Single chloroplast in folio imaging sheds light on photosystem energy redistribution during state transitions

Oxygenic photosynthesis is driven by light absorption in photosystem I (PSI) and photosystem II (PSII). A balanced excitation pressure between PSI and PSII is required for optimal photosynthetic efficiency. State transitions serve to keep this balance. If PSII is overexcited in plants and green algae, a mobile pool of light-harvesting complex II (LHCII) associates with PSI, increasing its absorption cross-section and restoring the excitation balance. This is called state 2. Upon PSI overexcitation, this LHCII pool moves to PSII, leading to state 1. Whether the association/dissociation of LHCII with the photosystems occurs between thylakoid grana and thylakoid stroma lamellae during state transitions or within the same thylakoid region remains unclear. Furthermore, although state transitions are thought to be accompanied by changes in thylakoid macro-organization, this has never been observed directly in functional leaves. In this work, we used confocal fluorescence lifetime imaging to quantify state transitions in single Arabidopsis (Arabidopsis thaliana) chloroplasts in folio with sub-micrometer spatial resolution. The change in excitation-energy distribution between PSI and PSII was investigated at a range of excitation wavelengths between 475 and 665 nm. For all excitation wavelengths, the PSI/(PSI + PSII) excitation ratio was higher in state 2 than in state 1. We next imaged the local PSI/(PSI + PSII) excitation ratio for single chloroplasts in both states. The data indicated that LHCII indeed migrates between the grana and stroma lamellae during state transitions. Finally, fluorescence intensity images revealed that thylakoid macro-organization is largely unaffected by state transitions. This single chloroplast in folio imaging method will help in understanding how plants adjust their photosynthetic machinery to ever-changing light conditions.

Clinical Multiteam System Composition and Complexity Among Newly Diagnosed Early-Stage Breast, Colorectal, and Lung Cancer Patients With Multiple Chronic Conditions: A SEER-Medicare Analysis

PURPOSE

Sixty percent of adults have multiple chronic conditions at cancer diagnosis. These patients may require a multidisciplinary clinical team-of-teams, or a multiteam system (MTS), of high-complexity involving multiple specialists and primary care, who, ideally, coordinate clinical responsibilities, share information, and align clinical decisions to ensure comprehensive care needs are managed. However, insights examining MTS composition and complexity among individuals with cancer and comorbidities at diagnosis using US population-level data are limited.

METHODS

Using SEER-Medicare data (2006-2016), we identified newly diagnosed patients with breast, colorectal, or lung cancer who had a codiagnosis of cardiopulmonary disease and/or diabetes (n = 75,201). Zaccaro's theory-based classification of MTSs was used to categorize clinical MTS complexity in the 4 months following cancer diagnosis: high-complexity (≥ 4 clinicians from ≥ 2 specialties) and low-complexity (1-3 clinicians from 1-2 specialties). We describe the proportions of patients with different MTS compositions and quantify the incidence of high-complexity MTS care by patient groups.

RESULTS

The most common MTS composition was oncology with primary care (37%). Half (50.3%) received high-complexity MTS care. The incidence of high-complexity MTS care for non-Hispanic Black and Hispanic patients with cancer was 6.7% (95% CI, -8.0 to -5.3) and 4.7% (95% CI, -6.3 to -3.0) lower than non-Hispanic White patients with cancer; 13.1% (95% CI, -14.1 to -12.2) lower for rural residents compared with urban; 10.4% (95% CI, -11.2 to -9.5) lower for dual Medicaid-Medicare beneficiaries compared with Medicare-only; and 16.6% (95% CI, -17.5 to -15.8) lower for colorectal compared with breast cancer.

CONCLUSION

Incidence differences of high-complexity MTS care were observed among cancer patients with multiple chronic conditions from underserved populations. The results highlight the need to further understand the effects of and mechanisms through which care team composition, complexity, and functioning affect care quality and outcomes.

Multilevel factors associated with inequities in multidisciplinary cancer consultation

OBJECTIVE

To assess changes in the prevalence of multidisciplinary cancer consultations (MDCc) over the last decade and examine patient, surgeon, hospital, and neighborhood factors associated with receipt of MDCc among individuals diagnosed with cancer.

DATA SOURCE

Surveillance, Epidemiology and End Results (SEER)-Medicare data from 2006 to 2016.

STUDY DESIGN

We used time-series analysis to assess change in MDCc prevalence from 2007 to 2015. We also conducted multilevel logistic regression with random surgeon- and hospital-level effects to assess associations between patient, surgeon, neighborhood, and health care organization-level factors and receipt of MDCc during the cancer treatment planning phase, defined as the 2 months following cancer diagnosis.

DATA COLLECTION/EXTRACTION METHODS

We identified Medicare beneficiaries >65 years of age with surgically resected breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) stages I-III (n = 103,250).

PRINCIPAL FINDINGS

From 2007 to 2015, the prevalence of MDCc increased from 35.0% to 61.2%. Overall, MDCc was most common among patients with breast cancer compared to CRC and NSCLC. Cancer patients who were Black, had comorbidities, had dual Medicare-Medicaid coverage, were residing in rural areas or in areas with higher Black and Hispanic neighborhood composition were significantly less likely to have received MDCc. Patients receiving surgery at disproportionate payment-sharing or rural-designated hospitals had 2% (95% CI: -3.55, 0.58) and 17.6% (95% CI: -21.45, 13.70), respectively, less probability of receiving MDCc. Surgeon- and hospital-level effects accounted for 15% of the variance in receipt of MDCc.

CONCLUSIONS

The practice of MDCc has increased over the last decade, but significant geographical and health care organizational barriers continue to impede equitable access to and delivery of quality care across cancer patient populations. Multilevel and multicomponent interventions that target care coordination, health system, and policy changes may enhance equitable access to and receipt of MDCc.

Team-Based Care for Cancer Survivors With Comorbidities: A Systematic Review

Coordination of quality care for the growing population of cancer survivors with comorbidities remains poorly understood, especially among health disparity populations who are more likely to have comorbidities at the time of cancer diagnosis. This systematic review synthesized the literature from 2000 to 2022 on team-based care for cancer survivors with comorbidities and assessed team-based care conceptualization, teamwork processes, and outcomes. Six databases were searched for original articles on adults with cancer and comorbidity, which defined care team composition and comparison group, and assessed clinical or teamwork processes or outcomes. We identified 1,821 articles of which 13 met the inclusion criteria. Most studies occurred during active cancer treatment and nine focused on depression management. Four studies focused on Hispanic or Black cancer survivors and one recruited rural residents. The conceptualization of team-based care varied across articles. Teamwork processes were not explicitly measured, but teamwork concepts such as communication and mental models were mentioned. Despite team-based care being a cornerstone of quality cancer care, studies that simultaneously assessed care delivery and outcomes for cancer and comorbidities were largely absent. Improving care coordination will be key to addressing disparities and promoting health equity for cancer survivors with comorbidities.

Abstract PO-072: Care coordination for older cancer patients with multi-morbidities: Implications for addressing cancer health disparities

Purpose: Newly diagnosed cancer patients with multi-morbidities require a clinical care team of higher complexity due to greater care coordination demands to simultaneously coordinate cancer care and chronic disease management. Whereas teams of lower complexity may streamline care needs by using one clinician or discipline type to manage all care needs. However, this requires clinicians to understand that they are assuming other clinical roles and responsibilities or else care needs go unmanaged leading to poor health outcomes. Given that chronic disease management drops off following the cancer diagnosis, we examined whether cancer patients identifying as non-Hispanic Black, with dual Medicaid coverage, more chronic diseases, and later cancer stage were more likely to have a clinical care team of higher complexity in the 4-months post cancer diagnosis. Methods: Surveillance, Epidemiology and End Results (SEER)-Medicare data were used to identify patients with invasive breast, colorectal, or non-small cell lung cancer with a co-diagnosis of cardiopulmonary disease or diabetes (n=85,876). The data were linked with American Medical Association files to identify clinician's discipline (e.g., oncology, primary care, cardiology) from encounter claims. Using Zaccaro's classification of multi-team systems, we categorized the degree of complexity of the clinical care team: lower (1-2 disciplines and 1-3 clinicians) versus higher (2+ disciplines and 4+ clinicians). We used multivariable logistic regression to examine patient factors associated with having a clinical care team of higher complexity (compared with lower). Results: Among older cancer patients with multi-morbidities, the most common clinical care team composition was oncology with primary care (37%) followed by oncology, primary care, and medical subspecialty (34%). In the adjusted model, cancer patients were less likely to have a clinical care team of higher complexity if they were non-Hispanic Black compared to non-Hispanic White (OR: 0.88; 95% CI: 0.83, 0.93), dual Medicaid-Medicare covered compared with Medicare only (OR: 0.63; 95% CI: 0.61, 0.65), and diagnosed with stage III cancer compared to stage I (OR: 0.87; 95% CI: 0.84, 0.90). Cancer patients were more likely to have a clinical care team of higher complexity if they had cardiopulmonary disease (OR: 1.74; 95% CI: 1.68, 1.81) or diabetes (OR: 1.69; 95% CI: 1.63,1.75) compared with hypertension only. Conclusion: Clinical care teams of lower complexity were associated with identifying as Black, Medicaid coverage, and later stage, which are known factors associated with poorer care outcomes. This warrants further investigation to examine whether clinicians are assuming other clinicians' roles and responsibilities for patient care or if cancer care is taking precedence over other chronic diseases. Future research to address cancer care disparities need to focus on clinical care teams and the healthcare organizational context that provide and optimize care coordination for newly diagnosed cancer patients with multi-morbidities.

Citation Format: Michelle Doose, Dana Verhoeven, Janeth I. Sanchez, Veronica Chollette, Sallie J. Weaver. Care coordination for older cancer patients with multi-morbidities: Implications for addressing cancer health disparities [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-072.

Abstract IA-36: Fragmentation of care among Black women who have breast cancer and multiple comorbidities

Purpose: Black women newly diagnosed with breast cancer and who have multiple comorbidities at the time of cancer diagnosis require greater care coordination to simultaneously manage cancer care and other chronic conditions. Care coordination may be complicated when multiple clinicians from diverse disciplines are involved in managing care and are located in different health systems, defined as care fragmentation. Given that Black women are disproportionately burdened by comorbidities and breast cancer, we examined the degree of care fragmentation and care coordination experienced by this group from a health system and care team perspective using two population-based cohorts. Methods: We analyzed data from two separate cohorts of Black women diagnosed with breast cancer who had diabetes and/or cardiovascular disease. In the first study we used the Women's Circle of Health Follow-Up Study (n=228) to examine types of practice setting for first primary care visit and primary breast surgery, and, through medical chart abstraction, identified whether care visit was within or outside the same health system. In a separate study, we identified women from the SEER-Medicare database (n=3,420) diagnosed with breast cancer and used encounter claims to examine the complexity and composition of the clinical care team. Results: Care fragmentation was experienced by 79% of Black women in the Women's Circle of Health Follow-Up Study, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (p>.05). In the SEER-Medicare cohort, the most common clinical care team composition was oncology with primary care (45%) followed by oncology, primary care, and medical subspecialty (26%). In the adjusted model, Black women were more likely to have a clinical care team of higher complexity if they had cardiopulmonary disease (OR: 1.74; 95% CI: 1.68, 1.81) or diabetes (OR: 1.69; 95% CI: 1.63,1.75) compared with hypertension only. Women were also less likely to have a complex care team if they were dual Medicaid-Medicare covered (OR: 0.56; 95% CI: 0.48, 0.65) compared with Medicare only, rural residents (OR: 0.54; 95% CI: 0.42, 0.65) compared with urban, or diagnosed with stage III cancer (OR: 0.59; 95% CI: 0.47, 0.75) compared with stage I. Conclusion: The majority of Black breast cancer survivors with comorbidities see multiple clinicians from diverse disciplines and in different health systems, illustrating high care coordination demands and care fragmentation. However, the impact of the health system and care team on care outcomes still need to be assessed, and this includes care transitions into survivorship. To address cancer care disparities experienced by Black women, future research should consider examining clinician's perspectives regarding roles and responsibilities for chronic disease management and cancer care, as well as address care fragmentation across diverse healthcare delivery settings.

Citation Format: Michelle Doose, Janeth I. Sanchez, Dana Verhoeven, Veronica Chollette, Joel C. Cantor, Jesse J Plascak, Michael Steinberg, Chi-Chen Hong, Kitaw Demissie, Elisa Bandera, Jennifer Tsui, Sallie J. Weaver. Fragmentation of care among Black women who have breast cancer and multiple comorbidities [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr IA-36.

Assessment of potential process quality indicators for systemic treatment of breast cancer in Belgium: a population-based study

BACKGROUND

Quality indicators (QIs) for the management of breast cancer (BC) have been published in Europe and internationally. In Belgium, a task force was established to select measurable process indicators of systemic treatment for BC, focusing on appropriateness of delivered care. The objective of this study was to evaluate the results of the selected QIs, both nationally and among individual centres.

PATIENTS AND METHODS

Female Belgian residents with unilateral primary invasive BC diagnosed between 2010 and 2014 were selected from the Belgian Cancer Registry database. The national number enabled linkage with the national reimbursement database, which contains information on all reimbursed medical procedures. A total of 12 process indicators were measured on the population and hospital level. Intercentre variability was assessed by median results and interquartile ranges.

RESULTS

A total of 48  872 patients were included in the study. QIs concerning specific BC subtypes only applied to patients diagnosed in 2014 (n = 9855). Clinical stage (cStage) I patients (n = 17 116) were staged with positron emission tomography/computed tomography. Among patients who were pT1aN0 human epidermal growth factor receptor 2 (HER2) positive (n = 47), 25.5% (n = 12) received adjuvant trastuzumab. Among patients with de novo metastatic luminal A/B-like HER2-negative BC (n = 295), 17.3% (n = 51) received upfront chemotherapy. (Neo)adjuvant chemotherapy was administered in 52.4% (n = 12 592) of operated women with cStage I-III, in 37.0% (n = 1270) of operated women with cStage I-III luminal A/B-like HER2-negative BC, and in 19.1% of operated women with cStage I luminal A/B-like HER2-negative BC. In the population of operated patients with cStage I-III, of those younger than 70 years that started adjuvant endocrine therapy (n = 3591), 81.7% (n = 2932) continued treatment for ≥4.5 years. Among patients in cStage I-III older than 70 years (n = 8544), 19.0% (n = 1622) received (neo)adjuvant chemotherapy, whereas among patients with cStage I-III luminal A/B-like HER2-negative BC (n = 1388), 13.0% (n = 181) received (neo)adjuvant chemotherapy. In patients with cStage I-II luminal A/B-like HER2-negative BC older than 70 years (n = 1477), 11.6% (n = 171) were not operated and received upfront endocrine treatment.

CONCLUSION

Well-considered QIs using population-based data can evaluate quality of care and expose disparities among treatment centres. Their use in daily practice should be implemented in all centres treating BC.

Evaluation of applying IHC4 as a prognostic model in the translational study of Intergroup Exemestane Study (IES): PathIES

BACKGROUND

Intergroup Exemestane Study (IES) was a randomised study that showed a survival benefit of switching adjuvant endocrine therapy after 2-3 years from tamoxifen to exemestane. This PathIES aimed to assess the role of immunohistochemical (IHC)4 score in determining the relative sensitivity to either tamoxifen or sequential treatment with tamoxifen and exemestane.

PATIENTS AND METHODS

Primary tumour samples were available for 1274 patients (27% of IES population). Only patients for whom the IHC4 score could be calculated (based on oestrogen receptor, progesterone receptor, HER2 and Ki67) were included in this analysis (N = 430 patients). The clinical score (C) was based on age, grade, tumour size and nodal status. The association of clinicopathological parameters, IHC4(+C) scores and treatment effect with time to distant recurrence-free survival (TTDR) was assessed in univariable and multivariable Cox regression analyses. A modified clinical score (PathIEscore) (N = 350) was also estimated.

RESULTS

Our results confirm the prognostic importance of the original IHC4, alone and in conjunction with clinical scores, but no significant difference with treatment effects was observed. The combined IHC4 + Clinical PathIES score was prognostic for TTDR (P < 0.001) with a hazard ratio (HR) of 5.54 (95% CI 1.29-23.70) for a change from 1st quartile (Q1) to Q1-Q3 and HR of 15.54 (95% CI 3.70-65.24) for a change from Q1 to Q4.

CONCLUSION

In the PathIES population, the IHC4 score is useful in predicting long-term relapse in patients who remain disease-free after 2-3 years. This is a first trial to suggest the extending use of IHC4+C score for prognostic indication for patients who have switched endocrine therapies at 2-3 years and who remain disease-free after 2-3 years.

Team training in obstetrics: A multi-level evaluation

INTRODUCTION

Obstetric complications and adverse patient events are often preventable. Teamwork and situational awareness (SA) can improve detection and coordination of critical obstetric (OB) emergencies, subsequently improving decision making and patient outcomes. The purpose of this study was to assess the effectiveness of a team training intervention in improving learning and transfer of teamwork, SA, decision making, and cognitive bias as well as patient outcomes in OB.

METHOD

An adapted TeamSTEPPS training program was delivered to OB clinicians. Training targeted communication, mutual support, situation monitoring, leadership, SA, and cognitive bias. We conducted a repeated measures multilevel evaluation of the training using Kirkpatrick's (1994) framework of training evaluation to determine impact on trainee reactions, learning, transfer, and results. Data were collected using surveys, situational judgment tests (SJTs), observations, and patient chart reviews.

RESULTS

Participants perceived the training as useful. Additionally, participants acquired knowledge of communication strategies, though knowledge of other team competencies did not significantly improve nor did self-reported teamwork on the unit. Although SJT decision accuracy did not significantly improve for all scenarios, results of behavioral observation suggest that decision accuracy significantly improved on the job, and there was a marginally significant reduction in babies' hospital length of stay.

DISCUSSION

These findings indicate that the training intervention was partially effective, but more work needs to be done to determine the conditions under which training is most effective, and the ways in which to sustain improvements. Future research is needed to confirm its generalizability to additional OB units and departments.

Cilengitide combined with cetuximab and platinum-based chemotherapy as first-line treatment in advanced non-small-cell lung cancer (NSCLC) patients: results of an open-label, randomized, controlled phase II study (CERTO)

BACKGROUND

This multicentre, open-label, randomized, controlled phase II study evaluated cilengitide in combination with cetuximab and platinum-based chemotherapy, compared with cetuximab and chemotherapy alone, as first-line treatment of patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Patients were randomized 1:1:1 to receive cetuximab plus platinum-based chemotherapy alone (control), or combined with cilengitide 2000 mg 1×/week i.v. (CIL-once) or 2×/week i.v. (CIL-twice). A protocol amendment limited enrolment to patients with epidermal growth factor receptor (EGFR) histoscore ≥200 and closed the CIL-twice arm for practical feasibility issues. Primary end point was progression-free survival (PFS; independent read); secondary end points included overall survival (OS), safety, and biomarker analyses. A comparison between the CIL-once and control arms is reported, both for the total cohorts, as well as for patients with EGFR histoscore ≥200.

RESULTS

There were 85 patients in the CIL-once group and 84 in the control group. The PFS (independent read) was 6.2 versus 5.0 months for CIL-once versus control [hazard ratio (HR) 0.72; P = 0.085]; for patients with EGFR histoscore ≥200, PFS was 6.8 versus 5.6 months, respectively (HR 0.57; P = 0.0446). Median OS was 13.6 for CIL-once versus 9.7 months for control (HR 0.81; P = 0.265). In patients with EGFR ≥200, OS was 13.2 versus 11.8 months, respectively (HR 0.95; P = 0.855). No major differences in adverse events between CIL-once and control were reported; nausea (59% versus 56%, respectively) and neutropenia (54% versus 46%, respectively) were the most frequent. There was no increased incidence of thromboembolic events or haemorrhage in cilengitide-treated patients. αvβ3 and αvβ5 expression was neither a predictive nor a prognostic indicator.

CONCLUSIONS

The addition of cilengitide to cetuximab/chemotherapy indicated potential clinical activity, with a trend for PFS difference in the independent-read analysis. However, the observed inconsistencies across end points suggest additional investigations are required to substantiate a potential role of other integrin inhibitors in NSCLC treatment.

CLINICAL TRIAL REGISTRATION ID NUMBER

NCT00842712.

Divergent mucosal and systemic responses in children in response to acute otitis media

Acute otitis media (AOM), induced by respiratory bacteria, is a significant cause of children seeking medical attention worldwide. Some children are highly prone to AOMs, suffering three to four recurrent infections per year (prone). We previously determined that this population of children could have diminished anti-bacterial immune responses in peripheral blood that could fail to limit bacterial colonization in the nasopharynx (NP). Here, we examined local NP and middle ear (ME) responses and compared them to peripheral blood to examine whether the mucosa responses were similar to the peripheral blood responses. Moreover, we examined differences in effector cytokine responses between these two populations in the NP, ME and blood compartments at the onset of an AOM caused by either Streptococcus pneumoniae or non-typeable Haemophilus influenzae. We found that plasma effector cytokines patterned antigen-recall responses of CD4 T cells, with lower responses detected in prone children. ME cytokine levels did not mirror blood, but were more similar to the NP. Interferon (IFN)-γ and interleukin (IL)-17 in the NP were similar in prone and non-prone children, while IL-2 production was higher in prone children. The immune responses diverged in the mucosal and blood compartments at the onset of a bacterial ME infection, thus highlighting differences between local and systemic immune responses that could co-ordinate anti-bacterial immune responses in young children.

Abstract OT3-2-04: Prospective multicenter study evaluating the effect of impaired tamoxifen metabolization on efficacy in breast cancer patients receiving tamoxifen in the neo-adjuvant or metastatic setting - The CYPTAM-BRUT 2 trial

Background

Tamoxifen is often used for the prevention and treatment of hormone receptor positive breast cancer. It is a prodrug which is metabolized by human liver enzymes to more active metabolites. The principal active metabolite of tamoxifen is considered to be endoxifen, which is formed by cytochrome P450 (CYP) enzymes. These enzymes are highly polymorphic in humans and endoxifen plasma levels are modulated by the patient's genotype. The effect of lowered endoxifen plasma levels on tamoxifen efficacy, however, is not yet clear as results remain contradictory. However, the association between endoxifen plasma concentrations, multiple CYP-genotypes and clinical outcome has not been studied so far in a prospective study in patients with advanced breast cancer receiving first-line tamoxifen treatment.

Trial design

CYPTAM-BRUT 2 is a prospective multicenter open-label single-arm non-randomized observational trial approved by the UZ Leuven Ethics Committee. Eligibility criteria are postmenopausal women with estrogen receptor positive invasive breast cancer receiving tamoxifen as first-line therapy in the metastatic or neo-adjuvant setting. Prior adjuvant endocrine therapy is allowed if there is more than 12 months after completion of the adjuvant therapy.

Primary endpoint is the association between endoxifen steady-state plasma concentrations and objective response rate after 3-6 months of treatment using RECIST criteria. Main secondary endpoint is the relation between endoxifen plasma concentrations and clinical benefit (CR+PR+SD at 6 months) according to the RECIST criteria. Other secondary endpoints include progression-free survival, toxicity and the association between CYP2D6 genotype and clinical outcome. In addition, we will assess how much of the variation in endoxifen levels is explained by the genetic variants and CYP2D6 inhibitors.

The trial is designed to detect a statistical association between endoxifen and objective tumor response rate (ORR), under the assumption that the relationship is linear with an odds ratio (OR) of 1.49 per 10 nmol/l. Using available data on endoxifen concentrations, this OR is chosen to reflect an improvement from 10% ORR in the lowest endoxifen quartile to 30% in the highest endoxifen quartile when the overall ORR is around 18%. To have 90% power at a 5% significance level, 180 patients have to be included into the study. The main secondary study endpoint is clinical benefit at 6 months. The study has to include 243 patients to detect a statistically significant association with endoxifen with 80% power at a 5% significance level, assuming an OR of 1.28 per 10 nmol/l. This OR is chosen to reflect an improvement of clinical benefit at 6 months from 30% in the lowest endoxifen quartile to 50% in the highest endoxifen quartile (overall clinical benefit around 39%).

Patient accrual

Currently 257 patients from 22 participating centers in Belgium and Switzerland are included (May 2013). As the sample size calculation did not account for missing data, inclusions will continue until 243 patients who fulfill the inclusion criteria are included (i.e. target lesions, blood sample and response evaluation).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-2-04.

Phase II study of everolimus in patients with locally advanced or metastatic transitional cell carcinoma of the urothelial tract: clinical activity, molecular response, and biomarkers

BACKGROUND

This phase II study assessed the safety and efficacy of everolimus, an oral mammalian target of rapamycin inhibitor in advanced transitional carcinoma cell (TCC) after failure of platinum-based therapy.

PATIENTS AND METHODS

Thirty-seven patients with advanced TCC received everolimus 10 mg/day until progressive disease (PD) or unacceptable toxicity. The primary end point was the disease control rate (DCR), defined as either stable disease (SD), partial response (PR), or complete response at 8 weeks. Angiogenesis-related proteins were detected in plasma and changes during everolimus treatment were analyzed. PTEN expression and PIK3CA mutations were correlated to disease control.

RESULTS

Two confirmed PR and eight SD were observed, resulting in a DCR of 27% at 8 weeks. Everolimus was well tolerated. Compared with patients with noncontrolled disease, we observed in patients with controlled disease a significant higher baseline level of angiopoietin-1 and a significant early plasma decrease in angiopoietin-1, endoglin, and platelet-derived growth factor-AB. PTEN loss was observed only in patients with PD.

CONCLUSIONS

Everolimus showed clinical activity in advanced TCC. The profile of the plasma angiogenesis-related proteins suggested a role of the everolimus antiangiogenic properties in disease control. PTEN loss might be associated with everolimus resistance.

P5-18-04: Safety Profile of Ixabepilone as Adjuvant Treatment for Poor Prognosis Early Breast Cancer: First Results of the Unicancer-PACS 08 Trial

Purpose: PACS 01 trial demonstrated that the sequential adjuvant chemotherapy with FEC100 followed by docetaxel (D) significantly improves disease-free and overall survival in node-positive(N+) early breast cancer (BC). However, Triple negative (TN) and ER+/ PR-/HER2− subgroups are significantly associated to a worse prognosis even after adjunction of D. As Ixabepilone (Ixa) has notable preclinical and clinical activity in these subgroups, the PACS 08 trial aims to compare standard FEC100-D regimen to 3 cycles of FEC100 followed by 3 cycles of Ixa. We report the preliminary results of the toxicity profile.

Patients and methods: Patients (pts) had localized resectable unilateral ER-/PR-/HER2− or ER+/PR-/HER2− BC. Main inclusion criteria were: age&lt;70 years, normal cardiac, hepatic, haematological and renal functions. Arm A: pts received 3 cycles of FEC100 (F and C, each at 500 mg/m2, E 100 mg/m2, every 3 weeks) followed by 3 cycles of D (100 mg/m2 every 3 weeks); Arm B, Ixa 40 mg/m2 replaced D. Radiotherapy was mandatory after conservative surgery and endocrine therapy was given to ER+ pts. A 5% absolute difference in disease-free survival at 5 years is the main statistical end-point. Results: Between October 2007 and September 2010, 762 pts with TNBC or ER+/PR-/HER2− BC were enrolled. Recruitment was interrupted due to BMS decision to stop Ixa development in adjuvant setting. Main pts characteristics were well balanced between the 2 arms: median age 53 years, postmenopausal 57.8%, conservative surgery 68.4%, node positive 59.5%. A total of 755 pts were evaluable for safety. Treatment was completed for 93.4% and 86.1% of pts in arms A and B, respectively. During FEC100 sequence, toxicities were well balanced between the two arms. From cycle 4, whereas Gr3/4 sensory neurotoxicity (12pts; 3.5%) and thrombopenia (7pts; 2%) were reported in Ixa arm, none of these toxicities was reported in the D arm (p0.001). There were significantly more Gr3/4 neutropenia on day 21 in Ixa arm (13pts, 6.6% vs 4pts, 1.9%; p&lt;10.005). No significant difference was observed for febrile neutropenia. Fewer cutaneous toxicities were observed in Ixa arm (2pts, 0.6% vs 10pts, 2.6%; p&lt;0.05). No significant difference was observed neither for motor neurotoxicity or hepatic function between two arms. More pts discontinued treatment in Ixa arm compared to D arm (49pts (13%) vs 26pts (7%), p&lt;0.05). Main reasons were Gr3/4 haematological adverse events (AE) and Gr3/4 neurotoxicities for Ixa arm and due to GR3/4 haematological AE for D arm. One non expected Gr4 bullous dermatitis was reported during the first Ixa cycle. 2 deaths due to septic shock occured in Ixa arm (both at cycle 4 for a 56- and a 66-year-old woman). However, according to the IDMC no obvious precipitating factor questioning the Ixa arm was identified.

Conclusion: Our results indicate that D arm is more often associated to significant haematological toxicities, whereas both neurotoxicities and haematological toxicities are reported in the Ixa arm. Although significantly more pts discontinued treatment due to adverse events in Ixa arm compared to D arm, Ixa may still represent a promising therapeutic option for pts in the adjuvant setting especially for poor prognosis BC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-18-04.

Loss of growth factor receptor signaling in the oral mucosa during primary SIV infection may enhance apoptosis and promote pathogenesis

BACKGROUND

The development of susceptibility to secondary pathogenic infections in the oral cavity during HIV infection is likely to result from or coincide with deterioration of the local mucosal immune system.

METHODS

We have utilized the SIV model to investigate the kinetics and magnitude of oral pathogenesis during systemic dissemination of intravenously inoculated SIVmac251.

RESULTS

Viral replication was detected in oropharyngeal lymph nodes at 6 weeks post-infection and shown to be coincident with a broad scale loss of growth factor receptor transcription in the oral mucosa, providing multiple avenues for blocking the normal activity of apoptosis inhibitors that function through Bcl2- and p53-dependent pathways.

CONCLUSIONS

Our findings suggest that the normal balance between cell death and regeneration may be rapidly disrupted in the oral mucosa during the early stages of immunodeficiency virus infection, setting the stage for continuing deterioration of immune function and the development of susceptibility to secondary infections.

Weekly paclitaxel versus weekly docetaxel in elderly and frail patients with metastatic breast carcinoma having failed previous anthracyclines: a randomised phase II study of the Belgian Society of Medical Oncology

Abstract #6115

Rationale: Taxanes are considered as standard 2nd-line chemotherapy after anthracyclines in metastatic breast carcinoma (MBC). In one large randomized trial, Jones et al. (JCO 2005;23:5542) reported a mean objective remission rate (RR) of 32% with a median time to progression (TTP) of 24.6 weeks (wks) for 3-weekly docetaxel 100mg/m², while the corresponding figures for paclitaxel 175mg/m² were 25% and 15.6wks respectively. Nevertheless, excessive toxicity, especially myelosuppression, precludes their use in frail and/or elderly patients (pts). For the latter, weekly schemes were developed, which proved tolerable without losing efficacy. This randomized phase II trial investigated the efficacy and the tolerability of weekly docetaxel or paclitaxel in MBC pts considered unfit for a 3-weekly therapy. Eligibility criteria were age &gt;70 years, particular risk for myelosuppression (febrile neutropenia during previous chemotherapy, extensive radiation therapy, proven bone marrow invasion) or impaired hepatic function.&#x2028; Study design: 70pts accrued from Jan. 2002 to Aug. 2005 were randomized between arm A (33pts) receiving paclitaxel 80mg/m² weekly x8, and arm B (37pts), receiving docetaxel 36mg/m² weekly x8 after which a clinical response evaluation including CT-scan was performed. Pts with objective remission or stable disease (SD) pursued treatment 3/4 or 2/3 wks untill progression or unacceptable toxicity. For all pts, this was the first exposure to taxanes, unless they had received it in an adjuvant scheme, or in a palliative scheme with at least a 4 months lasting response. Study-endpoints were RR, TTP, overall survival (OS) and tolerability.&#x2028; Results: With paclitaxel, we obtained a RR of 55.2%, SD in 27.6% and progressive disease (PD) in 17.2% of the pts; median TTP was 21.1wks (95% CI:14.9-29.0) and median survival 55.7wks (95% CI:28.6-79.0). Corresponding results for docetaxel were: a RR of 45.2%, SD in 19.4% and PD in 35.4%; median TTP was 12.7wks (95% CI:8.4-29.3) and median survival 32wks (95% CI:19.4-50.9). Docetaxel and paclitaxel are known to have a different toxicity profile in 3-weekly regimens, with more hematotoxicity for docetaxel. In our study, boths products had a similar toxicity profile with more anemia, neutropenia and febrile neutropenia in the paclitaxel arm.&#x2028; Conclusions: Our study demonstrates that in pts with MBC unfit for 3-weekly docetaxel or paclitaxel, weekly administration of either compound may certainly be considered after anthracycline failure. They display different, but acceptable toxicity profiles, with levels of antitumoral efficacy comparable to those previously reported for 3-weekly regimens. A true valid comparison would require extension into a phase III trial.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6115.

Observational Aranesp Survey to Investigate the Q3W Schedule (OASIS): a prospective observational study of treatment of chemotherapy-induced anaemia with every 3 weeks darbepoetin alfa

INTRODUCTION

This prospective observational study examined the adherence to published European guidelines on erythropoiesis-stimulating agents (ESAs) and the pattern of use and effect of darbepoetin alfa (DA) 500 microg once every 3 weeks (Q3W) for the treatment of chemotherapy-induced anaemia (CIA).

MATERIALS AND METHODS

A total of 293 patients were included (263 solid tumour, 30 haematologic malignancy). Their mean age was 63 years, 51% were male, 57% had platinum-based chemotherapy. DA was started at a haemoglobin (Hb) level between 9 and 11 g/dL in 82% of patients.

RESULTS AND DISCUSSION

In an analysis correcting for transfusions, 55% of patients achieved > or =2 g/dL increase in Hb, and a Hb level of >11 g/dL was reached in 81%. Transfusion rate was 27%. Most patients (70%) were treated in a Q3W chemotherapy, and planned synchronisation of chemotherapy and Q3W DA could be maintained in 76%.

CONCLUSION

Adherence to European guidelines for DA treatment was good, and Q3W DA treatment was in synchronisation with Q3W chemotherapy in the majority of the patients, thereby reproducing the findings of a recent phase III study.

Simian immunodeficiency virus infection induces severe loss of intestinal central memory T cells which impairs CD4+ T-cell restoration during antiretroviral therapy

BACKGROUND

Simian immunodeficiency virus (SIV) infection leads to severe loss of intestinal CD4(+) T cells and, as compared to peripheral blood, restoration of these cells is slow during antiretroviral therapy (ART). Mechanisms for this delay have not been examined in context of which specific CD4(+) memory subsets or lost and fail to regenerate during ART.

METHODS

Fifteen rhesus macaques were infected with SIV, five of which received ART (FTC/PMPA) for 30 weeks. Viral loads were measured by real-time PCR. Flow cytometric analysis determined changes in T-cell subsets and their proliferative state.

RESULTS

Changes in proliferative CD4(+) memory subsets during infection accelerated their depletion. This reduced the central memory CD4(+) T-cell pool and contributed to slow CD4(+) T-cell restoration during ART.

CONCLUSION

There was a lack of restoration of the CD4(+) central memory and effector memory T-cell subsets in gut-associated lymphoid tissue during ART, which may contribute to the altered intestinal T-cell homeostasis in SIV infection.

Gene expression profiling of gut mucosa and mesenteric lymph nodes in simian immunodeficiency virus-infected macaques with divergent disease course

BACKGROUND

Although the majority of drug-naïve HIV-infected patients develop acquired immunodeficiency syndrome (AIDS), a small percentage remains asymptomatic without therapeutic intervention.

METHODS

We have utilized the simian immunodeficiency virus (SIV)-infected rhesus macaque model to gain insights into the molecular mechanisms of long-term protection against simian AIDS.

RESULTS

Chronically SIV-infected macaques with disease progression had high viral loads and CD4(+) T-cell depletion in mucosal tissue and peripheral blood. These animals displayed pathologic changes in gut-associated lymphoid tissue (GALT) and mesenteric lymph node that coincided with increased expression of genes associated with interferon induction, inflammation and immune activation. In contrast, the animal with long-term asymptomatic infection suppressed viral replication and maintained CD4(+) T cells in both GALT and peripheral blood while decreasing expression of genes involved in inflammation and immune activation.

CONCLUSIONS

Our findings suggest that reduced immune activation and effective repair and regeneration of mucosal tissues correlate with long-term survival in SIV-infected macaques.

Vegetable and animal products as determinants of colon cancer risk in Dutch men and women

To examine the relationship between colon cancer and food groups from vegetable or animal sources and their possible interactions with gender, we analyzed data from a Dutch case-control study. Dietary patterns were assessed for 232 colon cancer cases and 259 population controls. In multivariate analyses, the consumption of vegetables was associated significantly with reduced colon-cancer risk (odds ratio [OR] for highest cf lowest quartile of consumption = 0.4, 95 percent confidence interval [CI] = 0.2-0.7, P-trend = 0.0004). Consumption of fresh red meat was associated positively with risk in women (OR = 2.4, 95% CI = 1.0-5.7, P-trend = 0.04), especially for those with a high consumption of red meat relative to the consumption of vegetables and fruits (OR = 3.1). For men, no association with consumption of fresh red meat was found (OR = 0.9). No clear associations were found for other products of vegetable or animal origin. The results of this Dutch case-control study support the preventive potential of a high-vegetable diet in colon cancer risk. This study suggest this may be important for women consuming a diet high in red meat.

Microvessel quantification in primary colorectal carcinoma: an immunohistochemical study

The vascularisation of human primary colorectal carcinomas was studied immunohistochemically using the endothelial cell markers CD31 and factor VIII-related antigen. Tumour sections were systematically scanned at a magnification of x 100 to find areas of intense neovascularisation. Microvessel counts within these vascular 'hotspots' were performed at magnification x 250. Regions in which tumour cords were surrounded by a collagen IV-positive basement membrane were compared with those in which this was absent and with normal mucosa. CD31 appeared to be a more sensitive marker for endothelial cells than factor VIII-related antigen (mean 185 +/- 59 and 120 +/- 38 microvessels mm-2). Within individual tumour sections microvessel counts in vascular hotspots with highest vessel density correlated significantly with microvessel counts in vascular hotspots with second highest vessel density (P < 0.01). Microvessel counts in tumour areas where collagen IV-positive basement membrane were absent exceeded those in areas where it was present (factor of 1.7) and those in normal mucosa (factor of 1.6). The differences in vessel density between individual tumours and the low variability in vessel density within individual tumours using this quantification technique allow us to investigate the prognostic value of vessel density in areas of intense neovascularisation in human primary colorectal carcinomas.

Microvessel density, endothelial cell proliferation and tumour cell proliferation in human colorectal adenocarcinomas

BACKGROUND

Thymidine incorporation studies performed in animal tumour models, revealed major differences in endothelial cell proliferation when tumour tissue was compared with normal tissue. The fraction of proliferating endothelial cells is reported to be increased by a factor of 30 to 40 in tumour tissue.

PATIENTS AND METHODS

To make it possible to analyze the endothelial cell proliferation in human tumours, an immunohistochemical double staining technique comprising CD31, an endothelial cell marker, and Ki-67, a proliferation marker, was developed. Endothelial cell proliferation was analysed in 21 primary human colorectal adenocarcinomas and in the adjacent mucosa.

RESULTS

Proliferating endothelial cells were found throughout the entire carcinoma. The mean overall endothelial cell labeling index (ECLI) was 9.9% (range, 5.4-18.0), and the labeling index of endothelial cells in areas of intense neovascularisation was even higher. Mean ECLI in the vascular hot spots was 21.0% (range, 6.8-35.0), and the mean tumour cell labeling index (TCLI) in the maximally Ki-67 immunostained areas was 78.3% (range 47.0-89.7). In 14 of 21 carcinomas, these areas were predominantly found at the luminal margin of the tumour, as were the vascular hot spots. A significant positive correlation was found between tumour vascularity, measured in the vascular hot spots, and tumour cell proliferation, measured in the maximally Ki-67 immunostained areas (p < 0.05). To analyse this relation in more detail, microvessel density (MVD), TCLI and ECLI were determined per x400 microscopic field by scanning in sequence from the luminal tumour margin to the invasive tumour base. In all tumours, the pattern of the MVD per x400 field, from the luminal margin to the tumour base, was similar to that of the TCLI and ECLI.

CONCLUSIONS

These findings confirm that the fraction of cycling endothelial cells is higher in human colorectal carcinoma than in the adjacent mucosa which suggests that endothelial cells are proliferating in most of the individual capillaries in tumour tissue. Regional differences in MVD correlate with differences in tumour cell proliferation in these tumours.

Proliferation, basement membrane changes, metastasis and vascularization patterns in human breast cancer

Tumour cell proliferation shows a heterogeneous intratumour distribution. By comparison with the infiltrating component of breast cancers, the intraductal component has a significantly lower proliferation index. The cells at the periphery of infiltrating tumour strands have a higher proliferation activity than the cells in the core. A variable turn-over of basement membrane material is reported in infiltrating cancers. Increased amounts of type IV collagen are demonstrated in areas of periductal elastosis and of interstitial elastosis in breast cancer. Important parallels are found between metastatic tumour cells and the macrophages acting in the process of inflammation. We found evidence that displacements of tumour cells and macrophages are similar. Studies of vascularization in transplanted tumours cannot be extrapolated to man. A striking heterogeneity in the organization of vessels and in the expression of some markers is observed in human breast cancer.

Limited-data computed tomography algorithms for the physical sciences

Five limited-data computed tomography algorithms are compared. The algorithms used are adapted versions of the algebraic reconstruction technique, the multiplicative algebraic reconstruction technique, the Gerchberg-Papoulis algorithm, a spectral extrapolation algorithm descended from that of Harris [J. Opt. Soc. Am. 54, 931-936 (1964)], and an algorithm based on the singular value decomposition technique. These algorithms were used to reconstruct phantom data with realistic levels of noise from a number of different imaging geometries. The phantoms, the imaging geometries, and the noise were chosen to simulate the conditions encountered in typical computed tomography applications in the physical sciences, and the implementations of the algorithms were optimized for these applications. The multiplicative algebraic reconstruction technique algorithm gave the best results overall; the algebraic reconstruction technique gave the best results for very smooth objects or very noisy (20-dB signal-to-noise ratio) data. My implementations of both of these algorithms incorporate apriori knowledge of the sign of the object, its extent, and its smoothness. The smoothness of the reconstruction is enforced through the use of an appropriate object model (by use of cubic B-spline basis functions and a number of object coefficients appropriate to the object being reconstructed). The average reconstruction error was 1.7% of the maximum phantom value with the multiplicative algebraic reconstruction technique of a phantom with moderate-to-steep gradients by use of data from five viewing angles with a 30-dB signal-to-noise ratio.

Ultrastructural demonstration of type IV collagen deposits in periductal elastosis in breast cancer

In a previous study we demonstrated at light microscopical level the presence of variable amounts of type IV collagen in the areas of periductal and interstitial elastosis in breast cancer. The present work was directed towards a further study by immunoelectron microscopy of the distribution of type IV collagen in the areas of periductal elastosis. The semithin sections showed a distinct immunoreactivity of all basement membranes for type IV collagen but no staining of the interstitial stroma. Corresponding ultrathin sections demonstrated a broad basement membrane with immunoreactivity for type IV collagen at its outer side. Many punctiform deposits of type IV collagen were observed in the areas of periductal elastosis but not around normal ducts or vessels. Recently the role of type IV collagen as a structural component on anchoring plaques between the basement membrane and the underlying stroma in the dermis has been emphasized. The results of this study demonstrate the presence of type IV collagen deposits below a thickened basement membrane in breast cancer.

Comparison of cell growth in different parts of breast cancers

This study was performed to answer the question: which parts of breast cancers are active in terms of proliferation as measured by the Ki-67 antibody and in terms of cell division as measured by the mitotic index. Forty-six breast samples were studied, including 34 breast cancers and 12 benign conditions. The intraductal component of infiltrating breast cancers showed a significantly lower proliferation index than the infiltrating component. The cells at the periphery of infiltrating tumour strands showed a higher proliferation activity than the cells in the core. These findings suggest that infiltration advances through preferential active growth of the cells at the invasion front.

The presence of a type IV collagen skeleton associated with periductal elastosis in breast cancer

Using serial sections of frozen and AFA-fixed tissues from 34 breast cancers, we studied the presence of basement membrane material in the areas of elastosis. Various amounts of type IV collagen but not of laminin were demonstrated in areas of periductal elastosis. In some tumors, type IV collagen accumulated beneath the basement membrane. Periductal elastosis in areas of extensive fibrosis showed focal type IV collagen immunoreactivity, indicating remnants of ducts. Interstitial elastosis corresponded with weak type IV collagen reactivity. Each tumor showed type IV collagen immunostaining of the elastotic areas, with various degrees of intensity. Negative crossreactivity of the type IV collagen antibody with elastin was verified in skin biopsies with solar elastosis. Pre-incubation of the antibody with large amounts of elastin demonstrated an identical immunoreactivity. The specificity of the antibody was confirmed by ELISA and by Western blot analysis. To explain the periductal elastosis, we propose the following hypothesis. Excessive production of basement membrane material by the epithelial cells of the ducts leads to formation of a type IV collagen skeleton. This skeleton can act as the matrix for a secondary deposition of elastic material.

Desmin-positive stellate cells associated with angiogenesis in a tumour and non-tumour system

The angiogenesis induced after implantation of fragments of the Walker 256 carcinoma was compared with the angiogenesis following implantation of different amounts of Indian ink. Morphologically and chronologically the tumour system showed no difference from the Indian ink system, provided sufficient amounts of ink were implanted. Both systems were characterized by significant macrophage infiltration. The vascular development, which was clearly concentrated in a dense rim around the tumour, remained present when the tumour enlarged, suggesting an acquisition of vasculature by the tumour through vessel incorporation and not vessel ingrowth. Initially, scattered desmin-positive cells, in contact or encircled by collagen IV, were found in the developing angiogenic rim. Later many desmin-positive cells were found around vessels and could be identified by electron microscopy as pericytes. They exhibited close local contacts with endothelial cells. After incorporation of the peritumour vascular rim into the tumour the number of pericytes decreased and their shape became flattened and elongated.