A complex communication skills training program for physicians providing advanced cancer care - content development and barriers and solutions for implementation

Background: Early integration of oncology and patient-centered palliative care is the recommended clinical practice model for patients with advanced cancer. General and specific communication skills are necessary to achieve integrated patient-centered care, but require organized training to be adequately mastered. Challenges and barriers on several levels, i.e. organizational, professional and individual may, however, hamper implementation. The development, implementation, and evaluation of such an educational program focusing on communication skills contain many steps, considerations and lessons learned, which are described in this article.Methods: A multi-professional faculty developed, implemented, and evaluated an educational program through a 5-step approach. The program was part of a Norwegian cluster-randomized controlled trial aiming to test the effect of early integration of oncology and palliative care for patients with advanced cancer.Results: The result is the PALLiON educational program; a multi-faceted, evidence-based, and learner-centered program with a specific focus on physicians' communication skills. Four modules were developed: lectures, discussion groups, skills training, and coaching. These were implemented at the six intervention hospitals using different teaching strategies. Evaluation in a subgroup of participants showed a positive appraisal of the group discussions and skills training.Conclusion:We present our experiences and reflections regarding implementation and lessons learned, which should be considered in future developments and implementations; (1) Include experienced faculty with various backgrounds, (2) Be both evidence-based and learner-centered, (3) Choose teaching strategies wisely, (4) Expect resistance and skepticism, (5) Team up with management and gatekeepers, (6) Expect time to fly, and (7) Plan thorough assessment of the evaluation and effect.Trial registration: ClinicalTrials.gov identifier: NCT03088202.

Abstract P3-14-08: The influence of metabolic factors, migration, and ethnic disparities on breast cancer risk and treatment

Background: Migrant studies have shown an increase in breast cancer incidence rates among immigrants moving from a breast cancer low-incidence to a high-incidence country. However, 30 years after immigration, it remains equivocal to what degree metabolic factors and ethnic disparities affect breast cancer development and treatment. Methods: Using Cox regression models, we examined the association between ethnicity and breast cancer development, and whether this association varied by pre-diagnostic metabolic profiles among 13 802 women, aged 20-75 years, participating in the population-based Oslo Ethnic Breast Cancer Study. Ethnicity was categorized into: women of Western European descent (reference population) and women of non-western ethnicity (ethnic minority). The ethnic minority women were further subclassified into three groups: 1) South Asian, 2) Middle East and North African, and 3) all other non-western origin women. We defined four pre-diagnostic unfavorable metabolic factors (above median body mass index (>24.6 kg/m2), waist:hip ratio (>0.79), triglyceride:HDL-cholesterol ratio (>0.73), and blood pressure (>96.5 mmHg)), which were combined to define three metabolic profiles: (0-2, 3, and 4 unfavorable metabolic factors). A total of 557 women developed invasive breast cancer during a mean 16.5 years of follow-up. Detailed medical records were obtained. Results: Among women with an unfavorable metabolic profile, South Asian women, compared with Western European women, had a 2.3 times higher breast cancer risk (HR 2.30, 95% CI 1.18-4.49). Furthermore, the ethnic minority women, compared with the Western European women, were suggestively more likely to present with triple-negative breast cancer (OR 2.11, 95% CI 0.97-4.61), and less likely to complete all courses of planned taxane treatment (OR 0.26, 95% CI 0.08-0.82). No differences by ethnicity were observed in physicians’ decisions of planned breast cancer treatment, Conclusions: Our results support that metabolic factors, including body composition, serum lipids and blood pressure, are important when balancing breast cancer prevention and disease management among non-western women migrating from a breast cancer low-incidence to a high-incidence country. However, larger studies are needed.

Citation Format: Trygve Lofterød, Hanne Frydenberg, Marit Veierød, Anne Karen Jenum, Jon B Reitan, Erik Wist, Inger Thune. The influence of metabolic factors, migration, and ethnic disparities on breast cancer risk and treatment [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-14-08.

Immune phenotype of tumor microenvironment predicts response to bevacizumab in neoadjuvant treatment of ER-positive breast cancer

Antiangiogenic drugs are potentially a useful supplement to neoadjuvant chemotherapy for a subgroup of patients with human epidermal growth factor receptor 2 (HER2) negative breast cancer, but reliable biomarkers for improved response are lacking. Here, we report on a randomized phase II clinical trial to study the added effect of bevacizumab in neoadjuvant chemotherapy with FEC100 (5-fluorouracil, epirubicin and cyclophosphamide) and taxanes (n = 132 patients). Gene expression from the tumors was obtained before neoadjuvant treatment, and treatment response was evaluated by residual cancer burden (RCB) at time of surgery. Bevacizumab increased the proportion of complete responders (RCB class 0) from 5% to 20% among patients with estrogen receptor (ER) positive tumors (P = .02). Treatment with bevacizumab was associated with improved 8-year disease-free survival (P = .03) among the good responders (RCB class 0 or I). Patients treated with paclitaxel (n = 45) responded better than those treated with docetaxel (n = 21; P = .03). Improved treatment response was associated with higher proliferation rate and an immune phenotype characterized by high presence of classically activated M1 macrophages, activated NK cells and memory activated CD4 T cells. Treatment with bevacizumab increased the number of adverse events, including hemorrhage, hypertension, infection and febrile neutropenia, but despite this, the ECOG status was not affected.

Abstract P1-13-01: Lipoprotein and metabolite responses to physical exercise during adjuvant breast cancer treatment

Background: Adjuvant breast cancer treatment may cause metabolic perturbations, such as dyslipidaemia, potentially exacerbating risk of cardiometabolic disease as well as risk of breast cancer recurrence. Physical exercise may have beneficial metabolic effects, but it’s effect on serum lipoprotein- and metabolite profiles during adjuvant breast cancer treatment including chemotherapy is not yet well established.

Methods: The women participating in this pilot study of Energy Balance and Breast Cancer Aspects (EBBA)-II, were aged 38-69 years and diagnosed with stage I-II breast cancer. 60 breast cancer patients were randomized after surgery to a control group (n = 29, usual care) or an intervention group (n = 31, intervention), stratified by menopausal status. The patients in the intervention group received a detailed exercise program and met for supervised training sessions in groups of 10-12 women for 60 minutes twice a week during a 12 month period, and were in addition asked to perform at least 60 minutes of exercise at home (a total of 180 minutes of exercise weekly). Fasting serum samples were collected pre-surgery and after six months, and analysed by nuclear magnetic resonance (NMR)-spectroscopy and mass spectrometry. 170 metabolites and 109 lipoprotein subclass variables were quantified and analysed using orthogonalized partial least squares discriminant analysis. Statistical significance was assessed by permutation testing. Single variables were tested with Mann Whitney U-tests or multiple linear regression (NCT02240836).

Results: The breast cancer patients (n = 60) had at pre-surgery the following means: Age at diagnosis of 55.4 years (38-69 years), low density lipoprotein (LDL)-cholesterol 145.4 mg/dl (3.76 mmol/L), high density lipoprotein (HDL)-cholesterol 70.4 mg/dl (1.82 mmol/L), and triglycerides 101.9 mg/dl (1.15 mmol/L), and 58.3 % of the patients underwent chemotherapy (paclitaxel/docetaxel/5-FU/epirubicin/cyclophosphamide based adjuvant chemotherapy). Physical exercise ameliorated chemotherapy-induced increases in very low density lipoprotein (VLDL)- and intermediate density lipoprotein (IDL)-associated lipids, and reduced triglyceride enrichment in LDL and HDL compared with chemotherapy controls (p = 0.003). Physical exercise also significantly increased apoA1 (4.6 % increase vs 11.3 % decrease, q = 0.02) and apoA2 (5.2 % increase vs 13.0 % decrease, q = 0.01) compared with chemotherapy control patients. The NMR-measured lipid signal at 1.55-1.60 ppm increased after six months in chemotherapy recipients, but this was attenuated among chemotherapy recipients in the intervention group. No statistically significant effect of physical exercise on serum levels of small-molecular metabolites was detected.

Conclusion: Our findings suggest that physical exercise may prevent atherogenic alterations in lipoprotein profile induced by chemotherapy. The results indicate increased HDL particle number- and function, as well as increased triglyceride clearance in the intervention group. Thus, atherogenic alterations in lipoprotein profile may play a role in evaluating breast cancer treatment, and could potentially be biomarkers of importance for breast cancer prognosis and co-morbidity.

Citation Format: Torfinn Støve Madssen, Vidar Gordon Flote, Inger Thune, Gro Falkener Bertheussen, Anders Husøy, Steinar Lundgren, Hanne Frydenberg, Erik Wist, Ellen Schlichting, Jon Lømo, Anne McTiernan, Tone Frost Bathen, Guro Fanneløb Giskeødegård. Lipoprotein and metabolite responses to physical exercise during adjuvant breast cancer treatment [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-13-01.

Abstract P6-07-01: A translational and five-year clinical update in patients treated with neoadjuvant chemotherapy randomized to bevacizumab or control in HER2 negative breast cancer

Background: Bevacizumab added to conventional neoadjuvant chemotherapy increase the proportion of patients achieving a pathological complete response (pCR). Identifying patients responding to antiangiogenic therapy have been challenging. The primary objective of this study was to determine the molecular characteristics and treatment induced changes of the primary tumors with reference to treatment response. Clinical outcome measurements according to treatment were exploratory endpoints. Recent updated clinical results, in addition to extended molecular analyses are presented.

Methods: A phase II randomized clinical trial of HER2 negative primary tumors of ≥25 mm (n=132) was conducted, treated with neoadjuvant chemotherapy (4xFEC100 followed by taxane-based therapy) with or without the addition of bevacizumab. Biopsies were obtained at the time of diagnosis, after 12 weeks of treatment, and after 25 weeks at surgery. The response was evaluated using the criteria for determining the residual cancer burden (RCB). We derived a mean immune score per patient by calculating the average score from the 770 genes in the nCounter PanCancer immune panel to detect an association between immune activity and response to antiangiogenic therapy. In addition, the median five-year follow-up for disease recurrence are reported.

Results: The addition of bevacizumab increased the RCB class 0 (pCR) rate in the study population from 12% to 17% and the rate of “good responders” (RCB class 0 and 1) from 24% to 33%, without reaching statistical significance. A pronounced effect of bevacizumab combination therapy was observed in the hormone receptor (HR) positive tumors, were the percentage of patients achieving RCB class 0 increased from 5% to 20% (Fisher's Exact test, p=0.02). More HR positive patients achieved a good response and fewer patients were poor responders (RCB class 3) in the combination treatment arm (Wilcoxon, p=0.035). Previously, our unsupervised analyses demonstrated an enrichment of immune related genes in pretreatment samples from patients responding to combination therapy. A significantly higher mean immune score (p<0.001) was detected among the HR positive patients who received bevacizumab and achieved RCB class 0 after neoadjuvant treatment (n=11, 20%) . Five-year follow-up data revealed a total of 21 events in the study population; 9 relapses in patients treated with combination therapy, and 12 relapses in patients treated with chemotherapy only. DFS was not statistically different between the treatment groups (log rank, p=0.4257). However, among the patients achieving a good response an improved DFS was observed for those treated with combination therapy (1/22 vs. 5/16, log rank, p=0.0254).

Conclusion: Among locally advanced HER2-negative HR positive breast cancer patients, the addition of bevacizumab to neoadjuvant chemotherapy increased the rate of good responders and improved the DFS among these patients. An increased primary tumor immune score may predict good response to neoadjuvant antiangiogenic therapy in HR positive disease. Further studies are needed to validate the use of such immune panels for selection of patients most likely to benefit from antiangiogenic therapy.

Citation Format: Gythfeldt HvdL, Engebråten O, Naume B, Wist E, Borgen E, Lien T, Lindgjærde OC, Garred O, Schlichting E, Silwal-Pandit L, Borresen-Dale AL. A translational and five-year clinical update in patients treated with neoadjuvant chemotherapy randomized to bevacizumab or control in HER2 negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-07-01.

Time series analysis of neoadjuvant chemotherapy and bevacizumab-treated breast carcinomas reveals a systemic shift in genomic aberrations

Background

Chemotherapeutic agents such as anthracyclines and taxanes are commonly used in the neoadjuvant setting. Bevacizumab is an antibody which binds to vascular endothelial growth factor A (VEGFA) and inhibits its receptor interaction, thus obstructing the formation of new blood vessels.

Methods

A phase II randomized clinical trial of 123 patients with Her2-negative breast cancer was conducted, with patients treated with neoadjuvant chemotherapy (fluorouracil (5FU)/epirubicin/cyclophosphamide (FEC) and taxane), with or without bevacizumab. Serial biopsies were obtained at time of diagnosis, after 12 weeks of treatment with FEC ± bevacizumab, and after 25 weeks of treatment with taxane ± bevacizumab. A time course study was designed to investigate the genomic landscape at the three time points when tumor DNA alterations, tumor percentage, genomic instability, and tumor clonality were assessed. Substantial differences were observed with some tumors changing mainly between diagnosis and at 12 weeks, others between 12 and 25 weeks, and still others changing in both time periods.

Results

In both treatment arms, good responders (GR) and non-responders (NR) displayed significant difference in genomic instability index (GII) at time of diagnosis. In the combination arm, copy number alterations at 25 loci at the time of diagnosis were significantly different between the GR and NR. An inverse aberration pattern was also observed between the two extreme response groups at 6p22-p12 for patients in the combination arm. Signs of subclonal reduction were observed, with some aberrations disappearing and others being retained during treatment. Increase in subclonal amplification was observed at 6p21.1, a locus which contains the VEGFA gene for the protein which are targeted by the study drug bevacizumab. Of the 13 pre-treatment samples that had a gain at VEGFA, 12 were responders. Significant decrease of frequency of subclones carrying gains at 17q21.32-q22 was observed at 12 weeks, with the peak occurring at TMEM100, an ALK1 receptor signaling-dependent gene essential for vasculogenesis. This implies that cells bearing amplifications of VEGFA and TMEM100 are particularly sensitive to this treatment regime.

Conclusions

Taken together, these results suggest that heterogeneity and subclonal architecture influence the response to targeted treatment in combination with chemotherapy, with possible implications for clinical decision-making and monitoring of treatment efficacy.

Trial registration

NCT00773695. Registered 15 October 2008

Electronic supplementary material

The online version of this article (10.1186/s13073-018-0601-y) contains supplementary material, which is available to authorized users.

Ribociclib with letrozole vs letrozole alone in elderly patients with hormone receptor-positive, HER2-negative breast cancer in the randomized MONALEESA-2 trial

Purpose

Determine the efficacy and safety of first-line ribociclib plus letrozole in elderly patients with HR+, HER2− advanced breast cancer.

Methods

668 postmenopausal women with HR+, HER2− advanced breast cancer and no prior systemic therapy for advanced disease were enrolled in the Phase III MONALEESA-2 trial (NCT01958021); 295 patients were aged ≥ 65 years. Patients were randomized to ribociclib (600 mg/day; 3-weeks-on/1-week-off) plus letrozole (2.5 mg/day) or placebo plus letrozole until disease progression, unacceptable toxicity, death, or treatment discontinuation. The primary endpoint was PFS, which was evaluated in elderly (≥ 65 years) and younger (< 65 years) patients. Secondary endpoints included response rates and safety.

Results

Ribociclib plus letrozole significantly improved PFS vs placebo plus letrozole in elderly (hazard ratio: 0.608; 95% CI 0.394–0.937) and younger patients (hazard ratio: 0.523; 95% CI 0.378–0.723). Overall response rates were numerically higher in the ribociclib vs placebo arm, regardless of age. Ribociclib plus letrozole was well tolerated in elderly patients, with the safety profile similar to the overall study population. Nausea, vomiting, alopecia, and diarrhea were > 10% more frequent in the ribociclib plus letrozole vs placebo plus letrozole arm in both subgroups; most events were grade 1/2. In elderly patients, grade 1/2 anemia and fatigue were > 10% more frequent in the ribociclib plus letrozole vs placebo plus letrozole arm and discontinuation rates were similar in both arms.

Conclusions

Addition of ribociclib to letrozole is a valid therapeutic option for elderly patients with HR+, HER2− advanced breast cancer in the first-line setting.

Abstract 1813: Bevacizumab potentiates the proteomic response to neoadjuvant chemotherapy in breast cancer patients: Rppa exploration of consecutive tumor samples in the NeoAva randomized phase II trial

Antiangiogenic therapy using bevacizumab has proven effective for a number of cancers; however, in breast cancer there is an unmet need to identify patients that benefit from such treatment. Sampling of tumor biopsies before and during treatment, as well as at the time of surgery enables the assessment of response at multiple molecular levels. At the proteomic level reverse phase protein analysis (RPPA) support expression of numerous cancer associated proteins simultaneously, which can further be used to unravel molecular mechanisms associated with clinical response to bevacizumab treatment.

In this phase II clinical trial, patients with HER2 negative primary tumors of ≥25 mm were treated with neoadjuvant chemotherapy (4 x FEC100 + 12 weeks of taxane-based therapy) and randomized (1:1) to receive bevacizumab or not. Mammography, ultrasound and MR imaging were used for response evaluation, in addition to final pathology assessment. Tumor responses were evaluable in 132 patients; of which 66 received bevacizumab. Ratio of the tumor size at final pathology assessment, and at inclusion was calculated to obtain a continuous scale of response reflecting the percentage of tumor shrinkage in response to therapy. Tumor biopsies were removed before start of treatment, at week 12 at the start of taxane-based tharapy and at the time of surgery. Lysates from each sample was analyzed on reverse phase protein arrays (RPPA) for expression levels of 210 proteins of which 54 were phospho-specific.

The addition of bevacizumab to the chemotherapy do not alter proteomic response from week 0 to 25 to such extent that this patient group cluster naturally together. While the proteomic response from week 0 to 12 in both treatment arms had an overall similar profile regarding up- and down-regulated proteins, the combination treatment (FEC100 + bevacizumab) induced substantially more effect on the regulation of each protein. This suggests that bevacizumab treatment have the capability to potentiate the effects of the anthracyclin based chemotherapy from week 0 to 12. Conversely, from week 12-25 (taxane-based therapy + bevacizumab) this effect was lost or even reversed, possibly due to a de-vascularized and less accessible tumor. An exception to this observation was a few phospho-proteins that do seem to have sustained stronger regulation over the whole treatment period. We are in the process of analyzing in more detail the impact of phosphorylation and thus protein activation states on treatment response.

Deciphering molecular response and activity regulation at the proteomic level is a promising approach and may reveal novel knowledge with potential important clinical relevance.

Citation Format: Mads H. Haugen, Ole Christian Lingjaerde, Marit Krohn, Wei Zhao, Evita M. Lindholm, Laxmi Silwal-Pandit, Elin Borgen, Øystein Garred, Anne Fangberget, Marit M. Holmen, Ellen Schlichting, Helle K. Skjerven, Steinar Lundgren, Erik Wist, Bjørn Naume, Gunhild M. Maelandsmo, Yiling Lu, Anne-Lise Boerresen-Dale, Gordon B. Mills, Olav Engebraaten. Bevacizumab potentiates the proteomic response to neoadjuvant chemotherapy in breast cancer patients: Rppa exploration of consecutive tumor samples in the NeoAva randomized phase II trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1813. doi:10.1158/1538-7445.AM2017-1813

The Longitudinal Transcriptional Response to Neoadjuvant Chemotherapy with and without Bevacizumab in Breast Cancer

Purpose: Chemotherapy-induced alterations to gene expression are due to transcriptional reprogramming of tumor cells or subclonal adaptations to treatment. The effect on whole-transcriptome mRNA expression was investigated in a randomized phase II clinical trial to assess the effect of neoadjuvant chemotherapy with the addition of bevacizumab.Experimental Design: Tumor biopsies and whole-transcriptome mRNA profiles were obtained at three fixed time points with 66 patients in each arm. Altogether, 358 specimens from 132 patients were available, representing the transcriptional state before treatment start, at 12 weeks and after treatment (25 weeks). Pathologic complete response (pCR) in breast and axillary nodes was the primary endpoint.Results: pCR was observed in 15 patients (23%) receiving bevacizumab and chemotherapy and 8 patients (12%) receiving only chemotherapy. In the estrogen receptor-positive patients, 11 of 54 (20%) treated with bevacizumab and chemotherapy achieved pCR, while only 3 of 57 (5%) treated with chemotherapy reached pCR. In patients with estrogen receptor-positive tumors treated with combination therapy, an elevated immune activity was associated with good response. Proliferation was reduced after treatment in both treatment arms and most pronounced in the combination therapy arm, where the reduction in proliferation accelerated during treatment. Transcriptional alterations during therapy were subtype specific, and the effect of adding bevacizumab was most evident for luminal-B tumors.Conclusions: Clinical response and gene expression response differed between patients receiving combination therapy and chemotherapy alone. The results may guide identification of patients likely to benefit from antiangiogenic therapy. Clin Cancer Res; 23(16); 4662-70. ©2017 AACR.

Fatigue During and After Breast Cancer Therapy-A Prospective Study

CONTEXT

Chronic fatigue (CF) in breast cancer (BC) survivors is multifactorial and may be caused by immune activation triggered by BC or its treatment. In the Neoadjuvant Avastin in Breast Cancer study, BC patients received neoadjuvant chemotherapy (FEC100→taxane) ± bevacizumab, a monoclonal antibody with fatigue as a potential side effect.

OBJECTIVES

To examine fatigue levels and prevalence of CF before and during chemotherapy and at follow-up, and their associations with C-reactive protein (CRP) and clinical variables.

METHODS

Eighty-four HER2-negative patients with cT2-4N0-3M0 BC responded to questionnaires and had CRP measured before treatment (T0), after FEC100 (T1), after taxanes before surgery (T2), and at two-year follow-up (T3).

RESULTS

The prevalence of CF increased from 8% at T0 to 36% at T3, P < 0.0001. Fatigue levels peaked during chemotherapy from 12.0 at T0 to 20.0 at T2, and declined to 16.7 at T3, P < 0.001. Women with CF at T3 had higher fatigue levels at T0, T2, and T3 than those without CF (P ≤ 0.01). Psychological distress (P = 0.03) and pain (P = 0.04) at T3 were associated with CF at T3. Only psychological distress remained a significant predictor in multivariate analysis. CRP increased from T0 to T1 (P < 0.01) and declined to baseline values at T3, but changes were not associated with bevacizumab treatment. No association was found between bevacizumab or CRP, and fatigue levels or CF.

CONCLUSION

Neither bevacizumab treatment nor low-grade systemic inflammation as measured by CRP was associated with the increased fatigue levels and raised prevalence of CF, observed during and after BC therapy. Increased fatigue levels at baseline and psychological distress at T3 were associated with CF at T3.

Abstract P2-05-16: Establishment of molecular profiling for individual treatment decisions in early breast cancer – Clinical impact of PAM50 and PAM50 risk of recurrence score after more than 16 years follow up

Background

Molecular profiling has recently been included in recommendations for decisions on adjuvant treatment in breast cancer (BrCa). However, the use of molecular profiling has not yet been widely established in all countries. Additional studies may give important information about the clinical relevance of the tests.

Aims

The study aims to discover the long term prognostic impact of PAM50 and PAM50 ROR score on survival for early BrCa pts according to treatment, with comparison to the routine clinical and histopathological parameters.

Patients and methods

Unselected early BrCa pts (n=651) from the Oslo Micromet project (n=920) having available FFPE primary tumor tissue were included in the current study. The pts were enrolled from 1995-1998. Follow up status is available for distant disease (median FU 7 years) and BrCa death (16.0-19.7 years after study inclusion). Clinical and histopathological parameters have been collected from the hospital records. FFPE tissue sections were macrodissected, RNA isolated from the dissected tumor tissue, followed by analysis of the PAM50 gene list on the Nanostring Platform. The samples were run in research mode and the raw data was sent to Nanostring (Seattle) for determination of the PAM50 subtype and ROR score.

Results

Of the 651 included pts, 323 did not receive any adjuvant systemic treatment (pT1pN0 patients), 161 tamoxifen only, the rest chemotherapy+/-tamoxifen. Twelve preoperatively treated pts were excluded from the analyses. Of the 639 remaining pts, PAM50 molecular profiling defined 52.3% as LumA, 26.8% LumB, 10.6% HER2enriched and 10.3% Basal. Multivariate analysis showed that the PAM50 intrinsic subtypes yielded prognostic information in addition to the established clinicopathological variables (pT, Grade, pN, age HR/HER2 subgroups, systemic treatment)(BCSS: HazardR vs LumA: 2.7 (95% CI 1.7-4.1) for LumB, 3.5 (1.8-6.8) for HER2enriched, 1.8 (0.8-4.2) for Basal). For the HR+HER2- pts, the risk classification by ROR score was an independent prognostic factor (BCSS: HazardR vs low risk: 3.1 (1.2-8.1) for intermediate, 6.6 (2.5-17.1) for high risk). In univariate analysis, the PAM50 intrinsic subtype classification separated clinical outcome both for all pts, for no adjuvant treated pts (both p&lt;0.001, log rank), for the HR+HER2- (p&lt;0.001), HR+HER2+ (p=0.061) and HR-HER2- (p=0.015) subgroups. Among the pT1-2pN0 HR+HER2- pts with no adjuvant treatment (n=222), risk classification by ROR score categorized 52.7% of the pts as low risk with excellent prognosis (BrCa death 4.2%), 29.7% as intermediate risk (BrCa death 16.7%) and 17.6% as high risk (BrCa death 35.9%)(p&lt;001, log rank). For the pT1-2pN0-1 HR+HER2- pts who received adjuvant tamoxifen only (n=102), a low and similar risk of BrCa death was observed among the low and intermediate ROR risk groups. The high risk group had poor prognosis (BrCa death 32.7%)(p&lt;0.001). Similar results were obtained for patients classified as LumA.

Conclusions

PAM50 subtype classification and ROR score improves classification of BrCa pts into prognostic groups, allowing more precise identification of future recurrence risk and improved basis for adjuvant treatment decisions.

Citation Format: Naume B, Borgen E, Falk RS, Ohnstad HO, Lien TG, Aaserud M, Sveli MAT, Kyte JA, Kristensen V, Geitvik G, Schlichting E, Wist E, Sørlie T, Russnes H. Establishment of molecular profiling for individual treatment decisions in early breast cancer – Clinical impact of PAM50 and PAM50 risk of recurrence score after more than 16 years follow up [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-16.

Abstract P6-13-01: Proteomic response in breast cancer treated with neoadjuvant chemotherapy with and without bevacizumab: Reverse phase protein array (RPPA) results from NeoAva - A randomized phase II study

BACKGROUND: Patients with HER2 negative primary tumors of ≥25 mm were treated with neoadjuvant chemotherapy (4 x FEC100 + 12 weeks of taxane-based therapy) and randomized (1:1) to receive bevacizumab or not. Mammography, ultrasound and MR imaging were used for response evaluation, in addition to the final pathology assessment after surgery.

HYPOTHESIS: RPPA proteomic analyses support identification of molecular mechanisms associated with clinical response to bevacizumab treatment.

METHODS: Tumor responses were evaluable in 132 patients; of which 66 received bevacizumab. Ratio of the tumor size at final pathology assessment, and at inclusion was calculated to obtain a continuous scale of response reflecting the percentage of tumor shrinkage in response to therapy. Tumor material was obtained at screening, 12 weeks into treatment and at surgical removal of tumors at 25 weeks. Lysates from each sample was analyzed on reverse phase protein arrays (RPPA) for expression levels of 210 proteins of which 54 were phospho-specific.

RESULTS: Several proteins were found for which expression prior to treatment reflected a better response on tumor shrinkage in the combination treatment arm (chemotherapy+bevacizumab). The proteomic response from week 0 to 12 in both treatment arms had an overall similar profile regarding up- and down-regulated proteins; however, the combination treatment (FEC100 + bevacizumab) induced a more pronounced effect on regulation of each protein. This might reflect the capability of bevacizumab therapy to potentiate the effects of the anthracyclin based chemotherapy from week 0 to 12. Conversely, from week 12-25 (taxane-based therapy + bevacizumab) this effect was lost or even reversed, except for certain phosphoproteins where potentiation imposed by bevacizumab was sustained throughout the whole treatment period. We are in the process of analyzing the impact of phosphorylation and thus protein activation states on treatment response. Furthermore, tumors with low hormone receptor pathway score demonstrated a better response in the combination treatment (chemotherapy+bevacizumab). Additionally, in these good responders the hormone signaling pathway was significantly upregulated during treatment. Further investigations are conducted to determine if this was due to selective ablation of hormone receptor negative tumor cells, or a re-programming of the molecular phenotype of cells present prior to treatment. The above mentioned results have potentially important clinical relevance and will be further investigated with respect to subtypes and the biological pathways affected by antiangiogenic therapy.

Citation Format: Haugen MH, Lindgjærde OC, Krohn M, Zhao W, Lindholm EM, Silwal-Pandit L, Borgen E, Garred Ø, Fangberget A, Holmen MM, Schlichting E, Skjerven H, Lundgren S, Wist E, Naume B, Mælandsmo GM, Lu Y, Børresen-Dale A-L, Mills GB, Engebråten O. Proteomic response in breast cancer treated with neoadjuvant chemotherapy with and without bevacizumab: Reverse phase protein array (RPPA) results from NeoAva - A randomized phase II study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-13-01.

Ribociclib as First-Line Therapy for HR-Positive, Advanced Breast Cancer

BACKGROUND

The inhibition of cyclin-dependent kinases 4 and 6 (CDK4/6) could potentially overcome or delay resistance to endocrine therapy in advanced breast cancer that is positive for hormone receptor (HR) and negative for human epidermal growth factor receptor 2 (HER2).

METHODS

In this randomized, placebo-controlled, phase 3 trial, we evaluated the efficacy and safety of the selective CDK4/6 inhibitor ribociclib combined with letrozole for first-line treatment in 668 postmenopausal women with HR-positive, HER2-negative recurrent or metastatic breast cancer who had not received previous systemic therapy for advanced disease. We randomly assigned the patients to receive either ribociclib (600 mg per day on a 3-weeks-on, 1-week-off schedule) plus letrozole (2.5 mg per day) or placebo plus letrozole. The primary end point was investigator-assessed progression-free survival. Secondary end points included overall survival, overall response rate, and safety. A preplanned interim analysis was performed on January 29, 2016, after 243 patients had disease progression or died. Prespecified criteria for superiority required a hazard ratio of 0.56 or less with P<1.29×10^-5.

RESULTS

The duration of progression-free survival was significantly longer in the ribociclib group than in the placebo group (hazard ratio, 0.56; 95% CI, 0.43 to 0.72; P=3.29×10^-6 for superiority). The median duration of follow-up was 15.3 months. After 18 months, the progression-free survival rate was 63.0% (95% confidence interval [CI], 54.6 to 70.3) in the ribociclib group and 42.2% (95% CI, 34.8 to 49.5) in the placebo group. In patients with measurable disease at baseline, the overall response rate was 52.7% and 37.1%, respectively (P<0.001). Common grade 3 or 4 adverse events that were reported in more than 10% of the patients in either group were neutropenia (59.3% in the ribociclib group vs. 0.9% in the placebo group) and leukopenia (21.0% vs. 0.6%); the rates of discontinuation because of adverse events were 7.5% and 2.1%, respectively.

CONCLUSIONS

Among patients receiving initial systemic treatment for HR-positive, HER2-negative advanced breast cancer, the duration of progression-free survival was significantly longer among those receiving ribociclib plus letrozole than among those receiving placebo plus letrozole, with a higher rate of myelosuppression in the ribociclib group. (Funded by Novartis Pharmaceuticals; ClinicalTrials.gov number, NCT01958021 .).

Abstract 3268: Proteomic response in breast cancer treated with neoadjuvant chemotherapy with and without bevacizumab: Reverse phase protein array (RPPA) results from NeoAva - a randomized phase II study

BACKGROUND: In this phase II clinical trial, patients with HER2 negative primary tumors of ≥25 mm were treated with neoadjuvant chemotherapy (4 x FEC100 + 12 weeks of taxane-based therapy) and randomized (1:1) to receive bevacizumab or no bevacizumab. Mammography, ultrasound and MR imaging were used for response evaluation, in addition to final pathology assessment.

HYPOTHESIS: RPPA proteomic analyses support identification of molecular mechanisms associated with clinical response to bevacizumab treatment.

METHODS: Tumor responses were evaluable in 132 patients; of which 66 received bevacizumab. Ratio of the tumor size at final pathology assessment, and at inclusion was calculated to obtain a continuous scale of response reflecting the percentage of tumor shrinkage in response to therapy. Tumor material was obtained at screening, 12 weeks into treatment and at surgical removal of tumors at 25 weeks. Lysates from each sample was analyzed on reverse phase protein arrays (RPPA) for expression levels of 210 proteins of which 54 were phospho-specific. Data from protein analyses was compared to previously generated mRNA expression data.

RESULTS: Several proteins were found for which expression prior to treatment (week 0) reflected a better response on tumor shrinkage in the combination treatment arm (chemotherapy+bevacizumab): E.g. good responders had lower PDGFR-beta expression, and this was also observed at the mRNA level, while this result was not identified in the mono treatment arm (chemotherapy alone) on either level. The proteomic response from week 0 to 12 in both treatment arms had an overall similar profile regarding up- and down-regulated proteins; however, the combination treatment (FEC100 + bevacizumab) induced substantially more effect on regulation of each protein. This might reflect the capability of bevacizumab treatment to potentiate the effects of the anthracyclin based chemotherapy from week 0 to 12. Conversely, from week 12-25 (taxane-based therapy + bevacizumab) this effect was lost or even reversed, and reveals a possible need for further studies investigating changes in protein expression and correlation to response of a given treatment. Of particular interest were proteins that switched direction of regulation between the FEC and taxane-based regimes, however, these effects were not confined to the combination treatment and thus probably not due to the added bevacizumab. We are in the process of analyzing the impact of phosphorylation and thus protein activation states on treatment response. The above mentioned results have potentially important clinical relevance and will be further investigated with respect to subtypes and the biological pathways affected by antiangiogenic therapy.

Citation Format: Mads H. Haugen, Ole Christian Lingjaerde, Marit Krohn, Evita M. Lindholm, Laxmi Silwal-Pandit, Elin Borgen, Øystein Garred, Anne Fangberget, Marit M. Holmen, Ellen Schlichting, Helle Skjerven, Steinar Lundgren, Erik Wist, Bjoern Naume, Gunhild M. Maelandsmo, Yiling Lu, Anne-Lise Boerresen-Dale, Gordon B. Mills, Olav Engebraaten. Proteomic response in breast cancer treated with neoadjuvant chemotherapy with and without bevacizumab: Reverse phase protein array (RPPA) results from NeoAva - a randomized phase II study. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3268.

Abstract LB-337: Systemic shift in genomic aberrations in breast carcinomas during neoadjuvant chemotherapy in combination with bevacizumab

A time course study was designed to investigate the dynamics of copy number aberrations in tumor DNA during treatment of breast cancer patients. A phase II randomized clinical trial of Her2 negative breast cancer patients was conducted, with patients being treated with neoadjuvant chemotherapy (FEC and taxane), with or without bevacizumab. Serial biopsies were obtained at time of diagnosis, at 12 weeks after treatment with FEC +/- bevacizumab, and at 25 weeks after treatment with taxane +/- bevacizumab. Tumor DNA alterations and tumor percentage were studied over time, and substantial differences were observed with some tumors changing mainly between diagnosis and 12 weeks (after the FEC cycle), others between 12 and 25 weeks (taxanes), and still others changing in both time periods. In both treatment arms, good responders (GR) and non-responders (NR) displayed significant difference in genomic instability index (GII) at time of diagnosis. In the Combination arm at time of diagnosis, 25 loci harbored copy number alterations, which were significantly different between the GR and NR. An inverse aberration pattern was observed between the two extreme response groups at 6p22-p12 for patients in the Combination arm. In most cases, tumors that retained aberrations at all time points did not decrease in size. Signs of subclonal reduction were observed, with some aberrations disappearing and others being retained during treatment. In both treatment arms an increase in subclonal amplification was observed at 6p21.1, the locus which contains the VEGFA gene targeted by bevacizumab and was associated with good response. Significant decrease of frequency of subclones carrying gains at 17q21.32-q22 was observed at 12 week, with the peak occurring at TMEM100, an ALK1 receptor signaling-dependent gene essential for vasculogenesis. This implies that cells bearing amplifications of TMEM100 are particularly sensitive to the treatment regime. Taken together, these results suggest that heterogeneity and subclonal architecture influence the response to targeted treatment in combination with chemotherapy, with possible implications for clinical decision making and monitoring of treatment efficacy.

Citation Format: Elen K. Møller, Silje Nord, David Wedge, Ole Christian Lngjærde, Laxmi Silwal-Pandit, Hedda vdL Gythfeld, Hans Kristian M. Vollan, Thomas Fleischer, Marit Krohn, Ellen Schlichting, Elin Borgen, Øystein Garred, Marit M. Holmen, Erik Wist, Bjørn Naume, Peter V. Loo, Anne-Lise Børresen-Dale, Olav Engebråten, Vessela Kristensen. Systemic shift in genomic aberrations in breast carcinomas during neoadjuvant chemotherapy in combination with bevacizumab. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-337.

Aspects of posttraumatic stress disorder in long-term testicular cancer survivors: cross-sectional and longitudinal findings

PURPOSE

The purpose of this research is to study the prevalence of posttraumatic stress disorder (PTSD) and variables associated with PTSD in Norwegian long-term testicular cancer survivors (TCSs) both cross-sectionally and longitudinally.

METHODS

At a mean of 11 years after diagnosis, 1418 TCSs responded to a mailed questionnaire, and at a mean of 19 years after diagnosis, 1046 of them responded again to a modified questionnaire. Posttraumatic symptoms related to testicular cancer were self-rated with the Impact of Event Scale (IES) at the 11-year study only. An IES total score ≥35 defined Full PTSD, and a score 26-34 identified Partial PTSD, and the combination of Full and Partial PTSD defined Probable PTSD.

RESULTS

At the 11-year study, 4.5 % had Full PTSD, 6.4 % had Partial PTSD, and 10.9 % Probable had PTSD. At both studies, socio-demographic variables, somatic health, anxiety/depression, chronic fatigue, and neurotoxic adverse effects were significantly associated with Probable PTSD in bivariate analyses. Probable anxiety disorder, poor self-rated health, and neurotoxicity remained significant with Probable PTSD in multivariate analyses at the 11-year study. In bivariate analyses, probable PTSD at that time significantly predicted socio-demographic variables, somatic health, anxiety/depression, chronic fatigue, and neurotoxicity among participants of the 19-year study, but only probable anxiety disorder remained significant in multivariable analysis.

CONCLUSIONS

In spite of excellent prognosis, 10.9 % of long-term testicular cancer survivors had Probable PTSD at a mean of 11 years after diagnosis. Probable PTSD was significantly associated with a broad range of problems both at that time and was predictive of considerable problems at a mean of 19 year postdiagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

Among long-term testicular cancer survivors, 10.9 % have Probable PTSD with many associated problems, and therefore health personnel should explore stress symptoms at follow-up since efficient treatments are available.

Abstract P4-11-14: Molecular response in breast cancer treated with neoadjuvant chemotherapy with and without bevacizumab: Results from NeoAva - a randomized phase II study

The NeoAva study is a phase II clinical trial of patients with HER2 negative primary tumors of ≥25 mm treated with neoadjuvant chemotherapy (4 x FEC100 + 12 weeks of taxane-based therapy) and randomized (1:1) to receive bevacizumab or no bevacizumab. Mammography, ultrasound and MR imaging were used for response evaluation, in addition to final pathology assessment.

Tumor response were evaluable in 131 patients; of which 66 received bevacizumab in addition to chemotherapy. Tumor material was obtained at screening, 12 weeks into treatment and at surgical removal of tumors at 25 weeks. mRNA expression profiling was performed on Agilent 8x60K platform and the tumors were classified into LuminalA, LuminalB, Her2-enriched, Basal and Normal-like subtypes using the PAM50 classifier. Ratio of the tumor size at final pathology assessment, and at inclusion (by radiology assessment) was calculated to obtain a continuous scale of response reflecting the percentage of tumor shrinkage in response to therapy. Genomic Grade Index (GGI scores) based on expression profiles of 97 genes (including cell-cycle and proliferation genes) were calculated.

There were no significant differences in the tumor size, lymph node, hormone receptor status or PAM50 subtypes between the treatment arms. pCR in breast and axilla were obtained in 14 (21.1%) patients in the chemo+bev arm, and in 7 (10.6%) patients in the chemo-only arm. Tumors that obtained pCR were in higher number ER negative and TP53 mutated and exhibited Basal-like phenotype. The overall pCR rates were higher in the ER negative tumors compared to ER positive tumors {39.1% (9 of 23) vs 11.1% (12 of 108)}. However, addition of bevacizumab seemed to improve pCR in the ER positive patient group (9 vs 3) and not in ER negative patient group (5 vs 4).

On evaluating the continuous response variable, ER status, TP53 mutation status and PAM50 subtypes were significantly associated to response (p &lt; 0.001). GGI scores were highly correlated to response (p&lt; 0.001), i. e tumors with higher GGI scores showed better response. Importantly, when the chemo+bev and the chemo-only arms were evaluated separately, although similar trend of associations was observed in both arms, the associations were found to be enhanced in the chemo+bev arm.

Next, we evaluated a shift in PAM50 subtypes across the timepoints. A shift towards a better prognosis group, i.e Luminal A or Normal-like profile was observed in response to therapy. Distribution of Luminal A and Normal-like tumors at week 25, (and not at screening or week 12) was significantly different in the chemo+bev vs chemo-only group (p = 0.026, Fisher’s exact test).

GGI scores regressed across timepoints reflecting the loss of aggressive and proliferating component of the tumors in response to therapy. GGI scores in the chemo+bev group became significantly lower (p &lt; 0.01) already at week 12. This suggests that the removal of the proliferating component of the tumors by chemotherapy is accelerated and improved by addition of bevacizumab.

These results, with potentially important clinical relevance will be further investigated with respect to subtypes and the molecular changes induced by antiangiogenic therapy.

Citation Format: Olav Engebraaten, Laxmi Silwal-Pandit, Marit Krohn, Elen K Møller, Silje Nord, Thomas Fleischer, Hedda von der Lippe Gythfelt, Elin Borgen, Øystein Garred, Anne Fangberget, Marit Muri Holmen, Ellen Schlichting, Helle Skjerven, Steinar Lundgren, Vessela N Kristensen, Ole Christian Lingjaerde, Erik Wist, Bjørn Naume, Anne-Lise Børresen-Dale. Molecular response in breast cancer treated with neoadjuvant chemotherapy with and without bevacizumab: Results from NeoAva - a randomized phase II study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-11-14.

Abstract P4-14-01: A time course study of genomic instability in breast cancer patients receiving neoadjuvant therapy with or without bevacizumab

Tumor heterogeneity is an area of intense research, revealing tumors with high complexity consisting of different subclones and infiltrating cells. Identification of subclones that are resistant to therapy may be critical to improve treatment outcome.

The NeoAva study is a randomized phase II, clinical trial of Her2 negative breast cancer patients treated in a neoadjuvant setting with chemotherapy (FEC and taxane) +/- bevacizumab. Core needle biopsies were obtained at screening and after 12 weeks, and the tumor was surgically removed after 25 weeks. DNA copy number changes in the tumors were analyzed using Affymetrix SNP Array 6.0. Allele specific copy number changes were assessed using the Allele-Specific Copy number Analysis of Tumors (ASCAT) algorithm (Van Loo, Norgard et al., PNAS 2010) and allele-specific Piecewise Constant Fitting (asPCF) algorithms (Nilsen, Liestol et al., BMC Genomics 2012). Measures of genomic instability were obtained through the complex arm-wise aberration index (CAAI) that captures local rearrangements (‘firestorms’) (Russnes, Vollan et al., Sci Transl Med 2010).

Changes in copy number aberrations between the three different time points were observed in almost all tumors. Some tumors showed a decrease in tumor percentage and aberrations after just 12 weeks of treatment, where others showed loss of aberrations only at the time of surgery (25 weeks). Most of the tumors that did retain aberrations at all time points during treatment, did not demonstrate any decrease in tumor size. Other profiles indicated subclonal reduction, where some aberrations are kept throughout treatment and others disappear. Many of the tumors shrinking in size showed fewer whole arm aberrations than before treatment, but retained their focal amplicons. Some of the tumor aberrations seem to disappear after 12 weeks, but to reappear after 25 weeks, but with the addition of novel aberration.

Complex rearrangements were identified in 67% of tumors before treatment. The most frequent ‘firestorms’ were found on 20p, 11q and 8p. Some events were persistent through therapy, but the majority changed. An association between complex tumor genomes and patients having progressive disease/non-responders were observed.

These results show the complex structure of a tumor and suggest that heterogeneity will influence the response to treatment. The subclonal patterns of tumors may be of great importance for clinical decision-making, as well as for monitoring treatment efficacy.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-14-01.

Abstract P4-14-02: Molecular response in breast cancer tumors treated with neoadjuvant chemotherapy with and without bevacizumab: Results from NeoAva - A randomized phase II study

Patients treated with bevacizumab in addition to regular neoadjuvant chemotherapy achieve an increased rate of pathological complete response (pCR). The molecular characteristics of responding and non-responding tumors, including how treatment combinations influence the gene expression profiles and the signaling pathways, may be useful predictors of antiangiogenic response.

The NeoAva study included patients with HER2 negative primary tumors of ≥25 mm that were randomized (1:1) to receive neoadjuvant chemotherapy (4 x FEC100 + 12 weeks of taxane-based therapy) with or without bevacizumab. Mammography, ultrasound and MR imaging were used for response evaluation, in addition to final pathology assessment.

In the first part of the study 74 patients were evaluable for tumor response. The tumor size at time of inclusion was T2, T3 and T4 in 24.3%, 67.6% and 8.1% of the patients, respectively. Lymph node metastases were detected in 56.7% of the patients at inclusion and 82.4% were hormone receptor positive. There were no significant differences in the tumor size, lymph node or hormone receptor status between the treatment arms.

The patients were randomized with bevacizumab + chemotherapy (n = 37) and treatment with chemotherapy alone (n = 37). Of the nine patients who achieved pCR in breast and axilla (12.2%), seven patients received bevacizumab (7/37), while two were treated with chemotherapy alone (2/37). Four of the patients with pCR were hormone receptor negative, of which three received bevacizumab. Of the remaining five hormone receptor positive tumors that achieved complete response, four received bevacizumab.

In the second part of the study we evaluated gene expression signatures by RNA microarray and the time-response of pathways to treatment, using pathway analysis that integrates copy number and gene expression (Paradigm). Biopsies for molecular analyses were collected before therapy, after 12 weeks, and at surgery. Treatment associated gene expression changes to chemotherapy were subtracted, and bevacizumab associated differential expression was observed for 1069 genes. Furthermore, molecular profiling of the tumor tissue was performed at DNA level by copy number analysis (Affymetrix, SNP6.0) and mRNA level by gene expression arrays(Agilent 60K). At the screening time point, we found high proliferation through the activity of cyclin E and B and the transcription factors E2F1 and FOXM1. At 12 weeks, there was a strong increase in predicted p53 signaling, due to increased activity of downstream target genes. The 12 week timepoint was also characterized by an increase of Calmodulin 1, MAPK3, as well as Peroxisome proliferator-activated receptor alpha (PPAR-alpha), and both trends continued to the 25 week time point. At 25 weeks, there were broad increases in ERK1/2, JUN, and FOS signaling. The 25 week timepoint also showed a T-cell response signature that from increased activity of GATA3, IL6/IL6R, IL4, and NFATC1 and NFATC2. These results suggest that there are measurable and strongly significant aberrations in molecular activity during treatment, which may be useful to monitor treatment response.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-14-02.

Abstract P1-08-21: Detection and monitoring of circulating endothelial cells, circulating tumor cells and disseminated tumor cells during neoadjuvant breast cancer treatment including bevacizumab

Background: Results from studies with bevacizumab in addition to traditional neoadjuvant therapy (NAT) indicate a need for predictive biomarkers. As a sub-study of the NeoAva study (a neoadjuvant study), the aim was to investigate the potential association between the presence of circulating endothelial cells (CECs) in peripheral blood (PB), circulating tumor cells (CTCs) in PB and disseminated tumor cells (DTCs) in bone marrow (BM) at different time points during NAT +/- bevacizumab and at one year follow-up, and therapy response.

Patients and methods: A total of 150 HER2-negative patients with cT2-4 (≥ 2.5cm) N0-3 M0 status were randomized to receive NAT with or without bevacizumab. In this sub-study, 90 patients have so far been analyzed. Of these, 82 received chemotherapy (FEC100→taxane) and 8 received endocrine therapy (letrozole) + / - bevacizumab. Therapy response was evaluated according to the RECIST criteria and achievement of pathological complete response (pCR). Number of CECs, CTCs and DTCs were assessed at baseline after 12 weeks, at surgery (after 24 weeks) and at one year follow-up. Blood samples were analyzed by CellSearch® to assess CEC and CTC counts. The detection of DTCs was performed by immunocytochemical analysis of 2 × 106 BM mononuclear cells.

Results: The pathological complete response rate was 10 out of 90 (11.1%), eight of these patients received bevacizumab. For bevacizumab-treated patients with a change in CEC counts from baseline to time of surgery below median change (27 CECs), 35% (6/17) achieved pCR compared to 6% (1/18) in the group with a CEC count-increase above median change (p = 0.035). The corresponding pCR rates for patients not receiving bevacizumab (median CEC change 131 CECs) were 0% (0/15) and 13% (2/14), respectively. Stepwise testing of thresholds for CEC changes in the bevacizumab-arm revealed significant associations to pCR for change-values between 20 and 40. CTC- and DTC-status or -changes were not associated with tumor response or CEC changes.

Conclusion:

The presented results indicate that the level of change in the number of circulating endothelial cells during neoadjuvant therapy including bevacizumab is associated with the pathological complete response rate in breast cancer patients. This supports additional testing of CECs as a surrogate marker for response to this treatment. The analyses will be up-dated with results from the rest of the included patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-08-21.

Disseminated tumor cells as selection marker and monitoring tool for secondary adjuvant treatment in early breast cancer. Descriptive results from an intervention study

Background

Presence of disseminated tumor cells (DTCs) in bone marrow (BM) after completion of systemic adjuvant treatment predicts reduced survival in breast cancer. The present study explores the use of DTCs to identify adjuvant insufficiently treated patients to be offered secondary adjuvant treatment intervention, and as a surrogate marker for therapy response.

Methods

A total of 1121 patients with pN1-3 or pT1c/T2G2-3pN0-status were enrolled. All had completed primary surgery and received 6 cycles of anthracycline-containing chemotherapy. BM-aspiration was performed 8-12 weeks after chemotherapy (BM1), followed by a second BM-aspiration 6 months later (BM2). DTC-status was determined by morphological evaluation of immunocytochemically detected cytokeratin-positive cells. If DTCs were present at BM2, docetaxel (100 mg/m², 3qw, 6 courses) was administered, followed by DTC-analysis 1 month (BM3) and 13 months (BM4) after the last docetaxel infusion.

Results

Clinical follow-up (FU) is still ongoing. Here, the descriptive data from the study are presented. Of 1085 patients with a reported DTC result at both BM1 and BM2, 94 patients (8.7%) were BM1 positive and 83 (7.6%) were BM2 positive. The concordance between BM1 and BM2 was 86.5%. Both at BM1 and BM2 DTC-status was significantly associated with lobular carcinomas (p = 0.02 and p = 0.03, respectively; chi-square). In addition, DTC-status at BM2 was also associated with pN-status (p = 0.009) and pT-status (p = 0.03). At BM1 28.8% and 12.8% of the DTC-positive patients had ≥2 DTCs and ≥3 DTCs, respectively. At BM2, the corresponding frequencies were 47.0% and 25.3%. Of 72 docetaxel-treated patients analyzed at BM3 and/or BM4, only 15 (20.8%) had persistent DTCs. Of 17 patients with ≥3 DTCs before docetaxel treatment, 12 patients turned negative after treatment (70.6%). The change to DTC-negativity was associated with the presence of ductal carcinoma (p = 0.009).

Conclusions

After docetaxel treatment, the majority of patients experienced disappearance of DTCs. As this is not a randomized trial, the results can be due to effects of adjuvant (docetaxel/endocrine/trastuzumab) treatment and/or limitations of the methodology. The clinical significance of these results awaits mature FU data, but indicates a possibility for clinical use of DTC-status as a residual disease-monitoring tool and as a surrogate marker of treatment response.

Trial registration

Clin Trials Gov NCT00248703

Abstract P5-17-02: Molecular response in breast cancer tumors treated with neoadjuvant chemotherapy with and without bevacizumab: Results from NeoAva - a randomized phase II study

Withdrawn by Author

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-17-02.

The PRO-SELF(©) Pain Control Program improves patients' knowledge of cancer pain management

CONTEXT

Inadequate knowledge is one barrier to effective cancer pain management.

OBJECTIVES

This study's aim was to evaluate the effects of a psychoeducational intervention (the Norwegian version of the PRO-SELF(©) Pain Control Program) compared with a control group in increasing patients' knowledge of cancer pain management.

METHODS

Adult oncology outpatients with pain from bone metastasis of 2.5 or greater on a 0 to 10 numeric rating scale were randomized into the PRO-SELF (n=87) or control (n=92) groups. Patients completed a demographic questionnaire and the Pain Experience Scale (PES) at the beginning and end of the study to assess their knowledge and attitudes. The six-week intervention consisted of education, skills building, and nurse coaching. Mixed-model analyses with tests of a group×time interaction were done for each of the individual items and total PES scores to evaluate between-group differences in changes in knowledge over time.

RESULTS

Except for functional status, no differences were found between the PRO-SELF and control groups on any baseline demographic, clinical, or pain characteristics. Significant group×time interactions were found for all the single item and total PES scores. Compared with the control group, patients in the PRO-SELF group had significant increases in knowledge scores.

CONCLUSION

The use of a knowledge and attitude survey, like the PES, as part of a psychoeducational intervention provides an effective foundation for patient education in cancer pain management. This individualized approach to education about pain management may save staff time and improve patient outcomes.

Cardiotoxic effects of trastuzumab

BACKGROUND

Breast cancer with overexpression of the HER2 receptor is an aggressive type of breast cancer with poor prognosis. Trastuzumab (Herceptin) is a monoclonal antibody that binds to the HER2 receptor on the cell surface blocking the signals that promote cell-growth proliferation. Trastuzumab treatment has almost halved the risk of relapse, when given as an adjuvant, and has improved the overall survival in metastatic breast cancer. However, when given alone or in combination with cardiotoxic chemotherapy, especially anthracyclines, trastuzumab may lead to congestive heart failure of varying severity.

MATERIAL AND METHODS

The article is a non-systematic review of articles from clinical trails, basic research, and recommendations by Norwegian and international expert panels.

RESULTS

The cardiotoxic effects of trastuzumab and anthracycline in combination were already reported in the pivotal trials. Over ten years of research have revealed the mechanisms of cardiotoxicity with trastuzumab. Risk factors have been identified and recommendations drawn up for cardiac surveillance and treatment of patients with signs of heart failure. By following these recommendations the incidence of heart failure is reduced to approximately five per cent of treated patients.

CONCLUSION

In summary, the favourable effects of trastuzumab are convincing, but cardiotoxicity is a significant challenge in treatment. Risk factors for side effects indicate extra vigilance, but the side effects are unpredictable and all patients treated with trastuzumab must undergo regular cardiac surveillance.

P5-18-07: Presence of Disseminated Tumor Cells after Adjuvant Chemotherapy in Breast Cancer and Disseminated Tumor Cells Monitoring during Secondary Adjuvant Treatment

Introduction: Detection of disseminated tumor cells (DTC) after completion of systemic adjuvant treatment is a strong predictor of early systemic relapse and death. This analysis can discover early failure of a chosen adjuvant systemic treatment. In this study, we wanted to evaluate the value of DTC detection in bone marrow (BM) as a surrogate marker for response to docetaxel rescue treatment, to predict the effect of this treatment. Further, we wanted to compare disease free survival between patients treated with docetaxel resulting in eradication of DTC after treatment and patients treated with docetaxel where DTC persists after treatment. The follow up of the study is still ongoing. Here, we present the preliminary descriptive data from the study.

Materials and Methods: A total of 1128 pts with node positive or high risk node negative disease (T1c/T2GII-IIIN0) was enrolled in the period from October 2003 to May 2008. All patients had completed primary surgery and received 6 cycles of adjuvant antracycline containing chemotherapy. The first BM aspiration was performed 8–12 weeks after termination of adjuvant chemotherapy (BM1). A second BM aspiration was performed 6 months later (BM2). The processing of BM and DTC analysis (by ICC) were performed as previsously described (Wiedswang G et al, J Clin Oncol 2003). If BM2 was positive (+) for DTC, the patient was treated with docetaxel (3qw, 6 courses) Docetaxel-treated patients were reexamined at the inclusion hospital with new BM analysis at approximately 1 month (BM3) and 13 months (BM4) after the last docetaxel infusion.

Results: Of 997 patients with conclusive DTC results for both BM1 and BM2, 83 patients (8.3%) were BM1 positive and 78 (7.8%) BM2 positive. Among the BM1+ patients, 15 (18.1%) were BM2+. The concordance between BM1 and BM2 were 87%. Of the patients positive at one or both time points, the concordance was 10% (15/146). The BM1 was not significantly associated with primary tumor characteristics (although borderline significance for Grade and ER status), whereas for BM2, DTC+ patients had increased frequency of node positive disease and pN2-3 stage (p=0.001, chi-square), and were positively associated with lobular carcinoma (p=0.01, chi-square). At BM1 24.7% of the DTC+ patients had &gt;1 DTC, and 9.9% had ≥3 DTC. For BM2, 48.2% had &gt;1 DTC, and 25.7% had ≥3 DTC. For patients with positive BM2 receiving docetaxel, the BM3 turned DTC negative in 55 of 66 evaluable cases (83.3%), and 48 of 59 were negative in BM4 (81.4%). Of 67 patients with a conclusive BM result at either BM3 or BM4, 12 were BM positive. Of 16 patients with ≥3 DTC before docetaxel treatment, only 4 patients were positive after treatment (25%).

Conclusions: DTC status after adjuvant antracycline containing chemotherapy changes during the first 9 months of FU, with increased DTC positivity among patients with pN+ disease and lobular carcinomas. After docetaxel rescue treatment, the majority of patients experience disappearance of the DTCs. The clinical significance of these results awaits mature FU data, but the present results may indicate possibility for eradication of residual disease by alternative chemotherapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-18-07.

Phase III Randomized Study Comparing Docetaxel Plus Trastuzumab With Vinorelbine Plus Trastuzumab As First-Line Therapy of Metastatic or Locally Advanced Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer: The HERNATA Study

Purpose

To evaluate docetaxel or vinorelbine, both with trastuzumab, as first-line therapy of human epidermal growth factor receptor 2–positive advanced breast cancer.

Patients and Methods

Patients naive to chemotherapy for advanced disease were randomly assigned to docetaxel 100 mg/m2day 1 or vinorelbine 30 to 35 mg/m2on days 1 and 8, both combined with trastuzumab (8-mg/kg loading dose and 6-mg/kg maintenance dose) on day 1 every 3 weeks. The primary end point was time to progression (TTP).

Results

A total of 143 patients were randomly allocated to docetaxel, and 141 patients were assigned to vinorelbine. The median TTP for docetaxel and vinorelbine respectively was 12.4 months versus 15.3 months (hazard ratio [HR] = 0.94; 95% CI, 0.71 to 1.25; P = .67), median overall survival was 35.7 months versus 38.8 months (HR = 1.01; 95% CI, 0.71 to 1.42; P = .98), and the 1-year survival rate was 88% in both arms. Median time to treatment failure for study chemotherapy was 5.6 months versus 7.7 months (HR = 0.50; 95% CI, 0.38 to 0.64; P < .0001). The investigator-assessed overall response rate among 241 patients with measurable disease were 59.3% in both arms. More patients in the docetaxel arm discontinued therapy due to toxicity (P < .001). Significantly more treatment-related grade 3 to 4 febrile neutropenia (36.0% v 10.1%), leucopenia (40.3% v 21.0%), infection 25.1% v 13.0%), fever (4.3% v 0%), neuropathy (30.9% v 3.6%), nail changes (7.9% v 0.7%), and edema (6.5% v 0%) were reported with docetaxel.

Conclusion

The study failed to demonstrate superiority of any drug in terms of efficacy, but the vinorelbine combination had significantly fewer adverse effects and should be considered as an alternative first-line option.

Predictors and course of chronic fatigue in long-term breast cancer survivors

BACKGROUND

The course of fatigue in long-term breast cancer survivors (BCSs) is unknown. The current study examined chronic fatigue (CF) cross-sectionally and longitudinally in relapse-free women up to 10 years after multimodal treatment for BC stage II/III. The prevalence of persistent fatigue (PF: having CF at two assessments separated by >2 years) and its predictors were also investigated.

METHODS

Data from questionnaires (including the Fatigue Questionnaire and questions regarding socio-demographics and physical symptoms) were collected twice from 249 BCSs: 2.5-7 years post-BC diagnosis (T1) and 2.5-3 years thereafter (T2). A physical examination including blood sampling was performed at T1.

RESULTS

CF was diagnosed in 33% of the women at T1 and in 39% at T2, including 57 (23%) subjects with PF. Current psychological distress, treatment-area related discomfort and high body mass index (BMI) were associated with CF at T1 and predicted PF. Increased leukocyte count also predicted PF. Treatment for mental problems prior to the BC, increased hsCRP-level and respiratory symptoms were associated with CF at T1 but did not predict PF.

CONCLUSIONS

Women may experience fatigue up to 10 years after multimodal BC treatment, with about one third having CF and about one fourth having PF.

IMPLICATIONS FOR CANCER SURVIVORS

During follow-up, BCSs and their doctors should maximize their efforts to reduce psychological distress, overweight and pain within the BC-treated area, all linked to the development of persistent fatigue.

The personality trait of neuroticism is strongly associated with long-term morbidity in testicular cancer survivors

BACKGROUND

Neuroticism is a personality trait expressing nervousness and insecurity. Associations between neuroticism and morbidity in long-term cancer survivors have hardly been explored. The aim of this study was to explore associations between neuroticism and somatic and mental morbidity and lifestyle issues in long-term survivors of testicular cancer (TCSs).

MATERIAL AND METHODS

All Norwegian TCSs treated between 1980 and 1994 (n = 1 814) were invited to this cross-sectional study. Among them 1 428 (79% response rate) delivered valid data. Neuroticism was self-rated on an abridged version of the Eysenck Personality Inventory. Information was collected by mailed questionnaires. The associations of neuroticism and self-reported variables were tested with multivariate logistic regression analyses.

RESULTS

Neuroticism was significantly associated with presence of somatic complaints, reduced physical function, neurotoxic side-effects (tinnitus, hearing impairment, peripheral neuropathy, and Raynaud's Phenomenon), self-esteem, concerns about not being able to father children, sexual problems, hazardous alcohol use, daily use of medication, use of sedatives and hypnotics, recent visits to a general practitioner, and seeing a psychologist/ psychiatrist after ended cancer treatment. Poor self-rated health, higher number of negative life events, economical problems and problems getting loans granted showed significant associations with neuroticism.

DISCUSSION

Neuroticism in TCSs at long-term follow-up is significantly associated with somatic and mental morbidities, and several aspects of unhealthy lifestyle. High levels of neuroticism should be considered in TCSs expressing multiple complaints and concerns at follow-up consultations. Assessment of neuroticism may be clinically important in order to offer appropriate interventions to prevent and manage morbidity in TCSs.

[Survival after breast cancer--differences between Norwegian counties]

BACKGROUND

A major goal in Norwegian health politics is that all patients should have equal access to health services irrespective of where they live. Different access to health services may affect prognosis. Breast cancer is the most common type of cancer among Norwegian women. In this article we analyse breast cancer survival by Norwegian county.

MATERIAL AND METHODS

Population-based study including all Norwegian women diagnosed with breast cancer between 1985 and 2004. Breast cancer survival was analysed by county using Cox proportional hazards models.

RESULTS

41,833 women with breast cancer were included in the study. After a median follow-up time of 5.8 years, 16,494 (39.4 %) women died; 9953 (60.3 %) of them of breast cancer. Five-year breast cancer specific survival varied from 74.1 to 80.6 % in the different counties. Age-adjusted analyses that excluded women invited to mammography screening, showed a 20 % difference in breast cancer survival (HR 0.80; 95 %KI 0.72-0.90; p < 0.001) between the counties. For women diagnosed with tumours in stage two, the difference was 45 %. Treatment varied between counties, but the treatment trends were similar in the different counties during the study period.

INTERPRETATION

There is a significant difference in breast cancer survival between Norwegian counties. Possible explanations may be differences in offering of mammography screening, diagnostics and treatment.

17β-estradiol levels during an entire menstrual cycle in response to adult stature and insulin, of possible importance for breast cancer risk. The EBBA-I study

Abstract #4078

Background: The normal breast cells develop into malignant cells as a result of a complex interplay between genetic, environmental, nutritional and hormonal factors. Attained adult stature and insulin levels, risk factors for breast cancer, may also vary in response to the same factors. Thus, we hypothesize that 17β-estradiol, a key factor in the carcinogenesis of the breast, may vary in response to adult height in combination with insulin levels of possible importance of breast cancer risk.&#x2028; Methods: Among 204 healthy women, aged 25-35 years who participated in the Norwegian EBBA-I study, 17β-estradiol concentrations were measured in daily saliva samples throughout one entire menstrual cycle using radioimmunoassay (RIA). Attained height (cm) was measured, and serum concentrations of insulin were determined in fasting blood samples. The associations between adult height, insulin and 17β-estradiol levels throughout a menstrual cycle were studied using multivariate linear regression analyses and linear mixed models for repeated measures. Adjustments for potential confounding factors were performed.&#x2028; Results: A 37.2 % increase in 17β-estradiol levels was observed during the entire menstrual cycle among women with an adult height ≥170 cm (upper tertile) and insulin levels ≥ 90 pmol/L (upper tertile) compared to women with the same attained adult height, and insulin levels &lt; 90pmol/L. The association was even more pronounced when we looked into those women with attained adult height ≥170 cm (upper tertile) and serum insulin ≥ 101 pmol/L (upper quartile) (Fig. 1). Adjustments for potential confounding factors were performed.&#x2028; &#x2028; Conclusion: Our findings support that premenopausal levels of 17β-estradiol vary in response to adult height and insulin levels, suggesting that women who become taller are put at risk for higher estradiol levels throughout the entire menstrual cycle when their insulin levels rise, of possible importance for breast cancer risk.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4078.

Chronic cancer-related fatigue in long-term survivors of testicular cancer

OBJECTIVE

High prevalence of cancer-related fatigue (CRF) has been reported among many groups of cancer survivors when compared to the general population. However, this topic has rarely been studied in long-term survivors of testicular cancer (TCSs). The present multi-centre study examines the prevalence of chronic CRF in Norwegian TCSs compared to chronic general fatigue (GF) in the Norwegian general population, and associations between a variety of relevant variables and CRF in TCSs.

METHODS

Participants were 1431 TCSs, aged 18-75, at an average of 11 years posttreatment (range 4.5-21 years), and a sample of 1080 age-matched men from the general Norwegian population (GenPop). The participants responded to a mailed questionnaire that included the Fatigue Questionnaire for the assessment of chronic CRF and chronic GF.

RESULTS

The prevalence of chronic CRF was 17.1% (95% CI 15.2-19.1%) among TCSs compared to 9.7% of chronic GF in GenPop (95% CI 8.0-11.5%). Regression analyses showed that poor quality of life (QOL), various psychosocial and somatic problems, and neuroticism were highly associated with presence of chronic CRF in TCSs.

CONCLUSION

Chronic CRF is far more common among TCSs than chronic GF in the general population and is associated with poor QOL and multiple psychological and somatic health problems. As a consequence, fatigue should be in focus during routine follow-ups as well as later in the general medical care of TCSs.

Is the sexual function compromised in long-term testicular cancer survivors?

OBJECTIVES

This study explores sexual function in a large unselected sample of Norwegian testicular cancer survivors (TCSs) by comparing the results with population data.

METHODS

The study included 1084 TCSs aged 20-59 yr with mean follow-up time of 11.1 (range: 5-21) yr. They provided information about their medical, social, lifestyle, and familial situations on a questionnaire that included the Brief Male Sexual Function Inventory (BSFI). Outcome measures were mean BSFI domain scores and BSFI-based prevalence rates of sexual problems. The BSFI findings of an age-adjusted random sample of the Norwegian male population (N=929) constituted normative data (NORM). Descriptive statistics and logistic regression analyses were applied, and a significance level of <0.01 was applied.

RESULTS

Compared with NORM, TCSs had significantly worse scores on ejaculatory and sexual problems in both young (20-39 yr) and middle-aged (40-59 yr) groups. In the young group, sexual satisfaction was significantly better in TCSs versus NORM. Overall sexual problems were expressed by 38.8% of the TCSs versus 35.5% in NORM. In multivariate analyses, overall sexual problems in TCSs were significantly associated with increasing age, lack of a partner, and a higher anxiety score, while ejaculation problems showed significant association with lack of a partner, and a trend for chemotherapy and neurotoxic side effects (p=0.02).

CONCLUSIONS

Compared with NORM, ejaculatory function was compromised in TCSs. Overall sexual problems in TCSs were associated with factors also observed in NORM. Better sexual satisfaction in young TCSs compared with NORM should be noted.

Long-term follow-up of the SBG 9401 study comparing tailored FEC-based therapy versus marrow-supported high-dose therapy

BACKGROUND

The purpose was to investigate adjuvant marrow-supportive high-dose chemotherapy compared with an equitoxicity-tailored comparator arm.

PATIENTS AND METHODS

Five hundred and twenty-five women below the age of 60 years with operated high-risk primary breast cancer were randomised to nine cycles of granulocyte colony-stimulating factor supported and individually tailored FEC (5-fluorouracil, epirubicin, cyclophosphamide), (n = 251) or standard FEC followed by marrow-supported high-dose therapy with CTCb (cyclophosphamide, thiotepa, carboplatin) therapy (n = 274), followed by locoregional radiotherapy and tamoxifen for 5 years.

RESULTS

There were 104 breast cancer relapses in the tailored FEC group versus 139 in the CTCb group (double triangular method by Whitehead, P = 0.046), with a median follow-up of all included patients of 60.8 months. The event-free survival demonstrated 121 and 150 events in the tailored FEC- and CTCb group, respectively [P = 0.074, hazard ratio (HR) 0.804, 95% confidence interval (CI) 0.633-1.022]. Ten patients in the tailored FEC regimen developed acute myeloid leukaemia (AML)/myelodysplasia (MDS). One hundred deaths occurred in the tailored FEC group and 121 in the CTCb group (P = 0.287, HR 0.866, 95% CI 0.665-1.129).

CONCLUSION

The update of this study shows an improved outcome linked to the tailored FEC treatment in relation to breast cancer relapse, but also an increased incidence of AML/MDS.

2-year follow-up of trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer: a randomised controlled trial

BACKGROUND

Trastuzumab--a humanised monoclonal antibody against HER2--has been shown to improve disease-free survival after chemotherapy in women with HER2-positive early breast cancer. We investigated the drug's effect on overall survival after a median follow-up of 2 years in the Herceptin Adjuvant (HERA) study.

METHODS

HERA is an international multicentre randomised trial that compared 1 or 2 years of trastuzumab treatment with observation alone after standard neoadjuvant or adjuvant chemotherapy in women with HER2-positive node positive or high-risk node negative breast cancer. 5102 women participated in the trial; we analysed data from 1703 women who had been randomised for treatment with trastuzumab for 1 year and 1698 women from the control group, with median follow-up of 23.5 months (range 0-48 months). The primary endpoint of the trial was disease-free survival. Here, we assess overall survival, a secondary endpoint. Analyses were done on an intent-to-treat basis. This trial is registered with the European Clinical Trials Database, number 2005-002385-11.

FINDINGS

97 (5.7%) patients randomised to observation alone and 58 (3.4%) patients randomised to 1 year of treatment with trastuzumab were lost to follow-up. 172 women stopped trastuzumab prematurely. 59 deaths were reported for trastuzumab and 90 in the control group. The unadjusted hazard ratio (HR) for the risk of death with trastuzumab compared with observation alone was 0.66 (95% CI 0.47-0.91; p=0.0115). 218 disease-free survival events were reported with trastuzumab compared with 321 in the control group. The unadjusted HR for the risk of an event with trastuzumab compared with observation alone was 0.64 (0.54-0.76; p<0.0001).

INTERPRETATION

Our results show that 1 year of treatment with trastuzumab after adjuvant chemotherapy has a significant overall survival benefit after a median follow-up of 2 years. The emergence of this benefit after only 2 years reinforces the importance of trastuzumab in the treatment of women with HER2-positive early breast cancer.

Self-reported paresthesias, Raynaud’s phenomena, tinnitus, and hearing impairment in a large cohort of long-term testicular cancer (TC) survivors

4547

Background: Persisting side-effects of treatment may impair the well-being of TC survivors. The aim of this study was to assess long-term Raynaud’s phenomena, oto-, and neurotoxicity related to prior therapy. Methods: A follow-up survey was conducted in men treated for TC 1980–1994 in Norway. The 1319 eligible responders had a median follow-up time of 11 years (range 4–21) and were allocated to four separate treatment groups: Surgery (Surg), Radiotherapy (Rt), and chemotherapy (Cisplatin [Cis] ≤ 850 mg and Cis > 850 mg). The questionnaire included six items assessing the relevant toxicities. The responders’ scores were dichotomized [minor (“not at all” or “a little”) vs. major (“quite a bit” or “very much”)] and analyzed by logistic regression with Surg as reference. Results: The proportion of cases (%) reporting major symptoms and the corresponding Odds ratios (OR) varied significantly between treatment groups ( table ). Rt was not statistically significantly different from Surg for any symptom, but showed a trend for higher scores of paresthesias in the feet. Cis > 850 mg differed significantly for all symptoms with major symptoms reported by 25–49% with the highest OR (8.1) for Raynaud’s phenomena in hands. Apart from Raynaud’s phenomena, paresthesias in feet were the only symptom significantly different in Cis < 850 mg compared to Surg. Conclusions: Toxicities induced by cisplatin-based chemotherapy persist in many TC survivors. A cold climate may contribute to the high perception of Raynaud’s phenomena in Norwegian TC survivors.

[Table: see text]

No significant financial relationships to disclose.

Monitoring of disseminated tumor cells in bone marrow in high-risk breast cancer patients treated with high-dose chemotherapy

The present study aimed to investigate the clinical relevance of disseminated tumor cells (DTC) in breast cancer patients before and after high-dose adjuvant chemotherapy with or without progenitor stem-cell support. One hundred and eighteen high-risk stage II breast cancer patients entering the Scandinavian Study Group multicenter trial were randomized to 9 cycles of tailored and dose-escalated FEC (5-fluorouracil, epirubicin, cyclophosphamide) or 3 cycles of standard FEC followed by high-dose chemotherapy. Bone marrow (BM) samples at diagnosis and 6 months after completion of chemotherapy were assessed for the presence of cytokeratin positive (CK+) cells. Before treatment, 29% of the patients were CK+ (21% in the dose-escalated group and 36% in the high-dose-group). Six months after treatment, 17% of the patients were CK+ (17 and 16% respectively). Of the 95 patients who were evaluated 6 months after treatment, 60% were consistently CK-. CK+ cells in BM was evaluated as a prognostic and predictive marker and compared to other defined prognostic factors of the primary tumor. Monitoring BM changes at the time of diagnosis and 6 months posttreatment is an independent predictive factor for breast-cancer-specific survival (BCS) (p = 0.001). Those who have consistent CK negative (-) BM findings constitute a group of patients with good prognosis. Our results suggest that changes in CK+ cells in BM before and after chemotherapy can be used clinically as a surrogate maker to predict outcome in breast cancer patients.

Side effects and cancer-related stress determine quality of life in long-term survivors of testicular cancer

PURPOSE

The prevalence of long-term survivors after treatment for testicular cancer (TC) is increasing, and most studies display normal or only slightly reduced quality of life (QOL) in TC survivors (TCSs). Impaired QOL is claimed to be associated with treatment modality and its side effects, although most studies in this field can be criticized for various methodologic shortcomings. We wanted to examine variation in long-term QOL in TCSs in relation to TC treatment modality, side effects, and TC-related stress in a large population.

PATIENTS AND METHODS

QOL, side effects, and TC-related stress were self-rated by a questionnaire at a mean of 11 years of follow-up in 1,409 TCSs treated from 1980 to 1994. Norm data was obtained from 2,678 males who were representative of the general population. QOL was measured with the Short Form-36 (SF-36), and TC-related stress was measured with the Impact of Event Scale.

RESULTS

There were no clinically relevant differences in QOL between TCSs and age-adjusted norm data, although there was a slightly lowered SF-36 Physical Component Summary Score in TCSs. Variation of QOL in TCSs was related to self-reported side effects and TC-related stress but not to TC treatment modality. A significant association was found between side effects and TC-related stress.

CONCLUSION

TCSs do not suffer long term from reduced QOL, and only minor differences in QOL were found between different treatment modalities. TCSs who report more side effects or TC-related stress have increased risk for reduced QOL, but these associations are not explained by TC treatment modalities. Further QOL research in this area should explore vulnerability factors for side effects and TC-related stress.

Study of anxiety disorder and depression in long-term survivors of testicular cancer

PURPOSE

To increase our knowledge of the prevalence of anxiety disorder and depression in long-term testicular cancer survivors (TCSs), and to identify variables associated with such caseness.

PATIENTS AND METHODS

Participants were 1,408 TCSs treated between 1980 and 1994 in Norway. Participants provided information about their medical, social, and familial situation on a questionnaire. They also completed the Hospital Anxiety and Depression Scale (HADS). Anxiety disorder and depression were defined by a score >/= 8 on the HADS subscales. The prevalence rates were compared with age-adjusted norm data.

RESULTS

HADS-defined anxiety disorder was more prevalent in TCSs (19.2%; 95% CI, 17.2% to 21.3%) than in the norm sample (13.5%; 95% CI, 13.1% to 13.9%; P < .001), whereas the prevalence of HADS-defined depression did not differ from the norm (TCSs, 9.7%; 95% CI, 8.1% to 11.2% v norm, 10.1%, 95% CI, 9.5 to 10.5; P = .56). The relative risk for anxiety disorder was 1.49 (95% CI, 1.31 to 1.69) and for depression the relative risk was 0.96 (95% CI, 0.81 to 1.14) in TCSs compared with norm. In multivariate analyses, HADS-defined anxiety disorder in TCSs was associated with young age, peripheral neuropathy, economic problems, alcohol problems, sexual problems, relapse anxiety, and having been treated for mental problems.

CONCLUSION

Long-term TCSs have an increased risk of HADS-defined anxiety disorder that warrants clinical attention. Checking easily available demographic and TC-related data and use of a simple screening test such as HADS assists the identification of TCSs with anxiety disorder.