Comparative effectiveness and cost-effectiveness of natalizumab and fingolimod in rapidly evolving severe relapsing-remitting multiple sclerosis in the United Kingdom

AIM

To evaluate the real-world comparative effectiveness and the cost-effectiveness, from a UK National Health Service perspective, of natalizumab versus fingolimod in patients with rapidly evolving severe relapsing-remitting multiple sclerosis (RES-RRMS).

METHODS

Real-world data from the MSBase Registry were obtained for patients with RES-RRMS who were previously either naive to disease-modifying therapies or had been treated with interferon-based therapies, glatiramer acetate, dimethyl fumarate, or teriflunomide (collectively known as BRACETD). Matched cohorts were selected by 3-way multinomial propensity score matching, and the annualized relapse rate (ARR) and 6-month-confirmed disability worsening (CDW6M) and improvement (CDI6M) were compared between treatment groups. Comparative effectiveness results were used in a cost-effectiveness model comparing natalizumab and fingolimod, using an established Markov structure over a lifetime horizon with health states based on the Expanded Disability Status Scale. Additional model data sources included the UK MS Survey 2015, published literature, and publicly available sources.

RESULTS

In the comparative effectiveness analysis, we found a significantly lower ARR for patients starting natalizumab compared with fingolimod (rate ratio [RR] = 0.65; 95% confidence interval [CI], 0.57-0.73) or BRACETD (RR = 0.46; 95% CI, 0.42-0.53). Similarly, CDI6M was higher for patients starting natalizumab compared with fingolimod (hazard ratio [HR] = 1.25; 95% CI, 1.01-1.55) and BRACETD (HR = 1.46; 95% CI, 1.16-1.85). In patients starting fingolimod, we found a lower ARR (RR = 0.72; 95% CI, 0.65-0.80) compared with starting BRACETD, but no difference in CDI6M (HR = 1.17; 95% CI, 0.91-1.50). Differences in CDW6M were not found between the treatment groups. In the base-case cost-effectiveness analysis, natalizumab dominated fingolimod (0.302 higher quality-adjusted life-years [QALYs] and £17,141 lower predicted lifetime costs). Similar cost-effectiveness results were observed across sensitivity analyses.

CONCLUSIONS

This MSBase Registry analysis suggests that natalizumab improves clinical outcomes when compared with fingolimod, which translates to higher QALYs and lower costs in UK patients with RES-RRMS.

Abstract PD3-07: A phase II pre-surgical trial of lapatinib for the treatment of women with HER2 positive or EGFR positive ductal carcinoma in situ

Background: Estrogen receptor (ER)-negative tumors and human epidermal growth factor 2-Neu (HER2) positive breast cancers are known to be more clinically aggressive subtypes of breast cancer and account for 30% of all breast cancers. Women with HER2 + breast cancers, whether ER+ or ER -, require cytotoxic chemotherapy with a HER2-targeting agent, and often have adverse outcomes. Thus, preventive agents are needed to reduce the incidence of these subtypes of aggressive breast cancer. Lapatinib, a dual tyrosine kinase inhibitor, inhibits epidermal growth factor receptors (EGFR) and HER2 kinases and has shown to decrease breast cell proliferation in invasive breast cancer and adjacent premalignant lesions. Therefore, we conducted a multi-institutional randomized Phase II clinical trial to study the effects of the signal transduction inhibitor lapatinib in women with HER2-positive or EGFR-positive ductal carcinoma in situ (DCIS).

Methods: Randomized participants received either lapatinib (750mg, 1000mg, or 1500mg) or placebo daily for 2-6 weeks prior to their surgery. After minimal accrual, the trial was later amended to lapatinib 1000mg or placebo. Pre-treatment breast tissue was obtained from initial diagnostic core biopsy and post-treatment breast tissue was obtained from surgical excision specimen. Blood was obtained prior to surgery to assess serum lapatinib level. Participants kept a daily symptom assessment log and had a cardiac assessment at baseline and prior to surgery. Patients were instructed to take drug up to and including the day before surgery. The dual primary endpoint for this study was change in proliferation in pre- versus post-treatment biopsies between the two treatment arms, as measured by Ki67 as well as toxicity assessment. Secondary endpoints included incidence of DCIS at surgery and modulation of tissue biomarker expression in growth factor receptors (EGFR, ErbB2); phosphorylated growth factor receptor (phospho-ErbB2); signal transduction markers (MAPK, phospho-MAPK); hormone receptors (ER, PR); and p27.

Results:Twenty-two women (mean age: 51; range: 32-66) with HER2+ or EGFR+ DCIS were treated with lapatinib (1,000 or 1,500 mg) or placebo for 2–6 weeks prior to surgical excision. Ki67 expression was significantly decreased in the lapatinib treatment arms compared to placebo (p=0.0122). Diarrhea, fatigue, and skin reactions were notable adverse events that occurred predominately in the lapatinib arm compared to placebo. No grade 3 or 4 events related to the study drug were noted during the study. No changes were noted in cardiac function. DCIS was present in all surgical specimens in both arms. Invasive breast cancer was noted in 1 patient on lapatinib 1000mg and 3 patients on placebo. No statistically significant changes were noted in signal transduction biomarkers

Conclusion:These results demonstrate the effectiveness of lapatinib in reducing proliferation in women with EGFR+ or HER2+ DCIS. Even low-grade toxicities can deter use of an agent in the prevention setting. This and the lack of a risk model for HER2+ and triple negative breast cancer make the development of larger scale clinical prevention trials of lapatinib for the prevention a challenge.

Citation Format: Thomas PS, Contreras A, Pruthi S, Krontiras H, Rimawi M, Garber J, Wang T, Hilsenbeck SG, Vornik LA, Gilmer T, Friedman R, Heckman-Stoddard BM, Dunn B, Kuerer H, Brown PH. A phase II pre-surgical trial of lapatinib for the treatment of women with HER2 positive or EGFR positive ductal carcinoma in situ [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 PD3-07.

Abstract P4-03-02: Casting a wide net: Finding actionable results in non-breast cancer (BC) genes on multi-gene panel testing (MGPT) in a BC cohort

Background: MGPT for hereditary cancer syndromes allows for concurrent analysis of genes associated with many different cancer types. This may lead to the identification of unexpected mutations in genes with no BC link. The objective of this study was to examine the landscape of pathogenic mutations in a BC cohort who underwent MGPT, to assess if there was clinical suspicion for identified mutations and if the results would affect subjects' medical management.

Methods: Retrospective review of subjects with BC seen at a single institution who underwent MGPT from 1/1/15- 5/31/18 was conducted. MGPT was defined as testing of more than the 9 genes associated with BC (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, STK11, TP53). Deidentified pedigrees were analyzed by genetic counselors to determine whether there was clinical suspicion of the presence of the mutations using national testing guidelines or clinical diagnostic criteria.

Results: Among 3044 subjects, 365 (12%) were found to have one pathogenic mutation in at least one cancer susceptibility gene. Subjects with mutations in APC I307K, moderate-penetrance BC genes (NBN, RAD50, BARD1), and MUTYH were excluded from further analysis. We identified 52 pathogenic mutations in genes not typically associated with risk for BC in 51 (2%) subjects (table 1). There was clinical suspicion for the identified mutation in 17 (33%).

Table 1:Non-BC gene mutation landscape Number of MutationsClinical Suspicion (%)Lynch syndrome117 (64%)MLH110MSH221MSH632PMS254Ovarian181 (6%)BRIP1*111RAD51C40RAD51D30SHDx62 (33%)SDHA*30SDHC*32Other156 (40%)FH10HOXB13*32MITF32NF142VHL40CDKN2A21 (50%)Total5217 (33%)*Contains individuals that also have a mutation in a BC susceptibility gene

Conclusion: Of 3044 BC patients who underwent MGPT, 2% were found to have a pathogenic gene mutation that would have been missed by a smaller BC gene panel. Medical or surgical management would be affected by the MGPT result in 86% of subjects. Only 6% of subjects with genetic risk for ovarian cancer had a family history of this disease. The single FH and 3 of 4 VHL mutations are only associated with disease in the biallelic state; these findings do not affect the subjects' care, but have implications for reproductive risk. The HOXB13 mutations were found in female subjects only, but would have implications for their male relatives. NF1 mutations are associated with BC risk, but were included in this analysis due to a historically distinct clinical phenotype. Only 50% of NF1+ subjects had a clinical diagnosis or family history of NF1. In all cases, cascade testing was offered to at-risk family members, allowing for cancer and reproductive risk stratification and management. This study demonstrates how comprehensive MGPT can provide a more complete and personalized cancer risk assessment for BC patients and their families.

Citation Format: Culver S, Kipnis L, Stokes S, Bychkovsky B, Scheib R, Rana H, Garber J. Casting a wide net: Finding actionable results in non-breast cancer (BC) genes on multi-gene panel testing (MGPT) in a BC cohort [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-03-02.

Abstract P5-12-03: Withdrawn

This abstract was withdrawn by the authors.

Pollen-food allergy syndrome is a common allergic comorbidity in adults with eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is associated with atopic diseases including asthma, allergic rhinitis, and atopic dermatitis; however, limited data exist on the correlation between pollen-food allergy syndrome (PFAS) and EoE. We analyzed 346 adults with EoE treated at a single center between 2002 and 2016. Demographic and EoE-specific data including clinical features and measures of EoE disease severity and treatments were collected. The presence of other atopic diseases, family history, prevalence of peripheral eosinophilia and elevated IgE, and details of PFAS triggers were collected. Twenty six percent of the 346 subjects in our cohort had both EoE and PFAS (EoE-PFAS). Compared to subjects with EoE alone, subjects with EoE-PFAS had an increased frequency of allergic rhinitis (86.7% vs. 64.2%, P < 0.001) and family history of allergies (71.1% vs. 53.3%, P = 0.003), and comprised a higher proportion of EoE diagnoses made in the spring (Χ2 < 0.001). 43.3% of subjects with concurrent EoE and PFAS opted for treatment with elimination diet, and these measures failed to induce remission in 46.2% of cases. In most cases, elimination diet failed despite strict avoidance of PFAS trigger foods in addition to common EoE triggers including dairy, wheat, and eggs. EoE-PFAS was also associated with higher serum IgE at the time of EoE diagnosis (460.6 vs. 289.9, P < 0.019). Allergic rhinitis and a family history of food allergy were independently associated with having EoE-PFAS. The most common triggers of PFAS in adults with EoE are apples (21.1%), carrots (15.5%), and peaches (15.5%). Along with asthma, allergic rhinitis and atopic dermatitis, PFAS is a common allergic comorbidity that is highly associated with EoE. Further studies aimed at understanding mechanistic similarities and differences of PFAS and EoE may shed light on the pathogenesis of these closely related food allergy syndromes.

Prevention of Depression in At-Risk Adolescents: Moderators of Long-term Response

In a randomized controlled trial, we found that a cognitive behavioral program (CBP) was significantly more effective than usual care (UC) in preventing the onset of depressive episodes, although not everyone benefitted from the CBP intervention. The present paper explored this heterogeneity of response. Participants were 316 adolescents (M age = 14.8, SD = 1.4) at risk for depression due to having had a prior depressive episode or having current subsyndromal depressive symptoms and having a parent with a history of depression. Using a recursive partitioning approach to baseline characteristics, we (Weersing et al. 2016) previously had identified distinct risk clusters within conditions that predicted depressive episodes through the end of the continuation phase (month 9). The present study used the same risk clusters that had been derived in the CBP group through month 9 to reclassify the UC group and then to examine group differences in depression through month 33. We found that in this overall very high-risk sample, the CBP program was superior to UC among youth in the low-risk cluster (n = 33), characterized by higher functioning, lower anxiety, and parents not depressed at baseline, but not in the middle (n = 95) and high-risk (n = 25) clusters. Across conditions, significantly more depression-free days were found for youth in the low-risk cluster (M = 951.9, SD = 138.8) as compared to youth in the high-risk cluster (M = 800.5, SD = 226.7). Identification of moderators, based on purely prognostic indices, allows for more efficient use of resources and suggests possible prevention targets so as to increase the power of the intervention.

De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017

The 15th St. Gallen International Breast Cancer Conference 2017 in Vienna, Austria reviewed substantial new evidence on loco-regional and systemic therapies for early breast cancer. Treatments were assessed in light of their intensity, duration and side-effects, seeking where appropriate to escalate or de-escalate therapies based on likely benefits as predicted by tumor stage and tumor biology. The Panel favored several interventions that may reduce surgical morbidity, including acceptance of 2 mm margins for DCIS, the resection of residual cancer (but not baseline extent of cancer) in women undergoing neoadjuvant therapy, acceptance of sentinel node biopsy following neoadjuvant treatment of many patients, and the preference for neoadjuvant therapy in HER2 positive and triple-negative, stage II and III breast cancer. The Panel favored escalating radiation therapy with regional nodal irradiation in high-risk patients, while encouraging omission of boost in low-risk patients. The Panel endorsed gene expression signatures that permit avoidance of chemotherapy in many patients with ER positive breast cancer. For women with higher risk tumors, the Panel escalated recommendations for adjuvant endocrine treatment to include ovarian suppression in premenopausal women, and extended therapy for postmenopausal women. However, low-risk patients can avoid these treatments. Finally, the Panel recommended bisphosphonate use in postmenopausal women to prevent breast cancer recurrence. The Panel recognized that recommendations are not intended for all patients, but rather to address the clinical needs of the majority of common presentations. Individualization of adjuvant therapy means adjusting to the tumor characteristics, patient comorbidities and preferences, and managing constraints of treatment cost and access that may affect care in both the developed and developing world.

Abstract OT3-01-04: VADIS trial: Phase II trial of the nelipepimut-S peptide v accine in women with DCIS of the breast

Background: Our group has been investigating vaccination strategies in breast cancer. Specifically, we have been evaluating HER2-derived peptide vaccines including nelipepimut-S+GM-CSF administered adjuvantly to breast cancer patients who have been rendered disease-free with standard of care therapy but are at high risk for recurrence. Early phase clinical trials showed an approximately 50% reduction in relative recurrence risk in vaccinated patients. Based on these data, nelipepimut-S+GM-CSF is being evaluated in a phase III registration trial. Having shown the vaccine to be safe, effective in stimulating an antigen-specific immune response and potentially having clinical efficacy in the setting of secondary prevention, the current study was initiated to evaluate vaccination in DCIS patients. This trial represents an initial step to move the vaccine into the primary prevention setting.

Trial Design: Phase II, randomized, single-blind study. Patients will be randomized 2:1 to receive vaccine or GM-CSF alone. After enrollment, patients will receive 3 inoculations administered every other week preoperatively followed by surgery then completion of the vaccination series (3 additional inoculations) in the adjuvant setting.

Eligibility: The trial will enroll pre- or post-menopausal women with a diagnosis of DCIS made by core biopsy. The area of radiographic abnormality must measure at least 1 cm. Because the vaccine is a MHC class I, CD8+ T cell-eliciting vaccine, it is HLA restricted, and patients must be HLA-A2+ to enroll. Participants must also have an ECOG performance status &lt;2, adequate cardiac, kidney and liver function and be willing to comply with all study interventions and follow-up procedures.

Specific Aims: The trial's primary endpoint is to evaluate for nelipepimut-specific CD8+ T cells in the peripheral blood of vaccinated patients compared to patients receiving GM-CSF alone. Secondary endpoints include evaluating toxicity; determining the immune response in vivo by DTH, in vitro by evaluating for epitope spreading to other tumor antigens, and importantly in the tumor by assessing the degree of lymphocytic infiltration in surgically resected specimens. The extent of HER2 expression, Ki67 and cleaved caspase 3 in the resected specimen will also be assessed.

Statistical Methods: A total of 108 DCIS patients will be consented and screened for eligibility. 48 (45%) are expected to be HLA-A2 positive. These 48 patienst will be randomized 2:1 to vaccine or GM-CSF alone groups. Accounting for 10% attrition rate and for an approximately 5% non-evaluable sample rate, we expect to have 40 evaluable patients, 27 in the vaccine group and 13 in the GM-CSF alone group, that have baseline, pre-surgery, and post-surgery measures of nelipepimut-S-specific CD8+ T cells. We will have 82% power to detect a significant increase in nelipepimut-S-specific CD8+ T cells in the vaccine group versus the GM-CSF alone group.

Contact Info: The study is accruing at four sites to include Columbia University, Dana Farber Cancer Institute, MD Anderson Cancer Center and Memorial Sloan Kettering Cancer Center. Additional information can be obtained from the overall study PI, Dr. Elizabeth Mittendorf (eamitten@mdanderson.org). NCT0236582.

Citation Format: Mittendorf EA, Plitas G, Garber J, Crew K, Heckman-Stoddard B, Wojtowicz M, Vornik L, Peoples GE, Brown PH. VADIS trial: Phase II trial of the nelipepimut-S peptide vaccine in women with DCIS of the breast [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 OT3-01-04.

Abstract P5-06-04: Distinct BRCA1 and BRCA2 specific functions at stalled replication forks - Clinical implications for differences between BRCA1 and BRCA2 mutation driven cancer

This abstract was withdrawn by the authors.

Case Report-Loyalty, Legacy, and Ledger: Contextual Therapy in a Patient with a Family History of Ovarian Cancer

A client's emotional experiences and reactions to those experiences are influenced by his/her family of origin and direct or indirect interactions with various family members. Contextual therapists propose that a client's satisfaction with a relationship depends on the equity of his/her emotional interactions with family members. When relationships are inequitable, trust between individuals disintegrates. In order to reestablish trust in a relationship, a balance of interests must be restored. If not, imbalances may be passed down to future generations. A case of a woman with a family history of ovarian cancer is reviewed with the principles of contextual therapy in mind. In her family, several legacies have resulted in unbalanced relationships between family members that lead to difficulty in establishing trust within the genetic counseling session.

Doppler broadening thermometry of acetylene and accurate measurement of the Boltzmann constant

In this paper, we present accurate measurements of the fundamental Boltzmann constant based on a line-shape analysis of acetylene spectra in the ν1 + ν3 band recorded using a tunable diode laser. Experimental spectra recorded at low pressures (0.25 - 9 Torr), have been analyzed using a Speed Dependent Voigt model that takes into account the molecular speed dependence effects. This line-shape model reproduces the experimental data with good accuracy and allows us to determine precise line-shape parameters for the P(25) transition of the ν1 + ν3 band. From the recorded spectra we obtained the Doppler-width and then determined the Boltzmann constant, k(B).

Abstract OT1-4-01: Multicenter phase II trial of the novel compound PM01183 (P) in BRCA1/2-associated or unselected metastatic breast cancer (MBC)

Background: MBC is a clinically heterogeneous disease that cannot be cured with currently available treatment options. Selective approaches are needed to identify patient subgroups with different tumor sensitivities who will benefit the most from available therapies for MBC. PM01183 (P), also known as lurbinectedin, is a new anticancer drug that binds to the DNA minor groove inducing both double-strand breaks and transcription blocking. It has significant in vitro and in vivo activity against several tumor models, particularly breast cancer. P is more active against homologous recombination (HR)-deficient cell lines; hence, MBC patients (pts) with deleterious germline BRCA mutations might be more sensitive to P than sporadic tumors.

Methods: A multicenter, open-label, phase II study of P (7.0 mg fixed dose) as 1-hour intravenous infusion every 3 weeks in pts with MBC with or without known BRCA1/2 mutation at study entry. To be enrolled, pts must be women 18-75 years old with confirmed MBC pretreated with 1-3 chemotherapy regimens for MBC (including at least one prior trastuzumab-containing regimen for HER-2 overexpressing pts), measurable disease as per RECIST v1.1, performance status (PS) of 0-1 and adequate major organ function. Pts are excluded if pretreated with P, trabectedin, or radiotherapy (RT) on &gt;35% of bone marrow; if they have prior/concurrent malignant disease not in complete remission for &gt;5 years, clinically unstable central nervous system involvement, and other diseases/situations that might increase patient's risk; if they are pregnant or lactating women; or if they require RT.

Aims: The primary aim is to determine the antitumor activity of P, in terms of overall response rate (ORR), in two cohorts of MBC pts: BRCA+ (with known BRCA1/2 mutation), and unselected (with BRCA1/2 wild type or unknown mutation status). Secondary aims are to determine duration of response, clinical benefit (response or stable disease &gt; 3 months), PFS and one-year overall survival; to evaluate whether presence of BRCA1/2 mutation predicts response to P in MBC; to explore the activity of P in specific MBC subpopulations, safety, pharmacokinetics (PK), PK/pharmacodynamic correlations, and pharmacogenomics.

Planned enrollment is 117 evaluable pts: 53 in the BRCA+ cohort and 64 in the unselected cohort. P will be considered effective if confirmed objective response is achieved in ≥ 17 BRCA+ pts and ≥ 12 unselected patients. An ORR-based futility analysis will be conducted when 20 and 30 evaluable pts have been recruited in each cohort, respectively. If &lt;4 BRCA+ pts or &lt;3 unselected pts achieve response, recruitment into that cohort will be terminated. To date, 36 patients have been enrolled at 5 centers in 2 countries: 7 in the BRCA+ cohort and 29 in the unselected cohort. Additional sites are being recruited to participate.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-4-01.

Abstract PD01-08: Differences in estrogen receptor signaling in non-malignant primary ER-positive breast epithelial cells and breast cancer

Background: The estrogen receptor (ER) is expressed in ∼70% of sporadic breast cancer and activates genes driving cell proliferation and tumorigenesis. We have previously performed genome-wide analysis of ER binding sites in MCF-7 breast cancer cells, and identified distinct mechanisms of ER signaling. We have also previously used EpCAM and CD49f as markers to enrich for viable ER-positive (ER+) cells obtained from non malignant breast tissue. Here, we seek to elucidate differences in ER signaling between non-malignant and ER+ breast cancer cells.

Methods: Primary breast epithelial cells were obtained from patients undergoing reduction mammoplasties and surgical excision of ER+ breast cancer. After dissociation of breast reductions into a single-cell suspension, ER+ mature luminal (ML; EpCAM+CD49f−) and luminal progenitor (LP; EpCAM+CD49f+) subpopulations were obtained by flow cytometry. Following estrogen stimulation, RNA was extracted for gene microarray analysis. ER chromatin immunoprecipitation and DNA sequencing (ChIP-seq) was performed. These results were compared to MCF-7 breast cancer cells.

Results: Reduction mammoplasty and ER+ breast cancer tissues were analyzed, and compared to MCF-7 cells. Gene expression profiles were different between non-malignant tissue and ER+ breast cancer cells following estrogen stimulation, with a 2–3 fold higher number of ER regulated genes in ER+ breast cancer compared to ER+ non malignant cells, and few overlapping estrogen regulated genes. Genes that promotes cell cycling and cell proliferation were downregulated in non-malignant tissue, but were upregulated in breast cancer cells (P &lt; 10–5). CYP1A1, a major estradiol metabolizing enzyme, was upregulated in normal cells but downregulated in ER+ breast cancer cells. Motif analysis of ER ChIP-seq data in normal and ER+ breast cancer tissues demonstrated an enrichment of ER motifs in the overlapping sites and an enrichment of FOXA1 motifs in ER+ breast cancer cells and TCF12 motifs in non-malignant ER+ epithelial cells.

Conclusions: There are contrasting differences in ER signaling between normal mammary and breast cancer cells, with estrogen having anti-proliferative effects in normal luminal cells compared to pro-proliferative effects in breast cancer. ER ChIP-Seq has identified TCF12 as a major co-factor in non-malignant breast tissue whilst FOXA1 is a major co-factor in ER+ breast cancer. Our data provides evidence for key alterations in ER-signaling during tumorigenesis, and identifies potential mechanisms to target cancer specific ER signaling.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD01-08.

Survival of patients with multiple primary malignancies: a study of 783 patients with gastrointestinal stromal tumor

BACKGROUND

We sought to investigate the characteristics and survival rate of patients with gastrointestinal stromal tumor (GIST) associated with other primary malignancies.

PATIENTS AND METHODS

A total of 783 patients with GIST were identified from 1995 to 2007. Additional primaries included tumors not considered metastasis, invasion, or recurrence of GIST, nor non-melanoma skin cancer. Data on gender, age at diagnosis, follow-up time after diagnosis, and death were collected.

RESULTS

Of the 783 patients with GIST, 153(20%) were identified with at least one additional primary. Patients with additional primaries were more often men (M : F 1.5 versus 1.3) and older (66 versus 53 years). More patients had another cancer diagnosed before (134) than after (52) GIST. Primaries observed before GIST were cancers of the prostate (25), breast (12), esophagus (9), and kidney (7) and melanoma (6). Lung (5) and kidney (5) primaries were the most frequent after GIST. The 5-year survival was 68% for patients with primaries before GIST, 61% for patients with primaries after GIST, 58% for patients with GIST only, and 49% for patients with two or more primaries in addition to GIST (P = 0.002).

CONCLUSIONS

Approximately 20% of patients with GIST develop other cancers. Inferior median 5-year survival was observed in patients with GIST with two or more other cancers. The etiology and clinical implications of other malignancies in patients with GIST should be investigated.

Local Therapy in BRCA1/2 Carriers with Operable Breast Cancer: Comparison of Breast Conservation and Mastectomy

Background: Women with inherited germline BRCA1/2 mutations have a 55-85% cumulative risk of breast cancer (BC) by age 70. Thus, knowledge of expected outcomes following various treatments is needed to advise these patients should they be diagnosed with BC. It is unclear whether breast conservation (BCT) offers similar rates of tumor control as mastectomy (M) in BRCA1/2 carriers and it is doubtful whether a randomized trial comparing these options could be performed. Thus, this analysis compares the outcomes between similarly staged women with BRCA1/2 mutations treated with BCT vs. M.Methods: Women with deleterious BRCA1/2 mutations diagnosed with operable BC and who consented to longitudinal studies were identified at 10 institutions in the US, Australia, Spain and Israel. Patient, clinical and treatment characteristics were compared between those receiving BCT and those receiving M +/- RT. Time-to-event endpoints included first failure of treatment, diagnosis of contralateral breast cancer (CBC), and overall and BC-specific survival. Cox regression models were constructed to detect significant associations between patient and clinical characteristics and time-to-event endpoints.Results: Clinical characteristics and outcomes for 302 BCT and 353 M patients were compared. With a median F/U of 8.2 years for BCT patients and 8.9 years following M, 15-year local failure as first failure was significantly higher with BCT vs. M (23.5% vs. 5.5%, p&lt;0.0001). Multivariate analysis indicted choice of local therapy as the only factor significantly predicting local recurrence, with a 4.5-fold risk of local failure with BCT compared to M (p&lt;0.0001). Local failure analyses by cohort revealed the presence of a BRCA2 mutation (HR 2.8; p=0.024) and no use of adjuvant chemotherapy (HR 5.4; p=0.0001) as significant predictors within the BCT group; presence of invasive lobular cancer (HR 9.9; p=0.004) was the only significant predictor within the M cohort. No significant differences were seen in distant failure, BC-specific or overall survival by local therapy. 15-year estimates of CBC were 52.1% with BCT; 41.4% with M; and 37.9% with M+RT (p=0.44). Analyses of BCT vs. M +/- RT and surgery +/- RT did not reveal significant differences in CBC by cohort.Conclusions: The higher risk of local failure in BRCA1/2-associated BC treated with BCT compared to M did not translate into an increased risk of distant failure or mortality. RT did not result in a detectable increase in CBC at 15 years above baseline elevated rates. These results at both the involved and contralateral breasts should be discussed when patients with BRCA1/2-associated BC are considering local treatment options.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 959.

Estrogen Rececptor (ER)-Positive Breast Cancers in BRCA1 Mutation Carriers: Mutation-Related or Sporadic?

Background: Most invasive breast cancers (IBC) in BRCA1 mutation carriers are ER negative (-) and have a basal-like phenotype by expression array analysis. These tumors also have a characteristic constellation of histologic features including high grade, high mitotic rate, prominent lymphoid infiltrate, circumscribed or pushing margins, and geographic necrosis or a central fibrotic focus and typically lack ER, PR and HER2 expression (triple negative). ER positive (+) breast cancers also occur in women with germline BRCA1 mutations, but these tumors are less frequent and less well characterized. We previously reported that ER+ BRCA1-associated IBC show a wider spectrum of histologic types and grades than ER- cancers that occur in these patients. We raised the possibility that at least some ER+ BRCA1-associated IBC may be sporadic rather than mutation-related. However, it is not known how the features of these ER+ BRCA1-associated IBC compare with those of sporadic ER+ IBC.Design: To address this issue, we performed a case-control study of 60 ER+ BRCA1-associated IBC (cases) matched on age and year of diagnosis with 174 ER+ sporadic breast cancers (controls). Histologic sections of cases and controls were reviewed and the pathologic features were compared with each other as well with those of 85 ER- IBC that developed in BRCA1 mutation carriers.Results: Histologic features are summarized in the Table. When compared with ER+ controls, ER+ BRCA1-associated IBC were significantly more likely to be invasive ductal carcinomas (78% vs 58%;p=0.005), histologic grade 3 (47% vs 27%;p=0.006), and to have a high mitotic rate (29% vs 9%;p=0.0003). However, all of these features were significantly less frequent in ER+ BRCA1-associated IBC than in ER- BRCA1-associated IBC (p&lt;0.001 for all comparisons). ER+ BRCA1-associated IBC and ER+ controls were not significantly different from each other with regard to the frequency of moderate-severe lymphoid infiltrate, the presence of geographic necrosis or the presence of a fibrotic focus, but the frequency of all of these features in both groups was significantly lower than in ER- BRCA1-associated IBC (p&lt;0.01 for all comparisons). ER+ ControlsER+ BRCA1ER- BRCA1 N=174N=60N=85Histologic Type   Invasive Ductal58%78%96%Other42%22%4%Histologic Grade   327%47%96%1 or 273%53%4%Mitotic Rate   ≥10/10 HPF9%29%93%&lt;10/10 HPF91%71%7%Tumor Margin   Invasive96%90%37%Pushing/Circumscribed4%10%63%Lymphoid Infiltrate   Moderate-Severe16%7%30%Other84%93%70%Fibrotic Focus   Present7%12%56%Absent93%88%44%Geographic Necrosis   Present2%5%50%Absent98%95%50% Conclusions: ER+ breast cancers arising in women with BRCA1 germline mutations appear to be pathologically "intermediate" between ER- BRCA1-associated breast cancers and ER+ sporadic breast cancers. This raises the possibility that some ER+ BRCA1-associated invasive breast cancers are mutation-related and others are sporadic or that there is a unique mechanism by which ER+ cancers develop in mutation carriers. Immunophenotypic and molecular studies are in progress to further characterize this interesting group of tumors.This work was supported by a grant from the Breast Cancer Research Foundation.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5162.

Parental decisions and outcomes regarding disclosing maternal BRCA1 and 2 test results to children

9582

Background: BRCA1/2 testing is key to hereditary cancer risk management. Though testing is discouraged in children, prior work suggests they are informed of their tested mothers' mutation status; decisions and outcomes of parental disclosure to children remain largely unknown. Methods: We examined predictors of parental disclosure decisions to children ages 8–21 and related outcomes in a large clinical sample (221 tested mothers, 124 untested co-parents). Parents were interviewed prior to mothers' receipt of BRCA1/2 results and 1 and 6 months later. Descriptive analyses were conducted, and bivariate analyses identified candidate predictor variables (demographic, medical, psychosocial) for inclusion in multivariate logistic regression models. Results: 63% of mothers disclosed their results to their children within 1 month of receipt (44% of co-parents also disclosed to children); this increased to 68% by 6 months (55% among co-parents). Within parenting dyads, mothers were significantly more likely than co-parents to disclose to children in the short-term (X2=18.6, p<.0001). Predictors of maternal disclosure to children included not being a BRCA1/2 mutation carrier, older child age, stronger intentions to disclose, more favorable attitudes toward pediatric BRCA1/2 testing, a more open parent-child communication history, and a decisional balance favoring disclosure (all p's<.05). When examined simultaneously, mothers who were not mutation carriers (OR=4.02, 95% CI=1.35, 11.94), mothers of older children (OR=1.30, 95% CI=1.13, 1.49), and those with stronger intentions to disclose (OR=1.39, 95% CI=1.10, 1.76) were more likely to communicate. Other outcomes of maternal disclosure included greater satisfaction with the decision to disclose and more open parent-child communication following disclosure (all p's<.05). Conclusions: This is the largest and most well-characterized study on this topic to date. Short-term rates of parental disclosure to children were high, increasing over time. Parental disclosure decisions are determined by a complex array of both child and parent factors, with some benefits identified with disclosure. Findings indicate a need for additional work, including decision support interventions for communication with children.

No significant financial relationships to disclose.

Characterization of estrogen receptor-positive breast cancers in BRCA1 mutation carriers

Abstract #1105

Background: Invasive breast cancers (IBC) in BRCA1 mutation carriers are usually estrogen receptor (ER) negative (-) and more than 80% have a basal-like molecular phenotype. These tumors are typically poorly differentiated invasive ductal carcinomas with a high mitotic rate and frequently show a prominent lymphoid infiltrate, pushing or circumscribed margins, and geographic necrosis or a central fibrotic focus. However, some women with BRCA1 germline mutations develop ER positive (+) cancers; little is known about the characteristics of the ER+ tumors in this group.&#x2028; Design: We identified 41 ER+ IBC that developed in women with BRCA1 germline mutations with available pathologic material for review. The histologic features were analyzed in detail and compared with those of 45 ER- IBC that developed among BRCA1 mutation carriers.&#x2028; Results: Mean patient age was 46y for ER+ and 45y for ER- cases. Ninety percent of the ER+ cases and all the ER- cases were invasive ductal carcinomas or invasive carcinomas with ductal and lobular features. There were 2 mucinous and 2 tubular carcinomas in the ER+ group. The ER+ cancers exhibited a range of histologic grades: 12 (29.3%) were grade I, 10 (24.4%) grade II, and 18 (43.9%) grade III (1 case of microinvasive carcinoma could not be graded). In contrast, 43 of the 45 ER- cancers were grade III (95.6%) and 1 (2.2%) grade II (1 case of microinvasive carcinoma could not be graded). Histologic features commonly seen in association with ER- BRCA1 mutation-associated IBC were compared between the two groups and the results are summarized in the table.&#x2028; &#x2028; Of note, a brisk mitotic rate, pushing margin, and the presence of geographic necrosis/central fibrosis were all significantly more common in ER- than in ER+ tumors.&#x2028; Conclusions: To our knowledge, this study is the first to document in detail the histologic features of the uncommon ER+ IBC occurring in BRCA1 mutation carriers. Our observations suggest that ER+ IBC in BRCA1 mutation carriers represent a morphologically diverse group. This raises the possibility that at least some ER+ IBC that develop in women with germline BRCA1 mutations may be sporadic rather than BRCA1-associated. We are currently analyzing these lesions with a panel of biomarkers and assays for loss of heterozygosity at the BRCA1 mutation sites to further address this important issue.&#x2028; This work was supported by a grant from the Breast Cancer Research Foundation.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1105.

THE ASSOCIATION OF LOBULAR BREAST CANCER WITH GERMLINE MUTATIONS OF CDH1

Background: CDH1 encodes the cell-cell adhesion molecule, E-cadherin, for which loss of expression facilitates the infiltrative and metastatic potential of cancers. Germline mutations in CDH1 are associated with hereditary diffuse gastric cancer (HDGC), and in this setting female carriers have been estimated to have a 39-50% risk of lobular breast cancer (LBC) by age 80 years. Aim: To determine the frequency of CDH1 germline mutations inindividuals with early-onset LBC or those with LBC and a family history of multiple breast cancers but no gastric cancers. Methods: Germline DNA analysis of CDH1 in women with LBC, for whom germline BRCA1 and BRCA2 mutations have been excluded, who have been (1) diagnosed before the age of 45 years or (2) diagnosed at any age and have a family history of breast cancer. Results: Analysis of 194 LBC cases has thus far revealed two novel missense mutations predicted to affect protein function. Functional assays to assess their pathogenicity along with germline analyses of the remaining 200 cases are currently underway. Several unreported silent changes have also been identified and will be measured in a case- control sample to assess whether they are associated with LBC risk. Conclusion: Germline CDH1 mutations may cause a small proportion of familial and early onset LBC.

Genetic testing in young women with breast cancer: Results from a web-based survey

21093

Background: Young women with breast cancer have an increased risk of harboring a BRCA1/2 mutation. The frequency of genetic testing in this population is not well described. We evaluated the reported frequency and factors associated with genetic testing among young breast cancer survivors identified through the Young Survival Coalition (YSC), an international advocacy group for young women with breast cancer. Methods: Items regarding family history and genetic testing were included in a large web-based survey addressing quality of life and fertility issues for young women with breast cancer. All YSC members were invited by email in March 2003 (N= 1,703 women) to participate in this cross-sectional survey. Results: 657 women completed the on-line survey; 622 were eligible for this analysis (age <40, no metastatic or recurrent disease). Mean age at breast cancer diagnosis was 33 years; mean age when surveyed 35.5 years. Stages included: 0 (10%), I (27%), II (49%), III (12%), missing (3%). 90% of women were white; 64% married; 49% with children; 78% had at least a college education; 42% of women reported a 1st or 2nd degree relative with breast or ovarian cancer, and 13% considered themselves high-risk for harboring a genetic mutation at the time of diagnosis. At the time of the survey, 23% of women had undergone genetic testing, and 26% of those tested reported that a mutation was found. In a multivariate model, women who were younger (age 36–40 vs. age =30, O.R. 2.26, p=0.004), more educated (< college vs. > college education, O.R. 2.62, p=0.0009), had a family history of breast or ovarian cancer (O.R. 3.15, p<0.0001), and had had a mastectomy (O.R. 1.99, p=0.001) were more likely to have undergone genetic testing. Non-significant covariates included: age at survey, stage, time since diagnosis, race, marital status, employment, finances, insurance, number of children, comorbidities, baseline anxiety and depression, and fear of recurrence. Conclusion: The majority of women diagnosed with breast cancer age 40 and younger do not undergo genetic testing. Younger, more educated women with a family history of breast or ovarian cancer are more likely to get tested. Further research to define the appropriateness of genetic testing in this relatively high-risk population is warranted.

No significant financial relationships to disclose.

A candidate precursor to serous carcinoma that originates in the distal fallopian tube

The tubal fimbria is a common site of origin for early (tubal intraepithelial carcinoma or TIC) serous carcinomas in women with familial BRCA1 or 2 mutations (BRCA+). Somatic p53 tumour suppressor gene mutations in these tumours suggest a pathogenesis involving DNA damage, p53 mutation, and progressive loss of cell cycle control. We recently identified foci of strong p53 immunostaining-termed 'p53 signatures'-in benign tubal mucosa from BRCA+ women. To examine the relationship between p53 signatures and TIC, we compared location (fimbria vs ampulla), cell type (ciliated vs secretory), evidence of DNA damage, and p53 mutation status between the two entities. p53 signatures were equally common in non-neoplastic tubes from BRCA+ women and controls, but more frequently present (53%) and multifocal (67%) in fallopian tubes also containing TIC. Like prior studies of TIC, p53 signatures predominated in the fimbriae (80-100%) and targeted secretory cells (HMFG2 + /p73-), with evidence of DNA damage by co-localization of gamma-H2AX. Laser-capture microdissected and polymerase chain reaction-amplified DNA revealed reproducible p53 mutations in eight of 14 fully-analysed p53 signatures and all of the 12 TICs; TICs and their associated ovarian carcinomas shared identical mutations. In one case, a contiguous p53 signature and TIC shared the same mutation. Morphological intermediates between the two, with p53 mutations and moderate proliferative activity, were also seen. This is the first report of an early and distinct alteration in non-neoplastic upper genital tract mucosa that fulfils many requirements for a precursor to pelvic serous cancer. The p53 signature and its malignant counterpart (TIC) underline the significance of the fimbria, both as a candidate site for serous carcinogenesis and as a target for future research on the early detection and prevention of this disease.

Age at first birth and the risk of breast cancer in BRCA1 and BRCA2 mutation carriers

An early age at first full-term birth is associated with a reduction in the subsequent development of breast cancer among women in the general population. A similar effect has not yet been reported among women who carry an inherited BRCA1 or BRCA2 mutation. We conducted a matched case-control study on 1816 pairs of women with a BRCA1 (n = 1405) or BRCA2 (n = 411) mutation in an attempt to elucidate the relationship between age at first full-term pregnancy and the risk of developing breast cancer. Information about the age at first childbirth and other pregnancy-related variables was derived from a questionnaire administered to women during the course of genetic counselling. There was no difference in the mean age at first full-term birth in the cases and controls (24.9 years vs. 24.8 years; P = 0.81, respectively). Compared to women whose first child was born at or before 18 years of age, a later age at first full-term birth did not influence the risk of developing breast cancer (OR = 1.00 per year; 95% CI 0.98-1.03; P-trend = 0.67). Stratification by mutation status did not affect the results. These findings suggest that an early first full-term birth does not confer protection against breast cancer in BRCA mutation carriers. Nonetheless, BRCA mutation carriers opting for a prophylactic oophorectomy as a breast and/or ovarian cancer risk-reducing strategy should complete childbearing prior to age 40 when this prevention modality is most effective.

Histopathological features of breast cancers in women with germline TP53 mutations

10031

Background: Breast cancers (BR) in women with germline BRCA1 mutations are usually high-grade ductal carcinomas; 90% are negative for estrogen receptor (ER), progesterone receptor (PR) and HER2. No characteristic phenotype has been found for BRCA2-associated tumors. For women with germline TP53 mutations (Li Fraumeni Syndrome), breast cancer is the most common tumor; the risk of BR is 49% by age 60, with significant risk before age 40. The histopathological profile of BR in women with germline TP53 mutations has not been characterized. Methods: We identified BR from 17 female TP53 mutation carriers from the LFS family registry at Dana Farber Cancer Institute on which at least ER and PR data were available. Information on histology, hormone receptor and HER2 status by immunohistochemistry (IHC) was collected from medical records. Histology was not centrally reviewed. Results: 14 invasive ductal carcinoma (IDC) and 4 DCIS were identified in 17 women (1 woman had both) (see Table). The median age at diagnosis of invasive BR was 30 years (range 24–48), for DCIS it was 37 years (range 22–40). Of the 14 IDC, 11 (79%) were high grade (G3), 10 (71%) were ER positive, 7 (50%) PR positive, 6 PR negative and 1 PR unknown. Among 9 tumors with available HER2 status, 6 (67%) were positive. Both ER+/PR+ and ER-/PR- DCIS were observed. Conclusions: In young women with TP53 germline mutations, BR are more likely to be high grade and ER positive with no other distinct pattern in contrast to BRCA1-associated tumors. Findings of DCIS alone suggest potential value for mammographic screening. Confirmation of these results in a larger series will be important.

[Table: see text]

No significant financial relationships to disclose.

The PRIME curriculum. Clinical research training during residency

AIM

The Primary Medical Education (PRIME) program is an outpatient-based, internal medicine residency track nested within the University of California, San Francisco (UCSF) categorical medicine program. Primary Medical Education is based at the San Francisco Veteran's Affairs Medical Center (VAMC), 1 of 3 teaching hospitals at UCSF. The program accepts 8 UCSF medicine residents annually, who differentiate into PRIME after internship. In 2000, we implemented a novel research methods curriculum with the dual purposes of teaching basic epidemiology skills and providing mentored opportunities for clinical research projects during residency.

SETTING

Single academic internal medicine program.

PROGRAM DESCRIPTION

The PRIME curriculum utilizes didactic lecture, frequent journal clubs, work-in-progress sessions, and active mentoring to enable residents to "try out" a clinical research project during residency.

PROGRAM EVALUATION

Among 32 residents in 4 years, 22 residents have produced 20 papers in peer-reviewed journals, 1 paper under review, and 2 book chapters. Their clinical evaluations are equivalent to other UCSF medicine residents.

DISCUSSION

While learning skills in evidence-based medicine, residents can conduct high-quality research. Utilizing a collaboration of General Internal Medicine researchers and educators, our curriculum affords residents the opportunity to "try-out" clinical research as a potential future career choice.

Breast-feeding and the risk of breast cancer in BRCA1 and BRCA2 mutation carriers

BACKGROUND

Several studies have reported that the risk of breast cancer decreases with increasing duration of breast-feeding. Whether breast-feeding is associated with a reduced risk of hereditary breast cancer in women who carry deleterious BRCA1 and BRCA2 mutations is currently unknown.

METHODS

We conducted a case-control study of women with deleterious mutations in either the BRCA1 or the BRCA2 gene. Study participants, drawn from an international cohort, were matched on the basis of BRCA mutation (BRCA1 [n = 685] or BRCA2 [n = 280]), year of birth (+/-2 years), and country of residence. The study involved 965 case subjects diagnosed with breast cancer and 965 control subjects who had no history of breast or ovarian cancer. Information on pregnancies and breast-feeding practices was derived from a questionnaire administered to the women during the course of genetic counseling. Conditional logistic regression analyses were used to estimate odds ratios (ORs) for the risk of breast cancer. All statistical tests were two-sided.

RESULTS

Among women with BRCA1 mutations, the mean total duration of breast-feeding was statistically significantly shorter for case subjects than for control subjects (6.0 versus 8.7 months, respectively; mean difference = 2.7 months, 95% confidence interval [CI] = 1.4 to 4.0; P<.001). The total duration of breast-feeding was associated with a reduced risk of breast cancer (for each month of breast-feeding, OR = 0.98, 95% CI = 0.97 to 0.99; P(trend)<.001). Women with BRCA1 mutations who breast-fed for more than 1 year were less likely to have breast cancer than those who never breast-fed (OR = 0.55, 95% CI = 0.38 to 0.80; P =.001), although no such association was seen for BRCA2 (OR = 0.95, 95% CI = 0.56 to 1.59; P =.83).

CONCLUSIONS

Women with deleterious BRCA1 mutations who breast-fed for a cumulative total of more than 1 year had a statistically significantly reduced risk of breast cancer.

Progesterone receptor variant increases ovarian cancer risk in BRCA1 and BRCA2 mutation carriers who were never exposed to oral contraceptives

Oral contraceptives have been shown to be protective against hereditary ovarian cancer. The variant progesterone receptor allele named PROGINS is characterized by an Alu insertion into intron G and two additional mutations in exons 4 and 5. The PROGINS allele codes for a progesterone receptor with increased stability and increased hormone-induced transcriptional activity. We studied the role of the PROGINS allele as a modifying gene in hereditary breast and ovarian cancer. The study included 195 BRCA1 and BRCA2 carriers with a prior diagnosis of ovarian cancer, 392 carriers with a diagnosis of breast cancer and 249 carriers with neither cancer. Fifty-eight women had both forms of cancer. Five hundred and ninety-five women had a BRCA1 mutation and 183 women had a BRCA2 mutation. Overall, there was no association between disease status and the presence of the PROGINS allele. Information on oral contraception use was available for 663 of the 778 carriers of BRCA1 or BRCA2 mutations. Among the 449 subjects with a history of oral contraceptive use (74 cases and 365 controls), no modifying effect of PROGINS was observed [odds ratio (OR) 0.8; 95% confidence interval (CI) 0.5-1.3]. Among the 214 carriers with no past exposure to oral contraceptives, the presence of one or more PROGINS alleles was associated with an OR of 2.4 for ovarian cancer, compared to women without ovarian cancer and with no PROGINS allele (P = 0.004; 95% CI 1.4-4.3). The association was present after adjustment for ethnic group and for year of birth.

The relation of daily stressors to somatic and emotional symptoms in children with and without recurrent abdominal pain

Prior investigations of the relation between stressors and symptoms in children with recurrent abdominal pain (RAP) have focused on major negative life events. This study used consecutive daily telephone interviews to assess daily stressors and symptoms in 154 pediatric patients with RAP and 109 well children. Results showed that patients with RAP reported more frequent daily stressors than well children reported both at home and at school. Idiographic (within-subject) analyses indicated that the association between daily stressors and somatic symptoms was significantly stronger for patients with RAP than for well children. In contrast, the relation between daily stressors and negative affect did not differ between the groups. The relation between daily stressors and somatic symptoms was stronger for patients with RAP who had higher levels of trait negative affectivity.

Tubal ligation and risk of ovarian cancer in carriers of BRCA1 or BRCA2 mutations: a case-control study

BACKGROUND

In several case-control and prospective studies, tubal ligation has been associated with a decreased risk of invasive epithelial ovarian cancer. We aimed to assess the potential of tubal ligation in reducing the risk of ovarian cancer in women who carry predisposing mutations in the BRCA1 or BRCA2 genes.

METHODS

We did a matched case-control study among women from Canada, the USA, and the UK who had undergone genetic testing and who carried a pathogenic mutation in BRCA1 or BRCA2. Cases were 232 women with a history of invasive ovarian cancer, and controls were 232 women without ovarian cancer, and who had both ovaries intact. Cases and controls were matched for year of birth, country of residence, and mutation (BRCA1 or BRCA2). The odds ratio for developing ovarian cancer was estimated for tubal ligation, adjusting for oral contraceptive use, parity, history of breast cancer, and ethnic group.

FINDINGS

In an unadjusted analysis among BRCA1 carriers, significantly fewer cases than controls had ever had tubal ligation (30 of 173 [18%] vs 60 of 173 [35%], odds ratio 0.37 [95% CI 0.21-0.63]; p=0.0003). After adjustment for oral contraceptive use, parity, history of breast cancer and ethnic group, the odds ratio was 0.39 (p=0.002). Combination of tubal ligation and past use of an oral contraceptive was associated with an odds ratio of 0.28 (0.15-0.52). No protective effect of tubal ligation was seen among carriers of the BRCA2 mutation.

INTERPRETATION

Tubal ligation is a feasible option to reduce the risk of ovarian cancer in women with BRCA1 mutations who have completed childbearing.