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Muss HB, Polley MYC, Berry DA, Liu H, Cirrincione CT, Theodoulou M, Mauer AM, Kornblith AB, Partridge AH, Dressler LG, Cohen HJ, Kartcheske PA, Perez EA, Wolff AC, Gralow JR, Burstein HJ, Mahmood AA, Sutton LM, Magrinat G, Parker BA, Hart RD, Grenier D, Hurria A, Jatoi A, Norton L, Hudis CA, Winer EP, Carey L. Randomized Trial of Standard Adjuvant Chemotherapy Regimens Versus Capecitabine in Older Women With Early Breast Cancer: 10-Year Update of the CALGB 49907 Trial. J Clin Oncol 2019; 37:2338-2348. [PMID: 31339827 DOI: 10.1200/jco.19.00647] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Older women with breast cancer remain under-represented in clinical trials. The Cancer and Leukemia Group B 49907 trial focused on women age 65 years and older. We previously reported the primary analysis after a median follow-up of 2.4 years. Standard adjuvant chemotherapy showed significant improvements in recurrence-free survival (RFS) and overall survival compared with capecitabine. We now update results at a median follow-up of 11.4 years. PATIENTS AND METHODS Patients age 65 years or older with early breast cancer were randomly assigned to either standard adjuvant chemotherapy (physician's choice of either cyclophosphamide, methotrexate, and fluorouracil or cyclophosphamide and doxorubicin) or capecitabine. An adaptive Bayesian design was used to determine sample size and test noninferiority of capecitabine. The primary end point was RFS. RESULTS The design stopped accrual with 633 patients at its first sample size assessment. RFS remains significantly longer for patients treated with standard chemotherapy. At 10 years, in patients treated with standard chemotherapy versus capecitabine, the RFS rates were 56% and 50%, respectively (hazard ratio [HR], 0.80; P = .03); breast cancer-specific survival rates were 88% and 82%, respectively (HR, 0.62; P = .03); and overall survival rates were 62% and 56%, respectively (HR, 0.84; P = .16). With longer follow-up, standard chemotherapy remains superior to capecitabine among hormone receptor-negative patients (HR, 0.66; P = .02), but not among hormone receptor-positive patients (HR, 0.89; P = .43). Overall, 43.9% of patients have died (13.1% from breast cancer, 16.4% from causes other than breast cancer, and 14.1% from unknown causes). Second nonbreast cancers occurred in 14.1% of patients. CONCLUSION With longer follow-up, RFS remains superior for standard adjuvant chemotherapy versus capecitabine, especially in patients with hormone receptor-negative disease. Competing risks in this older population dilute overall survival benefits.
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Affiliation(s)
- Hyman B Muss
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | - Donald A Berry
- Alliance Statistics and Data Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Heshan Liu
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN
| | | | | | - Ann M Mauer
- Advocate Illinois Masonic Medical Center, Chicago, IL
| | | | | | - Lynn G Dressler
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | | | | | - Antonio C Wolff
- Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Julie R Gralow
- University of Washington Seattle Cancer Alliance, Seattle, WA
| | | | | | | | | | - Barbara A Parker
- Moores Cancer Center, University of California San Diego, La Jolla, CA
| | | | | | - Arti Hurria
- City of Hope Comprehensive Cancer Center, Duarte, CA.,Deceased
| | | | - Larry Norton
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Lisa Carey
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Dressler LG, Bell GC, Schuetze DP, Steciuk MR, Binns OA, Raab RE, Abernathy PM, Wilson CM, Kunutsor SE, Loveless MC, Ahearne PM, Messino MJ. Implementing a personalized medicine cancer program in a community cancer system. Per Med 2019; 16:221-232. [DOI: 10.2217/pme-2018-0112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Lynn G Dressler
- Independent Consultant, LGD consulting, Fairview, NC 287303, USA
- Independent Consultant, Asheville, NC 288014, USA
- Duke University Research Institute, Durham, NC 28777, USA
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
| | - Gillian C Bell
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
| | - David P Schuetze
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
| | - Mark R Steciuk
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
| | - Oliver A Binns
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
| | - Rachel E Raab
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
- Independent Scholar, Asheville, NC 2880, USA
| | - Pearl M Abernathy
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
| | - Carolyn M Wilson
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
| | - Sedope E Kunutsor
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
- Texas Cancer Registry, Austin, TX 73301
| | - Marika C Loveless
- Duke University Research Institute, Durham, NC 28777, USA
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
| | - Paul M Ahearne
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
| | - Michael J Messino
- Mission Health Cancer Center, Hospital Drive, Asheville, NC 28801, USA
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Dressler LG, Bell GC, Abernathy PM, Ruch K, Denslow S. Implementing pharmacogenetic testing in rural primary care practices: a pilot feasibility study. Pharmacogenomics 2019; 20:433-446. [PMID: 30983513 DOI: 10.2217/pgs-2018-0200] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 01/21/2023] Open
Abstract
Aim: Assess feasibility and perspectives of pharmacogenetic testing/PGx in rural, primary care physician (PCP) practices when PCPs are trained to interpret/apply results and testing costs are covered. Methods: Participants included PCPs who agreed to training, surveys and interviews and eligible patients who agreed to surveys and testing. 51 patients from three practices participated. Results: Prestudy, no PCP had ever ordered a PGx test. Test results demonstrated gene variations in 30% of patients, related to current medications, with PCPs reporting changes to drug management. Poststudy, test cost was still a concern, but now PCPs reported practical barriers, including the utilization of PGx results over time. PCPs and patients had favorable responses to testing. Summary: PGx testing is feasible in rural PCP practices.
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Affiliation(s)
- Lynn G Dressler
- Mission Health Personalized Medicine & Pharmacogenomics Program; currently Independent Consultant, LGDconsulting 512, Fairview, NC 28730, USA
| | - Gillian C Bell
- Mission Health Personalized Medicine & Pharmacogenomics Program, Asheville, NC 28801, USA
| | - Pearl M Abernathy
- Mission Health Personalized Medicine & Pharmacogenomics Program, Asheville, NC 28801, USA
| | - Karl Ruch
- Mission Health Personalized Medicine & Pharmacogenomics Program; currently OneOME, Minneapolis, MN,55405, USA
| | - Sheri Denslow
- Mission Health, Mission Research Institute, Asheville, NC 28801, USA
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Dressler LG, Bell GC, Ruch KD, Retamal JD, Krug PB, Paulus RA. Implementing a personalized medicine program in a community health system. Pharmacogenomics 2018; 19:1345-1356. [PMID: 30345883 DOI: 10.2217/pgs-2018-0130] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 12/25/2022] Open
Abstract
The implementation of a de novo personalized medicine program in a rural community health system serving an underserved population is described. Focusing on the safe use of drugs impacted by genetic variations in the non-oncology setting, we first addressed drug-gene pairs designated by the US FDA in black-box warnings (codeine, clopidogrel, abacavir, carbamazepine). The program's first success was a policy change to remove codeine from the pediatric formulary, rather than a testing recommendation. Pilot studies were then conducted with primary care providers to get them familiar with pharmacogenetic testing, and a consultative outpatient clinic for patients was developed. The assessment, planning, implementation, challenges, successes and lessons learned are described.
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Affiliation(s)
- Lynn G Dressler
- Personalized Medicine Department, Mission Health, 9 Vanderbilt Park Drive, Asheville, NC 28803, USA
| | - Gillian C Bell
- Personalized Medicine Department, Mission Health, 9 Vanderbilt Park Drive, Asheville, NC 28803, USA
| | - Karl D Ruch
- Personalized Medicine Department, Mission Health, 9 Vanderbilt Park Drive, Asheville, NC 28803, USA
| | - Jennifer D Retamal
- Informatics Department, Mission Health, 9 Vanderbilt Park Drive, Asheville, NC 28803, USA
| | - Paige B Krug
- Personalized Medicine Department, Mission Health, 9 Vanderbilt Park Drive, Asheville, NC 28803, USA
| | - Ronald A Paulus
- Office of the CEO, Mission Health, 9 Vanderbilt Park Drive, Asheville, NC 28803, USA
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Volpi S, Bult CJ, Chisholm RL, Deverka PA, Ginsburg GS, Jacob HJ, Kasapi M, McLeod HL, Roden DM, Williams MS, Green ED, Rodriguez LL, Aronson S, Cavallari LH, Denny JC, Dressler LG, Johnson JA, Klein TE, Leeder JS, Piquette-Miller M, Perera M, Rasmussen-Torvik LJ, Rehm HL, Ritchie MD, Skaar TC, Wagle N, Weinshilboum R, Weitzel KW, Wildin R, Wilson J, Manolio TA, Relling MV. Research Directions in the Clinical Implementation of Pharmacogenomics: An Overview of US Programs and Projects. Clin Pharmacol Ther 2018; 103:778-786. [PMID: 29460415 DOI: 10.1002/cpt.1048] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/31/2018] [Accepted: 02/14/2018] [Indexed: 12/29/2022]
Abstract
Response to a drug often differs widely among individual patients. This variability is frequently observed not only with respect to effective responses but also with adverse drug reactions. Matching patients to the drugs that are most likely to be effective and least likely to cause harm is the goal of effective therapeutics. Pharmacogenomics (PGx) holds the promise of precision medicine through elucidating the genetic determinants responsible for pharmacological outcomes and using them to guide drug selection and dosing. Here we survey the US landscape of research programs in PGx implementation, review current advances and clinical applications of PGx, summarize the obstacles that have hindered PGx implementation, and identify the critical knowledge gaps and possible studies needed to help to address them.
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Affiliation(s)
- Simona Volpi
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Carol J Bult
- The Jackson Laboratory for Mammalian Genetics, Bar Harbor, Maine, USA
| | - Rex L Chisholm
- Center for Genetic Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Geoffrey S Ginsburg
- Duke Center for Applied Genomic and Precision Medicine, Duke University, Durham, North Carolina, USA
| | - Howard J Jacob
- HudsonAlpha Institute for Biotechnology, Huntsville, Alabama, USA
| | - Melpomeni Kasapi
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Howard L McLeod
- DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
| | - Dan M Roden
- Department of Medicine, Pharmacology, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marc S Williams
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania, USA
| | - Eric D Green
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Laura Lyman Rodriguez
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, Florida, USA
| | - Joshua C Denny
- Departments of Biomedical Informatics and Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Lynn G Dressler
- Mission Health, Personalized Medicine Program, Asheville, North Carolina, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, Florida, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Minoli Perera
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura J Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Heidi L Rehm
- Department of Pathology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Marylyn D Ritchie
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Todd C Skaar
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nikhil Wagle
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Richard Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics and Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin W Weitzel
- Department of Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Robert Wildin
- Departments of Pathology and Laboratory Medicine, and Pediatrics, University of Vermont Medical Center, Burlington, Vermont, USA
| | | | - Teri A Manolio
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Mary V Relling
- Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Cavallari LH, Beitelshees AL, Blake KV, Dressler LG, Duarte JD, Elsey A, Eichmeyer JN, Empey PE, Franciosi JP, Hicks JK, Holmes AM, Jeng L, Lee CR, Lima JJ, Limdi NA, Modlin J, Obeng AO, Petry N, Pratt VM, Skaar TC, Tuteja S, Voora D, Wagner M, Weitzel KW, Wilke RA, Peterson JF, Johnson JA. The IGNITE Pharmacogenetics Working Group: An Opportunity for Building Evidence with Pharmacogenetic Implementation in a Real-World Setting. Clin Transl Sci 2017; 10:143-146. [PMID: 28294551 PMCID: PMC5421730 DOI: 10.1111/cts.12456] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 01/25/2017] [Indexed: 11/28/2022] Open
Affiliation(s)
- L H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA
| | - A L Beitelshees
- Department of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - K V Blake
- Biomedical Research Department, Nemours Children's Specialty Care, Jacksonville, Florida, USA
| | - L G Dressler
- Personalized Medicine and Pharmacogenetics Program, Mission Health, Asheville, North Carolina, USA
| | - J D Duarte
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA
| | - A Elsey
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA
| | - J N Eichmeyer
- Department of Oncology, St. Luke's Mountain States Tumor Institute, Boise, Idaho, USA
| | - P E Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - J P Franciosi
- Biomedical Research Department, Nemours Children's Specialty Care, Orlando, Florida, USA
| | - J K Hicks
- Division of Population Science, DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
| | - A M Holmes
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University - Purdue University, Indianapolis, Indiana, USA
| | - Ljb Jeng
- Departments of Medicine, Pathology, and Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - C R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - J J Lima
- Biomedical Research Department, Nemours Children's Specialty Care, Jacksonville, Florida, USA
| | - N A Limdi
- Department of Neurology, University of Alabama, Birmingham, Alabama, USA
| | - J Modlin
- Department of Oncology, St. Luke's Mountain States Tumor Institute, Boise, Idaho, USA
| | - A O Obeng
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - N Petry
- Department of Pharmacy Practice, North Dakota State University, Fargo, North Dakota, USA
| | - V M Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - T C Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - S Tuteja
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - D Voora
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - M Wagner
- Department of Oncology, St. Luke's Mountain States Tumor Institute, Boise, Idaho, USA
| | - K W Weitzel
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA
| | - R A Wilke
- Department of Internal Medicine, University of South Dakota, Sioux Falls, South Dakota, USA
| | - J F Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J A Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA
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Muluneh B, Deal A, Alexander MD, Keisler MD, Markey JM, Neal JM, Bernard S, Valgus J, Dressler LG. Patient perspectives on the barriers associated with medication adherence to oral chemotherapy. J Oncol Pharm Pract 2016; 24:98-109. [DOI: 10.1177/1078155216679026] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Appropriate use of oral chemotherapy is a challenge for patients and clinicians. The purpose of this study was to analyze cancer patients’ use of oral chemotherapies and identify opportunities to improve adherence. Methods We developed a 30-question survey to address frequency and reasons for reducing/skipping doses; sources of information for oral chemotherapy use; perceived importance of food–drug effects; and ease of understanding labeling directions. Results Ninety-three patients taking oral chemotherapies with chronic myeloid leukemia, renal cell carcinoma, breast cancer, and colorectal cancer completed the survey. This was a well-educated population with 69% (n = 62) having completed some college; 51% (n = 47) female and 59% (n = 54) older than 50 years of age. Thirty percent of patients reported forgetting to take their oral chemotherapy at least “sometimes”. Younger patients (<50 vs. ≥50, p = 0.002), shorter treatment duration (<6 vs. ≥6 months p = 0.03), or with chronic myeloid leukemia (vs. other diagnoses, p = 0.015) forget to take their oral chemotherapy at higher rates. Twenty-three percent (n = 21) indicated they intentionally skipped their oral chemotherapies and 38% (n = 8) of those did not inform their physicians. Forty-one percent (n = 28) taking drugs with significant food–drug effects did not think about their last meal before taking their oral chemotherapy and 80% (n = 55) did not understand the potential interactions. Additionally, 39% (n = 36/92) never looked at labeling and 15% (n = 14/91) had difficulty understanding label directions. Conclusion There are three main barriers associated with appropriate use of oral chemotherapies: misunderstanding about the timing of drug with food; stopping drug without informing physicians; and difficulty understanding labeling directions. A multipronged approach is needed to optimize communication of directions for optimal oral chemotherapy use.
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Affiliation(s)
- Benyam Muluneh
- Department of Pharmacy, University of North Carolina Medical Center
- Eshelman School of Pharmacy, University of North Carolina
| | - Allison Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina
| | - Maurice D Alexander
- Department of Pharmacy, University of North Carolina Medical Center
- Eshelman School of Pharmacy, University of North Carolina
| | - Meredith D Keisler
- Department of Pharmacy, University of North Carolina Medical Center
- Eshelman School of Pharmacy, University of North Carolina
| | - Janell M Markey
- Lineberger Comprehensive Cancer Center, University of North Carolina
| | | | | | - John Valgus
- Department of Pharmacy, University of North Carolina Medical Center
- Eshelman School of Pharmacy, University of North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina
| | - Lynn G Dressler
- Eshelman School of Pharmacy, University of North Carolina
- Fullerton Genetics Center, Mission Health Systems
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Dressler LG, Deal AM, Owzar K, Watson D, Donahue K, Friedman PN, Ratain MJ, McLeod HL. Participation in Cancer Pharmacogenomic Studies: A Study of 8456 Patients Registered to Clinical Trials in the Cancer and Leukemia Group B (Alliance). J Natl Cancer Inst 2015; 107:djv188. [PMID: 26160883 DOI: 10.1093/jnci/djv188] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 06/22/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinically annotated specimens from cancer clinical trial participants offer an opportunity for discovery and validation of pharmacogenomic findings. The purpose of this observational study is to better understand patient/institution factors that may contribute to participation in the pharmacogenomic component of prospective cancer clinical trials. METHODS Patient demographic information (age, sex, self-reported race) and institutional characteristics (CALGB/CTSU site, "diversity," and accrual) were evaluated for 8456 patients enrolled in seven CALGB phase III studies with a pharmacogenomic component. All statistical tests were two-sided. RESULTS The majority of patients (81%) consented to participate in the pharmacogenomic component. However, in a multivariable analysis, site (CALGB vs CTSU) and "institutional diversity" (percent minority cancer patients on national trials) were statistically significantly associated with participation. For both whites and nonwhites, patients from CALGB sites were more likely to participate compared with patients from CTSU sites (whites: odds ratio [OR] = 2.26, 95% confidence interval [CI] = 1.68 to 3.04, P < .001; nonwhites: OR = 1.79, 95% CI = 1.52 to 2.11, P < .001). However, as "institutional diversity" increased, the likelihood of participation in the pharmacogenomics component decreased for both white (OR = 0.94, 95% CI = 0.91 to 0.97, P < .001) and nonwhite patients (OR = 0.90, 95% CI = 0.81 to 1.00, P = .05). CONCLUSIONS Most clinical trial cancer patients across geographical, racial, and practice settings are willing to participate in pharmacogenomic studies. However, to promote equitable benefit to the larger cancer community, optimization of both patient and institutional participation are needed. Institutional factors may be even more compelling than patient demographics. Prospective studies are needed to identify and address barriers/incentives to participation in pharmacogenomic research at the patient, clinician, and institutional levels.
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Affiliation(s)
- Lynn G Dressler
- Personalized Medicine, Mission Cancer Care, Mission Health, Asheville, NC (LGD); Biostatistics Core, Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC (AMD); Alliance Statistics and Data Center, Duke University, Durham, NC (formerly the Cancer and Leukemia Group B Statistical and Data Management Center, Duke University, Durham, NC) (KO); GlaxoSmithKline, Research Triangle Park, NC (DW); Independent contractor, Williamsville, NY (KD); Department of Medicine and Center for Personalized Therapeutics, University of Chicago, Chicago, IL (PNF, MJR); DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL (HLM).
| | - Allison M Deal
- Personalized Medicine, Mission Cancer Care, Mission Health, Asheville, NC (LGD); Biostatistics Core, Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC (AMD); Alliance Statistics and Data Center, Duke University, Durham, NC (formerly the Cancer and Leukemia Group B Statistical and Data Management Center, Duke University, Durham, NC) (KO); GlaxoSmithKline, Research Triangle Park, NC (DW); Independent contractor, Williamsville, NY (KD); Department of Medicine and Center for Personalized Therapeutics, University of Chicago, Chicago, IL (PNF, MJR); DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL (HLM)
| | - Kouros Owzar
- Personalized Medicine, Mission Cancer Care, Mission Health, Asheville, NC (LGD); Biostatistics Core, Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC (AMD); Alliance Statistics and Data Center, Duke University, Durham, NC (formerly the Cancer and Leukemia Group B Statistical and Data Management Center, Duke University, Durham, NC) (KO); GlaxoSmithKline, Research Triangle Park, NC (DW); Independent contractor, Williamsville, NY (KD); Department of Medicine and Center for Personalized Therapeutics, University of Chicago, Chicago, IL (PNF, MJR); DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL (HLM)
| | - Dorothy Watson
- Personalized Medicine, Mission Cancer Care, Mission Health, Asheville, NC (LGD); Biostatistics Core, Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC (AMD); Alliance Statistics and Data Center, Duke University, Durham, NC (formerly the Cancer and Leukemia Group B Statistical and Data Management Center, Duke University, Durham, NC) (KO); GlaxoSmithKline, Research Triangle Park, NC (DW); Independent contractor, Williamsville, NY (KD); Department of Medicine and Center for Personalized Therapeutics, University of Chicago, Chicago, IL (PNF, MJR); DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL (HLM)
| | - Katherine Donahue
- Personalized Medicine, Mission Cancer Care, Mission Health, Asheville, NC (LGD); Biostatistics Core, Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC (AMD); Alliance Statistics and Data Center, Duke University, Durham, NC (formerly the Cancer and Leukemia Group B Statistical and Data Management Center, Duke University, Durham, NC) (KO); GlaxoSmithKline, Research Triangle Park, NC (DW); Independent contractor, Williamsville, NY (KD); Department of Medicine and Center for Personalized Therapeutics, University of Chicago, Chicago, IL (PNF, MJR); DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL (HLM)
| | - Paula N Friedman
- Personalized Medicine, Mission Cancer Care, Mission Health, Asheville, NC (LGD); Biostatistics Core, Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC (AMD); Alliance Statistics and Data Center, Duke University, Durham, NC (formerly the Cancer and Leukemia Group B Statistical and Data Management Center, Duke University, Durham, NC) (KO); GlaxoSmithKline, Research Triangle Park, NC (DW); Independent contractor, Williamsville, NY (KD); Department of Medicine and Center for Personalized Therapeutics, University of Chicago, Chicago, IL (PNF, MJR); DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL (HLM)
| | - Mark J Ratain
- Personalized Medicine, Mission Cancer Care, Mission Health, Asheville, NC (LGD); Biostatistics Core, Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC (AMD); Alliance Statistics and Data Center, Duke University, Durham, NC (formerly the Cancer and Leukemia Group B Statistical and Data Management Center, Duke University, Durham, NC) (KO); GlaxoSmithKline, Research Triangle Park, NC (DW); Independent contractor, Williamsville, NY (KD); Department of Medicine and Center for Personalized Therapeutics, University of Chicago, Chicago, IL (PNF, MJR); DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL (HLM)
| | - Howard L McLeod
- Personalized Medicine, Mission Cancer Care, Mission Health, Asheville, NC (LGD); Biostatistics Core, Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC (AMD); Alliance Statistics and Data Center, Duke University, Durham, NC (formerly the Cancer and Leukemia Group B Statistical and Data Management Center, Duke University, Durham, NC) (KO); GlaxoSmithKline, Research Triangle Park, NC (DW); Independent contractor, Williamsville, NY (KD); Department of Medicine and Center for Personalized Therapeutics, University of Chicago, Chicago, IL (PNF, MJR); DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL (HLM)
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9
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Kaphingst KA, Ivanovich J, Biesecker BB, Dresser R, Seo J, Dressler LG, Goodfellow PJ, Goodman MS. Preferences for return of incidental findings from genome sequencing among women diagnosed with breast cancer at a young age. Clin Genet 2015; 89:378-84. [PMID: 25871653 DOI: 10.1111/cge.12597] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [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: 12/30/2014] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 12/19/2022]
Abstract
While experts have made recommendations, information is needed regarding what genome sequencing results patients would want returned. We investigated what results women diagnosed with breast cancer at a young age would want returned and why. We conducted 60 semi-structured, in-person individual interviews with women diagnosed with breast cancer at age 40 or younger. We examined interest in six types of incidental findings and reasons for interest or disinterest in each type. Two coders independently coded interview transcripts; analysis was conducted using NVivo 10. Most participants were at least somewhat interested in all six result types, but strongest interest was in actionable results (i.e. variants affecting risk of a preventable or treatable disease and treatment response). Reasons for interest varied between different result types. Some participants were not interested or ambivalent about results not seen as currently actionable. Participants wanted to be able to choose what results are returned. Participants distinguished between types of individual genome sequencing results, with different reasons for wanting different types of information. The findings suggest that a focus on actionable results can be a common ground for all stakeholders in developing a policy for returning individual genome sequencing results.
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Affiliation(s)
- K A Kaphingst
- Department of Communication, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - J Ivanovich
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - B B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - R Dresser
- School of Law, Washington University, St. Louis, MO, USA
| | - J Seo
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | | | - P J Goodfellow
- College of Medicine, Ohio State University, Columbus, OH, USA
| | - M S Goodman
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
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10
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Dressler LG, Zeps N, Deal AM, Markey J, Knoppers B. Return of individual research results: Policies and experiences of cancer genomic researchers. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.11025] [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)
| | - Nikolajs Zeps
- Bendat Family Comprehensive Cancer Centre, St John of God HealthCare, Subiaco, Australia
| | - Allison Mary Deal
- Biostatistics Core Facility, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Janell Markey
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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11
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Abstract
Aim: The study aim was to understand physician experience and factors influencing the adoption of cancer pharmacogenomic (caPGx) testing by oncologists practicing in academic and nonacademic settings. Method: Anonymous paper surveys were distributed to oncologists practicing in North Carolina (USA). Results: Although 98% of oncologists see promise in utilizing PGx tests in their practice, few were comfortable with their knowledge (33%) or interpreting test results (37%). At one site, the survey was not distributed due to clinician unfamiliarity with the term ‘pharmacogenomics’. Compared with oncologists in academia, community oncologists were more likely to order the new Oncotype Dx™ test for colon cancer (33% vs 0; p = 0.0071), more likely to indicate future use of caPGx tests (94 vs 75%; p = 0.012) and less likely to have never ordered a caPGx test (2 vs 35%%; p < 0.001). Nearly every oncologist was interested in additional PGx education. Conclusion: A critical need exists to disseminate accurate and updated caPGx information to oncologists practicing in both academic and nonacademic settings.
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Affiliation(s)
- Lynn G Dressler
- Mission Health, Personalized Medicine Program, Fullerton Genetics Center, Asheville, NC 28803, USA
| | - Allison M Deal
- University of North Carolina, School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, NC 27599, USA
| | - Jai Patel
- Carolinas Medical Center, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC 28203, USA
| | - Janell Markey
- University of North Carolina, School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, NC 27599, USA
| | - Marcia Van Riper
- University of North Carolina, School of Nursing, Chapel Hill, NC 27599, USA
| | - Howard L McLeod
- Moffit Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
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12
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Dressler LG, Jones SS, Markey JM, Byerly KW, Roberts MC. Genomics education for the public: perspectives of genomic researchers and ELSI advisors. Genet Test Mol Biomarkers 2014; 18:131-40. [PMID: 24495163 PMCID: PMC3948600 DOI: 10.1089/gtmb.2013.0366] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS For more than two decades genomic education of the public has been a significant challenge. As genomic information becomes integrated into daily life and routine clinical care, the need for public education is even more critical. We conducted a pilot study to learn how genomic researchers and ethical, legal, and social implications advisors who were affiliated with large-scale genomic variation studies have approached the issue of educating the public about genomics. METHODS/RESULTS Semi-structured telephone interviews were conducted with researchers and advisors associated with the SNP/HAPMAP studies and the Cancer Genome Atlas Study. Respondents described approach(es) associated with educating the public about their study. Interviews were audio-recorded, transcribed, coded, and analyzed by team review. Although few respondents described formal educational efforts, most provided recommendations for what should/could be done, emphasizing the need for an overarching entity(s) to take responsibility to lead the effort to educate the public. Opposing views were described related to: who this should be; the overall goal of the educational effort; and the educational approach. Four thematic areas emerged: What is the rationale for educating the public about genomics?; Who is the audience?; Who should be responsible for this effort?; and What should the content be? Policy issues associated with these themes included the need to agree on philosophical framework(s) to guide the rationale, content, and target audiences for education programs; coordinate previous/ongoing educational efforts; and develop a centralized knowledge base. Suggestions for next steps are presented. CONCLUSION A complex interplay of philosophical, professional, and cultural issues can create impediments to genomic education of the public. Many challenges, however, can be addressed by agreement on a guiding philosophical framework(s) and identification of a responsible entity(s) to provide leadership for developing/overseeing an appropriate infrastructure to support the coordination/integration/sharing and evaluation of educational efforts, benefiting consumers and professionals.
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Affiliation(s)
- Lynn G. Dressler
- Mission Health, Fullerton Genetics Center, Personalized Medicine, Asheville, North Carolina
| | - Sondra Smolek Jones
- Department of Social Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Janell M. Markey
- Division of Hematology/Oncology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Katherine W. Byerly
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Megan C. Roberts
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
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13
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Dressler LG. Integrating personalized genomic medicine into routine clinical care: addressing the social and policy issues of pharmacogenomic testing. N C Med J 2013; 74:509-513. [PMID: 24316779] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The provision of personalized genomic medicine presents significant policy challenges, such as ensuring equitable patient access to testing, preparing clinicians to manage genomic results, justifying test reimbursement, sharing genomic information for patient care, and protecting patients against misuse of genetic information.
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Affiliation(s)
- Lynn G Dressler
- Personalized Medicine and Pharmacogenomics, Mission Health, Fullerton Genetics Center, 11 Vanderbilt Park Dr., Asheville, NC 28803, USA.
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14
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Dressler LG, Deal AM, Watson D, Hollis D, Owzar K, Donohue K, Friedman PN, Ratain MJ, McLeod HL. Participation in cancer pharmacogenomic studies in 8,456 patients registered to Cancer and Leukemia Group B (Alliance) clinical trials. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.6501] [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: 11/20/2022] Open
Abstract
6501 Background: Clinically annotated specimens from cancer clinical trial participants offer an opportunity for discovery and validation of pharmacogenomic findings. This observational study assessed patient (pt) and institutional factors that may contribute to participation in pharmacogenomic components of prospective cancer clinical trials. No trial in the study used pharmacogenomic results to guide therapy, but germline DNA was collected from consenting pts for future study of potential heritable variations associated with clinical outcome. Methods: Pt demographic data (age, sex, diagnosis, self-reported race) and institutional characteristics (CALGB/CTSU site, diversity, accrual rate) were evaluated for 8546 pts enrolled in 7 CALGB phase III trials with a pharmacogenomic component. Participation was defined as pt consent specific to this component documented in the CALGB database. Results: Most pts (81%) enrolled on the clinical trials consented to participate in the pharmacogenomic component. In a multivariable analysis, site (CALGB vs CTSU), self-reported race (non-white vs white) and institutional diversity (% minority cancer pts on national trials) were significantly associated with participation. Pts from CALGB sites were more likely to participate than pts at CTSU sites (OR 2.09, CI 1.60-2.73, p<0.0001). Non-white pts were less likely to participate than white pts (OR 0.48, CI 0.41-0.56, p<0.0001). A significant interaction between site and race was observed (OR 0.41, CI 0.37-0.47, p<0.0001). As institutional diversity increased, likelihood of participation in the pharmacogenomic component decreased for both white (p=0.0001) and non-white pts (p=0.054). Conclusions: Pharmacogenomic studies are achievable in the context of multicenter cancer clinical trials, but optimization of pt and institution participation is needed. Institutional factorsappear to be more important than pt demographics. To promote equitable pt benefit, prospective studies should be conducted to understand barriers and incentives to participation in pharmacogenomic research at the patient, clinician and institutional levels.
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Affiliation(s)
| | | | - Dorothy Watson
- Alliance Statistical and Data Center/Duke University Medical Center, Durham, NC
| | - Donna Hollis
- Cancer and Leukemia Group B Statistical Center, Durham, NC
| | | | | | | | | | - Howard L. McLeod
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
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15
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Dressler LG. Return of research results from pharmacogenomic versus disease susceptibility studies: what's drugs got to do with it? Pharmacogenomics 2012; 13:935-49. [PMID: 22676197 DOI: 10.2217/pgs.12.59] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
One of the most controversial ethical issues in genomics research is the return of individual research results to research subjects. As new technologies, including whole-genome sequencing, provide an increased opportunity for researchers to find clinically relevant research results, the questions related to if, when and how individual research results should be returned become more central to the ethical conduct of genomic research. In the absence of federal guidance on this issue, many groups and individuals have developed recommendations and suggestions to address these questions. Most of these recommendations have focused on the return of individual results from disease susceptibility studies. However, in addition to predicting the development of disease, genomic research also includes predicting an individual's response to drugs, especially the risk of developing adverse events. This article evaluates and compares the return of individual research results from disease susceptibility studies versus pharmacogenomic studies.
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Affiliation(s)
- Lynn G Dressler
- University of North Carolina, Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes & Policy, Institute of Pharmacogenomics & Individualized Therapy, 120 Mason Farm Rd, Genetic Medicine Building, Rm 1091, CB7361, Chapel Hill, NC 27599-7361, USA.
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16
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Muluneh B, Alexander M, Deal AM, Deal M, Markey J, Neal J, Bernard SA, Valgus J, Dressler LG. Prospective evaluation of perceived barriers to medication adherence by patients on oral antineoplastics. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.6042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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
6042 Background: Appropriate use of oral antineoplastics (OA), especially those with a food-effect, is a challenge for patients and clinicians. Patient adherence is essential to optimize outcomes, minimize toxicity, minimize bias in clinical trials, and reduce health care costs. As the use of OA grows, due to the narrow therapeutic margin, it is critical to understand the barriers to patient adherence. The purpose of this study was to analyze cancer patients’ use of OAs and identify opportunities to improve patient adherence. Methods: We developed and tested a 30-question survey to address frequency and reasons for reducing/skipping doses; sources of information for OA use; perceived importance of food-drug effects, and ease of understanding directions on vial label. Surveys, consisting of Likert scale and multiple choice questions, were distributed to adult cancer patients on OAs at the UNC Cancer Hospital clinics. Results: Seventy-seven patients taking OAs with CML, RCC, breast cancer, and GI tumors completed the survey with a response rate of 97%. This was a well-educated population with 71% having completed some college; 54% female and 58% older than 50 years. Forty-three percent of patients taking drugs with a significant food-drug effect (sorafenib, pazopanib, lapatinib, imatinib, nilotinib, and capecitabine) did not think about the last time they ate before taking their OA and 23% did not know that their OA had a food-drug effect. In addition, 21% of patients indicated they intentionally skipped/cut back on their OAs and 38% of those did not inform their physician. Although 97% reported no difficulty reading instructions on drug vial, nearly 20% had some difficulty understanding the directions. Conclusions: There are three main barriers associated with appropriate use of OAs: confusion or misunderstanding about the timing of drug with food; reducing/stopping drug without informing MD; and difficulty understanding directions on the drug vial label. A multipronged integrated approach involving the pharmacist, physician and nurse is needed to optimize communication of directions for optimal OA use.
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Affiliation(s)
- Benyam Muluneh
- University of North Carolina Hospitals and Clinics Department of Pharmacy, Chapel Hill, NC
| | - Maurice Alexander
- University of North Carolina Hospitals and Clinics Department of Pharmacy, Chapel Hill, NC
| | | | - Meredith Deal
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Janell Markey
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Jennifer Neal
- University of Virginia Health System Department of Pharmacy, Charlottesville, VA
| | | | - John Valgus
- University of North Carolina Hospitals and Clinics Department of Pharmacy, Chapel Hill, NC
| | - Lynn G. Dressler
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
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17
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Lara JF, Thor AD, Dressler LG, Broadwater G, Bleiweiss IJ, Edgerton S, Cowan D, Goldstein LJ, Martino S, Ingle JN, Henderson IC, Norton L, Winer EP, Hudis CA, Ellis MJ, Berry DA, Hayes DF. p53 Expression in node-positive breast cancer patients: results from the Cancer and Leukemia Group B 9344 Trial (159905). Clin Cancer Res 2011; 17:5170-8. [PMID: 21693655 DOI: 10.1158/1078-0432.ccr-11-0484] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE p53 as a prognostic and predictive factor in early-stage breast cancer has had mixed results. We studied p53 protein expression, by immunohistochemistry, in a randomized clinical trial of stage II patients treated with adjuvant doxorubicin and cyclophosphamide with or without paclitaxel [Cancer and Leukemia Group B (CALGB) 9344, INT0148]. PATIENTS AND METHODS Epithelial p53 expression was evaluated using two immunohistochemical antibodies (DO7 and 1801) in formalin-fixed, paraffin-embedded tissue from patients with node-positive breast cancer who were randomized to four cycles of cyclophosphamide and one of three doses of doxorubicin (60, 75, or 90 mg/m(2); AC) and to receive four subsequent cycles of paclitaxel (T) or not. Prognostic and predictive value of p53 protein expression was assessed, independent of treatment assignment, for escalating doses of doxorubicin or addition of T with endpoints of relapse-free (RFS) and overall survival (OS). RESULTS Of 3,121 patients, 1,887 patient specimens treated on C9344 were obtained, passed quality control, and evaluated for p53 expression. Expression was 23% and 27% for mAbs 1801 and D07, respectively, with 92% concordance. In univariate analysis, p53 positivity was associated with worse OS with either antibody, but only p53 staining with monoclonal antibody 1801 had significantly worse RFS. In multivariate analysis, p53 was not predictive of RFS or OS from either doxorubicin dose escalation or addition of paclitaxel regardless of the antibody. CONCLUSION Nuclear staining of p53 by immunohistochemistry is associated with worse prognosis in node-positive patients treated with adjuvant doxorubicin-based chemotherapy but is not a useful predictor of benefit from doxorubicin dose escalation or the addition of paclitaxel.
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Affiliation(s)
- Jonathan F Lara
- Department of Pathology, Saint Barnabas Medical Center, Livingston, NJ 07039, USA.
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18
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McGuire AL, Basford M, Dressler LG, Fullerton SM, Koenig BA, Li R, McCarty CA, Ramos E, Smith ME, Somkin CP, Waudby C, Wolf WA, Clayton EW. Ethical and practical challenges of sharing data from genome-wide association studies: the eMERGE Consortium experience. Genome Res 2011; 21:1001-7. [PMID: 21632745 DOI: 10.1101/gr.120329.111] [Citation(s) in RCA: 61] [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: 11/24/2022]
Abstract
In 2007, the National Human Genome Research Institute (NHGRI) established the Electronic MEdical Records and GEnomics (eMERGE) Consortium (www.gwas.net) to develop, disseminate, and apply approaches to research that combine DNA biorepositories with electronic medical record (EMR) systems for large-scale, high-throughput genetic research. One of the major ethical and administrative challenges for the eMERGE Consortium has been complying with existing data-sharing policies. This paper discusses the challenges of sharing genomic data linked to health information in the electronic medical record (EMR) and explores the issues as they relate to sharing both within a large consortium and in compliance with the National Institutes of Health (NIH) data-sharing policy. We use the eMERGE Consortium experience to explore data-sharing challenges from the perspective of multiple stakeholders (i.e., research participants, investigators, and research institutions), provide recommendations for researchers and institutions, and call for clearer guidance from the NIH regarding ethical implementation of its data-sharing policy.
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Affiliation(s)
- Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA.
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19
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O'Brien KM, Cole SR, Tse CK, Perou CM, Carey LA, Foulkes WD, Dressler LG, Geradts J, Millikan RC. Intrinsic breast tumor subtypes, race, and long-term survival in the Carolina Breast Cancer Study. Clin Cancer Res 2011; 16:6100-10. [PMID: 21169259 DOI: 10.1158/1078-0432.ccr-10-1533] [Citation(s) in RCA: 304] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Previous research identified differences in breast cancer-specific mortality across 4 intrinsic tumor subtypes: luminal A, luminal B, basal-like, and human epidermal growth factor receptor 2 positive/estrogen receptor negative (HER2(+)/ER(-)). EXPERIMENTAL DESIGN We used immunohistochemical markers to subtype 1,149 invasive breast cancer patients (518 African American, 631 white) in the Carolina Breast Cancer Study, a population-based study of women diagnosed with breast cancer. Vital status was determined through 2006 using the National Death Index, with median follow-up of 9 years. RESULTS Cancer subtypes luminal A, luminal B, basal-like, and HER2(+)/ER(-) were distributed as 64%, 11%, 11%, and 5% for whites, and 48%, 8%, 22%, and 7% for African Americans, respectively. Breast cancer mortality was higher for participants with HER2(+)/ER(-) and basal-like breast cancer compared with luminal A and B. African Americans had higher breast cancer-specific mortality than whites, but the effect of race was statistically significant only among women with luminal A breast cancer. However, when compared with the luminal A subtype within racial categories, mortality for participants with basal-like breast cancer was higher among whites (HR = 2.0, 95% CI: 1.2-3.4) than African Americans (HR = 1.5, 95% CI: 1.0-2.4), with the strongest effect seen in postmenopausal white women (HR = 3.9, 95% CI: 1.5-10.0). CONCLUSIONS Our results confirm the association of basal-like breast cancer with poor prognosis and suggest that basal-like breast cancer is not an inherently more aggressive disease in African American women compared with whites. Additional analyses are needed in populations with known treatment profiles to understand the role of tumor subtypes and race in breast cancer mortality, and in particular our finding that among women with luminal A breast cancer, African Americans have higher mortality than whites.
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Affiliation(s)
- Katie M O'Brien
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina 27599, USA
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20
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Rakhra-Burris TK, Auman JT, Deverka P, Dressler LG, Evans JP, Goldberg RM, Havener TM, Hoskins JM, Jonas DE, Long KM, Motsinger-Reif AA, Irvin WJ, Richards KL, Roederer MW, Valgus JM, Riper MV, Vernon JA, Zamboni WC, Wagner MJ, Walko CM, Weck KE, Wiltshire T, McLeod HL. Institutional profile. UNC Institute for Pharmacogenomics and Individualized Therapy: interdisciplinary research for individual care. Pharmacogenomics 2009; 11:13-21. [PMID: 20017668 DOI: 10.2217/pgs.09.167] [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: 11/21/2022] Open
Abstract
The Institute for Pharmacogenomics and Individualized Therapy (IPIT) at the University of North Carolina at Chapel Hill (NC, USA) is a collaborative, multidisciplinary unit that brings together faculty from different disciplines and crosses the traditional departmental/school structure to perform pharmacogenomics research. IPIT investigators work together towards the goal of developing therapies to enable the delivery of individualized medical care. The NIH-supported Comprehensive Research on Expressed Alleles in Therapeutic Evaluation (CREATE) group leads the field in the evaluation of pathways regulating drug activity, and also provides a foundation for future IPIT research. IPIT members perform bench research, clinical cohort analysis and prospective clinical intervention studies, research on the integration of pharmacogenomic therapy into practice and research to foster global health pharmacogenomics application through the Pharmacogenetics for Every Nation Initiative. IPIT Investigators are actively incorporating a pharmacogenomics curriculum into existing teaching programs at all levels.
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Affiliation(s)
- Tejinder K Rakhra-Burris
- UNC Institute for Pharmacogenomics & Individualized Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7361, USA
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21
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Abstract
After a 13-year battle in Congress--longer than it took to map the human genome--the Genetic Information Nondiscrimination Act (GINA) was passed into law on 21 May 2008. Before its passing, Francis Collins, then director of the National Human Genome Research Institute, testified before the 110th Congress that the success of personalized medicine hinged on the passing of the legislation. How will GINA, which takes effect in 2009, influence participation in pharmacogenomic research and clinical testing?
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Affiliation(s)
- L G Dressler
- Division of Pharmaceutical Outcomes and Policy, Institute of Pharmacogenomics and Individualized Therapy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA.
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22
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Abstract
Although the cancer research community has supported a "nondisclosure" position about the return of individual results to research subjects, new technologies, such as genome wide association studies, will reveal clinically relevant findings, some of which cannot be ignored. What recommendations exist that can guide researchers and Institutional Review Boards (IRBs) about this issue? This article summarizes the relevant public documents about the disclosure of individual research results to inform policy development. Four stakeholder groups were selected to make this comparison: federal, professional, advisory, and advocacy groups. Regardless of a group's position on disclosure, there was consensus that if research results were to be disclosed under any condition, the results must be analytically and clinically validated and that the researcher should not make this decision alone, but in conjunction with the IRB. There was no consensus, however, on the specific determinants for disclosure or what constitutes clinical validity. Although sufficient agreement exists to begin developing general guidelines about the process for disclosure of individual research results, the actual determinants with which to guide this decision remain challenging. An alternate framework that addresses the threshold of uncertainty a stakeholder is willing to accept, the positive predictive value of the research finding, and the magnitude of harm of returning results may be more effective to guide decision making. These assessments, along with what is considered useful information, requires the involvement of the research subject community to inform decision-making and move the policy process forward.
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Affiliation(s)
- Lynn G Dressler
- University of North Carolina School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Institute for Pharmacogenomics and Individualized Therapy, Chapel Hill, North Carolina, USA.
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23
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Muss HB, Berry DA, Cirrincione CT, Theodoulou M, Mauer AM, Kornblith AB, Partridge AH, Dressler LG, Cohen HJ, Becker HP, Kartcheske PA, Wheeler JD, Perez EA, Wolff AC, Gralow JR, Burstein HJ, Mahmood AA, Magrinat G, Parker BA, Hart RD, Grenier D, Norton L, Hudis CA, Winer EP. Adjuvant chemotherapy in older women with early-stage breast cancer. N Engl J Med 2009; 360:2055-65. [PMID: 19439741 PMCID: PMC3082436 DOI: 10.1056/nejmoa0810266] [Citation(s) in RCA: 431] [Impact Index Per Article: 28.7] [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: 12/25/2022]
Abstract
BACKGROUND Older women with breast cancer are underrepresented in clinical trials, and data on the effects of adjuvant chemotherapy in such patients are scant. We tested for the noninferiority of capecitabine as compared with standard chemotherapy in women with breast cancer who were 65 years of age or older. METHODS We randomly assigned patients with stage I, II, IIIA, or IIIB breast cancer to standard chemotherapy (either cyclophosphamide, methotrexate, and fluorouracil or cyclophosphamide plus doxorubicin) or capecitabine. Endocrine therapy was recommended after chemotherapy in patients with hormone-receptor-positive tumors. A Bayesian statistical design was used with a range in sample size from 600 to 1800 patients. The primary end point was relapse-free survival. RESULTS When the 600th patient was enrolled, the probability that, with longer follow-up, capecitabine therapy was highly likely to be inferior to standard chemotherapy met a prescribed level, and enrollment was discontinued. After an additional year of follow-up, the hazard ratio for disease recurrence or death in the capecitabine group was 2.09 (95% confidence interval, 1.38 to 3.17; P<0.001). Patients who were randomly assigned to capecitabine were twice as likely to have a relapse and almost twice as likely to die as patients who were randomly assigned to standard chemotherapy (P=0.02). At 3 years, the rate of relapse-free survival was 68% in the capecitabine group versus 85% in the standard-chemotherapy group, and the overall survival rate was 86% versus 91%. Two patients in the capecitabine group died of treatment-related complications; as compared with patients receiving capecitabine, twice as many patients receiving standard chemotherapy had moderate-to-severe toxic effects (64% vs. 33%). CONCLUSIONS Standard adjuvant chemotherapy is superior to capecitabine in patients with early-stage breast cancer who are 65 years of age or older. (ClinicalTrials.gov number, NCT00024102.)
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Dressler LG, Visscher D. Handling, storage, and preparation of human tissues. ACTA ACUST UNITED AC 2008; Chapter 5:Unit 5.2. [PMID: 18770712 DOI: 10.1002/0471142956.cy0502s01] [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: 11/12/2022]
Abstract
Human tissue for flow cytometry must be prepared as an adequate single-cell suspension. The appropriate methods for tissue collection, transport, storage, and dissociation depend on the cell parameters being measured and the localization of the markers. This unit includes a general method for collecting and transporting human tissue and preparing a tissue imprint. Protocols are supplied for tissue disaggregation by either mechanical or enzymatic means and for preparation of single-cell suspensions of whole cells from fine-needle aspirates, pleural effusions, abdominal fluids, or other body fluids. Other protocols detail preparation of intact nuclei from fresh, frozen, or paraffin-embedded tissue. Support protocols cover fixation, cryospin preparation, cryopreservation, and removal of debris.
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Affiliation(s)
- L G Dressler
- University of North Carolina, Chapel Hill, North Carolina, USA
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DiGiovanna MP, Stern DF, Edgerton S, Broadwater G, Dressler LG, Budman DR, Henderson IC, Norton L, Liu ET, Muss HB, Berry DA, Hayes DF, Thor AD. Influence of activation state of ErbB-2 (HER-2) on response to adjuvant cyclophosphamide, doxorubicin, and fluorouracil for stage II, node-positive breast cancer: study 8541 from the Cancer and Leukemia Group B. J Clin Oncol 2008; 26:2364-72. [PMID: 18390970 PMCID: PMC6589994 DOI: 10.1200/jco.2007.13.6580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Accepted: 01/24/2008] [Indexed: 11/20/2022] Open
Abstract
PURPOSE ErbB-2 (human epidermal growth factor receptor 2) overexpression may be predictive of relative resistance and/or sensitivity to specific chemotherapeutic agents. Results from a previous study from the Cancer and Leukemia Group B (CALGB 8541) demonstrated an interaction between ErbB-2 and increasing dose of adjuvant cyclophosphamide, doxorubicin, and fluorouracil (CAF) chemotherapy. Other studies have suggested that evaluation of the phosphorylated/activated form of ErbB-2 might be more precise in defining the impact of ErbB-2 in breast cancer. We have evaluated tumor tissue sections from CALGB 8541 patients to determine whether the interaction of ErbB-2 with CAF dose is dependent on ErbB-2 activation state, and whether phosphorylated ErbB-2 is an adverse prognostic factor in patients treated with CAF. PATIENTS AND METHODS Patients were randomly assigned to one of three dosing regimens of CAF. Paraffin samples from 992 of 1,572 patients who participated in CALGB 8541 were available. Of the 570 tumors with any staining for ErbB-2, 488 had tissue available for assay for phosphorylated ErbB-2, which was performed by immunohistochemistry. RESULTS Of 910 total assessable cases, 112 of 488 ErbB-2-positive cases (23%) stained positively for phosphorylated ErbB-2. The previously described interaction of dosing regimen of CAF with ErbB-2 was not dependent on phosphorylation status of ErbB-2. CONCLUSION Monitoring phosphorylation of ErbB-2 with an antiphospho-ErbB-2 antibody did not add further precision to identifying those patients most likely to benefit from increased dose of anthracycline-based adjuvant chemotherapy. Favorable outcomes are observed in ErbB-2-overexpressing patients treated with high-dose CAF regardless of ErbB-2 phosphorylation state.
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Affiliation(s)
- Michael P DiGiovanna
- Yale University School of Medicine, Section of Medical Oncology, 333 Cedar St, Room WWW 217, New Haven, CT 06510, USA.
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Hayes DF, Thor AD, Dressler LG, Weaver D, Edgerton S, Cowan D, Broadwater G, Goldstein LJ, Martino S, Ingle JN, Henderson IC, Norton L, Winer EP, Hudis CA, Ellis MJ, Berry DA. HER2 and response to paclitaxel in node-positive breast cancer. N Engl J Med 2007; 357:1496-506. [PMID: 17928597 DOI: 10.1056/nejmoa071167] [Citation(s) in RCA: 481] [Impact Index Per Article: 28.3] [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: 12/21/2022]
Abstract
BACKGROUND The status of human epidermal growth factor receptor type 2 (HER2) in breast-cancer cells predicts clinical outcomes in women who receive adjuvant anthracycline-based chemotherapy. We hypothesized that HER2 positivity predicts a benefit from adjuvant doxorubicin doses above standard levels, from the addition of paclitaxel after adjuvant chemotherapy with doxorubicin plus cyclophosphamide, or from both. METHODS We randomly selected 1500 women from 3121 women with node-positive breast cancer who had been randomly assigned to receive doxorubicin (60, 75, or 90 mg per square meter of body-surface area) plus cyclophosphamide (600 mg per square meter) for four cycles, followed by four cycles of paclitaxel (175 mg per square meter) or observation. Tissue blocks from 1322 of these 1500 women were available. Immunohistochemical analyses of these tissue specimens for HER2 with the CB11 monoclonal antibody against HER2 or with a polyclonal-antibody assay kit and fluorescence in situ hybridization for HER2 amplification were performed. RESULTS No interaction was observed between HER2 positivity and doxorubicin doses above 60 mg per square meter. HER2 positivity was, however, associated with a significant benefit from paclitaxel. The interaction between HER2 positivity and the addition of paclitaxel to the treatment was associated with a hazard ratio for recurrence of 0.59 (P=0.01). Patients with a HER2-positive breast cancer benefited from paclitaxel, regardless of estrogen-receptor status, but paclitaxel did not benefit patients with HER2-negative, estrogen-receptor-positive cancers. CONCLUSIONS The expression or amplification, or both, of HER2 by a breast cancer is associated with a benefit from the addition of paclitaxel after adjuvant treatment with doxorubicin (<60 mg per square meter) plus cyclophosphamide in node-positive breast cancer, regardless of estrogen-receptor status. Patients with HER2-negative, estrogen-receptor-positive, node-positive breast cancer may gain little benefit from the administration of paclitaxel after adjuvant chemotherapy with doxorubicin plus cyclophosphamide.
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Affiliation(s)
- Daniel F Hayes
- Breast Oncology Program,University of Michigan Comprehensive Cancer Center, Ann Arbor 48109, USA.
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Millikan RC, Newman B, Tse CK, Moorman PG, Conway K, Dressler LG, Smith LV, Labbok MH, Geradts J, Bensen JT, Jackson S, Nyante S, Livasy C, Carey L, Earp HS, Perou CM. Epidemiology of basal-like breast cancer. Breast Cancer Res Treat 2007; 109:123-39. [PMID: 17578664 PMCID: PMC2443103 DOI: 10.1007/s10549-007-9632-6] [Citation(s) in RCA: 565] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Accepted: 05/24/2007] [Indexed: 12/29/2022]
Abstract
Risk factors for the newly identified "intrinsic" breast cancer subtypes (luminal A, luminal B, basal-like and human epidermal growth factor receptor 2-positive/estrogen receptor-negative) were determined in the Carolina Breast Cancer Study, a population-based, case-control study of African-American and white women. Immunohistochemical markers were used to subtype 1,424 cases of invasive and in situ breast cancer, and case subtypes were compared to 2,022 controls. Luminal A, the most common subtype, exhibited risk factors typically reported for breast cancer in previous studies, including inverse associations for increased parity and younger age at first full-term pregnancy. Basal-like cases exhibited several associations that were opposite to those observed for luminal A, including increased risk for parity and younger age at first term full-term pregnancy. Longer duration breastfeeding, increasing number of children breastfed, and increasing number of months breastfeeding per child were each associated with reduced risk of basal-like breast cancer, but not luminal A. Women with multiple live births who did not breastfeed and women who used medications to suppress lactation were at increased risk of basal-like, but not luminal A, breast cancer. Elevated waist-hip ratio was associated with increased risk of luminal A in postmenopausal women, and increased risk of basal-like breast cancer in pre- and postmenopausal women. The prevalence of basal-like breast cancer was highest among premenopausal African-American women, who also showed the highest prevalence of basal-like risk factors. Among younger African-American women, we estimate that up to 68% of basal-like breast cancer could be prevented by promoting breastfeeding and reducing abdominal adiposity.
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Affiliation(s)
- Robert C Millikan
- Department of Epidemiology, CB #7435, School of Public Health, University of North Carolina, Chapel Hill, NC 27599-7435, USA.
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Affiliation(s)
- Lynn G Dressler
- Center for Genetic Research Ethics and Law Department of Bioethics, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4976, USA.
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Carey LA, Perou CM, Livasy CA, Dressler LG, Cowan D, Conway K, Karaca G, Troester MA, Tse CK, Edmiston S, Deming SL, Geradts J, Cheang MCU, Nielsen TO, Moorman PG, Earp HS, Millikan RC. Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study. JAMA 2006; 295:2492-502. [PMID: 16757721 DOI: 10.1001/jama.295.21.2492] [Citation(s) in RCA: 2667] [Impact Index Per Article: 148.2] [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: 12/23/2022]
Abstract
CONTEXT Gene expression analysis has identified several breast cancer subtypes, including basal-like, human epidermal growth factor receptor-2 positive/estrogen receptor negative (HER2+/ER-), luminal A, and luminal B. OBJECTIVES To determine population-based distributions and clinical associations for breast cancer subtypes. DESIGN, SETTING, AND PARTICIPANTS Immunohistochemical surrogates for each subtype were applied to 496 incident cases of invasive breast cancer from the Carolina Breast Cancer Study (ascertained between May 1993 and December 1996), a population-based, case-control study that oversampled premenopausal and African American women. Subtype definitions were as follows: luminal A (ER+ and/or progesterone receptor positive [PR+], HER2-), luminal B (ER+ and/or PR+, HER2+), basal-like (ER-, PR-, HER2-, cytokeratin 5/6 positive, and/or HER1+), HER2+/ER- (ER-, PR-, and HER2+), and unclassified (negative for all 5 markers). MAIN OUTCOME MEASURES We examined the prevalence of breast cancer subtypes within racial and menopausal subsets and determined their associations with tumor size, axillary nodal status, mitotic index, nuclear pleomorphism, combined grade, p53 mutation status, and breast cancer-specific survival. RESULTS The basal-like breast cancer subtype was more prevalent among premenopausal African American women (39%) compared with postmenopausal African American women (14%) and non-African American women (16%) of any age (P<.001), whereas the luminal A subtype was less prevalent (36% vs 59% and 54%, respectively). The HER2+/ER- subtype did not vary with race or menopausal status (6%-9%). Compared with luminal A, basal-like tumors had more TP53 mutations (44% vs 15%, P<.001), higher mitotic index (odds ratio [OR], 11.0; 95% confidence interval [CI], 5.6-21.7), more marked nuclear pleomorphism (OR, 9.7; 95% CI, 5.3-18.0), and higher combined grade (OR, 8.3; 95% CI, 4.4-15.6). Breast cancer-specific survival differed by subtype (P<.001), with shortest survival among HER2+/ER- and basal-like subtypes. CONCLUSIONS Basal-like breast tumors occurred at a higher prevalence among premenopausal African American patients compared with postmenopausal African American and non-African American patients in this population-based study. A higher prevalence of basal-like breast tumors and a lower prevalence of luminal A tumors could contribute to the poor prognosis of young African American women with breast cancer.
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Affiliation(s)
- Lisa A Carey
- Division of Hematology/Oncology, School of Public Health, Department of Epidemiology, University of North Carolina-Lineberger Comprehensive Cancer Center, Chapel Hill, NC 27599-7305, USA.
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Dressler LG, Berry DA, Broadwater G, Cowan D, Cox K, Griffin S, Miller A, Tse J, Novotny D, Persons DL, Barcos M, Henderson IC, Liu ET, Thor A, Budman D, Muss H, Norton L, Hayes DF. Comparison of HER2 status by fluorescence in situ hybridization and immunohistochemistry to predict benefit from dose escalation of adjuvant doxorubicin-based therapy in node-positive breast cancer patients. J Clin Oncol 2005; 23:4287-97. [PMID: 15994142 DOI: 10.1200/jco.2005.11.012] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE HER2 is a clinically important tumor marker in breast cancer; however, there is controversy regarding which method reliably measures HER2 status. We compared three HER2 laboratory methods: immunohistochemistry (IHC), fluorescence in situ hybridization (FISH) and polymerase chain reaction (PCR), to predict disease-free survival (DFS) and overall survival (OS) after adjuvant doxorubicin-based therapy in node-positive breast cancer patients. METHODS This is a Cancer and Leukemia Group B (CALGB) study, using 524 tumor blocks collected from breast cancer patients registered to clinical trial CALGB 8541. IHC employed CB11 and AO-11-854 monoclonal antibodies; FISH used PathVysion HER2 DNA Probe kit; PCR utilized differential PCR (D-PCR) methodology. RESULTS Cases HER2 positive by IHC, FISH and D-PCR were 24%, 17%, and 18%, respectively. FISH and IHC were clearly related (kappa = 64.8%). All three methods demonstrated a similar relationship for DFS and OS. By any method, for patients with HER2-negative tumors, there was little or no effect of dose of adjuvant doxorubicin-based therapy. For patients with HER2-positive tumors, all three methods predicted a benefit from dose-intense (high-dose) compared with low- or moderate-dose adjuvant doxorubicin-based therapy. CONCLUSION FISH is a reliable method to predict clinical outcome following adjuvant doxorubicin-based therapy for stage II breast cancer patients. There is a moderate level of concordance among the three methods (IHC, FISH, PCR). None of the methods is clearly superior. Although IHC-positive/FISH-positive tumors yielded the greatest interaction with dose of therapy in predicting outcome, no combination of assays tested was statistically superior.
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Affiliation(s)
- Lynn G Dressler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, CB 7295, Mason Farm Rd, Chapel Hill, NC 27599-7295, USA.
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Usary J, Llaca V, Karaca G, Presswala S, Karaca M, He X, Langerød A, Kåresen R, Oh DS, Dressler LG, Lønning PE, Strausberg RL, Chanock S, Børresen-Dale AL, Perou CM. Mutation of GATA3 in human breast tumors. Oncogene 2004; 23:7669-78. [PMID: 15361840 DOI: 10.1038/sj.onc.1207966] [Citation(s) in RCA: 197] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
GATA3 is an essential transcription factor that was first identified as a regulator of immune cell function. In recent microarray analyses of human breast tumors, both normal breast luminal epithelium and estrogen receptor (ESR1)-positive tumors showed high expression of GATA3. We sequenced genomic DNA from 111 breast tumors and three breast-tumor-derived cell lines and identified somatic mutations of GATA3 in five tumors and the MCF-7 cell line. These mutations cluster in the vicinity of the highly conserved second zinc-finger that is required for DNA binding. In addition to these five, we identified using cDNA sequencing a unique mis-splicing variant that caused a frameshift mutation. One of the somatic mutations we identified was identical to a germline GATA3 mutation reported in two kindreds with HDR syndrome/OMIM #146255, which is an autosomal dominant syndrome caused by the haplo-insufficiency of GATA3. The ectopic expression of GATA3 in human 293T cells caused the induction of 73 genes including six cytokeratins, and inhibited cell line doubling times. These data suggest that GATA3 is involved in growth control and the maintenance of the differentiated state in epithelial cells, and that GATA3 variants may contribute to tumorigenesis in ESR1-positive breast tumors.
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Affiliation(s)
- Jerry Usary
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
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Chung CH, Parker JS, Karaca G, Wu J, Funkhouser WK, Moore D, Butterfoss D, Xiang D, Zanation A, Yin X, Shockley WW, Weissler MC, Dressler LG, Shores CG, Yarbrough WG, Perou CM. Molecular classification of head and neck squamous cell carcinomas using patterns of gene expression. Cancer Cell 2004; 5:489-500. [PMID: 15144956 DOI: 10.1016/s1535-6108(04)00112-6] [Citation(s) in RCA: 473] [Impact Index Per Article: 23.7] [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] [Received: 11/04/2003] [Revised: 02/02/2004] [Accepted: 03/09/2004] [Indexed: 12/15/2022]
Abstract
The prognostication of head and neck squamous cell carcinoma (HNSCC) is largely based upon the tumor size and location and the presence of lymph node metastases. Here we show that gene expression patterns from 60 HNSCC samples assayed on cDNA microarrays allowed categorization of these tumors into four distinct subtypes. These subtypes showed statistically significant differences in recurrence-free survival and included a subtype with a possible EGFR-pathway signature, a mesenchymal-enriched subtype, a normal epithelium-like subtype, and a subtype with high levels of antioxidant enzymes. Supervised analyses to predict lymph node metastasis status were approximately 80% accurate when tumor subsite and pathological node status were considered simultaneously. This work represents an important step toward the identification of clinically significant biomarkers for HNSCC.
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Affiliation(s)
- Christine H Chung
- Division of Hematology/Oncology, Department of Medicine, Vanderbuilt-Ingram Cancer Center, Vanderbuilt University School of Medicine, Nashville, Tennessee 37232, USA
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Furberg H, Millikan RC, Geradts J, Gammon MD, Dressler LG, Ambrosone CB, Newman B. Reproductive factors in relation to breast cancer characterized by p53 protein expression (United States). Cancer Causes Control 2004; 14:609-18. [PMID: 14575358 DOI: 10.1023/a:1025682410937] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To evaluate the potential etiologic heterogeneity of breast cancer by examining whether associations with reproductive and other personal characteristics differed by p53 protein expression status. METHODS Data from the Carolina Breast Cancer Study, a population-based, case-control study of 861 cases and 790 controls, were utilized. Immunohistochemical staining for the p53 protein was performed on 638 archived tumor specimens; 46% of cases were classified as p53+. Two separate unconditional logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CI) for p53+ and p53- breast cancer relative to controls for reproductive and other personal characteristics. Analyses were performed separately for younger (< or = 45 years) and older (>45 years) women. RESULTS Risk factor profiles largely overlapped for p53+ and p53- breast cancer, with the exception of oral contraceptive (OC) use among younger women and a family history of breast cancer. Prolonged OC use was more strongly associated with p53+ breast cancer [OR 3.1 (95% CI: 1.2-8.1) than p53- breast cancer (OR 1.3 (95% CI: 0.6-3.2)] among younger women only. A first-degree family history of breast cancer was associated with p53+ breast cancer among younger women [OR 1.5 (95% CI: 1.0-2.2)] and older women [OR 1.4 (95% CI: 0.9-2.3)], but not p53- breast cancer in either age-group. CONCLUSIONS These results provide little evidence of breast cancer heterogeneity as classified by p53 expression status. However, although not statistically significant, OC use among younger women and family history of breast cancer may operate through a pathway involving p53 alterations to increase risk of breast cancer.
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Affiliation(s)
- H Furberg
- Derald H. Ruttenberg Cancer Center, Mt. Sinai School of Medicine, New York, NY 10029-6574, USA.
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Furberg H, Millikan RC, Geradts J, Gammon MD, Dressler LG, Ambrosone CB, Newman B. Environmental factors in relation to breast cancer characterized by p53 protein expression. Cancer Epidemiol Biomarkers Prev 2002; 11:829-35. [PMID: 12223426] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
Findings from studies of cigarette smoking and low-dose ionizing radiation exposure and breast cancer are unclear. Laboratory studies indicate that both exposures can cause DNA damage, potentially increasing cancer risk if such mutations occur in growth control genes, such as p53. We examined the potential etiologic heterogeneity of breast cancer by evaluating whether associations between cigarette smoking and low-dose ionizing radiation and breast cancer differed by p53 protein expression status. Data were obtained from the Carolina Breast Cancer Study, a population-based, case-control study conducted among African-American and white women ages 20-74 years. Questionnaire data were available from 861 women with incident, primary invasive breast cancer and 790 community-based controls. p53 immunostaining was performed on tissue from 683 women with breast cancer; 46% were classified as p53+. Two separate unconditional logistic regression models were used to calculate odds ratios (ORs) for p53+ and p53- breast cancer, as compared with controls, in relation to smoking and low-dose ionizing radiation exposure. Smoking was not differentially associated with p53+ or p53- breast cancer, even when duration, dose, and passive smoking status were considered. Exposure to individual sources of radiation did not differ for p53+ and p53- breast cancers. However, ORs for combined exposure to chest X-rays and occupational radiation were higher for p53+ [OR, 2.2; 95% confidence interval (CI), 1.0-5.3] than p53- breast cancer (OR, 1.2; 95% CI, 0.5-3.4). Combined exposure to radiation from other medical sources as well as occupational exposure was also higher for p53+ (OR, 3.7; 95% CI, 0.8-16.8) than for p53- breast cancer (OR, 1.7; 95% CI, 0.3-10.5). Although preliminary, our results suggest that exposure to multiple sources of low-dose ionizing radiation may contribute to the development of p53+ breast cancer.
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Affiliation(s)
- Helena Furberg
- Derald H. Ruttenberg Cancer Center, Mt. Sinai School of Medicine. New York, New York 10029, USA
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Stitzenberg KB, Calvo BF, Iacocca MV, Neelon BH, Sansbury LB, Dressler LG, Ollila DW. Cytokeratin immunohistochemical validation of the sentinel node hypothesis in patients with breast cancer. Am J Clin Pathol 2002; 117:729-37. [PMID: 12090421 DOI: 10.1309/7606-f158-ugjw-yble] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
No standard method for handling and histopathologic examination of the sentinel node (SN) exists. We hypothesized that a focused examination of all nodes with serial sectioning and cytokeratin immunohistochemical staining would confirm the SN as the node most likely to harbor metastasis. Intraoperative lymphatic mapping and sentinel lymphadenectomy using blue dye and (99m)technetium-labeled sulfur colloid were performed. All nodes were stained with H&E. All tumor-free nodes underwent additional sectioning and staining with H&E and an immunohistochemical stain. Routine H&E examination detected SN metastases in 27.6% of cases. Occult SN metastases were identified in 12.7% of cases. None of the 724 non-SNs examined contained occult metastases. The SN false-negative rate was zero. This study confirms histopathologically that the SN has biologic significance as the axillary node most likely to harbor metastatic tumor Standardization of the handling, sectioning, and staining of the SN is necessary as lymphatic mapping and sentinel lymphadenectomy become integrated into the care of patients with breast cancer
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Amador-Zarco JJ, Mora-Tiscareño A, Sangri-Pinto AG, Braun-Roth G, Dressler LG, Kulwichit W, Van Dyke T, Calderón-Garcidueñas L. Nasal squamous cell carcinoma in a child. J Otolaryngol 2002; 31:45-9. [PMID: 11881772 DOI: 10.2310/7070.2002.19327] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Page DL, Gray R, Allred DC, Dressler LG, Hatfield AK, Martino S, Robert NJ, Wood WC. Prediction of node-negative breast cancer outcome by histologic grading and S-phase analysis by flow cytometry: an Eastern Cooperative Oncology Group Study (2192). Am J Clin Oncol 2001; 24:10-8. [PMID: 11232942 DOI: 10.1097/00000421-200102000-00002] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Histologic evaluation and reporting of invasive breast cancer has effectively used Nottingham combined histologic grade (NCHG). This approach to predict outcome in invasive breast cancer has not been tested in multicenter cooperative trials. Histologic slides from selected breast cancer cases entered on node-negative Eastern Cooperative Oncology Group trials were assigned grades. Two pathologists evaluated cases for NCHG defined from differentiation, mitotic index, and nuclear grade. The study population consisted of separate samples from low- and high-risk strata, where low risk was estrogen receptor positive with a tumor size of less than 3 cm and high risk was estrogen receptor negative or tumor size greater than or equal to 3 cm. The rate of agreement was generally good, with 80% of cases classified the same for mitotic count and 76% of the cases classified the same for combined grade. There were no cases disagreeing from the lowest to the highest of the three categories. The median follow-up is 11.6 years, but for analysis of survival, this was truncated at 5 years. Mitotic index and combined grade as assessed by both pathologists showed significant associations with survival. High combined histologic grade was predictive for response to cyclophosphamide/methotrexate/5-fluorouracil (CMF) with survival differences at 5 years of 30% in the treated high-grade patients over the untreated patients. Overall, it is clear that pathologists can have close agreement in assignment of combined histologic grades, with highly significant prediction in univariate and borderline significance in multivariate analysis in prognostication of time to recurrence as well as survival. Thus, stratification used in these trials was highly prognostic as hoped, leaving a role for histologic grading in these relatively large tumors, more powerful than S-phase analysis in this series. In the subgroups of high-risk patients randomized between CMF and observation, there was a suggestion that the high-combined-grade group was predictive of treatment efficacy. We conclude that a combined histologic grade with defined criteria may be reliably assigned by practiced pathologists using readily available criteria, and that the measure may be of use in prognostication and prediction of therapeutic responsiveness when done in a technically ideal fashion.
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Affiliation(s)
- D L Page
- Vanderbilt University, Nashville, Tennessee, USA.
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Simpson JF, Gray R, Dressler LG, Cobau CD, Falkson CI, Gilchrist KW, Pandya KJ, Page DL, Robert NJ. Prognostic value of histologic grade and proliferative activity in axillary node-positive breast cancer: results from the Eastern Cooperative Oncology Group Companion Study, EST 4189. J Clin Oncol 2000; 18:2059-69. [PMID: 10811671 DOI: 10.1200/jco.2000.18.10.2059] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The identification of a subset of patients with axillary lymph node-positive breast cancer with an improved prognosis would be clinically useful. We report the prognostic importance of histologic grading and proliferative activity in a cohort of patients with axillary lymph node-positive breast cancer and compare these parameters with other established prognostic factors. PATIENTS AND METHODS This Eastern Cooperative Oncology Group laboratory companion study (E4189) centered on 560 axillary lymph node-positive patients registered onto one of six eligible clinical protocols. Flow cytometric (ploidy and S-phase fraction [SPF]) and histopathologic analyses (Nottingham Combined Histologic Grade and mitotic index) were performed on paraffin-embedded tissue from 368 patients. RESULTS Disease recurred in 208 patients; in 161 (77%), within the first 5 years. Mitotic index and grade were associated with both ploidy and SPF (P </=.01). Within the first 5 years of follow-up, mitotic index (P =.004), grade (P =.004), ploidy (P =. 006), and SPF (P =.05) were associated with time to recurrence; there was also a significant association with survival. The effect of mitotic index was largely a result of the difference between 0 to 2 mitoses/10 high-power fields (HPF; 5-year recurrence of 31%) and more than 2 mitoses/10 HPF (5-year recurrence of 52%). The 0 to 2 mitoses/10 HPF group was independently associated with improved prognosis at 5 years (P =.002) in regression models that included other standard prognostic factors. CONCLUSION A subset of axillary lymph node-positive patients with improved prognosis may be identified using a lower (< 3 mitoses/10 HPF) mitotic count than is usually performed.
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Affiliation(s)
- J F Simpson
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Abstract
HER2 measurement holds great promise in predicting response to a variety of systemic therapies an exciting step forward in the management of breast cancer patients. The enthusiasm surrounding the clinical importance of HER2, however, is tempered by the uncertainty regarding the clinical usefulness and accuracy of the different methodologies currently available to assess HER2 status. In this paper the authors address laboratory and technical issues associated with methods which measure HER2 overexpression or amplification. We also discuss how these issues can influence the clinical utility and routine application of this marker. While a tumor marker may be considered clinically relevant, it must be proven to be clinically useful. Optimally, this should occur in the setting of a randomized clinical trial, using methods that are reliable, reproducible, and biologically accurate. For HER2 testing to be a useful, routine clinical marker several critical issues need to addressed. These include the determination and validation of the clinical utility of each method to predict response to the different systemic therapies currently associated with HER2. In addition, there is need to set standards for assay performance and interpretation of assay results, based on criteria that are clinically validated.
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Affiliation(s)
- L G Dressler
- University of North Carolina, Lineberger Comprehensive Cancer Center, Department of Medicine, Chapel Hill, North Carolina 27599-7295, USA.
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Dressler LG, Geradts J, Burroughs M, Cowan D, Millikan RC, Newman B. Policy guidelines for the utilization of formalin-fixed, paraffin-embedded tissue sections: the UNC SPORE experience. University of North Carolina Specialized Program of Research Excellence. Breast Cancer Res Treat 1999; 58:31-9. [PMID: 10634516 DOI: 10.1023/a:1006354627669] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Paraffin blocks represent a valuable resource that has allowed investigators to apply today's technology to address scientific questions in a shorter period of time and in more diverse populations than would have been possible with fresh or frozen tissue. However, in addition to being an exhaustible resource, there is concern regarding the appropriate use of these tissues, both with respect to medical or legal considerations and quality control and quality assurance practices. We describe policy guidelines to address these concerns, including: safeguards to address medical/legal and patient confidentiality issues, quality control and quality assurance for tissue sectioning, processing and storage, database management for sample tracking, and scientific review for utilization of specimens. These policies and procedures have been developed and implemented by the University of North Carolina (UNC) Specialized Program of Research Excellence (SPORE) in the Breast Cancer Immunohistochemistry (IHC) Core laboratory, in collaboration with our study pathologists, participants, and research investigators. It is our hope that the information and experience described here may stimulate discussion that can ultimately lead to a uniform policy for handling formalin-fixed paraffin-embedded tissues in research.
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Affiliation(s)
- L G Dressler
- The University of North Carolina, Lineberger Comprehensive Cancer Center and School of Public Health, Department of Medicine, Chapel Hill 27599-7295, USA.
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Affiliation(s)
- L G Dressler
- University of North Carolina-Chapel Hill, Lineberger Comprehensive Cancer Center School of Medicine 27599
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Dressler LG, Duncan MH, Varsa EE, McConnell TS. DNA content measurement can be obtained using archival material for DNA flow cytometry. A comparison with cytogenetic analysis in 56 pediatric solid tumors. Cancer 1993; 72:2033-41. [PMID: 8395970 DOI: 10.1002/1097-0142(19930915)72:6<2033::aid-cncr2820720640>3.0.co;2-j] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [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: 01/30/2023]
Abstract
BACKGROUND Although flow cytometry (FCM) has become a widely used technique for the measurement of DNA content in solid tumors, the correlation of ploidy analysis by FCM with cytogenetic analysis (CGA) is not well described. The sensitivities of G-banded CGA and FCM were compared to determine the accuracy of the DNA index value (DI) as a measurement of chromosome number. METHODS Tumor specimens from 56 pediatric cases were analyzed for DNA content by both FCM and CGA. Nuclei for FCM were prepared from archival tissue in 53 specimens using a modification of the Hedley technique and from fresh tissue in 3 specimens. Metaphase chromosomes for CGA were prepared from standard solid tumor harvests and Giemsa-trypsin banding procedures. Ploidy status for this study was defined as (1) diploid--DI between 0.97 and 1.03 by FCM or chromosome number +/- 2 from normal by CGA (44-48); and (2) aneuploid--DI < 0.97 or > 1.03 by FCM or total chromosomes < 44 or > 48 by CGA. RESULTS Forty-nine of the 56 pediatric specimens were evaluable by both techniques. Concordance was observed in 34 cases (69%) between the two techniques in assigning similar ploidy status to a tumor (22 diploid and 12 aneuploid). It also was observed that among the aneuploid concordant cases, the actual DI obtained from archival material could predict total chromosome number with 95% accuracy. The 15 discordant cases showed a distinct aneuploid population by FCM, but were diploid by CGA. CONCLUSIONS A correlation of 69% was obtained between both techniques to assign a similar ploidy status (diploid versus aneuploid) in 56 pediatric solid tumors. These results support the combined use of CGA and FCM to obtain the most complete analysis of DNA content and chromosome abnormalities in pediatric solid tumors. FCM on formalin-fixed, paraffin-embedded tissue can be used to measure total DNA content.
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Affiliation(s)
- L G Dressler
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque
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Dressler LG. DNA flow cytometry measurements as surrogate endpoints in chemoprevention trials: clinical, biological, and quality control considerations. J Cell Biochem Suppl 1993; 17G:212-8. [PMID: 8007701 DOI: 10.1002/jcb.240531139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
DNA flow cytometric evaluation of S-phase fraction (SPF) is a strong and consistent predictor of relapse-free survival in the node-negative breast cancer patient. As such, it can be implicated as a marker of tumor aggressiveness and has been shown to be an independent predictor of outcome in a multivariate setting. Measurement of ploidy status is less well-defined as a marker of prognosis, but may be an important marker of response to therapy. Estimation of DNA ploidy and proliferative capacity by flow cytometry can be obtained from virtually any type of specimen, including fine needle aspirates, fresh or frozen material, as well as formalin-fixed, paraffin-embedded material, as long as there is a sufficient number of tumor nuclei for assay. Therefore, the assay has clinical relevance in predicting relapse, as well as providing flexibility for sample preparation. In addition, flow cytometric measurements are biologically relevant markers. In general, DNA index is a good estimate of total chromosome number. SPF, using sophisticated modeling algorithms, shows good correlation with thymidine labeling index and/or bromodeoxyuridine incorporation, two standard assays used to measure DNA synthesis in fresh tissue. Recently, preliminary data in locally advanced breast cancer have indicated that ploidy and/or S-phase may also be useful in predicting cellular response to chemotherapy. Although there is good justification for measuring these parameters, appropriate quality control and quality assurance measures must be incorporated into all aspects of the assay--from sample handling and preparation to interpretation of cell cycle and histogram data.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- L G Dressler
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill 27599-7305
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Affiliation(s)
- L G Dressler
- University of New Mexico School of Medicine, UNM Cancer Center, Albuquerque
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Clark GM, Mathieu MC, Owens MA, Dressler LG, Eudey L, Tormey DC, Osborne CK, Gilchrist KW, Mansour EG, Abeloff MD. Prognostic significance of S-phase fraction in good-risk, node-negative breast cancer patients. J Clin Oncol 1992; 10:428-32. [PMID: 1740681 DOI: 10.1200/jco.1992.10.3.428] [Citation(s) in RCA: 83] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Formalin-fixed, paraffin-embedded tissues from axillary node-negative breast cancer patients were analyzed by flow cytometry to determine the prognostic significance of DNA ploidy and S-phase fraction (SPF). PATIENTS AND METHODS All patients were registered on a good-risk control arm of an intergroup clinical trial. They had small- to intermediate-sized (less than 3 cm), estrogen receptor (ER)-positive tumors and received no adjuvant therapy after modified radical mastectomy or total mastectomy with low axillary-node sampling. The median follow-up was 4.8 years. RESULTS Assessable ploidy results were obtained from 92% of the 298 specimens studied (51% diploid, 49% aneuploid), and SPFs were assessable for 83% of the tumors. SPFs for diploid tumors ranged from 0.7% to 11.9% (median, 3.6%), compared with a range of 1.2% to 26.7% (median, 7.6%) for aneuploid tumors (P less than .0001). No significant differences in disease-free or overall survival were observed between patients with diploid and aneuploid tumors. Using different SPF cutoffs by ploidy status (4.4% for diploid, 7.0% for aneuploid), patients with low SPFs had significantly longer disease-free survival rates than patients with high SPFs (P = .0008). The actuarial 5-year relapse rates were 15% and 32% for patients with low (n = 142) and high SPFs (n = 105), respectively. Similar relationships between SPF and clinical outcome were observed for patients with diploid tumors (P = .053) and for patients with aneuploid tumors (P = .0012). CONCLUSION S-phase fraction provides additional prognostic information for predicting disease-free survival for axillary node-negative breast cancer patients with small, ER-positive tumors.
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Affiliation(s)
- G M Clark
- University of Texas Health Science Center, San Antonio 78284-7884
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Abstract
The appropriate management of the breast cancer patient with early stage disease is a controversial, frustrating issue. If laboratory tests could accurately predict tumor behavior, however, the clinician and patient would be greatly aided in their treatment decisions. Although imperfect, there are several new and significant factors that can be used to predict patient prognosis; the most promising and well studied of these factors are DNA flow cytometry measurements. There are at least two estimates of tumor aggressiveness that we can obtain from DNA flow cytometry: one is an estimate of the tumor DNA content or ploidy and the other is an estimate of the tumor proliferative capacity. These measurements have their greatest clinical impact in the node negative patient predicting for relapse-free survival and overall survival. Estimates of proliferative capacity are independent predictors of patient prognosis. Estimates of DNA content are at times controversial and yet still are helpful in distinguishing prognostic subgroups of proliferative activity and may have additional clinical relevance. This discussion will summarize the data obtained from DNA flow cytometry measurements supporting their use as clinically important markers of prognosis in the node-negative patient.
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Affiliation(s)
- L G Dressler
- University of New Mexico School of Medicine, Center for Molecular and Cellular Diagnostics, Albuquerque 87131
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48
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Affiliation(s)
- L G Dressler
- Division of Molecular and Cellular Diagnostics, University of New Mexico Cancer Center, Albuquerque 87131
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49
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Varsa EW, McConnell TS, Dressler LG, Duncan M. Atypical congenital mesoblastic nephroma. Report of a case with karyotypic and flow cytometric analysis. Arch Pathol Lab Med 1989; 113:1078-80. [PMID: 2549909] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Atypical congenital mesoblastic nephroma is a rare infantile renal tumor that may behave aggressively in older infants. A case of atypical congenital mesoblastic nephroma occurring in an 8-month-old hispanic male was analyzed by routine histopathologic, cytogenetic, and retrospective flow cytometric analysis for DNA ploidy. Light microscopy revealed marked hypercellularity. The karyotype was abnormal, with the following configuration: 45,XY,-1,-3,-9,-9,-15,-17,-21,+del(1)(q21q25),+der(3), t(3;9;15)(q23;p22;q11),+der(9),t(3;9;15) (q23;p22;q11),+der(9),t(9;?) (p?22;?),+r21, + mar. Retrospective DNA ploidy analysis revealed a DNA index of 1.0. The significance of karyotypic changes occurring in mesenchymal renal tumors of this type is currently unknown. Cytogenetic analysis might be of prognostic value in these potentially aggressive tumors.
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Affiliation(s)
- E W Varsa
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque 87131
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Abstract
More accurate prediction of the prognosis in women with node-negative breast cancer may improve physicians' ability to identify the patients most likely to benefit from systematic adjuvant therapy. With this in mind, we performed DNA flow-cytometric measurements of ploidy and the fraction of cells in the synthesis phase of the cell cycle (S-phase fraction) on 395 specimens of node-negative breast cancer from our bank of frozen tumors, using the aliquots of pulverized frozen tissue from steroid-receptor assays. The median duration of follow-up in patients still alive at the time of analysis was 59 months. Thirty-two percent of the 345 specimens that could be evaluated were diploid, and 68 percent were aneuploid. The probability of disease-free survival at five years was 88 +/- 3 percent in patients with diploid tumors and 74 +/- 3 percent in those with aneuploid tumors (P = 0.02). The S-phase fraction was not a significant additional predictor of disease-free survival in patients with aneuploid tumors. However, the probability of disease-free survival in patients with diploid tumors and low S-phase fractions was 90 +/- 3 percent at five years, as compared with 70 +/- 13 percent in those with diploid tumors and high S-phase fractions (P = 0.007). Similar differences in overall survival were noted. We conclude that DNA flow-cytometric measurements of ploidy and S-phase fraction can be performed on frozen specimens of tumors and are potentially important predictors of disease-free and overall survival in patients with node-negative breast cancer.
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Affiliation(s)
- G M Clark
- Department of Medicine, University of Texas Health Science Center, San Antonio 78284-7884
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