Epigenetic regulation of H3K27me3 in laying hens with fatty liver hemorrhagic syndrome induced by high-energy and low-protein diets

BACKGROUND

Fatty liver hemorrhagic syndrome (FLHS) in the modern poultry industry is primarily caused by nutrition. Despite encouraging progress on FLHS, the mechanism through which nutrition influences susceptibility to FLHS is still lacking in terms of epigenetics.

RESULTS

In this study, we analyzed the genome-wide patterns of trimethylated lysine residue 27 of histone H3 (H3K27me3) enrichment by chromatin immunoprecipitation-sequencing (ChIP-seq), and examined its association with transcriptomes in healthy and FLHS hens. The study results indicated that H3K27me3 levels were increased in the FLHS hens on a genome-wide scale. Additionally, H3K27me3 was found to occupy the entire gene and the distant intergenic region, which may function as silencer-like regulatory elements. The analysis of transcription factor (TF) motifs in hypermethylated peaks has demonstrated that 23 TFs are involved in the regulation of liver metabolism and development. Transcriptomic analysis indicated that differentially expressed genes (DEGs) were enriched in fatty acid metabolism, amino acid, and carbohydrate metabolism. The hub gene identified from PPI network is fatty acid synthase (FASN). Combined ChIP-seq and transcriptome analysis revealed that the increased H3K27me3 and down-regulated genes have significant enrichment in the ECM-receptor interaction, tight junction, cell adhesion molecules, adherens junction, and TGF-beta signaling pathways.

CONCLUSIONS

Overall, the trimethylation modification of H3K27 has been shown to have significant regulatory function in FLHS, mediating the expression of crucial genes associated with the ECM-receptor interaction pathway. This highlights the epigenetic mechanisms of H3K27me3 and provides insights into exploring core regulatory targets and nutritional regulation strategies in FLHS.

Clonal Hematopoiesis Risk Score and All-Cause and Cardiovascular Mortality in Older Adults

Importance

Clonal hematopoiesis (CH) with acquired pathogenic variants in myeloid leukemia driver genes is common in older adults but of unknown prognostic value.

Objective

To investigate the prevalence of CH and the utility of the CH risk score (CHRS) in estimating all-cause and disease-specific mortality in older adults with CH.

Design, Setting, and Participants

This population-based prospective cohort study involved community-dwelling older adults (aged 67-90 years) without hematologic malignant neoplasms (HMs) who were participants in the Atherosclerosis Risk in Communities Visit 5 at 4 US centers: Forsyth County, North Carolina; Jackson, Mississippi; Minneapolis, Minnesota; and Washington County, Maryland. Samples were collected from 2011 to 2013, sequencing was performed in 2022, and data analysis was completed in 2023.

Exposure

The exposure was a diagnosis of CH. CHRS scores (calculated using 8 demographic, complete blood cell count, and molecular factors) were used to categorize individuals with CH into low-risk (CHRS ≤9.5), intermediate-risk (CHRS >9.5 to <12.5), and high-risk (CHRS ≥12.5) groups.

Main Outcomes and Measures

The primary outcome was all-cause mortality, and secondary outcomes were HM mortality, cardiovascular disease mortality, and death from other causes.

Results

Among 3871 participants without a history of HM (mean [SD] age, 75.7 [5.2] years; 2264 [58.5%] female individuals; 895 [23.1%] Black individuals; 2976 White individuals [76.9%]), 938 (24.2%) had CH. According to the CHRS, 562 (59.9%) were low risk, 318 (33.9%) were intermediate risk, and 58 (6.2%) were high risk. During a median (IQR) follow-up of 7.13 (5.63-7.78) years, 570 participants without CH (19.4%) and 254 participants with CH (27.1%) died. Mortality by CHRS risk group was 128 deaths (22.8%) for low risk, 93 (29.2%) for intermediate risk, and 33 (56.9%) for high risk. By use of multivariable competing risk regression, subdistribution hazard ratios (sHRs) for all-cause mortality were 1.08 (95% CI, 0.89-1.31; P = .42) for low-risk CH, 1.12 (95% CI, 0.89-1.41; P = .31) for intermediate-risk CH, and 2.52 (95% CI, 1.72-3.70; P < .001) for high-risk CH compared with no CH. Among individuals in the high-risk CH group, the sHR of death from HM (6 deaths [10.3%]) was 25.58 (95% CI, 7.55-86.71; P < .001) and that of cardiovascular death (12 deaths [20.7%]) was 2.91 (95% CI, 1.55-5.47; P < .001).

Conclusions and Relevance

In this cohort study, the CHRS was associated with all-cause, HM-related, and cardiovascular disease mortality in older adults with CH and may be useful in shared decision-making to guide clinical management and identify appropriate candidates for clinical trials.

In vitro antibacterial effects of Broussonetia papyrifera leaf extract and its anti-colitis in DSS-treated mice

Recently, the hybrid Broussonetia papyrifera (BP) has been extensively cultivated and predominantly utilized in ruminants because of its high protein and bioactive compound content. In the present study, the effects of an ethanolic extract of BP leaves (BPE, 200 mg/kg) on mitigating 2% dextran sodium sulfate (DSS)-induced intestinal inflammation in mice were evaluated. BPE is rich in flavonoids, polyphenols, and polysaccharides, and displays potent antioxidant and antibacterial activities against pathogenic strains such as Clostridium perfringens, Salmonella Typhimurium, and Salmonella enterica subsp. enterica in vitro. In a mouse study, oral administration of DSS resulted in weight loss, incidence of diarrhea, enlargement of the liver and spleen, impaired colonic morphology, downregulation of both gene and protein expression related to intestinal antioxidant (Nrf2) and barrier function (ZO-1), decreased diversity of colonic microbiota, and 218 differentially altered colonic metabolites; however, co-treatment with BPE did not restore these modified aspects except for the liver index and colonic bacterial diversity. The singular treatment with BPE did not manifest evident side effects in normal mice but induced a mild occurrence of diarrhea and a notable alteration in the colonic metabolite profile. Moreover, a single BPE administration augmented the abundance of the commensal beneficial bacteria Faecalibaculum and Akkermansia genera. Overall, the extract of BP leaves did not demonstrate the anticipated effectiveness in alleviating DSS-induced intestinal inflammation.

Results of a Phase Ib Study Investigating Durvalumab in Combination with Eribulin in Patients with HER2-Negative Metastatic Breast Cancer and Recurrent Ovarian Cancer

INTRODUCTION

The release of tumor-associated antigens with cytotoxic chemotherapy treatment may enhance the response to immune checkpoint blockade. Eribulin is a microtubule inhibitor with proven overall survival (OS) benefit in metastatic breast cancer (MBC), which may also enhance intratumoral vascular remodeling. Durvalumab, a humanized monoclonal antibody, targets the programmed cell death ligand-1 (PD-L1) receptor. This study sought to determine the maximum tolerated dose and recommended phase II dose (RP2D) of eribulin in combination with durvalumab, as well as the safety and preliminary antitumor activity of the combination in patients with previously treated HER2-negative (HER2-) MBC and recurrent ovarian cancer (ROC).

METHODS

Cohorts of 3-6 patients with HER2- MBC and ROC were treated in a modified 3+3 design. Eligible patients received escalating doses of eribulin (1.1 mg/m2 or 1.4 mg/m2 IV on day 1 and day 8) with durvalumab (1.12 g IV on day 1) in 21-day cycles until dose-limiting toxicity (DLT), intolerable adverse events (AEs), disease progression, or other reasons for withdrawal.

PRIMARY ENDPOINT

the rate of DLTs during cycles 1 and 2 of therapy. Secondary endpoints: AE rate, objective response rate (ORR), progression-free survival (PFS), and OS.

RESULTS

Nine patients with a median of 4 prior therapies for advanced disease were treated: 5 patients with HER2- MBC (1 with triple-negative disease and 4 with hormone-positive disease) and 4 patients with ROC. The RP2D of eribulin was 1.4 mg/m2 in combination with durvalumab. There were no DLTs experienced during the first two cycles of therapy. The most common treatment-related AEs (>50%) were fatigue, neutropenia, decreased white blood cell count, anemia, AST and alkaline phosphatase elevation, hyperglycemia, and nausea; most were grade 1 or 2. There was one immune-related AE of grade 3 (hepatitis) after 5 cycles of treatment, for which patient came off study. Two other patients discontinued study drug related to toxicity (neutropenia [n = 1], hepatic toxicity [n = 1]). ORR was 55%, and 4 additional patients experienced stable disease. All MBC patients exhibited a response to therapy. Median PFS was 6.2 months. Median OS was 15.0 months.

CONCLUSION

The combination of eribulin at a dose of 1.4 mg/m2 with standard dose durvalumab had a favorable AE profile in patients with previously treated HER2- MBC and ROC. The early antitumor activity observed in all MBC patients enrolled in the study suggests that further investigation of this combination is warranted.

SNPs at SMG7 Associated with Time from Biochemical Recurrence to Prostate Cancer Death

BACKGROUND

A previous genome-wide association study identified several loci with genetic variants associated with prostate cancer survival time in two cohorts from Sweden. Whether these variants have an effect in other populations or if their effect is homogenous across the course of disease is unknown.

METHODS

These variants were genotyped in a cohort of 1,298 patients. Samples were linked with age, PSA level, Gleason score, cancer stage at surgery, and times from surgery to biochemical recurrence to death from prostate cancer. SNPs rs2702185 and rs73055188 were tested for association with prostate cancer-specific survival time using a multivariate Cox proportional hazard model. SNP rs2702185 was further tested for association with time to biochemical recurrence and time from biochemical recurrence to death with a multi-state model.

RESULTS

SNP rs2702185 at SMG7 was associated with prostate cancer-specific survival time, specifically the time from biochemical recurrence to prostate cancer death (HR, 2.5; 95% confidence interval, 1.4-4.5; P = 0.0014). Nine variants were in linkage disequilibrium (LD) with rs2702185; one, rs10737246, was found to be most likely to be functional based on LD patterns and overlap with open chromatin. Patterns of open chromatin and correlation with gene expression suggest that this SNP may affect expression of SMG7 in T cells.

CONCLUSIONS

The SNP rs2702185 at the SMG7 locus is associated with time from biochemical recurrence to prostate cancer death, and its LD partner rs10737246 is predicted to be functional.

IMPACT

These results suggest that future association studies of prostate cancer survival should consider various intervals over the course of disease.

Abstract 2225: A composite smoking-related plasma protein score is associated with smoking-related cancer risk and mortality beyond self-reported smoking history in Atherosclerosis Risk in Communities Study (ARIC)

Background: Cigarette smoking is a leading causal risk factor for 13 cancers. Widely used self-reported smoking/packyears may not fully capture individualized risk of smoking-related cancer. Biomarkers (e.g., smoking-related proteins) may reflect biological effect of smoking and refine risk for personalized cancer screening recommendation.

Methods: Protein levels were measured by SomaScan assay (log2 transformed) in Visit 3 plasma from ARIC. Participants were divided 50/50 into set-1 for protein selection and score building and set-2 for association analyses. In set-1, protein levels were evaluated in association with smoking status, packyears smoked, and time since quitting using linear regression. Proteins that passed the Bonferroni threshold were screened with elastic net regression to address correlation. For positively-related proteins, those with levels ≥median were assigned the weight of 1. For inversely-related proteins, those 3 yrs ago, former-quit&lt;3 yrs ago, never) and packyears.

Results: 9901 participants without a prior cancer history were included (46% male, mean age=60 yr, median follow-up=20.1 yr). In set-1, we selected 36, 46, 4 (65 unique) proteins related to current smoker, former-quit&lt;3 yrs ago, packyears, respectively. In set-2, we ascertained 589 and 381 smoking-associated cancer cases and deaths, respectively. Median score was 31 (IQR: 12). The aHRs for smoking-related cancer incidence and mortality (Q4 vs Q1) were 2.35 (95% CI 1.83-3.02, p-trend&lt;0.001) and 2.96 (2.12-4.14; p-trend&lt;0.001) before adjusting for smoking, and 1.28 (0.96-1.70; p-trend=0.06) and 1.52 (1.04-2.22; p-trend=0.04) after adjusting for smoking. The aHRs for lung cancer were 6.81 (4.11-11.28), 6.84 (3.82-12.24), 2.02 (1.15-3.55) and 2.08 (1.09-3.95), respectively (all p-trend≤0.03).

Conclusions: We showed that a preliminary, protein-derived composite score provides relative risk information beyond known cancer risk factors and self-reported smoking. Use of such a score may provide value for refining individualized risk for smoking-associated cancers and may guide precision screening.

Funding: NHLBI, NCI, NPCR.

Citation Format: Meng Ru, Christopher Douville, Christie M. Ballantyne, Kenneth R. Butler, Josef Coresh, David J. Couper, Ron C. Hoogeveen, Corinne E. Joshu, Jiayun Lu, Michael T. Marrone, Anna E. Prizment, Adrienne Tin, Elizabeth A. Platz. A composite smoking-related plasma protein score is associated with smoking-related cancer risk and mortality beyond self-reported smoking history in Atherosclerosis Risk in Communities Study (ARIC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2225.

Racial Disparities in Time to Treatment Persist in the Setting of a Comprehensive Breast Center

BACKGROUND

Racial disparities in breast cancer care have been linked to treatment delays. We explored whether receiving care at a comprehensive breast center could mitigate disparities in time to treatment.

METHODS

Retrospective chart review identified breast cancer patients who underwent surgery from 2012 to 2018 at a comprehensive breast center. Time-to-treatment intervals were compared among self-identified racial and ethnic groups by negative binomial regression models.

RESULTS

Overall, 2094 women met the inclusion criteria: 1242 (59%) White, 262 (13%) Black, 302 (14%) Hispanic, 105 (5%) Asian, and 183 (9%) other race or ethnicity. Black and Hispanic patients more often had Medicaid insurance, higher American Society of Anesthesiologists (ASA) scores, advanced-stage breast cancer, mastectomy, and additional imaging after breast center presentation (p < 0.05). After controlling for other variables, racial or ethnic minority groups had consistently longer intervals to treatment, with Black women experiencing the greatest disparity (incidence rate ratio 1.42). Time from initial comprehensive breast center visit to treatment was also significantly shorter in White patients versus non-White patients (p < 0.0001). Black race, Medicaid insurance/being uninsured, older age, earlier stage, higher ASA score, undergoing mastectomy, having reconstruction, and requiring additional pretreatment work-up were associated with a longer time from initial visit at the comprehensive breast center to treatment on multivariable analysis (p < 0.05).

CONCLUSION

Racial or ethnic minority groups have significant delays in treatment even when receiving care at a comprehensive breast center. Influential factors include insurance delays and necessity of additional pretreatment work-up. Specific policies are needed to address system barriers in treatment access.

Nicotinamide mononucleotide supplementation protects the intestinal function in aging mice and D-galactose induced senescent cells

The nicotinamide adenine dinucleotide (NAD⁺) level shows a temporal decrease during the aging process, which has been deemed as an aging hallmark. Nicotinamide mononucleotide (NMN), a key NAD⁺ precursor, shows the potential to retard the age-associated functional decline in organs. In the current study, to explore whether NMN has an impact on the intestine during the aging process, the effects of NMN supplementation on the intestinal morphology, microbiota, and NAD⁺ content, as well as its anti-inflammatory, anti-oxidative and barrier functions were investigated in aging mice and D-galactose (D-gal) induced senescent IPEC-J2 cells. The results showed that 4 months of NMN administration had little impact on the colonic microbiota and NAD⁺ content in aging mice, while it significantly increased the jejunal NAD⁺ content and improved the jejunal structure including increasing the villus length and shortening the crypt. Moreover, NMN supplementation significantly up-regulated the mRNA expression of SIRT3, SIRT6, nuclear factor E2-related factor 2 (Nrf2), heme oxygenase-1 (HO-1), the catalytic subunit of glutamate-cysteine ligase (GCLC), superoxide dismutase 2 (SOD2), occludin, and claudin-1, but down-regulated the mRNA expression of tumor necrosis factor alpha (TNF-α). Specifically, in the D-gal induced senescent IPEC-J2 cells, 500 μM NMN restored the increased mRNA expression of interleukin 6 (IL6ST), IL-1A, nuclear factor (NF-κB1), and claudin-1 to normal levels to some extent. Furthermore, NMN treatment significantly affected the mRNA expression of antioxidant enzymes including NQO1, GCLC, SOD 2 and 3, and GSH-PX1, 3 and 4. In addition, 200 μM NMN enhanced the cell viability and total antioxidant capacity and lowered the reactive oxygen species level of senescent IPEC-J2 cells. Notably, NMN restored the down-regulated protein expression of occludin and claudin-1 induced by D-gal. The above data demonstrated the potential of NMN in ameliorating the structural and functional decline in the intestine during aging.

Impact of Screening Mammography on Treatment in Young Women Diagnosed with Breast Cancer

BACKGROUND

There is little data exploring the impact of screening mammography on subsequent treatment in the 40-49-year age group with breast cancer. We sought to assess the association between frequency of mammography in young women and extent of surgery and chemotherapy required.

METHODS

An IRB-approved retrospective review was performed of patients diagnosed with breast cancer between ages 40 and 49 years from 1 January 2010 to 19 November 2018 within a single health system. Patients were grouped based on last screening 1-24 months prior to diagnosis (1-24 group), > 25 months prior to diagnosis (> 25 group), never screened, and > 25+ never screened (combination group). Multivariate logistic regression models were used to assess for associations between screening intervals and tumor and nodal stage, chemotherapy use, and extent of surgery.

RESULTS

Of 869 patients included for analysis, 20% were never screened, 60% screened 1-24 months, and 19% screened > 25 months prior to diagnosis. Compared with the 1-24 months group, the never-screened group, > 25 months group, and combined group were more likely to receive chemotherapy. The never-screened and combined groups were more likely to undergo mastectomy and/or axillary lymph node dissection. Of patients undergoing upfront surgery, the > 25 months and combined groups were more likely to receive adjuvant chemotherapy, while the never-screened and combined groups were more likely to have nodal disease.

CONCLUSION

Our findings support the initiation of screening mammography at age 40 years to reduce the risk of aggressive treatments for newly diagnosed breast cancers in this group.

Bias in Patient Experience Scores in Radiation Oncology: A Multicenter Retrospective Analysis

PURPOSE

Patient experience scores are increasingly important in measuring quality of care and determining reimbursement from payers, including the Hospital Value-Based Purchasing Program and the Radiation Oncology Model. However, the role of bias in patient experience scores in oncology is unknown, raising the possibility that such payment structures may inadvertently perpetuate bias in reimbursement. Therefore, the authors characterized patient-, physician-, and practice-level predictors of patient experience scores in patients undergoing radiation therapy.

METHODS

The authors retrospectively reviewed patient experience surveys for radiation oncology patients treated at two large multisite academic cancer centers. The outcome was responses on four survey questions. Covariates included self-reported patient demographics, physician characteristics, practice setting characteristics, and wait-time rating linked to each survey. Multivariable ordinal regression models were fitted to identify predictors of receiving a higher score on each of the survey questions.

RESULTS

In total, 2,868 patients completed surveys and were included in the analysis. Patient experience scores were generally high, with >90% of respondents answering 5 of 5 on the four survey items. Physician gender was not associated with any measured patient experience outcomes (P > 0.40 for all). Independent predictors of higher score included a wait-time experience classified as "good" as compared with "not good" (q < .001 for all).

CONCLUSIONS

Oncology practices aiming to improve patient experience scores may wish to focus their attention on improving wait times for patients. Although a difference in patient experience scores on the basis of physician gender was not observed, such bias is likely to be complex, and further research is needed to characterize its effects.

The Impacts of Short-Term NMN Supplementation on Serum Metabolism, Fecal Microbiota, and Telomere Length in Pre-Aging Phase

Aging is a natural process with concomitant changes in the gut microbiota and associate metabolomes. Beta-nicotinamide mononucleotide, an important NAD+ intermediate, has drawn increasing attention to retard the aging process. We probed the changes in the fecal microbiota and metabolomes of pre-aging male mice (C57BL/6, age: 16 months) following the oral short-term administration of nicotinamide mononucleotide (NMN). Considering the telomere length as a molecular gauge for aging, we measured this in the peripheral blood mononuclear cells (PBMC) of pre-aging mice and human volunteers (age: 45-60 years old). Notably, the NMN administration did not influence the body weight and feed intake significantly during the 40 days in pre-aging mice. Metabolomics suggested 266 upregulated and 58 downregulated serum metabolites. We identified 34 potential biomarkers linked with the nicotinamide, purine, and proline metabolism pathways. Nicotinamide mononucleotide significantly reduced the fecal bacterial diversity (p < 0.05) with the increased abundance of Helicobacter, Mucispirillum, and Faecalibacterium, and lowered Akkermansia abundance associated with nicotinamide metabolism. We propose that this reshaped microbiota considerably lowered the predicated functions of aging with improved immune and cofactors/vitamin metabolism. Most notably, the telomere length of PBMC was significantly elongated in the NMN-administered mice and humans. Taken together, these findings suggest that oral NMN supplementation in the pre-aging stage might be an effective strategy to retard aging. We recommend further studies to unravel the underlying molecular mechanisms and comprehensive clinical trials to validate the effects of NMN on aging.

Does previous history of cancer or atypia predict histologic upgrade for pure intraductal papillomas diagnosed via core biopsy? A study of 490 cases at a single institution

BACKGROUND

Management of pure intraductal papillomas (IDP) without atypia diagnosed on core needle biopsy (CNB) remains controversial given highly variable rates of upgrade in the literature.

AIM

We sought to identify clinical and histologic factors that predict upgrade to atypia or malignancy in a large population.

METHODS AND RESULTS

A retrospective review was performed of all cases of pure IDP diagnosed on CNB and then surgically excised at a single institution from 2008 to 2018. Clinical, radiologic, and pathologic factors were compared in the no upgrade, upgrade to atypia, or upgrade to cancer groups. Univariate analysis was performed comparing no upgrade and upgrade to cancer or atypia. Four hundred and thirty nine patients were identified with a total of 490 IDP and a median age of 50 years (range 16-85). Of these patients, 54 (12.3%) were upgraded to atypia after surgical excision and five (1.1%) were upgraded to cancer. The presence of multiple papillomas in a single patient was a significant predictor of upgrade to cancer or atypia (p < .01), as well as age over ≥55 years (p < .01) and a prior history of cancer (p < .01). No other clinical, radiologic and histologic factors were found to be significant predictors of upgrade. 40/439 (9.1%) patients in the total cohort had prior history of cancer, and of these, 2/40 (5%) were found to have a new cancer after excision.

CONCLUSIONS

In patients with pure IDP on CNB, the upgrade rate to malignancy was 1.1%, while 12.3% were upgraded to atypia. The clinical significance of identifying atypia in a papilloma is unknown, especially in a patient with a prior history of atypia or cancer. However, the majority of patients who were upgraded to either atypia or cancer had no prior history of high-risk or malignant breast disease and are therefore considered true clinical upgrades. As such excision for IDP should be considered.

Secondary Invasive Breast Events among Patients with Hormone-Positive Breast Cancer and High-Risk Oncotype DX Recurrence Scores 26-30 and ≥31

BACKGROUND

The Oncotype DX Recurrence Score (ODx RS) is the most widely adopted genomic assay used to guide treatment for patients with early-stage, hormone-positive (HR+) breast cancer (BC), with higher scores predicting greater risk of recurrence and benefit from chemotherapy. Patients with ODx RS >25 typically recieve adjuvant chemotherapy; however, data regarding efficacy of chemotherapy for reducing recurrence in this population have been mixed.

OBJECTIVES

This study aimed to evaluate outcomes of patients with early-stage HR+ BC with high-risk ODx RS (26-30 and ≥31) in order to assess treatment patterns and outcomes. We hypothesized that the benefit of chemotherapy in these groups may be minimal and that select patients may forgo chemotherapy in favor of more aggressive endocrine therapy and ovarian suppression.

METHODS

We performed a retrospective analysis of 515 patients with early-stage, HR+ BC with high-risk ODx RS 26-30 and ≥31 treated between 2006 and 2018. Patients were stratified by RS: low-risk (≤10), intermediate-risk (11-25), and high-risk (≥26). The Kaplan-Meier method was used to estimate the time to secondary invasive breast events (SIBE) or distributions overall and among different RS groups with the log rank test used to compare distributions between groups.

RESULTS

Rates of chemotherapy administration were 7% among the low-risk group, 18% among the intermediate-risk group, and 83% among high-risk patients with 41 SIBE (8%) reported. When stratified by ODx RS, 5-year rates of SIBE were 4%, 6%, and 16% for low-risk, intermediate-risk, and high-risk RS, respectively. Among the 27 lymph node (LN)-negative patients with ODx RS 26-30, 74% received chemotherapy. The 5-year rate of SIBE was 25% among patients who received chemotherapy and 33% among those who did not (p = 0.5489). Among the 23 LN-negative patients with ODx RS ≥31, 91% of patients received chemotherapy. The 5-year rate of SIBE was 0% both with and without chemotherapy.

CONCLUSIONS

There was no statistically significant difference in SIBE for patients with high-risk ODx RS based on chemotherapy treatment. More aggressive endocrine therapy with ovarian suppression has become an alternative to chemotherapy among patients with intermediate-risk ODx RS (16-25). This approach may be useful among patients with high-risk ODx RS, with additional studies needed in this patient population.

Dietary phytoestrogen intake and lung cancer risk: an analysis of the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial

Phytoestrogens (PEs) have estrogen-like activity and were found to lower incidences of several hormone-dependent cancers. Emerging evidence suggests that estrogen may play a role in lung cancer carcinogenesis. We aim to evaluate dietary PE intake and lung cancer risk using data from the Prostate, Lung, Colorectal, and Ovarian cancer screening trial. A total of 1,706 lung cancer cases were identified. The association between lung cancer risk and PE intake (in quartiles) was calculated using the Cox proportional hazard models adjusting for potential confounders. Stratified analyses by smoking status, sex, and histology were also performed. The highest quartile of total PE intake was associated with a reduced risk of lung cancer compared to the lowest quartile (HR=0.85, 95%CI: 0.73-0.99 for > 1,030 μg/day vs < 290 μg/day) (P trend=0.56). Similar patterns were observed among ever smokers (HR=0.84, 95%CI: 0.71-0.98), non-small cell histology (HR=0.84, 95CI: 0.72-0.99), male (HR=0.84, 95%CI: 0.69-1.03) and female (HR=0.80, 95%CI: 0.64-0.99 for 510-1,030 μg/day, HR=0.84, 95%CI: 0.67-1.06 for > 1,030 μg/day vs < 290 μg/day) subjects with no significant linear trend observed. Despite a lower consumption compared to the Asian population, increased PE intake still appears to decrease lung cancer risk in a Caucasian-dominant population. Future studies are needed to replicate these results in independent cohorts and shed a light on the potential mechanism of the protective effect of PEs on lung carcinogenesis and the interaction between PEs, smoking, and endogenous estrogens.

A first radiotherapy application of functional bulboclitoris anatomy, a novel female sexual organ-at-risk, and organ-sparing feasibility study

OBJECTIVE

The bulboclitoris (clitoris and vestibular bulbs) is the primary organ responsible for female sexual arousal and orgasm. Effects of radiotherapy on the bulboclitoris are unknown, as its structure/function has yet to be described in radiotherapy, and it overlaps only partially with the external genitalia structure. Our aim was to: describe bulboclitoris structure, function and delineation; compare volume of and dose delivered to the bulboclitoris vs external genitalia; and, compare bulboclitoris-sparing IMRT (BCS-IMRT) to standard IMRT (S-IMRT) to determine reoptimization feasibility.

METHODS

Our expert team (anatomist, pelvic radiologist, radiation oncologist) reviewed bulboclitoris anatomy and developed contouring guidance for radiotherapy. 20 female patients with anal cancer treated with chemoradiation were analyzed. Sexual organs at risk (OARs) included the external genitalia and the bulboclitoris. Volumes, dice similarity coefficients (DSCs) and dose received using S-IMRT were compared. Plans were reoptimized using BCS-IMRT. Dose-volume histograms (DVHs) for PTVs and all OARs were compared for BCS-IMRT vs S-IMRT.

RESULTS

Bulboclitoris structure, function and delineation are described herein. The bulboclitoris occupies 20cc (IQR:12-24), largely distinct from the external genitalia (DSC <0.05). BCS-IMRT was superior to S-IMRT in reducing the dose to the bulboclitoris, with the greatest reductions in V30 and V40, with no significant changes in dose to other OARs or PTV 1/V95.

CONCLUSION

The bulboclitoris can be contoured on planning imaging, largely distinct from the external genitalia. Compared with S-IMRT, BCS-IMRT dramatically reduced dose to the bulboclitoris in anal cancer planning. BCS-IMRT might safely reduce sexual toxicity compared with standard approaches.

ADVANCES IN KNOWLEDGE

The structure and function of the bulboclitoris, the critical primary organ responsible for female sexual arousal and orgasm, has yet to be described in the radiotherapy literature. Structure, function and delineation of the bulboclitoris are detailed, delineation and bulboclitoris-sparing IMRT were feasible, and sparing reduces the dose to the bulboclitoris nearly in half in female patients receiving IMRT for anal cancer, warranting further clinical study.

Abstract 2585: Dietary isoflavone intake and lung cancer risk: an analysis using data from the prostate, lung, colorectal, and ovary (PLCO) trial

Introduction: Dietary isoflavones are mainly from soy-based foods and are widely consumed in Asian countries. Isoflavone has a similar chemical structure to estrogen and has been suggested to decrease the risk of breast cancer by acting as an estrogen antagonist. Lung cancer development was also suggested to be affected by estrogen signaling. We aim to explore isoflavone intake and lung cancer risk using the prospective PLCO trial.

Methods: Data regarding dietary intake using the food frequency questionnaire, demographic and reproductive information and lung cancer diagnosis were extracted. The associations between lung cancer risk and isoflavone intake (in quartiles) overall and stratified by gender and smoking status were calculated using the Cox proportional hazard models adjusting for potential confounders. SAS 9.4 were used to perform all statistical analyses.

Results: During the 1,215,948 person-year follow-up, a total of 1,706 lung cancer cases were diagnosed. Overall (Table), the highest quartile of isoflavone intake was associated with 26% reduced risk of lung cancer compared to the lowest quartile. When the analysis was stratified by gender and further by smoking status (never vs ever), the decreased risk was only observed among male ever smokers (Q4 vs Q1: HR=0.78, 95%CI: 0.64-0.96) but not their female counterparts (Q4 vs Q1: HR=0.85, 95%CI: 0.68-1.08).

Discussion: This is the first prospective cohort study investigating isoflavone intake and lung cancer risk and we found a protective effect of isoflavone intake against lung cancer risk particularly among male ever smokers, despite an overall lower isoflavone intake among the US populations compared to the Asian populations. Future studies are needed to replicate these results in independent cohorts and shed a light on the potential mechanism of the protective effect of isoflavones on lung carcinogenesis and the interactions between isoflavones, smoking and endogenous estrogens.

Table. Multivariate-adjusted hazard ratios (HRs) for lung cancer risk according to intake of isoflavones stratified by gender and smoking statusQuartiles of isoflavone intakeP for trendQ1Q2Q3Q4Overall No. of cases574413382337 Person-years322,453290,995302,050300,449 HR 95%CIaReference0.91 (0.80-1.03)0.88 (0.77-1.01)0.84 (0.73-0.98)0.56Men Overall No. of cases344251223194 Person-years168,817142,536138,872145,416 HR 95%CIbReference0.95 (0.81-1.13)0.94 (0.78-1.12)0.83 (0.68-1.02)0.36Never smokers No. of cases10161413 Person-years58,70954,63355,67259,906 HR 95%CIcReference1.92 (0.86-4.27)1.77 (0.76-4.09)1.69 (0.68-4.21)0.86Ever smokers No. of cases334235209181 Person-years110,10887,90383,20085,510 HR 95%CIdReference0.96 (0.81-1.14)0.96 (0.80-1.15)0.78 (0.64-0.96)0.08Womene Overall No. of cases230162159143 Person-years153,637148,459163,178155,033 HR 95%CIReference0.85 (0.69-1.04)0.82 (0.66-1.01)0.85 (0.68-1.08)0.92 Never smokers No. of cases23201728 Person-years84,77085,85896,08491,777 HR 95%CIReference0.89 (0.48-1.66)0.74 (0.38-1.42)1.37 (0.73-2.56)0.65 Ever smokers No. of cases207142142115 Person-years68,86662,60167,09563,257 HR 95%CIReference0.88 (0.71-1.10)0.83 (0.66-1.05)0.80 (0.66-1.03)0.87Abbreviations: Q1: (first) lowest quartile; Q2: second quartile; Q3: third quartile Q4: (fourth) highest quartile; HR: hazard ratioaModel = Model c + smoking status + genderbModel = Model c +smoking statuscModel adjusted for age, race, BMI, marital status, education level, alcohol use, family history of any cancer, daily energy intake, vitamin C intake, vitamin E intake and beta-carotene intake.dModel = Model c +pack-year of smokingeAll models among women additionally adjusted for age at menarche, age at menopause and use of hormonal replacement therapy (yes/no).

Citation Format: Qian Wang, Meng Ru, Paolo Boffetta. Dietary isoflavone intake and lung cancer risk: an analysis using data from the prostate, lung, colorectal, and ovary (PLCO) trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2585.

Radical surgery in malignnant pleural mesothelioma (MPM): An analysis of SEER database

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Background: MPM is an aggressive malignnancy with poor overall prognosis. A combined treatment approach involving radical surgery (RS), radiation (RT) and chemotherapy (CT) provide improved survival compared to systemic treatment alone. Selecting patients who may benefit from RS is challenging. The NCCN guidelines recommend that up to T3N1M0 (Stage IIIA) epithelioid or biphasic MPM should be considered for multimodality therapy incorporating RS. However, the impact of clinical and pathologic features within each histologic subtype of MPM on RS outcomes is unknown. Methods: MPM patients from the SEER 18 program from 2004-2015 were identified. Cox proportional hazard regression models were used to examine the independent contribution of several clinical and pathologic features on overall survival (OS) in patients who received RS vs those that did not. Results: A total of 5,498 MPM patients were identified, of which 531 underwent RS. Overall, RS was associated with improved OS in the multivariate model adjusting for important clinical and pathological characteristics (Table). When stratifying according to histology, epithelioid subtype was linked to improved OS with RS despite of the presence male gender, age > 60 years old, T3, T4 or N2 or above disease; and the OS improved among those who also underwent CT ± RT with RS. Patients with sarcomatoid histology also had OS benefit from RS (HR=0.59, 95%CI: 0.37-0.93), even those that were > 60 years old, but not among those with more advanced disease (T3/4, N2/3). Sarcomatoid patients who received CT ± RT (HR = 0.52, 95%CI: 0.30-0.90) also experienced OS benefit. Among biphasic histology, no OS benefit was found overall (P = 0.11) or within other high-risk clinical features except for those who were treated CT ± RT (HR = 0.64, 95%CI: 0.45-0.90). Conclusions: Our findings demonstrate that the presence of high-risk clinical and pathologic features does not impact OS benefit of RS in epithelioid MPM, however should be considered when deciding on RS in sarcomatoid and biphasic histologies. Poor prognostic histology especially sarcomatoid subtype may experience improved survival with RS if in conjunction with other treatment modalities.[Table: see text]

Prognostic Factors and Survival Outcomes among Patients with Breast Cancer and Brain Metastases at Diagnosis: A National Cancer Database Analysis

INTRODUCTION

The aim of this study was to assess for clinicopathologic and socioeconomic features that predict improved survival for patients with advanced breast cancer with synchronous brain metastases at diagnosis.

METHODS

We utilized the National Cancer Database (NCDB) to identify all patients with brain metastases present at diagnosis, with adequate information on receptor status (ER, PR, Her2), clinical T stage of cT1-4, clinical M1, with 3,943 patients available for analysis. The association between brain metastases patterns and patient/disease variables was examined by robust Poisson regression model. Cox proportional hazards model was used to quantify the associations between overall survival (OS) and these variables.

RESULTS

In univariable analysis, OS was significantly associated with the number of sites of metastases (p < 0.0001). Patients with 2 or more additional extracranial sites of metastases had significantly worse OS (median 8.8 months, 95% confidence interval [CI] 7.8, 9.9) than patients with brain metastases only (median OS 10.6 months, 95% CI 9.4, 12.9) or brain metastases plus one other extracranial site of metastases (median OS 13.1 months, 95% CI 11.8, 14.4). Risk factors which predicted poor prognosis included triple-negative disease, high comorbidity score, poorly differentiated tumors, invasive lobular histology, multi-organ involvement of metastases, and government or lack of insurance. Factors which improve survival include younger age and Hispanic race.

DISCUSSION/CONCLUSION

Using a large NCDB, we identified various factors associated with prognosis for patients with brain metastases at the time of breast cancer diagnosis. Insurance status and related socioeconomic challenges provide potential areas for improvement in care for these patients. This information may help stratify patients into prognostic categories at the time of diagnosis to improve treatment plans.

Abstract PS6-27: Secondary invasive breast events (SIBE) among patients with oncotype DX recurrence scores (RS) 26-30 and &gt;31: Results from a large oncotype database

Background: Oncotype RS is a 21-gene assay used to predict the likelihood of distant recurrence and benefit of chemotherapy in patients with lymph node negative (LN-), hormone positive (HR+) breast cancer (BC). The Oncotype RS is used to identify patients who may be spared chemotherapy in the adjuvant setting without adverse impact on survival or secondary invasive breast events (SIBE). Results of the TAILORx trial (Sparano et al, 2018) provided evidence that chemotherapy can likely be spared for most patients with oncotype RS&lt;25, with chemotherapy benefit potentially related to chemotherapy-induced menopause. More aggressive endocrine therapy with concurrent ovarian suppression in pre-menopausal women may mitigate the need for chemotherapy among patients with higher RS. We developed a large oncotype database to determine rates of SIBE (ipsilateral recurrence, contralateral breast cancer or metastatic recurrence) among patients with higher genomic risk (Oncotype RS 26-30 and &gt; 31) to determine the benefit of chemotherapy among these groups. Methods:We identified 887 patients with early-stage, HR+ BC treated between 2006-2018. Among these patients, 515 had treatment and follow-up data available for SIBE analysis. Median follow-up for SIBE was 62 months with 41 SIBE (8%) including both LN+ and LN- patients. When stratified by RS using conservative cutoffs (Sparano et al, 2018): low risk (&lt;10), intermediate risk (11-25), and high risk (&gt;26), 5 year rates of SIBE were 4%, 6% and 16% respectively. The Kaplan Meier method was used to estimate the time to SIBE distributions overall and among different RS groups with the log rank test used to compare distributions between groups. Results: Among 887 patients, 616 (69%) were post-menopausal. A total of 654 (74%) patients had surgical management, of which 226 underwent mastectomy (35%) and 428 underwent lumpectomy (65%). Among the 630 patients who received adjuvant therapy, 14 (2%) received chemotherapy alone, 143 (23%) received a combination of chemotherapy/endocrine therapy and 473 (75%) received endocrine therapy alone. Twenty-four patients (3%) refused one or more recommended therapies. Three hundred fourteen patients (50%) also received radiation therapy. Rates of chemotherapy administration were 8% among low RS, 16% among intermediate RS and 82% among high RS patients (73% for RS 26-30 and 90% for RS &gt;31). One-hundred eighty six of 887 patients were missing chemotherapy administration data as they were likely treated at another center. Patients with treatment data available and adequate follow up were included in the SIBE analysis (n=515). Among the 27 LN- patients with RS 26-30, twenty (74%) received chemotherapy and the remaining seven (26%) did not. The five year rate of SIBE was 25% among patients who received chemotherapy and 33% among those who did not receive chemotherapy; p=0.5489. Among the 23 LN negative patients with RS &gt;31, twenty-one (91%) patients received chemotherapy and the remaining two (9%) did not. The five year rate of SIBE was 0% in both patients who received chemotherapy and in patients who did not receive chemotherapy; p-value not estimable in this subgroup due to no SIBE in either group. Conclusion: In this large oncotype database, there was no statistically significant difference in SIBE for patients with higher genomic risk (RS 26-30 and &gt;31) whether or not they received chemotherapy. This data was limited by small numbers of patients in these sub-groups. More aggressive endocrine therapy with ovarian suppression has become an alternative option to spare chemotherapy in intermediate risk patients (RS 11-25). This approach may be useful among patients with even higher risk oncotype scores. Prospective randomized studies may be useful to determine utility of chemotherapy among patients with RS &gt;26.

Citation Format: Brittney S Zimmerman, Krystal Cascetta, Natalie Berger, Serena Tharakan, Kelly Suchman, Julia Blanter, Erin Moshier, Meng Ru, Shabnam Jaffer, Amy Tiersten. Secondary invasive breast events (SIBE) among patients with oncotype DX recurrence scores (RS) 26-30 and &gt;31: Results from a large oncotype database [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 PS6-27.

Trends in neoadjuvant chemotherapy versus surgery-first in stage I HER2-positive breast cancer patients in the National Cancer DataBase (NCDB)

BACKGROUND

Neoadjuvant chemotherapy (NAC) is the standard of care for locally advanced HER2 + breast cancer (BC). Optimal sequencing of treatment (NAC vs. surgery first) is less clear cut in stage I (T1N0) HER2 + BC, where information from surgical pathology could impact adjuvant treatment decisions. Utilizing the NCDB, we evaluated the trend of NAC use compared to upfront surgery in patients with small HER2 + BC.

METHODS

We identified NCDB female patients diagnosed with T1 N0 HER2 + BC from 2010 through 2015. Prevalence ratios (PR) using multivariable robust Poisson regression models were calculated to measure the association between baseline characteristics and the receipt of NAC. Analysis of trends over time was denoted by annual percent change (APC) of NAC versus surgery upfront.

RESULTS

Of the 14,949 that received chemotherapy and anti-HER2 therapy during the study period, overall 1281 (8.6%) received NAC and 13,668 (91.4%) received adjuvant treatment. Patients receiving NAC increased annually from 4.2% in 2010 to 17.3% in 2015, with the most rapid increase occurring between years 2013 (8.5%) and 2014 (14.2%). The greatest increase was seen in patients with cT1c tumors with an APC of 37.8% over the study period (95% CI 29.0, 47.3%, p < 0.01), although a significant trend was likewise seen in patients with cT1a (APC = 26.1%,95% CI 1.59, 56.6%), and cT1b (APC = 27.4%, 95% CI 18.0, 37.7%) tumors. Predictors of neoadjuvant therapy receipt were age younger than 50 (PR = 1.69, 95% CI 1.52, 1.89), Mountain/Pacific area (PR = 1.24, 95% CI 1.05, 1.46), and estrogen receptor negativity (ER- PR + : PR = 2.01, 95% CI 1.51, 2.68; ER- PR- : PR = 1.49, 95% CI 1.32, 1.69).

CONCLUSIONS

Neoadjuvant therapy for T1 N0 HER2 + BC increased over the study period and was mostly due increased use in clinical T1c tumors. This may be consistent with secular change in Pertuzumab treatment following FDA approval in 2013.

Air Quality Response in China Linked to the 2019 Novel Coronavirus (COVID-19) Lockdown

Efforts to stem the spread of COVID-19 in China hinged on severe restrictions to human movement starting 23 January 2020 in Wuhan and subsequently to other provinces. Here, we quantify the ancillary impacts on air pollution and human health using inverse emissions estimates based on multiple satellite observations. We find that Chinese NOx emissions were reduced by 36% from early January to mid-February, with more than 80% of reductions occurring after their respective lockdown in most provinces. The reduced precursor emissions increased surface ozone by up to 16 ppb over northern China but decreased PM2.5 by up to 23 μg m-3 nationwide. Changes in human exposure are associated with about 2,100 more ozone-related and at least 60,000 fewer PM2.5-related morbidity incidences, primarily from asthma cases, thereby augmenting efforts to reduce hospital admissions and alleviate negative impacts from potential delayed treatments.

Adherence to NCCN Guidelines for Genetic Testing in Breast Cancer Patients: Who Are We Missing?

BACKGROUND

Genetic predisposition accounts for 5-10% of all breast cancers (BC) diagnosed. NCCN guidelines help providers identify appropriate candidates for counseling and testing. Concerns about underutilization of genetic testing have spurred interest in broader peri-diagnostic testing. We evaluated surgeon adherence to NCCN guidelines and studied patterns of testing in newly diagnosed BC patients.

METHODS

A total of 397 patients were identified with newly diagnosed BC treated at our institution between 2016 and 2017 with no prior genetic testing. Eligibility for genetic testing based on NCCN criteria, referral, and patient compliance were recorded.

RESULTS

In total, 212 of 397 (53%) met NCCN testing criteria. Fifty-nine of 212 (28%) patients went untested despite meeting one or more criteria. Fourteen of 59 (24%) of these were referred but did not comply. Most common criteria for meeting eligibility for testing both in the overall cohort and among missed patients were family history-based. Age > 45 years old and non-Ashkenazi Jewish descent were predictive of missed referral (p < 0.01). We identified pathogenic mutations in 16 of 153 (10%) patients who did undergo testing (11 (7%) BRCA1 or 2 and 5 (3%) with other predisposition gene mutations) or 16 of 397 (4%) among the overall group.

CONCLUSIONS

Our data highlight the underutilization of genetic testing. Even in the setting of a full-service breast center with readily available genetic counseling, there is a substantial miss rate for identifying eligible patients, related to assessment of family history, patient age, and ethnicity, as well as patient compliance. Broader peri-diagnostic testing should be considered, and higher compliance rates with patients referred should be sought.

Abstract CT262: Multicenter, phase I/II trial of anastrozole, palbociclib, trastuzumab, and pertuzumab in HR-positive, HER2-positive metastatic breast cancer

Background: Overexpression or amplification of HER2 occurs in approximately 15-20% of patients and roughly half of these tumors are hormone receptor (HR) positive. The use of aromatase inhibitors in the metastatic setting is well established while significant improvement in overall survival has been established with the use of trastuzumab or pertuzumab in HER2-overexpressing tumors. This study will examine the combination of endocrine therapy, palbociclib, and dual HER2 therapy with pertuzumab and trastuzumab in women with metastatic HR+, HER2+ breast cancer. Trial Design: Multicenter, phase I/II trial of Anastrozole, Palbociclib, Trastuzumab and Pertuzumab in HR+, Her2+ metastatic breast cancer. Eligibility Criteria: Newly diagnosed stage IV HR+, HER2+ breast cancer patients. Specific Aims: Phase I: To determine the maximum dose tolerated of palbociclib. Phase II: To determine the clinical benefit rate (CBR) of treatment with anastrozole, palbociclib, trastuzumab, and pertuzumab in HR+, HER2+ metastatic breast cancer patients. Exploratory: Examine potential biomarkers of response to palbociclib including expression of cyclin D1, cyclin E1 and E2, CDK 2, CDK 4, CDK 6, retinoblastoma, phosphorylated retinoblastoma, and p16. RNA sequencing will be used to assess for other predictors of response in an unbiased manner to assess for correlation with inhibition of Ki-67 and phosphorylated retinoblastoma expression as well as evaluate for potential mechanisms of resistance. Methods: This study will evaluate the maximum tolerated dose (MTD) of the Anastrozole, Palbociclib, Trastuzumab and Pertuzumab. Once the MTD is reached, we will assess the clinical benefit rate using a Simon's II stage design among a maximum 30 patients. Accrual: Maximum of 36 subjects. Current Enrollment: Enrollment to phase I ended in October 2018 with one dose escalation to palbociclib 125mg, at which level one DLT was observed. Thus, the MTD was determined at palbociclib 125 mg and subsequent phase II patients will be treated at this dose level. Enrollment to phase II began in February 2019. 39% of planned patients have been enrolled as of January 2020. Clinical trial registry number: NCT03304080.

Citation Format: Krystal Pauline Cascetta, Poulikos Poulikakos, Charles Shapiro, Julie Fasano, Aarti Bhardwaj, Hanna Irie, Anupama Goel, Paula Klein, Meng Ru, Amy Tiersten. Multicenter, phase I/II trial of anastrozole, palbociclib, trastuzumab, and pertuzumab in HR-positive, HER2-positive metastatic breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT262.

Use of neoadjuvant versus adjuvant chemotherapy for hormone receptor-positive breast cancer: a National Cancer Database (NCDB) study

INTRODUCTION

Neoadjuvant chemotherapy (NAC) is a well-established therapeutic option for patients with locally advanced disease often allowing downstaging and facilitation of breast conserving therapy. With evolution of better targeted treatment regimens and awareness of improved outcomes for significant responders, use of NAC has expanded particularly for triple negative and HER2-positive (HER2+) breast cancer. In this study, we explore utility of neoadjuvant chemotherapy for hormone receptor-positive HER2-negative (HR+ HER2-) patients.

METHODS

Patients with HR+ HER2- breast cancer treated with chemotherapy before or after surgery were identified from 2010 to 2015 in the NCDB. Multivariable regression models adjusted for covariates were used to determine associations within these groups.

RESULTS

Among 134,574 patients (clinical stage 2A, 64%; 2B, 21%; 3, 15%), 105,324 (78%) had adjuvant chemotherapy (AC) and 29,250 (22%) received NAC. Use of NAC increased over time (2010-2015; 13.2-19.4% and PR = 1.34 for 2015; p < 0.0001). Patients were more likely to receive NAC with cT3, cT4, and cN+ disease. Patients less likely to receive NAC were age ≥ 50, lobular carcinoma, increased Charlson-Deyo score, and government insurance. Complete response (pCR) was noted in 8.3% of NAC patients. Axillary downstaging occurred in 21% of patients, and predictors included age < 50 years, black race, poorly differentiated grade, invasive ductal histology, and either ER or PR negativity.

CONCLUSIONS

NAC use among HR+ HER2- breast cancer patients has expanded over time and offers downstaging of disease for some patients, with pCR seen in only a small subset, but downstaging of the axilla in 21%. Further analysis is warranted to determine the subgroup of patients with HR+ HER2- disease who benefit from this approach.

Distribution of oncotype recurrence scores in invasive lobular carcinomas

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Background: Invasive lobular carcinomas (ILC) account for approximately 10-15% of all invasive breast cancers, with the majority of cases presenting as ER/PR positive and HER2 negative. As a result, they often exhibit more robust responses to hormone therapy than adjuvant chemotherapy. Oncotype Recurrence Score (RS) RS is a 21-gene assay used to predict the rate of distant recurrence and response to chemotherapy in women with node-negative, hormone-positive breast cancers. Limited evidence exists regarding oncotype scores for ILC tumors, thus the aim of this study was to examine the distribution and risk stratification of Oncotype RS in ILC tumors. Methods: We analyzed patient and tumor characteristics of 492 patients- 417 (85%) IDC (intraductal carcinoma) and 75 (15%) ILC. Chi-square tests and Wilcoxon rank-sum tests were used to compare categorical and numerical outcomes, respectively. Results: No significant difference was found between IDC and ILC in terms of age and ER/PR positivity. The RS raw scores were also not significantly different between the two groups (both had median scores of 16). ILC patients were significantly more likely to be in the lower RS risk groups using the traditional (Paik) cutoff than ILC patients (61%, 39% and 0% in low, medium and high-risk groups as compared to 57%, 33% and 10% in IDC, p < 0.01). Of 417 patients with IDC, there were 16 recurrences (4%) with a median time from diagnosis to recurrence of 43 months (IQR: 28 Ð 58 months), while 1 in 75 ILC patients had recurrence at 50 months. Conclusions: Oncotype RS scores have the potential to guide treatment decisions in node-negative breast cancers. Though mean RS were similar between ILC and IDC patients, ILC were more likely to be distributed in low-risk groups. Our study was limited by a small sample size and a single ILC recurrence. Further research is needed to determine oncotype RS and recurrence rates. Future studies with longer term follow up can help better elucidate patterns of recurrence scores and recurrence rates based on histologic tumor type. [Table: see text]

Results of a phase Ib study investigating durvalumab in combination with eribulin in patients with metastatic HER2-negative breast cancer and recurrent ovarian cancer

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Background: The release of tumor-associated antigens with cytotoxic chemotherapy treatment may enhance the response to immune checkpoint blockade. Eribulin is a novel microtubule inhibitor with proven overall survival (OS) benefit in metastatic breast cancer (MBC), which may also enhance intratumoral vascular remodeling. Durvalumab, a humanized monoclonal antibody, targets the programmed cell death ligand-1 (PD-L1) receptor. This study sought to determine the recommended phase II dose (RP2D) of eribulin in combination with durvalumab, as well as the safety and preliminary anti-tumor activity of the combination in patients with previously treated HER2-negative MBC and recurrent ovarian cancer (ROC). Methods: Cohorts of 3-6 patients with HER2-negative MBC and ROC were treated in a modified 3+3 design. Eligible patients received escalating doses of eribulin (1.1mg/m2 or 1.4 mg/m2 IV on day 1 and day 8) with durvalumab (1.12g IV on day 1) in 21-day cycles until dose-limiting toxicity (DLT), intolerable adverse events (AEs), disease progression, or other reasons for withdrawal. Primary endpoint: the rate of dose limiting toxicities (DLTs) during cycle 1 and 2 of therapy. Secondary endpoints: AE rate, Objective Response Rate (ORR), progression-free survival (PFS), and OS. Results: Nine patients [median age 63 (37-77)] with median 4 prior therapies for advanced disease were treated: 5 patients with HER2-negative MBC and 4 patients with ROC. The RP2D of eribulin was 1.4mg/m2 in combination with durvalumab. There were no DLTs experienced during the first two cycles of therapy. The most common treatment-related AEs ( > 50%) were fatigue, neutropenia, decreased white blood cell count, anemia, AST and alkaline phosphatase elevation, hyperglycemia, and nausea; most were grade 1/2. There was one immune-related AE of grade ≥3 (hepatitis). Three patients discontinued study drug related to toxicity [neutropenia (n = 1), hepatic toxicity (n = 2)]. ORR was 55% (all partial response) and 4 additional patients experienced stable disease; all MBC patients experienced a response to therapy. Median PFS was 6.2 months. Median OS has not been reached. Conclusions: The combination of eribulin and durvalumab had a favorable AE profile in patients with previously treated HER2- MBC and ROC. The early anti-tumor activity observed in this study suggests that further investigation of this combination is warranted. Clinical trial information: NCT03430518 .

The application of metagenomic next-generation sequencing in diagnosing Chlamydia psittaci pneumonia: a report of five cases

Background

Chlamydia psittaci pneumonia is a zoonotic infectious disease caused by Chlamydia psittaci. Diagnostic tools, including culture, serologic test and PCR-based methods, are available but prone to false negative results.

Case presentation

This report included five cases of Chlamydia psittaci pneumonia. Symptoms and signs common to all 5 cases included fever, coughing, generalized muscle ache, and most notably, inflammatory infiltration of the lungs upon chest CT and X-ray. Metagenomic next-generation sequencing (mNGS) revealed the presence of Chlamydia psittaci in biopsy lung tissue in 3 cases and bronchoalveolar lavage fluid in the remaining 2 cases. Three patients responded to doxycycline plus moxifloxacin; two patients responded to moxifloxacin alone.

Conclusions

mNGS could be used to diagnose Chlamydia psittaci pneumonia.

Abstract P3-07-11: BRCA mutations and association with discordance in a large oncotype database

BACKGROUND: BRCA mutated tumors have been shown to be associated with higher recurrence scores as compared to BRCA negative breast cancer patients. Prior studies have demonstrated 7-19% discordance between oncotype RS and tumor grade (TG) in breast cancer patients. We developed a large oncotype database to determine if BRCA mutation status is associated with discordance.

METHODS: We identified 723 patients (32 (4%) BRCA positive patients and 691 (96%) BRCA negative patients) with early-stage, hormone positive BC treated between 2006-2018, with tumor characteristics available for analysis.

Discordance was defined as one or two-step difference between RS (low, intermediate, high risk) and TG (well (WD), moderately (MD) and poorly (PD) differentiated).

BRCA status was defined as BRCA 1 deleterious mutation, BRCA 2 deleterious mutation, BRCA mutation of unknown type, BRCA variant of undetermined significance (VUS) or other mutation.

N(%) or median were used to describe patients’ characteristics between groups and compared by Mann-Whitney U test at the confidence level of 5%.

RESULTS: Among these patients, there were 32 patients (4% of total) who had any documented mutation or VUS. 16% had documented deleterious mutation in BRCA 1, 22% BRCA 2, 6% BRCA unknown type, 25% BRCA VUS, and 31% other VUS (most commonly CHEK2 and ATM).

Median RS was 23.5 in patients with deleterious BRCA mutations (1, 2 or unknown) vs. 16 in patients in the BRCA negative database which was statistically significant (p&lt;0.01).

One step and two-step discordance was present in 46% and 8% respectively of patients with deleterious BRCA mutations vs. 53% and 11% respectively in the BRCA negative database.

CONCLUSIONS: Patients with deleterious BRCA mutations demonstrated no difference in rates of discordance as compared to BRCA negative patients. We further demonstrated that patients with BRCA positive tumors display higher recurrence scores than patients with BRCA negative tumors.

Citation Format: Julia Blanter, Brittney Zimmerman, Serena Tharakan, Krystal Cascetta, Meng Ru, Amy Tiersten. BRCA mutations and association with discordance in a large oncotype database [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-07-11.

BRCA Mutation Association with Recurrence Score and Discordance in a Large Oncotype Database

BACKGROUND

The Oncotype DX Breast Cancer Assay is a 21-gene assay used to predict the likelihood of distant recurrence and the benefit of chemotherapy in patients with node-negative, tamoxifen-treated breast cancer. Prior studies demonstrated 7-19% discordance, or a difference between the recurrence score (RS) and tumor grade (TG) in breast cancer patients. BRCA mutated tumors (BRCA+) have been shown to be associated with higher RS as compared to BRCA-negative patients (BRCA-).

OBJECTIVES

We developed a large Oncotype RS database to determine if the BRCA mutation status is associated with discordance.

METHODS

We identified 723 patients (32 [4%] mutation-positive and 691 [96%] mutation-negative patients) with early-stage, hormone-positive breast cancer treated between 2006 and 2018, with tumor characteristics available for analysis. Discordance was defined as one- or two-step difference between RS (low, intermediate, high risk) and TG (well [WD], moderately [MD], and poorly [PD] differentiated). Mutation positive was defined as BRCA1 deleterious mutation, BRCA2 deleterious mutation, BRCA mutation of unknown type, BRCA variant of undetermined significance (VUS) or other mutation (classified as other VUS). Number (%) or median were used to describe patient characteristics between groups and were compared by the Kruskal-Wallis test at a significance level of 5%.

RESULTS

Among these patients, there were 32 (4% of total) who were identified as mutation-positive. Of those patients, 16% had a documented deleterious mutation in BRCA1, 22% in BRCA2, 6% had a BRCA mutation of unknown type (either 1 or 2), 25% were BRCA VUS, and 31% other VUS (most commonly CHEK2 and ATM). The median RS was 23.5 in patients with deleterious BRCA mutations (1, 2 or unknown) versus 16 in patients in the BRCA-negative database, which was statistically significant (p < 0.01). One- and two-step discordance was present in 46 and 8%, respectively, of patients with deleterious BRCA mutations versus 53 and 11%, respectively, in the BRCA-negative database.

CONCLUSIONS

Patients with deleterious BRCA mutations demonstrated no difference in rates of discordance as compared to BRCA-negative patients. We further demonstrated that patients with BRCA-positive tumors display higher RS than patients with BRCA-negative tumors.

Diabetes and Metformin Association with Recurrence Score in a Large Oncotype Database of Breast Cancer Patients

<b><i>Background:</i></b> The Oncotype DX® (ODX) is a genomic assay that provides clinicians with a prediction of benefit of chemotherapy in node-negative, tamoxifen-treated breast cancer. However, the relationship between ODX recurrence score (RS) and diabetes, a common comorbidity in breast cancer patients, has been inadequately described in the literature. Specifically, the association of diabetes treatment with metformin and RS is inconclusive, with different studies reporting conflicting results. Because diabetes has been associated with higher RS, it has been suggested that management of diabetes with metformin in breast cancer patients may be associated with a lower RS. <b><i>Objectives:</i></b> We studied a large cohort of early-stage, hormone-positive breast cancer patients to determine if there is an association between RS and metformin treatment. <b><i>Methods:</i></b> In this study, we retrospectively examined the medical records of 514 early-stage, hormone-positive breast cancer patients who had oncotype testing performed between 2007 and 2017. Number (%) or median were used to describe the patients’ characteristics between groups and were compared by the Kruskal-Wallis test at a significance level of 5%. <b><i>Results:</i></b> Of this cohort, 67 (13%) had a diabetes diagnosis at the time of breast cancer diagnosis, including both diabetes mellitus and pre-diabetes. The median RS for non-diabetic patients was 16 and the median RS for diabetic patients was 15. This difference was not significant, nor was there a statistical difference in RS between diabetic patients taking metformin (median RS = 15) and diabetic patients not taking metformin (median RS = 15). These results held true even when controlling for BMI. <b><i>Conclusions:</i></b> We conclude that neither diabetes diagnosis nor metformin use is associated with a difference in oncotype RS in this population of diabetic patients.

Safety and Efficacy of Liver Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma After Segmental Transarterial Radioembolization

PURPOSE

With increasing use of radiation for hepatocellular carcinoma (HCC) through transarterial radioembolization (TARE) and stereotactic body radiation therapy (SBRT), there is concern for increased radiation-related complications when using SBRT after TARE. This study compares safety of SBRT after segmental TARE versus transarterial chemoembolization (TACE).

METHODS AND MATERIALS

A retrospective review identified patients receiving SBRT after TACE or TARE for HCC from 2011 to 2017. TARE was delivered subselectively to individual segments using yttrium-90 with Theraspheres. Patients were assessed over time for Child-Turcott-Pugh (CTP)/albumin-bilirubin (ALBI) scores, and Common Terminology Criteria for Adverse Events version 4.0 grade ≥3 events. Linear mixed models were used to examine the trend of CTP and ALBI over time and compare groups. Secondary endpoints were objective response rate via modified Response Evaluation Criteria in Solid Tumors (RECIST), local control, and overall survival.

RESULTS

Ninety-nine patients met criteria with median follow-up of 9.8 months (range, 0.9-47): 31 had SBRT after segmental TARE and 68 patients post-TACE. The groups were well balanced with regard to etiology of HCC, baseline CTP and ALBI scores, and SBRT dose, but there were significant differences in baseline Eastern Cooperative Oncology Group performance status, Barcelona Clinic Liver Cancer staging, and median follow-up. There was a significant increase in post-SBRT CTP and ALBI scores (P < .0001) for both groups. However, there was no significant difference in rise in CTP (P = .11) or ALBI score (P = .82) over time between SBRT post-TACE versus post-segmental TARE. There was no significant increase in ≥grade 3 toxicity postsegmental TARE. There was also no significant difference in local controls (P = 1.0) and overall survival (P = .26) between cohorts, but objective response rate was worse post-TARE.

CONCLUSIONS

SBRT after segmental TARE with Theraspheres appears to have acceptable tolerability and is effective compared with SBRT after TACE. Longer follow-up with larger numbers is needed to verify these data.

Practice Changing Potential of TAILORx: A Retrospective Review of the National Cancer Data Base from 2010 to 2015

BACKGROUND

Uncertainty regarding chemotherapy benefit among breast cancer patients with intermediate Oncotype Dx^® recurrence scores (RS; 11-25) led to the TAILORx study. We evaluated chemotherapy use in patients with intermediate RS to determine practice change potential based on the TAILORx results.

METHODS

National Cancer Data Base patients with hormone receptor-positive/human epidermal growth factor receptor 2 (HER2)-negative, N0 breast cancer were identified and were divided into three groups: Group A, ≤ 50 years of age (RS 11-15); Group B, ≤ 50 years of age (RS 16-25); and Group C, > 50 years of age (RS 11-25). Demographic and clinical factors were compared using Chi square tests and Poisson regression models to determine predictors of chemotherapy receipt.

RESULTS

Overall, 37,087 patients met the inclusion criteria, with 6.3% in Group A and 11.7% in Group C having received chemotherapy that may have been avoided based on TAILORx. The majority of Group B (64.7%) did not receive chemotherapy, whereas TAILORx showed potential benefit from treatment. Chemotherapy use decreased over time for all intermediate RS patients. T2 tumors, high grade, and treatment before 2012 increased the likelihood of chemotherapy receipt among both groups. Younger patients with the lower intermediate RS (Group A) were more likely to receive chemotherapy if they had treatment at community or comprehensive centers, whereas moderate grade was also a significant factor to receive chemotherapy in Group B. Significant factors in older patients (Group C) were Black race, estrogen receptor-positive/progesterone receptor-negative, and moderate/high grade.

CONCLUSIONS

The most potential impact of TAILORx findings on practice change is for patients ≤ 50 years of age with RS of 16-25 who did not receive chemotherapy but may benefit. These findings may serve as a baseline for future analysis of practice patterns related to TAILORx.

Effects of jaw exercise intervention timing on outcomes following oral and oropharyngeal cancer surgery: Pilot study

BACKGROUND

Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation.

METHODS

A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively.

RESULTS

Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points.

CONCLUSIONS

The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.

The Effect of Glucose Levels Prior to Hematopoietic Cell Transplantation on Post-Transplant Complications and Health Resource Utilization

Background: Abnormal blood glucose (BG) levels during hematopoietic cell transplantation (HCT) are associated with increased infections, delayed engraftment, and prolonged hospitalization, though little is known about these associations. Materials and Methods: We retrospectively evaluated mean BG levels in the week prior to HCT and subsequent outcomes for 852 HCTs at our hospital from 1/2009 – 12/2013 pertaining to 745 patients. Outcomes included infections (pneumonia, C. difficile, positive cultures, administration of antimicrobials, or neutropenic fever), time-to-engraftment (TTE), and quality indicators (30- and 90-day readmission rates [RR] and median length-of-stay [LOS]). Results: We retrospectively evaluated mean BG levels in the week prior to HCT and subsequent outcomes for 852 HCTs at our hospital from 1/2009 – 12/2013 pertaining to 745 patients. Outcomes included infections (pneumonia, C. difficile, positive cultures, administration of antimicrobials, or neutropenic fever), time-to-engraftment (TTE), and quality indicators (30- and 90-day readmission rates [RR] and median length-of-stay [LOS]). Conclusion: Pre-HCT BG trends may be a prognostic biomarker for adverse outcomes, and thus can help improve quality of care for HCT patients.

The Effect of Glucose Levels Prior to Hematopoietic Cell Transplantation on Post-Transplant Complications and Health Resource Utilization

Background: Abnormal blood glucose (BG) levels during hematopoietic cell transplantation (HCT) are associated with increased infections, delayed engraftment, and prolonged hospitalization, though little is known about these associations. Materials and Methods: We retrospectively evaluated mean BG levels in the week prior to HCT and subsequent outcomes for 852 HCTs at our hospital from 1/2009 - 12/2013 pertaining to 745 patients. Outcomes included infections (pneumonia, C. difficile, positive cultures, administration of antimicrobials, or neutropenic fever), time-to-engraftment (TTE), and quality indicators (30- and 90-day readmission rates [RR] and median length-of-stay [LOS]). Results: 404 patients met the criteria for involvement in this study. The population was 55% male and was racially and ethnically mixed (White 38%, African American 23%, Hispanic 6%, Asian 7%, Other 21%). Mean age was 57+14 years. Significantly more patients in Group 2 were diagnosed with pneumonia (19%) compared with the Group 1 (7%) and Group 3 (10%) [p=.0054]. Patients in Group 2 also had significantly longer median LOS: Group 1-23 days, Group 2-26 days, Group 3-22 days [p = .0157]. No significant differences were noted in terms of the other infectious complications or in time-to-engraftment or readmissions. Conclusion: Pre-HCT BG trends may be a prognostic biomarker for adverse outcomes, and thus can help improve quality of care for HCT patients.

A multicentered randomized phase II comparison of single-agent carboplatin versus the combination of carboplatin and everolimus for the treatment of advanced triple-negative breast cancer

TPS1109

Background: Triple negative breast cancer (TNBC) is an aggressive disease with unmet clinical needs. Women with TNBC tend to be younger and demonstrate early recurrence, higher histological grade, higher rate of visceral metastasis and increased mortality rates when compared to hormone positive breast cancer. Prognosis for metastatic TNBC is especially poor. Due to lack of targeted therapies, there is no standard treatment of choice for triple negative breast cancer and chemotherapy remains the accepted standard. Many chemotherapeutic agents have been reported to have clinical activity either as single agent or in combination. Seventy percent of breast cancers with BRCA-1 germline mutations are triple negative, which suggests a shared carcinogenic pathway between them. In preoperative and metastatic settings, both TNBC and BRCA-1 associated breast cancers are particularly sensitive to DNA cross-linking agents such as platinum compounds due to defective DNA repair by homologous recombination. The recent TNT trial showed in patients with triple negative metastatic or recurrent locally advanced breast cancer with BRCA1/2 mutations, carboplatin resulted in a significantly higher overall response rate versus docetaxel (68% versus 33.3%; p=0.03). Triple negative breast cancers are associated with a high frequency of PTEN loss, which leads to mTOR activation. Moreover, it has been reported that mTOR activation may confer resistance to platinum agents such as cisplatin, a phenomenon that may be reversible by the addition of an mTOR inhibitor such as everolimus. There are reports of synergy between mTOR inhibitors and platinum compounds in pre-clinical and clinical data. Methods: We have opened a multi-centered randomized phase II trial comparing carboplatin AUC 4 q 3 weeks vs carboplatin AUC 4 q 3 weeks combined with daily 5 mg everolimus. 41 of planned 72 patients from the Mount Sinai Health System have been enrolled and are randomized in a 2:1 allocation. The primary objective is to compare progression-free survival in patients treated with carboplatin+everolimus to patients treated with carboplatin alone. Patients may have had up to 3 prior regimens for metastatic disease. Exploratory biomarker assessment is being done to identify markers of response. Clinical trial information: NCT02531932.

Oncotype recurrence score (RS) and discordance in patients with secondary invasive breast events (SIBE)

e12016

Background: Oncotype RS is a 21-gene assay used to predict the likelihood of distant recurrence and benefit of chemotherapy in patients with node-negative, tamoxifen treated breast cancer (BC). We developed a database to determine rates of SIBE and identify cases of discordance between Oncotype RS and tumor grade (TG). Our goal was to recognize patients with discordant tumors who had SIBE, with implications for patient management. Methods: We identified 618 patients (645 samples) with early-stage, hormone positive BC treated between 2006-2018, with tumor characteristics available for analysis. Among these patients, there were 24 SIBE (n = 24) from 23 patients (3.7%). When stratified by RS using traditional cutoffs (Paik, 2004), rates of SIBE were 2.8%, 5.0% and 4.5% in low, intermediate and high-risk groups respectively. Discordance was defined as 1 or 2-step difference between RS (low, intermediate, high risk) and TG (well (WD), moderately (MD) and poorly (PD) differentiated). Prior studies demonstrated 7-19% “2-step discordance” between TG and RS (i.e. PD tumors with low-risk RS or WD tumors with high-risk RS). N(%) or median were used to describe patients’ characteristics between groups and compared by Mann-Whitney U test at the confidence level of 5%. Results: Of the 24 SIBE, 42% had low RS ( < 18), 46% had intermediate RS (18-30) 12% had high RS ( > 31). Median RS was 22 and median age at secondary event was 61 (67% post-menopausal). At time of SIBE, 54% were metastatic, 25% locally recurrent and 21% contralateral. Within this dataset, 63% were 1-step and 4% were 2-step discordant. Significantly fewer patients were treated with systemic chemotherapy in the discordant group (p < 0.01), though 94% displayed MD or PD TG. Discordant tumors tended to have lower RS (median 14 vs. 24) and be larger. There were no significant differences in menopausal status or Oncotype ER/PR score. Conclusions: Although the sample size of patients with SIBE is small, our data suggests that patients with discordant tumors of low-risk RS but higher TG may be receiving inadequate treatment (i.e. no chemotherapy). In addition to RS, other factors such as discordance, TG and size should perhaps be considered when determining treatment plans.

Stratification of oncotype (ODX) Recurrence Score (RS) by Breast Cancer Index (BCI) and its relation to discordance

e12025

Background: ODX is a gene-expression panel predictive of 10-year risk of distant recurrence and has shown prognostic value in both node-negative (LN-) and node-positive (LN+) breast cancer (BC) patients. BCI predicts 10-year risk of recurrence and also identifies those that may benefit from extended adjuvant endocrine therapy (EET). We stratified ODX RS by BCI to compare its precision in predicting recurrence category and its relation to discordance. Methods: 49 women with HR+, LN- and LN+ BC with available ODX and BCI RS with median follow up of 6 years were included. BCI risk groups were evaluated using predetermined cutoffs. RS were stratified by traditional ODX and TAILORx cutoffs and were considered discordant if there was a 1-step or 2-step difference between ODX risk group (low, intermediate, high) and tumor grade (well, moderately and poorly differentiated). N (%) or median (range) were used to describe patients’ characteristics between BCI groups and compared by chi-square test or Fisher’s exact at the confidence level of 5%. Results: Using traditional RS cutoffs, BCI reclassified 42.3% of patients with low RS as intermediate (IR) or high risk (HR). 69% with intermediate RS were reclassified to low risk (LR) and 12% were upgraded to HR by BCI. 27% of low and intermediate RS had a high benefit from EET. 2-step discordance was 14.3%. Using TAILORx RS cutoffs, BCI reclassified 20% of patients with low RS as IR. None were upgraded to HR. In the intermediate RS group, 58% were reclassified as LR and 14% as HR. 24% of intermediate RS had a high benefit from EET. 2-step discordance was 2%. Conclusions: Patients classified as LR by TAILORx RS cutoffs are less likely to be reclassified as high or intermediate risk by BCI. No significant association was found between discordance among ODX RS and tumor grade and BCI prediction of recurrence or benefit of EET.

Dose Selection for Multiple Myeloma in Modern Era

PURPOSE

The management of multiple myeloma (MM) has evolved over the past 20 years, secondary to novel biologic therapeutics. Radiation therapy remains an important intervention in the management of painful lytic bone lesions. However, the currently used radiation therapy regimens were developed in the pre-biologic therapy era. The goal of this study is to assess the effects of dose and fractionation in pain control for patients with MM in the modern era.

METHODS AND MATERIALS

We conducted a retrospective study based on data collected from patients who received radiation therapy at our institute between 2007 and 2017. A total of 130 patients (266 treatment sites) were included in this study. Univariate Cox proportional hazards models were used to analyze the association of risk of pain recurrence with treatment characteristics and compute the hazard ratios (HRs).

RESULTS

The median follow-up time was 14 months. Patients who received a total dose of 20 to <30 Gy (including 20 Gy) had a significantly lower probability of pain recurrence when compared with those who received <20 Gy (HR, 0.36; 95% confidence interval, 0.14-0.94; P = .0365). There was no statistically significant difference in treatment response or pain recurrence between the different fraction numbers and sizes. However, we noted a trend indicating lower pain recurrence in the group that received 6 to 10 fractions of radiation therapy (P = .06). Among the most commonly used regimens, 8 Gy in a single fraction resulted in a statistically significant increased chance of pain recurrence compared with 20 Gy in 10 fractions and a borderline statistically significant increased chance of pain recurrence when compared with 30 Gy in 10 fractions.

CONCLUSIONS

Radiation therapy remains highly effective at managing lytic bone lesions in patients with MM, and 6- to 10-fraction treatment courses are equally as effective as longer courses at treating these lesions. Treatment with 20 Gy in 10 fractions resulted in a significantly lower probability of pain recurrence when compared with 8 Gy in 1 fraction.

Abstract P5-11-07: The significance of androgen receptor co-expression in ER+ metastatic breast cancer patients treated with palbociclib

Background: The PALOMA-1 and PALOMA-3 studies demonstrated a significant progression-free survival (PFS) advantage for palbociclib, a CDK4/6 inhibitor, in combination with letrozole or fulvestrant in the first or second line setting compared to these therapies alone in estrogen receptor (ER)+, HER2-negative metastatic breast cancer (MBC). Recent studies have revealed preliminary efficacy signals for androgen receptor (AR) blockade in MBC, predominately in AR+, triple negative patients. We sought to further evaluate AR expression and its significance in ER+ MBC patients treated with palbociclib early in their metastatic treatment course.

Methods: A retrospective review identified 22 patients treated with palbociclib for ER+, HER2- MBC after its FDA approval between January 1st, 2015 and October 1st, 2016 at our center with available pre-treatment tumor samples for analysis. Records were reviewed and clinical characteristics for each patient were analyzed. Archival tumor tissue was tested for AR, phosphorylated retinoblastoma (pRb), CDK6, p16, and CyclinE1 by immunohistochemistry assay for each patient. For AR, nuclear staining &gt;0% was considered positive. For all other IHC studies, intensity of staining &gt;2+ or staining in &gt;10% of cells was considered positive.

Results: The median age was 63.5 years (range 34-84); 23% were ≥ age 70. Our cohort was 35% African American, 60% Caucasian, and 5% Asian American. 64% of patients were post-menopausal and 59% had visceral metastases. 45% of patients were on their first line of treatment, 23% second line, and 32% third line. 68% of patients were on an aromatase inhibitor. Median follow up was 18.7 months (95% CI 13.9, 23.3 months). The AR was expressed in 59% of patients; 55% had expression &gt;10% and 41% had expression &gt;20%. AR+ patients were significantly more likely to experience event-free survival (EFS) (HR 0.26, p=0.01), with a median EFS of 18.8 months (AR- median EFS 5.4 months). AR expression was significantly associated with expression of pRb (100% of AR+ patients, p=0.02). CDK6, p16, and CyclinE1 expression were not associated with AR expression or EFS.

Conclusions: Our data show preliminary evidence of the significance of ER and AR co-expression in ER+, HER2- MBC. ER+, AR+ patients have significantly improved EFS when treated with palbociclib and endocrine therapy as compared with AR-, ER+ patients. There is evidence that AR expression is associated with pRB expression, which may represent a mechanism by which cell cycle inhibition with palbociclib is particularly efficacious in these patients. AR expression rates in ER+, HER2- MBC are significant, and may provide rationale for combining CDK4/6 inhibitors with AR targeting as a subsequent line of targeted therapy in these patients before cytotoxic chemotherapy is initiated. Further studies based on these results are underway.

Citation Format: Landry CA, Ru M, Jaffer S, Dimitrova M, Tiersten A. The significance of androgen receptor co-expression in ER+ metastatic breast cancer patients treated with palbociclib [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-11-07.

Stage-matched survival differences by ethnicity among gastric cancer patients of Asian ancestry treated in the United States

BACKGROUND

Differences have been noted in overall survival (OS) in gastric cancer (GC) between trials conducted in Western vs Asian countries. The National Cancer Database (NCDB) reports outcomes and patient/disease variables relevant to OS.

METHODS

Using NCDB, we identified 89 558 adult patients with GC diagnosed (2004-2012), where self-reported race/ethnicity was available. Cox proportional hazard model was used to calculate multivariable hazard ratio (HR) of death, adjusting for race/ethnicity, age, gender, insurance, histology, grade, location, stage, and treatment type.

RESULTS

After adjustment, Asian patients had improved OS (HR = 0.74, 95% confidence intervals [CI] = 0.71-0.77). There were differences in OS between Asian ethnicities compared with white patients (n = 69 945), notably with Korean (n = 1249, HR = 0.70, 95% CI = 0.64-0.75), Chinese (n = 1271, HR = 0.69, 95% CI = 0.64-0.75), and Indian/Pakistani patients (n = 492, HR = 0.68, 95% CI = 0.61-0.76). Japanese (n = 829, HR = 0.84, 95% CI = 0.77-0.91) and Vietnamese (n = 560, HR = 0.79, 95% CI = 0.71-0.88) OS was also improved (P < 0.0001), while Filipino patients showed no difference (n = 415, HR = 1.00). Black patients had slightly improved OS (n = 13 500, HR = 0.98, 95% CI = 0.95-1.00, P = 0.035).

CONCLUSIONS

This analysis supports improved OS in Asian patients independent of stage, treatment, and known patient or disease characteristics in this large US cohort, and is the largest to define OS differences between Asian ethnicities.

Overall Survival Trends and Clinical Characteristics of Plasmacytoma in the United States: A National Cancer Database Analysis

BACKGROUND

Given the rarity of plasmacytoma, large-scale database analysis can provide useful information regarding the clinical presentation and patient-related factors impacting overall survival (OS).

MATERIALS AND METHODS

The National Cancer Data Base was queried for patients with plasmacytoma between 2004 and 2013, excluding patients with systemic disease. Plasmacytomas were classified as originating in bone (P-bone), in extramedullary tissue (P-EM), or unspecified. Survival was estimated using the Kaplan-Meier and log-rank test method. We used Cox regression to determine specific outcomes adjusting for demographic, socioeconomic, geographic, facility type, year of diagnosis, and comorbid factors.

RESULTS

In total, 6225 patients were identified, of which 61.5% were men. The median age at diagnosis was 64 years (range, 18-90 years), and the median follow-up was 58 months. The primary site of disease was P-bone in 4056 (65.1%) patients and P-EM in 1468 (23.6%), and the remaining 701 patients were P-unspecified. The unadjusted median survival for solitary P-bone was 89 months (95% confidence interval, 82.9-95.0 months), and for solitary P-EM was 117.3 months (95% confidence interval, 108.8 months to not reached). Factors associated with improved OS include younger age, private insurance, higher income, solitary lesion, and lower comorbidity score. Patients with P-bone disease treated at academic facilities had improved OS. Only 65% of patients with solitary plasmacytoma lesions received radiation treatment. Age greater than 75 years and increased distance to treatment facility was associated with a decreased likelihood of receiving radiation.

CONCLUSIONS

This is the largest study examining outcomes of patients with plasmacytoma using a large database analysis, revealing unique aspects of P-EM versus P-bone and underutilization of radiation treatment.