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Laughlin AI, Cao Q, Bryson R, Haughey V, Abdul-Salaam R, Gonzenbach V, Rudraraju M, Eydman I, Tweed CM, Fala GJ, Patel K, Fox KR, Hanson CW, Bekelman JE, Shou H. Detection of Medication Taking Using a Wrist-Worn Commercially Available Wearable Device. JCO Clin Cancer Inform 2023; 7:e2200107. [PMID: 38127730 DOI: 10.1200/cci.22.00107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 07/17/2023] [Accepted: 10/31/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE Medication nonadherence is a persistent and costly problem across health care. Measures of medication adherence are ineffective. Methods such as self-report, prescription claims data, or smart pill bottles have been used to monitor medication adherence, but these are subject to recall bias, lack real-time feedback, and are often expensive. METHODS We proposed a method for monitoring medication adherence using a commercially available wearable device. Passively collected motion data were analyzed on the basis of the Movelet algorithm, a dictionary learning framework that builds person-specific chapters of movements from short frames of elemental activities within the movements. We adapted and extended the Movelet method to construct a within-patient prediction model that identifies medication-taking behaviors. RESULTS Using 15 activity features recorded from wrist-worn wearable devices of 10 patients with breast cancer on endocrine therapy, we demonstrated that medication-taking behavior can be predicted in a controlled clinical environment with a median accuracy of 85%. CONCLUSION These results in a patient-specific population are exemplar of the potential to measure real-time medication adherence using a wrist-worn commercially available wearable device.
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Affiliation(s)
- Amy I Laughlin
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Orlando Health Cancer Institute, Orlando Health, Orlando, FL
| | - Quy Cao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Virgilio Gonzenbach
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Igor Eydman
- Information Services, Penn Medicine, Philadelphia, PA
| | - Christopher M Tweed
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Glenn J Fala
- Information Services, Penn Medicine, Philadelphia, PA
| | - Kash Patel
- Hackensack Meridian Health, Princeton, NJ
| | - Kevin R Fox
- Perelman School of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - C William Hanson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Justin E Bekelman
- Perelman School of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Haochang Shou
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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2
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Makhlin I, McAndrew NP, Wileyto EP, Clark AS, Holmes R, Bottalico LN, Mesaros C, Blair IA, Jeschke GR, Fox KR, Domchek SM, Matro JM, Bradbury AR, Feldman MD, Hexner EO, Bromberg JF, DeMichele A. Ruxolitinib and exemestane for estrogen receptor positive, aromatase inhibitor resistant advanced breast cancer. NPJ Breast Cancer 2022; 8:122. [PMID: 36369506 PMCID: PMC9652412 DOI: 10.1038/s41523-022-00487-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022] Open
Abstract
Circulating IL-6, an activator of JAK/STAT signaling, is associated with poor prognosis and aromatase inhibitor (AI) resistance in hormone-receptor positive (HR+) breast cancer. Here we report the results of a phase 2 single-arm Simon 2-stage trial combining Ruxolitinib, an oral selective inhibitor of JAK1/2, with exemestane, a steroidal AI, in patients with HR+ metastatic breast cancer (MBC) after progression on non-steroidal AI (NSAI). Safety and efficacy were primary objectives, and analysis of inflammatory markers as predictors of response was a key secondary objective. Twenty-five subjects enrolled. The combination of ruxolitinib and exemestane was safe, though anemia requiring transfusion in 5/15 (33%) at the 25 mg dose in stage 1 led to a reduction to 15 mg twice daily in stage 2 (with no additional transfusions). Clinical benefit rate (CBR) in the overall study population was 24% (95% CI 9.4-45.1); 6/25 patients demonstrated stable disease for ≥6 months. Median progression-free survival was 2.8 months (95% CI 2.6-3.9). Exploratory biomarkers revealed high levels of systemic inflammation and 60% harbored a high-risk IL-6 genotype. Pharmacodynamics demonstrated modest on-target inhibition of phosphorylated-STAT3 by ruxolitinib at a tolerable dose. Thus, ruxolitinib combined with exemestane at a tolerable dose was safe but minimally active in AI-resistant tumors of patients with high levels of systemic inflammation. These findings highlight the need for more potent and specific therapies targeting inflammation in MBC.
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Affiliation(s)
- Igor Makhlin
- Division of Hematology/Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Nicholas P McAndrew
- Division of Hematology/Oncology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - E Paul Wileyto
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Amy S Clark
- Division of Hematology/Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Robin Holmes
- University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA, USA
| | - Lisa N Bottalico
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | - Clementina Mesaros
- Center for Excellence in Environmental Toxicology, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ian A Blair
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kevin R Fox
- Division of Hematology/Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Susan M Domchek
- Division of Hematology/Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Basser Center at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer M Matro
- Division of Hematology/Oncology, UC San Diego, San Diego, CA, USA
| | - Angela R Bradbury
- Division of Hematology/Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael D Feldman
- Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth O Hexner
- Division of Hematology/Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Angela DeMichele
- Division of Hematology/Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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3
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Makhlin I, Clark AS, Wileyto P, Goodman N, Ndicu J, DeLuca S, Clark C, Stavropoulos SW, Shih N, Feldman MD, Domchek SM, Matro JM, Shah PD, Knollman HM, Fox KR, Maxwell KN, Chodosh LA, DeMichele A. Abstract PD9-10: Investigating the clinical utility of tumor mutational burden in predicting rapid progression and death in patients with metastatic breast cancer. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd9-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background Up to 30% of breast cancer patients will eventually relapse with metastatic disease. With an increasing array of therapeutic options, there is an ongoing need for predictive biomarkers to help guide treatment strategies including sequencing of therapies in the metastatic setting. We sought to evaluate the prognostic and predictive potential of a panel-specific tumor mutational burden (TMB) in metastatic breast cancer patients.
Methods METAMORPH is a prospective, longitudinal cohort study. Eligible patients (pts) had newly diagnosed or progressive metastatic breast cancer and enrolled prior to starting a new line of therapy (physician’s choice) at the University of Pennsylvania. Pts underwent tissue biopsy of a suspected metastatic site. Tumor samples were analyzed for mutations and copy number alterations (CNA’s) using our institution’s CLIA-certified Center for Personalized Diagnostics (CPD) targeted gene panel, which evolved over the course of the study from 20 genes to 152 genes. TMB-high (TMB-H) was defined as ≥3 mutations and/or copy-number gains (CNG) among 18 genes shared across all panel versions. Pts were followed for time to progression (TTP), progression-free survival (PFS), and overall survival (OS). The frequency of rapid progressors and rapid death (defined as having progressed or died within 3 months of enrollment, respectively) was assessed.
Results Three hundred pts enrolled from 2013-2020, of whom 200 pts had CPD reports generated. Of these, 12 pts were excluded due to either no treatment change on enrollment (n=11) or different primary cancer on biopsy (n=1). Thus 188 pts were included in this analysis. The median age was 55 years (range 28-79). 77% of pts identified as white, 18% as Black or African American, and 3.2% as Asian. Pts had a median of 1 line (range 0-12) of prior systemic therapy in the metastatic setting. 46.8% had no prior therapies for MBC, while 31% had ≥3 prior lines of therapy. 74.4% were HR+, 22.8% TNBC, and 2.7% HR-/HER2+. 6.9% of the cohort were classified as TMB-H. The average mutation/CNG rate was 2.2/sample, and 22.5% had no mutations or CNA’s. The most common mutations were TP53 (35%) and PIK3CA (26%).
While TMB-H patients showed a statistically non-significant trend towards shorter median TTP and PFS compared with TMB-L, they comprised a significantly greater proportion of rapid progressors (54.5% vs 24.1%, p=0.027), with an odds ratio for rapid progression of 3.8 (95% CI 1.08-13.2). In a multivariate logistic regression analysis, TMB-H remained independently associated with rapid progression when adjusted for receptor subtype and next line of therapy. Receptor subtype analysis revealed that ER- (including ER-/PR+) patients with TMB-H had a shorter median TTP compared to ER- TMB-L (147 vs 68 days, p=0.03). TMB-H was also associated with significantly shorter OS compared with TMB-L (587 vs 648 days, p=0.02; HR 2.2 [95% CI 1.11-4.41]). 44.4% of TMB-H pts died within 3 months of enrollment, as compared to 11.0% of TMB-L pts (p=0.005), with an odds ratio for rapid death, adjusted for number of previous lines of therapy and receptor subtype, of 6.7 (95% CI 1.5-31.0).
Conclusion MBC pts who are TMB-H represent a population who are highly resistant to standard therapies, progress rapidly, and have significantly shorter overall survival with more rapid time to death. Our data support further studies investigating the utility of TMB as a predictive biomarker in directing patients away from standard treatment options and towards novel approaches e.g. immunotherapy.
Citation Format: Igor Makhlin, Amy S Clark, Paul Wileyto, Noah Goodman, John Ndicu, Shannon DeLuca, Candace Clark, S. William Stavropoulos, Natalie Shih, Michael D Feldman, Susan M Domchek, Jennifer M Matro, Payal D Shah, Hayley M Knollman, Kevin R Fox, Kara N Maxwell, Lewis A Chodosh, Angela DeMichele. Investigating the clinical utility of tumor mutational burden in predicting rapid progression and death in patients with metastatic breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD9-10.
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Affiliation(s)
| | - Amy S Clark
- University of Pennsylvania, Philadelphia, PA
| | | | | | - John Ndicu
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | - Kevin R Fox
- University of Pennsylvania, Philadelphia, PA
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4
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Pomponio MK, Burkbauer L, Goldbach M, Nazarian SM, Xie F, Clark AS, Matro JM, Fox KR, Shulman LN, Keele LJ, Tchou J. Refining the indications for neoadjuvant chemotherapy for patients with HER2+ breast cancer: A single institution experience. J Surg Oncol 2020; 121:447-455. [PMID: 31919848 DOI: 10.1002/jso.25814] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 12/09/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND We aim to compare the clinical outcomes of patients with early-stage HER2+ breast cancer treated with adjuvant chemotherapy (AC) and neoadjuvant chemotherapy (NAC). METHODS Patients with non-metastatic HER2+ breast cancer treated from 2009 to 2018 at our institution comprised our study cohort (n = 1254). Pathologic complete response (pCR) was defined as the absence of invasive disease in the breast and axilla after NAC. Log-rank, Kaplan-Meier, and inverse probability of treatment weighting were used to assess differences in disease-free and overall survival between groups stratified by AC vs. NAC and pCR vs. non-pCR. RESULTS The majority received AC (n = 787 or 62.8%) while 467 (37.2%) patients received NAC. Median follow up for AC and NAC groups was 46 and 28 months, respectively. The crude disease-free survival and overall survival of our study cohort were 92.2% and 89.1% for AC, 89.1% and 82.2% for NAC pCR, and 68.1% and 60.0% for NAC non-pCR, respectively. For clinical stage ≥IIB patients, NAC conferred a positive but statistically nonsignificant treatment effect over AC in multivariate analysis. CONCLUSIONS After adjusting for imbalances in our subgroups, we found that, regardless of the sequence of chemotherapy (AC vs. NAC), patients with early-stage HER2+ breast cancer had excellent outcomes.
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Affiliation(s)
- Maria K Pomponio
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Burkbauer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Macy Goldbach
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susanna M Nazarian
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fei Xie
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy S Clark
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer M Matro
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin R Fox
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lawrence N Shulman
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke J Keele
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Tchou
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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5
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Pomponio MK, Keele LJ, Fox KR, Clark AS, Matro JM, Shulman LN, Tchou JC. Does time to adjuvant chemotherapy (TTC) affect outcomes in patients with triple-negative breast cancer? Breast Cancer Res Treat 2019; 177:137-143. [PMID: 31119565 DOI: 10.1007/s10549-019-05282-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/16/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE A recent study reported that time to adjuvant chemotherapy (TTC) > 30 days was significantly associated with worse OS and DFS in triple-negative breast cancer (TNBC). Earlier studies, however, found that worse outcomes were associated with TTC > 60 days or > 90 days. As the trend for mastectomy with reconstruction continues to rise, TTC of < 30 days is often not feasible due to wound-healing issues in some of these patients. To elucidate the impact of TTC, we sought to evaluate the clinical outcomes associated with TTC in a contemporary cohort treated for TNBC at a single institution. METHODS A single-institution database was queried to identify nonmetastatic TNBC patients who received adjuvant chemotherapy from 2009 to 2018. TTC was defined as interval between date of surgery and adjuvant chemotherapy start date. Median TTC was used to divide our cohort into four quartiles; ≤ 31, 32-42, 43-56, and > 56 days. Logrank, Kaplan-Meier, and inverse probability weighting (IPW) tests were used to analyze disease-free (DFS) and overall survival (OS). RESULTS The mean TTC of our study cohort (n = 724) was 48 days (median TTC = 42 days). Black race, mastectomy without adjuvant radiation, and mastectomy with immediate reconstruction were associated with delayed TTC (all p-values < 0.01). In multivariate IPW analysis, TTC > 56 (n = 173) days did not impact DFS or OS compared to TTC ≤ 31 (n = 198) days (p = 0.27 and p = 0.21, respectively). Similar results were seen during subgroup analysis for groups identified as higher risk for delayed TTC. CONCLUSION Our results demonstrated that TTC was not significant or significantly associated with DFS or OS in patient receiving chemotherapy for operable TNBC. Our results were reassuring for patients electing mastectomy with immediate reconstruction, who may experience a longer TTC.
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Affiliation(s)
- Maria K Pomponio
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Luke J Keele
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin R Fox
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amy S Clark
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer M Matro
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence N Shulman
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia C Tchou
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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6
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Clark AS, McAndrew NP, Troxel A, Feldman M, Lal P, Rosen M, Burrell J, Redlinger C, Gallagher M, Bradbury AR, Domchek SM, Fox KR, O'Dwyer PJ, DeMichele AM. Combination Paclitaxel and Palbociclib: Results of a Phase I Trial in Advanced Breast Cancer. Clin Cancer Res 2019; 25:2072-2079. [PMID: 30635336 DOI: 10.1158/1078-0432.ccr-18-0790] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 12/03/2018] [Accepted: 01/07/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE The CDK 4/6 inhibitor palbociclib rapidly and reversibly inhibits the cell cycle. The goal of this study was to exploit the cell cycle through intermittent, alternating dosing with palbociclib/paclitaxel to enhance efficacy. We determined the combination dose-limiting toxicity (DLT) in patients with Rb protein-expressing, advanced breast cancer. PATIENTS AND METHODS This open-label, phase I trial (NCT01320592) enrolled patients to sequential cohorts of palbociclib orally dosed intermittently between days 1 and 19 of a 28-day cycle alternating with weekly paclitaxel. Dose escalation proceeded in a standard 3 + 3 design. Ten additional patients received the combination at the recommended phase II dose (RP2D). Those who reached response plateau ≥6 cycles could continue on palbociclib alone on a 3 week on/1 week off schedule at one dose level above their combination dose. RESULTS Twenty-seven patients enrolled. Although there was only 1 DLT (grade 3 alanine aminotransferase/aspartate aminotransferase at 125 mg), neutropenia (NTP) requiring dose modification in cycle 1 (C1) resulted in an RP2D of 75 mg palbociclib/80 mg/m2 paclitaxel. During C1, the most common adverse event was NTP, occurring in 15 patients (55.6%); grade 1 or 2 nausea and peripheral neuropathy were also observed in 8 patients each (29.6%). The clinical benefit rate was 55% at the RP2D; benefit was observed across all receptor subtypes. CONCLUSIONS Alternating sequential palbociclib/paclitaxel in patients with Rb+ advanced breast cancer is feasible and safe, without evidence of additive toxicity. This represents a new application for CDK 4/6 inhibitors in Rb+ breast cancer regardless of subtype; efficacy trials are warranted.
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Affiliation(s)
- Amy S Clark
- Department of Medicine, Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. .,Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas P McAndrew
- Department of Medicine, Division of Hematology/Oncology, University of California, Los Angeles, Los Angeles, California
| | - Andrea Troxel
- Department of Population Health, NYU School of Medicine, New York, New York
| | - Michael Feldman
- Department of Medicine, Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pathology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Priti Lal
- Department of Medicine, Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pathology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Rosen
- Department of Medicine, Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica Burrell
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen Redlinger
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maryann Gallagher
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela R Bradbury
- Department of Medicine, Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan M Domchek
- Department of Medicine, Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin R Fox
- Department of Medicine, Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter J O'Dwyer
- Department of Medicine, Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela M DeMichele
- Department of Medicine, Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Epidemiology, Biostatistics and Bioinformatics, University of Pennsylvania, Philadelphia, Pennsylvania
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7
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Silber JH, Rosenbaum PR, Ross RN, Reiter JG, Niknam BA, Hill AS, Bongiorno DM, Shah SA, Hochman LL, Even-Shoshan O, Fox KR. Disparities in Breast Cancer Survival by Socioeconomic Status Despite Medicare and Medicaid Insurance. Milbank Q 2019; 96:706-754. [PMID: 30537364 DOI: 10.1111/1468-0009.12355] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Policy Points Patients with low socioeconomic status (SES) experience poorer survival rates after diagnosis of breast cancer, even when enrolled in Medicare and Medicaid. Most of the difference in survival is due to more advanced cancer on presentation and the general poor health of lower SES patients, while only a very small fraction of the SES disparity is due to differences in cancer treatment. Even when comparing only low- versus not-low-SES whites (without confounding by race) the survival disparity between disparate white SES populations is very large and is associated with lower use of preventive care, despite having insurance. CONTEXT Disparities in breast cancer survival by socioeconomic status (SES) exist despite the "safety net" programs Medicare and Medicaid. What is less clear is the extent to which SES disparities affect various racial and ethnic groups and whether causes differ across populations. METHODS We conducted a tapered matching study comparing 1,890 low-SES (LSES) non-Hispanic white, 1,824 black, and 723 Hispanic white women to 60,307 not-low-SES (NLSES) non-Hispanic white women, all in Medicare and diagnosed with invasive breast cancer between 1992 and 2010 in 17 US Surveillance, Epidemiology, and End Results (SEER) regions. LSES Medicare patients were Medicaid dual-eligible and resided in neighborhoods with both high poverty and low education. NLSES Medicare patients had none of these factors. MEASUREMENTS 5-year and median survival. FINDINGS LSES non-Hispanic white patients were diagnosed with more stage IV disease (6.6% vs 3.6%; p < 0.0001), larger tumors (24.6 mm vs 20.2 mm; p < 0.0001), and more chronic diseases such as diabetes (37.8% vs 19.0%; p < 0.0001) than NLSES non-Hispanic white patients. Disparity in 5-year survival (NLSES - LSES) was 13.7% (p < 0.0001) when matched for age, year, and SEER site (a 42-month difference in median survival). Additionally, matching 55 presentation factors, including stage, reduced the disparity to 4.9% (p = 0.0012), but further matching on treatments yielded little further change in disparity: 4.6% (p = 0.0014). Survival disparities among LSES blacks and Hispanics, also versus NLSES whites, were significantly associated with presentation factors, though black patients also displayed disparities related to initial treatment. Before being diagnosed, all LSES populations used significantly less preventive care services than matched NLSES controls. CONCLUSIONS In Medicare, SES disparities in breast cancer survival were large (even among non-Hispanic whites) and predominantly related to differences of presentation characteristics at diagnosis rather than differences in treatment. Preventive care was less frequent in LSES patients, which may help explain disparities at presentation.
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Affiliation(s)
- Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia.,Leonard and Madlyn Abramson Cancer Center of the University of Pennsylvania.,University of Pennsylvania Perelman School of Medicine.,Division of Pediatric Oncology, Children's Hospital of Philadelphia.,The Wharton School, University of Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Paul R Rosenbaum
- The Wharton School, University of Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Richard N Ross
- Center for Outcomes Research, Children's Hospital of Philadelphia
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia
| | - Bijan A Niknam
- Center for Outcomes Research, Children's Hospital of Philadelphia
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia
| | | | - Shivani A Shah
- Center for Outcomes Research, Children's Hospital of Philadelphia
| | - Lauren L Hochman
- Center for Outcomes Research, Children's Hospital of Philadelphia
| | - Orit Even-Shoshan
- Center for Outcomes Research, Children's Hospital of Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Kevin R Fox
- Leonard and Madlyn Abramson Cancer Center of the University of Pennsylvania.,University of Pennsylvania Perelman School of Medicine.,Hospital of the University of Pennsylvania
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8
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Abstract
BACKGROUND Research has long noted higher prevalence rates of suicidal thoughts and behaviors among individuals with psychotic symptoms. Major theories have proposed several explanations to account for this association. Given the differences in the literature regarding the operationalization of psychosis and sample characteristics, a quantitative review is needed to determine to what extent and how psychosis confers risk for suicidality. METHODS We searched PsycInfo, PubMed, and GoogleScholar for studies published before 1 January 2016. To be included in the analysis, studies must have used at least one psychosis-related factor to longitudinally predict suicide ideation, attempt, or death. The initial search yielded 2541 studies. Fifty studies were retained for analysis, yielding 128 statistical tests. RESULTS Suicide death was the most commonly studied outcome (43.0%), followed by attempt (39.1%) and ideation (18.0%). The median follow-up length was 7.5 years. Overall, psychosis significantly conferred risk across three outcomes, with weighted mean ORs of 1.70 (1.39-2.08) for ideation, 1.36 (1.25-1.48) for attempt, and 1.40 (1.14-1.72) for death. Detailed analyses indicated that positive symptoms consistently conferred risk across outcomes; negative symptoms were not significantly associated with ideation, and were protective against death. Some small moderator effects were detected for sample characteristics. CONCLUSIONS Psychosis is a significant risk factor for suicide ideation, attempt, and death. The finding that positive symptoms increased suicide risk and negative symptoms seemed to decrease risk sheds light on the potential mechanisms for the association between psychosis and suicidality. We note several limitations of the literature and offer suggestions for future directions.
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Affiliation(s)
- X Huang
- Department of Psychology,Florida State University,Tallahassee, FL,USA
| | - K R Fox
- Department of Psychology,Harvard University,Cambridge, MA,USA
| | - J D Ribeiro
- Department of Psychology,Florida State University,Tallahassee, FL,USA
| | - J C Franklin
- Department of Psychology,Florida State University,Tallahassee, FL,USA
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9
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Bayne LJ, Nivar I, Goodspeed B, Wileyto P, Savage J, Shih NNC, Feldman MD, Edwards J, Clark AS, Fox KR, Matro JM, Domchek SM, Bradbury AR, Shah PD, Chislock EM, Belka GK, Wang J, Amaravadi R, Chodosh LA, DeMichele AM. Abstract OT2-07-09: Detection and targeting of minimal residual disease in breast cancer to reduce recurrence: The PENN-SURMOUNT and CLEVER trials. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-ot2-07-09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background:
Recurrent breast cancers arise from minimal residual disease (MRD): the pool of disseminated and circulating tumor cells (DTCs and CTCs) that survive in their host following treatment of primary breast cancer. Detection of DTCs in the bone marrow (BM) after treatment is strongly associated with an increased risk of recurrence. Through the analysis of novel genetically-engineered mouse models, we have generated a substantial body of evidence that autophagy and mTOR signaling play key roles in the survival of DTCs. Moreover, administration of agents that block these pathways in mice harboring MRD reduces DTC burden and concomitantly reduces tumor recurrence, providing the rationale for translating these findings to patients (pts).
Trial Design:
The PENN-SURMOUNT screening study uses a clinically validated IHC assay (DTC-IHC) to identify at-risk pts who harbor DTCs. DTC+ pts are eligible for enrollment on the CLEVER trial, which will determine the feasibility, safety and efficacy of administering hydroxychloroquine (HCQ) and/or everolimus (EVE) in DTC+ patients to target MRD and prevent recurrence. PENN-SURMOUNT is single center, prospective cohort study of pts who have completed therapy for primary breast cancer, are within 5 yrs of diagnosis and are at increased risk for relapse by virtue of nodal positivity, triple negative disease, ER+/Oncotype DX RS ≥ 25, or residual disease after neoadjuvant therapy. Pts undergo screening BM aspirate to test for DTCs following completion of adjuvant chemo and radiotherapy. The primary objective of the study is to determine the incidence and frequency of MRD in pts who have completed primary treatment for breast cancer and to ascertain eligibility for the CLEVER recurrence prevention trial.
CLEVER is a randomized, controlled, open label phase II pilot trial. Target enrollment is 60 pts, with 15 pts allocated to each of 4 treatment arms: HCQ (600 mg BID), EVE (10mg daily), combination HCQ/EVE, or control/observation. A cycle is 28 days of continuous dosing. After a 3-month observation period, control pts will be offered HCQ/EVE therapy for 6 cycles; thus, the control group is actually a delayed treatment group and all pts will receive treatment. Pts who demonstrate persistent DTCs after 6 cycles will continue on combination therapy for an additional 6 cycles. The primary endpoint is feasibility of administering HCQ, EVE or the combination in this population. Secondary objectives include safety, efficacy (DTC reduction), and 3-year RFS. The principal translational objective is to assess the utility of a novel DTC assay, "DTC-Flow", for more sensitive detection and response to study therapy, compared to DTC-IHC. Additional translational objectives include determining whether patient DTCs, CTCs, and cell-free circulating plasma tumor DNA (ptDNA) biologically reflect the primary tumor and predict response.
As of 5/23/17, 58 patients have been enrolled to PENN SURMOUNT, with a DTC-positivity rate of 22.6%; CLEVER opened in 2/2017; 11 patients are currently enrolled. Contact information: angela.demichele@uphs.upenn.edu
Key words: Recurrence, disseminated tumor cells, dormancy, minimal residual disease, autophagy, mTOR, Everolimus, hydroxychloroquine
Citation Format: Bayne LJ, Nivar I, Goodspeed B, Wileyto P, Savage J, Shih NNC, Feldman MD, Edwards J, Clark AS, Fox KR, Matro JM, Domchek SM, Bradbury AR, Shah PD, Chislock EM, Belka GK, Wang J, Amaravadi R, Chodosh LA, DeMichele AM. Detection and targeting of minimal residual disease in breast cancer to reduce recurrence: The PENN-SURMOUNT and CLEVER trials [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 OT2-07-09.
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Affiliation(s)
- LJ Bayne
- University of Pennsylvania, Philadelphia, PA
| | - I Nivar
- University of Pennsylvania, Philadelphia, PA
| | - B Goodspeed
- University of Pennsylvania, Philadelphia, PA
| | - P Wileyto
- University of Pennsylvania, Philadelphia, PA
| | - J Savage
- University of Pennsylvania, Philadelphia, PA
| | - NNC Shih
- University of Pennsylvania, Philadelphia, PA
| | - MD Feldman
- University of Pennsylvania, Philadelphia, PA
| | - J Edwards
- University of Pennsylvania, Philadelphia, PA
| | - AS Clark
- University of Pennsylvania, Philadelphia, PA
| | - KR Fox
- University of Pennsylvania, Philadelphia, PA
| | - JM Matro
- University of Pennsylvania, Philadelphia, PA
| | - SM Domchek
- University of Pennsylvania, Philadelphia, PA
| | - AR Bradbury
- University of Pennsylvania, Philadelphia, PA
| | - PD Shah
- University of Pennsylvania, Philadelphia, PA
| | - EM Chislock
- University of Pennsylvania, Philadelphia, PA
| | - GK Belka
- University of Pennsylvania, Philadelphia, PA
| | - J Wang
- University of Pennsylvania, Philadelphia, PA
| | - R Amaravadi
- University of Pennsylvania, Philadelphia, PA
| | - LA Chodosh
- University of Pennsylvania, Philadelphia, PA
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10
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Abstract
Summary Successful public health initiatives require multi-sector collaboration. AVONet was a UK collaborative developed to provide evidence-based strategies for active ageing. This study explored the success of AVONet in the achievement of its objectives as perceived by all partners. A convergent parallel mixed-methods design was employed, utilizing a quantitative survey and qualitative semi-structured interviews. Data collection was undertaken in September 2010, 18 months after establishing the collaborative and 6 months after funding had ceased. AVONet partners (n = 24) completed a 27-item survey. A sub-sample of four academics and four practitioners participated in semi-structured interviews. Quantitative and qualitative comparisons were made between academics' and practitioners' perceptions of success, potential for sustainability and satisfaction with structure and relationships. Participants perceived the AVONet collaborative positively. Significant between-group (academic v practitioner) differences in survey responses were observed for success (U = 19.5; p = 0.003) and structure (U = 125.5; p = 0.001). Strong positive correlations were observed between success and structure and balance between information transfer and exchange (r = 0.756; p < 0.001). Interviews confirmed positive perceptions and perceived importance of the collaborative and highlighted the need for further integration and tangible outcomes for practitioners. Suggestions to enhance sustainability were provided, such as smaller working groups and local council-led governance. Perceived success in building a multi-sectoral collaborative can be achieved during a 10-month period, despite differing needs of contributors. For collaboratives developed as a result of external funding aimed primarily at facilitating research, involvement of practitioners at an early stage may help set more comprehensive goals, supportive communication strategies, and increase potential for sustainability.
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Affiliation(s)
- H J Littlecott
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, Cardiff, UK
| | - K R Fox
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK.,Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK
| | - A Stathi
- Department for Health, University of Bath, Bath, UK
| | - J L Thompson
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
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11
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Mao JJ, Wagner KE, Seluzicki CM, Hugo A, Galindez LK, Sheaffer H, Fox KR. Integrating Oncology Massage Into Chemoinfusion Suites: A Program Evaluation. J Oncol Pract 2017; 13:e207-e216. [PMID: 28045616 DOI: 10.1200/jop.2016.015081] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE This article reports on the development, implementation, and evaluation of an integrative clinical oncology massage program for patients undergoing chemotherapy for breast cancer in a large academic medical center. MATERIALS AND METHODS We describe the development and implementation of an oncology massage program embedded into chemoinfusion suites. We used deidentified program evaluation data to identify specific reasons individuals refuse massage and to evaluate the immediate impact of massage treatments on patient-reported outcomes using a modified version of the Distress Thermometer delivered via iPad. We analyzed premassage and postmassage data from the Distress Thermometer using paired t test and derived qualitative data from participants who provided written feedback on their massage experiences. RESULTS Of the 1,090 massages offered, 692 (63%) were accepted. We observed a significant decrease in self-reported anxiety (from 3.9 to 1.7), nausea (from 2.5 to 1.2), pain (from 3.3 to 1.9), and fatigue (from 4.8 to 3.0) premassage and postmassage, respectively (all P < .001). We found that 642 survey participants (93%) were satisfied with their massage, and 649 (94%) would recommend it to another patient undergoing treatment. Spontaneous patient responses overwhelmingly endorsed the massage as relaxing. No adverse events were reported. Among the 398 patients (36%) who declined a massage, top reasons were time concerns and lack of interest. CONCLUSION A clinical oncology massage program can be safely and effectively integrated into chemoinfusion units to provide symptom control for patients with breast cancer. This integrative approach overcomes patient-level barriers of cost, time, and travel, and addresses the institutional-level barrier of space.
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Affiliation(s)
- Jun J Mao
- Memorial Sloan Kettering Cancer Center, New York, NY; and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Karen E Wagner
- Memorial Sloan Kettering Cancer Center, New York, NY; and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Christina M Seluzicki
- Memorial Sloan Kettering Cancer Center, New York, NY; and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Audra Hugo
- Memorial Sloan Kettering Cancer Center, New York, NY; and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Laura K Galindez
- Memorial Sloan Kettering Cancer Center, New York, NY; and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Heather Sheaffer
- Memorial Sloan Kettering Cancer Center, New York, NY; and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Kevin R Fox
- Memorial Sloan Kettering Cancer Center, New York, NY; and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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12
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Lowenfeld L, Mick R, Datta J, Xu S, Fitzpatrick E, Fisher CS, Fox KR, DeMichele A, Zhang PJ, Weinstein SP, Roses RE, Czerniecki BJ. Dendritic Cell Vaccination Enhances Immune Responses and Induces Regression of HER2 pos DCIS Independent of Route: Results of Randomized Selection Design Trial. Clin Cancer Res 2016; 23:2961-2971. [PMID: 27965306 DOI: 10.1158/1078-0432.ccr-16-1924] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 10/27/2016] [Accepted: 11/19/2016] [Indexed: 11/16/2022]
Abstract
Purpose: Vaccination with HER2 peptide-pulsed DC1s stimulates a HER2-specific T-cell response. This randomized trial aimed to establish safety and evaluate immune and clinical responses to vaccination via intralesional (IL), intranodal (IN), or both intralesional and intranodal (ILN) injection.Experimental Design: Fifty-four HER2pos patients [42 pure ductal carcinoma in situ (DCIS), 12 early invasive breast cancer (IBC)] were enrolled in a neoadjuvant HER2 peptide-pulsed DC1 vaccine trial. Patients were randomized to IL (n = 19), IN (n = 19), or ILN (n = 16) injection. Immune responses were measured in peripheral blood and sentinel lymph nodes by ELISPOT or in vitro sensitization assay. Pathologic response was assessed in resected surgical specimens.Results: Vaccination by all injection routes was well tolerated. There was no significant difference in immune response rates by vaccination route (IL 84.2% vs. IN 89.5% vs. ILN 66.7%; P = 0.30). The pathologic complete response (pCR) rate was higher in DCIS patients compared with IBC patients (28.6% vs. 8.3%). DCIS patients who achieved pCR (n = 12) and who did not achieve pCR (n = 30) had similar peripheral blood anti-HER2 immune responses. All patients who achieved pCR had an anti-HER2 CD4 immune response in the sentinel lymph node, and the quantified response was higher by response repertoire (P = 0.03) and cumulative response (P = 0.04).Conclusions: Anti-HER2 DC1 vaccination is a safe and immunogenic treatment to induce tumor-specific T-cell responses in HER2pos patients; immune and clinical responses were similar independent of vaccination route. The immune response in the sentinel lymph nodes, rather than in the peripheral blood, may serve as an endpoint more reflective of antitumor activity. Clin Cancer Res; 23(12); 2961-71. ©2016 AACR.
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Affiliation(s)
- Lea Lowenfeld
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rosemarie Mick
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jashodeep Datta
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Shuwen Xu
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth Fitzpatrick
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Carla S Fisher
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kevin R Fox
- Division of Medical Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Angela DeMichele
- Division of Medical Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Paul J Zhang
- Department of Pathology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Susan P Weinstein
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Brian J Czerniecki
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
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13
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Ribeiro JD, Franklin JC, Fox KR, Bentley KH, Kleiman EM, Chang BP, Nock MK. Letter to the Editor: Suicide as a complex classification problem: machine learning and related techniques can advance suicide prediction - a reply to Roaldset (2016). Psychol Med 2016; 46:2009-2010. [PMID: 27091309 DOI: 10.1017/s0033291716000611] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J D Ribeiro
- Department of Psychology,Vanderbilt University,Nashville,TN,USA
| | - J C Franklin
- Department of Psychology,Vanderbilt University,Nashville,TN,USA
| | - K R Fox
- Department of Psychology,Harvard University,Cambridge,MA,USA
| | - K H Bentley
- Center for Anxiety and Related Disorders,Boston University,Boston, MA,USA
| | - E M Kleiman
- Department of Psychology,Harvard University,Cambridge,MA,USA
| | - B P Chang
- Department of Medicine,Columbia University,New York, NY,USA
| | - M K Nock
- Department of Psychology,Harvard University,Cambridge,MA,USA
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14
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Simmonds BAJ, Hannam KJ, Fox KR, Tobias JH. An exploration of barriers and facilitators to older adults' participation in higher impact physical activity and bone health: a qualitative study. Osteoporos Int 2016; 27:979-987. [PMID: 26556738 PMCID: PMC4767848 DOI: 10.1007/s00198-015-3376-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 10/19/2015] [Indexed: 11/04/2022]
Abstract
SUMMARY This qualitative study explored the acceptability of high-impact physical activity for increasing bone strength in later life. Thematic analysis established the barriers and facilitators to this physical activity. They prioritised joint over skeletal health, of which they had little concept. Interventions need to clearly communicate the rationale and benefits. INTRODUCTION The aim of this study was to explore the acceptability of doing high-impact physical activity in later life. METHODS This qualitative study was embedded within a large-scale observational study and was designed to address specific objectives and feed into a subsequent intervention. Five focus groups with physically active men and women (over 50 years) were used to develop an interview topic guide to explore the acceptability of high-impact physical activity in older men and women (over 65 years) in South West England. A total of 28 semi-structured interviews with 31 participants were then conducted and transcripts analysed thematically. RESULTS Three main barriers emerged: conceptualising bone, damage to joints and falling/safety concerns. Two main facilitators were also identified: the need to understand clear tangible benefits and incorporation of activity into everyday habits. Older adults were interested how high-impact physical activity would help to maintain their mobility, independence or social relationships. Some participants wanted tangible feedback from accelerometers, health care professionals and/or bone scans in order to develop a more intimate knowledge of their bone health. CONCLUSIONS Interventions incorporating high-impact physical activity for older adults need to communicate how this activity can impact more broadly on health and lives; that physical activity will be safe, beneficial and not damaging to their joints will need to be clearly conveyed. Ways in which high-impact physical activity can be habitualised into everyday activities, be fun and interactive may help facilitate longer term adoption.
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Affiliation(s)
- B A J Simmonds
- Musculoskeletal Research Unit, Learning and Research Building, The University of Bristol, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK.
| | - K J Hannam
- Musculoskeletal Research Unit, Learning and Research Building, The University of Bristol, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
| | - K R Fox
- Centre for Exercise Nutrition and Health Sciences, School for Policy Studies, The University of Bristol, 8 Priory Road, Bristol, BS8 1TZ, UK
| | - J H Tobias
- Musculoskeletal Research Unit, Learning and Research Building, The University of Bristol, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
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15
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DeMichele AM, Colameco CB, Kalota A, Troxel AB, Holmes R, Cimildoro R, Zafman K, Fox KR, Domchek SM, Gogineni K, Bradbury AR, Matro JM, Shih N, Feldman MD, Clark AS, Hexner EO, Bromberg JF. Abstract CT114: A phase II trial of exemestane and ruxolitinib for aI-resistant ER+ breast cancer: Interim safety, efficacy, and biomarker analysis. Cancer Res 2015. [DOI: 10.1158/1538-7445.am2015-ct114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Resistance to aromatase inhibitors in ER+ breast cancer leads to recurrence and progression in the metastatic setting. JAK/STAT pathway activation is a resistance mechanism that could potentially be overcome with the use of JAK inhibitor therapy.
Methods: We performed a phase II trial of exemestane, 25 mg daily, and ruxolitinib, 25 mg BID, in postmenopausal women with advanced, ER+ breast cancer who had progressed on a non-steroidal aromatase inhibitor and had either measureable or bone-only disease. A Simon 2-stage design was employed. A “go” decision to second stage would occur if fewer than 5/15 patients experienced any grade 3/4 toxicity requiring discontinuation from the study within the first treatment cycle.
Results: Fifteen patients were enrolled; during cycle 1, no patient discontinued for toxicity and 1 patient went off study for progression of bone disease. 36 grade 3 events occurred; anemia was most common (n = 5), requiring transfusion in all patients. 47% required dose reduction. No partial or complete responses occurred; 3/15 (20%) had stable disease ≥6 months (clinical benefit, CB). Baseline CRP ≥8 was significantly associated with CB (3/3 CB vs. 1/11 non-CB; p = 0.011); other markers, including baseline ESR, IL-6 genotype status and primary tumor phosphoSTAT3 expression were not associated with CB in this small sample, though high tumoral pSTAT3 was seen in 66% of CB and 33% of non-CB. A novel pharmacodynamic (PD) assay to assess STAT3 phosphorylation in peripheral blood mononuclear cells after ruxolitinib exposure demonstrated differential effects in patients with CB vs. those without CB.
Conclusions: The combination of exemestane and the JAK2 inhibitor ruxolitinib met safety criteria for continued enrollment. Anemia, an expected toxicity of R, was common and the high rate of severe anemia and need for dose reductions has led to a decision to reduce the starting dose of ruxolitinib to 15 mg BID moving forward. Promising predictive markers, including CRP, tumor pSTAT3 and a novel PD assay for pSTAT3 will be further evaluated.
Citation Format: Angela M. DeMichele, Christopher B. Colameco, Anna Kalota, Andrea B. Troxel, Robin Holmes, Rebecca Cimildoro, Kelly Zafman, Kevin R. Fox, Susan M. Domchek, Keerthi Gogineni, Angela R. Bradbury, Jennifer M. Matro, Natalie Shih, Michael D. Feldman, Amy S. Clark, Elizabeth O. Hexner, Jacqueline F. Bromberg. A phase II trial of exemestane and ruxolitinib for aI-resistant ER+ breast cancer: Interim safety, efficacy, and biomarker analysis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr CT114. doi:10.1158/1538-7445.AM2015-CT114
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Affiliation(s)
| | | | - Anna Kalota
- 1University of Pennsylvania, Philadelphia, PA
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16
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Thøgersen-Ntoumani C, Loughren EA, Kinnafick FE, Taylor IM, Duda JL, Fox KR. Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial. Scand J Med Sci Sports 2015; 25:778-87. [PMID: 25559067 DOI: 10.1111/sms.12398] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2014] [Indexed: 01/09/2023]
Abstract
Physical activity may regulate affective experiences at work, but controlled studies are needed and there has been a reliance on retrospective accounts of experience. The purpose of the present study was to examine the effect of lunchtime walks on momentary work affect at the individual and group levels. Physically inactive employees (N = 56; M age = 47.68; 92.86% female) from a large university in the UK were randomized to immediate treatment or delayed treatment (DT). The DT participants completed both a control and intervention period. During the intervention period, participants partook in three weekly 30-min lunchtime group-led walks for 10 weeks. They completed twice daily affective reports at work (morning and afternoon) using mobile phones on two randomly chosen days per week. Multilevel modeling was used to analyze the data. Lunchtime walks improved enthusiasm, relaxation, and nervousness at work, although the pattern of results differed depending on whether between-group or within-person analyses were conducted. The intervention was effective in changing some affective states and may have broader implications for public health and workplace performance.
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Affiliation(s)
- C Thøgersen-Ntoumani
- School of Psychology and Speech Pathology, Curtin University, Perth, Western Australia, Australia
| | - E A Loughren
- School of Sport and Exercise, University of Gloucestershire, Gloucester, UK
| | - F-E Kinnafick
- School of Health, University of Northampton, Northampton, UK
| | - I M Taylor
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - J L Duda
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - K R Fox
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
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17
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Silber JH, Rosenbaum PR, Ross RN, Niknam BA, Ludwig JM, Wang W, Clark AS, Fox KR, Wang M, Even-Shoshan O, Giantonio BJ. Racial disparities in colon cancer survival: a matched cohort study. Ann Intern Med 2014; 161:845-54. [PMID: 25506853 DOI: 10.7326/m14-0900] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Differences in colon cancer survival by race are a recognized problem among Medicare beneficiaries. OBJECTIVE To determine to what extent the racial disparity in survival is due to disparity in presentation characteristics at diagnosis or disparity in subsequent treatment. DESIGN Black patients with colon cancer were matched with 3 groups of white patients: a "demographic characteristics" match controlling for age, sex, diagnosis year, and Survey, Epidemiology, and End Results (SEER) site; a "presentation" match controlling for demographic characteristics plus comorbid conditions and tumor characteristics, including stage and grade; and a "treatment" match, including presentation variables plus details of surgery, radiation, and chemotherapy. SETTING 16 U.S. SEER sites. PATIENTS 7677 black patients aged 65 years or older diagnosed between 1991 and 2005 in the SEER-Medicare database and 3 sets of 7677 matched white patients, followed until 31 December 2009. MEASUREMENTS 5-year survival. RESULTS The absolute difference in 5-year survival between black and white patients was 9.9% (95% CI, 8.3% to 11.4%; P<0.001) in the demographic characteristics match. This disparity remained unchanged between 1991 and 2005. After matching for presentation characteristics, the difference decreased to 4.9% (CI, 3.6% to 6.1%; P<0.001). After additional matching for treatment, this difference decreased to 4.3% (CI, 2.9% to 5.5%; P<0.001). The disparity in survival attributed to treatment differences made up only an absolute 0.6% of the overall 9.9% survival disparity. LIMITATION An observational study limited to elderly Medicare fee-for-service beneficiaries living in selected geographic areas. CONCLUSION Racial disparities in colon cancer survival did not decrease among patients diagnosed between 1991 and 2005. This persistent disparity seemed to be more related to presentation characteristics at diagnosis than to subsequent treatment differences. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality and National Science Foundation.
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Miller K, O'Neill AM, Dang CT, Northfelt DW, Gradishar WJ, Goldstein LJ, Mayer IA, Brufsky A, Bloom SH, Sparano JA, Tevaarwerk A, Fox KR, Hendricks CB, Balcueva EP, Sledge GW. Bevacizumab (Bv) in the adjuvant treatment of HER2-negative breast cancer: Final results from Eastern Cooperative Oncology Group E5103. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.500] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kathy Miller
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN
| | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Ingrid A. Mayer
- Vanderbilt-Ingram Cancer Center, Vanderbilt University, School of Medicine, Nashville, TN
| | - Adam Brufsky
- University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | | | | | | | - Kevin R. Fox
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
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Clark AS, O'Dwyer PJ, Heitjan D, Lal P, Feldman MD, Gallagher M, Redlinger C, Colameco C, Lewis D, Zafman K, Langer M, Rosen MA, Gogineni K, Bradbury AR, Domchek SM, Fox KR, DeMichele A. A phase I trial of palbociclib and paclitaxel in metastatic breast cancer. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Amy Sanders Clark
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Peter J. O'Dwyer
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | | | - Priti Lal
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | | | - Maryann Gallagher
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Colleen Redlinger
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | - David Lewis
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Kelly Zafman
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Melissa Langer
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | - Kevin R. Fox
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Angela DeMichele
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
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Datta J, Yang RL, Brod AM, Mick R, Berk E, Fitzpatrick E, Xu S, Fox KR, Kelz RR, Czerniecki BJ. Anti-HER2 CD4 T helper type 1 response in breast cancer: Is there a role for immunorestoration? J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jashodeep Datta
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rachel L Yang
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Andrew M Brod
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rosemarie Mick
- Department of Biostatistics and Epidemiology, Abramson Cancer Center, University of Pennsylvania,, Philadelphia, PA
| | - Erik Berk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Shuwen Xu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kevin R. Fox
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Clark AS, Lal P, Tan KS, Heitjan DF, Feldman M, Zhang P, Gallagher M, Domchek S, Gogineni K, Keefe S, Fox KR, O'Dwyer P, DeMichele A. Abstract P2-16-20: Biomarkers to predict response to the CDK 4/6 inhibitor, palbociclib (PD 0332991) in a single-agent phase II trial in advanced breast cancer. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p2-16-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The Cyclin D1-CDK4/6 complex is critical in regulating the G1/S checkpoint and phosphorylation of retinoblastoma protein (Rb); palbociclib is a highly-selective CDK 4/6 inhibitor. CCND1, the gene encoding Cyclin D1, is amplified in 15% of breast tumors; p16, the endogenous inhibitor of the complex is lost in up to half of breast tumors. We hypothesized that breast tumors containing either alteration or a high proliferative rate would have enhanced sensitivity to palbociclib. We conducted a single-agent, phase II trial of palbociclib in patients with advanced breast cancer (UPCC03909). In this trial, the clinical benefit rate (partial response [PR] + stable disease ≥6 months [6mSD]) was 17% (DeMichele, ASCO, 2013). The current analysis was a secondary endpoint to determine whether Rb expression, p16 loss, Ki-67 index or CCND1 amplification predicted response in the phase II trial.
Methods: Enrollment on UPCC03909 required archival tumor collection from either primary tumor or metastatic lesions. Fresh frozen paraffin-embedded (FFPE) tumor sections were tested for expression of Rb, Ki-67 and p16 by immunohistochemistry (IHC), and CCND1 amplification by fluorescence in situ hybridization. Categorical variables based on% tumor staining and intensity scores (negative defined as 0 or 1+ intensity staining, equivocal defined as 2+ staining or 3+ in <30%, or positive defined as 3+ staining intensity in 30%) were generated for Rb and p16 nuclear staining. Fisher's Exact test was used to test for associations between nominal factors, the Cochran-Mantel-Hænszel test for associations between ordinal factors, and the Cox proportional hazard model for association of progression-free survival (PFS) with biomarkers.
Results: Thirty-seven patients were enrolled; response evaluation is available in 36/37. All had FFPE tumor available for Rb, 33/37 (89%)for CCND1 amplification and 29/37 (78%) for Ki-67 and p16 analyses. For complete results see Table 1.
Conclusions: These results provide preliminary evidence that breast tumors more likely to respond to palbociclib may have higher Rb nuclear expression, lower Ki67 indices and/or loss of p16. Larger studies are needed to confirm these results.
Table 1: Biomarker Summary and ResponseBiomarkerBiomarker CategoizationFrequency (%)Response Rate PR+6mSD/total (%)PFS Hazard Ratio (95%CI)Overall Population (n = 37) 6/36 (17%) Ki-67 (n = 29)≤ 10 (n = 20)69%4/19 (21%)1.00 > 10 (n = 9)31%1/9 (11%)1.20 (0.50, 2.88)Rb (n = 37)Nuclear Score: Negative (n = 11)30%0/11 (0%)1.00 Equivocal (n = 15)40%2/14 (14.3%)0.72 (0.28, 1.84) Positive (n = 11)30%4/11 (36.4%)0.71 (0.28, 1.80)p16 (n = 29)Loss or Low Expression (n = 16)55%4/16 (25%)1.00 Moderate or High Expression (n = 13)45%1/12 (8.3%)1.08 (0.47, 2.49)CCND1 Amplification (n = 34)Non-amplified (n = 25)88%4/25 (16%)1.00 Amplified (n = 9)12%1/8 (12.5%)1.06 (0.46, 2.4)
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-20.
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Affiliation(s)
- AS Clark
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - P Lal
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - KS Tan
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - DF Heitjan
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - M Feldman
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - P Zhang
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - M Gallagher
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - S Domchek
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - K Gogineni
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - S Keefe
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - KR Fox
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - P O'Dwyer
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
| | - A DeMichele
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA; Pfizer, New York, NY
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Affiliation(s)
- Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Pavey TG, Taylor AH, Fox KR, Hillsdon M, Anokye N, Campbell JL, Foster C, Green C, Moxham T, Mutrie N, Searle J, Trueman P, Taylor RS. Republished research: Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. Br J Sports Med 2013; 47:526. [PMID: 23620507 DOI: 10.1136/bjsports-2012-e6462rep] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- T G Pavey
- Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, Exeter EX2 4SG, UK.
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24
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Silber JH, Rosenbaum PR, Clark AS, Giantonio BJ, Ross RN, Teng Y, Wang M, Niknam BA, Ludwig JM, Wang W, Even-Shoshan O, Fox KR. Characteristics associated with differences in survival among black and white women with breast cancer. JAMA 2013; 310:389-97. [PMID: 23917289 DOI: 10.1001/jama.2013.8272] [Citation(s) in RCA: 231] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Difference in breast cancer survival by race is a recognized problem among Medicare beneficiaries. OBJECTIVE To determine if racial disparity in breast cancer survival is primarily attributable to differences in presentation characteristics at diagnosis or subsequent treatment. DESIGN, SETTING, AND PATIENTS Comparison of 7375 black women 65 years and older diagnosed between 1991 to 2005 and 3 sets of 7375 matched white control patients selected from 99,898 white potential controls, using data for 16 US Surveillance, Epidemiology and End Results (SEER) sites in the SEER-Medicare database. All patients received follow-up through December 31, 2009, and the black case patients were matched to 3 white control populations on demographics (age, year of diagnosis, and SEER site), presentation (demographics variables plus patient comorbid conditions and tumor characteristics such as stage, size, grade, and estrogen receptor status), and treatment (presentation variables plus details of surgery, radiation therapy, and chemotherapy). MAIN OUTCOMES AND MEASURES 5-Year survival. RESULTS The absolute difference in 5-year survival (blacks, 55.9%; whites, 68.8%) was 12.9% (95% CI, 11.5%-14.5%; P < .001) in the demographics match. This difference remained unchanged between 1991 and 2005. After matching on presentation characteristics, the absolute difference in 5-year survival was 4.4% (95% CI, 2.8%-5.8%; P < .001) and was 3.6% (95% CI, 2.3%-4.9%; P < .001) lower for blacks than for whites matched also on treatment. In the presentation match, fewer blacks received treatment (87.4% vs 91.8%; P < .001), time from diagnosis to treatment was longer (29.2 vs 22.8 days; P < .001), use of anthracyclines and taxols was lower (3.7% vs 5.0%; P < .001), and breast-conserving surgery without other treatment was more frequent (8.2% vs 7.3%; P = .04). Nevertheless, differences in survival associated with treatment differences accounted for only 0.81% of the 12.9% survival difference. CONCLUSIONS AND RELEVANCE In the SEER-Medicare database, differences in breast cancer survival between black and white women did not substantially change among women diagnosed between 1991 and 2005. These differences in survival appear primarily related to presentation characteristics at diagnosis rather than treatment differences.
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Affiliation(s)
- Jeffrey H Silber
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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DeMichele A, Clark AS, Heitjan D, Randolph S, Gallagher M, Lal P, Feldman MD, Zhang PJ, Schnader A, Zafman K, Domchek SM, Gogineni K, Keefe SM, Fox KR, O'Dwyer PJ. A phase II trial of an oral CDK 4/6 inhibitor, PD0332991, in advanced breast cancer. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.519] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
519 Background: The G1/S checkpoint of the cell cycle is frequently dysregulated in breast cancer (BC). Initial efficacy of PD0332991, a potent oral inhibitor of cyclin-dependent kinases (CDKs) 4/6 was shown in a variety of solid tumors and in combination with letrozole in a randomized phase II trial. Methods: We performed a phase II, single arm trial of PD0332991 in women with advanced BC. The primary objectives were safety and efficacy. Eligible patients had histologically-confirmed, stage IV BC with primary or metastatic tumor positive for retinoblastoma (Rb) protein expression, measureable disease by RECIST and adequate organ function/performance status. PD0332991 was given at 125 mg orally, days 1 – 21 of a 28-day cycle. Tumor was assessed every 2 cycles. A two-stage statistical design was employed. Secondary objectives included predictive biomarker assessment. Results: 36 patients were enrolled; 28 who completed cycle 1 are reported: 18 (64%) HR+/Her2-, 2 (7%) HR+/Her2+ and 8 (29%) HR-/Her2-. 90% had prior chemotherapy for metastatic disease (median 3 lines); 78% had prior hormonal therapy (median 2 lines). Grade 3/4 toxicities were limited to transient neutropenia (50%) and thrombocytopenia (21%). One episode of neutropenic sepsis occurred in cycle 1 in patient with 6 prior chemo regimens. All other toxicities were grade 1/2. Treatment was interrupted in 7 (25%) and dose reduced in 13 (46%) pts for cytopenias. For response data see table. Responses occurred at dose levels as low as 50 mg. Median PFS (months, 95% CI) was 4.1 (2.3,7.7) for ER+/Her2-, 18.8 (5.1,∞) for ER+/Her+ and 1.8 (0.9,∞) for ER-/Her2-. 27/28 patients discontinued study for progressive disease (PD); 1 due to patient preference. Conclusions: Therapy with PD0332991 alone is well-tolerated and demonstrates response or prolonged stable disease (SD) in patients with BC despite prior hormonal and chemotherapy. Expansion within subtypes and molecular predictors of response are being investigated. Clinical trial information: NCT01037790. [Table: see text]
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Affiliation(s)
- Angela DeMichele
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Maryann Gallagher
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Priti Lal
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | | | - Paul J. Zhang
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Allison Schnader
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Kelly Zafman
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Susan M. Domchek
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | | | | | - Kevin R. Fox
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Peter J. O'Dwyer
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
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Rech AJ, Mick R, Martin S, Recio A, Aqui NA, Powell DJ, Colligon TA, Trosko JA, Leinbach LI, Pletcher CH, Tweed CK, DeMichele A, Fox KR, Domchek SM, Riley JL, Vonderheide RH. CD25 blockade depletes and selectively reprograms regulatory T cells in concert with immunotherapy in cancer patients. Sci Transl Med 2012; 4:134ra62. [PMID: 22593175 DOI: 10.1126/scitranslmed.3003330] [Citation(s) in RCA: 244] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Regulatory T cells (T(regs)) are key mediators of immune tolerance and feature prominently in cancer. Depletion of CD25(+) FoxP3(+) T(regs) in vivo may promote T cell cancer immunosurveillance, but no strategy to do so in humans while preserving immunity and preventing autoimmunity has been validated. We evaluated the Food and Drug Administration-approved CD25-blocking monoclonal antibody daclizumab with regard to human T(reg) survival and function. In vitro, daclizumab did not mediate antibody-dependent or complement-mediated cytotoxicity but rather resulted in the down-regulation of FoxP3 selectively among CD25(high) CD45RA(neg) T(regs). Moreover, daclizumab-treated CD45RA(neg) T(regs) lost suppressive function and regained the ability to produce interferon-γ, consistent with reprogramming. To understand the impact of daclizumab on T(regs) in vivo, we performed a clinical trial of daclizumab in combination with an experimental cancer vaccine in patients with metastatic breast cancer. Daclizumab administration led to a marked and prolonged decrease in T(regs) in patients. Robust CD8 and CD4 T cell priming and boosting to all vaccine antigens were observed in the absence of autoimmunity. We conclude that CD25 blockade depletes and selectively reprograms T(regs) in concert with active immune therapy in cancer patients. These results suggest a mechanism to target cancer-associated T(regs) while avoiding autoimmunity.
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Affiliation(s)
- Andrew J Rech
- Abramson Family Cancer Research Institute, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Chalder M, Wiles NJ, Campbell J, Hollinghurst SP, Searle A, Haase AM, Taylor AH, Fox KR, Baxter H, Davis M, Thorp H, Winder R, Wright C, Calnan M, Lawlor DA, Peters TJ, Sharp DJ, Turner KM, Montgomery AA, Lewis G. A pragmatic randomised controlled trial to evaluate the cost-effectiveness of a physical activity intervention as a treatment for depression: the treating depression with physical activity (TREAD) trial. Health Technol Assess 2012; 16:1-164, iii-iv. [PMID: 22398106 DOI: 10.3310/hta16100] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The TREAting Depression with physical activity (TREAD) study investigated the cost-effectiveness of a physical activity intervention, in addition to usual general practitioner care, as a treatment for people with depression. DESIGN An individually randomised, pragmatic, multicentre randomised controlled trial with follow-up at 4, 8 and 12 months. A subset of participants took part in a qualitative study that investigated the acceptability and perceived benefits of the intervention. SETTING General practices in the Bristol and Exeter areas. PARTICIPANTS Aged 18-69 years with an International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10) diagnosis of depression and scoring ≥ 14 on the Beck Depression Inventory (BDI). Those who were unable to complete self-administered questionnaires in English, with medical contraindications to physical activity or with psychosis, bipolar disorder or serious drug abuse were excluded. INTERVENTIONS We devised an intervention designed to encourage choice and autonomy in the adoption of physical activity. It consisted of up to three face-to-face and ten telephone contacts delivered by a trained physical activity facilitator over an 8-month period. MAIN OUTCOME MEASURES The primary outcome was the BDI score measured at 4 months. Secondary outcomes included depressive symptoms over the 12 months and quality of life, antidepressant use and level of physical activity. RESULTS The study recruited 361 patients, with 182 randomised to the intervention arm and 179 to the usual care arm; there was 80% retention at the 4-month follow-up. The intervention group had a slightly lower BDI score at 4 months [-0.54, 95% confidence interval (CI) -3.06 to 1.99] but there was no evidence that the intervention improved outcome for depression. Neither was there any evidence to suggest a difference in the prescription of or self-reported use of antidepressants. However, the amount of physical activity undertaken by those who had received the intervention was increased (odds ratio 2.3, 95% CI 1.3 to 3.9) and was sustained beyond the end of the intervention. From a health-care perspective, the intervention group was more costly than the usual care group, with the cost of the intervention £220 per person on average. It is therefore extremely unlikely that the intervention is cost-effective as a treatment for depression using current willingness-to-pay thresholds. CONCLUSIONS This physical activity intervention is very unlikely to lead to any clinical benefit in terms of depressive symptoms or to be a cost-effective treatment for depression. Previous research has reported some benefit and there are three possible reasons for this discrepancy: first, even though the intervention increased self-reported physical activity, the increase in activity was not sufficiently large to lead to a measurable influence; second, only more vigorous activity might be of benefit; and third, previous studies had recruited individuals with a pre-existing commitment to physical activity. Future research is needed to identify and explain the mechanisms by which depression might be effectively treated, including, in particular, specific guidance on the optimum type, intensity and duration of physical activity required to produce a therapeutic effect. TRIAL REGISTRATION Current Controlled Trials ISRCTN16900744. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 10. See the HTA programme website for further project information.
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Affiliation(s)
- M Chalder
- Academic Unit of Psychiatry, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Silber JH, Rosenbaum PR, Clark AS, Wang M, Teng Y, Ross RN, Ludwig J, Niknam B, Even-Shoshan O, Giantonio BJ, Fox KR. Racial disparities in breast cancer survival. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.6000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6000 Background: Reducing racial disparities in breast cancer survival has been a federal priority since the early 1990’s. We present a new method to assess disparities using sequential multivariate matching. We ask if racial disparities have increased or decreased over time and if so, what were potential reasons for such changes. Methods: We studied all women over 65 years of age in the Medicare fee for service system diagnosed with breast cancer between 1991 and 2005 who were treated in one of 12 SEER sites (the sites in SEER since 1991). There were 5,251 black patients (74% early stage (I-III), 9% late stage (IV) and 17% missing stage) and 72,695 white patients (81% early stage, 5% late stage and 14% missing stage). All black cases represented the focal group for all matches. Using multivariate matching and the propensity score, white controls were matched to blacks in steps: (1) White controls matched to black cases on age and year of diagnosis; (2) Age, year of diagnosis, and stage; (3): Age, year, stage, estrogen receptor status, grade, and 30 comorbidities. We then compare 5-year survival in the Pre and Post-Taxane periods (1991-1998, 1999-2005). Results: When whites were matched to blacks on age and diagnosis year, 5-year Kaplan-Meier survival was 69.2% vs. 56.7%, P < 0.0001. Matching additionally on stage, differences = 64.1% vs. 56.7%, P < 0.0001; Matching further on tumor characteristics and 30 comorbidities, the disparity reduced to 61.6% vs. 56.7%, P < 0.0001. Comparing trends over time, white-black differences in survival matched for age and year were 67.6% vs. 55.2% (P < 0.0001) in the pre-Taxane era (difference = 12.4%) and 71.2% vs. 58.7% (P < 0.0001) in the post Taxane era (difference = 12.5%); age and year matched paired racial differences were not different across eras (P = 0.389). Conclusions: While there may have been some improvements in overall survival, racial disparities in breast cancer survival have not improved, despite important policy initiatives and treatment advances. Adjusting for presentation at diagnosis does reduce differences in survival, but even these differences remain large and significant, suggesting that differences in both presentation and treatment given presentation are contributing to this disparity.
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Affiliation(s)
- Jeffrey H. Silber
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Paul R. Rosenbaum
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | | | - Min Wang
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yun Teng
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Richard N. Ross
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justin Ludwig
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bijan Niknam
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Orit Even-Shoshan
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bruce J. Giantonio
- The Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Kevin R. Fox
- The Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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Pavey TG, Anokye N, Taylor AH, Trueman P, Moxham T, Fox KR, Hillsdon M, Green C, Campbell JL, Foster C, Mutrie N, Searle J, Taylor RS. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess 2012; 15:i-xii, 1-254. [PMID: 22182828 DOI: 10.3310/hta15440] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. DATA SOURCES MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. METHODS Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. RESULTS Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. LIMITATIONS We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. CONCLUSIONS There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- T G Pavey
- Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK
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Pavey TG, Taylor AH, Fox KR, Hillsdon M, Anokye N, Campbell JL, Foster C, Green C, Moxham T, Mutrie N, Searle J, Trueman P, Taylor RS. Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. BMJ 2011; 343:d6462. [PMID: 22058134 PMCID: PMC3209555 DOI: 10.1136/bmj.d6462] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the impact of exercise referral schemes on physical activity and health outcomes. Design Systematic review and meta-analysis. DATA SOURCES Medline, Embase, PsycINFO, Cochrane Library, ISI Web of Science, SPORTDiscus, and ongoing trial registries up to October 2009. We also checked study references. Study selection Design: randomised controlled trials or non-randomised controlled (cluster or individual) studies published in peer review journals. POPULATION sedentary individuals with or without medical diagnosis. Exercise referral schemes defined as: clear referrals by primary care professionals to third party service providers to increase physical activity or exercise, physical activity or exercise programmes tailored to individuals, and initial assessment and monitoring throughout programmes. Comparators: usual care, no intervention, or alternative exercise referral schemes. RESULTS Eight randomised controlled trials met the inclusion criteria, comparing exercise referral schemes with usual care (six trials), alternative physical activity intervention (two), and an exercise referral scheme plus a self determination theory intervention (one). Compared with usual care, follow-up data for exercise referral schemes showed an increased number of participants who achieved 90-150 minutes of physical activity of at least moderate intensity per week (pooled relative risk 1.16, 95% confidence intervals 1.03 to 1.30) and a reduced level of depression (pooled standardised mean difference -0.82, -1.28 to -0.35). Evidence of a between group difference in physical activity of moderate or vigorous intensity or in other health outcomes was inconsistent at follow-up. We did not find any difference in outcomes between exercise referral schemes and the other two comparator groups. None of the included trials separately reported outcomes in individuals with specific medical diagnoses. Substantial heterogeneity in the quality and nature of the exercise referral schemes across studies might have contributed to the inconsistency in outcome findings. Conclusions Considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis.
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Affiliation(s)
- T G Pavey
- Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, Exeter EX2 4SG, UK.
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Fox KR, Hillsdon M, Sharp D, Cooper AR, Coulson JC, Davis M, Harris R, McKenna J, Narici M, Stathi A, Thompson JL. Neighbourhood deprivation and physical activity in UK older adults. Health Place 2011; 17:633-40. [PMID: 21292536 DOI: 10.1016/j.healthplace.2011.01.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 12/24/2010] [Accepted: 01/06/2011] [Indexed: 11/29/2022]
Abstract
The benefits of regular physical activity for older adults are now well-established but this group remain the least active sector of the population. In this paper, the association between levels of neighbourhood deprivation and physical activity was assessed. A sample of 125 males with a mean age of 77.5 (±5.6) years, and 115 females with a mean age of age 78.6 (±8.6) underwent 7-day accelerometry, a physical performance battery, and completed a daily journeys log. Univariate associations between physical activity parameters and level of deprivation of neighbourhood were extinguished in regression models controlling for age, gender, and level of educational attainment. Age, gender, educational attainment, body mass index, physical function, and frequency of journeys from the home explained between 50% and 54% of variance in activity parameters. These results suggest the importance of strategies to help older adults maintain physical function, healthy weight, and remain active in their communities.
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Affiliation(s)
- K R Fox
- Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Tyndall Avenue, Bristol BS8 1TN, UK.
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Coulson JC, Fox KR, Lawlor DA, Trayers T. Residents' diverse perspectives of the impact of neighbourhood renewal on quality of life and physical activity engagement: improvements but unresolved issues. Health Place 2011; 17:300-10. [PMID: 21145277 PMCID: PMC3032047 DOI: 10.1016/j.healthplace.2010.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 07/28/2010] [Accepted: 11/08/2010] [Indexed: 11/16/2022]
Abstract
Few studies have been published on the reactions of residents to modifications of their residential landscape. We explored residents' experiences of home zone remodelling and construction of a new cycle-walkway in a deprived neighbourhood with a particular focus on aspects of quality of life and physical activity participation. Focus groups (n=5 groups, 21 individuals) were used to investigate residents' perceptions of the effects of neighbourhood change on their lives. Consultation by planners was received positively. Several aspects of the neighbourhood were perceived to have improved, including spatial aesthetics, lighting and streetscape planting. However, influence on physical activity was minimal. Car-focused behaviour and ownership remained dominant, and safety related concerns limited behavioural choices. Residents highlighted many socio-environmental challenges that remained such as sense of neighbourhood safety, poor public transport provision, people's parking behaviour locally, and problem neighbours, and these tended to dominate conversations. Infrastructural intervention may be one important part of multi-layered solutions to improved neighbourhood life.
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Affiliation(s)
- J C Coulson
- University of Bristol, Department of Exercise, Nutrition and Health Sciences, Centre for Sport, Exercise and Health, Tyndall Avenue, Bristol BS8 1TP, UK.
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Hirsh RL, Fox KR. Duration of chemotherapy for early stage breast cancer: have we reached the limit? What is the survival impact of amenorrhea? Curr Treat Options Oncol 2010; 11:59-62. [PMID: 21061193 DOI: 10.1007/s11864-010-0123-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hirsh RL, Fox KR. HER2 blockade: is combination therapy better than monotherapy? Curr Treat Options Oncol 2010; 11:63-5. [PMID: 21052878 DOI: 10.1007/s11864-010-0125-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Norman SA, Localio AR, Kallan MJ, Weber AL, Torpey HAS, Potashnik SL, Miller LT, Fox KR, DeMichele A, Solin LJ. Risk factors for lymphedema after breast cancer treatment. Cancer Epidemiol Biomarkers Prev 2010; 19:2734-46. [PMID: 20978176 PMCID: PMC2976830 DOI: 10.1158/1055-9965.epi-09-1245] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND As cancer treatments evolve, it is important to reevaluate their effect on lymphedema risk in breast cancer survivors. METHODS A population-based random sample of 631 women from metropolitan Philadelphia, Pennsylvania, diagnosed with incident breast cancer in 1999 to 2001, was followed for 5 years. Risk factor information was obtained by questionnaire and medical record review. Lymphedema was assessed with a validated questionnaire. Using Cox proportional hazards models, we estimated the relative incidence rates [hazard ratios (HR)] of lymphedema with standard adjusted multivariable analyses ignoring interactions, followed by models including clinically plausible treatment interactions. RESULTS Compared with no lymph node surgery, adjusted HRs for lymphedema were increased following axillary lymph node dissection [ALND; HR, 2.61; 95% confidence interval (95% CI), 1.77-3.84] but not sentinel lymph node biopsy (SLNB; HR, 1.04; 95% CI, 0.58-1.88). Risk was not increased following irradiation [breast/chest wall only: HR, 1.18 (95% CI, 0.80-1.73); breast/chest wall plus supraclavicular field (+/- full axilla): HR, 0.86 (95% CI, 0.48-1.54)]. Eighty-one percent of chemotherapy was anthracycline based. The HR for anthracycline chemotherapy versus no chemotherapy was 1.46 (95% CI, 1.04-2.04), persisting after stratifying on stage at diagnosis or number of positive nodes. Treatment combinations involving ALND or chemotherapy resulted in approximately 4- to 5-fold increases in HRs for lymphedema [e.g., HR of 4.16 (95% CI, 1.32-12.45) for SLNB/chemotherapy/no radiation] compared with no treatment. CONCLUSION With standard multivariable analyses, ALND and chemotherapy increased lymphedema risk whereas radiation therapy and SLNB did not. However, risk varied by combinations of exposures. IMPACT Treatment patterns should be considered when counseling and monitoring patients for lymphedema.
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Affiliation(s)
- Sandra A Norman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA 19104-6021, USA.
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Stathi A, McKenna J, Fox KR. Processes associated with participation and adherence to a 12-month exercise programme for adults aged 70 and older. J Health Psychol 2010; 15:838-47. [PMID: 20453043 DOI: 10.1177/1359105309357090] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study investigated the processes associated with the engagement of adults aged 70 years and older in a 12-month long research-based structured exercise programme. A sample of 21 participants (Mean age (SD) 75.8 (3.9); 14 females) and six exercise class leaders or researchers involved in the programme participated in individual semi-structured interviews. Transcripts were analysed with the principles of interpretive qualitative analysis. Our findings suggest that a programme that runs locally, provides individual attention/tailoring, delivers meaningful benefits, offers a staged approach to efficacy building, creates a sense of ownership, and provides intergenerational support and opportunities for social interaction, facilitates exercise engagement in later life.
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Affiliation(s)
- A Stathi
- School for Health, University of Bath, Bath, UK.
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Thompson JL, Jago R, Brockman R, Cartwright K, Page AS, Fox KR. Physically active families - de-bunking the myth? A qualitative study of family participation in physical activity. Child Care Health Dev 2010; 36:265-74. [PMID: 20047594 DOI: 10.1111/j.1365-2214.2009.01051.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The benefits of physical activity for reducing obesity and related chronic diseases are well known. The need for more family-based interventions to increase physical activity is frequently cited in the literature; however, little is known about if and how families are physically active together, and what factors might influence family-based participation in regular physical activity. This study examined the types of activities (physical and sedentary) engaged in as a family and explored parents' perceptions of the importance, frequency, nature and barriers to family physical activity. METHODS Semi-structured telephone interviews were conducted with 30 parents (26 female, four male) of 10- to 11-year-old schoolchildren who attended either low, middle or high socio-economic status schools in Bristol, UK. Interviews were transcribed verbatim, anonymized and analysed using conventional content analysis. RESULTS The majority of parents rated family engagement in physical activity as important, and identified benefits such as increased parent-child communication, spending time together, enjoyment, enhanced mental health, weight control and physical fitness. Despite these benefits most parents reported their families did little or no physical activity together as a family unit during the week, and any activities performed together were usually sedentary in nature. They reported increased family physical activity on the weekends but rarely including the full family unit simultaneously. Parents in two-parent households commonly paired off with one or more children because of complexities of schedules. Commonly reported barriers were busy lifestyles, diverse ages and interests of children and adults, bad weather, and lack of access to facilities, transportation and money to support activities. CONCLUSIONS Family-based interventions might be more effective if they are designed to accommodate the complex demands and needs of two-parent and single-parent families and provide affordable, diverse activities appealing to a wide range of interests.
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Affiliation(s)
- Janice L Thompson
- Department of Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK.
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Dua JS, Cooper AR, Fox KR, Stuart AG. Exercise: the neglected risk factor and the neglected treatment. Heart 2009; 95:1278. [PMID: 19605753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
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van de Vliet P, Onghena P, Knapen J, Fox KR, Probst M, van Coppenolle H, Pieters G. Assessing the additional impact of fitness training in depressed psychiatric patients receiving multifaceted treatment: a replicated single-subject design. Disabil Rehabil 2009; 25:1344-53. [PMID: 14660202 DOI: 10.1080/09638280310001616330] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Exercise has been put forward as a therapeutic means for the treatment of clinical depression. METHODS In this study, 29 patients, all with diagnosed with mood disorder, completed daily measurements of depression and physical well-being during periods ranging from 77 to 436 days (M = 146.5). Fitness training was added to the treatment after a period and changes before (A-phase) and after (B-phase) the implementation of this training were the subject of investigation. Data were analysed by means of randomization tests with an AB-design and time-series analysis. Replication of the findings was investigated using Fisher's multiplicative method. RESULTS Adding fitness training to the treatment of clinical depression does not systematically lead to changes in self-reported feelings of depression on top of benefits that may be due to other treatments. CONCLUSIONS Since the present findings are not in agreement with previous studies, the absence of statistically significant changes in self-reported feelings of depression is discussed within the complexity of the 'exercise - depression' relationship in inpatient populations. These included the severity of their depression, the potential ceiling effect of a multifaceted treatment programme and the initial increase in depression due to the confrontational nature of the intervention.
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Affiliation(s)
- P van de Vliet
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.
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Roses RE, Paulson EC, Sharma A, Schueller JE, Nisenbaum H, Weinstein S, Fox KR, Zhang PJ, Czerniecki BJ. HER-2/neu overexpression as a predictor for the transition from in situ to invasive breast cancer. Cancer Epidemiol Biomarkers Prev 2009; 18:1386-9. [PMID: 19383888 DOI: 10.1158/1055-9965.epi-08-1101] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The clinical implications of HER-2/neu (HER2) expression in ductal carcinoma in situ (DCIS) lesions have yet to be clearly elucidated; this despite the more frequent expression of HER2 in high-grade DCIS lesions compared with invasive cancers. We hypothesized that HER2 overexpression in DCIS is associated with more rapid progression to invasive disease. Immunohistochemical staining for estrogen receptor, progesterone receptor, and HER2 was done on DCIS specimens. Univariate analysis and a multivariate logistic regression were done to determine whether estrogen receptor, progesterone receptor, or HER2 status, comedo necrosis, nuclear grade, lesion size, or patient age predicted the presence of associated invasive disease in patients with DCIS. Invasive foci were found in association with HER2 overexpressing DCIS at a higher frequency than with DCIS that did not overexpress HER2. Although high nuclear grade, large lesion size, and HER2 overexpression were all associated with the presence of invasive disease on univariate analysis, HER2 was the only significant predictor for the presence of invasive disease after multivariate adjustment (odds ratio, 6.4; P = 0.01). These data indicate that HER2 overexpression in DCIS lesions predicts the presence of invasive foci in patients with DCIS and suggest that targeting of HER2 in an early disease setting may forestall or prevent disease progression.
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Affiliation(s)
- Robert E Roses
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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DeMichele A, Fox KR. Optimizing outcomes with bevacizumab by better targeting patients and tumors. Oncology (Williston Park) 2009; 23:339-340. [PMID: 19476263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Angela DeMichele
- Breast Cancer Program, Abramson Cancer Center, University of Pennsylvania, USA
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Roses RE, Paulson EC, Sharma A, Schueller JE, Nisenbaum H, Weinstein S, Fox KR, Zhang PJ, Czerniecki BJ. HER-2/neu over-expressing DCIS phenotypes and the transition from in situ to invasive breast cancer: implications for breast cancer prevention. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-1161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #1161
Background: Prognostically significant invasive breast cancer subtypes, distinguishable through immunohistochemistry for ER, PR and HER-2/neu expression, have recently been identified. The implication of similar phenotypic patterns in ductal carcinoma in situ (DCIS) lesions remains uncertain. The objective of this study was to determine whether DCIS phenotypes are associated with different rates of progression to invasive cancer.
 Methods: Immunohistochemical staining for ER, PR and HER-2/neu was performed on biopsy and resection specimens from consecutive patients evaluated with DCIS between March 2003 and May 2008. DCIS lesions were characterized as luminal A (ER+ or PR+, HER-2/neu-), luminal B (ER+ or PR+, HER-2/neu+), HER-2/neu positive (ER- and PR-, HER-2/neu+) or basal-like (ER-, PR- and HER-2/neu-). All patients underwent breast MRI and those patients with evidence of invasive disease greater than 1cm in largest dimension were excluded from the analysis. Rates of invasive disease associated with DCIS lesions with different phenotypes were compared using a chi square test. Multivariate logistic regression was used to evaluate the relationship between phenotype and invasion adjusting for patient age, lesion size, nuclear grade, and the presence of comedo necrosis.
 Results: One hundred and seven patients were included in the analysis. Luminal A was the most common phenotype and accounted for 59% of lesions (63/107). Associated invasive disease was identified in 6 patients with such lesions (10%). The HER-2/neu positive phenotype accounted for 21% of lesions (23/107). Invasive disease was identified in 8 patients with such lesions (35%). Seventeen patients had luminal B DCIS (16%) and 8 of these patients had associated invasive disease (47%). Basal-like lesions were uncommon; only four patients with such lesions were identified. The rates of invasion differed significantly between groups (overall rxc chi square p=0.002). By univariate analysis, the rates of invasion associated with luminal B and HER-2/neu positive phenotypes were significantly higher than the rate of invasion associated with the luminal A phenotype (p<0.001 and p=0.005, respectively). Luminal B DCIS was significantly associated with invasive disease after multivariate adjustment (OR=11.1 p <0.001).
 Discussion: Invasive foci are more commonly associated with HER-2/neu over-expressing DCIS phenotypes. Moreover, co-expression of HER-2/neu and ER in DCIS lesions is an independent predictor for the presence of associated invasive disease. Novel therapies targeting HER-2/neu in addition to anti-estrogen therapies may, therefore, play a role in breast cancer prevention.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1161.
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Affiliation(s)
- RE Roses
- 1 Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - EC Paulson
- 1 Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - A Sharma
- 1 Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - JE Schueller
- 1 Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - H Nisenbaum
- 2 Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - S Weinstein
- 2 Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - KR Fox
- 4 Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - PJ Zhang
- 3 Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - BJ Czerniecki
- 1 Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Fox KR. Adding bevacizumab to paclitaxel in the first-line treatment of metastatic breast cancer. Curr Oncol Rep 2009; 11:5-6. [PMID: 19080734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Fox KR. Prescribing adjuvant letrozole to patients well after the completion of tamoxifen: a good idea? Curr Oncol Rep 2009; 11:6-7. [PMID: 19080735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Fox KR. Avoiding the use of anthracyclines in the adjuvant therapy of breast cancer: the "TC" (docetaxel and cyclophosphamide) regimen. Curr Oncol Rep 2008; 10:7-8. [PMID: 18366954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Fox KR. Clinical trials report. Curr Oncol Rep 2008. [DOI: 10.1007/s11912-008-0003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Fox KR. The role of MRI scanning of the contralateral breast in women with newly diagnosed breast cancer: a new care standard or not? Curr Oncol Rep 2008; 10:8-9. [PMID: 18366955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Domchek SM, Recio A, Mick R, Clark CE, Carpenter EL, Fox KR, DeMichele A, Schuchter LM, Leibowitz MS, Wexler MH, Vance BA, Beatty GL, Veloso E, Feldman MD, Vonderheide RH. Telomerase-specific T-cell immunity in breast cancer: effect of vaccination on tumor immunosurveillance. Cancer Res 2007; 67:10546-55. [PMID: 17974999 DOI: 10.1158/0008-5472.can-07-2765] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The human telomerase reverse transcriptase (hTERT) is nearly universally overexpressed in human cancer, contributes critically to oncogenesis, and is recognized by cytotoxic T cells that lyse tumors. CD8+ T cells specific for hTERT naturally occur in certain populations of cancer patients in remission, but it remains poorly understood whether such T cells could contribute to tumor immunosurveillance. To address this issue, we induced hTERT-specific T cells in vivo via peptide vaccination in 19 patients with metastatic breast cancer who otherwise had no measurable T-cell responses to hTERT at baseline. Tumor-infiltrating lymphocytes (TIL) were evident after, but not before vaccination, with 4% to 13% of postvaccine CD8+ TIL specific for the immunizing hTERT peptide. Induction of TIL manifested clinically with tumor site pain and pruritus and pathologically with alterations in the tumor microenvironment, featuring histiocytic accumulation and widespread tumor necrosis. hTERT-specific CD8+ T cells were also evident after vaccination in the peripheral blood of patients and exhibited effector functions in vitro including proliferation, IFN-gamma production, and tumor lysis. An exploratory landmark analysis revealed that median overall survival was significantly longer in those patients who achieved an immune response to hTERT peptide compared with patients who did not. Immune response to a control cytomegalovirus peptide in the vaccine did not correlate with survival. These results suggest that hTERT-specific T cells could contribute to the immunosurveillance of breast cancer and suggest novel opportunities for both therapeutic and prophylactic vaccine strategies for cancer.
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Affiliation(s)
- Susan M Domchek
- Abramson Cancer Center, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Benfield LL, Fox KR, Peters DM, Blake H, Rogers I, Grant C, Ness A. Magnetic resonance imaging of abdominal adiposity in a large cohort of British children. Int J Obes (Lond) 2007; 32:91-9. [PMID: 18193066 DOI: 10.1038/sj.ijo.0803780] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe abdominal adipose tissue distribution in a large sample of contemporary British children; to determine the influence of gender, stage of maturation and body mass index (BMI) on abdominal adipose tissue distribution; and to compare the ability of BMI and waist circumference to predict abdominal adipose tissue. SUBJECTS AND METHODS A total of 74 boys (mean age 13.4+/-0.4 years) and 96 girls (mean age 13.5+/-0.5 years) were selected from volunteer children enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC). Height, weight and waist circumference were measured and BMI calculated. Stage of sexual maturation was available for 113 children using a self-report questionnaire based on Tanner's criteria. Magnetic resonance imaging was used to assess subcutaneous abdominal adipose tissue (SAAT) and intra-abdominal adipose tissue (IAAT) volumes and patterning. RESULTS Boys had lower levels of IAAT (P=0.036) and SAAT (P=0.003) than girls. IAAT and SAAT were higher in overweight and obese boys and girls when compared with normal weight children (P<0.0001). This pattern was also reflected in waist circumference groups. Boys had higher IAAT/SAAT ratios than girls, indicating proportionately more adipose tissue deposited intra-abdominally (P=0.002). However, both boys and girls deposited less than 10% of their abdominal fat as internal adipose tissue. WC predicted 67.4% of the variance in IAAT (P<0.001), and BMI predicted 84.8% of the variance in SAAT (P<0.001). However, BMI as the best single predictor explained only 8.4% of the variance in the IAAT/SAAT ratio (P<0.001). CONCLUSIONS At this age and stage of sexual maturation, the amount of IAAT remains relatively small. WC and BMI offer a feasible alternative to the MRI estimation of IAAT and SAAT, respectively, in a population-based sample of boys and girls. International Journal of Obesity (2008) 32, 91-99; doi:10.1038/sj.ijo.0803780; published online 27 November 2007.
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Affiliation(s)
- L L Benfield
- Department of Exercise, Nutrition, and Health Sciences, Centre for Sport, Exercise and Health, University of Bristol, Bristol, UK
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Affiliation(s)
- K R Fox
- Department of Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK.
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