal therapy and adjuvant chemotherapy have contributed significantly to the falling rates of breast cancer mortality. The introduction of taxanes and aromatase inhibitors in the adjuvant setting represents recent important improvements. More recently, the demonstration of significant benefit in the adjuvant setting with novel molecular targeted therapies (such as trastuzumab [Herceptin; Genentech, Inc., South San Francisco, CA, http://www.gene.com]) is already beginning to have a substantial impact on the adjuvant treatment of patients with certain tumor characteristics (i.e., HER-2 positivity). Neoadjuvant treatment represents an approach that offers an intermediate end point (i.e., pathologic complete response) that can be used as a marker of therapeutic activity. Furthermore, the use of genomic profiling is starting to replace the traditional prognostic and predictive factors currently used to estimate risks for recurrence and response to particular adjuvant therapies. These recent developments have demonstrated that the notion of approaching zero relapse in breast cancer patients is now within our reach.
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Affiliation(s)
- Eleftherios P Mamounas
- Northeastern Ohio Universities College of Medicine, Aultman Cancer Center, 2600 6th Street SW, Canton, Ohio 44710, USA.
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Colozza M, de Azambuja E, Cardoso F, Bernard C, Piccart MJ. Breast Cancer: Achievements in Adjuvant Systemic Therapies in the Pre‐Genomic Era. Oncologist 2006; 11:111-25. [PMID: 16476832 DOI: 10.1634/theoncologist.11-2-111] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In recent decades, the use of adjuvant systemic therapies for early breast cancer has increased extensively and has most likely contributed to the decline in breast cancer mortality observed in the U.S. and in some European countries. The last few years have witnessed accelerated progress in the treatment of early breast cancer, with the introduction of taxanes and aromatase inhibitors and, most impressively, trastuzumab to the adjuvant portfolio. When compared with anthracycline-based regimens, the addition of taxanes to treatments for patients with node-positive breast cancer has shown benefits in disease-free survival and, in some trials, in overall survival; however, these drugs are not yet universally accepted as standard treatment. Significant improvements in endocrine therapy in both pre- and postmenopausal patients with endocrine-responsive disease have been made. In the postmenopausal setting, aromatase inhibitors have shown superiority over tamoxifen in a direct comparison upfront or when given in sequence after 2-5 years of tamoxifen, but the optimal modality of administration remains unclear. For premenopausal women, ovarian function suppression with luteinizing hormone-releasing hormone analogues combined with tamoxifen has generated similar results to cyclophosphamide, methotrexate, 5-fluorouracil (CMF)-based regimens. Recently, trastuzumab has had a dramatic impact on the evolution of human epidermal growth factor receptor 2 (HER-2)-positive early breast cancer treated with standard adjuvant modalities; specifically, relapses, including distant relapses, have been halved. In this review, we summarize these main achievements, discuss the currently available adjuvant treatment options for breast cancer patients, and emphasize the need for more efficient translational research to improve individual treatment tailoring.
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Nitz UA, Mohrmann S, Fischer J, Lindemann W, Berdel WE, Jackisch C, Werner C, Ziske C, Kirchner H, Metzner B, Souchon R, Ruffert U, Schütt G, Pollmanns A, Schmoll HJ, Middecke C, Baltzer J, Schrader I, Wiebringhaus H, Ko Y, Rösel S, Schwenzer T, Wernet P, Hinke A, Bender HG, Frick M. Comparison of rapidly cycled tandem high-dose chemotherapy plus peripheral-blood stem-cell support versus dose-dense conventional chemotherapy for adjuvant treatment of high-risk breast cancer: results of a multicentre phase III trial. Lancet 2005; 366:1935-44. [PMID: 16325695 DOI: 10.1016/s0140-6736(05)67784-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Breast cancer with extensive axillary-lymph-node involvement has a poor prognosis after conventional treatment. In trials with historical controls, high-dose chemotherapy produced improved outcomes. We compared an intensive double-cycle high-dose chemotherapy regimen with an accelerated conventionally dosed regimen in high-risk breast cancer in a multicentre trial. METHODS Patients with at least nine positive nodes were randomly assigned either two courses of accelerated (2-week intervals, with filgrastim support), conventionally dosed epirubicin and cyclophosphamide followed by two courses of high-dose chemotherapy (epirubicin, cyclophosphamide, and thiotepa supported by peripheral-blood progenitors) or four identical cycles of epirubicin and cyclophosphamide followed by three cycles of accelerated cyclophosphamide, methotrexate, and fluorouracil. The primary endpoint was event-free survival. Analyses were done both by intention to treat and per protocol. FINDINGS 403 patients were enrolled; 201 were assigned high-dose chemotherapy and 202 conventional treatment. The mean number of positive nodes was 17.6, and median follow-up was 48.6 months. 4-year event-free survival (intention-to-treat analysis) was 60% (95% CI 53-67) in the high-dose chemotherapy group and 44% (37-52) in the control group (p=0.00069). The corresponding overall survival was 75% (69-82) versus 70% (64-77; p=0.02). There were no treatment-related deaths. INTERPRETATION Our finding of significant improvements in both event-free and overall survival for high-dose chemotherapy compared with a dose-dense conventional regimen contrasts with the results of other studies. The discrepancy might be due partly to design differences (tandem, brief induction) between our regimen and those studied in other trials. This approach merits further study.
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Abstract
The taxanes docetaxel and paclitaxel have established roles as two of the most active agents in the treatment of metastatic breast cancer. These two drugs are now being incorporated into the management of early breast cancer. A first generation of trials has explored whether the addition of taxanes either sequentially or in combination with adjuvant anthracycline-based chemotherapy improves outcome for patients with early breast cancer. A second generation of trials are now underway which are based on the assumption that taxanes are beneficial in the adjuvant setting, and are comparing the different taxanes, dosing regimens and the addition of further agents. Trials in the neoadjuvant setting have recently demonstrated improved response rates with the addition of taxanes into existing anthracycline-based regimes. This review critically appraises these trials and provides an overview of ongoing research in the area.
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Affiliation(s)
- Alistair E Ring
- Department of Medical Oncology, Thomas Guy House, Guy's Hospital, London SE1 9RT, UK
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