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Albain KS, Yau C, Petricoin EF, Wolf DM, Lang JE, Chien AJ, Haddad T, Forero-Torres A, Wallace AM, Kaplan H, Pusztai L, Euhus D, Nanda R, Elias AD, Clark AS, Godellas C, Boughey JC, Isaacs C, Tripathy D, Lu J, Yung RL, Gallagher RI, Wulfkuhle JD, Brown-Swigart L, Krings G, Chen YY, Potter DA, Stringer-Reasor E, Blair S, Asare SM, Wilson A, Hirst GL, Singhrao R, Buxton M, Clennell JL, Sanil A, Berry S, Asare AL, Matthews JB, DeMichele AM, Hylton NM, Melisko M, Perlmutter J, Rugo HS, Symmans WF, van’t Veer LJ, Yee D, Berry DA, Esserman LJ. Neoadjuvant Trebananib plus Paclitaxel-based Chemotherapy for Stage II/III Breast Cancer in the Adaptively Randomized I-SPY2 Trial-Efficacy and Biomarker Discovery. Clin Cancer Res 2024; 30:729-740. [PMID: 38109213 PMCID: PMC10956403 DOI: 10.1158/1078-0432.ccr-22-2256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 10/11/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Abstract
PURPOSE The neutralizing peptibody trebananib prevents angiopoietin-1 and angiopoietin-2 from binding with Tie2 receptors, inhibiting angiogenesis and proliferation. Trebananib was combined with paclitaxel±trastuzumab in the I-SPY2 breast cancer trial. PATIENTS AND METHODS I-SPY2, a phase II neoadjuvant trial, adaptively randomizes patients with high-risk, early-stage breast cancer to one of several experimental therapies or control based on receptor subtypes as defined by hormone receptor (HR) and HER2 status and MammaPrint risk (MP1, MP2). The primary endpoint is pathologic complete response (pCR). A therapy "graduates" if/when it achieves 85% Bayesian probability of success in a phase III trial within a given subtype. Patients received weekly paclitaxel (plus trastuzumab if HER2-positive) without (control) or with weekly intravenous trebananib, followed by doxorubicin/cyclophosphamide and surgery. Pathway-specific biomarkers were assessed for response prediction. RESULTS There were 134 participants randomized to trebananib and 133 to control. Although trebananib did not graduate in any signature [phase III probabilities: Hazard ratio (HR)-negative (78%), HR-negative/HER2-positive (74%), HR-negative/HER2-negative (77%), and MP2 (79%)], it demonstrated high probability of superior pCR rates over control (92%-99%) among these subtypes. Trebananib improved 3-year event-free survival (HR 0.67), with no significant increase in adverse events. Activation levels of the Tie2 receptor and downstream signaling partners predicted trebananib response in HER2-positive disease; high expression of a CD8 T-cell gene signature predicted response in HR-negative/HER2-negative disease. CONCLUSIONS The angiopoietin (Ang)/Tie2 axis inhibitor trebananib combined with standard neoadjuvant therapy increased estimated pCR rates across HR-negative and MP2 subtypes, with probabilities of superiority >90%. Further study of Ang/Tie2 receptor axis inhibitors in validated, biomarker-predicted sensitive subtypes is warranted.
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Affiliation(s)
- Kathy S. Albain
- Loyola University Chicago Stritch School of Medicine, Chicago, IL
| | - Christina Yau
- University of California San Francisco, San Francisco, CA
| | | | - Denise M. Wolf
- University of California San Francisco, San Francisco, CA
| | | | - A. Jo Chien
- University of California San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Debu Tripathy
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Janice Lu
- University of Southern California, Los Angeles, CA
| | | | | | | | | | - Gregor Krings
- University of California San Francisco, San Francisco, CA
| | - Yunn Yi Chen
- University of California San Francisco, San Francisco, CA
| | | | | | - Sarah Blair
- University of California San Diego, La Jolla, CA
| | - Smita M. Asare
- Quantum Leap Healthcare Collaborative, San Francisco, CA
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | - Ruby Singhrao
- University of California San Francisco, San Francisco, CA
| | | | | | | | | | - Adam L. Asare
- Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | | | - Nola M. Hylton
- University of California San Francisco, San Francisco, CA
| | | | | | - Hope S. Rugo
- University of California San Francisco, San Francisco, CA
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Kyalwazi B, Yau C, Campbell MJ, Yoshimatsu TF, Chien AJ, Wallace AM, Forero-Torres A, Pusztai L, Ellis ED, Albain KS, Blaes AH, Haley BB, Boughey JC, Elias AD, Clark AS, Isaacs CJ, Nanda R, Han HS, Yung RL, Tripathy D, Edmiston KK, Viscusi RK, Northfelt DW, Khan QJ, Asare SM, Wilson A, Hirst GL, Lu R, Symmans WF, Yee D, DeMichele AM, van ’t Veer LJ, Esserman LJ, Olopade OI. Race, Gene Expression Signatures, and Clinical Outcomes of Patients With High-Risk Early Breast Cancer. JAMA Netw Open 2023; 6:e2349646. [PMID: 38153734 PMCID: PMC10755617 DOI: 10.1001/jamanetworkopen.2023.49646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/26/2023] [Indexed: 12/29/2023] Open
Abstract
Importance There has been little consideration of genomic risk of recurrence by breast cancer subtype despite evidence of racial disparities in breast cancer outcomes. Objective To evaluate associations between clinical trial end points, namely pathologic complete response (pCR) and distant recurrence-free survival (DRFS), and race and examine whether gene expression signatures are associated with outcomes by race. Design, Setting, and Participants This retrospective cohort study used data from the Investigation of Serial Studies to Predict Your Therapeutic Response With Imaging and Molecular Analysis 2 (I-SPY 2) multicenter clinical trial of neoadjuvant chemotherapy with novel agents and combinations for patients with previously untreated stage II/III breast cancer. Analyses were conducted of associations between race and short- and long-term outcomes, overall and by receptor subtypes, and their association with 28 expression biomarkers. The trial enrolled 990 female patients between March 30, 2010, and November 5, 2016, with a primary tumor size of 2.5 cm or greater and clinical or molecular high risk based on MammaPrint or hormone receptor (HR)-negative/ERBB2 (formerly HER2 or HER2/neu)-positive subtyping across 9 arms. This data analysis was performed between June 10, 2021, and October 20, 2022. Exposure Race, tumor receptor subtypes, and genomic biomarker expression of early breast cancer. Main Outcomes and Measures The primary outcomes were pCR and DRFS assessed by race, overall, and by tumor subtype using logistic regression and Cox proportional hazards regression models. The interaction between 28 expression biomarkers and race, considering pCR and DRFS overall and within subtypes, was also evaluated. Results The analytic sample included 974 participants (excluding 16 self-reporting as American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or multiple races due to small sample sizes), including 68 Asian (7%), 120 Black (12%), and 786 White (81%) patients. Median (range) age at diagnosis was 47 (25-71) years for Asian, 49 (25-77) for Black, and 49 (23-73) years for White patients. The pCR rates were 32% (n = 22) for Asian, 30% for Black (n = 36), and 32% for White (n = 255) patients (P = .87). Black patients with HR-positive/ERBB2-negative tumors not achieving pCR had significantly worse DRFS than their White counterparts (hazard ratio, 2.28; 95% CI, 1.24-4.21; P = .01), with 5-year DRFS rates of 55% (n = 32) and 77% (n = 247), respectively. Black patients with HR-positive/ERBB2-negative tumors, compared with White patients, had higher expression of an interferon signature (mean [SD], 0.39 [0.87] and -0.10 [0.99]; P = .007) and, compared with Asian patients, had a higher mitotic score (mean [SD], 0.07 [1.08] and -0.69 [1.06]; P = .01) and lower estrogen receptor/progesterone receptor signature (mean [SD], 0.31 [0.90] and 1.08 [0.95]; P = .008). A transforming growth factor β signature had a significant association with race relative to pCR and DRFS, with a higher signature associated with lower pCR and worse DRFS outcomes among Black patients only. Conclusions and Relevance The findings show that women with early high-risk breast cancer who achieve pCR have similarly good outcomes regardless of race, but Black women with HR-positive/ERBB2-negative tumors without pCR may have worse DRFS than White women, highlighting the need to develop and test novel biomarker-informed therapies in diverse populations.
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Affiliation(s)
- Beverly Kyalwazi
- Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Christina Yau
- Department of Surgery, University of California, San Francisco
| | | | - Toshio F. Yoshimatsu
- Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, Illinois
| | - A. Jo Chien
- Department of Hematology Oncology and Surgery, University of California, San Francisco Helen Diller Comprehensive Cancer Center, San Francisco
| | - Anne M. Wallace
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, La Jolla
| | | | - Lajos Pusztai
- Department of Medical Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | | | - Kathy S. Albain
- Division of Hematology-Oncology, Department of Medicine, University of Minnesota, Minneapolis
| | - Anne H. Blaes
- Division of Hematology-Oncology, Department of Medicine, University of Minnesota, Minneapolis
| | - Barbara B. Haley
- Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas
| | | | | | - Amy S. Clark
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | | | - Rita Nanda
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, Illinois
| | - Hyo S. Han
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Rachel L. Yung
- Department of Medicine, School of Medicine, University of Washington, Seattle
| | - Debasish Tripathy
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Rebecca K. Viscusi
- Department of Surgery, University of Arizona College of Medicine, Tucson
| | | | - Qamar J. Khan
- Division of Medical Oncology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City
| | - Smita M. Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | | | - Ruixiao Lu
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | - William Fraser Symmans
- Division of Pathology and Laboratory Medicine, Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Douglas Yee
- Division of Hematology-Oncology, Department of Medicine, University of Minnesota, Minneapolis
| | - Angela M. DeMichele
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Laura J. van ’t Veer
- Department of Laboratory Medicine, University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco
| | | | - Olufunmilayo I. Olopade
- Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, Illinois
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Andreassen MMS, Loubrie S, Tong MW, Fang L, Seibert TM, Wallace AM, Zare S, Ojeda-Fournier H, Kuperman J, Hahn M, Jerome NP, Bathen TF, Rodríguez-Soto AE, Dale AM, Rakow-Penner R. Restriction spectrum imaging with elastic image registration for automated evaluation of response to neoadjuvant therapy in breast cancer. Front Oncol 2023; 13:1237720. [PMID: 37781199 PMCID: PMC10541212 DOI: 10.3389/fonc.2023.1237720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/08/2023] [Indexed: 10/03/2023] Open
Abstract
Purpose Dynamic contrast-enhanced MRI (DCE) and apparent diffusion coefficient (ADC) are currently used to evaluate treatment response of breast cancer. The purpose of the current study was to evaluate the three-component Restriction Spectrum Imaging model (RSI3C), a recent diffusion-weighted MRI (DWI)-based tumor classification method, combined with elastic image registration, to automatically monitor breast tumor size throughout neoadjuvant therapy. Experimental design Breast cancer patients (n=27) underwent multi-parametric 3T MRI at four time points during treatment. Elastically-registered DWI images were used to generate an automatic RSI3C response classifier, assessed against manual DCE tumor size measurements and mean ADC values. Predictions of therapy response during treatment and residual tumor post-treatment were assessed using non-pathological complete response (non-pCR) as an endpoint. Results Ten patients experienced pCR. Prediction of non-pCR using ROC AUC (95% CI) for change in measured tumor size from pre-treatment time point to early-treatment time point was 0.65 (0.38-0.92) for the RSI3C classifier, 0.64 (0.36-0.91) for DCE, and 0.45 (0.16-0.75) for change in mean ADC. Sensitivity for detection of residual disease post-treatment was 0.71 (0.44-0.90) for the RSI3C classifier, compared to 0.88 (0.64-0.99) for DCE and 0.76 (0.50-0.93) for ADC. Specificity was 0.90 (0.56-1.00) for the RSI3C classifier, 0.70 (0.35-0.93) for DCE, and 0.50 (0.19-0.81) for ADC. Conclusion The automatic RSI3C classifier with elastic image registration suggested prediction of response to treatment after only three weeks, and showed performance comparable to DCE for assessment of residual tumor post-therapy. RSI3C may guide clinical decision-making and enable tailored treatment regimens and cost-efficient evaluation of neoadjuvant therapy of breast cancer.
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Affiliation(s)
- Maren M. Sjaastad Andreassen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Oncology, Vestre Viken, Drammen, Norway
| | - Stephane Loubrie
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
| | - Michelle W. Tong
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
| | - Lauren Fang
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
| | - Tyler M. Seibert
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Anne M. Wallace
- Department of Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Somaye Zare
- Department of Pathology, University of California, San Diego, La Jolla, CA, United States
| | - Haydee Ojeda-Fournier
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
| | - Joshua Kuperman
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
| | - Michael Hahn
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
| | - Neil P. Jerome
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tone F. Bathen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Radiology and Nuclear Medicine, St. Olav’s University Hospital, Trondheim, Norway
| | - Ana E. Rodríguez-Soto
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
| | - Anders M. Dale
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Rebecca Rakow-Penner
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
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4
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Parker BA, Shatsky RA, Schwab RB, Wallace AM, Wolf DM, Hirst GL, Brown-Swigart L, Esserman LJ, van 't Veer LJ, Ghia EM, Yau C, Kipps TJ. Association of baseline ROR1 and ROR2 gene expression with clinical outcomes in the I-SPY2 neoadjuvant breast cancer trial. Breast Cancer Res Treat 2023; 199:281-291. [PMID: 37029329 PMCID: PMC10175386 DOI: 10.1007/s10549-023-06914-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 03/12/2023] [Indexed: 04/09/2023]
Abstract
PURPOSE ROR1 and ROR2 are Type 1 tyrosine kinase-like orphan receptors for Wnt5a that are associated with breast cancer progression. Experimental agents targeting ROR1 and ROR2 are in clinical trials. This study evaluated whether expression levels of ROR1 or ROR2 correlated with one another or with clinical outcomes. METHODS We interrogated the clinical significance of high-level gene expression of ROR1 and/or ROR2 in the annotated transcriptome dataset from 989 patients with high-risk early breast cancer enrolled in one of nine completed/graduated/experimental and control arms in the neoadjuvant I-SPY2 clinical trial (NCT01042379). RESULTS High ROR1 or high ROR2 was associated with breast cancer subtypes. High ROR1 was more prevalent among hormone receptor-negative and human epidermal growth factor receptor 2-negative (HR-HER2-) tumors and high ROR2 was less prevalent in this subtype. Although not associated with pathologic complete response, high ROR1 or high ROR2 each was associated with event-free survival (EFS) in distinct subtypes. High ROR1 associated with a worse EFS in HR + HER2- patients with high post-treatment residual cancer burden (RCB-II/III) (HR 1.41, 95% CI = 1.11-1.80) but not in patients with minimal post-treatment disease (RCB-0/I) (HR 1.85, 95% CI = 0.74-4.61). High ROR2 associated with an increased risk of relapse in patients with HER2 + disease and RCB-0/I (HR 3.46, 95% CI = 1.33-9.020) but not RCB-II/III (HR 1.07, 95% CI = 0.69-1.64). CONCLUSION High ROR1 or high ROR2 distinctly identified subsets of breast cancer patients with adverse outcomes. Further studies are warranted to determine if high ROR1 or high ROR2 may identify high-risk populations for studies of targeted therapies.
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Affiliation(s)
- Barbara A Parker
- Department of Medicine and Moores Cancer Center, University of California San Diego, La Jolla, CA, 92093, USA.
| | - Rebecca A Shatsky
- Department of Medicine and Moores Cancer Center, University of California San Diego, La Jolla, CA, 92093, USA
| | - Richard B Schwab
- Department of Medicine and Moores Cancer Center, University of California San Diego, La Jolla, CA, 92093, USA
| | - Anne M Wallace
- Department of Surgery and Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Denise M Wolf
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gillian L Hirst
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Lamorna Brown-Swigart
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Laura J Esserman
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Laura J van 't Veer
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Emanuela M Ghia
- Department of Medicine and Moores Cancer Center, University of California San Diego, La Jolla, CA, 92093, USA
- Center for Novel Therapeutics, University of California San Diego, La Jolla, CA, USA
| | - Christina Yau
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Thomas J Kipps
- Department of Medicine and Moores Cancer Center, University of California San Diego, La Jolla, CA, 92093, USA
- Center for Novel Therapeutics, University of California San Diego, La Jolla, CA, USA
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O'Keefe TJ, Wallace AM. Prognostic Significance of Residual Ductal Carcinoma In Situ After Complete Response of Invasive Breast Cancer to Neoadjuvant Therapy. JAMA Surg 2023:2801768. [PMID: 36811893 DOI: 10.1001/jamasurg.2022.8238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- Thomas J O'Keefe
- The Comprehensive Breast Health Center, Division of Breast Surgery, University of California, San Diego, La Jolla
| | - Anne M Wallace
- The Comprehensive Breast Health Center, Division of Breast Surgery, University of California, San Diego, La Jolla
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O'Keefe TJ, Harismendy O, Wallace AM. Bilateral mastectomy associated with higher breast cancer mortality among patients with estrogen receptor positive progesterone receptor negative localized breast cancer. Chin Clin Oncol 2023; 12:3. [PMID: 36922359 DOI: 10.21037/cco-22-87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/16/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Rates of mastectomy for patients with localized breast cancer remain high despite decades of evidence that breast conservation therapy is equally effective. The impact of progesterone receptor (PR) status on the relative efficacy of surgical extent for localized estrogen receptor (ER) positive breast cancer on breast cancer mortality has not been studied. METHODS This retrospective cohort study included patients diagnosed with breast cancer between 1998 and 2015 using data from the Surveillance, Epidemiology and End Results (SEER) program. Female patients aged 40-70 with T1-2N0M0 ER positive breast cancer were included. Patients in this study either underwent lumpectomy without radiation, lumpectomy with radiation, unilateral mastectomy without radiation, or bilateral mastectomy without radiation for their disease. Breast cancer specific mortality was the main outcome of interest, calculated using competing risks methods to estimate cumulative incidence and hazard ratios among the treatment groups. RESULTS After one-to-one matching, 23,080 patients were included with median follow-up time 7.6 years (interquartile range, 4.0-8.3 years). Median age at diagnosis was 52 years (interquartile range, 47-59 years). Among patients, 19,996 (86.6%) had PR+ disease and 3,084 (13.4%) of patients had PR-. Among patients with PR- disease, bilateral mastectomy was associated with higher cumulative incidence of breast cancer mortality relative to patients undergoing lumpectomy with radiation, with 10-year cumulative incidences of 9.2% [95% confidence interval (CI): 6.6-12.7%] vs. 4.4% (95% CI: 3.0-6.6%). This difference was significant in the adjusted multivariate model [hazard ratio (HR) =1.77; 95% CI: 1.12-2.82; P=0.02]. CONCLUSIONS Bilateral mastectomy was associated with significantly increased risk of breast cancer mortality relative to lumpectomy with radiation for patients with PR- disease. Unilateral mastectomy and lumpectomy without radiation were associated with increased risk for breast cancer mortality relative to lumpectomy with radiation for patients with PR+ disease.
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Affiliation(s)
- Thomas J O'Keefe
- Division of Breast Surgery and The Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA, USA
| | - Olivier Harismendy
- Division of Biomedical Informatics, Department of Medicine, and Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Anne M Wallace
- Division of Breast Surgery and The Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA, USA
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7
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O'Keefe TJ, Chau H, Harismendy O, Wallace AM. Risk factors for breast cancer mortality after ductal carcinoma in situ diagnosis differ from those for invasive recurrence. Surgery 2023; 173:305-311. [PMID: 36435650 DOI: 10.1016/j.surg.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 09/12/2022] [Accepted: 10/06/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Breast cancer mortality after ductal carcinoma in situ is rare, making it difficult to predict which patients are at risk and to identify whether risk factors for this outcome are the same as those for invasive recurrence. We aimed to identify whether risk factors for invasive recurrences are similar to those for breast cancer death after a diagnosis of pure ductal carcinoma in situ. METHODS The Surveillance, Epidemiology, and End Results Program was queried for female patients diagnosed with pure ductal carcinoma in situ. Cumulative incidence was estimated by treatment group using competing risks. Competing risks regression was then performed for the development of in-breast invasive recurrence with competing risks of breast and non-breast cancer death. Competing risks regression was then again performed for development of breast cancer mortality with the competing risk of non-breast cancer death. RESULTS A total of 29,515 patients were identified. Of them, 164 patients suffered breast cancer mortality without an intervening invasive recurrence, and 44 suffered breast cancer mortality after an invasive in-breast recurrence. On competing risks analysis for invasive in-breast recurrence, significant factors included lesion size >5 cm (hazard ratio = 1.59, 95% confidence interval 1.24-2.04, P < .001), diffuse disease (hazard ratio = 0.0005, 95% confidence interval 0.0003-0.0007, P < .001), other race (hazard ratio = 1.29, 95% confidence interval 1.10-1.52, P = .002), Black race (hazard ratio = 1.21, 95% confidence interval 1.01-1.46, P = .04), age at diagnosis (hazard ratio = 0.99, confidence interval 0.98-1.00, P = .02), low-grade disease (hazard ratio = 0.79, 95% confidence interval 0.64-0.96, P = .02), lumpectomy with radiation (hazard ratio = 0.67, 95% confidence interval 0.58-0.77, P < .001), and mastectomy (hazard ratio = 0.36, 95% confidence interval 0.30-0.44, P < .001). Significant factors for breast cancer mortality included age at diagnosis (hazard ratio = 1.04, 95% confidence interval 1.03-1.05, P < .001), Black race (hazard ratio = 2.88, 95% confidence interval 2.08-3.99, P < .001), diffuse disease (hazard ratio = 6.02, 95% confidence interval 1.39-26.07, P = .02), lumpectomy with radiation (hazard ratio = 0.51, 95% confidence interval 0.36-0.72, P < .001), and mastectomy (hazard ratio = 0.60, 95% confidence interval 0.50-0.92, P = .02). CONCLUSION Our results suggested that risk factors for in-breast invasive recurrence after a diagnosis of pure ductal carcinoma in situ differ from risk factors for breast cancer mortality and development of metastatic recurrence. In-breast invasive recurrence is not the only consideration for breast cancer specific mortality in ductal carcinoma in situ patients.
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Affiliation(s)
- Thomas J O'Keefe
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA.
| | - Harrison Chau
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA
| | - Olivier Harismendy
- Moores Cancer Center and Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA
| | - Anne M Wallace
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA
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Ilfeld BM, Said ET, Gabriel RA, Curran BP, Swisher MW, Jacobsen GR, Wallace AM, Doucet J, Adams LM, Ventro GJ, Abdullah B, Finneran JJ. Wearable, noninvasive, pulsed shortwave (radiofrequency) therapy for analgesia and opioid sparing following outpatient surgery: A proof-of-concept case series. Pain Pract 2022. [PMID: 36463434 DOI: 10.1111/papr.13188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/15/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND It is often difficult to concurrently provide adequate analgesia while minimizing opioid requirements following ambulatory surgery. Nonthermal, pulsed shortwave (radiofrequency) fields are a noninvasive treatment used as an adjunct analgesic and wound healing therapy. The devices may be placed by nursing staff in less than a minute, are relatively inexpensive and readily available, theoretically provide analgesia for nearly any anatomic location, and have no systemic side effects-patients cannot detect any sensations from the devices-or significant risks. Here we present a case series to demonstrate the use of pulsed, electromagnetic field devices for outpatient herniorrhaphy and breast surgery. CASE REPORT Following moderately painful ambulatory umbilical (n = 3) and inguinal (n = 2) hernia repair as well as bilateral breast surgery (n = 2), patients had taped over their surgical incision(s) 1 or 2 noninvasive, wearable, disposable, pulsed shortwave therapy devices (RecoveryRx, BioElectronics Corporation, Frederick, Maryland) which functioned continuously for 30 days. Average resting pain scores measured on the 0-10 numeric rating scale were a median of 0 during the entire treatment period. Six patients avoided opioid use entirely, while the remaining individual required only 5 mg of oxycodone during the first postoperative day. CONCLUSIONS These cases demonstrate that the ambulatory use of pulsed shortwave devices is feasible and may be an effective analgesic, possibly obviating opioid requirements following outpatient herniorrhaphy and breast surgery. Considering the lack of any side effects, adverse events, and misuse/dependence/diversion potential, further study with a randomized, controlled trial appears warranted.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anaesthesiology, University of California San Diego, California, USA.,Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Engy T Said
- Department of Anaesthesiology, University of California San Diego, California, USA
| | - Rodney A Gabriel
- Department of Anaesthesiology, University of California San Diego, California, USA.,Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Brian P Curran
- Department of Anaesthesiology, University of California San Diego, California, USA
| | - Matthew W Swisher
- Department of Anaesthesiology, University of California San Diego, California, USA.,Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Garth R Jacobsen
- Department of Surgery, University of California San Diego, California, USA
| | - Anne M Wallace
- Department of Surgery, University of California San Diego, California, USA
| | - Jay Doucet
- Department of Surgery, University of California San Diego, California, USA
| | - Laura M Adams
- Department of Surgery, University of California San Diego, California, USA
| | - George J Ventro
- Department of Surgery, University of California San Diego, California, USA
| | - Baharin Abdullah
- Department of Anaesthesiology, University of California San Diego, California, USA
| | - John J Finneran
- Department of Anaesthesiology, University of California San Diego, California, USA.,Outcomes Research Consortium, Cleveland, Ohio, USA
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9
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Lang JE, Forero-Torres A, Yee D, Yau C, Wolf D, Park J, Parker BA, Chien AJ, Wallace AM, Murthy R, Albain KS, Ellis ED, Beckwith H, Haley BB, Elias AD, Boughey JC, Yung RL, Isaacs C, Clark AS, Han HS, Nanda R, Khan QJ, Edmiston KK, Stringer-Reasor E, Price E, Joe B, Liu MC, Brown-Swigart L, Petricoin EF, Wulfkuhle JD, Buxton M, Clennell JL, Sanil A, Berry S, Asare SM, Wilson A, Hirst GL, Singhrao R, Asare AL, Matthews JB, Melisko M, Perlmutter J, Rugo HS, Symmans WF, van 't Veer LJ, Hylton NM, DeMichele AM, Berry DA, Esserman LJ. Safety and efficacy of HSP90 inhibitor ganetespib for neoadjuvant treatment of stage II/III breast cancer. NPJ Breast Cancer 2022; 8:128. [PMID: 36456573 PMCID: PMC9715670 DOI: 10.1038/s41523-022-00493-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/10/2022] [Indexed: 12/03/2022] Open
Abstract
HSP90 inhibitors destabilize oncoproteins associated with cell cycle, angiogenesis, RAS-MAPK activity, histone modification, kinases and growth factors. We evaluated the HSP90-inhibitor ganetespib in combination with standard chemotherapy in patients with high-risk early-stage breast cancer. I-SPY2 is a multicenter, phase II adaptively randomized neoadjuvant (NAC) clinical trial enrolling patients with stage II-III breast cancer with tumors 2.5 cm or larger on the basis of hormone receptors (HR), HER2 and Mammaprint status. Multiple novel investigational agents plus standard chemotherapy are evaluated in parallel for the primary endpoint of pathologic complete response (pCR). Patients with HER2-negative breast cancer were eligible for randomization to ganetespib from October 2014 to October 2015. Of 233 women included in the final analysis, 140 were randomized to the standard NAC control; 93 were randomized to receive 150 mg/m2 ganetespib every 3 weeks with weekly paclitaxel over 12 weeks, followed by AC. Arms were balanced for hormone receptor status (51-52% HR-positive). Ganetespib did not graduate in any of the biomarker signatures studied before reaching maximum enrollment. Final estimated pCR rates were 26% vs. 18% HER2-negative, 38% vs. 22% HR-negative/HER2-negative, and 15% vs. 14% HR-positive/HER2-negative for ganetespib vs control, respectively. The predicted probability of success in phase 3 testing was 47% HER2-negative, 72% HR-negative/HER2-negative, and 19% HR-positive/HER2-negative. Ganetespib added to standard therapy is unlikely to yield substantially higher pCR rates in HER2-negative breast cancer compared to standard NAC, and neither HSP90 pathway nor replicative stress expression markers predicted response. HSP90 inhibitors remain of limited clinical interest in breast cancer, potentially in other clinical settings such as HER2-positive disease or in combination with anti-PD1 neoadjuvant chemotherapy in triple negative breast cancer.Trial registration: www.clinicaltrials.gov/ct2/show/NCT01042379.
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Affiliation(s)
- Julie E Lang
- University of Southern California, Los Angeles, USA.
| | | | | | - Christina Yau
- University of California San Francisco, San Francisco, USA
| | - Denise Wolf
- University of California San Francisco, San Francisco, USA
| | - John Park
- University of California San Francisco, San Francisco, USA
| | | | - A Jo Chien
- University of California San Francisco, San Francisco, USA
| | - Anne M Wallace
- University of California San Francisco, San Francisco, USA
| | - Rashmi Murthy
- University of Texas MD Anderson Cancer Center, Houston, USA
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Maywood, USA
| | | | | | | | | | | | | | | | - Amy S Clark
- University of Pennsylvania, Philadelphia, USA
| | | | | | | | | | | | - Elissa Price
- University of California San Francisco, San Francisco, USA
| | - Bonnie Joe
- University of California San Francisco, San Francisco, USA
| | | | | | | | | | | | | | | | | | - Smita M Asare
- Quantum Leap Healthcare Collaborative, San Francisco, USA
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, USA
| | | | - Ruby Singhrao
- University of California San Francisco, San Francisco, USA
| | - Adam L Asare
- Quantum Leap Healthcare Collaborative, San Francisco, USA
| | | | | | | | - Hope S Rugo
- University of California San Francisco, San Francisco, USA
| | | | | | - Nola M Hylton
- University of California San Francisco, San Francisco, USA
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10
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Osdoit M, Yau C, Symmans WF, Boughey JC, Ewing CA, Balassanian R, Chen YY, Krings G, Wallace AM, Zare S, Fadare O, Lancaster R, Wei S, Godellas CV, Tang P, Tuttle TM, Klein M, Sahoo S, Hieken TJ, Carter JM, Chen B, Ahrendt G, Tchou J, Feldman M, Tousimis E, Zeck J, Jaskowiak N, Sattar H, Naik AM, Lee MC, Rosa M, Khazai L, Rendi MH, Lang JE, Lu J, Tawfik O, Asare SM, Esserman LJ, Mukhtar RA. Association of Residual Ductal Carcinoma In Situ With Breast Cancer Recurrence in the Neoadjuvant I-SPY2 Trial. JAMA Surg 2022; 157:1034-1041. [PMID: 36069821 PMCID: PMC9453630 DOI: 10.1001/jamasurg.2022.4118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
Importance Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in breast cancer strongly correlates with overall survival and has become the standard end point in neoadjuvant trials. However, there is controversy regarding whether the definition of pCR should exclude or permit the presence of residual ductal carcinoma in situ (DCIS). Objective To examine the association of residual DCIS in surgical specimens after neoadjuvant chemotherapy for breast cancer with survival end points to inform standards for the assessment of pathologic complete response. Design, Setting, and Participants The study team analyzed the association of residual DCIS after NAC with 3-year event-free survival (EFS), distant recurrence-free survival (DRFS), and local-regional recurrence (LRR) in the I-SPY2 trial, an adaptive neoadjuvant platform trial for patients with breast cancer at high risk of recurrence. This is a retrospective analysis of clinical specimens and data from the ongoing I-SPY2 adaptive platform trial of novel therapeutics on a background of standard of care for early breast cancer. I-SPY2 participants are adult women diagnosed with stage II/III breast cancer at high risk of recurrence. Interventions Participants were randomized to receive taxane and anthracycline-based neoadjuvant therapy with or without 1 of 10 investigational agents, followed by definitive surgery. Main Outcomes and Measures The presence of DCIS and EFS, DRFS, and LRR. Results The study team identified 933 I-SPY2 participants (aged 24 to 77 years) with complete pathology and follow-up data. Median follow-up time was 3.9 years; 337 participants (36%) had no residual invasive disease (residual cancer burden 0, or pCR). Of the 337 participants with pCR, 70 (21%) had residual DCIS, which varied significantly by tumor-receptor subtype; residual DCIS was present in 8.5% of triple negative tumors, 15.6% of hormone-receptor positive tumors, and 36.6% of ERBB2-positive tumors. Among those participants with pCR, there was no significant difference in EFS, DRFS, or LRR based on presence or absence of residual DCIS. Conclusions and Relevance The analysis supports the definition of pCR as the absence of invasive disease after NAC regardless of the presence or absence of DCIS. Trial Registration ClinicalTrials.gov Identifier NCT01042379.
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MESH Headings
- Adult
- Female
- Humans
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Neoadjuvant Therapy
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm, Residual/drug therapy
- Receptor, ErbB-2
- Retrospective Studies
- Young Adult
- Middle Aged
- Aged
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Affiliation(s)
- Marie Osdoit
- Department of Surgery, University of California San Francisco, San Francisco
| | - Christina Yau
- Department of Surgery, University of California San Francisco, San Francisco
| | - W. Fraser Symmans
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston
| | | | - Cheryl A. Ewing
- Department of Surgery, University of California San Francisco, San Francisco
| | - Ron Balassanian
- Department of Pathology, University of California San Francisco, San Francisco
| | - Yunn-Yi Chen
- Department of Pathology, University of California San Francisco, San Francisco
| | - Gregor Krings
- Department of Pathology, University of California San Francisco, San Francisco
| | - Anne M Wallace
- Department of Surgery, University of California San Diego, La Jolla
| | - Somaye Zare
- Department of Pathology, University of California San Diego, La Jolla
| | - Oluwole Fadare
- Department of Pathology, University of California San Diego, La Jolla
| | - Rachael Lancaster
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Shi Wei
- Department of Pathology, University of Alabama at Birmingham
| | - Constantine V. Godellas
- Department of Surgery, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Ping Tang
- Department of Pathology, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Todd M Tuttle
- Department of Surgery, University of Minnesota, Minneapolis
| | - Molly Klein
- Laboratory Medicine and Pathology, Masonic Cancer Center, Minneapolis, Minnesota
| | - Sunati Sahoo
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Tina J. Hieken
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jodi M. Carter
- Laboratory Medicine and Pathology, May Clinic, Rochester, Minnesota
| | - Beiyun Chen
- Laboratory Medicine and Pathology, May Clinic, Rochester, Minnesota
| | | | - Julia Tchou
- Department of Surgery, University of Pennsylvania, Philadelphia
| | - Michael Feldman
- Pathology & Laboratory Medicine, University of Pennsylvania, Philadelphia
| | - Eleni Tousimis
- Department of Surgery, Georgetown University, Washington, DC
| | - Jay Zeck
- Pathology and Laboratory Medicine, Georgetown University, Washington, DC
| | | | - Husain Sattar
- Department of Pathology, University of Chicago, Illinois
| | - Arpana M. Naik
- Department of Surgery, Oregon Health & Science University, Portland
| | | | - Marilin Rosa
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Laila Khazai
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Mara H. Rendi
- Department of Pathology, University of Washington, Seattle
| | - Julie E. Lang
- Department of Surgery, University of Southern California, Los Angeles
| | - Janice Lu
- Department of Medicine, University of Southern California, Los Angeles
| | - Ossama Tawfik
- Department of Pathology, University of Kansas, Kansas City
| | | | - Laura J. Esserman
- Department of Surgery, University of California San Francisco, San Francisco
| | - Rita A. Mukhtar
- Department of Surgery, University of California San Francisco, San Francisco
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11
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Besser AH, Fang LK, Tong MW, Sjaastad Andreassen MM, Ojeda-Fournier H, Conlin CC, Loubrie S, Seibert TM, Hahn ME, Kuperman JM, Wallace AM, Dale AM, Rodríguez-Soto AE, Rakow-Penner RA. Tri-Compartmental Restriction Spectrum Imaging Breast Model Distinguishes Malignant Lesions from Benign Lesions and Healthy Tissue on Diffusion-Weighted Imaging. Cancers (Basel) 2022; 14:cancers14133200. [PMID: 35804972 PMCID: PMC9264763 DOI: 10.3390/cancers14133200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/25/2022] [Accepted: 06/27/2022] [Indexed: 02/02/2023] Open
Abstract
Diffusion-weighted MRI (DW-MRI) offers a potential adjunct to dynamic contrast-enhanced MRI to discriminate benign from malignant breast lesions by yielding quantitative information about tissue microstructure. Multi-component modeling of the DW-MRI signal over an extended b-value range (up to 3000 s/mm2) theoretically isolates the slowly diffusing (restricted) water component in tissues. Previously, a three-component restriction spectrum imaging (RSI) model demonstrated the ability to distinguish malignant lesions from healthy breast tissue. We further evaluated the utility of this three-component model to differentiate malignant from benign lesions and healthy tissue in 12 patients with known malignancy and synchronous pathology-proven benign lesions. The signal contributions from three distinct diffusion compartments were measured to generate parametric maps corresponding to diffusivity on a voxel-wise basis. The three-component model discriminated malignant from benign and healthy tissue, particularly using the restricted diffusion C1 compartment and product of the restricted and intermediate diffusion compartments (C1 and C2). However, benign lesions and healthy tissue did not significantly differ in diffusion characteristics. Quantitative discrimination of these three tissue types (malignant, benign, and healthy) in non-pre-defined lesions may enhance the clinical utility of DW-MRI in reducing excessive biopsies and aiding in surveillance and surgical evaluation without repeated exposure to gadolinium contrast.
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Affiliation(s)
- Alexandra H. Besser
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
| | - Lauren K. Fang
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
| | - Michelle W. Tong
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
| | - Maren M. Sjaastad Andreassen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Postboks 8905, 7491 Trondheim, Norway;
| | - Haydee Ojeda-Fournier
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
| | - Christopher C. Conlin
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
| | - Stéphane Loubrie
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
| | - Tyler M. Seibert
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
- Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, CA 92093, USA
- Department of Bioengineering, University of California-San Diego, La Jolla, CA 92093, USA
| | - Michael E. Hahn
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
| | - Joshua M. Kuperman
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
| | - Anne M. Wallace
- Department of Surgery, University of California-San Diego, La Jolla, CA 92093, USA;
| | - Anders M. Dale
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
- Department of Neuroscience, University of California-San Diego, La Jolla, CA 92093, USA
| | - Ana E. Rodríguez-Soto
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
| | - Rebecca A. Rakow-Penner
- Department of Radiology, University of California-San Diego, La Jolla, CA 92093, USA; (A.H.B.); (L.K.F.); (M.W.T.); (H.O.-F.); (C.C.C.); (S.L.); (T.M.S.); (M.E.H.); (J.M.K.); (A.M.D.); (A.E.R.-S.)
- Department of Bioengineering, University of California-San Diego, La Jolla, CA 92093, USA
- Correspondence:
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12
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Ilfeld BM, Finneran Iv JJ, Dalstrom D, Wallace AM, Abdullah B, Said ET. Percutaneous auricular nerve stimulation (neuromodulation) for the treatment of pain following outpatient surgery: a proof-of-concept case series. Reg Anesth Pain Med 2022; 47:rapm-2022-103777. [PMID: 35715011 PMCID: PMC9340022 DOI: 10.1136/rapm-2022-103777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Following outpatient surgery, it is often difficult to provide adequate analgesia while concurrently minimizing opioid requirements. Ultrasound-guided percutaneous peripheral nerve stimulation has been proposed as an analgesic, but requires physician-level skills, advanced equipment, up to an hour to administer, and is frequently cost prohibitive. In contrast, percutaneous auricular neuromodulation may be placed by nursing staff in a few minutes without additional equipment, theoretically provides analgesia for nearly any anatomic location, lacks systemic side effects, and has no significant risks. We now present a case report to demonstrate proof of concept for the off-label use of an auricular neuromodulation device-originally developed to treat symptoms associated with opioid withdrawal-to instead provide analgesia following outpatient surgery. CASE PRESENTATION Following moderately painful ambulatory orthopedic and breast surgery, seven patients had an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) affixed within the recovery room in approximately 5 min and discharged home. Average resting and dynamic pain scores measured on the 0-10 Numeric Rating Scale were a median of 1 over the first 2 days, subsequently falling to 0. Five patients avoided opioid use entirely, while the remaining two each consumed 5 mg of oxycodone during the first 1-2 postoperative days. After 5 days, the devices were removed at home and discarded. CONCLUSIONS These cases demonstrate that ambulatory percutaneous auricular neuromodulation is feasible and may be an effective analgesic and decreasing or even negating opioid requirements following outpatient surgery. Considering the lack of systemic side effects, serious adverse events, and misuse/dependence/diversion potential, further study with a randomized, controlled trial appears warranted.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - John J Finneran Iv
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - David Dalstrom
- Department of Orthopedic Surgery, University of California San Diego, La Jolla, California, USA
| | - Anne M Wallace
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Baharin Abdullah
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
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13
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Dolendo IM, Wallace AM, Armani A, Waterman RS, Said ET, Gabriel RA. Predictive Analytics for Inpatient Postoperative Opioid Use in Patients Undergoing Mastectomy. Cureus 2022; 14:e23079. [PMID: 35464574 PMCID: PMC9001875 DOI: 10.7759/cureus.23079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: The use of opioids in mastectomy patients is a particular challenge, having to balance the management of acute pain while minimizing risks of continuous opioid use postoperatively. Despite attempts to decrease postmastectomy opioid use, including regional anesthetics, gabapentinoids, topical anesthetics, and nonopioid anesthesia, prolonged opioid use remains clinically significant among these patients. The goal of this study is to identify risk factors and develop machine-learning-based models to predict patients who are at higher risk for postoperative opioid use after mastectomy. Methods: In this retrospective cohort study, we collected data from patients that underwent mastectomy procedures. The primary outcome of interest was defined as oxycodone milligram equivalents (OME) greater than or equal to the 75% of OME use on a postoperative day 1. Model performance (area under the receiver-operating characteristics curve (AUC)) of various machine learning approaches was calculated via 10-fold cross-validation. Odds ratio (OR) and 95% confidence intervals (CI) were reported. Results: There were a total of 148 patients that underwent mastectomy and were included. The medium (quartiles) postoperative day 1 opioid use was 5 mg OME (0.25 mg OME). Using multivariable logistic regression, the most protective factors against higher opioid use was being postmenopausal (OR: 0.13, 95% CI: 0.03-0.61, p = 0.009) and cancer diagnosis (OR: 0.19, 95% CI: 0.05-0.73, p = 0.01). The AUC was 0.725 (95% CI: 0.572-0.876). There was no difference in the performance of other machine-learning-based approaches. Conclusions: The ability to predict patients’ postoperative pain could have a significant impact on preoperative counseling and patient satisfaction.
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14
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O'Keefe TJ, Harismendy O, Wallace AM. Large and diffuse ductal carcinoma in situ: potentially lethal subtypes of "preinvasive" disease. Int J Clin Oncol 2022; 27:121-130. [PMID: 34618239 PMCID: PMC10874643 DOI: 10.1007/s10147-021-02036-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/17/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Trials for DCIS have not explored whether outcomes for patients with large disease burden requiring mastectomy are comparable to those of patients with lumpectomy-amenable disease. We aim to identify whether patients with DCIS larger than 5 cm and diffuse-type DCIS differ in breast cancer mortality (BCM) from patients with disease less than 5 cm. METHODS Patients diagnosed with DCIS in the SEER program were assessed to identify factors prognostic of breast-cancer-specific survival using competing risks regression. RESULTS 44,849 patients met criteria for the cumulative incidence estimate. On competing risks cumulative incidence approximation, the 10-year estimate for BCM for each group was 1.3%, 1.3%, 2.3%, and 5.1%, respectively, and the difference among groups was significant (p = 0.017). On competing risks regression of patients with known covariates, both diffuse-type disease and disease larger than 5 cm (hazard ratio [HR] = 6.2 and 1.7, p = 0.013 and p = 0.042, respectively) were associated with increased risk of BCM. After matching, DCIS > 5 cm and diffuse disease were associated with increased BCM relative to disease < 5 cm (HR = 1.69, p = 0.04). Among patients undergoing mastectomy for disease larger than 5 cm or diffuse disease, the 10-year cumulative incidence for BCM was 0.5% among patients undergoing bilateral mastectomy and 2.4% for patients undergoing unilateral mastectomy. CONCLUSION Patients with large and diffuse DCIS represent uncommon but poorly studied DCIS subgroups with worse prognoses than patients with disease smaller than 5 cm. Further studies are needed to elucidate the appropriate treatment for these patients.
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Affiliation(s)
- Thomas J O'Keefe
- Division of Breast Surgery and The Comprehensive Breast Health Center, University of California San Diego, 0819, 3855 Health Sciences Dr, La Jolla, CA, 92037, USA.
| | - Olivier Harismendy
- Division of Biomedical Informatics, Department of Medicine, Moores Cancer Center, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA, 92037, USA
| | - Anne M Wallace
- Division of Breast Surgery and The Comprehensive Breast Health Center, University of California San Diego, 0819, 3855 Health Sciences Dr, La Jolla, CA, 92037, USA
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15
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Rodríguez-Soto AE, Andreassen MMS, Fang LK, Conlin CC, Park HH, Ahn GS, Bartsch H, Kuperman J, Vidić I, Ojeda-Fournier H, Wallace AM, Hahn M, Seibert TM, Jerome NP, Østlie A, Bathen TF, Goa PE, Rakow-Penner R, Dale AM. Characterization of the diffusion signal of breast tissues using multi-exponential models. Magn Reson Med 2021; 87:1938-1951. [PMID: 34904726 DOI: 10.1002/mrm.29090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/12/2021] [Accepted: 11/01/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Restriction spectrum imaging (RSI) decomposes the diffusion-weighted MRI signal into separate components of known apparent diffusion coefficients (ADCs). The number of diffusion components and optimal ADCs for RSI are organ-specific and determined empirically. The purpose of this work was to determine the RSI model for breast tissues. METHODS The diffusion-weighted MRI signal was described using a linear combination of multiple exponential components. A set of ADC values was estimated to fit voxels in cancer and control ROIs. Later, the signal contributions of each diffusion component were estimated using these fixed ADC values. Relative-fitting residuals and Bayesian information criterion were assessed. Contrast-to-noise ratio between cancer and fibroglandular tissue in RSI-derived signal contribution maps was compared to DCE imaging. RESULTS A total of 74 women with breast cancer were scanned at 3.0 Tesla MRI. The fitting residuals of conventional ADC and Bayesian information criterion suggest that a 3-component model improves the characterization of the diffusion signal over a biexponential model. Estimated ADCs of triexponential model were D1,3 = 0, D2,3 = 1.5 × 10-3 , and D3,3 = 10.8 × 10-3 mm2 /s. The RSI-derived signal contributions of the slower diffusion components were larger in tumors than in fibroglandular tissues. Further, the contrast-to-noise and specificity at 80% sensitivity of DCE and a subset of RSI-derived maps were equivalent. CONCLUSION Breast diffusion-weighted MRI signal was best described using a triexponential model. Tumor conspicuity in breast RSI model is comparable to that of DCE without the use of exogenous contrast. These data may be used as differential features between healthy and malignant breast tissues.
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Affiliation(s)
- Ana E Rodríguez-Soto
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Maren M Sjaastad Andreassen
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lauren K Fang
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Christopher C Conlin
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Helen H Park
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Grace S Ahn
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Hauke Bartsch
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Joshua Kuperman
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Igor Vidić
- Department of Physics, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Haydee Ojeda-Fournier
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Anne M Wallace
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Michael Hahn
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Tyler M Seibert
- Department of Radiation Oncology, University of California San Diego, La Jolla, California, USA.,Department of Bioengineering, University of California San Diego, La Jolla, California, USA
| | - Neil Peter Jerome
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Radiology and Nuclear Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Agnes Østlie
- Department of Radiology and Nuclear Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Tone Frost Bathen
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Radiology and Nuclear Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Pål Erik Goa
- Department of Physics, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Radiology and Nuclear Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Rebecca Rakow-Penner
- Department of Radiology, University of California San Diego, La Jolla, California, USA.,Department of Bioengineering, University of California San Diego, La Jolla, California, USA
| | - Anders M Dale
- Department of Radiology, University of California San Diego, La Jolla, California, USA
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16
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Clark AS, Yau C, Wolf DM, Petricoin EF, van 't Veer LJ, Yee D, Moulder SL, Wallace AM, Chien AJ, Isaacs C, Boughey JC, Albain KS, Kemmer K, Haley BB, Han HS, Forero-Torres A, Elias A, Lang JE, Ellis ED, Yung R, Tripathy D, Nanda R, Wulfkuhle JD, Brown-Swigart L, Gallagher RI, Helsten T, Roesch E, Ewing CA, Alvarado M, Crane EP, Buxton M, Clennell JL, Paoloni M, Asare SM, Wilson A, Hirst GL, Singhrao R, Steeg K, Asare A, Matthews JB, Berry S, Sanil A, Melisko M, Perlmutter J, Rugo HS, Schwab RB, Symmans WF, Hylton NM, Berry DA, Esserman LJ, DeMichele AM. Neoadjuvant T-DM1/pertuzumab and paclitaxel/trastuzumab/pertuzumab for HER2 + breast cancer in the adaptively randomized I-SPY2 trial. Nat Commun 2021; 12:6428. [PMID: 34741023 PMCID: PMC8571284 DOI: 10.1038/s41467-021-26019-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/10/2021] [Indexed: 12/02/2022] Open
Abstract
HER2-targeted therapy dramatically improves outcomes in early breast cancer. Here we report the results of two HER2-targeted combinations in the neoadjuvant I-SPY2 phase 2 adaptive platform trial for early breast cancer at high risk of recurrence: ado-trastuzumab emtansine plus pertuzumab (T-DM1/P) and paclitaxel, trastuzumab and pertuzumab (THP). Eligible women have >2.5 cm clinical stage II/III HER2+ breast cancer, adaptively randomized to T-DM1/P, THP, or a common control arm of paclitaxel/trastuzumab (TH), followed by doxorubicin/cyclophosphamide, then surgery. Both T-DM1/P and THP arms 'graduate' in all subtypes: predicted pCR rates are 63%, 72% and 33% for T-DM1/P (n = 52), THP (n = 45) and TH (n = 31) respectively. Toxicity burden is similar between arms. Degree of HER2 pathway signaling and phosphorylation in pretreatment biopsy specimens are associated with response to both T-DM1/P and THP and can further identify highly responsive HER2+ tumors to HER2-directed therapy. This may help identify patients who can safely de-escalate cytotoxic chemotherapy without compromising excellent outcome.
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Affiliation(s)
- Amy S Clark
- University of Pennsylvania, Philadelphia, PA, USA.
| | - Christina Yau
- University of California San Francisco, San Francisco, CA, USA
| | - Denise M Wolf
- University of California San Francisco, San Francisco, CA, USA
| | | | | | - Douglas Yee
- University of Minnesota, Minneapolis, MN, USA
| | | | | | - A Jo Chien
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | - Hyo S Han
- Moffitt Cancer Center, Tampa, FL, USA
| | | | | | - Julie E Lang
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | - Erin Roesch
- University of California San Diego, San Diego, CA, USA
| | - Cheryl A Ewing
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | - Smita M Asare
- University of California San Francisco, San Francisco, CA, USA
| | - Amy Wilson
- University of California San Francisco, San Francisco, CA, USA
| | - Gillian L Hirst
- University of California San Francisco, San Francisco, CA, USA
| | - Ruby Singhrao
- University of California San Francisco, San Francisco, CA, USA
| | - Katherine Steeg
- University of California San Francisco, San Francisco, CA, USA
| | - Adam Asare
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | - Hope S Rugo
- University of California San Francisco, San Francisco, CA, USA
| | | | | | - Nola M Hylton
- University of California San Francisco, San Francisco, CA, USA
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17
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Symmans WF, Yau C, Chen YY, Balassanian R, Klein ME, Pusztai L, Nanda R, Parker BA, Datnow B, Krings G, Wei S, Feldman MD, Duan X, Chen B, Sattar H, Khazai L, Zeck JC, Sams S, Mhawech-Fauceglia P, Rendi M, Sahoo S, Ocal IT, Fan F, LeBeau LG, Vinh T, Troxell ML, Chien AJ, Wallace AM, Forero-Torres A, Ellis E, Albain KS, Murthy RK, Boughey JC, Liu MC, Haley BB, Elias AD, Clark AS, Kemmer K, Isaacs C, Lang JE, Han HS, Edmiston K, Viscusi RK, Northfelt DW, Khan QJ, Leyland-Jones B, Venters SJ, Shad S, Matthews JB, Asare SM, Buxton M, Asare AL, Rugo HS, Schwab RB, Helsten T, Hylton NM, van 't Veer L, Perlmutter J, DeMichele AM, Yee D, Berry DA, Esserman LJ. Assessment of Residual Cancer Burden and Event-Free Survival in Neoadjuvant Treatment for High-risk Breast Cancer: An Analysis of Data From the I-SPY2 Randomized Clinical Trial. JAMA Oncol 2021; 7:1654-1663. [PMID: 34529000 DOI: 10.1001/jamaoncol.2021.3690] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Residual cancer burden (RCB) distributions may improve the interpretation of efficacy in neoadjuvant breast cancer trials. Objective To compare RCB distributions between randomized control and investigational treatments within subtypes of breast cancer and explore the relationship with survival. Design, Setting, and Participants The I-SPY2 is a multicenter, platform adaptive, randomized clinical trial in the US that compares, by subtype, investigational agents in combination with chemotherapy vs chemotherapy alone in adult women with stage 2/3 breast cancer at high risk of early recurrence. Investigational treatments graduated in a prespecified subtype if there was 85% or greater predicted probability of higher rate of pathologic complete response (pCR) in a confirmatory, 300-patient, 1:1 randomized, neoadjuvant trial in that subtype. Evaluation of a secondary end point was reported from the 10 investigational agents tested in the I-SPY2 trial from March 200 through 2016, and analyzed as of September 9, 2020. The analysis plan included modeling of RCB within subtypes defined by hormone receptor (HR) and ERBB2 status and compared control treatments with investigational treatments that graduated and those that did not graduate. Interventions Neoadjuvant paclitaxel plus/minus 1 of several investigational agents for 12 weeks, then 12 weeks of cyclophosphamide/doxorubicin chemotherapy followed by surgery. Main Outcomes and Measures Residual cancer burden (pathological measure of residual disease) and event-free survival (EFS). Results A total of 938 women (mean [SD] age, 49 [11] years; 66 [7%] Asian, 103 [11%] Black, and 750 [80%] White individuals) from the first 10 investigational agents were included, with a median follow-up of 52 months (IQR, 29 months). Event-free survival worsened significantly per unit of RCB in every subtype of breast cancer (HR-positive/ERBB2-negative: hazard ratio [HZR], 1.75; 95% CI, 1.45-2.16; HR-positive/ERBB2-positive: HZR, 1.55; 95% CI, 1.18-2.05; HR-negative/ERBB2-positive: HZR, 2.39; 95% CI, 1.64-3.49; HR-negative/ERBB2-negative: HZR, 1.99; 95% CI, 1.71-2.31). Prognostic information from RCB was similar from treatments that graduated (HZR, 2.00; 95% CI, 1.57-2.55; 254 [27%]), did not graduate (HZR, 1.87; 95% CI, 1.61-2.17; 486 [52%]), or were control (HZR, 1.79; 95% CI, 1.42-2.26; 198 [21%]). Investigational treatments significantly lowered RCB in HR-negative/ERBB2-negative (graduated and nongraduated treatments) and ERBB2-positive subtypes (graduated treatments), with improved EFS (HZR, 0.61; 95% CI, 0.41-0.93) in the exploratory analysis. Conclusions and Relevance In this randomized clinical trial, the prognostic significance of RCB was consistent regardless of subtype and treatment. Effective neoadjuvant treatments shifted the distribution of RCB in addition to increasing pCR rate and appeared to improve EFS. Using a standardized quantitative method to measure response advances the interpretation of efficacy. Trial Registration ClinicalTrials.gov Identifier: NCT01042379.
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Affiliation(s)
- W Fraser Symmans
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Christina Yau
- Department of Surgery, University of California, San Francisco
| | - Yunn-Yi Chen
- Department of Pathology, University of California, San Francisco
| | - Ron Balassanian
- Department of Pathology, University of California, San Francisco
| | - Molly E Klein
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Lajos Pusztai
- Department of Medicine, Medical Oncology, Yale University, New Haven, Connecticut
| | - Rita Nanda
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Barbara A Parker
- Division of Hematology-Oncology, Department of Medicine, University of California, San Diego, La Jolla
| | - Brian Datnow
- Department of Pathology, University of California, San Diego, La Jolla
| | - Gregor Krings
- Department of Pathology, University of California, San Francisco
| | - Shi Wei
- Department of Anatomic Pathology, University of Alabama at Birmingham
| | - Michael D Feldman
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia
| | - Xiuzhen Duan
- Department of Pathology, Loyola University, Chicago, Illinois
| | - Beiyun Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Husain Sattar
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Laila Khazai
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Jay C Zeck
- Department of Pathology, Georgetown University, Washington, DC
| | - Sharon Sams
- Department of Pathology, University of Colorado Anschutz Medical Center, Aurora
| | | | - Mara Rendi
- Department of Anatomic Pathology, University of Washington, Seattle
| | - Sunati Sahoo
- Department of Pathology, University of Texas Southwestern, Dallas
| | - Idris Tolgay Ocal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona
| | - Fang Fan
- Department of Pathology, University of Kansas Medical Center, Kansas City
| | | | - Tuyethoa Vinh
- Department of Pathology, Inova Health System, Fairfax, Virginia
| | - Megan L Troxell
- Department of Pathology, Oregon Health and Science University, Portland
| | - A Jo Chien
- Division of Hematology-Oncology, Department of Medicine, University of California, San Francisco
| | - Anne M Wallace
- Department of Surgery, University of California, San Diego, La Jolla
| | - Andres Forero-Torres
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham
| | - Erin Ellis
- Medical Oncology, Swedish Cancer Institute, Seattle, Washington
| | - Kathy S Albain
- Division of Hematology-Oncology, Department of Medicine, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Rashmi K Murthy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Judy C Boughey
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Minetta C Liu
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Barbara B Haley
- Division of Hematology-Oncology, Department of Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Anthony D Elias
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Center, Aurora
| | - Amy S Clark
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Kathleen Kemmer
- Division of Hematology-Oncology, Department of Medicine, Oregon Health & Science University, Portland
| | - Claudine Isaacs
- Division of Hematology-Oncology, Department of Medicine, Georgetown University, Washington, DC
| | - Julie E Lang
- Department of Surgery, University of Southern California, Los Angeles
| | - Hyo S Han
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Kirsten Edmiston
- Department of Surgery, Inova Schar Cancer Institute, Fairfax, Virginia
| | - Rebecca K Viscusi
- Department of Surgery, University of Arizona Health Sciences, Tucson, Arizona
| | - Donald W Northfelt
- Department of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Qamar J Khan
- Division of Oncology, Department of Medicine, University of Kansas, Kansas City
| | | | - Sara J Venters
- Department of Laboratory Medicine, University of California, San Francisco
| | - Sonal Shad
- Department of Surgery, University of California, San Francisco
| | | | - Smita M Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | | | - Adam L Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | - Hope S Rugo
- Division of Hematology-Oncology, Department of Medicine, University of California, San Francisco
| | - Richard B Schwab
- Division of Hematology-Oncology, Department of Medicine, University of California, San Diego, La Jolla
| | - Teresa Helsten
- Division of Hematology-Oncology, Department of Medicine, University of California, San Diego, La Jolla
| | - Nola M Hylton
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Laura van 't Veer
- Department of Laboratory Medicine, University of California, San Francisco
| | | | - Angela M DeMichele
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Douglas Yee
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis
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18
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Yee D, Isaacs C, Wolf DM, Yau C, Haluska P, Giridhar KV, Forero-Torres A, Jo Chien A, Wallace AM, Pusztai L, Albain KS, Ellis ED, Beckwith H, Haley BB, Elias AD, Boughey JC, Kemmer K, Yung RL, Pohlmann PR, Tripathy D, Clark AS, Han HS, Nanda R, Khan QJ, Edmiston KK, Petricoin EF, Stringer-Reasor E, Falkson CI, Majure M, Mukhtar RA, Helsten TL, Moulder SL, Robinson PA, Wulfkuhle JD, Brown-Swigart L, Buxton M, Clennell JL, Paoloni M, Sanil A, Berry S, Asare SM, Wilson A, Hirst GL, Singhrao R, Asare AL, Matthews JB, Hylton NM, DeMichele A, Melisko M, Perlmutter J, Rugo HS, Fraser Symmans W, Van't Veer LJ, Berry DA, Esserman LJ. Ganitumab and metformin plus standard neoadjuvant therapy in stage 2/3 breast cancer. NPJ Breast Cancer 2021; 7:131. [PMID: 34611148 PMCID: PMC8492731 DOI: 10.1038/s41523-021-00337-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 08/26/2021] [Indexed: 12/11/2022] Open
Abstract
I-SPY2 is an adaptively randomized phase 2 clinical trial evaluating novel agents in combination with standard-of-care paclitaxel followed by doxorubicin and cyclophosphamide in the neoadjuvant treatment of breast cancer. Ganitumab is a monoclonal antibody designed to bind and inhibit function of the type I insulin-like growth factor receptor (IGF-1R). Ganitumab was tested in combination with metformin and paclitaxel (PGM) followed by AC compared to standard-of-care alone. While pathologic complete response (pCR) rates were numerically higher in the PGM treatment arm for hormone receptor-negative, HER2-negative breast cancer (32% versus 21%), this small increase did not meet I-SPY's prespecified threshold for graduation. PGM was associated with increased hyperglycemia and elevated hemoglobin A1c (HbA1c), despite the use of metformin in combination with ganitumab. We evaluated several putative predictive biomarkers of ganitumab response (e.g., IGF-1 ligand score, IGF-1R signature, IGFBP5 expression, baseline HbA1c). None were specific predictors of response to PGM, although several signatures were associated with pCR in both arms. Any further development of anti-IGF-1R therapy will require better control of anti-IGF-1R drug-induced hyperglycemia and the development of more predictive biomarkers.
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Affiliation(s)
- Douglas Yee
- Masonic Cancer Center, University of Minnesota, 420 Delaware St., SE, MMC 480, Minneapolis, MN, 55455, USA.
| | - Claudine Isaacs
- Georgetown University, 3800 Reservoir Rd, NW, Washington, DC, 20007, USA
| | - Denise M Wolf
- University of California San Francisco Department of Laboratory Medicine, 2340 Sutter Street, S433, San Francisco, CA, 94115, USA
| | - Christina Yau
- University of California San Francisco Department of Laboratory Medicine, 2340 Sutter Street, S433, San Francisco, CA, 94115, USA
| | - Paul Haluska
- Mayo Clinic Rochester c/o Merck Corporation, 126 E. Lincoln Ave Rahway, New Jersey, 07065, USA
| | - Karthik V Giridhar
- Mayo Clinic Division of Medical Oncology, 200 1st St SW, Rochester, MN, 55905, USA
| | - Andres Forero-Torres
- University of Alabama at Birmingham c/o Seattle Genetics, 21823 30th Drive S.E., Bothell, WA, 98021, USA
| | - A Jo Chien
- University of California San Francisco Division of Hematology-Oncology, 550 16th Street, San Francisco, CA, 94158, USA
| | - Anne M Wallace
- University of California San Diego Department of Surgery, 3855 Health Sciences Dr, M/C 0698, La Jolla, CA, 92093, USA
| | - Lajos Pusztai
- Yale University Medical Onciology, 111 Goose Lane, Fl 2, Guilford, CT, 06437, USA
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine Cardinal Bernardin Cancer Center, 2160 South First Ave, Maywood, IL, 60153, USA
| | - Erin D Ellis
- Swedish Cancer Institute Medical Oncology, 1221 Madison Street, Seattle, WA, 98104, USA
| | - Heather Beckwith
- Masonic Cancer Center, University of Minnesota, 420 Delaware St., SE, MMC 480, Minneapolis, MN, 55455, USA
| | - Barbara B Haley
- UT Southwestern Medical Center Division of Hematology-Oncology, 5323 Harry Hines Blvd, Bldg E6.222D, Dallas, TX, 75390-9155, USA
| | - Anthony D Elias
- University of Colorado Anschutz Medical Center Division of Medical Oncology, 1665 Aurora Ct., Rm. 3200, MS F700, Aurora, CO, 80045, USA
| | - Judy C Boughey
- Mayo Clinic Division of Medical Oncology, 200 1st St SW, Rochester, MN, 55905, USA
| | - Kathleen Kemmer
- OHSU Knight Cancer Institute South Waterfront Center for Health and Healing, 3303 SW Bond Ave Building 1, Suite 7, Portland, OR, 97239, USA
| | - Rachel L Yung
- University of Washington Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA, 98109-1023, USA
| | - Paula R Pohlmann
- Georgetown University, 3800 Reservoir Rd, NW, Washington, DC, 20007, USA
| | - Debu Tripathy
- MD Anderson Cancer Center, 1515 Holcombe, Houston, Texas, 77030, USA
| | - Amy S Clark
- University of Pennsylvania Division of Hematology-Oncology 3 Perelman Center, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Hyo S Han
- Moffit Cancer Center, 2902 USF Magnolia Drive, Tampa, FL, 33612, USA
| | - Rita Nanda
- University of Chicago Section of Hematology/Oncology, 5841S. Maryland Avenue, MC 2115, Chicago, IL, 60437, USA
| | - Qamar J Khan
- University of Kansas Division of Oncology, 2330 Shawnee Mission Pkwy, Ste 210, Westwood, KS, 66205, USA
| | - Kristen K Edmiston
- Inova Medical Group, 3580 Joseph Siewick Dr 101, Fairfax, VA, 22033-1764, USA
| | - Emanuel F Petricoin
- George Mason University Institute for Advanced Biomedical Research, 10920 George Mason Circle Room 2008, MS1A9, Manassas, Virginia, 20110, USA
| | - Erica Stringer-Reasor
- University of Alabama at Birmingham Hematology/Oncology, 1802 Sixth Avenue South 2510, Birmingham, AL, 35294-3300, USA
| | - Carla I Falkson
- Wilmot Cancer Institute Pluta Cancer Center, 125 Red Creek Drive, Rochester, NY, 14623, USA
| | - Melanie Majure
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
| | - Rita A Mukhtar
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
| | - Teresa L Helsten
- University of California San Diego Division of Hematology-Oncology, 9400 Campus Point Dr, La Jolla, CA, 92037, USA
| | - Stacy L Moulder
- MD Anderson Cancer Center, 1515 Holcombe, Houston, Texas, 77030, USA
| | - Patricia A Robinson
- Loyola University Chicago Stritch School of Medicine Cardinal Bernardin Cancer Center, 2160 South First Ave, Maywood, IL, 60153, USA
| | - Julia D Wulfkuhle
- George Mason University Institute for Advanced Biomedical Research, 10920 George Mason Circle Room 2008, MS1A9, Manassas, Virginia, 20110, USA
| | - Lamorna Brown-Swigart
- University of California San Francisco Department of Laboratory Medicine, 2340 Sutter Street, S433, San Francisco, CA, 94115, USA
| | - Meredith Buxton
- University of California San Francisco c/o Global Coalition for Adaptive Research, 1661 Massachusetts Ave, Lexington, MA, 02420, USA
| | - Julia L Clennell
- University of California San Francisco c/o IQVIA, 135 Main St 21 floor, San Francisco, CA, 94105, USA
| | | | - Ashish Sanil
- Berry Consultants, LLC 3345 Bee Cave Rd Suite 201, Austin, TX, 78746, USA
| | - Scott Berry
- Berry Consultants, LLC 3345 Bee Cave Rd Suite 201, Austin, TX, 78746, USA
| | - Smita M Asare
- Quantum Leap Healthcare Collaborative, 3450 California St, San Francisco, CA, 94143, USA
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, 3450 California St, San Francisco, CA, 94143, USA
| | - Gillian L Hirst
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
| | - Ruby Singhrao
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
| | - Adam L Asare
- Quantum Leap Healthcare Collaborative, 3450 California St, San Francisco, CA, 94143, USA
| | - Jeffrey B Matthews
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
| | - Nola M Hylton
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
| | - Angela DeMichele
- University of Pennsylvania Division of Hematology-Oncology 3 Perelman Center, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michelle Melisko
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
| | - Jane Perlmutter
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
| | - Hope S Rugo
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
| | - W Fraser Symmans
- MD Anderson Cancer Center, 1515 Holcombe, Houston, Texas, 77030, USA
| | - Laura J Van't Veer
- University of California San Francisco Department of Laboratory Medicine, 2340 Sutter Street, S433, San Francisco, CA, 94115, USA
| | - Donald A Berry
- Quantum Leap Healthcare Collaborative, 3450 California St, San Francisco, CA, 94143, USA
| | - Laura J Esserman
- University of California San Francisco, 550 16th Street, 6464, San Francisco, CA, 94158, USA
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19
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Pusztai L, Yau C, Wolf DM, Han HS, Du L, Wallace AM, String-Reasor E, Boughey JC, Chien AJ, Elias AD, Beckwith H, Nanda R, Albain KS, Clark AS, Kemmer K, Kalinsky K, Isaacs C, Thomas A, Shatsky R, Helsten TL, Forero-Torres A, Liu MC, Brown-Swigart L, Petricoin EF, Wulfkuhle JD, Asare SM, Wilson A, Singhrao R, Sit L, Hirst GL, Berry S, Sanil A, Asare AL, Matthews JB, Perlmutter J, Melisko M, Rugo HS, Schwab RB, Symmans WF, Yee D, Van't Veer LJ, Hylton NM, DeMichele AM, Berry DA, Esserman LJ. Durvalumab with olaparib and paclitaxel for high-risk HER2-negative stage II/III breast cancer: Results from the adaptively randomized I-SPY2 trial. Cancer Cell 2021; 39:989-998.e5. [PMID: 34143979 PMCID: PMC11064785 DOI: 10.1016/j.ccell.2021.05.009] [Citation(s) in RCA: 117] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/01/2021] [Accepted: 05/17/2021] [Indexed: 01/03/2023]
Abstract
The combination of PD-L1 inhibitor durvalumab and PARP inhibitor olaparib added to standard paclitaxel neoadjuvant chemotherapy (durvalumab/olaparib/paclitaxel [DOP]) was investigated in the phase II I-SPY2 trial of stage II/III HER2-negative breast cancer. Seventy-three participants were randomized to DOP and 299 to standard of care (paclitaxel) control. DOP increased pathologic complete response (pCR) rates in all HER2-negative (20%-37%), hormone receptor (HR)-positive/HER2-negative (14%-28%), and triple-negative breast cancer (TNBC) (27%-47%). In HR-positive/HER2-negative cancers, MammaPrint ultra-high (MP2) cases benefited selectively from DOP (pCR 64% versus 22%), no benefit was seen in MP1 cancers (pCR 9% versus 10%). Overall, 12.3% of patients in the DOP arm experienced immune-related grade 3 adverse events versus 1.3% in control. Gene expression signatures associated with immune response were positively associated with pCR in both arms, while a mast cell signature was associated with non-pCR. DOP has superior efficacy over standard neoadjuvant chemotherapy in HER2-negative breast cancer, particularly in a highly sensitive subset of high-risk HR-positive/HER2-negative patients.
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Affiliation(s)
- Lajos Pusztai
- Breast Medical Oncology, Yale Cancer Center, Yale School of Medicine, 333 Cedar Steet, PO Box 208032, New Haven, CT 06510, USA.
| | - Christina Yau
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | - Denise M Wolf
- Department of Laboratory Medicine, University of California, San Francisco, CA 94143, USA
| | - Hyo S Han
- Medical Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Lili Du
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Anne M Wallace
- Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA 92037, USA
| | - Erica String-Reasor
- Department of Hematology & Oncology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Judy C Boughey
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - A Jo Chien
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | - Anthony D Elias
- Department of Internal Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Heather Beckwith
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Rita Nanda
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Kathy S Albain
- Hematology/Oncology, Loyola University Chicago Stritch School of Medicine, Chicago, IL 60153, USA
| | - Amy S Clark
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kathleen Kemmer
- Knight Cancer Institute, Oregon Health & Sciences University, Portland, OR 97239, USA
| | - Kevin Kalinsky
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY 10032, USA
| | - Claudine Isaacs
- Lombardi Comprehensive Care Center, Georgetown University, Washington, DC 20007, USA
| | - Alexandra Thomas
- Medical Oncology and Hematology, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Rebecca Shatsky
- Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA 92037, USA
| | - Theresa L Helsten
- Moores Cancer Center, University of California San Diego, La Jolla, CA 92037, USA
| | - Andres Forero-Torres
- Department of Hematology & Oncology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Minetta C Liu
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Lamorna Brown-Swigart
- Department of Laboratory Medicine, University of California, San Francisco, CA 94143, USA
| | - Emmanuel F Petricoin
- Center for Applied Proteomics and Molecular Medicine, George Mason University, Manassas, VA 20110, USA
| | - Julia D Wulfkuhle
- Center for Applied Proteomics and Molecular Medicine, George Mason University, Manassas, VA 20110, USA
| | - Smita M Asare
- Quantum Leap Healthcare Collaborative, San Francisco, CA 94118, USA
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, CA 94118, USA
| | - Ruby Singhrao
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | - Laura Sit
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | - Gillian L Hirst
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | - Scott Berry
- Berry Consultants, LLC, Austin, TX 78746, USA
| | | | - Adam L Asare
- Quantum Leap Healthcare Collaborative, San Francisco, CA 94118, USA
| | - Jeffrey B Matthews
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | | | - Michelle Melisko
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | - Hope S Rugo
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | - Richard B Schwab
- Moores Cancer Center, University of California San Diego, La Jolla, CA 92037, USA
| | - W Fraser Symmans
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Doug Yee
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Laura J Van't Veer
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | - Nola M Hylton
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
| | - Angela M DeMichele
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Laura J Esserman
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA
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20
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Gabriel RA, Swisher MW, Sztain JF, Curran BP, Said ET, Abramson WB, Khatibi B, Alexander BS, Finneran JJ, Wallace AM, Armani A, Blair S, Dobke M, Suliman A, Reid C, Donohue MC, Ilfeld BM. Serratus anterior plane versus paravertebral nerve blocks for postoperative analgesia after non-mastectomy breast surgery: a randomized controlled non-inferiority trial. Reg Anesth Pain Med 2021; 46:773-778. [PMID: 34158376 PMCID: PMC8380889 DOI: 10.1136/rapm-2021-102785] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/28/2021] [Indexed: 12/04/2022]
Abstract
Background Paravertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral technique. Methods Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection serratus or paravertebral block in a subject-masked fashion (ropivacaine 0.5%; 20 mL unilateral; 16 mL/side bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room with serratus blocks (measurement: Numeric Rating Scale), and (2) opioid consumption would be non-inferior with serratus blocks in the operating and recovery rooms. In order to claim that serratus blocks are non-inferior to paravertebral blocks, both hypotheses must be at least non-inferior. Results Within the recovery room, pain scores for participants with serratus blocks (n=49) had a median (IQR) of 4.0 (0–5.5) vs 0 (0–3.0) for those with paravertebral blocks (n=51): 0.95% CI −3.00 to −0.00; p=0.001. However, the difference in morphine equivalents did not reach statistical significance for superiority with the serratus group consuming 14 mg (10–19) vs 10 mg (10–16) for the paravertebral group: 95% CI −4.50 to 0.00, p=0.123. Since the 95% CI lower limit of −4.5 was less than our prespecified margin of −2.0, we failed to conclude non-inferiority of the serratus block with regard to opioid consumption. Conclusions Serratus blocks provided inferior analgesia compared with paravertebral blocks. Without a dramatic improvement in safety profile for serratus blocks, it appears that paravertebral blocks are superior to serratus blocks for postoperative analgesia after non-mastectomy breast surgery. Trial registration number NCT03860974.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA .,Department of Medicine, Division of Biomedical Informatics, University of California San Diego, La Jolla, California, USA
| | - Matthew W Swisher
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA
| | - Brian P Curran
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA
| | - Engy T Said
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA
| | - Wendy B Abramson
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA
| | - Brenton S Alexander
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA
| | - John J Finneran
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA
| | - Anne M Wallace
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Ava Armani
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Sarah Blair
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Marek Dobke
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Ahmed Suliman
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Christopher Reid
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Michael C Donohue
- Department of Neurology, University of Southern California, Los Angeles, California, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA
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21
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Chien AJ, Soliman HH, Ewing CA, Boughey JC, Campbell MJ, Rugo HS, Wallace AM, Albain KS, Stringer-Reasor EM, Church AL, Kalinsky K, Elias AD, Mitri ZI, Clark AS, Nanda R, Thomas A, Yau C, Berry DA, Esserman L. Evaluation of intra-tumoral (IT) SD-101 and pembrolizumab (Pb) in combination with paclitaxel (P) followed by AC in high-risk HER2-negative (HER2-) stage II/III breast cancer: Results from the I-SPY 2 trial. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.508] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
508 Background: I-SPY 2 is a multicenter, phase 2 trial using response-adaptive randomization within molecular subtypes defined by receptor status and MammaPrint (MP) risk to evaluate novel agents as neoadjuvant therapy for women with high-risk breast cancer. SD-101 is an investigational Toll-like receptor 9 (TLR9) agonist CpG-C class oligodeoxynucleotide that stimulates the production of IFN-α and interleukin (IL)-12, functional maturation of plasmacytoid dendritic cells, and production of cytotoxic antibodies. IT SD-101 was combined with systemic anti-PD-1 antibody Pb to investigate the antitumor and immunologic activity of this novel immunotherapeutic strategy. Methods: Women with tumors ≥ 2.5cm were eligible for screening. Only pts (pts) with HER2- disease were eligible for this treatment. Treatment included weekly P x 12 in combination with IT SD-101 2 mg/ml (1 ml for T2 tumors, 2 ml for >T3 tumors) weekly x 4, then q3 weeks x 2, and IV Pb q3 weeks x 4, followed by doxorubicin/cyclophosphamide (AC) q2-3 weeks x 4 (SD-101+Pembro 4). Pts in the control arm received weekly P x 12 followed by AC q2-3 weeks x 4. The I-SPY 2 methods have been previously published. This investigational arm was eligible for graduation (>85% chance of success in a 300-person phase 3 neoadjuvant trial) in 3 of 10 pre-defined signatures: HER2-, hormone receptor (HR)+/HER2- and HR-/HER2-. Results: 75 pts were randomized and evaluable in SD-101+Pembro 4 treatment arm. The control arm included 329 historical controls enrolled since April 2010. The study arm was stopped due to maximal patient accrual. Pt characteristics were balanced; 56% HR+, 44% HR-. The probability that SD-101+Pembro4 was superior to control exceeded 97% for all eligible tumor signatures, but did not reach the threshold for graduation in any of the signatures. However, it is notable that the rate of pCR/Residual Cancer Burden 1 (RCB1) in the HR+/HER2- signature was 51%. Preliminary safety events for SD-101+Pembro 4 include increased rates of fever, neutropenia, febrile neutropenia, transaminitis, and immune-related events, including adrenal insufficiency. Conclusions: The SD-101+Pembro 4 regimen was active but did not meet the pre-specified threshold for graduation in I-SPY 2. pCR/RCB 1 analysis suggests improved response in the HR+/HER-negative signature compared to control. The clinical significance of these findings needs to be weighed against the potential risk of immune-related toxicities. Clinical trial information: NCT01042379. [Table: see text]
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Affiliation(s)
- Amy Jo Chien
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Hope S. Rugo
- University of California, San Francisco, San Francisco, CA
| | | | - Kathy S. Albain
- Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | | | - An L Church
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | | | | | | | | | - Rita Nanda
- University of Chicago Medical Center, Chicago, IL
| | | | - Christina Yau
- University of California, San Francisco, San Francisco, CA
| | - Donald A Berry
- University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - Laura Esserman
- University of California, San Francisco, San Francisco, CA
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22
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Rodríguez-Soto AE, Fang LK, Holland D, Zou J, Park HH, Keenan KE, Bartsch H, Kuperman J, Wallace AM, Hahn M, Ojeda-Fournier H, Dale AM, Rakow-Penner R. Correction of Artifacts Induced by B 0 Inhomogeneities in Breast MRI Using Reduced-Field-of-View Echo-Planar Imaging and Enhanced Reversed Polarity Gradient Method. J Magn Reson Imaging 2021; 53:1581-1591. [PMID: 33644939 DOI: 10.1002/jmri.27566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Diffusion-weighted (DW) echo-planar imaging (EPI) is prone to geometric distortions due to B0 inhomogeneities. Both prospective and retrospective approaches have been developed to decrease and correct such distortions. PURPOSE The purpose of this work was to evaluate the performance of reduced-field-of-view (FOV) acquisition and retrospective distortion correction methods in decreasing distortion artifacts for breast imaging. Coverage of the axilla in reduced-FOV DW magnetic resonance imaging (MRI) and residual distortion were also assessed. STUDY TYPE Retrospective. POPULATION/PHANTOM Breast phantom and 169 women (52.4 ± 13.4 years old) undergoing clinical breast MRI. FIELD STRENGTH/SEQUENCE A 3.0 T/ full- and reduced-FOV DW gradient-echo EPI sequence. ASSESSMENT Performance of reversed polarity gradient (RPG) and FSL topup in correcting breast full- and reduced-FOV EPI data was evaluated using the mutual information (MI) metric between EPI and anatomical images. Two independent breast radiologists determined if coverage on both EPI data sets was adequate to evaluate axillary nodes and identified residual nipple distortion artifacts. STATISTICAL TESTS Two-way repeated-measures analyses of variance and post hoc tests were used to identify differences between EPI modality and distortion correction method. Generalized linear mixed effects models were used to evaluate differences in axillary coverage and residual nipple distortion. RESULTS In a breast phantom, residual distortions were 0.16 ± 0.07 cm and 0.22 ± 0.13 cm in reduced- and full-FOV EPI with both methods, respectively. In patients, MI significantly increased after distortion correction of full-FOV (11 ± 5% and 18 ± 9%, RPG and topup) and reduced-FOV (8 ± 4% both) EPI data. Axillary nodes were observed in 99% and 69% of the cases in full- and reduced-FOV EPI images. Residual distortion was observed in 93% and 0% of the cases in full- and reduced-FOV images. DATA CONCLUSION Minimal distortion was achieved with RPG applied to reduced-FOV EPI data. RPG improved distortions for full-FOV images but with more modest improvements and limited correction near the nipple. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Ana E Rodríguez-Soto
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Lauren K Fang
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Dominic Holland
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Jingjing Zou
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California, USA
| | - Helen H Park
- School of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Kathryn E Keenan
- National Institute of Standards and Technology Boulder, Colorado, USA
| | - Hauke Bartsch
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Joshua Kuperman
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Anne M Wallace
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Michael Hahn
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Haydee Ojeda-Fournier
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Anders M Dale
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Rebecca Rakow-Penner
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
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23
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Andreassen MMS, Rodríguez-Soto AE, Conlin CC, Vidić I, Seibert TM, Wallace AM, Zare S, Kuperman J, Abudu B, Ahn GS, Hahn M, Jerome NP, Østlie A, Bathen TF, Ojeda-Fournier H, Goa PE, Rakow-Penner R, Dale AM. Discrimination of Breast Cancer from Healthy Breast Tissue Using a Three-component Diffusion-weighted MRI Model. Clin Cancer Res 2021; 27:1094-1104. [PMID: 33148675 PMCID: PMC8174004 DOI: 10.1158/1078-0432.ccr-20-2017] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/29/2020] [Accepted: 10/29/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Diffusion-weighted MRI (DW-MRI) is a contrast-free modality that has demonstrated ability to discriminate between predefined benign and malignant breast lesions. However, how well DW-MRI discriminates cancer from all other breast tissue voxels in a clinical setting is unknown. Here we explore the voxelwise ability to distinguish cancer from healthy breast tissue using signal contributions from the newly developed three-component multi-b-value DW-MRI model. EXPERIMENTAL DESIGN Patients with pathology-proven breast cancer from two datasets (n = 81 and n = 25) underwent multi-b-value DW-MRI. The three-component signal contributions C 1 and C 2 and their product, C 1 C 2, and signal fractions F 1, F 2, and F 1 F 2 were compared with the image defined on maximum b-value (DWI max), conventional apparent diffusion coefficient (ADC), and apparent diffusion kurtosis (K app). The ability to discriminate between cancer and healthy breast tissue was assessed by the false-positive rate given a sensitivity of 80% (FPR80) and ROC AUC. RESULTS Mean FPR80 for both datasets was 0.016 [95% confidence interval (CI), 0.008-0.024] for C 1 C 2, 0.136 (95% CI, 0.092-0.180) for C 1, 0.068 (95% CI, 0.049-0.087) for C 2, 0.462 (95% CI, 0.425-0.499) for F 1 F 2, 0.832 (95% CI, 0.797-0.868) for F 1, 0.176 (95% CI, 0.150-0.203) for F 2, 0.159 (95% CI, 0.114-0.204) for DWI max, 0.731 (95% CI, 0.692-0.770) for ADC, and 0.684 (95% CI, 0.660-0.709) for K app. Mean ROC AUC for C 1 C 2 was 0.984 (95% CI, 0.977-0.991). CONCLUSIONS The C 1 C 2 parameter of the three-component model yields a clinically useful discrimination between cancer and healthy breast tissue, superior to other DW-MRI methods and obliviating predefining lesions. This novel DW-MRI method may serve as noncontrast alternative to standard-of-care dynamic contrast-enhanced MRI.
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Affiliation(s)
- Maren M Sjaastad Andreassen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ana E Rodríguez-Soto
- Department of Radiology, University of California San Diego, La Jolla, California
| | - Christopher C Conlin
- Department of Radiology, University of California San Diego, La Jolla, California
| | - Igor Vidić
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tyler M Seibert
- Department of Radiology, University of California San Diego, La Jolla, California
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Anne M Wallace
- Department of Surgery, University of California San Diego, La Jolla, California
| | - Somaye Zare
- Department of Pathology, University of California San Diego, La Jolla, California
| | - Joshua Kuperman
- Department of Radiology, University of California San Diego, La Jolla, California
| | - Boya Abudu
- School of Medicine, University of California San Diego, La Jolla, California
| | - Grace S Ahn
- School of Medicine, University of California San Diego, La Jolla, California
| | - Michael Hahn
- Department of Radiology, University of California San Diego, La Jolla, California
| | - Neil P Jerome
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Agnes Østlie
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tone F Bathen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Radiology and Nuclear Medicine, St. Olav's University Hospital, Trondheim, Norway
| | | | - Pål Erik Goa
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Radiology and Nuclear Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Rebecca Rakow-Penner
- Department of Radiology, University of California San Diego, La Jolla, California.
| | - Anders M Dale
- Department of Radiology, University of California San Diego, La Jolla, California
- Department of Neuroscience, University of California San Diego, La Jolla, California
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24
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O'Keefe T, Harismendy O, Esserman L, Wallace AM. Personalization of Ductal Carcinoma In-Situ Management: Large Databases and an Emerging Role for Global Data Sharing. Arch Breast Cancer 2021. [DOI: 10.32768/abc.2021814-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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O’Keefe TJ, Harismendy O, Wallace AM. Histopathological growth distribution of ductal carcinoma in situ: tumor size is not “one size fits all”. Gland Surg 2021; 11:307-318. [DOI: 10.21037/gs-21-599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/07/2022] [Indexed: 11/06/2022]
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Wang HY, Thorson JA, Hinds BR, Swalchick W, Parker BA, Chong A, Wallace AM, Goodman AM. Cutaneous intralymphatic anaplastic lymphoma kinase-negative anaplastic large-cell lymphoma arising in a patient with multiple rounds of breast implants. J Cutan Pathol 2020; 48:659-662. [PMID: 33314229 DOI: 10.1111/cup.13936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 11/30/2022]
Abstract
Primary cutaneous anaplastic large-cell lymphoma and breast implant-associated ALCL (BIA-ALCL) are rare subtypes of anaplastic lymphoma kinase (ALK)-negative ALCLs originating from skin and breast implants, respectively. Herein, we report a unique case of cutaneous ALK-negative ALCL occurring in the skin of left medial breast from a patient with multiple rounds of bilateral breast implants and a history of breast carcinoma. The lymphoma cells are entirely confined to the lymphatic channels in the dermis, and the patient has no other areas of skin abnormality, no lymphadenopathy, peri-implant fluid accumulation, or masses from the bilateral capsules of implants. The differential diagnosis and its relationship with breast implants are further explored.
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Affiliation(s)
- Huan-You Wang
- Division of Laboratory and Genomic Medicine, Department of Pathology, University of California San Diego Health System, La Jolla, California, USA
| | - John A Thorson
- Division of Laboratory and Genomic Medicine, Department of Pathology, University of California San Diego Health System, La Jolla, California, USA
| | - Brian R Hinds
- Department of Dermatology, University of California San Diego Health System, La Jolla, California, USA
| | - William Swalchick
- Division of Laboratory and Genomic Medicine, Department of Pathology, University of California San Diego Health System, La Jolla, California, USA
| | - Barbara A Parker
- Division of Hematology/Oncology, Department of Medicine, University of California San Diego Health System, La Jolla, California, USA
| | - Alice Chong
- Department of Radiology, University of California San Diego Health System, La Jolla, California, USA
| | - Anne M Wallace
- Department of Surgery, University of California San Diego Health System, La Jolla, California, USA
| | - Aaron M Goodman
- Division of Blood and Marrow Transplant, Department of Medicine, University of California San Diego Health System, La Jolla, California, USA
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Halasz SR, O'Keefe T, Wallace AM, Blair SL. Ductal carcinoma in situ in patients younger than 30 years: differences in adjuvant endocrine therapy and outcomes. Breast Cancer Res Treat 2020; 186:551-559. [PMID: 33180236 DOI: 10.1007/s10549-020-06014-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/03/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To use the National Cancer Database to assess treatment patterns in very young women with ductal carcinoma in situ (DCIS) given their propensity for higher risk features and increased risk of recurrence. METHODS We used the NCDB to identify female patients who underwent surgery for a first cancer diagnosis of DCIS within three different age groups: ≤30, 31-50, and >50. Demographic information, tumor characteristics, and initial treatment patterns were characterized and compared. Univariable and multivariable logistic regression of individuals with hormone-receptor-positive disease who underwent breast-conserving surgery (BCS) was conducted to assess for group differences in adjuvant endocrine therapy utilization. Survival analysis was conducted via Kaplan-Meier method and Cox regression. RESULTS We identified 236,832 patients meeting inclusion criteria. Individuals in the youngest group were more likely to be a minority, had better Charlson-Deyo scores, lived further from their treatment facility, and were less often insured. This group also had more unfavorable tumor features and were more likely to undergo bilateral mastectomy. In subgroup analysis of patients with hormone-receptor-positive disease who underwent BCS, the youngest group was significantly less likely to have received endocrine therapy. There was also a trend toward worse overall survival in the youngest group. CONCLUSION We report differences in demographics, tumor characteristics, and treatment of very young women with DCIS. Given the known reduction in recurrence with use of adjuvant endocrine therapy, there may be room for increasing therapy rates or otherwise altering guidelines for treatment of young women with hormone-receptor-positive DCIS who undergo BCS.
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Affiliation(s)
- Sasha R Halasz
- Department of Surgery, University of California San Diego, 9300 Campus Point Drive, #7220, La Jolla, CA, 92037, USA
| | - Thomas O'Keefe
- Department of Surgery, University of California San Diego, 9300 Campus Point Drive, #7220, La Jolla, CA, 92037, USA
| | - Anne M Wallace
- Division of Breast Surgery and The Comprehensive Breast Health Center, University of California San Diego, Mailbox 0819, 3855 Health Sciences Dr, La Jolla, CA, 92037, USA
| | - Sarah L Blair
- Division of Breast Surgery and The Comprehensive Breast Health Center, University of California San Diego, Mailbox 0819, 3855 Health Sciences Dr, La Jolla, CA, 92037, USA.
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Yee D, DeMichele AM, Yau C, Isaacs C, Symmans WF, Albain KS, Chen YY, Krings G, Wei S, Harada S, Datnow B, Fadare O, Klein M, Pambuccian S, Chen B, Adamson K, Sams S, Mhawech-Fauceglia P, Magliocco A, Feldman M, Rendi M, Sattar H, Zeck J, Ocal IT, Tawfik O, LeBeau LG, Sahoo S, Vinh T, Chien AJ, Forero-Torres A, Stringer-Reasor E, Wallace AM, Pusztai L, Boughey JC, Ellis ED, Elias AD, Lu J, Lang JE, Han HS, Clark AS, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Park JW, Liu MC, Olopade O, Leyland-Jones B, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, Haugen P, Hylton NM, Van't Veer LJ, Perlmutter J, Melisko ME, Wilson A, Peterson G, Asare AL, Buxton MB, Paoloni M, Clennell JL, Hirst GL, Singhrao R, Steeg K, Matthews JB, Asare SM, Sanil A, Berry SM, Esserman LJ, Berry DA. Association of Event-Free and Distant Recurrence-Free Survival With Individual-Level Pathologic Complete Response in Neoadjuvant Treatment of Stages 2 and 3 Breast Cancer: Three-Year Follow-up Analysis for the I-SPY2 Adaptively Randomized Clinical Trial. JAMA Oncol 2020; 6:1355-1362. [PMID: 32701140 PMCID: PMC7378873 DOI: 10.1001/jamaoncol.2020.2535] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/17/2020] [Indexed: 01/04/2023]
Abstract
Importance Pathologic complete response (pCR) is a known prognostic biomarker for long-term outcomes. The I-SPY2 trial evaluated if the strength of this clinical association persists in the context of a phase 2 neoadjuvant platform trial. Objective To evaluate the association of pCR with event-free survival (EFS) and pCR with distant recurrence-free survival (DRFS) in subpopulations of women with high-risk operable breast cancer treated with standard therapy or one of several novel agents. Design, Setting, and Participants Multicenter platform trial of women with operable clinical stage 2 or 3 breast cancer with no prior surgery or systemic therapy for breast cancer; primary tumors were 2.5 cm or larger. Women with tumors that were ERBB2 negative/hormone receptor (HR) positive with low 70-gene assay score were excluded. Participants were adaptively randomized to one of several different investigational regimens or control therapy within molecular subtypes from March 2010 through 2016. The analysis included participants with follow-up data available as of February 26, 2019. Interventions Standard-of-care neoadjuvant therapy consisting of taxane treatment with or without (as control) one of several investigational agents or combinations followed by doxorubicin and cyclophosphamide. Main Outcomes and Measures Pathologic complete response and 3-year EFS and DRFS. Results Of the 950 participants (median [range] age, 49 [23-77] years), 330 (34.7%) achieved pCR. Three-year EFS and DRFS for patients who achieved pCR were both 95%. Hazard ratios for pCR vs non-pCR were 0.19 for EFS (95% CI, 0.12-0.31) and 0.21 for DRFS (95% CI, 0.13-0.34) and were similar across molecular subtypes, varying from 0.14 to 0.18 for EFS and 0.10 to 0.20 for DRFS. Conclusions and Relevance The 3-year outcomes from the I-SPY2 trial show that, regardless of subtype and/or treatment regimen, including 9 novel therapeutic combinations, achieving pCR after neoadjuvant therapy implies approximately an 80% reduction in recurrence rate. The goal of the I-SPY2 trial is to rapidly identify investigational therapies that may improve pCR when validated in a phase 3 confirmatory trial. Whether pCR is a validated surrogate in the sense that a therapy that improves pCR rate can be assumed to also improve long-term outcome requires further study. Trial Registration ClinicalTrials.gov Identifier: NCT01042379.
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Affiliation(s)
- Douglas Yee
- Masonic Cancer Center, University of Minnesota, Minneapolis
| | | | - Christina Yau
- Department of Surgery, University of California, San Francisco
| | - Claudine Isaacs
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - W Fraser Symmans
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Yunn-Yi Chen
- Department of Pathology, University of California, San Francisco
| | - Gregor Krings
- Department of Pathology, University of California, San Francisco
| | - Shi Wei
- Department of Pathology, University of Alabama Birmingham
| | - Shuko Harada
- Department of Pathology, University of Alabama Birmingham
| | - Brian Datnow
- Department of Pathology, University of California, San Diego
| | - Oluwole Fadare
- Department of Pathology, University of California, San Diego
| | - Molly Klein
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Stefan Pambuccian
- Department of Pathology, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Beiyun Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Kathi Adamson
- Department of Pathology, Swedish Cancer Institute, Seattle, Washington
| | - Sharon Sams
- Department of Pathology, University of Colorado, Denver
| | | | | | - Mike Feldman
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia
| | - Mara Rendi
- Department of Anatomic Pathology, University of Washington, Seattle
| | - Husain Sattar
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Jay Zeck
- Department of Pathology, Georgetown University, Washington, DC
| | - Idris T Ocal
- Laboratory Medicine and Pathology, Mayo Clinic Scottsdale, Scottsdale, Arizona
| | - Ossama Tawfik
- Department of Pathology and Laboratory Medicine, University of Kansas, Lawrence
| | | | - Sunati Sahoo
- Department of Pathology, University of Texas Southwestern, Dallas
| | - Tuyethoa Vinh
- Inova Pathology Institute, Inova Health System, Falls Church, Virginia
| | - A Jo Chien
- Division of Hematology and Oncology, University of California, San Francisco
| | | | | | - Anne M Wallace
- Department of Surgery, University of California, San Diego
| | - Lajos Pusztai
- Medical Oncology, Yale Cancer Center, New Haven, Connecticut
| | - Judy C Boughey
- Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota
| | - Erin D Ellis
- Medical Oncology, Swedish Cancer Institute, Seattle, Washington
| | | | - Janice Lu
- Medical Oncology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Julie E Lang
- Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Hyo S Han
- Medical Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Amy S Clark
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rita Nanda
- Hematology and Oncology, University of Chicago Medical Center, Chicago, Illinois
| | | | - Qamar J Khan
- Medical Oncology, University of Kansas Medical Center, Lawrence
| | | | - David M Euhus
- Department of Surgery, Johns Hopkins Medicine, Baltimore, Maryland
| | | | | | - Kathleen Kemmer
- Knight Cancer Institute, Oregon Health & Science University, Portland
| | - John W Park
- Division of Hematology and Oncology, University of California, San Francisco
| | - Minetta C Liu
- Department of Oncology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Olufunmilayo Olopade
- Hematology and Oncology, University of Chicago Medical Center, Chicago, Illinois
| | | | - Debasish Tripathy
- Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Stacy L Moulder
- Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Hope S Rugo
- Division of Hematology and Oncology, University of California, San Francisco
| | | | - Shelly Lo
- Medical Oncology, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | | | | | | | - Nola M Hylton
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Laura J Van't Veer
- Department of Laboratory Medicine, University of California, San Francisco
| | | | - Michelle E Melisko
- Division of Hematology and Oncology, University of California, San Francisco
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | - Garry Peterson
- Department of Surgery, University of California, San Francisco
| | - Adam L Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | | | | | | | - Gillian L Hirst
- Department of Surgery, University of California, San Francisco
| | - Ruby Singhrao
- Department of Surgery, University of California, San Francisco
| | - Katherine Steeg
- Department of Surgery, University of California, San Francisco
| | | | - Smita M Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California
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Pusztai L, Han HS, Yau C, Wolf D, Wallace AM, Shatsky R, Helsten T, Boughey JC, Haddad T, Stringer-Reasor E, Falkson C, Chien AJ, Mukhtar R, Elias A, Virginia B, Nanda R, Yee D, Kalinsky K, Albain KS, Muller AS, Kemmer K, Clark AS, Isaacs C, Thomas A, Hylton N, Symmans WF, Perlmutter J, Melisko M, Rugo HS, Schwab R, Wilson A, Wilson A, Singhrao R, Asare S, van't Veer LJ, DeMichele AM, Sanil A, Berry DA, Esserman LJ. Abstract CT011: Evaluation of durvalumab in combination with olaparib and paclitaxel in high-risk HER2 negative stage II/III breast cancer: Results from the I-SPY 2 TRIAL. Tumour Biol 2020. [DOI: 10.1158/1538-7445.am2020-ct011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Baker JL, Mailey B, Tokin CA, Blair SL, Wallace AM. Postmastectomy Reconstruction is Associated with Improved Survival in Patients with Invasive Breast Cancer: A Single-institution Study. Am Surg 2020. [DOI: 10.1177/000313481307901004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Breast reconstruction after mastectomy positively affects psychosocial well-being; however, the influence of reconstruction on cancer outcomes is unknown. The objective of our study was to compare survival in reconstructed versus nonreconstructed patients after mastectomy. All consecutive female patients diagnosed with invasive breast cancer and treated with mastectomy between 2002 and 2011 were identified from our single-institution database. All cancer operations were performed by two surgeons. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. To identify the effect of reconstruction on survival, a multivariate Cox regression analysis was performed. Of 474 patients treated, 340 (71.7%) underwent breast reconstruction. At a mean follow-up 3.3 years, reconstructed patients had a longer 5-year survival (91 vs 74%, P < 0.001). After controlling for age, race, payer source, cancer stage, triple negative status, and receipt of radiation or chemotherapy, reconstructed patients maintained a survival advantage over nonreconstructed patients (hazard ratio, 0.47; 95% confidence interval, 0.25 to 0.88; P = 0.02). Patients with breast cancer who undergo reconstruction have longer survival than nonreconstructed patients. The explanation for this finding may be related to improved psychosocial qualities of life versus possible antitumorigenic effects of implants.
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Affiliation(s)
- Jennifer L. Baker
- Department of Surgery, University of California, San Diego, San Diego, California
| | - Brian Mailey
- Department of Surgery, University of California, San Diego, San Diego, California
- Plastic and Reconstructive Surgery, University of California, San Diego, San Diego, California
| | - Christopher A. Tokin
- Department of Surgery, University of California, San Diego, San Diego, California
| | - Sarah L. Blair
- Department of Surgery, University of California, San Diego, San Diego, California
- Division of Surgical Oncology, University of California, San Diego, San Diego, California
| | - Anne M. Wallace
- Department of Surgery, University of California, San Diego, San Diego, California
- Division of Surgical Oncology, University of California, San Diego, San Diego, California
- Plastic and Reconstructive Surgery, University of California, San Diego, San Diego, California
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O'Keefe TJ, Wallace AM. Surveillance, Epidemiology, and End Results program underestimates breast cancer-specific mortality after ductal carcinoma in situ diagnosis. Breast Cancer Res Treat 2020; 182:761-762. [PMID: 32529407 DOI: 10.1007/s10549-020-05733-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/07/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Thomas J O'Keefe
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, 3855 Health Sciences Dr, La Jolla, Mailbox 0819, San Diego, CA, 92037, USA.
| | - Anne M Wallace
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, 3855 Health Sciences Dr, La Jolla, Mailbox 0819, San Diego, CA, 92037, USA
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O'Keefe TJ, Blair SL, Hosseini A, Harismendy O, Wallace AM. HER2-Overexpressing Ductal Carcinoma In Situ Associated with Increased Risk of Ipsilateral Invasive Recurrence, Receptor Discordance with Recurrence. Cancer Prev Res (Phila) 2020; 13:761-772. [PMID: 32493703 DOI: 10.1158/1940-6207.capr-20-0024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/04/2020] [Accepted: 05/29/2020] [Indexed: 01/01/2023]
Abstract
The impact of HER2 status in ductal carcinoma in situ (DCIS) on the risk of progression to invasive ductal carcinoma (IDC) has been debated. We aim to use a national database to identify patients with known HER2 status to elucidate the effect of HER2 overexpression on ipsilateral IDC (iIDC) development. We performed survival analysis on patient-level data using the U.S. NCI's Surveillance Epidemiology and End Results program. We identified patients diagnosed with DCIS who underwent lumpectomy and had known HER2 status. Competing risks analysis was performed. A total of 1,540 patients had known HER2 status and met inclusion criteria. Median age at diagnosis was 60, median follow-up time was 44.5 months. A total of 417 (27.1%) patients were HER2 positive and 1,035 (67.2%) were HER2 negative. Twenty-two (1.4%) patients developed iIDC and 27 (1.8%) developed ipsilateral in situ or contralateral disease. The estimated cumulative incidence of iIDC at 5 years was 1.9% for all patients, 1.2% for HER2-negative and borderline patients, and 3.9% for HER2-positive patients. On multivariate competing risks regression, two factors were significant for iIDC: radiation (protective) therapy within 24 months (HR, 0.05; P = 0.00006) and HER2 overexpression (increased likelihood; HR, 2.72; P = 0.044). Patients with HER2-positive DCIS were more likely to have recurrences with receptor discordance. HER2 may serve as a prognostic factor for invasive recurrence and was the only lesion-related factor to significantly relate to iIDC development. It may also be associated with receptor discordance of recurrences. Further large studies will be needed to confirm these results.
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Affiliation(s)
- Thomas J O'Keefe
- Division of Breast Surgery And The Comprehensive Breast Health Center, University of California San Diego, La Jolla, California.
| | - Sarah L Blair
- Division of Breast Surgery And The Comprehensive Breast Health Center, University of California San Diego, La Jolla, California
| | - Ava Hosseini
- Division of Breast Surgery And The Comprehensive Breast Health Center, University of California San Diego, La Jolla, California
| | - Olivier Harismendy
- Moores Cancer Center and Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
| | - Anne M Wallace
- Division of Breast Surgery And The Comprehensive Breast Health Center, University of California San Diego, La Jolla, California
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Li W, Onishi N, Newitt DC, Harnish R, Jones EF, Wilmes LJ, Gibbs J, Price E, Joe BN, Chien AJ, Berry DA, Boughey JC, Albain KS, Clark AS, Edmiston KK, Elias AD, Ellis ED, Euhus DM, Han HS, Isaacs C, Khan QJ, Lang JE, Lu J, Meisel JL, Mitri Z, Nanda R, Northfelt DW, Sanft T, Stringer-Reasor E, Viscusi RK, Wallace AM, Yee D, Yung R, Melisko ME, Perlmutter J, Rugo HS, Schwab R, Symmans WF, van't Veer LJ, Yau C, Asare SM, DeMichele A, Goudreau S, Abe H, Sheth D, Wolverton D, Fountain K, Ha R, Wynn R, Crane EP, Dillis C, Kuritza T, Morley K, Nelson M, Church A, Niell B, Drukteinis J, Oh KY, Jafarian N, Brandt K, Choudhery S, Bang DH, Mullins C, Woodard S, Zamora KW, Ojeda-Fornier H, Eghedari M, Sheth P, Hovanessian-Larsen L, Rosen M, McDonald ES, Spektor M, Giurescu M, Newell MS, Cohen MA, Berman E, Lehman C, Smith W, Fitzpatrick K, Borders MH, Yang W, Dogan B, Esserman LJ, Hylton NM. Abstract P6-02-01: The effect of background parenchymal enhancement on the predictive performance of functional tumor volume measured in MRI. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p6-02-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Strong background parenchymal enhancement (BPE) may cause overestimation in tumor volume measured from dynamic contrast-enhanced (DCE) MRI, which may adversely affect the ability of MR tumor volume to predict treatment outcome for patients undergoing neoadjuvant chemotherapy (NAC). Specifically, an overestimation of tumor volume can result in misclassification of patients with complete pathologic response (pCR) as non-responders, leading to less confidence in MRI prediction. As well, overestimation of extent of disease might lead to more aggressive surgical therapy than necessary. This study investigated whether high BPE in the contralateral breast influences the predictive performance of MRI-measured functional tumor volume (FTV) for patients with locally advanced breast cancer undergoing NAC.
Methods: patients (n=990) enrolled in the I-SPY 2 TRIAL who were randomized to the graduated experimental drug arms or controls from 2010 to 2016 were analyzed. Each patient had 4 MRI exams: pre-NAC (T0), after 3 weeks of NAC (T1), between NAC regimens (T2), and post-NAC (T3). FTV was calculated at each MRI exam by summing voxels meeting enhancement thresholds. Background parenchymal enhancement (BPE) in the contralateral breast was calculated automatically as mean percentage enhancement on the early (nominal 150sec post-contrast) image in the fibroglandular tissue segmented from 5 continuous axial slices centered in the inferior-to-superior stack. For each treatment time point, patients having both FTV and BPE measurements were included in the analysis. The area under the ROC curve (AUC) was estimated as the association between FTV and pCR at T1, T2, and T3. The analysis was conducted in the full patient cohort and in sub-cohorts defined by hormone receptor (HR) and HER2 status. In each patient cohort, a cut-off BPE value was selected to classify patients with high vs. low BPE by testing AUCs estimated with low-BPE patients reached maximum when the cut-off value varied from median to maximum in steps of 10%.
Results: Out of 990 patients, 878 had pCR outcome data (pCR or non-pCR, pCR rate = 35%). Table 1 shows the number of patients, pCR rate, and AUC of FTV for predicting pCR using all patients available vs. a subset patients with low BPE (< BPE cut-off). In the full cohort, AUC increased slightly across all time points after patients with high BPE were removed. In the HR+/HER2- subtype, AUC increased at T1 after removal of cases with high BPE (0.65 vs. 0.71). For HR-/HER2+, AUC increased substantially after removal of high BPE cases (0.65 to 0.86 at T1, 0.71 to 0.87 at T2, and 0.71 to 0.89 at T3), with greater improvement at the early time point (T1) compared to later time points (T2 and T3). Only a slight improvement in the AUC was observed in the HR+/HER2+ and HR-/HER2- subtypes across all time points.
Conclusions: High background parenchymal enhancement adversely affected the predictive performance of functional tumor volume measured by DCE-MRI, at early treatment time point for HR+/HER2- and across all time points for HR-/HER2+ cancer subtype. The adverse effect might be offset using subtype-optimized enhancement threshold in calculating functional tumor volume.
Table 1 Effect of BPE on the prediction of pCR using FTV at various treatment time pointsT1T2T3npCR rateAUCBPE cut-offnpCR rateAUCBPE cut-offnpCR rateAUCBPE cut-offFullAll64734%0.662762334%0.701761134%0.6925Subset45334%0.6831133%0.7230534%0.72HR+/HER2-All26218%0.651924918%0.718225518%0.7519Subset13118%0.7124818%0.7120419%0.76HR+/HER2+All10636%0.642110538%0.62269634%0.7120Subset5332%0.668438%0.665740%0.73HR-/HER2+All5175%0.65204774%0.71204973%0.7116Subset3073%0.862871%0.872475%0.89HR-/HER2-All22842%0.682822243%0.751821143%0.6916Subset15940%0.7111137%0.7810540%0.75
Citation Format: Wen Li, Natsuko Onishi, David C Newitt, Roy Harnish, Ella F Jones, Lisa J Wilmes, Jessica Gibbs, Elissa Price, Bonnie N Joe, A. Jo Chien, Donald A Berry, Judy C Boughey, Kathy S Albain, Amy S Clark, Kirsten K Edmiston, Anthony D Elias, Erin D Ellis, David M Euhus, Heather S Han, Claudine Isaacs, Qamar J Khan, Julie E Lang, Janice Lu, Jane L Meisel, Zaha Mitri, Rita Nanda, Donald W Northfelt, Tara Sanft, Erica Stringer-Reasor, Rebecca K Viscusi, Anne M Wallace, Douglas Yee, Rachel Yung, Michelle E Melisko, Jane Perlmutter, Hope S Rugo, Richard Schwab, W. Fraser Symmans, Laura J van't Veer, Christina Yau, Smita M Asare, Angela DeMichele, Sally Goudreau, Hiroyuki Abe, Deepa Sheth, Dulcy Wolverton, Kelly Fountain, Richard Ha, Ralph Wynn, Erin P Crane, Charlotte Dillis, Theresa Kuritza, Kevin Morley, Michael Nelson, An Church, Bethany Niell, Jennifer Drukteinis, Karen Y Oh, Neda Jafarian, Kathy Brandt, Sadia Choudhery, Dae Hee Bang, Christiane Mullins, Stefanie Woodard, Kathryn W Zamora, Haydee Ojeda-Fornier, Mohammad Eghedari, Pulin Sheth, Linda Hovanessian-Larsen, Mark Rosen, Elizabeth S McDonald, Michael Spektor, Marina Giurescu, Mary S Newell, Michael A Cohen, Elise Berman, Constance Lehman, William Smith, Kim Fitzpatrick, Marisa H Borders, Wei Yang, Basak Dogan, Laura J Esserman, Nola M Hylton. The effect of background parenchymal enhancement on the predictive performance of functional tumor volume measured in MRI [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-02-01.
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Affiliation(s)
- Wen Li
- 1University of California, San Francisco, San Francisco, CA
| | - Natsuko Onishi
- 1University of California, San Francisco, San Francisco, CA
| | - David C Newitt
- 1University of California, San Francisco, San Francisco, CA
| | - Roy Harnish
- 1University of California, San Francisco, San Francisco, CA
| | - Ella F Jones
- 1University of California, San Francisco, San Francisco, CA
| | - Lisa J Wilmes
- 1University of California, San Francisco, San Francisco, CA
| | - Jessica Gibbs
- 1University of California, San Francisco, San Francisco, CA
| | - Elissa Price
- 1University of California, San Francisco, San Francisco, CA
| | - Bonnie N Joe
- 1University of California, San Francisco, San Francisco, CA
| | - A. Jo Chien
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | - Amy S Clark
- 5University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | | | | | - Julie E Lang
- 13University of Southern California, Los Angeles, CA
| | - Janice Lu
- 13University of Southern California, Los Angeles, CA
| | | | - Zaha Mitri
- 15Oregon Health & Science University, Portland, OR
| | - Rita Nanda
- 16The University of Chicago Medical Center, Chicago, IL
| | | | | | | | | | | | | | - Rachel Yung
- 23CTEP, National Cancer Institute, Rockville, MD
| | | | | | - Hope S Rugo
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | - Christina Yau
- 1University of California, San Francisco, San Francisco, CA
| | - Smita M Asare
- 26Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | - Sally Goudreau
- 27University of Texas Southwestern Medical Center, Dallas, TX
| | - Hiroyuki Abe
- 16The University of Chicago Medical Center, Chicago, IL
| | - Deepa Sheth
- 16The University of Chicago Medical Center, Chicago, IL
| | | | | | - Richard Ha
- 28Columbia University, New York City, NY
| | - Ralph Wynn
- 28Columbia University, New York City, NY
| | | | | | | | | | | | - An Church
- 22University of Minnesota, Minneapolis, MN
| | | | | | - Karen Y Oh
- 15Oregon Health & Science University, Portland, OR
| | | | | | | | | | | | | | | | | | | | - Pulin Sheth
- 13University of Southern California, Los Angeles, CA
| | | | - Mark Rosen
- 5University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | - Wei Yang
- 25University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - Basak Dogan
- 25University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | | | - Nola M Hylton
- 1University of California, San Francisco, San Francisco, CA
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Helsten TL, Lo SS, Yau C, Kalinsky K, Elias AD, Wallace AM, Chien AJ, Lu J, Lang JE, Albain KS, Stringer-Reasor E, Clark AS, Boughey JC, Ellis ED, Yee D, DeMichele A, Isaacs C, Perlmutter J, Rugo HS, Schwab R, Hylton NM, Symmans WF, Melisko ME, van't Veer LJ, Wilson A, Singhrao R, Asare SM, Sanil A, Berry DA, Esserman LJ. Abstract P3-11-02: Evaluation of patritumab/paclitaxel/trastuzumab over standard paclitaxel/trastuzumab in early stage, high-risk HER2 positive breast cancer: Results from the neoadjuvant I-SPY 2 trial. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p3-11-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: I-SPY2 is a multicenter, phase 2 trial using response-adaptive randomization within biomarker subtypes to evaluate novel agents as neoadjuvant therapy for high-risk breast cancer. The primary endpoint is pathologic complete response (pCR) at surgery. The goal is to identify (graduate) regimens with ≥ 85% Bayesian predictive probability of success (i.e., demonstrating superiority to control) in a future 300-patient phase 3 1:1 randomized neoadjuvant trial with pCR endpoint within signatures defined by hormone-receptor (HR), HER2, and MammaPrint (MP) status. Regimens may leave the trial for futility (< 10% probability of success), maximum sample size accrual (with probability of success ≥ 10% and < 85%), or safety concerns as recommended by the independent DSMB. For HER2+ patients, the I-SPY2 control arm was 12 weekly cycles of paclitaxel+trastuzumab (TH, control) followed by doxorubicin/cyclophosphamide (AC) q2-3 weeks x4 and surgery. Patritumab is a fully human monoclonal antibody that inhibits HER3. In this experimental arm for HER2+ patients, patritumab was given q3w x 4 cycles (18mg/kg loading dose followed by 9mg/kg/dose) concurrent with paclitaxel and trastuzumab q1w x 12 weeks (PTH, treatment), followed by AC q2-3w.
Methods: Women with tumors ≥ 2.5cm were eligible for screening. MP low/HR+ tumors were ineligible. MRI scans (baseline, 3 weeks after start of therapy, prior to AC, and prior to surgery) were used in a longitudinal statistical model to predict pCR for individual patients. Analysis was intention to treat. Patients who switched to non-protocol therapy count as non-pCR. Patients on treatment arm therapy at the time of arm closure are non-evaluable. Graduation potential was in 3 of 10 pre-defined signatures: all HER2+, HR-/HER2+, and HR+/HER2+.
Results: The PTH regimen was stopped at the recommendation of the Safety Working Group and DSMB based on a safety event (bilateral sensorineural hearing loss, Gr 3) observed in one patient. At the time of arm closure, N=31 patients had received PTH treatment; 4 patients receiving PTH were changed to non-protocol therapy and removed from the analysis. The final estimated pCR report will consider 27 PTH and 31 TH as evaluable patients. Accrual was insufficient to assess graduation, however, there appears to be good signal in the HER2+HR- but not HER2+HR+ signatures.
I-SPY 2 TRIAL Est. pCR at time of arm closureSignaturesPTH (Treatment)N= 31TH (Control)N = 31All (HER2+)0.40 (0.22 - 0.59), n=310.23 (0.09 - 0.37), n=31HR-/HER2+0.64 (0.36 - 0.91), n=110.30 (0.12 - 0.47), n=12HR+/HER2+0.28 (0.08 - 0.48), n=200.20 (0.06 - 0.34), n=19
HR+/HER2+0.28 (0.08 - 0.48), n=200.20 (0.06 - 0.34), n=19The patient who developed Gr3 sensorineural hearing loss 6 days after the 2nd patritumab (and 4th paclitaxel/trastuzumab) treatment, did not recover her hearing after patritumab was stopped, and also reported Gr3 vulvovaginal pain, vulvitis, and vaginal inflammation. Other gynecological symptoms in the PTH arm include: 1 pt with Gr1 vaginal hemorrhage, and 1 pt with Gr2 dyspareunia. There was a higher frequency of Gr3 hypokalaemia (12.5% vs. 3.2%). One pt in the PTH arm reported Gr3 small intestinal obstruction which resolved with conservative management.
Conclusion: The I-SPY 2 study aims to assess the probability that investigational regimens will be successful in a phase 3 neoadjuvant trial; PTH was stopped due to safety concerns, although there was activity in the HER2+ HR- signature. This is the first report of Gr3 hearing loss associated with patritumab/paclitaxel/trastuzumab, and thus attribution is uncertain.
Citation Format: Teresa L Helsten, Shelly S Lo, Christina Yau, Kevin Kalinsky, Anthony D Elias, Anne M Wallace, A. Jo Chien, Janice Lu, Julie E Lang, Kathy S Albain, Erica Stringer-Reasor, Amy S Clark, Judy C Boughey, Erin D Ellis, Douglas Yee, Angela DeMichele, Claudine Isaacs, Jane Perlmutter, Hope S Rugo, Richard Schwab, Nola M. Hylton, W. Fraser Symmans, Michelle E Melisko, Laura J van't Veer, Amy Wilson, Ruby Singhrao, Smita M Asare, Ashish Sanil, Donald A Berry, Laura J Esserman. Evaluation of patritumab/paclitaxel/trastuzumab over standard paclitaxel/trastuzumab in early stage, high-risk HER2 positive breast cancer: Results from the neoadjuvant I-SPY 2 trial [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-11-02.
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Affiliation(s)
| | | | - Christina Yau
- 3University of California, San Francisco, San Francisco, CA
| | | | | | | | - A. Jo Chien
- 3University of California, San Francisco, San Francisco, CA
| | - Janice Lu
- 6University of Southern California, Los Angeles, CA
| | - Julie E Lang
- 6University of Southern California, Los Angeles, CA
| | | | | | - Amy S Clark
- 8University of Pennsylvania, Philadelphia, PA
| | | | | | - Douglas Yee
- 11Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | | | | | | | - Hope S Rugo
- 3University of California, San Francisco, San Francisco, CA
| | | | - Nola M. Hylton
- 3University of California, San Francisco, San Francisco, CA
| | | | | | | | - Amy Wilson
- 16Quantum Leap Healthcare Collaborative, San Francisco, CA
| | - Ruby Singhrao
- 3University of California, San Francisco, San Francisco, CA
| | - Smita M Asare
- 16Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | - Donald A Berry
- 14University of Texas, M.D. Anderson Cancer Center, Houston, TX
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Liu MC, Robinson PA, Yau C, Wallace AM, Chien AJ, Stringer-Reasor E, Nanda R, Yee D, Albain KS, Boughey JC, Han HS, Elias AD, Kalinsky K, Clark AS, Kemmer K, Isaacs C, Lang JE, Lu J, Sanft T, DeMichele A, Hylton NM, Melisko ME, Perlmutter J, Rugo HS, Schwab R, Symmans WF, van't Veer LJ, Haugen PK, Wilson A, Singhrao R, Asare S, Sanil A, Berry DA, Esserman LJ. Abstract P3-09-02: Evaluation of a novel agent plus standard neoadjuvant therapy in early stage, high-risk HER2 negative breast cancer: Results from the I-SPY 2 TRIAL. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p3-09-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: I-SPY2 is a multicenter, response-adaptive randomization phase 2 trial to evaluate novel agents when added to standard neoadjuvant therapy for women with high-risk stage II/III breast cancer - weekly paclitaxel + investigational treatment x 12 wks followed by doxorubicin & cyclophosphamide(AC) q3 wks x 4 vs. weekly paclitaxel/AC (control). The primary endpoint is pathologic complete response (pCR). The goal for all investigational arms is to identify/graduate regimens with ≥85% Bayesian predictive probability of success (i.e. demonstrating superiority to control) in a future 300-patient phase 3 1:1 randomized neoadjuvant trial with a pCR endpoint within signatures defined by hormone-receptor (HR) & HER2 status & MammaPrint (MP). Findings from the graduated, previously reported Pembro4 arm (Nanda et al, ASCO 2017) supported investigation of de-escalating therapy, and determining if pembrolizumab (an anti-PD-1 antibody) alone q3 wks x 4 after weekly paclitaxel x 12 wks + pembrolizumab q3 wks x 4 was sufficient to sustain response without AC.
Methods: Women with tumors ≥2.5cm were eligible for screening. MP low/HR+ were ineligible. MRI scans (at baseline, 3 wks, 12 wks, and prior to surgery) were used in a longitudinal statistical model to predict pCR for individual patients (pts). Pts who receive non-protocol therapy (e.g., carboplatin or AC for the Pembro8-noAC arm) count as non-pCR. Pembro8-noAC was open to HER2- pts for evaluation in 3 of 10 pre-defined signatures: HER2-, HR+/HER2-, and HR-/HER2-. Regimens exit the trial for futility (<10% probability of success), maximum sample size accrual (10% <probability of success <85%), or safety as recommended by the independent DSMB.
Results: Pembro8-noAC was randomized to 73 pts, 3 of whom progressed while receiving pembrolizumab alone on study. Randomization to this arm continued after the first report because the rate of progression during AC over the course of the trial was estimated to be 6.5% based on serial MRI studies. However, notification of the third case prompted the study team to ask the DSMB for the summary response for this arm. Although it did not meet formal stopping rules for either graduation or futility, Pembro8-noAC was not near the target threshold pCR rates of 60% for HR-/HER2- and 30% for HR+/HER2+. As a result of this information, combined with the on-treatment progressions, assignment to Pembro8-noAC was discontinued. Treatment with pembrolizumab alone was no longer allowed due to the potential concern for progression, and investigators were given the option to administer AC with pembrolizumab or proceed with definitive surgery following the 12 weeks of paclitaxel + pembrolizumab. 34 pts had surgery results at the time the study was closed. Of the remaining 39 pts, 34 pts have on-therapy MRI assessments. Estimated pCR rates were based on all pts with information at the time (see table). Immune-related adverse events included grade 3 colitis (n=2), grade 3 pneumonitis (n=1), grade 3 transaminitis (n=1), grade 3 hypothyroidism (n=1), and grade 1-2 adrenal insufficiency (n=5).
Conclusion: Although Pembro8-noAC is performing at least as well as standard paclitaxel/AC, the likelihood is very low that the regimen would be successful in a phase 3 trial. Pembrolizumab alone following 12 weeks of paclitaxel + pembrolizumab was not sufficient to sustain a response. This was quickly assessed with a small number of patients.
Estimated pCR rateSignature(95% prob interval)Pembro8-noACControlHER2-0.210.2(0.09-0.32)(0.15-0.25)HR-/HER2-0.270.27(0.09-0.45)(0.19-0.35)HR+/HER2-0.150.15(0.01-0.29)(0.09-0.20)
Citation Format: Minetta C. Liu, Patricia A Robinson, Christina Yau, Anne M Wallace, A. Jo Chien, Erica Stringer-Reasor, Rita Nanda, Douglas Yee, Kathy S Albain, Judy C Boughey, Heather S Han, Anthony D Elias, Kevin Kalinsky, Amy S Clark, Kathleen Kemmer, Claudine Isaacs, Julie E Lang, Janice Lu, Tara Sanft, Angela DeMichele, Nola M Hylton, Michelle E Melisko, Jane Perlmutter, Hope S Rugo, Richard Schwab, W. Fraser Symmans, Laura J van't Veer, Patricia K Haugen, Amy Wilson, Ruby Singhrao, Smita Asare, Ashish Sanil, Donald A Berry, Laura J Esserman. Evaluation of a novel agent plus standard neoadjuvant therapy in early stage, high-risk HER2 negative breast cancer: Results from the I-SPY 2 TRIAL [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-09-02.
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Affiliation(s)
| | | | - Christina Yau
- 3University of California, San Francisco, San Francisco, CA
| | | | - A. Jo Chien
- 3University of California, San Francisco, San Francisco, CA
| | | | - Rita Nanda
- 6The University of Chicago Medical Center, Chicago, IL
| | - Douglas Yee
- 7Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | | | | | | | | | | | - Amy S Clark
- 11University of Pennsylvania, Philadelphia, PA
| | | | | | - Julie E Lang
- 14University of Southern California, Los Angeles, CA
| | - Janice Lu
- 14University of Southern California, Los Angeles, CA
| | | | | | - Nola M Hylton
- 3University of California, San Francisco, San Francisco, CA
| | | | | | - Hope S Rugo
- 3University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Amy Wilson
- 19Quantum Leap Healthcare Collaborative, San Francisco, CA
| | - Ruby Singhrao
- 3University of California, San Francisco, San Francisco, CA
| | - Smita Asare
- 19Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | - Donald A Berry
- 17University of Texas, M.D. Anderson Cancer Center, Houston, TX
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Onishi N, Li W, Newitt DC, Harnish R, Gibbs J, Jones EF, Nguyen A, Wilmes L, Joe BN, Campbell MJ, Basu A, van’t Veer LJ, DiMichele A, Yee D, Berry DA, Albain KS, Boughey JC, Chien AJ, Clark AS, Edmiston KK, Elias AD, Ellis ED, Euhus DM, Han HS, Isaacs C, Khan QJ, Lang JE, Lu J, Meisel JL, Mitri Z, Nanda R, Northfelt DW, Sanft T, Stringer-Reasor E, Viscusi RK, Wallace AM, Yung R, Melisko ME, Perlmutter J, Rugo HS, Schwab R, Symmans WF, Asare SM, Yau JE, Yau C, Esserman LJ, Hylton NM. Abstract PD9-05: Lack of background parenchymal enhancement suppression in breast MRI during neoadjuvant chemotherapy may be associated with inferior treatment response in hormone receptor positive breast cancer. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-pd9-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose
In breast MRI, contrast enhancement of normal fibroglandular tissue is referred to as background parenchymal enhancement (BPE). Hormonal status significantly affects the degree of BPE, potentially due to the association with mammary vascularity and activity1-5. Studies have shown that BPE may be associated with breast cancer survival6, treatment response to neoadjuvant chemotherapy (NAC)7,8 and future breast cancer risk9. In most patients undergoing NAC, BPE is suppressed by the nonspecific anti-proliferative effects of chemotherapy on normal breast and/or ovary5,10. However, some patients exhibit equivalent or even stronger BPE post-NAC compared to pre-NAC. We hypothesized that non-suppressed BPE in post-NAC MRI may be associated with inferior treatment response. This study aimed to investigate the association between BPE suppression and treatment response as defined by pathologic complete response (pCR).
Methods
This study included patients with stage II/III breast cancer enrolled in the I-SPY 2 TRIAL being treated with standard NAC with or without investigational agents. The whole cohort was split into two subgroups based on hormone receptor status (HR+, n= 536; HR-, n=452). Patients underwent dynamic contrast enhanced MRIs at four time points during NAC: baseline (T0), after 3 weeks of the first regimen (T1), inter-regimen (T2), and pre-surgery (T3). Using in-house software, the contralateral breast parenchyma was automatically segmented for the entire breast volume. Quantitative BPE (qBPE) was calculated as the mean early (~150s post-contrast injection) percent enhancement of the central 50% of the axial slices. A breast radiologist reviewed all exams and excluded those where automated segmentation failed to accurately define tissue. For T1, T2 and T3, BPE was categorized based on the change from T0 as suppressed (qBPE < qBPE[T0]) or non-suppressed (qBPE ≥ qBPE[T0]). Chi-squared test was used to examine the association between BPE suppression and pCR, with p<0.05 considered statistically significant.
Results
HR+ cohort: pCR rates were lower for patients with non-suppressed BPE than those with suppressed BPE at every visit (T1-T3) (Table 1). The difference was statistically significant at T2 (p=0.04) and T3 (p=0.01).
Table 1: HR+ cohortpCR rate (%)No. of pCR patientsNo. of non-pCR patientsTotal number of patientsP valueOverall22.8122414536BPE at T1suppressed23.6822663480.45non-suppressed20.532124156BPE at T2suppressed25.7972803770.04*non-suppressed16.01789106BPE at T3suppressed25.7982833810.01*non-suppressed12.5128496
HR- cohort: pCR rates were slightly lower for the non-suppressed BPE group, but no statistically significant association was found (Table 2).
Table 2: HR- cohortpCR rate (%)No. of pCR patientsNo. of non-pCR patientsTotal number of patientsP valueOverall44.7202250452BPE at T1suppressed46.81411603010.66non-suppressed44.45265117BPE at T2suppressed48.81441512950.79non-suppressed47.3434891BPE at T3suppressed49.31461502960.94non-suppressed48.9434588
Conclusion
In HR+ breast cancer, lack of BPE suppression may indicate inferior treatment response. The contrasting results in HR+ and HR- cohorts are noteworthy in terms of the possible relationship between suppression of normal mammary and ovarian activity and treatment response in HR+ cancer.
Reference
Radiographics 2014; 34: 234-47.
Radiology 1997; 203: 137-44.
Radiology 1997; 203: 145-9.
Breast J 2005; 11: 236-41.
AJR Am J Roentgenol 2015; 204: 669-73.
Eur Radiol 2018; 28: 4705-16.
Eur Radiol 2016; 26: 1590-6.
Transl Oncol 2015; 8: 204-9.
J Clin Oncol 2019; : JCO1800378.
Radiology 2015; 277: 687-96.
Citation Format: Natsuko Onishi, Wen Li, David C. Newitt, Roy Harnish, Jessica Gibbs, Ella F. Jones, Alex Nguyen, Lisa Wilmes, Bonnie N. Joe, Michael J. Campbell, Amrita Basu, Laura J. van’t Veer, Angela DiMichele, Douglas Yee, Donald A. Berry, Kathy S. Albain, Judy C. Boughey, A. Jo Chien, Amy S. Clark, Kirsten K. Edmiston, Anthony D. Elias, Erin D. Ellis, David M. Euhus, Heather S. Han, Claudine Isaacs, Qamar J. Khan, Julie E. Lang, Janice Lu, Jane L. Meisel, Zaha Mitri, Rita Nanda, Donald W. Northfelt, Tara Sanft, Erica Stringer-Reasor, Rebecca K. Viscusi, Anne M. Wallace, Rachel Yung, Michelle E. Melisko, Jane Perlmutter, Hope S. Rugo, Richard Schwab, W. Fraser Symmans, Smita M. Asare, Julie E. Yau, Christina Yau, Laura J. Esserman, Nola M. Hylton. Lack of background parenchymal enhancement suppression in breast MRI during neoadjuvant chemotherapy may be associated with inferior treatment response in hormone receptor positive breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD9-05.
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Affiliation(s)
- Natsuko Onishi
- 1University of California, San Francisco, San Francisco, CA
| | - Wen Li
- 1University of California, San Francisco, San Francisco, CA
| | | | - Roy Harnish
- 1University of California, San Francisco, San Francisco, CA
| | - Jessica Gibbs
- 1University of California, San Francisco, San Francisco, CA
| | - Ella F. Jones
- 1University of California, San Francisco, San Francisco, CA
| | - Alex Nguyen
- 1University of California, San Francisco, San Francisco, CA
| | - Lisa Wilmes
- 1University of California, San Francisco, San Francisco, CA
| | - Bonnie N. Joe
- 1University of California, San Francisco, San Francisco, CA
| | | | - Amrita Basu
- 1University of California, San Francisco, San Francisco, CA
| | | | | | - Douglas Yee
- 3Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | | | | | | | - A. Jo Chien
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | - Julie E. Lang
- 14University of Southern California, Los Angeles, CA
| | - Janice Lu
- 14University of Southern California, Los Angeles, CA
| | | | - Zaha Mitri
- 16Oregon Health & Science University, Portland, OR
| | - Rita Nanda
- 17The University of Chicago Medical Center, Chicago, IL
| | | | | | | | | | | | - Rachel Yung
- 23CTEP, National Cancer Institute, Bethesda, MD
| | | | | | - Hope S. Rugo
- 1University of California, San Francisco, San Francisco, CA
| | | | | | - Smita M. Asare
- 26Quantum Leap Healthcare Collaborative, San Francisco, CA
| | - Julie E. Yau
- 14University of Southern California, Los Angeles, CA
| | - Christina Yau
- 1University of California, San Francisco, San Francisco, CA
| | | | - Nola M. Hylton
- 1University of California, San Francisco, San Francisco, CA
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Yau C, DeMichele A, Symmans WF, Pusztai L, Yee D, Clark AS, Hatzis C, Matthews JB, Carter J, Chen YY, Cole K, Khazai L, Klein M, Kokh D, Krings G, Sahoo S, Albain KS, Chien AJ, Edmiston KK, Elias AD, Ellis ED, Euhus DM, Han HS, Isaacs C, Khan QJ, Lang JE, Lu J, Meisel JL, Mitri Z, Nanda R, Northfelt DW, Sanft T, Stringer-Reasor E, Viscusi RK, Wallace AM, Yung R, Hylton NM, Boughey JC, Melisko ME, Perlmutter J, Rugo HS, Schwab R, van' t Veer LJ, Berry DA, Esserman LJ. Abstract P2-20-02: Site of recurrence after neoadjuvant therapy: Clues to biology and impact on endpoints. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p2-20-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Achieving a pathologic complete response (pCR) has been shown on the patient level to predict excellent long-term event-free survival outcomes. Residual cancer burden (RCB) quantifies the extent of residual disease for patients who did not achieve pCR. A high proportion of metastatic events to the central nervous system (CNS), a known chemotherapy sanctuary site, was previously observed among the small number of relapses in patients achieving a pCR (Symmans et al 2017), raising the possibility that these CNS events may be independent of response in the breast. I-SPY2 is an adaptively randomized, phase II, platform trial that evaluates new drugs and combinations in the neoadjuvant setting for women with high-risk primary breast cancer. In this study, we evaluated the type and sites of recurrences by RCB classes in the I-SPY 2 TRIAL.
Methods: I-SPY 2 patients enrolled prior to 11/2016 across 9 experimental and control arms, with available RCB and event-free survival (EFS) data were included in this analysis. The median follow-up is 3.8 years. We summarized the EFS event type, further sub-dividing the distant recurrence events by their site of relapse (CNS-only, CNS and other sites, Non-CNS). We estimated the overall and site-specific distant recurrence incidence in each RCB class at 3 years using a competing risk (Fine-Gray) model. In addition, we assessed the association between RCB and distant recurrence free survival including all distant recurrences (DRFS), as well as excluding the CNS-only recurrences (non-CNS DRFS) using a Cox model. Our statistics do not adjust for multiplicities beyond variables evaluated in this study.
Results: Among 938 subjects, there were 180 EFS events, including 28 (16%) local recurrences (without distant recurrence and/or death) and 152 DRFS events. Among the DRFS events, 25 patients died without a distant recurrence. 127 experienced distant recurrences, including 22 (17.3%) with CNS-only, 16 (12.6%) with CNS and other sites, 87 (68.5%) with non-CNS distant recurrence; 2 (1.6%) patients had missing recurrence site information. Incidence of CNS-only recurrences are low and are similar across RCB classes (pCR/RCB-0 (n=338): 1%, RCB-I (n=129): 3%, RCB-II (n=328): 2%, RCB-III (n=143): 2% at 3 years). In contrast, the incidence of non-CNS recurrences increase with increasing RCB (RCB-0: 2%, RCB-I: 4%, RCB-II: 11%, RCB-III: 19% at 3 years). DRFS of RCB-I patients do not significantly differ from those achieving a pCR/RCB-0 (DRFS at 3 years: 92% vs. 95%, hazard ratio: 1.77 (0.87-3.63)); the small numerical difference is further reduced when the CNS-only recurrences are excluded (non-CNS DRFS at 3 years: 95% vs. 96%, hazard ratio: 1.48 (0.61-3.58)). CNS recurrences among DRFS events are proportionally higher within the pCR (5/16 (31%)) and RCB-I (5/12 (42%)) than in the RCB-II (8/57 (14%)) and RCB-III (4/42 (9%)) groups largely because of the relative low frequency of non-CNS recurrence events.
Conclusions: In our high-risk I-SPY 2 cohort, CNS-only recurrences are uncommon but appear similar across RCB groups, independent of response, suggesting that the CNS is a treatment sanctuary site. In contrast, non-CNS recurrence rates increase as RCB increases. These findings, if confirmed, support the use of RCB to identify patients with excellent outcomes beyond those achieving a pCR; and suggest that inclusion of CNS only recurrences as an outcome event may impact the association between neoadjuvant therapy response and long-term outcome.
Citation Format: Christina Yau, Angela DeMichele, W. Fraser Symmans, Lajos Pusztai, Douglas Yee, Amy S. Clark, Christos Hatzis, Jeffrey B. Matthews, Jodi Carter, Yunn-Yi Chen, Kimberly Cole, Laila Khazai, Molly Klein, Dina Kokh, Gregor Krings, Sunati Sahoo, Kathy S. Albain, A. Jo Chien, Kirsten K. Edmiston, Anthony D. Elias, Erin D. Ellis, David M. Euhus, Heather S. Han, Claudine Isaacs, Qamar J. Khan, Julie E. Lang, Janice Lu, Jane L. Meisel, Zaha Mitri, Rita Nanda, Donald W. Northfelt, Tara Sanft, Erica Stringer-Reasor, Rebecca K. Viscusi, Anne M. Wallace, Rachel Yung, Nola M. Hylton, Judy C. Boughey, Michelle E. Melisko, Jane Perlmutter, Hope S. Rugo, Richard Schwab, Laura J. van' t Veer, Donald A. Berry, Laura J. Esserman. Site of recurrence after neoadjuvant therapy: Clues to biology and impact on endpoints [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-20-02.
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Affiliation(s)
- Christina Yau
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | - Douglas Yee
- 5Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | | | | | | | | | - Yunn-Yi Chen
- 1University of California, San Francisco, San Francisco, CA
| | | | | | - Molly Klein
- 5Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Dina Kokh
- 9University of Alabama at Birmingham, Birmingham, AL
| | - Gregor Krings
- 1University of California, San Francisco, San Francisco, CA
| | | | | | - A. Jo Chien
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Heather S. Han
- 1University of California, San Francisco, San Francisco, CA
| | | | | | - Julie E. Lang
- 18University of Southern California, Los Angeles, CA
| | - Janice Lu
- 18University of Southern California, Los Angeles, CA
| | | | - Zaha Mitri
- 20Oregon Health & Science University, Portland, OR
| | - Rita Nanda
- 21The University of Chicago Medical Center, Chicago, IL
| | | | | | | | | | | | | | - Nola M. Hylton
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | - Hope S. Rugo
- 1University of California, San Francisco, San Francisco, CA
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Li W, Onishi N, Newitt DC, Gibbs J, Wilmes LJ, Jones EF, Joe BN, Sit LS, Yau C, Chien AJ, Price E, Albain KS, Kuritza T, Morley K, Boughey JC, Brandt K, Choudhery S, Clark AS, Rosen M, McDonald ES, Elias AD, Wolverton D, Fountain K, Euhus DM, Han HS, Niell B, Drukteinis J, Lang JE, Lu J, Meisel JL, Mitri Z, Nanda R, Northfelt DW, Sanft T, Stringer-Reasor E, Viscusi RK, Wallace AM, Yee D, Yung R, Asare SM, Melisko ME, Perlmutter J, Rugo HS, Schwab R, Symmans WF, van't Veer LJ, Berry DA, DeMichele A, Abe H, Sheth D, Edmiston KK, Ellis ED, Ha R, Wynn R, Crane EP, Dillis C, Nelson M, Church A, Isaacs C, Khan QJ, Oh KY, Jafarian N, Bang DH, Mullins C, Woodard S, Zamora KW, Ojeda-Fornier H, Sheth P, Hovanessian-Larsen L, Eghtedari M, Spektor M, Giurescu M, Newell MS, Cohen MA, Berman E, Lehman C, Smith W, Fitzpatrick K, Borders MH, Yang W, Dogan B, Goudreau S, Brown T, Esserman LJ, Hylton NM. Abstract PD9-04: Breast cancer subtype specific association of pCR with MRI assessed tumor volume progression during NAC in the I-SPY 2 trial. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-pd9-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: In an adaptive randomized trial, when new treatment combinations are being tested, it is important to be able to identify patients who are progressing on treatment so that they can be changed to a different therapeutic regimen. We know that even within the molecularly high risk patients in I-SPY 2, there is considerable variation in biology. In this study, we will present results of using MRI-calculated functional tumor volume (FTV) to identify tumor progression for each breast cancer subtype.
Methods: Patients (n=990) enrolled in the I-SPY 2 TRIAL who were randomized to the graduated experimental drug arms or controls from 2010 to 2016 were analyzed. Four MRI exams were performed for each patient: pre-NAC (T0), after 3 weeks of NAC (T1), between regimens (T2), and post-NAC (T3). Functional tumor volume (FTV) was calculated at each exam by summing voxels meeting enhancement thresholds. Tumor progression at T1, T2 or T3 was identified by a positive FTV change relative to T0. Visual inspection was used to exclude false progression due to strong background parenchymal enhancement post-contrast, prominent vessels, motion, or insufficient image quality. pCR was defined as no invasive disease in the breast and lymph nodes. Negative predictive value for pCR was defined as:NPV=number of true non-pCRs / number of patients with MRI assessed tumor progressions, where “true non-pCRs” referred to patients who were non-pCRs at surgery and were assessed as progressors by MRI. The analysis was performed in the full cohort and in sub-cohorts defined by HR and HER2 statuses.
Results: Out of 990 patients, 878 had pCR outcome data (pCR or non-pCR, pCR rate = 35%). Total and non-pCR numbers for each subtype, number of patients with tumor progression assessed by MRI at T1, T2, and T3, and NPVs, are shown in Table 1. In the full cohort, the NPV increased consistently over treatment, from T1 (NPV=83%) to T2 (93%), and to T3 (100%). The HER2+ cancer subtypes showed fewer MRI-assessed tumor progressions than HER2- subtypes: e.g. 10/209 (5%) vs. 108/669 (16%) at T1. NPV was 100% for HER2+ subtypes at T1 and T2 except for a single misclassification of a HR- tumor at T1. Only 6 tumor progressors, all HER2- were identified at T3, and all were confirmed at surgery as non-pCRs (NPV=100%). For HR+/HER2-, the NPV increased slightly from 89% at T1 to 91% at T2, while triple negative subtype had a more substantial increase, from 78% to 92%.
Conclusions: Our study showed strong association between tumor progressors assessed by MRI with true non-pCRs after NAC. For HER2+ tumors, although MRI progressors are rare, they strongly indicate non-pCR at all treatment time points, while HER2- subtypes show more accurate results later in treatment. We are evaluating MRI change at 6 weeks to determine if that time point is sufficient to predict progressors.
Table 1 MRI assessed tumor progression at different treatment time pointN/non-pCRs/%non-pCRMRI assessed tumor progressionT1 (after 3 weeks)T2 (inter-regimen)T3 (post-NAC)NNPV (%)NNPV (%)NNPV (%)Full cohort878/572/65%11883.14192.76100%HR+/HER2-344/280/81%4588.91190.93100%HR+/HER2+134/85/63%610021000N/AHR-/HER2+75/23/31%47521000N/Atriple negative325/184/57%6377.82692.33100%
Citation Format: Wen Li, Natsuko Onishi, David C Newitt, Jessica Gibbs, Lisa J Wilmes, Ella F Jones, Bonnie N Joe, Laura S Sit, Christina Yau, A. Jo Chien, Elissa Price, Kathy S Albain, Theresa Kuritza, Kevin Morley, Judy C Boughey, Kathy Brandt, Sadia Choudhery, Amy S Clark, Mark Rosen, Elizabeth S McDonald, Anthony D Elias, Dulcy Wolverton, Kelly Fountain, David M Euhus, Heather S Han, Bethany Niell, Jennifer Drukteinis, Julie E Lang, Janice Lu, Jane L Meisel, Zaha Mitri, Rita Nanda, Donald W Northfelt, Tara Sanft, Erica Stringer-Reasor, Rebecca K Viscusi, Anne M Wallace, Douglas Yee, Rachel Yung, Smita M Asare, Michelle E Melisko, Jane Perlmutter, Hope S Rugo, Richard Schwab, W. Fraser Symmans, Laura J van't Veer, Donald A Berry, Angela DeMichele, Hiroyuki Abe, Deepa Sheth, Kirsten K Edmiston, Erin D Ellis, Richard Ha, Ralph Wynn, Erin P Crane, Charlotte Dillis, Michael Nelson, An Church, Claudine Isaacs, Qamar J Khan, Karen Y Oh, Neda Jafarian, Dae Hee Bang, Christiane Mullins, Stefanie Woodard, Kathryn W Zamora, Haydee Ojeda-Fornier, Pulin Sheth, Linda Hovanessian-Larsen, Mohammad Eghtedari, Michael Spektor, Marina Giurescu, Mary S Newell, Michael A Cohen, Elise Berman, Constance Lehman, William Smith, Kim Fitzpatrick, Marisa H Borders, Wei Yang, Basak Dogan, Sally Goudreau, Thelma Brown, Laura J Esserman, Nola M Hylton. Breast cancer subtype specific association of pCR with MRI assessed tumor volume progression during NAC in the I-SPY 2 trial [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD9-04.
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Affiliation(s)
- Wen Li
- 1University of California, San Francisco, San Francisco, CA
| | - Natsuko Onishi
- 1University of California, San Francisco, San Francisco, CA
| | - David C Newitt
- 1University of California, San Francisco, San Francisco, CA
| | - Jessica Gibbs
- 1University of California, San Francisco, San Francisco, CA
| | - Lisa J Wilmes
- 1University of California, San Francisco, San Francisco, CA
| | - Ella F Jones
- 1University of California, San Francisco, San Francisco, CA
| | - Bonnie N Joe
- 1University of California, San Francisco, San Francisco, CA
| | - Laura S Sit
- 1University of California, San Francisco, San Francisco, CA
| | - Christina Yau
- 1University of California, San Francisco, San Francisco, CA
| | - A. Jo Chien
- 1University of California, San Francisco, San Francisco, CA
| | - Elissa Price
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | - Amy S Clark
- 4University of Pennsylvania, Philadelphia, PA
| | - Mark Rosen
- 4University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | | | | | | | - Julie E Lang
- 8University of Southern California, Los Angeles, CA
| | - Janice Lu
- 8University of Southern California, Los Angeles, CA
| | | | - Zaha Mitri
- 10Oregon Health & Science University, Portland, OR
| | - Rita Nanda
- 11The University of Chicago Medical Center, Chicago, IL
| | | | | | | | | | | | | | - Rachel Yung
- 18CTEP, National Cancer Institute, Rockville, MD
| | - Smita M Asare
- 19Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | | | - Hope S Rugo
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | - Hiroyuki Abe
- 11The University of Chicago Medical Center, Chicago, IL
| | - Deepa Sheth
- 11The University of Chicago Medical Center, Chicago, IL
| | | | | | - Richard Ha
- 25Columbia University, New York City, NY
| | - Ralph Wynn
- 25Columbia University, New York City, NY
| | | | | | | | - An Church
- 17University of Minnesota, Minneapolis, MN
| | | | | | - Karen Y Oh
- 10Oregon Health & Science University, Portland, OR
| | | | | | | | | | | | | | - Pulin Sheth
- 8University of Southern California, Los Angeles, CA
| | | | | | | | | | | | | | | | | | | | | | | | - Wei Yang
- 21University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - Basak Dogan
- 21University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - Sally Goudreau
- 30University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Nola M Hylton
- 1University of California, San Francisco, San Francisco, CA
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Swisher MW, Wallace AM, Sztain JF, Said ET, Khatibi B, Abanobi M, Finneran IV JJ, Gabriel RA, Abramson W, Blair SL, Hosseini A, Dobke MK, Donohue MC, Ilfeld BM. Erector spinae plane versus paravertebral nerve blocks for postoperative analgesia after breast surgery: a randomized clinical trial. Reg Anesth Pain Med 2020; 45:260-266. [DOI: 10.1136/rapm-2019-101013] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 01/31/2023]
Abstract
BackgroundParavertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also provides perioperative breast analgesia, but is purported to be easier to administer with a favorable safety profile. However, it remains unknown if the new ESPB provides comparable analgesia as the decades-old PVB technique.MethodsSubjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection ESPB or PVB in a subject-blinded fashion (ropivacaine 0.5% with epinephrine; 20 mL unilateral or 16 mL/side for bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room as measured on a Numeric Rating Scale (NRS) with ESPB, and (2) opioid consumption would be non-inferior in the operating and recovery rooms with ESPB.ResultsBoth pain scores and opioid consumption were higher in subjects with ESPBs (n=50) than PVBs (n=50; median NRS 3.0 vs 0; 95% CI −3.0 to 0; p=0.0011; and median morphine equivalents 2.0 vs 1.5 mg; 95% CI −1.2 to −0.1; p=0.0043). No block-related adverse events occurred in either group.ConclusionsPVBs provided superior analgesia and reduced opioid requirements following non-mastectomy breast surgery. To compare the relatively rare complications between the techniques will require a sample size 1–2 orders of magnitude greater than the current investigation; however, without a dramatic improvement in safety profile for ESPBs, it appears that PVBs are superior to ESPBs for postoperative analgesia after non-mastectomy breast surgery.Trial registration numberNCT03549234.
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Gabriel RA, Finneran JJ, Swisher MW, Said ET, Sztain JF, Khatibi B, Wallace AM, Hosseini A, Trescot AM, Ilfeld BM. Ultrasound-guided percutaneous intercostal cryoanalgesia for multiple weeks of analgesia following mastectomy: a case series. Korean J Anesthesiol 2019; 73:163-168. [PMID: 31475505 PMCID: PMC7113157 DOI: 10.4097/kja.19332] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 08/26/2019] [Indexed: 12/02/2022] Open
Abstract
Background Acute post-mastectomy pain is frequently challenging to adequately treat with local anesthetic-based regional anesthesia techniques due to its relatively long duration measured in multiple weeks. Case We report three cases in which preoperative ultrasound-guided percutaneous intercostal nerve cryoneurolysis was performed to treat pain following mastectomy. Across all postoperative days and all three patients, the mean pain score on the numeric rating scale was 0 for each day. Similarly, no patient required any supplemental opioid analgesics during the entire postoperative period; and, no patient reported insomnia or awakenings due to pain at any time point. This was a significant improvement over historic cohorts. Conclusions Ultrasound-guided percutaneous cryoanalgesia is a potential novel analgesic modality for acute pain management which has a duration that better-matches mastectomy than other currently-described techniques. Appropriately powered randomized, controlled clinical trials are required to demonstrate and quantify both potential benefits and risks.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA.,Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA
| | - John J Finneran
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Matthew W Swisher
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Engy T Said
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Anne M Wallace
- Department of Surgery, University of California, San Diego, La Jolla, CA, USA
| | - Ava Hosseini
- Department of Surgery, University of California, San Diego, La Jolla, CA, USA
| | | | - Brian M Ilfeld
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
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Schwab R, Clark AS, Yau C, Hylton N, Li W, Wolfe D, Chien AJ, Wallace AM, Forero-Torres A, Stringer-Reasor E, Nanda R, Jaskowiak N, Boughey J, Haddad T, Han HS, Lee C, Albain K, Isaacs C, Elias AD, Ellis ED, Shah P, Lang JE, Lu J, Tripathy D, Kemmer K, Yee D, Haley B, Majure M, Roesch E, Vaklavas C, Ewing C, Helsten T, Symmans WF, Perlmutter J, Rugo HS, Melisko M, Wilson A, Singhrao R, Veer LV', DeMichele A, Asare S, Berry D, Esserman LJ. Abstract CT136: Evaluation of talazoparib in combination with irinotecan in early stage, high-risk HER2 negative breast cancer: Results from the I-SPY 2 TRIAL. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-ct136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: I-SPY2 is a multicenter, Phase II trial using response-adaptive randomization within biomarker subtypes to evaluate novel agents as neoadjuvant therapy for high-risk at least T2N0 breast cancer. The primary endpoint is pathologic complete response (pCR) at surgery. The goal is to identify regimens that have ≥ 85% Bayesian predictive probability of success in a 300-patient phase 3 neoadjuvant trial defined by hormone-receptor (HR) and HER2 status, and MammaPrint (MP). Regimens may leave the trial for futility (< 10% probability of success), maximum sample size accrual (with probability of success ≥ 10% and < 85%), or as recommended by the independent DSMB. For HER2- subjects the control arm is weekly paclitaxel x12 then doxorubicin & cyclophosphamide (AC) q2-3 weeks x4. For this arm, paclitaxel was omitted and replaced with maximum tolerated dose PARPi talazoparib with synergy dosed irinotecan (25mg/m2). Paclitaxel could be given adjuvantly for these subjects and non-responding subjects could be taken off of experimental therapy.
Methods: Women with tumors ≥ 2.5cm were eligible for screening. MP low/HR+ tumors were ineligible. MRI scans (baseline, 3 cycles after start of therapy, prior to AC, and prior to surgery) were used in a longitudinal statistical model to predict pCR for individual patients. Talazoparib was given at 1mg daily with 25mg/m2 irinotecan q2wks. Analysis was intention to treat. Subjects who switched to non-protocol therapy count as non-pCR. Subjects on experimental therapy at time of arm closure are non-evaluable. Talazoparib/irinotecan (TI) was open only to HER2- tumors and eligible for graduation in 3 of 10 pre-defined signatures: HER2-, HR+HER2- and HR-/HER2-.
Results: TI did not meet criteria for graduation and was stopped at the recommendation of the DSMB based on expectations of limited activity beyond that seen with standard treatment. Maximum sample size had been reached at the time of this recommendation and subjects currently receiving TI were allowed to continue or change to standard therapy.
Exploratory “as treated” analysis for response in gBRCA mutation carriers showed 6/10 gBRCA carriers attained a pCR in the TI arm. Except for 1 patient these gBRCA pCR subjects had >90% tumor reduction by MRI after TI and prior to AC (range: 68-96%). In the TI arm pCR rates were also higher in subjects with a PARPi7-High/MP2 gene expression signature (0.344 vs 0.146). Expected differences in toxicity were seen between arms including g3/4 peripheral neuropathy on control therapy which included paclitaxel (2.6% vs none) and g3/4 neutropenia with TI (30.2% vs 8.2%). Notably gBRCA mutation carriers receiving TI had higher rates of g3/4 neutropenia (60% vs 25.9%).
Conclusion: The I-SPY2 study finds the probability that investigational regimens will be successful in a Phase III neoadjuvant trial; TI did not reach the efficacy threshold of 85% probability of success in Phase III in any of the 3 signatures. However by adding talazoparib with synergy dosed irinotecan we were able to omit paclitaxel and observe similar estimated pCR rates. This informs current work to evolve the I-SPY2 trial design to reduce toxicity without compromising outcomes and develop successful combinations targeted to biology, including DNA repair deficiency.
Citation Format: Richard Schwab, Amy S. Clark, Christina Yau, Nola Hylton, Wen Li, Denise Wolfe, A Jo Chien, Anne M. Wallace, Andres Forero-Torres, Erica Stringer-Reasor, Rita Nanda, Nora Jaskowiak, Judy Boughey, Tufia Haddad, Heather S. Han, Catherine Lee, Kathy Albain, Claudine Isaacs, Anthony D. Elias, Erin D. Ellis, Payal Shah, Julie E. Lang, Janice Lu, Debasish Tripathy, Kathleen Kemmer, Douglas Yee, Barbara Haley, Melanie Majure, Erin Roesch, Christos Vaklavas, Cheryl Ewing, Teresa Helsten, W Fraser Symmans, Jane Perlmutter, Hope S. Rugo, Michelle Melisko, Amy Wilson, Ruby Singhrao, Laura van 't Veer, Angela DeMichele, Smita Asare, Don Berry, Laura J. Esserman. Evaluation of talazoparib in combination with irinotecan in early stage, high-risk HER2 negative breast cancer: Results from the I-SPY 2 TRIAL [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT136.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Amy Wilson
- 18Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | | | | | - Smita Asare
- 18Quantum Leap Healthcare Collaborative, San Francisco, CA
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Silverstein J, Suleiman L, Yau C, Price ER, Singhrao R, Yee D, DeMichele A, Isaacs C, Albain KS, Chien AJ, Forero-Torres A, Wallace AM, Pusztai L, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Leyland-Jones B, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, Berry DA, Asare SM, Esserman LJ, Boughey JC, Mukhtar RA. Abstract P2-14-01: The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 TRIAL. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p2-14-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: In women with breast cancer receiving neoadjuvant chemotherapy, residual cancer burden (RCB) predicts distant recurrence and survival. In those with high risk tumors, locoregional recurrence (LRR) remains a concern, and has been associated with type of local therapy received. We evaluated the impact of local therapy on LRR in the ISPY-2 TRIAL.
Methods: Data were analyzed in Stata 14.2, using Chi2 test, log rank test, and a Cox proportional hazards model. RCB was considered a categorical variable (0/1 versus 2/3), as described in prior publications. Breast surgery categories were lumpectomy +/- radiotherapy, or mastectomy +/- radiotherapy. Axillary surgery was defined as sentinel lymph node (SLN) surgery (≤6 nodes removed) or axillary dissection (>6 nodes).
Results: Follow up data from the I-SPY2 TRIAL were available for 630 patients (median follow up 2.76 yrs, range 0.4-7.2). Type of local therapy was significantly associated with clinical stage at presentation, with stage III patients most frequently undergoing mastectomy + radiation (p<0.001). Women with higher RCB were more likely to undergo mastectomy than those with lower RCB (61.3% vs 48.8% mastectomy rate, p=0.002), and more likely to receive adjuvant radiotherapy (62.0% vs 53.9%, p=0.048). There was no association between clinical stage, type of surgery, or radiotherapy and LRR (Table). Higher RCB was significantly associated with LRR, with 3 year locoregional recurrence free rate of 95.1% in RCB 0/1 versus 89.9% in RCB 2/3 (p=0.003).
In a Cox model adjusting for clinical stage, tumor subtype, surgical therapy, RCB status, nodal radiation, and age, significant predictors for LRR were tumor subtype and RCB status. Hazard ratio (HR) for LRR in those with RCB 0/1 was 0.39 compared to those with RCB 2/3 (95% CI 0.17-0.87, p=0.021). There was no difference in LRR between breast conservation and mastectomy; within the breast conservation group, those who had lumpectomy alone had higher hazard of LRR compared to those having lumpectomy + radiation (HR 3.1, 95% CI 1.1-9.2, p=0.043).
Conclusions: Extent of surgical therapy was not associated with local tumor control, regardless of advanced tumor stage at presentation. Rather, tumor biology and response to therapy were the best predictors of LRR. These data highlight the opportunity to minimize the morbidity of extensive surgical therapy for patients with excellent response to systemic therapy.
LRR rates by clinical features and treatment status FrequencyLRR RateP valueClinical Stage 0.5I240 (47.5%)5.8% II185 (36.6%)8.7% III80 (15.8%)6.3% Tumor Subtype 0.014ER+PR+Her2-161 (26.4%)3.1% ER+PR-Her2-56 (9.2%)3.6% Her2+176 (28.9%)6.3% Triple negative216 (35.5%)11.1% Local therapy 0.169Lumpectomy85 (13.5%)11.8% Lumpectomy with radiation198 (31.4%)5.6% Mastectomy173 (27.5%)5.2% Mastectomy with radiation174 (27.6%)8.6% Axillary surgery 0.23None5 (0.8%)20% SLN329 (52.2%)5.8% ALND296 (47%)8.5% Axillary radiation 0.535Yes42 (6.7%)9.5% No588 (93.3%)7.0% Axillary management 0.2No surgery or radiation5 (0.8%)20.0% SLN312 (50%)5.3% SLN+Axillary radiation17 (2.7%)8.3% ALND271 (43%)10.3% ALND+Axillary radiation25 (4%)5.4% RCB 0.0020/1293 (50.1%)3.8% 2/3292 (49.9%)10.3%
Citation Format: Silverstein J, Suleiman L, Yau C, Price ER, Singhrao R, Yee D, DeMichele A, Isaacs C, Albain KS, Chien AJ, Forero-Torres A, Wallace AM, Pusztai L, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Leyland-Jones B, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, I-SPY 2 TRIAL Consortium, Berry DA, Asare SM, Esserman LJ, Boughey JC, Mukhtar RA. The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 TRIAL [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-01.
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Affiliation(s)
- J Silverstein
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - L Suleiman
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - C Yau
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - ER Price
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - R Singhrao
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - D Yee
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - A DeMichele
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - C Isaacs
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - KS Albain
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - AJ Chien
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - A Forero-Torres
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - AM Wallace
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - L Pusztai
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - ED Ellis
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - AD Elias
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - JE Lang
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - J Lu
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - HS Han
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - AS Clark
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - L Korde
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - R Nanda
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - DW Northfelt
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - QJ Khan
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - RK Viscusi
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - DM Euhus
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - KK Edmiston
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - SY Chui
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - K Kemmer
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - WC Wood
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - JW Park
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - MC Liu
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - O Olopade
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - B Leyland-Jones
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - D Tripathy
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - SL Moulder
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - HS Rugo
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - R Schwab
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - S Lo
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - T Helsten
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - H Beckwith
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - DA Berry
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - SM Asare
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - LJ Esserman
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - JC Boughey
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
| | - RA Mukhtar
- University of California, San Francisco, San Francisco, CA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN; University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Loyola University, Maywood, IL; University of Alabama at Birmingham, Birmingham, AL; University of California, San Diego, La Jolla, CA; Yale Cancer Center, New Haven, CT; Swedish Cancer Institute, Seattle, WA; University of Colorado, Denver, Aurora, CO; University of Southern California, Los Angeles, CA; Moffitt Cancer Center, Tampa, FL; CTEP, National Cancer Institute, Bethesda, MD; The University of Chicago Medical Center, Chicago, IL; Mayo Clinic, Scottsdale, Scottsdale, AZ; University of Kansas, Westwood, KS; University of Arizona, Tucson, AZ; Johns Hopkins Medicine, Dallas, TX; Inova Health System, Fairfax, VA; Genentech, Portland, OR; Oregon Health & Science University, Portland, OR; Emory University, Atlanta, GA; Mayo Clinic, Rochester, Rochester, MN; Avera Cancer Institute Center for Precision
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Dreher N, Layton TM, Parker BA, Shibley WP, Acerbi I, Wallace AM, Blair S, Pierce JP, Glantz S, Guydish J, Hiatt R, van 't Veer L, Esserman L. Abstract P4-10-03: Tobacco exposure and breast cancer. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p4-10-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Smoking is a known risk factor for various types of cancer, and breast cancer patients who smoke are known to have higher breast cancer mortality. However, few studies have found an association between smoking and breast cancer incidence or tumor biology. The Athena Breast Health Network distributes an intake questionnaire at the UCSF and UCSD breast care centers which can be used to investigate links between tobacco exposure and the characteristics of incident breast cancer.
Methods: Intake questionnaires were distributed to all new patients at the UCSF and UCSD breast care centers from December 2012 to May 2018. Patients who completed the questionnaire with a known diagnosis of breast cancer were compared to those without in a case-control study. Breast cancer diagnoses were determined by ICD9 diagnosis codes from the patients' medical records. The association of smoking and breast cancer prevalence and biology was analyzed using generalized linear models and Fisher tests in R.
Results: Of the 7727 patients who completed the Athena intake questionnaire at UCSF and UCSD, 5499 consented to have their data used for research. A first analysis was conducted on 4175 UCSF patients alone: 2186 of the UCSF patients who had completed the questionnaire had a documented breast cancer diagnosis, vs 1989 with no known diagnosis at the time of this analysis. 1096 of the 4175 UCSF patients reported having ever smoked, including 73 who had accrued 30 or more pack years. Complete pathology data was available for 1120 cancer patients. Controlling for age, more patients with invasive breast cancer reported having ever smoked, with an odd's ratio (OR) of 2.32 (p = .0043). By including DCIS, the OR drops slightly to 2.26 (p = .0058). Taking alcohol consumption into account as a confounder lowered the OR to 2.19 (p = .0454). Overall, the risk of breast cancer increases with each additional pack year (OR = 1.08, p = .0211), independent of age. There are no significant differences in tumor biology for any smoking group.
Conclusions: A history of smoking is associated with an increased risk of developing breast cancer and is directly related to cumulative pack years exposure. This association should be further validated in cohort studies.
Citation Format: Dreher N, Layton TM, Parker BA, Shibley WP, Acerbi I, Wallace AM, Blair S, Pierce JP, Glantz S, Guydish J, Hiatt R, van 't Veer L, Esserman L, Athena Breast Health Network Investigators and Advocate Partners. Tobacco exposure and breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-10-03.
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Affiliation(s)
- N Dreher
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - TM Layton
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - BA Parker
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - WP Shibley
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - I Acerbi
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - AM Wallace
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - S Blair
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - JP Pierce
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - S Glantz
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - J Guydish
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - R Hiatt
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - L van 't Veer
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - L Esserman
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
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Chien AJ, Tripathy D, Albain KS, Symmans WF, Rugo HS, Melisko ME, Wallace AM, Schwab R, Helsten T, Forero-Torres A, Stringer-Reasor E, Ellis ED, Kaplan HG, Nanda R, Jaskowiak N, Murthy R, Godellas C, Boughey JC, Elias AD, Haley BB, Kemmer K, Isaacs C, Clark AS, Lang JE, Lu J, Korde L, Edmiston KK, Northfelt DW, Viscusi RK, Yee D, Perlmutter J, Hylton NM, Van't Veer LJ, DeMichele A, Wilson A, Peterson G, Buxton MB, Paoloni M, Clennell J, Berry S, Matthews JB, Steeg K, Singhrao R, Hirst GL, Sanil A, Yau C, Asare SM, Berry DA, Esserman LJ. MK-2206 and Standard Neoadjuvant Chemotherapy Improves Response in Patients With Human Epidermal Growth Factor Receptor 2-Positive and/or Hormone Receptor-Negative Breast Cancers in the I-SPY 2 Trial. J Clin Oncol 2019; 38:1059-1069. [PMID: 32031889 DOI: 10.1200/jco.19.01027] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The phosphatidylinositol 3-kinase/Akt/mammalian target of rapamycin is a key pathway of survival and therapeutic resistance in breast cancer. We evaluated the pan-Akt inhibitor MK-2206 in combination with standard therapy in patients with high-risk early-stage breast cancer. PATIENTS AND METHODS I-SPY 2 is a multicenter, phase II, open-label, adaptively randomized neoadjuvant platform trial that screens experimental therapies and efficiently identifies potential predictive biomarker signatures. Patients are categorized by human epidermal growth factor receptor 2 (HER2), hormone receptor (HR), and MammaPrint statuses in a 2 × 2 × 2 layout. Patients within each of these 8 biomarker subtypes are adaptively randomly assigned to one of several experimental therapies, including MK-2206, or control. Therapies are evaluated for 10 biomarker signatures, each of which is a combination of these subtypes. The primary end point is pathologic complete response (pCR). A therapy graduates with one or more of these signatures if and when it has an 85% Bayesian predictive probability of success in a hypothetical phase III trial, adjusting for biomarker covariates. Patients in the current report received standard taxane- and anthracycline-based neoadjuvant therapy without (control) or with oral MK-2206 135 mg/week. RESULTS MK-2206 graduated with 94 patients and 57 concurrently randomly assigned controls in 3 graduation signatures: HR-negative/HER2-positive, HR-negative, and HER2-positive. Respective Bayesian mean covariate-adjusted pCR rates and percentage probability that MK-2206 is superior to control were 0.48:0.29 (97%), 0.62:0.36 (99%), and 0.46:0.26 (94%). In exploratory analyses, MK-2206 evinced a numerical improvement in event-free survival in its graduating signatures. The most significant grade 3-4 toxicity was rash (14% maculopapular, 8.6% acneiform). CONCLUSION The Akt inhibitor MK-2206 combined with standard neoadjuvant therapy resulted in higher estimated pCR rates in HR-negative and HER2-positive breast cancer. Although MK-2206 is not being further developed at this time, this class of agents remains of clinical interest.
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Affiliation(s)
- A Jo Chien
- University of California, San Francisco, San Francisco, CA
| | | | | | | | - Hope S Rugo
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | - Rita Nanda
- The University of Chicago Medical Center, Chicago, IL
| | | | - Rashmi Murthy
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | - Amy S Clark
- University of Pennsylvania, Philadelphia, PA
| | - Julie E Lang
- University of Southern California, Los Angeles, CA
| | - Janice Lu
- University of Southern California, Los Angeles, CA
| | - Larissa Korde
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD
| | | | | | | | - Douglas Yee
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | | | - Nola M Hylton
- University of California, San Francisco, San Francisco, CA
| | | | | | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, CA
| | - Garry Peterson
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | - Ruby Singhrao
- University of California, San Francisco, San Francisco, CA
| | | | | | - Christina Yau
- University of California, San Francisco, San Francisco, CA
| | - Smita M Asare
- Quantum Leap Healthcare Collaborative, San Francisco, CA
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Unkart JT, Proudfoot J, Wallace AM. Outcomes of "one-day" vs "two-day" injection protocols using Tc-99m tilmanocept for sentinel lymph node biopsy in breast cancer. Breast J 2018; 24:526-530. [PMID: 29498443 DOI: 10.1111/tbj.13002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 11/29/2022]
Abstract
No prior studies have compared Tc-99m tilmanocept (TcTM) one-day and two-day injection protocols for sentinel lymph node (SLN) biopsy in breast cancer (BC). We retrospectively identified patients with clinically node-negative BC undergoing SLN biopsy at our institution. Patients received a single, intradermal peritumoral injection of TcTM on day of surgery or day prior to surgery in addition to an intraoperative injection of isosulfan blue dye. Univariable and multivariable Poisson regression count models were constructed to assess the effects of injection timing, radiologist, patient and surgeon characteristics on the number of removed SLNs. A total of 617 patients underwent SLN biopsy with TcTM and blue dye. Sixty-seven (10.9%) patients were injected with the two-day protocol. Patients in the one-day protocol had a mean of 3.0 (standard deviation (SD) 1.9) SLNs removed compared with 2.7 (SD 1.4) SLNs in the two-day protocol, P-value = .13. On multivariable analysis, patient age and operating surgeon significantly affected the number of removed SLNs; however, the injection timing and the nuclear radiologist did not influence the number of removed SLNs. The performance of Tc-99m tilmanocept did not differ significantly between one-day and two-day injection protocols. These results are similar to other radiotracers used for SLN biopsy in BC.
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Affiliation(s)
- Jonathan T Unkart
- Department of Surgery, Moores Cancer Center, University of California, San Diego, CA, USA
| | - James Proudfoot
- Biostatistics Unit, Altman Clinical Translational Research Institute, University of California, San Diego, CA, USA
| | - Anne M Wallace
- Department of Surgery, Moores Cancer Center, University of California, San Diego, CA, USA
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Hosseini A, Esserman LJ, Wallace AM, Au A, Mukhtar RA. Abstract P5-22-22: Breast tumor location in BRCA mutation carriers and implications for prevention. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p5-22-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction:
Close to 65% of BRCA mutation carriers do not choose prophylactic mastectomy, despite their high breast cancer risk. Breast reduction mammoplasty is a surgical technique shown to reduce breast cancer risk and can be modified to target specific areas of the breast. We wondered if a majority of tumors in BRCA mutation carriers would be confined to one quadrant, allowing for the use of targeted cosmetic mammoplasty as a novel method of risk reduction.
Methods:
We reviewed imaging reports on 103 consecutive patients with BRCA mutations and invasive breast cancer, and categorized tumor location by quadrant. Tumors spanning >1 quadrant were classified as being in both. Bilateral cancers were counted separately. Categorical variables were compared with the chi-squaredtest.
Results:
Mean age at breast cancer diagnosis was 44 years with mean tumor size of 2.2 cm (0.1-7cm). 92% of tumors were invasive ductal carcinoma, 46% were hormone receptor positive, 10% Her2 positive, and 44% triple negative. 70% of the tumors were unicentric. Tumors were significantly more likely to be in the upper outer quadrant whether or not multicentric tumors were included in the analysis (p<0.00001). Her2 positive tumors were more likely to be multicentric than other subtypes (p=0.021).
Conclusions:
More than half of breast cancers in BRCA mutation carriers form in the upper outer quadrant, suggesting that removing this quadrant through breast reduction mammoplasty could significantly reduce breast cancer risk. For women who are not ready for prophylactic mastectomy, this data supports an intermediate risk reduction step instead of only offering surveillance.
Citation Format: Hosseini A, Esserman LJ, Wallace AM, Au A, Mukhtar RA. Breast tumor location in BRCA mutation carriers and implications for prevention [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-22.
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Affiliation(s)
- A Hosseini
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - LJ Esserman
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - AM Wallace
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - A Au
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
| | - RA Mukhtar
- University of California, San Francisco, San Francisco, CA; University of California, San Diego, San Diego, CA
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Wallace AM, Bogard MT, Zbikowski SM. Intrapersonal Variation in Goal Setting and Achievement in Health Coaching: Cross-Sectional Retrospective Analysis. J Med Internet Res 2018; 20:e32. [PMID: 29374005 PMCID: PMC5807624 DOI: 10.2196/jmir.8892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/21/2017] [Accepted: 12/08/2017] [Indexed: 12/28/2022] Open
Abstract
Background Chronic conditions in the United States are among the most costly and preventable of all health problems. Research suggests health coaching is an effective strategy for reducing health risks including decreases in weight, blood pressure, lipids, and blood glucose. Much less is known about how and when coaching works. Objective The aim of this study was to conduct an analysis of intrapersonal variations in participants’ progression in health coaching, examining gender and age-related differences. Methods This was a cross-sectional, retrospective analysis of 35,333 health coaching participants between 2012 and 2016. Differences in number of goals and activities set and completed, and number of interactions were assessed using negative binomial models. Differences in goal type were assessed using logistic regression for gender and using the Welch test for age to account for unequal variances. Results Participants choosing online coaching were more likely to be younger and female (P<.001). Gender and age differences were found for the types of goals set by participants. Regarding program activity, women set and completed 12% more action steps than men (P<.001), averaging 21% more interactions than men (P<.001); no gender differences were found in number of goals completed (P=.12), although the percentage of males and females completing goals was significantly different at 60 and 120 days postenrollment (P<.001). Results indicated significant age-related differences in all aspects of program activity: number of interactions, goals set and completed, action steps set and completed (all P values <.01), as well as significant differences in percentage of individuals completing initial goals within 30 days, with older individuals completing more than younger individuals did (all P values <.001). Conclusions This study found significant intrapersonal variation in how people participate in and progress through a coaching program. Age-related variations were found in all aspects of coaching activity, from modality preference and initial choice of goal type (eg, weight management, tobacco cessation) to goal completion, whereas gender-related differences were demonstrated for all program activities except number of goals set and completed. These findings indicate that to maximize behavior change, coaches need to personalize the coaching experience to the individual.
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Affiliation(s)
- Anne M Wallace
- Wellness Science and Analytics, Humana, Inc, Louisville, KY, United States
| | - Matthew T Bogard
- Wellness Science and Analytics, Humana, Inc, Louisville, KY, United States
| | - Susan M Zbikowski
- Wellness Science and Analytics, Humana, Inc, Louisville, KY, United States
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Unkart JT, Chen SL, Wapnir IL, González JE, Harootunian A, Wallace AM. Erratum to: Intraoperative Tumor Detection Using a Ratiometric Activatable Fluorescent Peptide: A First-in-Human Phase 1 Study. Ann Surg Oncol 2017; 24:693. [PMID: 28762115 DOI: 10.1245/s10434-017-6028-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jonathan T Unkart
- Department of Surgery, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | | | - Irene L Wapnir
- Department of Surgery, Stanford University, Stanford, CA, USA
| | | | | | - Anne M Wallace
- Department of Surgery, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA.
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Unkart JT, Wallace AM. Use of 99mTc-Tilmanocept as a Single Agent for Sentinel Lymph Node Identification in Breast Cancer: A Retrospective Pilot Study. J Nucl Med Technol 2017; 45:181-184. [PMID: 28705929 DOI: 10.2967/jnmt.117.194415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
99mTc-tilmanocept received recent Food and Drug Administration approval for lymphatic mapping in 2013. However, to our knowledge, no prior studies have evaluated the use of 99mTc-tilmanocept as a single agent in sentinel lymph node (SLN) biopsy in breast cancer. Methods: We executed this retrospective pilot study to assess the ability of 99mTc-tilmanocept to identify sentinel nodes as a single agent in clinically node-negative breast cancer patients. Patients received a single intradermal injection overlying the tumor of either 18.5 MBq (0.5 mCi) of 99mTc-tilmanocept on the day of surgery or 74.0 MBq (2.0 mCi) on the day before surgery by a radiologist. Immediate 3-view lymphoscintigraphy was performed. Intraoperatively, SLNs were identified with a portable γ-probe. A node was classified as hot if the count (per second) of the node was more than 3 times the background count. Descriptive statistics are reported. Results: Nineteen patients underwent SLN biopsy with single-agent 99mTc-tilmanocept. Immediate lymphoscintigraphy identified at least 1 sentinel node in 13 of 17 patients (76.5%). Intraoperatively, at least 1 (mean, 1.7 ± 0.8; range, 1-3) hot node was identified in all patients. Three patients (15.8%) had 1 disease-positive SLN. Conclusion: In this small, retrospective pilot study, 99mTc-tilmanocept performed well as a single agent for intraoperative sentinel node identification in breast cancer. A larger, randomized clinical trial is warranted to compare 99mTc-tilmanocept as a single agent with other radiopharmaceuticals for sentinel node identification in breast cancer.
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Affiliation(s)
- Jonathan T Unkart
- Department of Surgery, Moores Cancer Center, University of California-San Diego, La Jolla, California
| | - Anne M Wallace
- Department of Surgery, Moores Cancer Center, University of California-San Diego, La Jolla, California
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Unkart JT, Chen SL, Wapnir IL, González JE, Harootunian A, Wallace AM. Intraoperative Tumor Detection Using a Ratiometric Activatable Fluorescent Peptide: A First-in-Human Phase 1 Study. Ann Surg Oncol 2017; 24:3167-3173. [PMID: 28699134 DOI: 10.1245/s10434-017-5991-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Positive surgical margins remain a significant challenge in breast cancer surgery. This report describes the use of a novel, first-in-human ratiometric activatable cell-penetrating peptide in breast cancer surgery. METHODS A two-part, multi-institutional phase 1 trial of AVB-620 with a 3+3 dose escalation and dose-expansion cohorts was conducted. The patients received an infusion of AVB-620 2-20 h before planned lumpectomy/mastectomy and sentinel node biopsy/axillary dissection. Imaging analysis was performed on images obtained from the surgical field as well as post-excision surgical specimens. Pathology reports were obtained to correlate imaging results with histopathologic data. Information on physical adverse events and laboratory abnormalities were recorded. RESULTS A total of 27 patients received infusion of AVB-620 and underwent surgical excision of breast cancer. The findings showed no adverse events or laboratory values attributable to infusion of AVB-620. The 8-mg dose was selected from the dose-escalation cohort for use with the expansion cohort based on imaging data. Region-of-interest (ROI) imaging analysis from the 8-mg cohort demonstrated measurable changes between pathology confirmed tumor-positive and tumor-negative tissue. CONCLUSION Intraoperative imaging of surgical specimens after infusion with AVB-620 allowed for real-time tumor detection. Infusion of AVB-620 is safe and may improve intraoperative detection of malignant tissue during breast cancer operations.
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Affiliation(s)
- Jonathan T Unkart
- Department of Surgery, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | | | - Irene L Wapnir
- Department of Surgery, Stanford University, Stanford, CA, USA
| | | | | | - Anne M Wallace
- Department of Surgery, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA.
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