O050 A ten-year review of methodological trends and outcomes in riskreducing mastectomy and associated reconstruction at a tertiary referral centre

Introduction

Risk-reducing mastectomy (RRM) is the removal of breast tissue to substantially decrease the risk of developing breast cancer in individuals with higher breast cancer susceptibility due to strong family history or genetic mutations. This retrospective study evaluates cases of RRM, and subsequent reconstruction performed at a tertiary referral centre over the last decade, with emphasis on mastectomy and reconstructive trends.

Methods

A retrospective review of all cases of RRM performed between January 2010 and January 2020, divided into two groups corresponding to the first half (group 1) and second half (group 2) of the decade was conducted. Data collected included demographics, genetic test results, family and personal history of breast cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and complications.

Results

A total of 167 patients (group 1=76, group 2=91) underwent RRM, with a significant increase in cases of RRM despite negative genetic test results (p=0.047). The proportion of nipple sparing techniques for RRM compared to more traditional skin-sparing techniques. Concomitantly, post-RRM reconstruction has progressively become solely implant-based, to coincide with a rise in ADM usage. This is consistent with national trends towards fewer complex autologous procedures.

Take-home message

Emergent trends in risk-reducing mastectomy and reconstructive techniques are occurring against a background of broadened indications for RRM and more frequent patient requests for RRM in the absence of any documented pathogenic gene mutation. As breast surgery continues to evolve, it is important to evaluate specific trends such as more conservative forms of mastectomy and novel techniques/devices for breast reconstruction to ensure optimal patient care and levels of satisfaction.

Abstract PS7-44: Energetics and lifestyle in inherited syndromes (ELLIE'S study)

Background: US women have a 1 in 8 lifetime chance of developing breast cancer (BC), with an estimated 10% resulting from a hereditary BC gene mutation. Individuals with mutations in genes such as BRCA1 and BRCA2 have an increased risk of breast and ovarian cancer, as well as other types of cancers. At present, there are more than a dozen other hereditary cancer related genetic mutations that have an associated moderate to high risk of developing cancer. Along with an ability to identify and characterize risk in individuals with a hereditary cancer mutation, there is a need to study modifiable factors such as dietary intake and physical activity in relation to an individual’s risk for cancer.

Obesity and poor physical fitness are independently associated with an increased risk of BC and recurrence. There is a paucity of data on the impact of BMI, obesity, and physical activity on primary and recurrent BC in genetic mutation carriers. Women with a moderate penetrance gene mutation are at a high risk for BC and yet are likely to have an impact from modifiable risk factors. The impact of obesity, diet, and physical activity on BC risk and outcomes needs to be further characterized in genetic mutation carriers.

Methods: A short REDCap electronic survey was disseminated on social media and through our advocate partner Facing our Risk of Cancer Empowered (FORCE). Eligible participants include males or females, ≥18 years with a hereditary cancer genetic mutation. The survey includes questions regarding personal health, weight, height, metabolic risk factors, reproductive history as well as personal and/or family history of cancer and gene mutation status. In addition, includes a standardized assessment for diet (14-Item Mediterranean Diet Tool) and physical activity (IPAQ and modifiable PAQ). The first 1000 participants are compensated for their time with a $10 e-card. The survey is available in English and Spanish. The Spanish version was developed in collaboration with JUNTOS Kansas City.

Objectives: To establish a cohort and describe obesity rates, physical activity, metabolic factors, and nutrition in a cohort of individuals that have an increased risk of cancer due to a hereditary cancer genetic mutation.

Results: A total of N = 1,117 surveys have been completed as of June 30, 2020. Of them, 61.2% were removed from final analysis due to incomplete surveys, internet bots, and multiple single-user entries. A total N = 443 surveys have been verified and included in this analysis. Demographics: 98.6% female (n= 437), 94.4% white (n = 418) and median age 46 (range 19 – 77 yrs). Mutations represented in the cohort include: BRCA2 (39.0%), BRCA1 (29.1%), CHEK2 (13.1%), and ATM (5.9%) and < 5%: PALB2, RAD51D, and TP53. Median BMI 24.9 ± 6.06 stdv. BMI 25 to < 30: 26.4% (n = 117). BMI 30 or > 30: 23.47% (n = 104). 61.3% responders are currently trying to lose weight. Attempts at weight loss: No attempts: n = 60 (13.5%), at least 1: n = 55 (12.4%), 2-5: n = 211 (47.6%), 6 or more: n = 117 (26.4%). Limitations to exercise include motivation (26.9%), time (23.5%), not liking exercise (15.6%), and lack of gym memberships (12.4%). 74.9% (n = 332) responded that they are interested in participating in future studies. The Spanish survey was made available 3/3/2020, no responses to date.

Conclusion: Individuals harboring a hereditary cancer genetic mutation are interested and willing to participate in research focused on lifestyle modifications and association with cancer risk. Rates of being overweight or obese are high and many have made multiple attempts at weight loss and find common barriers to exercise. Social media is a feasible platform to recruit to a lifestyle research project in a rare population. Additional steps to limit internet trolls, bots, and repetitive responses are necessary but did not impede recruitment. Further effort and collaboration are needed to expand the survey to underrepresented minorities.

Citation Format: Lauren E Nye, Kendra Cruz, Sue Friedman, Diane Rose, Christie Befort, Debra K Sullivan, Jill M Hamilton-Reeves, Lisa M Harlan-Williams, Fariba Behbod, Jo Wick, Melinda Irwin, Jennifer Klemp. Energetics and lifestyle in inherited syndromes (ELLIE'S study) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-44.

Efficacy of Weight Loss Interventions in United States Active Duty Military Populations: A Systematic Review

BACKGROUND

Since the beginning of overseas contingency operations, the percent of service members who are considered overweight or obese has tripled to 15% for men and 20% for women. This has implications for national security if the country is unable to staff its military with fit-to-fight individuals. The purpose of this systematic review is to move policy efforts forward by illuminating the efficacy of several lifestyle interventions for active duty service members since 2001. It aims to both identify common aspects of successful interventions and also identify interventions without success so DoD leaders may replace those initiatives.

MATERIALS AND METHODS

The electronic database PubMed was searched from September 11, 2001 to May 15, 2020. Studies were included if the target population was United States active duty service members from any branch, the study included an intervention, and the measured outcome was weight loss. Seven studies met final inclusion criteria.

RESULTS

Interventions with corresponding weight loss data are summarized in Table III. This review found that there is not a sufficient body of evidence to determine if interventions to aid active duty service members in losing weight are effective.

CONCLUSION

However, as a collection, the studies could support the notion that military members get the best results when interventions are convenient, modern, personalized, and accessible. More studies are needed, and future studies with larger sample sizes and longer durations would be valuable in determining efficacy of weight loss interventions. Undoubtedly, enrollment and compliance is difficult with military member moves and competing mission requirements. Ideally, the DoD should work to aggregate the efforts in this field, as many initiatives are not captured, shared, and utilized by other installations or other services. Data silos and unpublished or underdeveloped research reactively addresses issues and does not proactively address them. Policy change will need to be nested in further research, as well as consider the food environment on bases and possible prevention efforts.

Pilot study of combined aerobic and resistance exercise on fatigue for patients with head and neck cancer: Inflammatory and epigenetic changes

This pilot study examined whether a combined aerobic resistance exercise program reduced fatigue and the potential inflammatory and epigenetic mechanisms in patients with head and neck cancer (HNC) receiving intensity-modulated radiotherapy. The exercise group (N = 12) received a 3-month supervised aerobic resistance exercise intervention that was initiated before a 6-week radiotherapy regimen; the control group (N = 14) received standard care. Fatigue was measured using Multidimensional Fatigue Inventory-20; physical function measures included a 6-minute walk distance (6MWD), chair stands, bicep curls, and hand grip strength. Inflammatory markers and DNA methylation data were acquired using standardized protocol. Patients were mostly white (93%) and male (81%) with a mean age of 57 years. At the end of the intervention, the exercise group had a marginal decrease in fatigue compared with the control (-5.0 vs. 4.9; P = 0.10). The exercise group had a significantly greater improvement in 6MWD (29.8 vs. -55.5 m; P = 0.04), and a marginally smaller decline in hand grip (-0.3 vs. -5.8 lbs; P = 0.05) at the end of the intervention than the control. No significant difference in inflammatory markers was observed between groups. Lower plasma interleukin (IL) 6, IL1 receptor antagonist, tumor necrosis factor α (TNFα), soluble TNF receptor II and C-reactive protein were significantly associated with increased 6MWD, chair stand, and bicep curl at the end of the intervention (p < 0.05). Among the 1152 differentially methylated sites (DMS) after intervention (p < 0.001), 163 DMS were located in gene promoter regions. Enrichment analysis suggested that the top 10 upstream regulators were associated with tumor (HNF4A, RPP38, HOXA9, SAHM1, CDK7, NDN, RPS15) and inflammation (IRF7, CRKL, ONECUT1). The top 5 diseases or functions annotations of the 62 hypermethylated DMS indicated anti-tumor and anti-inflammatory effects that might be linked to exercise. These findings suggest that exercise may improve physical performance and reduce fatigue, which could be further linked to decreased inflammation, during active radiotherapy for HNC patients. Larger studies are warranted.

An International Survey Evaluating Factors Influencing the Use of Total Intravenous Anaesthesia

The purpose of this study was to evaluate factors influencing the use of propofol-based total intravenous anaesthesia (TIVA) since despite TIVA being a well-established technique, it is used far less frequently than volatile anaesthesia. Questions were formulated after reviewing the literature for perceived disadvantages of TIVA and meeting with a focus group consisting of both senior and junior anaesthestists from our department. Once the survey had been formulated, specialist anaesthetists from professional colleges and societies from several countries were invited to complete the survey on an electronic web-based platform to allow evaluation of the respondent's rating of the importance of a range of factors in their decision not to use TIVA for a particular case. Basic descriptive statistics were determined using SPSS statistical software, while graphical depictions of data were handled using R for statistical analysis. A total of 763 survey responses were included in the final analysis and stratified according to the frequency of TIVA use. Among the infrequent users, issues such as additional effort, institutional preference, lack of real-time monitoring of propofol concentration, risk of missing drug delivery failure and increased turnaround time were among the top reasons mentioned. Interestingly, these issues were considered far less important among the frequent users when not choosing TIVA. We concluded that frequent and infrequent users respond quite differently to similar technical TIVA-related factors. Non-technical factors may play an important role in the infrequent user's decision not to use TIVA for a particular case.

Abstract P5-11-02: Impact of pre-operative exercise and mind-body interventions on patient-reported outcomes in women with newly diagnosed breast cancer

Background: Breast cancer diagnosis has a number of adverse psychological effects. The Pre-Operative Health and Body (PreHAB) Study tested the impact of exercise and mind-body interventions upon on mood, quality of life, and patient-reported outcomes in women with newly diagnosed breast cancer.

Methods: Women with newly diagnosed Stage I-III breast cancer were enrolled through Dana-Farber Cancer Institute and Yale University breast cancer clinics prior to surgery. Participants were randomized 1:1 to an aerobic and strength-training exercise intervention, comprised of twice-weekly meetings with an exercise trainer and home based aerobic exercise, or to a self-directed mind-body relaxation intervention, comprised of a book and CD focused on relaxation and visualization. Participants engaged in the interventions between enrollment and surgery. The EORTC QLQ C-30, Hospital Anxiety and Depression Scale, and Perceived Stress Scale were collected at enrollment and prior to surgery.

Results: 49 women were randomized (27 exercise and 22 control). Mean time between enrollment and surgery was 4.2 weeks. At baseline, patients reported moderate levels of anxiety, stress, insomnia, and lack of appetite, as well as diminished emotional and cognitive functioning (Table). Exercise participants significantly increased minutes of weekly exercise vs. mind-body participants (increase of 203 vs. 23 min/wk, p&lt;0.0001). Mind body participants engaged in the intervention on average 69% of days during the intervention period. Pre-post changes demonstrated that participation in the mind-body intervention led to improvements in emotional and cognitive functioning and a reduction in anxiety and stress, and participation in the exercise intervention led to improvements in global quality of life, insomnia, appetite, and stress (Table). Women in the mind-body group experienced a significantly greater improvement in cognitive functioning as compared to women in the exercise group.

Conclusions: Women with newly diagnosed breast cancer reported a number of physical and psychological symptoms in the pre-operative period. Exercise and mind-body interventions demonstrated promising benefits in improving functioning and reducing symptoms. More work is needed to develop pre-operative programs to help reduce the distress imparted by a cancer diagnosis in the critical time between diagnosis and surgery.

Table*

 Exercise Mind Body Between Groups BaselineChangep valueBaselineChangep valuep valueEmotional Functioning68.6 (23.3)4.7 (18.3)0.2966.3 (24.2)10.0 (20.5)0.050.64Cognitive Functioning79.5 (24.6)-3.3 (24.1)0.6273.8 (22.1)11.7 (15.4)0.0020.03QOL74.0 (15.3)9.7 (15.9)0.00569.0 (21.1)7.5 (18.5)0.110.78Insomnia35.9 (32.6)-16.7 (32.6)0.0334.9 (35.7)-8.3 (21.3)0.060.52Lack of Appetite17.9 (27.0)-13.3 (27.2)0.0311.1 (19.2)-5.0 (22.4)0.530.29Anxiety8.3 (3.4)-0.6 (2.9)0.259.2 (2.5)-1.6 (2.3)0.0060.35Stress14.7 (7.2)-2.2 (4.9)0.0618.4 (5.5)-3.1 (6.8)0.060.77

*Results reported as means (SD). Positive scores on functional and QOL measures indicate improvements; negative scores on symptom measures indicate a decrease in symptoms.

Citation Format: Ligibel JA, Giobbie-Hurder A, Dillion D, Shockro L, Campbell N, Rhei E, Troyan S, Dominici L, Golshan M, Chagpar A, Yung R, Freedman R, Tolaney S, Winer E, Frank E, McTiernan A, Irwin M. Impact of pre-operative exercise and mind-body interventions on patient-reported outcomes in women with newly diagnosed breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-11-02.

Abstract S5-05: Impact of pre-operative exercise on breast cancer gene expression

Background: Exercise is linked to a lower risk of developing and dying from breast cancer, but the biological mechanisms through which exercise could impact breast cancer are unclear. In animal models, exercise impacts tumor formation and progression, but there are few data regarding direct effects of exercise on tumor tissue in humans. The Pre-Operative Health and Body (PreHAB) Study was a randomized window of opportunity trial designed to explore the impact of exercise on molecular pathways in women with breast cancer.

Methods: Inactive women with Stage I-III breast cancer were enrolled through Dana-Farber Cancer Institute and Yale University prior to surgery. Participants were randomized 1:1 to an aerobic and strength training exercise intervention or mind body control intervention and participated in the interventions between enrollment and the time of surgery. Tumor tissue was collected at enrollment and surgery; samples were reviewed by a breast pathologist and were macrodissected to include sections of tumor with at least 10% cellularity. Capture RNA-sequencing of the transcriptome coding regions was performed using the Illumina Truseq RNA access platform.

Results: 49 women were randomized (27 exercise and 22 control). At baseline, mean age was 52.6, BMI was 30.2kg/m2 and exercise was 49 min/wk. Mean time between enrollment and surgery was 4.2 weeks. Participants in the exercise arm significantly increased exercise vs. controls (increase of 203 vs. 23 min/wk, p&lt;0.0001). Transcriptomic analysis was performed on the tumors from the pre and post intervention biopsies from 32 patients (16 exercise and 16 control). Quality Control analysis of the RNA-sequencing data showed an average read depth of 25 million reads per sample, mapping ∼79% to exonic regions. Principal Component Analysis revealed no read bias or batch effects and unsupervised clustering showed that pre- and post-operative samples clustered together by patient. Differential gene expression analysis by DEseq2 revealed a limited number of individual genes with significant changes after the intervention. KEGG pathway analysis, however, of 214 KEGG pathways using the bioconductor package GAGE (Generally Applicable Gene-Set Enrichment for Pathway Analysis) demonstrated upregulation of 13 unique pathways between the baseline biopsy and surgical excision in exercise participants and none in mind body participants (q&lt;0.1). The top ranked upregulated pathway was cytokine-cytokine receptor interactions (q=6.93E-05, set size=238 genes). Il6, CCL3 and other cytokines are among the genes upregulated in this pathway. Analysis also demonstrated downregulation of 13 unique pathways (q&lt;0.1) including cell cycle, RNA transport and DNA replication pathways, in exercise participants over the intervention period.

Conclusions: A pre-operative exercise intervention led to alterations in gene expression in tumor tissue in women with breast cancer. Validation in additional data sets and an analysis of which cellular compartments within the tumor are responsible for the changes is needed. These findings demonstrate that exercise may have a direct effect on breast tumor tissue in humans, providing new insights into the biologic mechanisms through which exercise could lower the risk of developing and dying from breast cancer.

Citation Format: Ligibel JA, Irwin M, Dillon D, Barry W, Giobbie-Hurder A, Frank E, Winer EP, McTiernan A, Cornwell M, Pun M, Brown M, Jeselsohn R. Impact of pre-operative exercise on breast cancer gene expression [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S5-05.

Socioeconomic status and lifestyle behaviours in cancer survivors: smoking and physical activity

PURPOSE

Smoking cessation and increased physical activity (pa) have been linked to better outcomes in cancer survivors. We assessed whether socioeconomic factors influence changes in those behaviours after a cancer diagnosis.

METHODS

As part of a cross-sectional study, a diverse group of cancer survivors at the Princess Margaret Cancer Centre (Toronto, ON), completed a questionnaire about past and current lifestyle behaviours and perceptions about the importance of those behaviours with respect to their health. The influence of socioeconomic indicators on smoking status and physical inactivity at 1 year before and after diagnosis were assessed using multivariable logistic regression with adjustment for clinico-demographic factors.

RESULTS

Of 1222 participants, 1192 completed the smoking component. Of those respondents, 15% smoked before diagnosis, and 43% of those smokers continued to smoke after. The proportion of survivors who continued to smoke increased with lower education level (p = 0.03). Of the 1106 participants answering pa questions, 39% reported being physically inactive before diagnosis, of whom 82% remained inactive afterward. Survivors with a lower education level were most likely to remain inactive after diagnosis (p = 0.003). Lower education level, household income, and occupation were associated with the perception that pa had no effect or could worsen fatigue and quality of life (p ≤ 0.0001).

CONCLUSIONS

In cancer survivors, education level was a major modifier of smoking and pa behaviours. Lower socioeconomic status was associated with incorrect perceptions about pa. Targeting at-risk survivors by education level should be evaluated as a strategy in cancer survivorship programs.

Abstract P3-08-01: Randomized controlled trial of weight loss vs. usual care on telomere length in women with breast cancer: The lifestyle, exercise and nutrition (LEAN) study

PURPOSE: Some studies suggest that telomere shortening due to repeated cell divisions may be associated with increased breast cancer risk and mortality. Obesity is also associated with increased breast cancer risk and mortality. Few studies have examined telomere length as a potential mechanism/biomarker mediating the obesity-breast cancer association. One study published of a diet, physical activity and support intervention in prostate cancer patients found a positive association between lifestyle changes and relative lengthening of telomeres, and another study of weight loss in healthy postmenopausal women observed no effect of weight loss on leukocyte telomere length. The purpose of our study was to examine the effect of a 6-month diet- and exercise-induced weight loss intervention vs. usual care on telomere length in 100 breast cancer survivors.

METHODS: 100 breast cancer survivors with BMI≥25 kg/m2 were randomly assigned to a weight loss counseling intervention with either telephone or in-person counseling (n = 67) or usual care group (n=33). Weight loss counseling included eleven 30-minute counseling sessions over 6 months, focusing on reducing caloric intake, increasing physical activity and behavioral therapy. Body composition (height, weight, and DEXA scans), physical activity and diet were measured at baseline and 6-months. Fasting blood samples were also collected at baseline and 6 months. Relative telomere length (T/S: telomere length/single copy of gene albumin) was measured by quantitative-polymerase chain reaction (qPCR) done on buffy coat extracted genomic DNA. Mean baseline to 6-month changes were compared between groups (intent-to-treat) using generalized estimating equations and Pearson correlation coefficients.

RESULTS: Baseline characteristics were similar for women randomized to each group. Women were 59±7 years, with BMI 33.1±6.6 kg/m2 and were 2.9±2.1 years from diagnosis; 91% were non-Hispanic white, and 51% were diagnosed with Stage I breast cancer. Average 6-month weight loss was 6.2% and 2.0% for weight loss and usual care groups, respectively (p=0.0004). At baseline, higher % body fat was associated with shorter T/S (r = -0.31, P=0.012). After 6 months, women randomized to weight loss experienced a 4% T/S lengthening compared to a 5% T/S shortening in the usual care group (P=0.10) (Table 1).

Effect of weight loss vs. usual care on leukocyte telomere lengthLEAN VariableUsual Care  Weight Loss Group  TelomereNMeanSDNMeanSDBaseline330.850.26630.750.216 Month Change26-0.040.21540.030.18  (-5%)  (+4%)p=.10SD=Standard Deviation

CONCLUSION: Our results indicate that higher % body fat is associated with shorter leukocyte telomere length, and weight loss was associated with an increase in leukocyte telomere length, suggesting that telomere length may be a mechanism mediating the relationship between obesity and breast cancer risk and mortality.

Citation Format: Sanft T, Lu L, Harrigan M, Cartmel B, Zhou Y, Chagpar A, Pusztai L, Irwin M. Randomized controlled trial of weight loss vs. usual care on telomere length in women with breast cancer: The lifestyle, exercise and nutrition (LEAN) study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-08-01.

Abstract 5039: Physical activity is associated with improved quality of life in cancer survivors: A population-based analysis

Introduction: The CDC recommends cancer survivors engage in 150 minutes of moderate- or 75 minutes of vigorous-intensity physical activity, along with 2 sessions of strength training, every week. We sought to determine whether meeting these guidelines was correlated with improved quality of life in a large contemporary population-based sample of cancer survivors.

Methods: Data regarding quality of life, physical activity and other covariates were obtained from the 2010 National Health Interview Survey, the largest source of health information of people in the United States. Quality of life was determined by the answer to the question, “In general, would you say your quality of life is…”, with potential responses of “excellent”, “very good”, “good”, “fair” and “poor”. Correlation between meeting CDC guidelines and self-reported quality of life was assessed with univariate and multivariate analyses using SUDAAN software.

Results: A weighted total of 19,441,052 cancer survivors in the United States were included in this analysis. Only 10.4% of cancer survivors met physical activity guidelines. Meeting guidelines was significantly correlated with White race, young age, cancer type, higher education, and private insurance on univariate analysis (all p&lt;0.01). Meeting guidelines was also correlated with decreased fatigue and higher self-reported quality of life, physical health, mental health status, and reported satisfaction with social activities and relationships (all p&lt;0.01). On multivariate analysis controlling for race, age, sex, cancer type, education, and insurance, meeting physical activity guidelines remained significantly correlated with higher quality of life (OR=3.69, 95% CI: 1.2-11.6, p=0.03).

Conclusions: Only 10.4% of cancer survivors meet physical activity guidelines. Meeting guidelines is significantly associated with improved quality of life, independent of other sociodemographic factors, and should therefore be encouraged.

Multivariate analysis for “good-excellent” quality of lifeParameterOdds Ratio (95% CI)P-value Met physical activity guidelinesYes3.69 (1.2-11.6)0.03 No1.00RaceWhite1.000.34 Black0.84 (0.53-1.34)Asian0.42 (0.16-1.10)Hispanic0.96 (0.60-1.56Other0.48 (0.12-1.85)Age&lt;401.000.01 40-600.58 (0.31-1.09&gt;601.43 (0.70-2.89)SexMale1.000.07 Female1.48 (.97-2.27)Cancer typeBreast1.000.09 Cervical1.03 (0.49-2.19)Colorectal0.85 (0.42-1.71)Lung0.37 (0.17-.79)Lymphoma/Leukemia0.75 (0.34-1.65)Melanoma1.08 (0.47-2.48)Ovarian0.79 (0.19-3.22)Prostate1.59 (0.71-3.56)Thyroid0.42 (0.11-1.60)Uterine0.91 (0.44-1.86Other1.15 (0.73-1.84)Education level&lt;Grade 121.00&lt;0.01 High School Grad1.51 (1.02-2.23)Associate Degree2.82 (1.78-4.46)Bachelor's Degree4.83 (2.55-9.14)Master's Degree3.66 (1.64-8.16Professional/Doctorate6.31 (1.61-24.78)Insurance statusNone1.00&lt;0.01 Medicare0.86 (0.41-1.78)Medicaid0.64 (0.32-1.28)Military0.56 (0.21-1.51Private3.08 (1.59-5.97)

Citation Format: Apoorva Tewari, Melinda Irwin, Anees Chagpar. Physical activity is associated with improved quality of life in cancer survivors: A population-based analysis. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5039. doi:10.1158/1538-7445.AM2014-5039

The impact of survivorship care plans on knowledge among breast cancer survivors

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Background: Despite the Institute of Medicine’s recommendation that all cancer survivors be provided with a survivorship care plan (SCP), there is limited information as to whether SCPs improve knowledge. The purpose of this study was to examine the impact of SCPs on patient knowledge regarding tumor stage, cancer treatment and potential risk of long-term side effects, surveillance recommendations, and perceived knowledge of their therapy. Methods: 75 English-speaking women over the age of 18 were enrolled in this prospective study. The participants’ treatment progress was tracked through the electronic medical record and used to create the SCP, which was given to them at the completion of treatment (defined as the time patients had completed radiation and/or chemotherapy treatments and initiated on hormonal therapy, if applicable). Knowledge of stage, treatments, potential side effects, and surveillance recommendations were assessed before receiving the SCP and again two months later. Accuracy of responses was compared using the McNemar test. Results: The median patient age was 56.8 ± 12.5 and 47.1% were stage I, 37.3% were stage II, and 15.7% were stage III. Participants were statistically more accurate in identifying their stage after receiving their SCP than at baseline (72.6% vs. 92.2%, p = 0.0016). While many patients were more accurate in the identification of the cancer treatment they received after SCP, the only significant improvement was in identifying 5-Fluorouracil as chemotherapy received (65.5% vs. 89.7%, p=0.0196). Patients were more accurate in identifying potential side effects but were only statistically more accurate at identifying leukemia as a risk factor (36.0% vs. 46.9%, p=0.0348). At baseline and follow up patients perceived that they had a high level of understanding as it related to their cancer stage (60.4%, and 66.7%), treatment (69.4%, and 71.4%), and surveillance recommendations (61.4%, and 54.6%). Conclusions: SCPs appear to improve patient knowledge in several important areas including basic and specific treatment details, surveillance recommendations, and potential side effects. Delivery of a SCPs is one strategy to improve knowledge of treatments received.

Weight Loss Intervention for Breast Cancer Survivors: A Systematic Review

To determine the effectiveness of weight loss intervention for breast cancer survivors. From October 2012 until March 2013, Pubmed was searched for weight loss intervention trials that reported body weight or weight loss as a primary outcome. Fifteen of these studies are included in this review. Of the 15 studies included, 14 resulted in statistically significant weight loss and 10 obtained clinically meaningful weight loss of ≥5 % from baseline. Evidence was provided of the feasibility of using several methods of weight loss intervention (telephone, in person, individual, group). Successful intervention used a comprehensive approach, with dietary, physical activity, and behavior modification components. Weight loss improved cardiovascular risk factors and markers of glucose homeostasis. However, there is insufficient evidence to identify the components of this intervention that led to successful weight loss, or to determine the weight loss necessary to affect biomarkers linked to breast cancer prognosis. The small number of randomized controlled trials shared several limitations, including small study sample sizes and lack of follow-up beyond 6 months. Intervention with longer follow-up revealed weight regain, showing the importance of considering strategies to promote long-term weight maintenance. Weight loss intervention for breast cancer survivors can lead to statistically significant and clinically meaningful weight loss, but the limited number of interventional studies, small sample sizes, and short duration of follow-up in many studies limit our ability to draw conclusions regarding the most efficacious weight-loss intervention after a breast cancer diagnosis. The findings to date are encouraging, but research on the effect of weight loss on breast cancer recurrence and mortality, and on prevention of weight gain for women newly diagnosed with breast cancer, is needed.

Astronomical algorithms for automated analysis of tissue protein expression in breast cancer

BACKGROUND

High-throughput evaluation of tissue biomarkers in oncology has been greatly accelerated by the widespread use of tissue microarrays (TMAs) and immunohistochemistry. Although TMAs have the potential to facilitate protein expression profiling on a scale to rival experiments of tumour transcriptomes, the bottleneck and imprecision of manually scoring TMAs has impeded progress.

METHODS

We report image analysis algorithms adapted from astronomy for the precise automated analysis of IHC in all subcellular compartments. The power of this technique is demonstrated using over 2000 breast tumours and comparing quantitative automated scores against manual assessment by pathologists.

RESULTS

All continuous automated scores showed good correlation with their corresponding ordinal manual scores. For oestrogen receptor (ER), the correlation was 0.82, P<0.0001, for BCL2 0.72, P<0.0001 and for HER2 0.62, P<0.0001. Automated scores showed excellent concordance with manual scores for the unsupervised assignment of cases to 'positive' or 'negative' categories with agreement rates of up to 96%.

CONCLUSION

The adaptation of astronomical algorithms coupled with their application to large annotated study cohorts, constitutes a powerful tool for the realisation of the enormous potential of digital pathology.

Tissue expanders: early experience of a novel treatment option for perineal herniation

PURPOSE

Acquired perineal hernias through the reconstructed pelvic floor can complicate radical pelvic operations including abdominoperineal resection of rectum. Operative intervention is indicated for symptomatic hernias. There is a lack of consensus as to the best operative technique. Here we present a novel method for repairing perineal herniation using saline-filled tissue expanders.

METHODS

Perineal hernia repair may be affected either via an abdominal or via a perineal approach. After adhesiolysis to remove small bowel from the pelvis, a Natrelle™ 150SH tissue expander (Allergan Inc., California, USA) or Siltex™ Round Becker (Mentor Medical Systems, Holland) of appropriate size is inserted in the pelvis and the button placed in a subcutaneous pocket in the perineal skin. The tissue expander is then filled with saline until it fills the true anatomical pelvis without bladder compression. The volume may be increased or decreased postoperatively by accessing the subcutaneous button.

RESULTS

We have performed this procedure in three patients with some success, all of whom have experienced symptomatic relief. The tissue expander may subsequently be removed without recurrence of symptoms, due to the fibrous capsule which forms. One patient required re-operation to elevate a herniating tissue expander. The tissue expander was removed earlier than anticipated to avoid deep pelvic infection in another.

CONCLUSION

Our early experience suggests that using saline-filled tissue expanders to fill dead space in the pelvis after radical surgery may prove to be a valuable approach to perineal herniation, particularly if adjuvant radiotherapy is planned.

Post diagnosis weight gain and the role of exercise in breast cancer survivors

9007

Background: Obesity is linked to poor breast cancer (Br Ca) outcomes including higher risk of recurrence and death. No study has examined if post-diagnosis weight (wt) gain modifies the effect of exercise interventions on body composition. We examined wt change from diagnosis (diag) to enrollment (enroll) into a 6-mo randomized trial of exercise v. usual care to explore if post-diagnosis wt gain modified the effect of exercise on body wt, body fat, lean body mass (LBM) and bone mineral density (BMD) in breast cancer survivors. Methods: 75 inactive Br Ca survivors were recruited and randomized to exercise (n = 37) or usual care (UC) (n = 38). At baseline, women completed a questionnaire assessing self-report wt at diag and at the time of enroll into the study (~3 yr). The exercise group participated in 150 min/wk of supervised exercise. The UC group maintained their physical activity level. Body composition was assessed at enroll and 6-mo via dual-energy X-ray absorptiometry (DXA) by one radiologist blinded to intervention group. Results: Wt and DXA data were available for 68 / 75 participants. On average, women gained 3.3±8.2 kg from diag to enroll, with 53% gaining wt (mean = 8.9 ± 6.8 kg) and 47% maintaining or losing wt (mean change = -2.9 ±3.9 kg). The majority of wt gain occurred among women who were non-obese at diag (BMI < 30), with 60% of non-obese women gaining wt (mean = 8.0 ± 6.8 kg) compared with 38% of obese women gaining wt (mean = 12.2 ± 6.4 kg). Those randomized to exercise lost body fat including women who gained wt since diag (mean % fat loss for exercisers (-0.92 ± 0.31) vs. UC (0.36 ±0.30), p = .0063) and women who did not gain wt since diag (mean % fat loss for exercisers (-0.65 ± 0.39) vs. UC (0.45±0.47), p = .08) even after adjusting for obesity status at diag. Similar improvements in LBM and BMD were observed with exercise in women who did or did not gain wt since diag. Conclusions: Wt gain in Br Ca survivors is common, the majority of weight gain in this study occurred among women who were not obese at diag. Exercise led to body fat loss and other favorable body composition changes among both non-obese and obese women. Exercise and other wt management programs should be offered to all Br Ca survivors regardless of BMI at diagnosis as a strategy towards prevention of wt gain.

Aromatase inhibitors, arthralgias, and exercise in breast cancer survivors

TPS669

Background: A substantial number of breast cancer survivors who are taking aromatase inhibitors (AIs) complain of side effects including arthralgias. Given the efficacy of AIs, it is essential that we identify approaches to mitigate arthralgias. We are conducting an NCI-funded trial is to examine the impact of a year-long exercise intervention in 180 breast cancer survivors taking an AI and experiencing at least mild arthralgias. Outcomes include severity of arthralgias, endocrine-related quality of life, % body fat, bone mass, and serum markers of inflammation. The purpose of this abstract is to present preliminary recruitment and adherence results. Methods: Women are being recruited via the Connecticut Tumor Registry and Rapid Case Ascertainment Shared Resource of Yale Cancer Center into the Hormones and Physical Exercise (HOPE) Study. Participants are randomly assigned to exercise (n = 90) or usual care (n = 90). The exercise intervention includes supervised resistance and unsupervised aerobic exercise sessions over 12 months. Data are collected at baseline, 3-, 6-, 9 and 12-months. Results: Study recruitment began in April 2010 and will continue through December 2012. As of January 1, 2012, we have received 1605 names of potentially eligible women. Of these 1605, 777 women are waiting to be screened (e.g., letter mailed to patient or on hold because recently diagnosed), 244 women could not be screened (e.g., unable to contact by phone), and 584 women have completed a telephone screening. Of the 584 women screened, 24% were ineligible because of discontinuing AIs because of arthralgias or chose not to take AIs primarily because of this potential side effect; another 36% were ineligible for various reasons; 24% were not interested; 11% were randomized (n = 65 women); and 5% are undergoing baseline visits (n = 29). On average, women are 62 yrs old and have been taking an AI for 1.8 yrs. Twenty-three women have completed the trial, with high exercise adherence rates (attendance to supervised sessions = 82% ). Conclusions: A growing number of women are choosing to not take AIs or are discontinuing AIs because of side effects. Our study may prove beneficial for the growing number of women diagnosed with hormone receptor-positive breast cancer each year.

Trial of exercise in ovarian cancer survivors

TPS1614

Background: Physical activity (PA) has been associated with improved QOL and survival in breast and colorectal cancer survivors, yet no study has examined the effect of exercise on ovarian cancer outcomes. The purpose of our NCI-funded trial is to examine, in 230 women diagnosed with Stage I-IV ovarian cancer, the impact of exercise vs. attention control on: QOL, body composition, and serum markers associated with ovarian cancer. This abstract presents preliminary recruitment and adherence results. Methods: Women are being recruited via Connecticut Tumor Registry and Yale Cancer Center into the Women’s Activity and Lifestyle Study in Connecticut (WALC). We are also recruiting patients nationally via self-referral and collaboration with medical oncologists at DFCI and Summa Akron City Hospital. Women are randomly assigned to exercise (n = 115) or attention control (n = 115). Both groups receive weekly telephone calls for six months from a certified health educator to discuss ovarian cancer health topics. In addition, the exercise group receives PA counseling to participate in 150 min/wk of aerobic exercise (primarily brisk walking) for six months. Results: Study recruitment began in March, 2010 and will be ongoing through December, 2013. As of December 31, 2011, we have identified 556 potentially eligible women. Of these, 145 are recently diagnosed and are awaiting screening, 115 were unable to be contacted, and 296 have completed the telephone screening. Of the 270, 46% were ineligible (e.g., already exercising, physical limitations); 30% were not interested, 24% (n = 66) have been randomized, and 9% (n = 24) are undergoing baseline visits. On average, women are 62 years old, diagnosed 1.8 years in the past, with primarily stage III disease. Thirty-three patients have completed the trial, with high adherence among women randomized to exercise (average 141 min/wk of exercise reported and 75% of exercisers participating in at least 150 min/wk of exercise). Conclusions: Women are interested in and able to participate in exercise after an ovarian cancer diagnosis. Our trial could suggest a unique and important role for exercise in ovarian cancer care given that physical and functional aspects of QOL are often the most compromised in ovarian cancer patients.

Injuries in sedentary individuals enrolled in a 12-month, randomized, controlled, exercise trial

BACKGROUND

The risk of musculoskeletal injury with the introduction of moderate-to-vigorous exercise in sedentary adults is not well established. The purpose of this report is to examine the effect of a 12-month exercise intervention on musculoskeletal injury and bodily pain in predominately overweight, sedentary men (n = 102) and women (n = 100), ages 40 to 75 years.

METHODS

Participants were randomized to a moderate-to-vigorous aerobic exercise intervention (EX) (6 d/wk, 60 min/d, 60% to 85% max. heart rate) or usual lifestyle control (CON). Participants completed a self-report of musculoskeletal injury and body pain at baseline and 12-months.

RESULTS

The number of individuals reporting an injury (CON; 28% vs. EX; 28%, P = .95) did not differ by group. The most commonly injured site was lower leg/ankle/foot. The most common causes of injury were sports/physical activity, home maintenance, or "other." In the control group, bodily pain increased over the 12 months compared with the exercise group (CON -7.9, EX -1.4, P = .05). Baseline demographics and volume of exercise were not associated with injury risk.

CONCLUSIONS

Previously sedentary men and women randomized to a 12-month aerobic exercise intervention with a goal of 360 min/wk reported the same number of injuries as those in the control group and less bodily pain.

Factors associated with physical activity among Canadian high school students

OBJECTIVES

Identifying multi-level factors affecting physical activity (PA) levels among adolescents is essential to increasing activity to promote health within this population. This study examines the associations between PA and 11 independent factors among Manitoba high school students.

METHODS

The sample included 31,202 grade 9-12 students who completed the Manitoba Youth Health Survey. Associations between PA and independent factors were examined separately and through multivariate regression. Analyses were stratified by gender.

RESULTS

Perception of athletic ability, school location, parental encouragement and number of active friends were strong predictors of activity for moderately active and active males and females. Grade was a significant predictor of PA for females at both levels of activity but only significant for males when comparing active to inactive students. Perception of schoolwork and means of transport were minimally associated with PA.

CONCLUSIONS

Results highlight the importance of targeting multiple levels of influence to increase PA among youth. Programs should focus on older students, females and those who are inactive or moderately active. In addition, social modeling of PA and increasing self-efficacy around activity should be encouraged.

Telomerase expression and telomere length in breast cancer and their associations with adjuvant treatment and disease outcome

Introduction

Telomere length plays important roles in maintaining genome stability and regulating cell replication and death. Telomerase has functions not only to extend telomere length but also to repair DNA damage. Studies have shown that telomerase may increase cancer cell resistance to DNA-damaging anticancer agents; tamoxifen may suppress telomerase expression in breast cancer cells. This study aimed to investigate the role of telomere length and telomerase activity in breast cancer prognosis.

Methods

qPCR and qRT-PCR were used to analyze telomere length and telomerase expression, respectively, in tumor samples of 348 breast cancer patients. Cox regression analysis was performed to examine telomere length and telomerase expression in association with disease-free survival and cause-specific mortality.

Results

Telomere length had no relation to tumor features or disease outcomes. Telomerase expression was detected in 53% of tumors. Larger tumors or aggressive disease were more likely to have telomerase expression. Among patients treated with chemotherapy, high telomerase was found to be associated with increased risk of death (hazard ratio (HR) = 3.15; 95% CI: 1.34 to 7.40) and disease recurrence (HR = 2.04; 95% CI: 0.96 to 4.30) regardless of patient age, disease stage, tumor grade, histological type or hormone receptor status. Patients treated with endocrine therapy had different results regarding telomerase: high telomerase appeared to be associated with better survival outcomes. Telomerase expression made no survival difference in patients who received both chemotherapy and endocrine therapy.

Conclusions

Overall, telomerase expression was not associated with disease outcome, but this finding may be masked by adjuvant treatment. Patients with high telomerase expression responded poorly to chemotherapy in terms of disease-free and overall survival, but fared better if treated with endocrine therapy.

A review of web-based weight loss interventions in adults

Unprecedented obesity rates are changing the burden of disease worldwide and obesity-related health complications are increasing healthcare costs. In response, researchers, clinicians and public health practitioners are seeking new and effective tools such as the Internet to effect weight loss. This review highlights peer-reviewed literature on randomized controlled trials that examine Internet-delivered weight loss and maintenance programmes. The scope of this review is broader than previous reviews, including more males and non-Caucasian participants. The reviewed studies show intervention results ranging from no weight loss to an average loss of 7.6 kg. It is difficult to draw a definitive conclusion on the potential impact of Internet-based weight loss as study methods are highly variable between papers, low adherence was recorded and not all studies include a control group. As the demand for low-cost, efficacious interventions that yield statistically significant and/or clinically relevant results grows, more rigorous, population-specific research is needed to determine if Internet-delivered interventions may slow or reverse with weight gain and obesity and the associated health consequences.

Weight, physical activity, diet, and prognosis in breast and gynecologic cancers

Diet, physical activity, and weight may affect prognosis among women who are diagnosed with breast or gynecologic cancer. Observational studies show associations between being overweight or obese and weight gain with several measures of reduced prognosis in women with breast cancer and some suggestion of poor prognosis in underweight women. Observational studies have shown an association between higher levels of physical activity and improved breast cancer-specific and all-cause mortality, although a dose-response relationship has not been established. One large randomized controlled trial reported increased disease-free survival after a mean of 5 years in patients with breast cancer randomly assigned to a low-fat diet versus control. However, another trial of similar size found no effect from a high vegetable/fruit, low-fat diet on breast cancer prognosis. The few reported studies suggest that obesity negatively affects endometrial cancer survival, while the limited data are mixed for associations of weight with ovarian cancer prognosis. Insufficient data exist for assessing associations of weight, physical activity, or diet with prognosis in other gynecologic cancers. Associations of particular micronutrient intake and alcohol use with prognosis are not defined for any of these cancers. The effects of dietary weight loss and increase in physical activity on survival or recurrence in breast and gynecologic cancers are not yet established, and randomized controlled trials are needed for definitive data.

CERTAIN EFFECTS OF SALTS ON THE PENETRATION OF BRILLIANT CRESYL BLUE INTO NITELLA

The effect of various substances on living cells may be advantageously studied by exposing them to such substances and observing their subsequent behavior in solutions of a basic dye, brilliant cresyl blue. The rate of penetration of the basic dye, brilliant cresyl blue, is decreased when cells are exposed to salts with monovalent cations before they are placed in the dye solution (made up with borate buffer mixture). This inhibiting effect is assumed to be due to the effect of the salts on the protoplasm. This effect is not readily reversible when cells are transferred to distilled water, but it is removed by salts with bivalent or trivalent cations. In some cases it disappears in dye made up with phosphate buffer mixture, or with borate buffer mixture at the pH value in which the borax predominates, and in the case of NaCl it disappears in dye containing NaCl. No inhibiting effect is seen when cells are exposed to NaCl solution containing MgCl₂ before they are placed in the dye solution. The rate of penetration of dye is not decreased when cells are previously exposed to salts with bivalent and trivalent cations. The rate is slightly increased when cells are placed in the dye solution containing a salt with monovalent cation and probably with bivalent or trivalent cations. In the case of the bivalent and trivalent salts the increase is so slight that it may be negligible.

ON THE NATURE OF THE DYE PENETRATING THE VACUOLE OF VALONIA FROM SOLUTIONS OF METHYLENE BLUE

When uninjured cells of Valonia are placed in methylene blue dissolved in sea water it is found, after 1 to 3 hours, that at pH 5.5 practically no dye penetrates, while at pH 9.5 more enters the vacuole. As the cells become injured more dye enters at pH 5.5, as well as at pH 9.5. No dye in reduced form is found in the sap of uninjured cells exposed from 1 to 3 hours to methylene blue in sea water at both pH values. When uninjured cells are placed in azure B solution, the rate of penetration of dye into the vacuole is found to increase with the rise in the pH value of the external dye solution. The partition coefficient of the dye between chloroform and sea water is higher at pH 9.5 than at pH 5.5 with both methylene blue and azure B. The color of the dye in chloroform absorbed from methylene blue or from azure B in sea water at pH 5.5 is blue, while it is reddish purple when absorbed from methylene blue and azure B at pH 9.5. Dry salt of methylene blue and azure B dissolved in chloroform appears blue. It is shown that chiefly azure B in form of free base is absorbed by chloroform from methylene blue or azure B dissolved in sea water at pH 9.5, but possibly a mixture of methylene blue and azure B in form of salt is absorbed from methylene blue at pH 5.5, and azure B in form of salt is absorbed from azure B in sea water at pH 5.5. Spectrophotometric analysis of the dye shows the following facts. 1. The dye which is absorbed by the cell wall from methylene blue solution is found to be chiefly methylene blue. 2. The dye which has penetrated from methylene blue solution into the vacuole of uninjured cells is found to be azure B or trimethyl thionine, a small amount of which may be present in a solution of methylene blue especially at a high pH value. 3. The dye which has penetrated from methylene blue solution into the vacuole of injured cells is either methylene blue or a mixture of methylene blue and azure B. 4. The dye which is absorbed by chloroform from methylene blue dissolved in sea water is also found to be azure B, when the pH value of the sea water is at 9.5, but it consists of azure B and to a less extent of methylene blue when the pH value is at 5.5. 5. Methylene blue employed for these experiments, when dissolved in sea water, in sap of Valonia, or in artificial sap, gives absorption maxima characteristic of methylene blue. Azure B found in the sap collected from the vacuole cannot be due to the transformation of methylene blue into this dye after methylene blue has penetrated into the vacuole from the external solution because no such transformation detectable by this method is found to take place within 3 hours after dissolving methylene blue in the sap of Valonia. These experiments indicate that the penetration of dye into the vacuole from methylene blue solution represents a diffusion of azure B in the form of free base. This result agrees with the theory that a basic dye penetrates the vacuole of living cells chiefly in the form of free base and only very slightly in the form of salt. But as soon as the cells are injured the methylene blue (in form of salt) enters the vacuole. It is suggested that these experiments do not show that methylene blue does not enter the protoplasm, but they point out the danger of basing any theoretical conclusion as to permeability on oxidation-reduction potential of living cells from experiments made or the penetration of dye from methylene blue solution into the vacuole, without determining the nature of the dye inside and outside the cell.

THE PENETRATION OF DYES AS INFLUENCED BY HYDROGEN ION CONCENTRATION

When cells of Nitella are placed in buffer solutions at pH 9, there is a very slow and gradual increase in the pH of the sap from pH 5.6 to 6.4 (when death of the cells takes place). If the living cells are placed in 0.002 per cent dye solutions of brilliant cresyl blue at different pH values (from pH 6.6 to pH 9), it is found that the rate of penetration of the dye, and the final equilibrium attained, increases with increase in pH value, which can be attributed to an increase in the active protein (or other amphoteric electrolyte) in the cell which can combine with the dye.

SPECTROPHOTOMETRIC STUDIES OF PENETRATION : V. RESEMBLANCES BETWEEN THE LIVING CELL AND AN ARTIFICIAL SYSTEM IN ABSORBING METHYLENE BLUE AND TRIMETHYL THIONINE

The rate of diffusion through the non-aqueous layer of the protoplasm depends largely on the partition coefficients mentioned above. Since these cannot be determined we have employed an artificial system in which chloroform is used in place of the non-aqueous layer of the protoplasm. The partition coefficients may be roughly determined by shaking up the aqueous solutions with chloroform and analyzing with the spectrophotometer (which is necessary with methylene blue because we are dealing with mixtures). This will show what dyes may be expected to pass through the protoplasm into the vacuole in case it behaves like the artificial system. From these results we may conclude that the artificial system and the living cell act almost alike toward methylene blue and azure B, which supports the notion of non-aqueous layers in the protoplasm. There is a close resemblance between Valonia and the artificial system in their behavior toward these dyes at pH 9.5. In the case of Nitella, on the other hand, with methylene blue solution at pH 9.2 the sap in the artificial system takes up relatively more azure B (absorption maximum at 650 mµ) than the vacuole of the living cell (655 mµ). But both take up azure B much more rapidly than methylene blue. A comparison cannot be made between the behavior of the artificial system and that of the living cell at pH 5.5 since in the latter case there arises a question of injury to cells before enough dye is collected in the sap for analysis.

THE BEHAVIOR OF CHLORIDES IN THE CELL SAP OF NITELLA

1. A method is given for determining the chloride content in a drop (less than 0.03 cc.) of the cell sap of Nitella. 2. Chlorides accumulate in the sap to the extent of 0.128 M; this accumulation can be followed during the growth of the cell. The chloride content does not increase when the cell is placed for 2 days in solutions (at pH 6.2) containing chlorides up to 0.128 M. 3. The exosmosis of chlorides from injured cells can be followed quantitatively. When one end of the cell is cut off a wave of injury progresses toward the other end; this is accompanied by a progressive exosmosis of chlorides.

MECHANISM OF THE ACCUMULATION OF DYE IN NITELLA ON THE BASIS OF THE ENTRANCE OF THE DYE AS UNDISSOCIATED MOLECULES

The rate of penetration of brilliant cresyl blue into the living cells of Nitella indicates that the dye enters only in the form of the undissociated molecule. At equilibrium the total concentration of the dye in the sap is proportional to the concentration of the free base in the outside solution.

STUDIES ON PENETRATION OF DYES WITH GLASS ELECTRODE : V. WHY DOES AZURE B PENETRATE MORE READILY THAN METHYLENE BLUE OR CRYSTAL VIOLET?

Glass electrode measurements of the pH value of the sap of cells of Nitella show that azure B in the form of free base penetrates the vacuoles and raises the pH value of the sap to about the same degree as the free base of the dye added to the sap in vitro, but the dye salt dissolved in the sap does not alter the pH value of the sap. It is concluded that the dye penetrates the vacuoles chiefly in the form of free base and not as salt. The dye from methylene blue solution containing azure B free base as impurity penetrates and accumulates in the vacuole. This dye must be azure B in the form of free base, since it raises the pH value of the sap to about the same extent as the free base of azure B dissolved in the sap in vitro. The dye absorbed by the chloroform from methylene blue solution behaves like the dye penetrating the vacuole. These results confirm those of spectrophotometric analysis previously published. Crystal violet exists only in one form between pH 5 and pH 9.2, and does not alter the pH value of the sap at the concentrations used. It does not penetrate readily unless cells are injured. A theory of "multiple partition coefficients" is described which explains the mechanism of the behavior of living cells to these dyes. When the protoplasm is squeezed into the sap, the pH value of the mixture is higher than that of the pure sap. The behavior of such a mixture to the dye is very much like that of the sap except that with azure B and methylene blue the rise in the pH value of such a mixture is not so pronounced as with sap when the dye penetrates into the vacuoles. Spectrophotometric measurements show that the dye which penetrates from methylene blue solution has a primary absorption maximum at 653 to 655 mµ (i.e., is a mixture of azure B and methylene blue, with preponderance of azure B) whether we take the sap alone or the sap plus protoplasm. These results confirm those previously obtained with spectrophotometric measurements.

ACCUMULATION OF BRILLIANT CRESYL BLUE IN THE SAP OF LIVING CELLS OF NITELLA IN THE PRESENCE OF NH(3)

When the living cells of Nitella are placed in a solution of brilliant cresyl blue containing NH(4)Cl, the rate of accumulation of the dye in the sap is found to be lower than when the cells are placed in a solution of dye containing no NH(4)Cl and this may occur without any increase in the pH value of the cell sap. This decrease is found to be primarily due to the presence of NH(3) in the sap and seems not to exist where NH(3) is present only in the external solution at the concentration used.

THE EFFECT OF ACETATE BUFFER MIXTURES, ACETIC ACID, AND SODIUM ACETATE, ON THE PROTOPLASM, AS INFLUENCING THE RATE OF PENETRATION OF CRESYL BLUE INTO THE VACUOLE OF NITELLA

When living cells of Nitella are exposed to a solution of sodium acetate and are then placed in a solution of brilliant cresyl blue made up with a borate buffer mixture at pH 7.85, a decrease in the rate of penetration of dye is found, without any change in the pH value of the sap. It is assumed that this inhibiting effect is caused by the action of sodium on the protoplasm. This effect is not manifest if the dye solution is made up with phosphate buffer mixture at pH 7.85. It is assumed that this is due to the presence of a greater concentration of base cations in the phosphate buffer mixture. In the case of cells previously exposed to solutions of acetic acid the rate of penetration of dye decreases with the lowering of the pH value of the sap. This inhibiting effect is assumed to be due chiefly to the action of acetic acid on the protoplasm, provided the pH value of the external acetic acid is not so low as to involve an inhibiting effect on the protoplasm by hydrogen ions as well. It is assumed that the acetic acid either has a specific effect on the protoplasm or enters as undissociated molecules and by subsequent dissociation lowers the pH value of the protoplasm. With acetate buffer mixture the inhibiting effect is due to the action of sodium and acetic acid on the protoplasm. The inhibiting effect of acetic acid and acetate buffer mixture is manifested whether the dye solution is made up with borate or phosphate buffer mixture at pH 7.85. It is assumed that acetic acid in the vacuole serves as a reservoir so that during the experiment the inhibiting effect still persists.

SPECTROPHOTOMETRIC STUDIES OF PENETRATION : IV. PENETRATION OF TRIMETHYL THIONIN INTO NITELLA AND VALONIA FROM METHYLENE BLUE

Spectrophotometric measurements show that it is chiefly the trimethyl thionin that is present in the sap extracted from the vacuoles of uninjured cells of Nitella or Valonia which have been placed in methylene blue solution at a little above pH 9. Whether these measurements were made immediately or several hours later the same results were obtained. Methylene blue is detected in the sap (1) when the cells are injured or (2) when the contamination of the sap from the stained cell wall occurs at the time of extraction. The sap is found to be incapable of demethylating methylene blue dissolved in it even on standing for several hours. It is somewhat uncertain as to whether the trimethyl thionin penetrated as such from the external methylene blue solution which generally contains this dye as impurity (in too small concentration for detection by spectrophotometer but detectable by extraction with chloroform), or whether it has formed from methylene blue in the protoplasm. The evidences described in the text tend to favor the former explanation. Theory is discussed on basis of more rapid penetration of trimethyl thionin (in form of free base) than of methylene blue, or of trimethyl thionin in form of salt.

ON THE ACCUMULATION OF DYE IN NITELLA

Living cells of Nitella were placed in different concentrations of brilliant cresyl blue solutions at pH 6.9. It was found that the greater the concentration of the external dye solution, the greater was the speed of accumulation of the dye in the cell sap and higher was the concentration of dye found in the sap at equilibrium. Analysis of the time curves showed that the process may be regarded as a reversible pseudounimolecular reaction. When the concentration in the sap is plotted as ordinates and the concentration in the outside solution as abscissae the curve is convex toward the abscissae. There is reason to believe that secondary changes involving injury take place as the dye accumulates and that if these changes did not occur the curve would be concave toward the abscissae. The process may be explained as a chemical combination of the dye with a constituent of the cell. This harmonizes with the fact that the temperature coefficient is high (about 4.9). Various other possible explanations are discussed.

THE PENETRATION OF BASIC DYE INTO NITELLA AND VALONIA IN THE PRESENCE OF CERTAIN ACIDS, BUFFER MIXTURES, AND SALTS

When living cells of Nitella are exposed to an acetate buffer solution until the pH value of the sap is decreased and subsequently placed in a solution of brilliant cresyl blue, the rate of penetration of dye into the vacuole is found to decrease in the majority of cases, and increase in other cases, as compared with the control cells which are transferred to the dye solution directly from tap water. This decrease in the rate is not due to the lowering of the pH value of the solution just outside the cell wall, as a result of diffusion of acetic acid from the cell when cells are removed from the buffer solution and placed in the dye solution, because the relative amount of decrease (as compared with the control) is the same whether the external solution is stirred or not. Such a decrease in the rate may be brought about without a change in the pH value of the sap if the cells are placed in the dye solution after exposure to a phosphate buffer solution in which the pH value of the sap remains normal. The rate of penetration of dye is then found to decrease. The extent of this decrease is the greater the lower the pH value of the solution. It is found that hydrochloric acid and boric acid have no effect while phosphoric acid has an inhibiting effect at pH 4.8 on stirring. Experiments with neutral salt solutions indicate that a direct effect on the cell (decreasing penetration) is due to monovalent base cations, while there is no such effect directly on the dye. It is assumed that the effect of the phosphate and acetate buffer solutions on the cell, decreasing the rate of penetration, is due (1) to the penetration of these acids into the protoplasm as undissociated molecules, which dissociate upon entrance and lower the pH value of the protoplasm or to their action on the surface of the protoplasm, (2) to the effect of base cations on the protoplasm (either at the surface or in the interior), and (3) possibly to the effect of certain anions. In this case the action of the buffer solution is not due to its hydrogen ions. In the case of living cells of Valonia under the same experimental conditions as Nitella it is found that the rate of penetration of dye decreases when the pH value of the sap increases in presence of NH₃, and also when the pH value of the sap is decreased in the presence of acetic acid. Such a decrease may be brought about even when the cells are previously exposed to sea water containing HCl, in which the pH value of the sap remains normal.

COMPARATIVE STUDIES ON RESPIRATION : VI. INCREASED PRODUCTION OF CARBON DIOXIDE ACCOMPANIED BY DECREASE OF ACIDITY

In petals of Salvia high concentrations of ether cause an increase in oxygen consumption and in the production of CO(2), while at the same time a decrease occurs in the acidity of the cell contents.

THE PERMEABILITY OF LIVING CELLS TO DYES AS AFFECTED BY HYDROGEN ION CONCENTRATION

1. An accurate quantitative method of measuring the penetration of dye into the living cell is described. 2. Cresyl blue is unable to penetrate rapidly unless the pH outside the cell is decidedly greater than that inside. The rate of penetration increases with increasing pH. 3. Around pH 9 penetration of the dye is rapid while the reverse is true of exosmosis. At low pH values (5.9) exosmosis is rapid and penetration is very slow.

EXIT OF DYE FROM LIVING CELLS OF NITELLA AT DIFFERENT pH VALUES

Experiments on the exit of brilliant cresyl blue from the living cells of Nitella, in solutions of varying external pH values containing no dye, confirm the theory that the relation of the dye in the sap to that in the external solution depends on the fact that the dye exists in two forms, one of which (DB) can pass through the protoplasm while the other (DS) passes only slightly. DB increases (by transformation of DS to DB) with an increase in the pH value, and is soluble in substances like chloroform and benzene. DS increases with decrease in pH value and is insoluble (or nearly so) in chloroform and benzene. The rate of exit of the dye increases as the external pH value decreases. This may be explained on the ground that DB as it comes out of the cell is partly changed to DS, the amount transformed increasing as the pH value decreases. The rate of exit of the dye is increased when the pH value of the sap is increased by penetration of NH(3).