Association of Sarcopenia With Toxicity-Related Discontinuation of Adjuvant Endocrine Therapy in Women With Early-Stage Hormone Receptor-Positive Breast Cancer

PURPOSE

Sarcopenia, an age-related decline in muscle mass and physical function, is associated with increased toxicity and worse outcomes in women with breast cancer (BC). Sarcopenia may contribute to toxicity-related early discontinuation of adjuvant endocrine  therapy (aET) in women with hormone receptor-positive (HR+) BC but remains poorly characterized.

METHODS AND MATERIALS

This multicenter, retrospective cohort study included consecutive women with stage 0-II HR+ BC who received breast conserving therapy (lumpectomy and radiation therapy) and aET from 2011 to 2017 with a 5-year follow-up. Skeletal muscle index (SMI, cm2/m2) was analyzed using a deep learning model on routine cross-sectional radiation simulation imaging; sarcopenia was dichotomized according to previously validated reports. The primary endpoint was toxicity-related aET discontinuation; logistic regression analysis evaluated associations between SMI/sarcopenia and aET discontinuation. Cox regression analysis evaluated associations with time to aET toxicity, ipsilateral breast tumor recurrence (IBTR), and disease-free survival (DFS).

RESULTS

A total of 305 women (median follow-up, 89 months) were included with a median age of 67 years and early-stage BC (12% stage 0, 65% stage I). A total of 60 (20%) women experienced toxicity-related aET discontinuation. Sarcopenia was associated with toxicity-related early discontinuation of aET (odds ratio, 2.18; P = .036) and shorter time to aET toxicity (hazard ratio [HR], 1.62; P = .031). SMI or sarcopenia were not independently associated with IBTR or DFS; toxicity-related aET discontinuation was associated with worse IBTR (HR, 9.47; P = .002) and worse DFS (HR, 4.53; P = .001).

CONCLUSIONS

Among women with early-stage HR+ BC who receive adjuvant radiation therapy and hormone therapy, sarcopenia is associated with toxicity-related early discontinuation of aET. Further studies should validate these findings in women who did not receive adjuvant radiation therapy. These high-risk patients may be candidates for aggressive symptom management and/or alternative treatment strategies to improve outcomes.

Utilization of an Electronic Patient-Reported Outcome Platform to Evaluate the Psychosocial and Quality-of-Life Experience Among a Community Sample of Ovarian Cancer Survivors

PURPOSE

Novel distress screening approaches using electronic patient-reported outcome (ePRO) measurements are critical for the provision of comprehensive quality community cancer care. Using an ePRO platform, the prevalence of psychosocial factors (distress, post-traumatic growth, resilience, and financial stress) affecting quality of life in ovarian cancer survivors (OCSs) was examined.

METHODS

A cross-sectional OCS sample from the National Ovarian Cancer Coalition-Illinois Chapter completed web-based clinical, sociodemographic, and psychosocial assessment using well-validated measures: Hospital Anxiety/Depression Scale-anxiety/depression, Post-traumatic Growth Inventory, Brief Resilience Scale, comprehensive score for financial toxicity, and Functional Assessment of Cancer Therapy-Ovarian (FACT-O/health-related quality of life [HRQOL]). Correlational analyses between variables were conducted.

RESULTS

Fifty-eight percent (174 of 300) of OCS completed virtual assessment: median age 59 (range 32-83) years, 94.2% White, 60.3% married/in domestic partnership, 59.6% stage III-IV, 48.8% employed full-time/part-time, 55.2% had college/postgraduate education, 71.9% completed primary treatment, and median disease duration 6 (range < 1-34) years. On average, OCS endorsed normal levels of anxiety (mean ± standard deviation = 6.9 ± 3.8), depression (4.1 ± 3.6), mild total distress (10.9 ± 8.9), high post-traumatic growth (72.6 ± 21.5), normal resilience (3.7 ± 0.72), good FACT-O-HRQOL (112.6 ± 22.8), and mild financial stress (26 ± 10). Poor FACT-O emotional well-being was associated with greater participant distress (P < .001). Partial correlational analyses revealed negative correlations between FACT-O-HRQOL and anxiety (r = -0.65, P < .001), depression (r = -0.76, P < .001), and total distress (r = -0.92, P < .001). Yet, high FACT-O-HRQOL was positively correlated with post-traumatic coping (r = 0.27; P = .006) and resilience (r = 0.63; P < .001).

CONCLUSION

ePRO assessment is feasible for identification of unique psychosocial factors, for example, financial toxicity and resilience, affecting HRQOL for OCS. Future investigation should explore large-scale, longitudinal ePRO assessment of the OCS psychosocial experience using innovative measures and community-based advocacy populations.

Anxiety Shapes Expectations of Therapeutic Benefit in Phase I Trials for Patients With Advanced Cancer and Spousal Caregivers

PURPOSE

Advanced cancer patients (ACP) hope to receive significant therapeutic benefit from phase I trials despite terminal disease and presumed symptom burdens. We examined associations between symptom burdens and expectations of therapeutic benefit for ACP and spousal caregivers (SC) during phase I trials.

PATIENTS AND METHODS

A prospective cohort of ACP-SC enrolled in phase I trials was assessed at baseline and one month using symptom burden measures evaluating depression, state-trait anxiety, quality of life, global health, post-traumatic coping, and marital adjustment. Interviews evaluated expectations of benefit.

RESULTS

Fifty-two phase I ACP and 52 SC (N = 104) were separately assessed and interviewed at baseline and one month. Total population demographics included the following: median age 61 years (28-78), 50% male, 100% married, 90% White, and 46% ≥ college education. At T1, ACP reported symptoms of mild state anxiety, mild trait anxiety, poor global health, and quality of life. SC reported moderate state and mild trait anxiety and good global health with little disability at baseline. State anxiety was a significant predictor of ACP expectations for phase I producing the following therapeutic benefits: stabilization (P = .01), shrinkage (P < .01), and remission (P = .04). Regression analyses also revealed negative associations between SC expectation for stabilization and SC anxiety: state (P = .01) and trait (P = .02). ACP quality of life was also negatively associated with SC expectations for stabilization (P = .02) and shrinkage (P = .01).

CONCLUSION

Anxiety, both state and trait, impacts couples' beliefs regarding the likelihood of therapeutic benefit from phase I trial participation.

Direct-to-Consumer Advertising for Cancer Centers and Institutes: Ethical Dilemmas and Practical Implications

In the United States, many cancer centers advertise their clinical services directly to the public. Although there are potential public benefits from such advertising, including increased patient awareness of treatment options and improved access to care and clinical trials, there is also potential for harm through misinformation, provision of false hope, inappropriate use of health care resources, and disruption in doctor-patient relationships. Although patient education through advertising is appropriate, misleading patients in the name of gaining market share, boosting profits, or even boosting trial accrual is not. It is critical that rigorous ethical guidelines are adopted and that oversight is introduced to ensure that cancer center marketing supports good patient care and public health interests. Patients with cancer have been identified as an especially vulnerable population because of fears and anxiety related to their diagnosis and the very real need to identify optimal sources of care. Cancer organizations have a fiduciary duty and a moral and legal obligation to provide truthful information to avoid deceptive, inaccurate claims associated with treatment success. In this article, actionable recommendations are provided for both the oncologist and the cancer center's marketing team to promote ethical marketing of services to patients with cancer. This tailored guidance for the oncology community includes explicit communication on (1) ensuring fair and balanced promotion of cancer services, (2) avoiding exaggeration of claims in the context of reputational marketing, (3) providing data and statistics to support direct and implied assertions of treatment success, and (4) defining eligible patient groups in the context of marketing for research. These recommendations for cancer centers are designed to promote ethical quality marketing information to patients with cancer.

An innovative, internet-based assessment of financial toxicity (FT), psychological distress, and quality of life (QOL) in ovarian cancer survivors (OCS)

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Background: FT is recognized as a significant predictor of stress for OCS on treatment yet little is known about its impact during long-time survivorship. Using an innovative, internet-based design, we assessed the prevalence of FT, psychological distress, and QOL among OCS. Methods: OCS members from the National Ovarian Cancer Coalition (NOCC) completed this web-based assessment using the following measures: COmprehensive Score for Financial Toxicity (COST); Hospital Anxiety/Depression Scale (HADSA/D); and the Functional Assessment of Cancer Therapy-Ovarian (FACIT-O/QOL). Clinical/socio-demographic data were collected. COST-FT severity was categorized into low FT/high FT and the correlation (r) between COST scores and self-reported QOL and distress was conducted. Results: A total of 146/300 (49% ) NOCC subjects were approached for study participation and completed the FT, distress, QOL web-based assessment. Demographics include: median age 59y (range 32-83y); 92.5% Caucasian, 64.4% married/domestic partnership; 59.6% Stage III-IV cancer-diagnosis; median disease duration 6y (range < 1-34y); 50% employed full/part-time; 54.8% college/post-graduate education; and 71.9% completed treatment. Median COST score for the total population was 27 (range: 1–44). The median score in the low FT tertile was 16 (range: 1-22), while the high FT median score was 31 (range: 23-44). High FT respondents rated their HADS-anxiety (8.3 ± 4.9 v. 6.2 ± 3.5, p = 0.002); HADS-depression (5.3 ± 4.2 v. 3.1 ± 3.0, p = 0.004); and overall FACT-O/QOL (99.8 ± 23.6 v. 118.7 ± 19.5; p = 0.001) as significantly worse compared to low FT respondents. Significant moderate correlations between COST and FACT-O/QOL (r = -0.52; p < 0.001), HADS-anxiety (r = 0.4, p < 0.001), and HADS-depression (r = 0.44, p < 0.001) were identified. Older age was associated with less FT (r = -0.30, p < 0.001). Conclusions: Innovative methods of FT evaluation, e.g. using advocacy groups (NOCC) and internet-based assessment, is feasible, and may offer new ways to follow the distress of long term survivor cohorts. Our study data reveal that FT impacts OCS QOL and distress.

Abstract GS6-01: Surgical treatment after neoadjuvant systemic therapy in young women with breast cancer: Results from a prospective cohort study

Background

Young women are more likely than older women to present with higher stage breast cancer (BC) and may benefit to a greater extent from downstaging with neoadjuvant systemic treatment (NST). Young age is also associated with greater likelihood of pathologic complete response (pCR). Using a large prospective cohort of young women with BC, we investigated response to neoadjuvant therapy, eligibility for breast conserving surgery (BCS) pre- and post-NST, and surgical treatment.

Methods

The Young Women's Breast Cancer Study (YWS) is a multi-center cohort of women diagnosed with BC at age ≤40, that enrolled 1302 patients from 2006 to 2016. Disease characteristics and treatment information were obtained through medical record and central pathology review. Surgical recommendation before and after NST, conversion from BCS borderline/ineligible to BCS eligible, surgery, documented reasons for choosing mastectomy (MTX) among BCS eligible women, and final pathologic response were independently reviewed.

Results

Among 1302 women enrolled in YWS, 801 (62%) presented with unilateral stage I-III breast cancer and 317(40%) received NST. Median age was 36 years old (22-40). Pre-NST, 85/317 (27%) were BCS eligible, 49 (15%) were borderline, and 169 (53%) were not eligible (16 inflammatory breast cancer (IBC), 88 large tumor size /cosmetic, 48 diffuse calcifications, and 83 multicentricity). Among the 218 patients who were BCS ineligible/borderline pre-NST, 82 (38%) became eligible for BCS after NST. 4 patients who were BCS eligible pre-NST became ineligible. Of all patients eligible for BCS post-NST (n=163), 80 (49%) attempted BCS, 74 (93%) of whom were successful, and 83 (51%) chose MTX. Reasons for choosing MTX included: patient preference (38/83 (46%)), BRCA or TP53 mutation (31 (37%)), family history (3 (4%)), unknown (11 (13%)). On final pathology, 75 (24%) patients had pCR. Among patients who achieved a pCR, 48 (64%) underwent MTX, fewer than half (21/48 (44%)) were for anatomic indications (IBC, large tumor at diagnosis, diffuse calcifications, multicentric disease).

Conclusion

While NST doubled the proportion of young women eligible for BCS, nearly half chose MTX regardless of response to NST, mostly for personal preference or high-risk preventative reasons. These data highlight that surgical decision making among young women with breast cancer is often driven by factors beyond extent of disease and clinical response to therapy.

Table 1.Clinical-pathologic characteristicsCharacteristicsNumber%Pre NST surgical recommendation  BCS eligible8526.8Borderline4915.5BCS ineligible16953.3Unknown144.4Clinical Response  Complete20263.7Partial9229.0Stable30.9Progressing72.2Unknown134.1Pathologic Response  pCR (No invasive or DCIS)7524No pCR24276Post NST Surgical recommendation  BCS eligible16351.4BCS ineligible14445.4Unknown103.2Attempted surgery  BCS8025.2MTX23674.1Unknown20.6Final Surgery  BCS7423.3MTX24176unknown20.6

Citation Format: Kim HJ, Dominici L, Rosenberg S, Pak LM, Poorvu PD, Ruddy K, Tamimi R, Schapira L, Come S, Peppercorn J, Borges V, Warner E, Vardeh H, Collins L, King T, Partridge A. Surgical treatment after neoadjuvant systemic therapy in young women with breast cancer: Results from a prospective cohort study [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 GS6-01.

Abstract P6-22-03: Tumor phenotype and concordance in synchronous bilateral breast cancer in young women

Background: Synchronous bilateral breast cancer is rare, with reported incidence from 0.3-12%; the incidence and pattern of bilateral breast cancer among younger women is unknown. Here we report the incidence and phenotypes of bilateral breast cancer in women ≤40 years of age enrolled in the Young Women's Study (YWS) cohort.

Methods: The YWS is a multi-center, prospective cohort study that enrolled women with newly diagnosed breast cancer at age ≤40 years from 2006-2016. Those with synchronous bilateral breast cancer (in-situ and/or invasive) formed our study cohort. Disease characteristics and treatment were obtained by medical record review. Central pathology review was performed to capture histologic features and categorize the tumor phenotype as either luminal A (hormone receptor (HR)+, HER2-, grade 1 or 2), luminal B (HR+, HER2+, or HER2- and grade 3), HER2-type (HR-, HER2+), or triple negative (TNC; HR/HER2-). Tumor phenotypes of bilateral breast cancers were compared and evaluated for concordance.

Results: Among 1302 patients enrolled in the YWS, 20 (1.5%) patients presented with bilateral disease, with median age of diagnosis of 38 years (range 18-40). The majority of patients (13 (65%)) presented with unilateral symptoms and contralateral disease was identified on subsequent imaging. 12 (60%) reported a positive family history of breast cancer and 17 (85%) underwent genetic testing; resulting in the identification of 6 mutation carriers (2 BRCA1, 3 BRCA2, 1 TP53). The majority of patients (15 (75%)) underwent bilateral mastectomy, 1 underwent unilateral mastectomy with contralateral lumpectomy, and 4 underwent bilateral lumpectomy. On pathology, 2 patients had bilateral in-situ disease, 5 had unilateral invasive and contralateral in-situ disease, and 13 had bilateral invasive disease. Of those with bilateral invasive disease, all had concordant tumor histology (92% ductal, 8% ductal and lobular), 10 (77%) patients had bilateral luminal tumors and when fully characterized 6 were of the same luminal type. Only one patient had bilateral basal-like breast cancer.

Patient ID ERPRHer2 amplifiedGradePhenotype1Left++-2Luminal A Right++-3Luminal B3Left++-3Luminal B Right++-3Luminal B6Left++-3Luminal B Right++-3Luminal B9Left++-2Luminal A Right++-2Luminal A10Left+++3Luminal B Right++-2Luminal A12Left+--3Luminal B Right+--2Luminal A13Left---NABasal-like Right++-NALuminal A or B14Left+++2Luminal B Right++-3Luminal B15Left++-3Luminal B Right+++3Luminal B16Left+++3Luminal B Right--+NAHEr2-type17Left---3Basal-like Right---3Basal-like19Left++-2Luminal A Right++-3Luminal B20Left++-1Luminal A Right++-2Luminal A

Conclusions: Among a large cohort of young women, only 20 (1.5%) had bilateral disease, and the majority of the invasive tumors were of the luminal phenotype, yet frequently differed by grade or HER2 status; supporting the need for thorough pathologic evaluation of bilateral disease to determine risk and tailor treatment. Overall the low incidence of bilateral disease and preponderance of the luminal phenotype in this population is reassuring.

Citation Format: Pak LM, Rosenberg SM, Ruddy KJ, Tamimi RM, Peppercorn J, Schapira L, Borges VF, Come SE, Warner E, Snow C, Collins L, King TA, Partridge AH. Tumor phenotype and concordance in synchronous bilateral breast cancer in young women [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 P6-22-03.

Abstract GS6-06: Local therapy and quality of life outcomes in young women with breast cancer

Background: Increasing rates of mastectomy, primarily bilateral mastectomy (BMx), have been most dramatic in young women with breast cancer (BC). Impact on long-term quality of life (QOL) is largely unknown.

Methods: Between 10/2016-11/2017, we administered the BREAST-Q, a validated patient-reported outcomes measure, to women dx with BC at age ≤40 in a large prospective cohort study. Demographic and treatment information was obtained by surveys and chart review. Mean BREAST-Q scores for each domain (breast satisfaction, physical, psychosocial, and sexual) were compared by surgery types; higher BREAST-Q scores (range: 0-100) indicate better QOL. Linear regression was used to identify predictors of BREAST-Q domain scores.

Results: 581 women with stage 0-3 BC completed the BREAST-Q a median of 5.8 years from dx. Median age at dx was 37 (range: 26-40) years; 86% had stage 0, 1 or 2 disease; 28% had breast-conserving surgery (BCS); 72% had mastectomy (Mx), among whom 72% underwent BMx and 89% had reconstruction. Mean BREAST-Q scores (unadjusted) for breast satisfaction, psychosocial, and sexual well-being were lower for patients having unilateral mastectomy (UMx) or BMx compared to BCS; physical function was similar among groups. In multivariate analysis, lower BREAST-Q psychosocial scores were associated with radiation and Mx (UMx or BMx). Lower sexual well-being scores were also associated with Mx. Lower satisfaction with breast scores following radiation were of a clinically significant magnitude (β -8.1 95% CI -11.9- -4.3, p-value 0.03). Lower scores for physical well-being were seen for patients reporting lymphedema and higher for those who had undergone surgery more than 5 years prior. Lower scores across all 4 domains were associated with reported financial distress.

BREAST-Q domain mean scores (SD) BMxUMxBCSp-valueBreast satisfaction60.3 (18.9)59.5 (21.3)65.9 (20.7)0.008Physical well-being78.6 (14.9)79.7 (15.1)78.9 (15.5)0.8Psychosocial well-being68.1 (20.8)70.5 (21.2)76.1 (20.5)&lt;0.001Sexual well-being48.6 (21.3)53.2 (21.7)57.5 (18.7)&lt;0.001SD Standard deviation

Conclusion: Local therapy in young breast cancer survivors may have a persistent impact on their breast satisfaction, psychosocial, and sexual outcomes, with particular effects from UMx or BMx. Socio-economic stressors also appear to play a role. When counseling young women about their surgical decisions, knowledge of potential long-term QOL impact is of critical importance.

Citation Format: Dominici LS, Hu J, King TA, Ruddy KJ, Tamimi RM, Peppercorn J, Schapira L, Borges VF, Come SE, Warner E, Partridge AH, Rosenberg SM. Local therapy and quality of life outcomes in young women with 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 GS6-06.

Abstract P2-08-07: Prognostic impact of the 21-gene recurrence score assay among young women with node-negative and node-positive ER+/HER2- breast cancer

Background: The 21-gene Recurrence Score (RS) assay is prognostic among women with early-stage estrogen receptor (ER) positive and human epidermal growth factor receptor 2 (HER2) negative breast cancer (BC) and is used to select patients for chemotherapy (CT). Young women (age &lt;40) have represented a minority in studies evaluating gene expression assays, including TAILORx, and additional data in young women are needed.

Methods: In the Young Women's Breast Cancer Study, a prospective cohort study of women diagnosed with BC at age &lt;40 enrolling between 2006-2016 (N=1302), we identified those with stage I-III ER+/HER2- BC. Disease and treatment information were obtained through serial surveys and medical record review. The RS was performed on banked specimens for those not tested clinically. Distant recurrence free interval (DRFI), defined as distant recurrence or BC specific death, by risk group was assessed using Cox regression and Kaplan-Meier survival estimates. Outcomes by receipt of CT were explored in the RS 11-25 group, and due to small number of events, reported descriptively.

Results: Among eligible women (N=577), 189 (33%) had undergone RS testing and 320 (56%) had banked specimens sufficient for testing. Median follow-up was 6 years. Median age at diagnosis was 37, most had N0 BC (300/509, 59%), and the majority had RS 11-25 (306/509, 60%). RS result was significantly associated with DRFI in N0 BC, with hazard ratio (HR) (95% CI) of 0.29 (0.07,1.30) and 0.21 (0.09,0.50) for RS&lt;11 and RS 11-25, respectively, relative to RS&gt;26 (and trended towards significance in N1 BC). Results were similar using conventional RS groups. Among women with N0 BC and RS 11-25, 44% received CT, with two events in the 86 receiving CT (2.3%) and 6 events in the 109 without CT (5.5%); 5/8 (63%) occurred in those with RS 20-25.

Table 1 N0N1Total Cohort N%N%N% 3005916332509100Median Age37.137.537.2Tumor Stage      T120869694229358T28227784817635T3103159357T4001151Grade      I4716855711II16555794926652III8829754618536Not assessed  1 1 PR status by IHC      Negative (&lt;1%)2071710398Positive (&gt;=1%)280931469047092Chemotherapy      No1414712715430Yes159531519335570Ovarian Suppression      No263881499145289Yes37121495711TAILORx RS Groups      RS &lt;1133111495411RS 11-2519565885430660RS &gt;=267224613714929Conventional RS Groups      RS &lt;1812742543319939RS 18-3012542694221142RS &gt;=31481640259919

Table 2 6-year freedom from distant recurrence or breast cancer deathDRFI HR (95% CI) N0N1N0N1TAILORx RS Groups    RS &lt;1194.4%92.3%0.29 (0.07,1.30)0.21 (0.03,1.61)RS 11-2596.9%85.2%0.21 (0.09, 0.50)0.55 (0.27,1.12)RS &gt;=2685.1%71.3%RefRefConventional RS Groups    RS &lt;1897.5%85.9%0.19 (0.06,0.59)0.31 (0.13,0.74)RS 18-3093.1%87.3%0.39 (0.16,1.00)0.32 (0.14,0.73)RS &gt;=3186.4%62.8%RefRef

Conclusions: The RS is prognostic among young women with node-negative and node-positive BC, and is a valuable tool for risk stratification. Disease outcomes among young women with N0 disease and RS 11-25, a minority of whom received CT, are very good. Evaluation of the effect of ovarian suppression/CT-induced amenorrhea by RS/treatment strata is ongoing.

Citation Format: Poorvu PD, Gelber SI, Rosenberg SM, Ruddy KJ, Tamimi RM, Collins LC, Peppercorn J, Schapira L, Borges VF, Come SE, Warner E, Jakubowski DM, Russell C, Winer EP, Partridge AH. Prognostic impact of the 21-gene recurrence score assay among young women with node-negative and node-positive ER+/HER2- 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 P2-08-07.

Abstract P4-01-06: Comparison of tumor genotyping and cell-free circulating tumor DNA sequencing in metastatic breast cancer patients and their utility in the selection of matched therapy

Background: Oncogenic mutations are potential targets for therapeutic intervention in metastatic breast cancer (MBC). While tumor genotyping (TG) has been viewed as the gold standard for identifying oncogenic mutations, cell-free circulating tumor DNA (cfDNA) is emerging as an alternate technique. We previously reported the selection of matched therapy targeted to an actionable mutation based on either TG or cfDNA testing (Vidula N, ASCO, 2018). Therefore, we are now comparing TG and cfDNA results in MBC patients undergoing both tests to examine their relative utility in the selection of matched therapy.

Methods: Patients with MBC at an academic institution who underwent both TG (Next Generation Sequencing/NGS, institutional platform, 104 gene assay) and cfDNA testing (NGS/Guardant360, 73 gene assay) between 1/2016-10/2017 were identified. A chart review was conducted to identify tumor subtype, demographics, treatment, TG and cfDNA results, and clinical outcomes. The relative utility of these tests in the selection of matched therapy was determined, and linked with clinical outcomes (progression-free survival and overall survival).

Results: Thirty patients who underwent both TG and cfDNA testing were identified. The median age was 60 years, the majority (97%) had hormone receptor (HR) positive/HER2 negative disease, and most patients had recurrent disease (83.3%) at MBC diagnosis. The median number of therapies prior to obtaining either test was 1 (cfDNA range 0-9, TG range 0-8). The majority had simultaneous cfDNA and tumor genotyping testing (83.3%) versus sequential testing (16.7%). Twenty-four (80%) patients had actionable mutations detected by cfDNA compared to 19 (63.3%) patients with actionable mutations detected by TG. The median number of actionable mutations detected by cfDNA was 2 (range 0-11) compared with a median of 1 (range 0-4) detected by TG. Failure of TG occurred in 2 of 30 patients (6.7%) but no test failures were seen with cfDNA. Eleven of 30 patients (36.7%) had ≥ 1 concordant mutation via cfDNA and TG. Altogether, 12 out of 30 (40%) patients received matched therapy, 5 of which were based on cfDNA actionable mutations alone (ESR1, ERBB2, CCND1, and PIK3CA), and 7 based on cfDNA and TG results (ESR1, PIK3CA, STK11, and BRCA). Twelve of 24 (50%) patients with actionable cfDNA mutations went on to receive matched therapy compared with 7 of 19 (36.8%) patients with actionable TG results. Matched therapies included SERDs, inhibitors of CDK 4/6, PI3K, mTOR, HER2 directed therapy, and DNA damaging chemotherapy. The impact of matched therapy on survival outcomes will be presented at the meeting.

Conclusions: In patients undergoing both TG and cfDNA testing, both tests identify a significant cohort of HR+ MBC patients with actionable mutations, with greater detection of actionable mutations by cfDNA. Greater application of matched therapy occurred via cfDNA, which independently informed the selection of matched therapies. Further research is needed to prospectively evaluate the clinical utility of blood based genotyping assays versus TG for patients with MBC.

Citation Format: Vidula N, Juric D, Niemierko A, Spring L, Moy B, Malvarosa G, Yuen M, Habin K, Shin J, Peppercorn J, Isakoff S, Ellisen L, Iafrate AJ, Bardia A. Comparison of tumor genotyping and cell-free circulating tumor DNA sequencing in metastatic breast cancer patients and their utility in the selection of matched therapy [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 P4-01-06.

Abstract PD1-13: Somatic BRCA mutation detection by circulating tumor DNA analysis in patients with metastatic breast cancer: Incidence and association with tumor genotyping results, germline BRCA mutation status, and clinical outcomes

Introduction:

BRCA mutations may impact patient outcomes, as well as chemotherapy response in patients with breast cancer (BC). While germline BRCA mutations have been well-studied, the incidence and clinical impact of somatic BRCA mutations have not been well-described. We evaluated the presence of BRCA mutations, and the association between somatic BRCA mutations with clinical outcomes in patients with metastatic breast cancer (MBC).

Methods:

We identified patients with MBC who underwent ctDNA testing by Guardant360 at our institution before the start of a new therapy. From this subset of patients, we subsequently identified those patients with circulating tumor DNA (ctDNA) BRCA 1 or 2 mutations. We conducted a retrospective review of medical and pathology records to identify tumor subtype, germline BRCA testing results, and tissue genotyping results based on institutional Snapshot-NGS genotyping assay. In addition, we conducted a multivariate analysis to evaluate the hazard ratio (HR) for the association between ctDNA BRCA mutation and progression free survival (PFS) adjusting for age, number of prior therapies, and type of therapy.

Results

Among patients with MBC (N = 178), 27 (15.2%) had BRCA alterations detected by ctDNA analysis. Among patients with ctDNA BRCA alterations, the median age at metastatic diagnosis was 53; 16/24 (66.6%) had hormone receptor (HR)+/HER2- BC, 5/24 (20.8%) had triple negative (TN) BC, 2/24 (8.3%) had HR-/HER2+ BC, and 1/24 (4.2%) had HR+/HER2+ BC. Of patients with ctDNA BRCA mutations, only a minority (16.7%) had BRCA alterations detected by genotyping of archival tumor, and only 1 (3.7%) had a germline BRCA mutation (BRCA 1). In multivariate analysis, patients with BRCA mutant tumors, had similar median PFS as compared to non-BRCA mutant breast cancer (HR: 1.17; p = 0.58). Overall survival analysis and impact of BRCA mutations on response to therapy, particularly DNA damaging agents, will be presented at the meeting.

Conclusions:

BRCA mutations by ctDNA are detectable in a significant proportion of MBC patients. Most BRCA mutations detected by ctDNA were not identified by genotyping of archival tissue, and were not associated with germline BRCA mutations, suggesting that somatic BRCA mutations may be detected by sensitive blood-based genotyping assays in patients who are not known BRCA carriers. The therapeutic impact of DNA damaging agents and PARP inhibitors in MBC patients with somatic BRCA alterations is not known and warrants additional research.

Citation Format: Vidula N, Isakoff SJ, Niemierko A, Malvarosa G, Park H, Abraham E, Spring L, Peppercorn J, Moy B, Ellisen LW, Juric D, Bardia A. Somatic BRCA mutation detection by circulating tumor DNA analysis in patients with metastatic breast cancer: Incidence and association with tumor genotyping results, germline BRCA mutation status, and clinical outcomes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD1-13.

Abstract P3-12-06: Fertility concerns and their impact on hormonal therapy decisions in young breast cancer survivors

Background: Fertility is a critical issue for young breast cancer (BC) survivors and can be diminished by adjuvant chemotherapy or by age-related decline in ovarian reserve over time. Little is known about how fertility concerns affect decision-making and persistence with endocrine therapy (ET) given the standard 5-10 year duration of therapy during which pregnancy is contraindicated.

Methods: As part of a multi-center, prospective cohort study enrolling women with newly diagnosed (dx) BC at age ≤40 years between 2006-2016, we identified participants with HR+, Stage I-III BC, without documented recurrence and with at least 3 years of follow-up. Participants completed serial surveys that include questions about socio-demographics, fertility issues and outcomes, treatment, and decision-making. ET use and pregnancy outcomes were evaluated up to 5 years post-dx (mean follow-up: 4.4 years). We used t-tests and chi-square tests to evaluate differences between women who indicated at least once in the first 2 years following diagnosis that fertility concerns affected their ET decisions and those who did not, and multi-variable logistic regression to identify factors independently associated (p≤0.05) with indicating ET decisions were affected by fertility concerns.

Results: Among 479 women included in this analysis, 33% (156/479) indicated that fertility concerns affected their decision regarding hormonal therapy – by choosing to defer treatment, stop early, or indicating that they may stop early or interrupt at a future time. Among these women, 44% (67/156) did not initiate or stopped ET (at least temporarily) vs. 21% (68/323) among women who did not indicate that fertility concerns affected their decision (p&lt;0.0001). Among the 67 women with fertility concerns who did not initiate/discontinued ET, 29 (43%) subsequently reported a pregnancy within 5 years of dx. Women who were younger at dx, not partnered, nulliparous, and those who had a pre-treatment discussion about fertility with a provider were more likely to indicate that fertility concerns affected their ET decision (Table). In multi-variable analyses, only no or low parity remained significant: no children at diagnosis vs. ≥2 OR 9.86, 95% CI: 5.19-18.75, 1 child at diagnosis vs. ≥2: OR 6.28, 95% CI: 3.18-12.39.

Conclusion: Concern about fertility is a contributor to ET decisions among a significant number of young women with HR+ BC. Ongoing research, including the POSITIVE trial (NCT 02308085), an international study that is exploring the safety and feasibility of interrupting ET for pregnancy after HR+ BC, will provide much needed evidence that will help inform and guide both patients and providers as they make fertility and treatment decisions.

Table Fertility concerns affected decisionFertility concerns did not affect decisionpAge at dx - mean (SD)34.0 (3.8)36.3 (3.8)&lt;0.0001Stage  0.17172 (46)128 (40) 269 (44)146 (45) 315 (10)49 (15) Chemo  0.41Yes112 (73)247 (77) No41 (27)75 (23) Radiation  0.96Yes98 (64)205 (64) No56 (36)116 (36) Partnered  &lt;0.0001Yes106 (69)272 (84) No48 (31)50 (16) Children pre-diagnosis  &lt;0.0001094 (64)73 (23) 131 (21)43 (14) &gt; 2 children22 (15)197 (63) Pre-treatment fertility discussion  0.0003Yes127 (88)225 (73) No17 (12)84 (27) 

Citation Format: Poorvu PD, Ruddy KJ, Gelber SI, Tamimi RM, Peppercorn J, Schapira L, Borges VF, Come SE, Partridge AH, Rosenberg SM. Fertility concerns and their impact on hormonal therapy decisions in young breast cancer survivors [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-12-06.

Abstract PD8-06: Attitudes towards use of archived biospecimens among patients with cancer

Background: Oncology research increasingly involves biospecimen collection and data-sharing. Ethical questions have emerged when researchers seek to use archived biospecimens for purposes that were not well defined in the original informed consent document (ICD). We sought to inform ongoing debates by assessing patient views on these issues.

Methods: We administered a cross-sectional self administered anonymous paper survey among patients at the Massachusetts General Hospital Cancer Center. Survey questions addressed attitudes towards cancer research and willingness to donate biospecimens, expectations regarding use of biospecimens and protections of research participants, and preferences regarding specific ethical dilemmas regarding use of archived biospecimens. Results are descriptive with comparisons among participants on the sociodemographic and clinical characteristics using chi-square and Fisher's exact tests.

Results: 187 patients offered participation agreed and returned the survey (Response rate 66%). Mean age was 59 (range 2 to 91), 81% were women, 86% were white, and 81% were college educated. Among all participants, 67% had breast cancer and 33% metastatic disease. 34% had participated in a clinical trial, 27% had donated tissue for research and 93% indicated willingness to donate tissue for research. The vast majority of participants (94%) expected both that donated tissue would be used to help as many patients as possible and (92%) that privacy of a donors health information would be carefully protected. 33% expected that donated tissue would only be used for research they specifically approved and 44% that data would not be shared with other researchers. We presented 3 hypothetical scenarios in which researchers sought to use stored biospecimens from a breast cancer clinical trial for future research that was not described in the original iICD. For scenario 1, in which the ICD stated tissue would only be used for breast cancer research, 75% supported use of tissue to study other cancers as well. For scenario 2, in which the ICD specified somatic genetic research only, 89% supported use of tissue for germline research if deemed important by investigators. For scenario 3, in which the ICD stated that data would not be shared beyond the investigators, 72% supported data sharing within a national data repository. Only 28% of participants endorsed concerns that a patient could be identified from their genetic information and 12% were concerned with potential harms from donation to biobanks. However, 38% felt that they owned their tissue and should control how it is used. We did not detect significant differences in responses on the basis of sociodemographic characteristics, cancer type, disease stage, or research experience.

Conclusion: Patients with cancer are highly supportive of tissue donation for research and expect that donated tissue will be used to to maximize scientific results. They also expect that interests of research participants will be protected. When there is uncertainly regarding the use of archived biospecimens based on historical ICD and inability to recontact research participants, the interest of participants in seeing productive use of their tissue for science should be considered.

Citation Format: Peppercorn J, Campbell E, Rabin J, Quain K, Hlubocky F, Colyar D, Sequist L, Bardia A, Horick N, Isakoff S, Mathews D. Attitudes towards use of archived biospecimens among patients with cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD8-06.

Abstract P6-12-08: Fertility interest, management and outcomes in young BRCA+ breast cancer survivors

Background: Young women with BRCA mutations may face fertility issues given the standard recommendation for risk-reducing oophorectomy after childbearing has been completed or before age 40. Potential transmission of the affected gene to future progeny may also be a concern. Little is known regarding the perspectives, management, and outcomes of young breast cancer survivors with BRCA mutations, who also face risks of recurrent disease and treatment effects on fertility.

Methods: As part of a multi-center, prospective cohort study of newly diagnosed breast cancer (BC) at age ≤40 years enrolling between 2006-2016, we identified women with stage I-III BC who had self-reported results of genetic testing. Participants are surveyed at baseline then annually regarding their breast cancer treatment, genetic testing, fertility interest, pregnancy attempts, and pregnancies. Chi-square tests were used to compare proportions of carriers vs non-carriers who were interested in future biologic children, took steps to preserve fertility, underwent bilateral oophorectomy, attempted pregnancy, and became pregnant in the 5 years following diagnosis.

Results: Carriers (n=104) and non-carriers (n=662) were similar in age and stage, but greater proportions of carriers had ER negative disease and received chemotherapy (Table 1). The proportion of carriers and non-carriers interested in future biologic children was similar prior to diagnosis (51% vs 38%; p=0.18), 1 year following diagnosis (30% vs 27%; p=0.44), and 5 years following diagnosis (14% vs 15%; p=0.26). Similar proportions of carriers (12%) and non-carriers (14%) took steps to prevent infertility prior to treatment. Greater proportions of carriers indicated that concern about having a child at higher risk of breast cancer affected their interest in future biologic children (15% vs 4%, p=0.02) and underwent bilateral oophorectomy (61% vs 9%, p&lt;0.0001), but there was no difference in rates of pregnancy attempts (15% vs 11%, p=0.62), or pregnancies (12% vs 8%, p=0.36) in the five years following diagnosis.

Conclusion: Young breast cancer survivors with known BRCA mutations have similar interest in future fertility and both attempt and become pregnant at similar rates to non-carriers in the five years following diagnosis. Impact of specific BRCA mutation (1 or 2), ER status of tumor, and timing of pregnancy attempts will be explored in future analyses.

Table 1: BRCA mutation carriers, n (%)Non-carriers, n (%)X2 p-valueAge  0.47&lt;3018 (17)86 (13) 31-3529 (28)201 (30) 36-4057 (55)375 (57) Stage  0.73I40 (39)260 (39) II46 (44)307 (46) III18 (17)95 (14) Partnered  0.44Yes77 (74)509 (77) No27 (26)148 (22) Missing0 (0)5 (1) Children pre-diagnosis  0.33Yes62 (60)427 (64) No42 (40)235 (36) Phenotype  &lt;0.0001ER and/or PR+48 (46)490 (74) ER and PR-56 (54)171 (26) Missing0 (0)1 (0) Adjuvant hormones  &lt;0.0001Yes44 (42)488 (74) No60 (58)174 (26) Chemotherapy  0.003Yes96 (92)529 (80) No8 (8)132 (2) Missing0 (0)1 (0) 

Citation Format: Poorvu PD, Gelber SI, Ruddy KJ, Seiger K, Tamimi RM, Peppercorn J, Schapira L, Borges VF, Come SE, Partridge AH, Rosenberg SM. Fertility interest, management and outcomes in young BRCA+ breast cancer survivors [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-08.

The impact of sleep disturbances (SD) on quality of life, psychological morbidity, and survival of advanced cancer patients (ACP) and caregivers (CG)

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Background: SD have been described as a significant symptom burden for cancer patients and their caregivers. However, in advanced cancer, the prevalence of SD and its impact on the quality of life (QOL) and psychological morbidity of ACP over time has not been described. Methods: A prospective cohort of ACP participating in phase I trials was assessed at baseline (T1) and one month (T2) using psychosocial instruments: cognition (MMSE); depression(CES-D), state anxiety (STAI-S), QOL(FACIT-Pal), global health (SF-36). Semi-structured interviews evaluated SD patterns including: quality/latency, habitual efficiency, daytime dysfunction. Results: To date,152 subjects (76 ACP and 76 CG) have been separately interviewed at T1 and T2. For the total population: median age 61 (28-78y); 51% male; 100% married; 90% Ca; 64% > HS educ; 52% GI dx; 51% income < $65,000 yr; ACP median survival 7.9 months (0.41-18.2). At T1, 57% of ACP reported experiencing SD within the past week including: 55.6% insomnia, 44% nonrestorative sleep, 49% low energy, 48% daytime somnolence. For CG, 72% reported experiencing SD: 68% insomnia, 64% nonrestorative sleep, 69% fatigue, 66% daytime somnolence. At T2, rates remained consistent over time for both ACP and CG across time with the exception of increased insomnia at 61% and 76% respectively. After controlling for pain, mood, and fatigue, ACP with self-reported SD had higher STAI-S (33 ±11 v 29 ±8 , p = 0.02) and poor global health (54 ± 19 v. 64 ± 21, p = 0.01) at T2. CG with SD had higher STAI-S anxiety (39 ± 17 v 35 ± 13, p = 0.03) and poor global health (75 ±26 v 88±16, p = .0002) at T2.Regression analyses revealed ACP with self-reported insomnia had poorer FACIT-Pal QOL (59 ± 9 v 63 ± 10, p = 0.01) over time. Prior chemotherapy was associated with ACP SD (70% v. 33%, p = 0.02). Regarding prognosis, ACP with insomnia had shorter median survival (5.5 v. 7.2 months, p = 0.01). Conclusions: SD are prevalent among ACP participating in clinical trials and were associated with disease progression, QOL, and anxiety. Multidisciplinary supportive care interventions designed to address SD are warranted.

Abstract S4-03: Exome sequencing reveals clinically actionable mutations in the pathogenesis and metastasis of triple negative breast cancer

Triple negative breast cancer (TNBC) represents a particularly aggressive and difficult to treat form of breast cancer. No specific genetic alterations have been described as characteristic of the disease, with the exception of association with BRCA1/2, EGFR, and KRAS mutations. In this study, we sought to define clinically actionable mutations in untreated metastatic tumors as well as compare the mutational status of metastatic samples with germ-line and primary tumors using whole exome sequencing.

We prospectively enrolled 38 patients with newly diagnosed metastatic TNBC and collected matched specimens of germ-line DNA, primary tumor and metastatic tumor. Median DFI from time of initial primary diagnosis to recurrence was 18 months (IQR = 1-24 months) and 9 patients presented with de novo metastatic disease. 34/38 patients went on to receive first-line treatment with nab-paclitaxel, carboplatin, and bevacizumab and ORR/PFS/OS are available.

Sites of TNBC metastatic tissue (n = 31) included: liver (10), chest wall (13), non-regional lymph nodes (4), and lung (4). 7 patients had inadequate metastatic tumor for sequencing. We performed whole-exome sequencing for all samples using the Agilent solution-based system of exon capture, which uses RNA baits to target all protein coding genes (CCDS database), as well as ∼700 human miRNAs from miRBase (v13). In all, we generated over 10 GB of sequencing data using high throughput sequencing on the Illumina platform.

We observed striking genetic heterogeneity among the metastatic and primary tumors. There was no single driver mutation that was common to the metastatic tumors indicating the diverse genetic pathways that contribute to metastasis. Early analysis suggests that mutations in APC and MTOR occur more frequently in metastatic tumors than in primary tumors. Nonsense mutations of ER were detected in both primary and metastatic tumors but not in germ-line DNA. EGFR and HER2 mutations were not found in any of the primary or metastatic TNBC samples.

This data provides the most comprehensive genetic portrait of metastatic and primary TNBC to date, and represents a significant first step in identifying the genetic causes of the disease, drivers of recurrence, and potential therapeutic targets. Full results, including the primary versus metastatic tumor mutational analysis will be presented.

This study was funded by a Susan G. Komen Grant SAC 100001.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S4-03.

Abstract P4-19-01: Attitudes of medical oncologists towards research biopsies

Background:

There is increasing interest in studying tissue from patients (pts) with metastatic breast cancer (MBC). Historically, limited tissue has been available. Possible barriers to research biopsies (bx) include pt and provider opinions; the contribution of each factor is unknown.

Methods:

309 academic breast medical oncologists (MOs) identified from the websites of each of the National Cancer Institute - designated cancer centers were invited to complete either a self-administered paper or online survey. Eligible MOs (MOs who saw breast cancer pts and who saw pts 4 hours/week.) were asked to predict what proportion of their pts with MBC would consent to additional bx (ABs, additional bx performed with a clinically indicated bx) or research purposes only bx(RPOBs, research bx performed as a standalone procedure). They were also asked about their comfort levels in asking pts with MBC to consider participating in ABs or RPOBs for various organs. Median values are reported. Two-sided Fisher's exact test was used to compare categorical variables using a a level of .05.

Results:

191 (101F,85M, 5 unknown) eligible MOs completed the survey. 29 MOs were ineligible (response rate = 191/280,68%). Median age was 50 (Range 33-80). Median years of oncology experience was 15 (Range 1-45). MOs predicted that 90%, 75%, 70% and 50%, of their pts would definitely/probably consider ABs of blood, skin, breast, or liver respectively. MOs predicted that 90%, 60%, 33%, and 20% of their pts would definitely/probably consider RPOBs of blood, skin, breast, or liver. 98% (95% CI 96%-100%), 96% (95% CI 92%-98%), 93% (95% CI 88%-96%) and 70% (95% CI 63%-77%) of MOs were very/somewhat comfortable asking pts for an AB of blood, skin, breast and liver respectively. 98% (95% CI 95%-99%), 93% (95% CI 89%-96%), 78% (95% CI 72%-84%) and 50% (95% CI 43%-58%) of MOs were very/somewhat comfortable asking pts to participate in a RPOB of blood, skin, breast and liver respectively.

No demographic characteristics (eg. sex, age) were associated with MOs’ comfort levels of asking pts to have an AB of blood, skin and breast.

Factors associated with increased comfort discussing an AB of the liver were: age &lt; 50 years (p = 0.01), in practice for &lt; 15 years (p = 0.01), ≥ 1 pt enrolled on clinical trials per month (p = 0.02), or having pts who had undergone bx for research in prior 3 months (p&lt;0.01).

MOs with ≥ 4 patients enrolled on clinical trials/month or whose pts had undergone research bx in the past 3 months were more likely to feel comfortable asking pts to have a RPOB of the breast (p&lt;0.01; p&lt;0.01) or liver (p = 0.03; p&lt;0.01).

The 3 most common reasons why MOs were reluctant to refer pts for participation in an AB include risk of a bx procedure (n = 128, 67%), pain/discomfort of a bx (n = 125, 65%), and logistical barriers (n = 42, 22%). These reasons are similar for RPOB; risk of a bx procedure, (n = 137, 72%), pain/discomfort of a bx (n = 134, 70%), and inconvenience to pt (time involved, travel, etc) (n = 58, 30%).

Conclusions:

Many MOs predict that the majority of their MBC pts will consider ABs of various organs. However, this decreases with RPOBs, particularly as the procedure becomes more invasive. More research is needed to understand factors that may influence MOs’ comfort levels asking pts to participate in such studies.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-19-01.

Attitudes of patients with metastatic breast cancer toward research biopsies

BACKGROUND

Research studies involving human tissue are increasingly common. However, patients' attitudes toward research biopsies are not well characterized, particularly when the biopsies are carried out outside the context of therapeutic trials.

PATIENTS AND METHODS

One hundred sixty patients with metastatic breast cancer (MBC) from two academic (n = 80) and two community (n = 80) hospitals completed a 29-item self-administered survey to evaluate their willingness to consider providing research purposes only biopsies (RPOBs) (as a stand-alone procedure) and additional biopsies (ABs) (additional needle passes at the time of a clinically indicated biopsy).

RESULTS

Eighty-two (51%) of 160 patients would consider having RPOBs, of which 42 (53%) and 40 (50%) patients were from academic and community hospitals, respectively. Patients who had more prior biopsies were less likely to consider RPOBs (RR = 0.6, 95% CI: 0.4-1.0, P = 0.03). Of 160 patients, 115 (72%) patients would consider having ABs. Of these, 64 (80%) and 51 (64%) patients from academic and community hospitals, respectively, would consider ABs (RR = 1.2, 95% CI: 1.0-1.5, P = 0.03).

CONCLUSIONS

Many patients with MBC in both academic and community settings report willingness to consider undergoing biopsies for research. Further research is needed to understand ethical, logistical and provider-based barriers to broader participation in such studies.

P1-11-07: Impact of Reduction in Cost-Sharing on Screening Mammography Utilization among Rural U.S. Women

Background: Early detection of breast cancer through mammography screening leads to earlier stage at diagnosis and improved survival. For reasons that are poorly understood, in recent years the rate of screening has demonstrated periods of decline, and screening has proved to be less common in rural compared to urban areas of the U.S. In 2006, the National Rural Electric Cooperative Association (NRECA) which provides health care to over 100,000 electrical workers and their families in primarily rural areas of the U.S. eliminated copayments for screening mammography in an effort to boost screening rates. We conducted a population based analysis of screening utilization to determine the impact of this policy initiative. Methods: Using the NRECA insurance database, all women aged 40 to 64 with no prior history of breast cancer or DCIS (based on ICD-9 codes) were identified and we evaluated claims data on annual screening mammography utilization (SMU) between 1999 and 2009 stratified by age group in 5 year intervals. Changes in SMU over time were assessed focusing on the periods before and after the policy change in January 2006. We also evaluated diagnosis of breast cancer and receipt of mastectomy and chemotherapy as a potential proxy for more advanced disease at diagnosis. Descriptive statistics were estimated and the mammography rate was fitted on years using the identity link (proc genmod in SAS). In order to test the impact of the 2006 change in cost-sharing on the trend in mammography rate, we introduced change point terms in slope and intercept to the linear model. Chi-squared test for 2×2 tables was used to compare SMU rates between two consecutive years for each age group. All p-values are two-sided.

Results: During this period, a mean of 20,825 women aged 40 to 64 each year received health insurance through NRECA. SMU increased from 38.1% in 1999 to 49.5% in 2009. Analyzing SMU before and after the change in cost sharing policy demonstrates a significant change in the rate of screening at the 2006 intercept (p = 0.0275) although the slope of year to year change in screening rate did not change. In stratified analysis there was a significant change in SMU between 2005 and 2006 for all age groups. In the 4 years prior to the NRECA change in policy, 554 women were diagnosed with breast cancer and 40 underwent mastectomy and chemotherapy. In comparison, from 2006 to 2009, only 20 women out of 540 with newly diagnosed breast cancer underwent such therapy (7.2% prior to policy change vs. 3.7% following, P = 0.01).

Conclusion: The impact of health plan benefits changes can be evaluated among a primarily rural population of women aged 40 to 64 using the novel NRECA database. Annual SMU remained low, but improved following elimination in copayments suggesting that financial barriers impact screening. Multiple factors may explain changes in SMU and treatment intensity over time. However, cost-sharing for high value health care services may have unintended negative consequences. Further evaluation of this database is planned to evaluate biannual screening rates, correlation with sociodemographic factors, impact of recent controversy over screening guidelines and additional barriers to screening utilization in this rural population.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-07.

Patients' Understanding of a CYP2D6 Tamoxifen Genotyping Study

Background: Pharmacogenomics is an emerging area for breast cancer research. Little is known about how well patients understand pharmacogenomics or the rationale for research in this area. The objective of this study was to analyze patient understanding of a clinical trial involving CYP2D6 genotyping to guide tamoxifen (T) therapy for breast cancer.Methods: We conducted a survey of understanding of pharmacogenomics and the purposes of a clinical trial among patients (pts) eligible for LCCC0801, a prospective Phase 2 study of CYP2D6 genotype-guided therapy for pts on tamoxifen for breast cancer. In this trial, we evaluated baseline endoxifen (E) levels and the impact of increased T dose to 40 mg/day among pts with any dysfunctional CYP2D6 alleles. The primary endpoint of change in E levels is not yet reported. All trial participants and those who declined participation were eligible for this survey. The research nurse administered 11 written questions at time of consent related to the purpose of this study and the nature of pharmacogenomic research. Pts had unlimited time to complete the survey written in a 5 point scale (strongly agree, agree, not sure, disagree, strongly disagree). For pts declining to enroll in the parent study, we offered an identical companion survey to which they could separately give consent.Results: Of 118 pts in the parent study, 117 completed the survey. Following informed consent, all respondents expressed confidence that they understood the purpose of the trial, 75% strongly agreed that they understood the purpose of the study. 98% of participants understood that this was a study of how different people respond to T, but 42% also incorrectly felt that this was a study of how different types of breast cancer respond to T, and 30% incorrectly felt that this study evaluated genetic risk for developing breast cancer. Though the consent form clearly stated that there may be no direct benefit to participants and that the purpose of the study was to help future pts, 68% reported that they would benefit directly, and only 22% felt the study was designed only to help future pts. When asked if the study involved genetics, 14% of pts disagreed, or were unsure. 45% of participants were uncomfortable or unsure with “having your doctor determine your T dose from the results of a genetic test.” Among a small sample of pts who declined trial participation but consented to the survey (13/30 decliners, 43%), compared to trial participants, fewer reported strong confidence in understanding the purpose of the trial (38% vs. 75%, p=0.0034), and a greater percentage identified an inaccurate purpose of the trial (69% vs. 42%, p = 0.043).Conclusions: After informed consent, a high percentage of participants in a pharmacogenomic clinical trial are able to correctly identify the primary purpose of the research, but a substantial minority hold false views about what the trial is designed to investigate. The majority of participants believe that they will directly benefit from trial participation, and few may understand that the primary purpose of the study is to improve care for future patients. Opportunities exist for improved understanding and communication of pharmacogenomic research and further evaluation of this area is needed.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6082.

Practice and Attitudes towards CYP2D6 Testing for Patients on Tamoxifen among US Oncologists

Background: CYP2D6 genotype has been associated with breast cancer outcomes for patients on Tamoxifen (TAM) and testing is commercially available. In the context of emerging data regarding the clinical relevance of CYP2D6 testing (CYPT) and uncertainty regarding how test results should be used in practice, we evaluated current practice and attitudes with regard to this novel pharmacogenomic test among U.S. oncologists.Methods: A survey was mailed to all breast cancer oncologists identified at National Comprehensive Cancer Network (NCCNO) centers and a random sample of community based oncologists (CBO) identified from the American Society of Clinical Oncology directory. The survey evaluated knowledge of the CYP2D test, use of the test, requests for the test by patients and third parties, and response to hypothetical test results. Associations between practice setting and CYP2D6 knowledge, CYPT, and practice patterns were evaluated. All statistical tests were two-sided.Results: 201 of 459 (44%) oncologists responded, including 97/173 (56%) of NCCNO and 104/286 (36%) of CBO. While 90% of all oncologists were aware of CYPT, only 31% had ever ordered CYPT, and only 14% used CYPT for ≥ 10% of patients on TAM. 22% had received a request for CYPT from a 3rd party. While NCCNO were more likely to be aware of CYPT (98% vs. 82%, p &lt; 0.001), and to receive requests for CYPT (33% vs. 12%, p &lt; 0.001), CBO reported higher frequency of CYPT in routine practice (21% vs. 11%, p = 0.06). Despite rare use, 66% of CBO and 44% of NCCNO reported they would order the test upon patient request (p &lt; 0.001). In hypothetical scenarios involving CYPT for patients on TAM, for premenopausal women with poor metabolism, 33% would make no change, while 38% would switch to ovarian suppression (OS) plus aromatase inhibitor (AI), 9% would switch to OS alone, and 8% would add OS to TAM. CBO were more likely to switch to OS + AI in this setting (47% vs. 31%, p &lt; 0.02), while NCCNO were more likely to recommend no change (50% vs. 18%, p &lt; 0.001). For premenopausal intermediate metabolizers, 33% of CBO would change management, compared to 8% of NCCN (p &lt; 0.001), with addition of OS to TAM being most frequent among both groups. For postmenopausal women with poor metabolism the majority of both CBO and NCCNO would switch to AI (82% vs. 71%, p = 0.08). Among oncologists who indicated they might change management based on CYPT results, 43% had never ordered the test. Respondents cited data from randomized trials, and professional guidelines as most influential for decisions regarding ordering tests.Conclusion: Despite calls for increased CYP2D6 testing at academic meetings and occasional requests by 3rd parties, use of CYPT is currently infrequent in oncology practice. Greater familiarity with breast cancer management correlated with lower use of CYPT and greater reluctance to change management based on test results at this time. Diversity in practice patterns and knowledge suggests a need for greater consensus on CYPT in routine practice, and highlights the need for further clinical research in this area.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1077.

Availability of experimental therapy outside of randomized clinical trials in oncology

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Background: Investigational cancer therapies may be available outside of trials, or “off protocol” (OPRx), with implications for patient safety, trial accrual, and access to care. Previous studies suggest OPRx is prevalent in oncology, but there is little consensus on when it should or should not be considered. We evaluated the scope and impact of OPRx through assessment of availability of the experimental arms of recent randomized trials (RCT), and evaluation of study outcomes and accrual. Methods: We conducted a Medline search to identify all English language phase III RCT of medical interventions in oncology over a 2-year period ending April 17, 2008. We determined availability of experimental interventions based on FDA approval for any indication. We limited assessment of accrual (time to trial completion, patients/month) to studies with US sites. Significance of results was assessed by Fisher's exact test and unpaired t-test. Results: We identified 172 eligible RCT. The majority of RCT (108, 63%) evaluated drugs that were available OPRx at trial initiation, while an additional 19 (11%) trial drugs became available during the trial. 64 (55%) were available due to FDA approval for the same cancer in a different setting, 40 (35%) for a different cancer, and 12 (10%) for a non-cancer indication. 25% of trials were conducted at only US sites, 15% included US and international sites, and 60% were international only. Trials in which OPRx was available had slower time to completion compared to trials in which OPRx was unavailable (48 vs. 26 months, p = 0.04) and a trend towards slower accrual (14.0 vs. 40.7 patients/month, p = 0.06). For the majority of RCT (66%), there was at least one grade 3/4 toxicity that was greater in the experimental arm, for 47% the experimental interventions proved superior for 1 major outcome, and 27% demonstrated improvement in overall survival. These outcomes did not vary based on availability OPRx. Conclusions: The majority of recent oncology trials involve experimental regimens that are available outside of a trial. The safety and efficacy of novel interventions must be determined by trials but availability of OPRX may impact accrual. Guidelines are needed for OPRx in oncology.

No significant financial relationships to disclose.

Comprehensive CYP2D6 genotyping in a multiracial U.S. breast cancer population

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Background: CYP2D6 genotyping has been suggested to avoid suboptimal responses to tamoxifen (T). Most studies to date are in white patients (pts) and focus on a limited number of genetic variants. In this clinical trial, we comprehensively examined CYP2D6 allele frequencies in women of heterogenous ethnicity taking tamoxifen (T). Methods: In LCCC 0801, pts on T ≥ 4 months and not on potent CYP2D6 inhibiting medications were genotyped using the CYP450 AmpliChip for 2D6 alleles: *1-*11, *15, *17, *19, *20, *29, *35, *36, *40, *41, *1XN, *2XN, *4XN, *10XN, *17XN, *35XN and *41XN. T dose was increased in pts with any intermediate or poor metabolizing (IM or PM) alleles [but not in pts homozygous for extensive metabolizing (EM) alleles]. Serial T metabolite levels are being assessed. Here we report the allele frequency data from this study compared to previously published cohorts. Results: 108 pts participated in the study: 24 (22%) African-Americans (AA), 76 (70%) non-Hispanic whites, 4 Asians, 3 Hispanics and 1 Spanish European. Genotyping revealed 28 (26%) EM/EM, 1 EM/UM (ultra-rapid), 29 (27%) EM/IM, 22 (20%) EM/PM, 8 (7%) IM/IM, 10 (9%) IM/PM, 9 (8%) PM/PM and 1 unknown. Conclusions: Pts in this trial had a similar frequency of PM alleles to previous reports, however a high proportion of pts have IM alleles. In particular, the majority (79%) of AA pts possess at least one variant allele. Since PM and IM genotypes have been associated with reduced T metabolism, this may have implications for T efficacy and emphasizes the importance of trials examining CYP2D6 genotyping as a determinant of T use. (Supported by Laboratory Corporation of America, Roche Diagnostics, NC UCRF, NCI SPORE.)

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Dose-dense nab-paclitaxel (nanoparticle albumin-bound paclitaxel) in adjuvant chemotherapy for breast cancer: A feasibility study

594

Background: We sought to evaluate the feasibility of substituting nab-paclitaxel (ABI-007) for paclitaxel as part of “dose-dense” adjuvant sequential doxorubicin / cyclophosphamide (AC) followed by taxane chemotherapy. Patients and Methods: Eligible patients had stage I-III breast cancer receiving adjuvant/neoadjuvant chemotherapy, ANC > 1500, and LVEF > 50%. Patients received AC (60 mg/m2 and 600 mg/m2) every 2 weeks × 4 cycles with G-CSF support, followed by nab- paclitaxel 260 mg/m2 every 2 weeks × 4 cycles. The endpoint was incidence of treatment delay during nab-paclitaxel therapy. Results: 66 women (median age 48 years) were enrolled. Among the first 11 given nab-paclitaxel without G-CSF support, one developed febrile neutropenia, and 4 had nab-paclitaxel treatment delays related to neutropenia (ANC < 1,000). The protocol was amended to require G-CSF support (filgrastim or pegfilgrastim) during nab-paclitaxel. Among the next 55 patients, 3 had febrile neutropenia, none during nab- paclitaxel. In cycles 6–8, nab-paclitaxel was delayed only 6 times (1 neutropenia, 3 hepatic toxicity, 2 patient scheduling); 96% of these cycles were delivered on time. By comparison, 82% of such cycles were delivered on time in a prior institutional study using paclitaxel. In the full cohort, 8 patients had nab-paclitaxel dose reduction, 4 for neuropathy, while other neuropathy was moderate (grade 2, n = 6; grade 3, n=1; grade 4, n=0). Conclusions: Administration of nab-paclitaxel every 2 weeks is feasible but requires G-CSF support. Data comparing nab-paclitaxel dose-delivery, toxicities and quality of life to paclitaxel as seen in prior studies will be presented.

No significant financial relationships to disclose.

A post-treatment individualized prescriptive exercise and recreation therapy intervention for breast cancer patients

19637

Background: The number of breast cancer survivors is increasing due to early detection and advancements in treatment leading to increased concern with long term side effects and quality of life after therapy for early stage breast cancer. The Get REAL & HEEL Breast Cancer Program addresses the physiological and psychological declines experienced by breast cancer survivors post-treatment through combined exercise (EX) and recreation therapy (RT) to strengthen the body and mind of survivors and improve overall QOL. Methods: Women with early stage breast cancer within 6 months from completion of initial therapy were recruited to participate in a combined EX and RT intervention. The EX consisted of cardiovascular endurance (VO2 Max), muscular endurance (ME) and flexibility (FL) training. The RT included activities such as leisure counseling, bio-feedback, heart-math, crafts, and a ropes course. Each participant engaged in an individually prescribed intervention for 8 weeks, 3 times per week, for approximately 1.5 hour per therapy session. A battery of fitness and psychological assessments including, VO2 Max, body composition (BC), ME, FL, fatigue (F), depression (D), QOL were used to assess baseline parameters and outcomes. Descriptive statistics presenting the results of baseline and final assessments were used to evaluate program outcomes. Results: Fifteen subjects, age 30 to 75, volunteered for the program. At initial analysis, clinically relevant changes in physiological and psychological parameters were observed. Improvements in VO2 Max, BC, and ME were observed for all subjects. Positive changes in psychological parameters were also observed in all of subjects including decreased F and D accompanied by increased QOL. Conclusions: The results of this pilot program are promising and suggest that further evaluation of this novel combination of EX and RT to improve physical and emotional functioning, and overall QOL after breast cancer treatment are warranted.

No significant financial relationships to disclose.

Use of experimental therapy outside of clinical trials among U.S. oncologists

6047

Background: Investigational cancer therapies being tested in clinical trials may be available outside of trials, or “off-protocol” (OPRx). There are no published data on either the frequency of OPRx or the attitudes of physicians towards OPRx. Methods: In spring 2005, we surveyed a random sample of American medical oncologists chosen from the ASCO directory regarding their attitudes and practices surrounding OPRx. We evaluated the correlation between demographic factors, attitudes, use of OPRx, and response to hypothetical cases. All statistical tests were two-sided. Results: 146 of 471 (31%) oncologists responded. 93% reported ever discussing OPRx and 81% ever prescribing OPRx. 66% reported prescribing OPRx ≥ once/year and 12% ≥ once/month. 68% reported denying requests for OPRx ≥ once/year and 6% ≥ once/month. Academic oncologists were simultaneously more likely than community oncologists to have ever provided OPRx (89% v. 75%, p = 0.06 by Fisher’s exact test), to discuss OPRx ≥ 1 month (45% v. 12%, p = .003), and to deny requests for OPRx ≥ 1 month (15% v. 2%, p = 0.02). While 61% of oncologists believe that patients should be discouraged from OPRx, only 31% felt it should not be available. 53% felt that patients considering trial enrollment should be informed if OPRx is available, whereas 34% disagreed. 26% felt that patients considering enrollment have a right to OPRx, whereas 56% disagreed. Neither practice setting nor other demographic factors predicted attitudes towards OPRx. For hypothetical cases, there was little consensus regarding when to prescribe OPRx. For example, prior to the release of data from recent trials, 41% reported that they would prescribe adjuvant trastuzumab OPRx at a patient’s request. Factors correlating with willingness to provide OPRx included non-academic practice setting (p = 0.04), > 15 years in practice (p = 0.08), belief that non-trial care and trial care are equivalent (p = 0.01) and belief that patients have a right to OPRx (p = 0.004). Conclusion: American oncologists commonly discuss and provide OPRx. Attitudes towards and utilization of OPRx vary substantially in the oncology community. Further discussion of OPRx and guideline development appear warranted.

No significant financial relationships to disclose.

Search for the genes responsible for familial Alzheimer's disease

Inherited or Familial Alzheimer's Disease (FAD) has clearly been shown to be a genetically heterogeneous disorder. Mutations in the gene on chromosome 21 encoding the beta-amyloid protein precursor (APP) have been shown to be linked to 2-3% of FAD kindreds examined around the world. A late onset FAD locus has been mapped to a region of chromosome 19 in which a recently isolated APP-like gene, APLP1 has also been localized, making this gene a strong candidate to harbor a late-onset FAD defect. More recently, a major FAD locus has been mapped to the long arm of chromosome 14. The chromosome 14 locus appears to be mainly linked to the gene defect in early onset FAD pedigrees. Besides the FAD loci on chromosome 21, 19, and 14, at least two other loci must exist since the gene defect in some early- and late-onset FAD pedigrees do not appear to segregate with markers from any of these autosomes. As different gene defects responsible for various forms of FAD are discovered, perhaps, a common basis for the etiology of this devastating disorder can be discerned.

Genetic heterogeneity of gene defects responsible for familial Alzheimer disease

Inherited Alzheimer's disease is a genetically heterogeneous disorder that involves gene defects on at least five chromosomal loci. Three of these loci have been found by genetic linkage studies to reside on chromosomes 21, 19, and 14. On chromosomes 21, the gene encoding the precursor protein of Alzheimer-associated amyloid (APP) has been shown to contain several mutations in exons 16 and 17 which account for roughly 2-3% of familial Alzheimer's disease (FAD). The other loci include what appears to be a susceptibility gene on chromosome 19 associated with late-onset (> 65 years) FAD, and a major early-onset FAD gene defect on the long arm of chromosome 14. In other early- and late-onset FAD kindreds, the gene defects involved do not appear to be linked to any of these three loci, indicating the existence of additional and as of yet unlocalized FAD genes. This review provides a historical perspective of the search for FAD gene defects and summarizes the progress made in world-wide attempts to isolate and characterize the genes responsible for this disorder.