Prediction of Benefit From Adjuvant Pertuzumab by 80-Gene Signature in the APHINITY (BIG 4-11) Trial

PURPOSE

At the primary analysis, the APHINITY trial reported a statistically significant but modest benefit of adding pertuzumab to standard adjuvant chemotherapy plus trastuzumab in patients with histologically confirmed human epidermal growth factor receptor 2 (HER2)-positive early-stage breast cancer. This study evaluated whether the 80-gene molecular subtyping signature (80-GS) could identify patients within the APHINITY population who derive the most benefit from dual anti-HER2 therapy.

METHODS

In a nested case-control study design of 1,023 patients (matched event to control ratio of 3:1), the 80-GS classified breast tumors into functional luminal type, HER2 type, or basal type. Additionally, 80-GS distinguished tumor subtypes that exhibited a single-dominant functional pathway versus tumors with multiple activated pathways. The primary end point was invasive disease-free survival (IDFS). Hazard ratios (HRs) were evaluated by Cox regression. After excluding patients without appropriate consent and those with missing data, 964 patients were included.

RESULTS

The 80-GS classified 50% (n = 479) of tumors as luminal type, 28% (n = 275) as HER2 type, and 22% (n = 209) as basal type. Most luminal-type tumors (86%) displayed a single-activated pathway, whereas 49% of HER2-type and 42% of basal-type tumors were dual activated. There was no significant difference in IDFS among different conventional 80-GS subtypes (single- and dual-activated subtypes combined). However, basal single-subtype tumors were significantly more likely to have an IDFS event (hazard ratio, 1.69 [95% CI, 1.12 to 2.54]) compared with other subtypes. HER2 single-subtype tumors displayed a trend toward greater beneficial effect on the addition of pertuzumab (hazard ratio, 0.56 [95% CI, 0.27 to 1.16]) compared with all other subtypes.

CONCLUSION

The 80-GS identified subgroups of histologically confirmed HER2-positive tumors with distinct biological characteristics. Basal single-subtype tumors exhibit an inferior prognosis compared with other subgroups and may be candidates for additional therapeutic strategies. Preliminary results suggest patients with HER2-positive, genomically HER2 single-subtype tumors may particularly benefit from added pertuzumab, which warrants further investigation.

Abstract GS5-10: Utility of the 70-gene MammaPrint test for prediction of extended endocrine therapy benefit in patients with early-stage breast cancer in the IDEAL Trial

Background: The IDEAL trial showed no significant benefit of 5 years extended endocrine therapy (EET) using letrozole in postmenopausal patients with hormone receptor positive (HR+) breast cancer (BC) versus 2.5 years. Genomic classifiers may assist with treatment decisions by predicting EET benefit. The 70-gene MammaPrint (MP) test classifies tumors as having a higher or lower risk of distant metastasis in HR+ early-stage BC. A MP lower risk result can be further classified as either Ultra-Low risk or Low risk of distant metastasis. In the NSABP B42 trial, MP predicted a statistically significant absolute benefit from EET in patients with a MP Low Risk result. Here, we aimed to determine the utility of MP in identifying a subgroup of patients enrolled in the IDEAL trial for which 5 years of EET is beneficial compared to 2.5 years.

Methods: A total of 869 patients had available primary tumor tissue for testing. MP results were available for 545/869 patients, of which 515 did not have an event at 2.5 year after randomization and were used for our analyses. The MP result for each patient was calculated by Agendia while blinded to patient clinical outcomes. The primary endpoint was distant recurrence (DR). Secondary endpoints were recurrence free interval (RFI) and breast cancer free interval (BCFI) as defined by STEEP criteria. Patients were classified as higher risk (score -1.000 - 0) or lower risk (score 0.001 - 1.000). Lower risk tumors were further classified as either MP Ultra-Low (score > 0.355) or MP Low Risk (score ≥ 0.001, ≤ 0.355). Likelihood ratio test based on stratified Cox proportional hazards (PH) model were used to evaluate treatment by risk group interaction. Differences in endpoints between treatment groups were assessed by stratified log-rank tests. Hazard ratios (HR) and 95% Confidence Intervals (CI) were computed based on the stratified Cox PH model.

Results: The clinical characteristics of the 515 IDEAL samples with a MP result were comparable to the whole IDEAL cohort (n=1820). Within the 2.5 year EET group, 50.6% (n=134) were MP higher risk and 49.4% (n=131) MP lower risk, of which 14.5% (n=19/131) were MP Ultra-Low. Within the 5 year EET group, 50.0% (n=125) were MP higher risk and 50.0% (n=125) MP lower risk, of which 11.2% (n=14/125) were MP Ultra-Low. Among patients with MP lower risk tumors, 5 years vs. 2.5 years of EET resulted in a significant absolute benefit of 9.8% for DR (HR=0.42, [95% CI 0.174-0.996]), 9.8% for RFI (HR=0.43, [95% CI 0.198-0.934]), and 8.8% (HR=0.53, [95% CI 0.264-1.055]) for BCFI, whereas patients with MP higher risk tumors did not derive significant benefit (Table 1). Within the MP lower risk group, 5 year vs 2.5 year EET benefit was more pronounced in MP Low tumors, which exhibited a significant benefit of 10.1% for DR (HR=0.32, [95% CI 0.116-0.866]), 11.7% for RFI (HR=0.35, [95% CI 0.147-0.824]), and 9.7% for BCFI (HR=0.48, [95% CI 0.225-1.015]); MP Ultra Low tumors did not derive significant benefit. Treatment-by-risk group interaction was statistically significant for RFI.

Conclusion: A significant EET benefit was observed for MammaPrint lower risk tumors but not for MP higher risk tumors. MammaPrint Low tumors exhibited the largest absolute benefit of 5 years of EET compared to 2.5 years. Consistent with the findings in the NSABP B42 trial, the results from this second randomized trial provide clinically meaningful implications in patient selection for extended endocrine therapy.

Table 1. IDEAL: 10-year outcome analysis comparing 5 years vs. 2.5 years of EET using letrozole stratified by MP risk. **MammaPrint Lower Risk & Higher Risk (n=515) and *** MammaPrint Low Risk & High Risk (n=482)

Citation Format: Gerrit-Jan Liefers, Elma Meershoek-Klein Kranenbarg, Marjolijn Duijm-de Carpentier, Cornelis J.H. van de Velde, Miranda Kleijn, Christa Dreezen, Andrea Menicucci, Laura van’t Veer, William Audeh. Utility of the 70-gene MammaPrint test for prediction of extended endocrine therapy benefit in patients with early-stage breast cancer in the IDEAL Trial [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr GS5-10.

Abstract PD3-01: BluePrint performance in predicting pertuzumab benefit in genomically HER2-positive patients: A biomarker analysis of the APHINITY trial

BACKGROUND:APHINITY is a phase III study (NCT01358877) which included 4805 patients (pts) with histologically centrally confirmed HER2+ early breast cancer (EBC) randomized to standard adjuvant chemotherapy (C) plus trastuzumab (T), plus either pertuzumab (P) or placebo1 for 1 year. With median follow up of 45 months, the primary analysis showed significant invasive disease-free survival (iDFS) benefit at 3 years with a hazard ratio (HR) of 0.81 (95% CI: 0.66-1.00; P = 0.045) for the addition of P to C/T1. BluePrint (BP) is an 80-gene molecular subtyping test that classifies EBC into functional basal, luminal and HER2 BP-subtypes3 according to gene expression. Previous studies showed that this genomic test can reclassify HER2+ EBC (as determined by IHC/FISH) into basal, luminal or HER2 BP-subtypes4. Recently, it was revealed that a smaller proportion of breast tumours may display two functionally activated BP pathways (BP dual activated subtypes, of which one is usually less pronounced), whereas the majority has clearly only one activated functional BP pathway (BP single activated subtypes)5. We hypothesized that BluePrint could identify a subgroup of patients within the APHINITY population who derived additional benefit from the addition of P to C/T.METHODS:Genomic results were obtained using RNA sequencing (RNAseq) data6 from a subset of APHINITY pts (N=970) derived from a 1023 unique patients nested case-control (NCC) set where event and matched controls were selected (1 iDFS event matched to 3 controls from the primary analysis database with 45 months median follow-up). Raw read counts were log2 transformed followed by quantile normalization prior to genomic assessment. BP subtype scores were calculated equally to the standard microarray diagnostic testing and calibrated based on a bridge analysis with matched microarray and RNAseq data. IDFS outcome based on genomic subtype and the treatment arm (P+C/T vs placebo + C/T) was analysed. Results are reported descriptively with 95% CIs.RESULTS:From the patients within the NCC subset, BP subtype testing classified the 970 pts as basal, n=210 (22%); luminal, n=485 (50%) and HER2, 275 (28%) subtypes, an expected finding since the majority were hormone receptor positive (N=598/970, 62%). Further dissection of the BP results showed single activated subtype in 123 of 210 (59%) basal, 413 of 485 (85%) luminal and 139 of 275 (51%) of HER2 subtype cancers.

After NCC-inverse probability weighted corrected multivariate Cox regression analysis, no significant differences in iDFS were observed among the different genomic subtypes. A greater benefit with the addition of P to T/C was suggested in the ‘single activated’ HER2 BP-subtype compared with other groups (single HER2 HR=0.56, 95% CI 0.27-1.15, single basal HR=0.89, 95% CI 0.44-1.79 and single luminal HR=0.93, 95% CI 0.61-1.41).

CONCLUSIONS:In this exploratory analysis, HER2+ tumors with a single transcriptional HER2 activated pathway showed a trend for greater benefit from pertuzumab than tumors in which multiple mitogenic pathways are activated. Further research is ongoing to confirm these findings.

References1.von Minckwitz G et al, NEMJ, 20172.Piccart M et al, SABCS, 20193.Krijgsman O et al, BCRT, 20114.Whitworth P et al, ASO, 20145.Kuilman M et al, EBCC12, 20206.Krop IE et al, ASCO, 2020

Citation Format: Ian Krop, Lorenza Mittempergher, Joseph Paulson, Fabrice Andre, Hervé Bonnefoi, Sherene Loi, Sibylle Loibl, Richard D Gelber, Carmela Caballero, Debora Fumagalli, Christa Dreezen, Rene Bernards, Laura van ‘t Veer, Martine Piccart. BluePrint performance in predicting pertuzumab benefit in genomically HER2-positive patients: A biomarker analysis of the APHINITY trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD3-01.

A clinical validation study of MammaPrint in hormone receptor-positive breast cancer from the Austrian Breast and Colorectal Cancer Study Group 8 (ABCSG-8) biomarker cohort

Background

MammaPrint is a prognostic assay based on gene expression in tumors from patients with early breast cancer. MammaPrint has been extensively validated and Food and Drug Administration cleared in fresh and formalin-fixed and paraffin-embedded (FFPE) tissue. We aimed to assess its prognostic performance in the biomarker cohort of the Austrian Breast and Colorectal Cancer Study Group 8 (ABCSG-8) patient population, and to obtain a higher level of evidence with regard to its clinical validity after RNA extraction from FFPE biobank tissue.

Patients and methods

A prespecified retrospective analysis to test the prognostic performance of the MammaPrint test to predict distant recurrence-free survival at 5 and 10 years as primary end point was carried out. MammaPrint risk, clinicopathological factors (after central pathological review), and clinical risk (using a modified version of Adjuvant! Online) were evaluated by Cox regression analyses.

Results

From 1347 available samples, 607 (45%) failed quality control after RNA extraction. In total, 658 (49%) patients were included in survival analyses: MammaPrint low risk versus high risk is a significant prognostic factor for distant recurrence-free survival at 5 years (94.0% versus 91.6%) with a significant risk reduction of 6.5% at 10 years (log-rank P value = 0.017, low risk 91.3% versus high risk 84.8%). The multivariable models suggest that hazard ratio (HR) is primarily driven by tumor stage (5-year HR 3.89; confidence interval 1.97-7.71) and nodal status (5-year HR 1.73; confidence interval 0.91-3.21). After adjustment for clinical risk groups, MammaPrint HRs remain stable with values just below 2.0 after the first 3 years.

Conclusions

The MammaPrint test showed significant prognostic performance at 5 and 10 years of follow-up. In the particular cohort of ABCSG-8, the statistical independence from clinically assessed covariates remains unclear, and no conclusions concerning the clinical validity of the test can be drawn.

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MammaPrint is a prognostic assay based on gene expression in tumors from patients with early breast cancer.

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MammaPrint has been extensively and successfully validated- but mostly in fresh tissue.

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We aimed to assess its prognostic performance in FFPE tissue from the ABCSG 8 biomarker cohort.

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The MammaPrint test showed significant prognostic performance at 5 and 10 years of follow-up.

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The statistical independence from clinically assessed covariates is unclear- the clinical validity in ABCSG 8 uncertain.

Investigating the concordance in molecular subtypes of primary colorectal tumors and their matched synchronous liver metastasis

To date, no systematic analyses are available assessing concordance of molecular classifications between primary tumors (PT) and matched liver metastases (LM) of metastatic colorectal cancer (mCRC). We investigated concordance between PT and LM for four clinically relevant CRC gene signatures. Twenty-seven fresh and 55 formalin-fixed paraffin-embedded pairs of PT and synchronous LM of untreated mCRC patients were retrospectively collected and classified according to the MSI-like, BRAF-like, TGFB activated-like and the Consensus Molecular Subtypes (CMS) classification. We investigated classification concordance between PT and LM and association of TGFBa-like and CMS classification with overall survival. Fifty-one successfully profiled matched pairs were used for analyses. PT and matched LM were highly concordant in terms of BRAF-like and MSI-like signatures, (90.2% and 98% concordance, respectively). In contrast, 40% to 70% of PT that were classified as mesenchymal-like, based on the CMS and the TGFBa-like signature, respectively, lost this phenotype in their matched LM (60.8% and 76.5% concordance, respectively). This molecular switch was independent of the microenvironment composition. In addition, the significant change in subtypes was observed also by using methods developed to detect cancer cell-intrinsic subtypes. More importantly, the molecular switch did not influence the survival. PT classified as mesenchymal had worse survival as compared to nonmesenchymal PT (CMS4 vs CMS2, hazard ratio [HR] = 5.2, 95% CI = 1.5-18.5, P = .0048; TGFBa-like vs TGFBi-like, HR = 2.5, 95% CI = 1.1-5.6, P = .028). The same was not true for LM. Our study highlights that the origin of the tissue may have major consequences for precision medicine in mCRC.

Performance Characteristics of the BluePrint® Breast Cancer Diagnostic Test

The analytical performance of a multi-gene diagnostic signature depends on many parameters, including precision, repeatability, reproducibility and intra-tumor heterogeneity. Here we study the analytical performance of the BluePrint 80-gene breast cancer molecular subtyping test through determination of these performance characteristics. BluePrint measures the expression of 80 genes that assess functional pathways which determine the intrinsic breast cancer molecular subtypes (i.e. Luminal-type, HER2-type, Basal-type). Knowing a tumor's dominant functional pathway can help allocate effective treatment to appropriate patients. Here we show that BluePrint is a highly precise and highly reproducible test with correlations above 98% based on the generated index and subtype concordance above 99%. Therefore, BluePrint can be used as a robust and reliable tool to identify breast cancer molecular subtypes.

MammaPrint and BluePrint Molecular Diagnostics Using Targeted RNA Next-Generation Sequencing Technology

Next-generation DNA sequencing is rapidly becoming an indispensable tool for genome-directed cancer diagnostics, but next-generation RNA sequencing (RNA-seq) is currently not standardly used in clinical diagnostics for expression assessment. However, multigene RNA diagnostic assays are used increasingly in the routine diagnosis of early-stage breast cancer. Two of the most widely used tests are currently available only as a central laboratory service, which limits their clinical use. We evaluated the use of RNA-seq as a decentralized method to perform such tests. The MammaPrint and BluePrint RNA-seq tests were found to be equivalent to the clinically validated microarray tests. The RNA-seq tests were highly reproducible when performed in different locations and were stable over time. The MammaPrint RNA-seq test was clinically validated. Our data demonstrate that RNA-seq can be used as a decentralized platform, yielding results substantially equivalent to results derived from the predicate diagnostic device.

Race and response to neoadjuvant chemotherapy according to MammaPrint risk

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Background: African-American (AA) women with breast cancer have a less favorable prognosis, likely due to differences in tumor biology. This is not only driven by the higher rate of triple negative/basal tumors in patients with AA ancestry, as worse outcome has also been seen in patients with luminal tumors. The Neoadjuvant BReast Cancer Symphony Trial (NBRST, NCT01479101) was a prospective trial that has shown an association of MammaPrint/BluePrint (MP/BP) with a rate of pathologic Complete Response (pCR) of 2% in Luminal A with 95% Distant Metastasis Free Interval at 3 years. Here, we determine the MP/BP risk distribution, response to therapy, and outcome in African American (AA) and Caucasian (Cau) patients. Methods: NBRST enrolled 1,072 breast cancer patients (pts) in the US (June 2011 and December 2014), median follow-up 34.9 months. The current unplanned analysis compared clinicopathological characteristics, molecular risk assignment and outcome with neoadjuvant chemotherapy (NACT) in AA and Cau pts. Molecular subtyping groups were assessed by MP/BP as follows: Luminal A (MammaPrint Low Risk), Luminal B (MammaPrint High Risk), HER2 and Basal types. Results: Out of 1,072 pts, 157 (15%) were AA, and 780 (73%) were Cau. AA patients were younger at diagnosis (52 vs 54 yrs; p = 0.016), had a higher likelihood of having higher grade (gr 3, 65% vs 53%; p = 0.005), ER-negative (45% vs 33%; p = 0.005) and lymph node positive tumors (71% vs 51; p < 0.001). MP/BP classified more AA patients as Basal type, 45% compared to 33% of Cau patients (p = 0.004). Fewer AA patients were classified as Luminal A (15%) compared to Cau pts (33%; p = 0.004). In multivariate analysis race was a significant factor for higher pCR rates to NACT in AA compared to Cau pts, together with PR, HER2, T-stage and Grade (HR = 1.679, 95% CI = (1.057, 2.67), p = 0.028). The pCR rate to NACT in patients with Basal tumors was 38% and similar in AA and Cau patients. In patients with hormone receptor positive and HER2 negative tumors, patients classified by MP/BP as Luminal A had lower pCR (2%) compared to non-luminal A (13%) (p = 0.0015). MP low risk patients had higher 3 yr DMFS (97%) than MP high risk patients (86%; p = 0.010). DMFS for AA MP Low Risk patients was 100%. Conclusions: In this study, MP was able to identify patients with hormone receptor positive tumors with low sensitivity to chemotherapy and good outcome, irrespective of race, suggesting that this test can be helpful to characterize the tumor’s biology and select patients who will not benefit from chemotherapy independently of their ancestry. Clinical trial information: NCT01479101.

Smartphone Application Monitoring of Acceleration Forces During Pneumatic Tube System Transport of Emergency Department Patient Samples

BACKGROUND

The use of pneumatic tube system (PTS) transport has gained considerable popularity in modern hospitals but is also associated with sample hemolysis. The potential contribution of PTS-associated acceleration forces to high hemolysis rates observed in the emergency department (ED) has not been investigated before and can be easily examined nowadays using smartphone applications. The first aim of our study was to investigate whether our PTS induces hemolysis of patient samples obtained from our ED. We also explored a potential correlation between hemolysis index (HI) on the one hand and acceleration forces during PTS transport or other potential causes of hemolysis related to patient characteristics on the other for two different blood sampling techniques.

METHODS

Blood samples from 100 ED patients were collected in one Sarstedt S-Monovette® serum tube (PTStransported to laboratory) and two BD Vacutainer® serum tubes (one PTS-transported and one hand-carried). For all serum samples HI was measured. A smartphone was sent along with the samples in order to register accelerations during transport. Patient's erythrocyte sedimentation rate (ESR), mean corpuscular volume (MCV), hematocrit, total cholesterol, low density lipoprotein (LDL), and high-density lipoprotein (HDL) concentration were determined as well.

RESULTS

Hemolysis rate was only 1 - 4% and 5% for PTS and hand-carried transport, respectively. Calculated acceleration vector sums for PTS transport from the ED to laboratory reached up to 131.49 m/second2 (13.40 g). No correlation could be demonstrated between HI on the one hand and acceleration forces acting on the samples during PTS transport or ESR, MCV, hematocrit, and HDL concentration on the other. However, an inverse correlation was noted between HI and cholesterol (total and LDL) concentration in serum tubes transported via PTS, though not in those carried by hand.

CONCLUSIONS

We demonstrated that our PTS does not induce or contribute to hemolysis of ED patient samples, even at high acceleration vector sums up to 13 g. Technological advancements such as the development of smartphone applications offer the ability to regularly monitor acceleration forces during PTS transport of patient samples. Low total cholesterol and LDL concentrations may affect the erythrocyte membrane fluidity, making erythrocytes more prone to hemolysis.

A breast cancer gene signature for indolent disease

PURPOSE

Early-stage hormone-receptor positive breast cancer is treated with endocrine therapy and the recommended duration of these treatments has increased over time. While endocrine therapy is considered less of a burden to patients compared to chemotherapy, long-term adherence may be low due to potential adverse side effects as well as compliance fatigue. It is of high clinical utility to identify subgroups of breast cancer patients who may have excellent long-term survival without or with limited duration of endocrine therapy to aid in personalizing endocrine treatment.

METHODS

We describe a new ultralow risk threshold for the 70-gene signature (MammaPrint) that identifies a group of breast cancer patients with excellent 20 year, long-term survival prognosis. Tumors of these patients are referred to as "indolent breast cancer." We used patient series on which we previously established and assessed the 70-gene signature high-low risk threshold.

RESULTS

In an independent validation cohort, we show that patients with indolent breast cancer had 100% breast cancer-specific survival at 15 years of follow-up.

CONCLUSIONS

Our data indicate that patients with indolent disease may be candidates for limited treatment with adjuvant endocrine therapy based on their very low risk of distant recurrences or death of breast cancer.

Prognostic Value of MammaPrint® in Invasive Lobular Breast Cancer

BACKGROUND

MammaPrint® is a microarray-based gene expression test cleared by the US Food and Drug Administration to assess recurrence risk in early-stage breast cancer, aimed to guide physicians in making neoadjuvant and adjuvant treatment decisions. The increase in the incidence of invasive lobular carcinomas (ILCs) over the past decades and the modest representation of ILC in the MammaPrint development data set calls for a stratified survival analysis dedicated to this specific subgroup.

STUDY AIM

The current study aimed to validate the prognostic value of the MammaPrint test for breast cancer patients with early-stage ILCs.

MATERIALS AND METHODS

Univariate and multivariate survival associations for overall survival (OS), distant metastasis-free interval (DMFI), and distant metastasis-free survival (DMFS) were studied in a study population of 217 early-stage ILC breast cancer patients from five different clinical studies.

RESULTS AND DISCUSSION

A significant association between MammaPrint High Risk and poor clinical outcome was shown for OS, DMFI, and DMFS. A subanalysis was performed on the lymph node-negative study population. In the lymph node-negative study population, we report an up to 11 times higher change in the diagnosis of an event in the MammaPrint High Risk group. For DMFI, the reported hazard ratio is 11.1 (95% confidence interval = 2.3-53.0).

CONCLUSION

Study results validate MammaPrint as an independent factor for breast cancer patients with early-stage invasive lobular breast cancer. Hazard ratios up to 11 in multivariate analyses emphasize the independent value of MammaPrint, specifically in lymph node-negative ILC breast cancers.

The role of non-viral load surrogate markers in HIV-positive patient monitoring during antiviral treatment

Monitoring the efficacy of highly active antiretroviral treatment (HAART) is crucial if disease progression and the emergence of viral mutants are to be avoided. Classical viral load monitoring is too expensive for large-scale use in resource-limited settings. Three alternative measures, CD4 count, total lymphocyte count (TLC) and haemoglobin, were evaluated as surrogate markers of treatment success (viral load below detection level) among 710 HIV-positive patients who started HAART in an HIV treatment centre in Belgium. TLC correlated well with changes in CD4 counts during HAART, but an increase in TLC alone was a poor predictor of treatment success. A combination of increases in both haemoglobin levels and TLC proved a reliable predictor of successful treatment outcome comparable to the increase in CD4 count, but its specificity and sensitivity were low.

Five-year immunological outcome of highly active antiretroviral treatment in a clinical setting: results from a single HIV treatment centre

Our objective was to study the evolution of CD4 cell count five years after starting highly active antiretroviral treatment (HAART) in a clinical setting. The study was performed at the HIV outpatient clinic, Institute of Tropical Medicine, Antwerp. All patients ( n = 225) who started HAART in 1997, who had a CD4 cell count within six months prior to starting HAART and who were subsequently followed for at least two years were included. Change in CD4 cell count after start of HAART and the influence of patient and clinical factors were investigated using graphical exploration, endpoint analysis and mixed-effects linear regression. The mean CD4 cell count at start of HAART was 280 cells/mm3. At the five-year endpoint of the study the mean increase in CD4 cell count was 333 cells/mm3, while 79% of the patients had a viral load less than 400 copies/mL. There was a significant negative correlation between increase in CD4 cell count at five years and time since first positive HIV test at start of HAART ( P = 0.021). Patients who ever had a HAART interruption of more than seven days had a significantly lower increase in CD4 cell count than those who did not (225 cells/mm3 compared with 438 cells/mm3; P < 0.001). A mixed-effects linear regression model additionally suggested a significant impact of exposure to antiretrovirals prior to HAART ( P = 0.03). Overall, the recovery of CD4 cell count after five years of HAART is good, although therapy interruptions have an important negative impact.

Equivalence of MammaPrint array types in clinical trials and diagnostics

MammaPrint is an FDA-cleared microarray-based test that uses expression levels of the 70 MammaPrint genes to assess distant recurrence risk in early-stage breast cancer. The prospective RASTER study proved that MammaPrint Low Risk patients can safely forgo chemotherapy, which is further subject of the prospective randomized MINDACT trial. While MammaPrint diagnostic results are obtained from mini-arrays, clinical trials may be performed on whole-genome arrays. Here we demonstrate the equivalence and reproducibility of the MammaPrint test. MammaPrint indices were collected for breast cancer samples: (i) on both customized certified array types (n = 1,897 sample pairs), (ii) with matched fresh and FFPE tissues (n = 552 sample pairs), iii) for control samples replicated over a period of 10 years (n = 11,333), and iv) repeated measurements (n = 280). The array type indicated a near perfect Pearson correlation of 0.99 (95 % CI: 0.989-0.991). Paired fresh and FFPE samples showed an excellent Pearson correlation of 0.93 (95 % CI 0.92-0.94), in spite of the variability introduced by intratumoral tissue heterogeneity. Control samples showed high consistency over 10 year's time (overall reproducibility of 97.4 %). Precision and repeatability are overall 98.2 and 98.3 %, respectively. Results confirm that the combination of the near perfect correlation between array types, excellent equivalence between tissue types, and a very high stability, precision, and repeatability demonstrate that results from clinical trials (such as MINDACT and I-SPY 2) are equivalent to current MammaPrint FFPE and fresh diagnostics, and can be used interchangeably.

Genomic classifiers (ColoPrint/MSI-Print) predict outcome and chemotherapy benefit in stage II and III colon cancer patients

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Background: Although the benefit of chemotherapy in stage II and III colon cancer patients is significant, many patients might not need adjuvant chemotherapy because they have a good prognosis even without additional treatment. ColoPrint is a gene expression classifier that distinguish patients with low or high risk of disease relapse. It was developed using whole genome expression data and has been validated in public datasets, independent European patient cohorts and technical studies (Salazar 2011 JCO, Maak 2012 Ann Surg). Methods: In this study, the commercial ColoPrint test was validated in stage II (n=96) and III patients (n=95) treated at the MD Anderson Cancer Center from 2003 to 2009. Frozen tissue specimen, clinical parameters, MSI-status and follow-up data (median follow-up 64 months) were available. The 64-gene MSI-signature developed to identify patients with deficient mismatch repair system (Tian 2012 J Path) was evaluated for its accuracy to identify MSI patients and also for prognosis. Results: In this cohort, ColoPrint classified 56% of stage II and III patients as being at low risk. The 3-year Relapse-Free-Survival (RFS) was 90.6% for Low Risk and 78.4% for High Risk patients with a HR of 2.33 (p=0.025). In uni-and multivariate analysis ColoPrint and stage were the only significant factors to predict outcome. The MSI-signature classified 47 patients (24.6%) as MSI-H and most MSI-H patients were ColoPrint low risk (81%). Patients who were ColoPrint low risk and MSI-H by signature had the best outcome with a 3-year RFS of 95% while patients with ColoPrint high risk had a worse outcome independently of the MSI-status. Low risk ColoPrint patients had a good outcome independent of stage or chemotherapy treatment (90.1% 3-year RFS for treated patients, 91.4% for untreated patients) while ColoPrint high risk patients treated with adjuvant chemotherapy had 3-year RFS of 84%, compared to 70.1% 3-year RFS in untreated patients (p=0.026). Conclusions: The combination of ColoPrint and MSI-Print improves the prognostic accuracy in stage II and stage III patients and may help the identification of patients at higher risk who are more likely to benefit from additional treatment

Gene expression signature to improve prognosis prediction of stage II and III colorectal cancer

PURPOSE

This study aims to develop a robust gene expression classifier that can predict disease relapse in patients with early-stage colorectal cancer (CRC).

PATIENTS AND METHODS

Fresh frozen tumor tissue from 188 patients with stage I to IV CRC undergoing surgery was analyzed using Agilent 44K oligonucleotide arrays. Median follow-up time was 65.1 months, and the majority of patients (83.6%) did not receive adjuvant chemotherapy. A nearest mean classifier was developed using a cross-validation procedure to score all genes for their association with 5-year distant metastasis-free survival.

RESULTS

An optimal set of 18 genes was identified and used to construct a prognostic classifier (ColoPrint). The signature was validated on an independent set of 206 samples from patients with stage I, II, and III CRC. The signature classified 60% of patients as low risk and 40% as high risk. Five-year relapse-free survival rates were 87.6% (95% CI, 81.5% to 93.7%) and 67.2% (95% CI, 55.4% to 79.0%) for low- and high-risk patients, respectively, with a hazard ratio (HR) of 2.5 (95% CI, 1.33 to 4.73; P = .005). In multivariate analysis, the signature remained one of the most significant prognostic factors, with an HR of 2.69 (95% CI, 1.41 to 5.14; P = .003). In patients with stage II CRC, the signature had an HR of 3.34 (P = .017) and was superior to American Society of Clinical Oncology criteria in assessing the risk of cancer recurrence without prescreening for microsatellite instability (MSI).

CONCLUSION

ColoPrint significantly improves the prognostic accuracy of pathologic factors and MSI in patients with stage II and III CRC and facilitates the identification of patients with stage II disease who may be safely managed without chemotherapy.

Prevalence and factors associated with sexual dysfunction among HIV-positive women in Europe

Little is known on female sexual dysfunction (FSD) among HIV-positive women. A cross-sectional survey in seven European HIV centres was performed and data on medical history, antiretroviral treatment and laboratory results were collected. Sexual function was evaluated by the Female Sexual Function Index (FSFI). The data from 166 women were available (response rate=77%). The non-respondents had a lower CD4 cell count, were older and more frequently of sub-Saharan African origin. The overall median FSFI was 25.2 (interquartile range=19.3). Thirty-six women (25%) had a FSFI score < or = 10. Depression, irritability and anxiety were associated with a low FSFI score. The participants reported a significant decrease in sex functioning since HIV diagnosis but not since the start of antiretroviral treatment. Sexual dysfunction in women with HIV infection is frequent and is mainly driven by psychological factors and by the HIV diagnosis.

The use of complementary and alternative medicine by persons with HIV infection in Europe

Between June 1996-September 1997 and December 1998-December 1999, two surveys using an anonymous questionnaire were carried out in Europe among persons living with HIV infection. The questionnaire included questions on use of antiretrovirals, complementary or alternative medicines. Vitamins/minerals were taken by 528 (58%) of the 1996-97 participants, compared to 326 (63%) of the 1998-99 participants (P =0.06). Homeopathy was taken by respectively 176 (21%) and 55 (14%) (P =0.003) participants and herbal products respectively by 213 (25%) and 77 (20%) (P =0.06). In multiple regression analysis a longer time since HIV diagnosis, having a higher education level and having a lower CD(+) lymphocyte count were associated with the use of homeopathy. A longer time since HIV diagnosis and a more advanced stage of the disease were associated with the use of herbal products. The study shows that despite the availability of highly active antiretroviral therapy many people with HIV infection still take complementary and alternative medicine.

Factors associated with a reduced CD4 lymphocyte count response to HAART despite full viral suppression in the EuroSIDA study

OBJECTIVES

To describe the prevalence and risk factors of poor CD4 count rise despite a good virological response on highly active antiretroviral treatment (HAART).

METHODS

The patients from the EuroSIDA study who started HAART with a baseline CD4 count of <350 cells/microL and where all viral load (pVL) measures remained below 500 HIV-1 RNA copies/mL between 6 and 12 months after the start of HAART were included. The risk factors for poor CD4 count rise were analyzed by multiple regression.

RESULTS

Seven hundred and eighty patients were included. A low CD4 count response was observed in 225 patients (29%). The risk factors for this condition were older age, lower CD4 count at baseline, higher increase from the nadir to baseline CD4 count and lower pVL at baseline. Patients taking > or =one drug from each of the three antiviral classes were more likely to have a good CD4 response but a minority of the study participants was taking this treatment regimen (3.1%) and the confidence interval was large.

CONCLUSIONS

A poor immune reconstitution despite a good virological control is frequent after initiation of HAART among patients with a baseline CD4 count of <350 cells/microL. The underlying mechanisms leading to this condition seems mainly driven by the age and the baseline immunological and virological status of the patients.

Financial situation of people living with HIV in Europe

The objective was to investigate the financial situation of people living with HIV in Europe. Two surveys using an anonymous questionnaire were organized in Europe among people living with HIV, the first in 1996-97 and the second in 1998-99. One thousand one hundred and sixty-one people from the 1996-97 survey and 899 from the 1998-99 survey were included. Four hundred and fifty-seven (42%) of the 1996-97 participants reported that their income had decreased since HIV diagnosis. The latter participants reported significantly more often difficulties in paying for housing (27% vs 20%), food (18% vs 12%) and transport (17% vs 12%) compared to 1998-99 participants. In multiple regression analysis, severity of HIV disease, not being on highly active antiretroviral therapy (HAART), younger age, lower education level and living in the South of Europe were associated with having financial difficulties. We concluded that since the introduction of HAART, the financial situation of persons living with HIV in Europe has improved, but a relatively large percentage of them still have financial difficulties.

Self-reported signs of lipodystrophy by persons living with HIV infection

OBJECTIVE

To identify risk factors for the development of lipodystrophy in HIV infected patients on highly active antiretroviral therapy.

METHODS

A survey among patients with HIV infection using an anonymous questionnaire was conducted in 10 European countries between December 1998 and December 1999. Nine hundred and four people receiving antiretrovirals, were included in the analyses.

RESULTS

368 (41%) people reported an increase in abdominal girth since commencing current antiretroviral treatment. Breast enlargement was reported by 106 people (12%). Lipoatrophy signs were reported by approximately one-third of the people: 291 (32%) complained about decrease in facial fat and 300 (33%) reported decrease in buttock fat. One hundred and thirty-one (15%) people reported both lipoatrophy signs and an increase in abdominal girth (mixed lipodystrophy syndrome). In multivariate analysis, the development of the mixed lipodystrophy syndrome was associated with a longer use of indinavir (OR=1.03, 95% CI: 1.00-1.06), ritonavir (OR=1.06, 1.02-1.09) and stavudine (OR=1.05, 1.02-1.08) and also with age, a longer duration of HIV seropositivity and an advanced stage of HIV infection.

CONCLUSIONS

This study suggests that multiple factors are associated with the occurrence of lipodystrophy, including the prolonged use of protease inhibitors.

Ritonavir/Saquinavir plus One Nucleoside Reverse Transcriptase Inhibitor (NRTI) versus Indinavir plus Two Nrtis in Protease Inhibitor-Naive HIV-1-Infected Adults (Iris Study)

Objectives

To compare the efficacy, tolerability and safety of a ritonavir 400 mg/saquinavir hard gel fomulation 400 mg twice daily versus an indinavir 800 mg once every 8 h containing first-line protease inhibitor (PI) treatment regimen.

Methods

Open, randomized, multicentre clinical trial. PI-naive patients received either ritonavir/saquinavir and one nucleoside reverse transcriptase inhibitor (NRTI) or indinavir and two NRTIs. Intention-to-treat (ITT) and on-treatment (OT) analyses were performed.

Results

The baseline characteristics of the study participants were similar in both arms, 67 patients (37%) were naive to antiretroviral treatment. The proportion of patients who achieved a plasma viral load below the level of detection of 400 copies/ml at week 48 was 43% (39/90) in the ritonavir/saquinavir arm and 63% (57/90) in the indinavir arm ( P=0.005, ITT analysis). Using an OT analysis, these percentages were 84% and 88%, respectively ( P=0.6). There were more drop-outs in the ritonavir/saquinavir arm than in the indinavir arm (35.6% (32/90) versus 15.6% (14/90), P=0.002), mainly due to gastro-intestinal side-effects. Abnormal liver tests and increased lipids levels were more frequently reported in the ritonavir/saquinavir arm than in the indinavir arm.

Conclusion

In PI-naive patients, indinavir in combination with two NRTIs was more effective and better tolerated than ritonavir/saquinavir plus one NRTI. Both treatments were very effective for patients who were able to tolerate them.

Rheumatological complications associated with the use of indinavir and other protease inhibitors

Several cases are reported of rheumatological pathology (temporomandibular dysfunction, frozen shoulder, Dupuytren's disease, and tendinitis) most probably related to the intake of indinavir in HIV positive patients. A survey using an anonymous questionnaire of 878 people with HIV infection treated with antiretroviral drugs suggests that other protease inhibitors may also cause arthralgia.

Ritonavir/saquinavir plus one nucleoside reverse transcriptase inhibitor (NRTI) versus indinavir plus two NRTIs in protease inhibitor-naive HIV-1-infected adults (IRIS study)

OBJECTIVES

To compare the efficacy, tolerability and safety of a ritonavir 400 mg/saquinavir hard gel fomulation 400 mg twice daily versus an indinavir 800 mg once every 8 h containing first-line protease inhibitor (PI) treatment regimen.

METHODS

Open, randomized, multicentre clinical trial. PI-naive patients received either ritonavir/saquinavir and one nucleoside reverse transcriptase inhibitor (NRTI) or indinavir and two NRTIs. Intention-to-treat (ITT) and on-treatment (OT) analyses were performed.

RESULTS

The baseline characteristics of the study participants were similar in both arms, 67 patients (37%) were naive to antiretroviral treatment. The proportion of patients who achieved a plasma viral load below the level of detection of 400 copies/ml at week 48 was 43% (39/90) in the ritonavir/saquinavir arm and 63% (57/90) in the indinavir arm (P=0.005, I

Receiving a positive HIV test result: the experience of patients in Europe

OBJECTIVE

To describe HIV-infected people's experience of the HIV test procedure in Europe.

METHODS

Between August 1996 and September 1997, anonymous self-administered questionnaires were distributed to HIV-infected people in 11 European countries.

RESULTS

A total of 1366 people completed the questionnaire (50% response rate). Of these, 194 (16%) had more than five negative HIV tests before being diagnosed as HIV positive, 179 (14%) were tested without consent and 192 (15%) were informed about the HIV positive test result by mail or by telephone. Of the 963 people who received a positive test result during a consultation, 247 (26%) reported that this visit lasted less than 10 min, 336 (35%) between 10 and 20 min, and 289 (30%) more than 20 min. Over half the total respondents (591, 54%) felt they did not receive adequate support when they were informed about being HIV positive, with 249 (19%) experiencing feelings of rejection. People who were diagnosed as HIV positive after 1994 reported more frequently receiving adequate support, information and understanding when the positive test result was revealed compared with those diagnosed before 1990.

CONCLUSION

A large number of our study participants did not endorse the way HIV tests were conducted and positive test results revealed. Although there was an improvement over time in the way HIV tests were conducted, they often did not conform to international guidelines.

Sexual dysfunction associated with protease inhibitor containing highly active antiretroviral treatment

BACKGROUND

A high proportion of individuals receiving highly active antiretroviral treatment (HAART) complain of sexual dysfunction (SD), encompassing a lack of desire or erectile dysfunction.

OBJECTIVE

To determine whether SD was associated with particular components of the HAART regimens and to identify risk factors for the development of SD in patients on HAART.

METHODS

A survey among patients with HIV infection using an anonymous questionnaire was conducted in 10 European countries between December 1998 and December 1999. A total of 904 individuals currently receiving antiretroviral agents were included in the analyses.

RESULTS

A decrease in sexual interest was significantly more frequently reported by subjects (men and women) using HAART containing protease inhibitors (PI) (308/766, 40%), compared with PI-naive patients (22/138, 16%; OR 3.55; 95% CI 2.15--5.89). In addition, a significantly larger number of PI-experienced men reported a decrease in sexual potency (216/628, 34%) compared with PI-naive men (12/99, 12%; OR 2.56; 95% CI 1.33--5.03). In multivariate analyses the following factors were associated with a decrease in sexual interest: a current PI-containing regimen, a history of a PI regimen, symptomatic HIV infection, age and homosexual contact as HIV transmission mode. Factors associated with a decrease in sexual potency were: current use of a PI-containing regimen, symptomatic HIV disease, age and the use of tranquillisers.

CONCLUSION

SD appears to be a common side-effect of HAART regimens containing a PI. The potential association between SD and other side-effects of HAART, such as lipodystrophy syndrome and neuropathy, should be investigated further.

Hospital services for people with HIV infection in Flanders: patients' satisfaction

Two questionnaire surveys about satisfaction with hospital services were carried out among HIV-infected people in Flanders. In a first survey (CIRCA '93 study) between 1993 and 1995, before highly active antiretroviral treatment (HAART) was available, questionnaires were distributed by HIV treatment centres, general practitioners and HIV support organizations: 315 people with HIV infection completed the questionnaire. The level of patient satisfaction was generally higher with services at university hospitals than at general hospitals. Most patients preferred to be hospitalized in a ward specialized in HIV care. Contact with other HIV-infected patients was generally experienced as supportive. The second survey included 34 patients with HIV-infection and 83 patients with lung disease. They were admitted to the same ward at the Antwerp University Hospital, between July 1996 and July 1997. Patients with HIV infections were expecting more services than patients with lung disease. Both studies showed that HIV-infected patients wanted to be actively involved in diagnostic and treatment decisions. The multidisciplinary approach, offered by the Antwerp University Hospital, was widely appreciated by patients and could be used as an example for organizing patient care for other diseases.

Antiretroviral treatments used among adults with HIV infection in Europe

International guidelines for the treatment of human immunodeficiency virus (HIV) infection change rapidly. They are mainly based on results from large-scale randomized clinical trials, but also on hypotheses. The objective of the study was to look at the use of antiretrovirals (ARVs) in different HIV treatment centres in Europe. Between August 1996 and September 1997 self-administered anonymous questionnaires were distributed to persons with HIV infection at inpatient and outpatient departments in 11 European countries; 1,366 people completed the questionnaire. Important differences in use of ARVs were noted between different centres. Zidovudine was the drug that was used predominantly in all countries and by 77% of all patients; the use of didanosine, zalcitabine and stavudine differed widely. Use of ARVs was found to be lower for people who reported intravenous drug use (compared to homosexual transmission), people with a low education level, and those with a monthly income lower than 992 Euro. The use of a protease inhibitor containing ARV treatment regimen was significantly lower in the centres in the south of Europe. Between 1996 and 1997, many persons with HIV infection in Europe received a suboptimal ARV treatment regimen. Use of ARVs should be improved for intravenous drug users, persons with lower educational level and lower income.

Participants in HIV clinical trials in Europe

In recent years an increasing number of antiretrovirals have become available. In order to define the optimal treatment regimens an increasing number of clinical trials are needed. Our objective was to study the profile of participants in HIV clinical trials in Europe and learn from their experience and views. Between August 1996 and September 1997, self-administered anonymous questionnaires were distributed to people with HIV infection at inpatient and outpatient clinics in 11 European countries. One thousand three hundred and sixty-six people completed the questionnaire (50% response rate). Four hundred and twenty (31%) of the respondents reported that they had previously participated in at least one HIV clinical trial. The percentage of people who had taken part in a clinical trial varied widely between the different centres, from 12% in Athens to 61% in Antwerp and Brussels. A significantly higher participation rate was observed in the northern and central part of Europe compared with the south (respectively 40% vs 18%) and also among people with a higher income. Most people (92%) stated that they were 'well' or 'very well' informed prior to enrolment in the trial. However, 4% reported that they had not given written approval and 22% felt that they were pushed into participating. Only 21% stated that they were informed about the outcome of the study on its completion. The most important reason for non-participation (37% of the non-participants) was because a clinical trial had never been proposed. In conclusion, a majority of people with HIV infection in European HIV treatment reference centres were willing to participate in clinical trials. HIV clinical trials in Europe should adhere more strictly to universal ethical standards.

Utilization of healthcare services by people living with HIV/AIDS in Europe. Eurosupport Group

Our objective was to compare the utilization of healthcare/support services for people with HIV infection in Europe. Between August 1996 and September 1997 self-administered anonymous questionnaires were distributed by reference HIV treatment centres and HIV support organizations. The questionnaire was completed by 1366 people living with HIV/AIDS. A small number of people had received influenza or pneumococcal vaccinations (34% and 19% respectively). Many patients did not receive dental care (48% of participants from the southern countries) and only 72% of the women had a gynaecological examination. More participants from the south reported insufficient access to healthcare/support services, particularly for nursing care (19%), psychological support (33%), nutritional advice (45%), access to support organizations (36%), and legal advice (46%). In conclusion, many people living with HIV/AIDS in Europe do not benefit from certain annual medical procedures proposed by international guidelines and consider themselves to have insufficient access to health/support services.

Risk factors for hepatotoxicity in HIV-1-infected patients receiving ritonavir and saquinavir with or without stavudine. Prometheus Study Group

Liver enzyme elevation (LEE) is commonly observed after combination antiretroviral therapy (ARVT) for HIV infection is begun. Potential risk factors for LEE after treatment with ritonavir and saquinavir with or without stavudine were investigated in 208 HIV-infected patients, by use of the Cox proportional hazard model. Eighteen patients (9%) developed LEE during the 48-week follow-up. Multivariate analysis, adjusted for baseline levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), showed that hepatitis B surface antigen (HBsAg) positivity (relative risk [RR], 8.8; 95% confidence interval [CI], 3.3-23.1) and the use of stavudine (RR, 4.9; 95% CI, 1.5-16.0) were the only significant risk factors for developing LEE. After LEE occurred, ALT and AST concentrations decreased by >50% in 13 of 14 patients who continued ARVT during LEE. In this study, it appeared safe to continue ARVT during LEE; however, more data from larger studies are required to confirm this finding.

Primary care involvement in human immune deficiency virus infection-a pan-European view. The Eurosupport Study Group

OBJECTIVE

The aim of this study was to compare the primary care experiences of human immunodeficiency virus (HIV)-positive individuals across Europe.

METHODS

An anonymous self-administered questionnaire study was carried out between August 1996 and August 1997. A total of 15 HIV/AIDS treatment centres and 14 HIV support organizations in 11 European countries participated in the distribution of questionnaires. Overall, 1366 completed questionnaires were included in the analysis from a total of 2751 distributed (50% response rate). The majority of respondents were homosexual men (53.6%), and 54.2% had AIDS or symptomatic HIV disease. The main outcome measures were use of GP services in the preceding 6 months, GP involvement in HIV care provision, satisfaction with current service provision and reasons for non-involvement of the primary care services.

RESULTS

Most patients (64.8%) had visited their GP at least once in the preceding 6 months, but 53.9% of respondents reported that their GP was not involved in their HIV care. Of these patients, 53.4% would like their GP to be involved. Patients from central European countries were more likely to have seen their GP than their counterparts from northern and southern countries (P < 0.005), and were less worried that the GP would not have enough knowledge about HIV (P = 0.002) or would not be sympathetic (P = 0.052).

CONCLUSIONS

There are clear differences in GP utilization by HIV-positive individuals across Europe, reflecting in part local service provision but primarily patients' attitudes and beliefs. Strategies to promote the involvement of primary health care services need to address patients' core beliefs, if these are to be changed.