Abstract A55: Natural killer cells genetically modified to overexpress DNAM-1 exert enhanced antitumor responses against CD112/CD155+ sarcomas and other malignancies

Sarcomas are a broad category of cancers arising from cells of mesenchymal origin that occur in bone and soft tissues. They affect humans of all ages, and standard treatment options remain ineffective at increasing overall survival. Targeted immunotherapy is a rapidly developing field that offers extremely promising therapeutic prospects for many cancers. However, sarcomas are vastly understudied in this field. Natural killer (NK) cells are immune cells with inherent tumor-killing abilities that are a promising option for cancer immunotherapy. However, tumors can dysregulate the expression of NK cells ligands to escape immune detection, and the details of these escape mechanisms are not well known in sarcomas. Thus, a better understanding of NK cell-sarcoma interactions is necessary for the development of novel immunotherapies. In order to address this, we generated 20 cell lines from primary sarcoma tumors and characterized a group of known cancer-related NK cell receptor ligands. Our results show that all primary sarcoma cell lines express the inhibitory NKp44 ligand, PCNA, as well as CD112 and/or CD155, both of which are ligands for the NK cell activating receptor DNAM-1. However, NK cell cytotoxicity against sarcoma cells is still relatively low. Therefore, we generated a cell-based screening platform in which genetically modified (GM) NK cells that overexpress one activating receptor at a time are tested for degranulation against different sarcoma cell lines (n=12). Our results indicated patient-specific involvement of multiple NK cell receptors. In line with the conserved expression of CD112 and CD155 on sarcoma cells, we observed that DNAM-1+ GM-NK cells display significantly enhanced antitumor responses against all 12 cell lines when compared to wild-type (WT)-NK cells. We further confirmed that this enhanced NK cell response was indeed DNAM-1-dependent by interfering with the CD155/DNAM-1 interaction using blocking antibodies targeting either the receptor or its ligand. Additionally, the response of DNAM-1+ versus WT-NK cells was tested against various cancer cell lines, including those derived from a metastatic prostate carcinoma (LNCaP), primary pancreatic ductal adenocarcinoma (Capan-2), primary colorectal adenocarcinoma (Caco-2), primary lung alveolar basal epithelial adenocarcinoma (A549), metastatic neuroblastoma (SH-Sy5y), metastatic nerve sheath tumor (SNF02.2), two melanomas (A375 and DM6), and two leukemias (K562 and THP-1). In conclusion, DNAM-1 overexpression elicited a dynamic increase in NK cell degranulation against all cancer cell lines tested, including those that failed to induce a notable response in WT-NK cells, supporting the broad potential applicability of the DNAM-1+ GM-NK cells for the treatment of several malignancies. Furthermore, tumors expressing CD112 and/or CD155 can be targeted by DNAM-1+ GM-NK cells, and our GM NK cell screening platform can be used for rapid screening against not only sarcomas but also several cancers.

Citation Format: Ece C. Sayitoglu, Michael Chrobok, Anna-Maria Georgoudaki, Benjamin J. Josey, Michelle Hartman, Esha Vallabhaneni, Rajeev Herekar, Savannah Bergeron, Robin Krueger, Tolga Sutlu, Evren Alici, Harry T. Temple, Adil D. Duru. Natural killer cells genetically modified to overexpress DNAM-1 exert enhanced antitumor responses against CD112/CD155+ sarcomas and other malignancies [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2018 Nov 27-30; Miami Beach, FL. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(4 Suppl):Abstract nr A55.

Abstract A23: Identification of prevalent targets for the development of tailored sarcoma immunotherapies using a rapid clinic-to-bench immunoprofiling pipeline

Sarcomas are rare malignancies of mesenchymal origin for which current treatment options are very limited. Due to the vast heterogeneity of the various subtypes, the development of new targeted therapies requires a customized approach. Checkpoint blockade therapies are a promising alternative that still have not been systematically investigated for sarcoma patients. Thus, utilizing the infrastructure of the Cell Therapy Core Facility (CTC) at Nova Southeastern University (NSU), we developed a clinic-to-bench pipeline that enables the processing of fresh tumor material after surgical excision to generate primary sarcoma cell lines for biobanking and research purposes. Using this pipeline, we have extensively characterized mRNA, miRNA and cell surface expression profiles from more than 40 sarcoma cell lines to date, as well as validated their tumorigenicity by assessing expression of sarcoma/cancer associated genes such as Birc5, Birc2, Bcl2, Ewsr1-fli1, Syt/Ssx and Pcna. Moreover, we assessed the expression of immunomodulatory molecules that may suppress antitumor responses, such as PD-L1, PD-L2, OX40L and CD40L, using multicolor flow cytometry. Detailed characterization of the immune profile of 7 bone-related and 7 soft tissue sarcoma cell lines, assessed after 12 weeks of in vitro serial passaging, revealed a common signature in the cell surface expression of proliferative marker PCNA, and lymphocyte ligands CD112 and CD115. Moreover, immunoprofiling of the PCNA/CD112/CD155+ sarcoma cell lines (n=14) demonstrated persistent expression of PD-L2 in all cell lines and the potential applications of currently clinically approved anti-PD-1 checkpoint inhibitors for sarcoma treatment. Importantly, the conserved expression of these proteins enabled the distinction of sarcoma tumor cells from other cells in the fresh primary tumor mix directly after isolation. Thus, we next performed a comparative analysis of the immune profile of 6 freshly isolated sarcoma tumors and their respective cell lines. Comparison of the surface expression profiles of the generated cell lines and the corresponding primary tumor cells showed that the initial phenotype was preserved after more than 12 weeks of expansion and after cryopreservation. This proves that the generated cell lines are an accurate tool that can be used for the development of novel personalized immunotherapies. Most importantly, our results enabled the design of a translational research pipeline that allows the systematic characterization of the immune profile of understudied sarcomas for the first time in order to gain insight into which patients may directly benefit from available immunotherapies and which may be eligible to enroll in clinical trials assessing the efficacy of checkpoint inhibitors. In summary, the generated sarcoma biobank serves as a unique and highly representative primary resource that can be utilized to identify potential candidates for novel targeted and personalized immunotherapies for the treatment of sarcomas.

Citation Format: Anna-Maria Georgoudaki, Robin Krueger, Michelle Hartman, Tamara Chinn, Dustin Tran, Reneé Potens, Wendy Weston, H. Thomas Temple, Adil D. Duru. Identification of prevalent targets for the development of tailored sarcoma immunotherapies using a rapid clinic-to-bench immunoprofiling pipeline [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2018 Nov 27-30; Miami Beach, FL. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(4 Suppl):Abstract nr A23.

Boosting Natural Killer Cell-Mediated Targeting of Sarcoma Through DNAM-1 and NKG2D

Sarcomas are malignancies of mesenchymal origin that occur in bone and soft tissues. Many are chemo- and radiotherapy resistant, thus conventional treatments fail to increase overall survival. Natural Killer (NK) cells exert anti-tumor activity upon detection of a complex array of tumor ligands, but this has not been thoroughly explored in the context of sarcoma immunotherapy. In this study, we investigated the NK cell receptor/ligand immune profile of primary human sarcoma explants. Analysis of tumors from 32 sarcoma patients identified the proliferative marker PCNA and DNAM-1 ligands CD112 and/or CD155 as commonly expressed antigens that could be efficiently targeted by genetically modified (GM) NK cells. Despite the strong expression of CD112 and CD155 on sarcoma cells, characterization of freshly dissociated sarcomas revealed a general decrease in tumor-infiltrating NK cells compared to the periphery, suggesting a defect in the endogenous NK cell response. We also applied a functional screening approach to identify relevant NK cell receptor/ligand interactions that induce efficient anti-tumor responses using a panel NK-92 cell lines GM to over-express 12 different activating receptors. Using GM NK-92 cells against primary sarcoma explants (n = 12) revealed that DNAM-1 over-expression on NK-92 cells led to efficient degranulation against all tested explants (n = 12). Additionally, NKG2D over-expression showed enhanced responses against 10 out of 12 explants. These results show that DNAM-1⁺ or NKG2D⁺ GM NK-92 cells may be an efficient approach in targeting sarcomas. The degranulation capacity of GM NK-92 cell lines was also tested against various established tumor cell lines, including neuroblastoma, Schwannoma, melanoma, myeloma, leukemia, prostate, pancreatic, colon, and lung cancer. Enhanced degranulation of DNAM-1⁺ or NKG2D⁺ GM NK-92 cells was observed against the majority of tumor cell lines tested. In conclusion, DNAM-1 or NKG2D over-expression elicited a dynamic increase in NK cell degranulation against all sarcoma explants and cancer cell lines tested, including those that failed to induce a notable response in WT NK-92 cells. These results support the broad therapeutic potential of DNAM-1⁺ or NKG2D⁺ GM NK-92 cells and GM human NK cells for the treatment of sarcomas and other malignancies.

The impact of a thin endometrial lining on fresh and frozen-thaw IVF outcomes: an analysis of over 40 000 embryo transfers

STUDY QUESTION

Does each millimeter decrease in endometrial thickness lead to lower pregnancy and live birth rates in fresh and frozen IVF cycles?

SUMMARY ANSWER

Clinical pregnancy and live birth rates decline as the endometrial thickness decreases below 8 mm in fresh IVF-ET and below 7 mm in frozen–thaw embryo transfer (ET) cycles.

WHAT IS KNOWN ALREADY

Previous studies have been heterogenous and have shown conflicting results on the impact of endometrial thickness on IVF outcomes. Most studies do not include many patients with an endometrial thickness below 6 mm, and there are few studies of frozen–thaw ET cycles.

STUDY DESIGN, SIZE, DURATION

This study is a retrospective cohort analysis of all Canadian IVF fresh and frozen–thaw ET cycles from the CARTR-BORN database for autologous and donor fresh and frozen–thaw IVF-ET cycles from 1 January 2013 to 31 December 2015. A total of 24 363 fresh and 20 114 frozen–thaw IVF-ET cycles were reported during this timeframe.

PARTICIPANTS/MATERIALS, SETTING, METHODS

33 Canadians clinics participated in voluntary reporting of IVF and pregnancy outcomes to the CARTR-BORN database. The impact of endometrial thickness on pregnancy, live birth and pregnancy loss rates were analyzed for fresh IVF-ET and frozen–thaw cycles.

MAIN RESULTS AND THE ROLE OF CHANCE

In fresh IVF-ET cycles, clinical pregnancy and live birth rates decreased (P < 0.0001) and pregnancy loss rates increased (P = 0.01) with each millimeter decline in endometrial thickness below 8 mm. Live birth rates were 33.7, 25.5, 24.6 and 18.1% for endometrial thickness ≥8, 7–7.9, 6–6.9 and 5–5.9 mm, respectively. In frozen–thaw ET cycles, clinical pregnancy (P = 0.007) and live birth rates decreased (P = 0.002) with each millimeter decline in endometrial thickness below 7 mm, with no significant difference in pregnancy loss rates. Live birth rates were 28.4, 27.4, 23.7, 15 and 21.2% for endometrial thickness ≥8, 7–7.9, 6–6.9, 5–5.9 and 4–4.9 mm, respectively. The likelihood of achieving an endometrial thickness ≥8 mm decreased with age (89.7, 87.8 and 83.9% in women <35, 35–39 and ≥40, respectively) (P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

This study only included cycles which proceeded to ET, which may overestimate pregnancy outcomes. Approximately 8% of cycles could not be included in the analysis due to data irregularity related to data entry. Demographic data aside from age were unavailable but may be important as lower endometrial thickness may be associated with poor ovarian response.

WIDER IMPLICATIONS OF THE FINDINGS

Although pregnancy and live birth rates decrease with endometrial thickness, reasonable outcomes were obtained even with lower endometrial thickness measurements. These data provide valuable guidance for both physicians and patients when confronted with decisions related to a persistently thin endometrium.

STUDY FUNDING/COMPETING INTEREST(S)

This study was not funded. The authors do not have any conflicts of interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Breast-conserving surgery versus mastectomy in young women with breast cancer in Asian settings

Background

Mastectomy rates among women with early breast cancer in Asia have traditionally been high. This study assessed trends in the surgical management of young women with early‐stage breast cancer in Asian settings. Survival in women treated with breast‐conserving surgery (BCS; lumpectomy with adjuvant radiotherapy) and those undergoing mastectomy was compared.

Methods

Young women (aged less than 50 years) newly diagnosed with stage I or II (T1–2 N0–1 M0) breast cancer in four hospitals in Malaysia, Singapore and Hong Kong in 1990–2012 were included. Overall survival (OS) was compared for patients treated by BCS and those who had a mastectomy. Propensity score analysis was used to account for differences in demographic, tumour and treatment characteristics between the groups.

Results

Some 63·5 per cent of 3536 women underwent mastectomy. Over a 15‐year period, only a modest increase in rates of BCS was observed. Although BCS was significantly associated with favourable prognostic features, OS was not significantly different for BCS and mastectomy; the 5‐year OS rate was 94·9 (95 per cent c.i. 93·5 to 96·3) and 92·9 (91·7 to 94·1) per cent respectively. Inferences remained unchanged following propensity score analysis (hazard ratio for BCS versus mastectomy: 0·81, 95 per cent c.i. 0·64 to 1·03).

Conclusion

The prevalence of young women with breast cancer treated by mastectomy remains high in Asian countries. Patients treated with BCS appear to survive as well as those undergoing mastectomy.

A systematic review of adaptations of evidence-based public health interventions globally

BACKGROUND

Adaptations of evidence-based interventions (EBIs) often occur. However, little is known about the reasons for adaptation, the adaptation process, and outcomes of adapted EBIs. To address this gap, we conducted a systematic review to answer the following questions: (1) What are the reasons for and common types of adaptations being made to EBIs in community settings as reported in the published literature? (2) What steps are described in making adaptations to EBIs? and (3) What outcomes are assessed in evaluations of adapted EBIs?

METHODS

We conducted a systematic review of English language publications that described adaptations of public health EBIs. We searched Ovid PubMed, PsycINFO, PsycNET, and CINAHL and citations of included studies for adapted public health EBIs. We abstracted characteristics of the original and adapted populations and settings, reasons for adaptation, types of modifications, use of an adaptation framework, adaptation steps, and evaluation outcomes.

RESULTS

Forty-two distinct EBIs were found focusing on HIV/AIDS, mental health, substance abuse, and chronic illnesses. More than half (62%) reported on adaptations in the USA. Frequent reasons for adaptation included the need for cultural appropriateness (64.3%), focusing on a new target population (59.5%), and implementing in a new setting (57.1%). Common adaptations were content (100%), context (95.2%), cultural modifications (73.8%), and delivery (61.9%). Most study authors conducted a community assessment, prepared new materials, implemented the adapted intervention, evaluated or planned to evaluate the intervention, determined needed changes, trained staff members, and consulted experts/stakeholders. Most studies that reported an evaluation (k = 36) included behavioral outcomes (71.4%), acceptability (66.7%), fidelity (52.4%), and feasibility (52.4%). Fewer measured adoption (47.6%) and changes in practice (21.4%).

CONCLUSIONS

These findings advance our understanding of the patterns and effects of modifications of EBIs that are reported in published studies and suggest areas of further research to understand and guide the adaptation process. Furthermore, findings can inform better reporting of adapted EBIs and inform capacity building efforts to assist health professionals in adapting EBIs.

Abstract P6-08-23: Not presented

This abstract was not presented at the symposium.

Abstract PD2-16: Risk of breast cancer after a false-positive screening mammogram in relation to mammographic abnormality: A population-based study in British Columbia

Background

Breast cancer screening by mammography has been shown to reduce breast cancer mortality, however false positive recall rates have consistently been identified as a harm of organized screening. The extent to which these recalled women are at increased risk of future breast cancer remains unclear.

Methods

The British Columbia Cancer Agency Screening Mammography Program (SMP), the first organized breast screening program in Canada offers screening mammography for women aged 40-74 since 1988. All women who had two or more screening mammograms between1988-2013 within the SMP were included in the study. They were followed until a breast cancer diagnosis, last screen date +5 years, or end of follow-up on Dec 31, 2013, whichever came first. The relative risk (RR) of breast cancer for women with a false-positive test compared with women with negative tests was estimated with Poisson regression, adjusted for age, and five calendar periods.

Results

A total of 772,289 women with 4.82 million screening mammograms and a median follow up of 11.8 years were included. There were 238,860 women with false positive findings and 26,950 cancers of which 16,084 screen detected and 10,866 non screen detected. Women without any false positive mammogram had a cancer incidence rate of 245/100 000 person-years at risk, whereas women with a false-positive test had an absolute rate of 447/100 000 person-years at risk. The adjusted RR [Value (95% CI)] of breast cancer after the first false-positive test was 1.73(1.68-1.77) for all, 1.65(1.61-1.70) for invasive, and 2.13(2.01-2.27) for in situ cancers respectively. The RR remained increased beyond 8 years after the false-positive test. Of the 5157 screen detected cancers after the first false positive test, 3358 (65%) were on the ipsilateral breast while 1799 (35%) were on the contralateral breast. Women with only one, two, three or four+ false positive test(s) had RR of 1.88(1.83-1.93), 1.42(1.35-1.49), 1.17(1.05-1.30), and 1.08(0.87-1.34) respectively for all cancers. Women with breast density &gt;50% at the time of false positive test had a twofold risk of breast cancer with a RR of 2.07(1.99-2.14), while those with breast density &lt;50% had a RR of 1.58(1.54-1.63). When stratified for mammographic features found on the first false positive mammogram, architectural distortion plus mass had the highest RR 4.68(3.16-6.93) for invasive cancers while calcifications alone and calcifications plus asymmetry had highest RR 5.57(4.88-6.36) and 4.07(2.49-6.66) for in situ cancers.

Conclusion

False positive mammogram correlates with an increased risk of developing breast cancer. 65% of the screen detected breast cancers post false positive mammogram occur in the ipsilateral breast. Mammographic abnormality features of the false positive mammogram are found to be predictors for the type of future breast cancer. Mammographic features at the time of recall predicts risk of subsequent cancer and may warrant increased surveillance.

Citation Format: Rajapakshe R, Miao H, Sam J, Farnquist B, Hartman M. Risk of breast cancer after a false-positive screening mammogram in relation to mammographic abnormality: A population-based study in British Columbia [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-16.

Risk of death from cardiovascular disease following breast cancer in Southeast Asia: a prospective cohort study

Breast cancer incidence and survival is high in Southeast Asia. As such, many women diagnosed with breast cancer are at risk of dying of other causes. Given the increased risk of cardiotoxicity induced by breast cancer treatments, it is important to identify patients at high risk of cardiovascular disease (CVD) mortality. The aim of this study was to investigate if this risk varies by age and ethnicity. Patient details were obtained from 5,868 Chinese, Malay, and Indian women diagnosed with in situ or non-metastasized invasive breast cancer at the National University Hospital of Singapore and KK Women's and Children's Hospital in Singapore. Death causes were obtained from the National Registry of Births and Deaths. Flexible parametric survival models estimated CVD mortality rates and hazard ratios. During a median follow-up of six years, 1,010 deaths occurred of which 6.8% were due to CVD. CVD mortality rates of older women peaked within the first year following diagnosis and increased over time since diagnosis. Indian had more than double the risk of CVD mortality than Chinese, independent of age at diagnosis and stage. Taking ethnicity and age into account may promote CVD risk stratification and management in (Southeast Asian) women with breast cancer.

MR Imaging in Cerebral Gliomas

A comparative analysis between MR examinations and histopathologic whole-brain sections regarding tumour components was performed in 5 brain specimens from patients with malignant glial brain tumours. All cases were examined with MR imaging in vitro and in 2 cases a close comparison with the MR examinations in vivo was also possible. The most homogeneous hypercellular area in malignant gliomas, giving the highest tumour grade, was not visualised on MR imaging as an isolated entity, either in vitro or in vivo. The most conspicuous tumour component, reflecting the heterogeneity of malignant gliomas, was necrosis. This feature was best depicted in the T2WI. In 4 of 5 cases, distant tumour spread of benign-looking tumour cells was found in areas visualised as normal on T2WI, outside the margins of the peritumoural oedema. In 2 cases, estimation of water content was performed immunohistochemically and a close correlation was found in each case between peritumoural and periventricular hyperintensity on T2WI and areas of pallor on the haematoxylin-eosin-stained whole-brain sections. These areas corresponded to microscopical oedema. MR imaging reflects underlying heterogeneous histopathology in malignant gliomas. The degree of malignancy of the lesion as a whole can thus be assessed by MR imaging. However, the method does not allow malignant gliomas to be correctly delineated.

Delineation of Gliomas with Magnetic Resonance Imaging Using Gd-DTPA in Comparison with Computed Tomography and Positron Emission Tomography

Fourteen patients with cerebral gliomas were investigated by MR imaging using Gd-DTPA (Magnevist), CT with the contrast agent iohexol (Omnipaque) and, as a reference, positron emission tomography (PET) using 11C-L-methionine. Tumour areas with disruption of the blood-brain-barrier (BBB) as seen on MR and CT were compared with areas with increased accumulation of methionine in PET. There were 6 patients with high-grade astrocytoma (grade III-IV), 5 with low-grade astrocytoma (grade I–II) and 3 with oligodendroglioma. In 4 high-grade tumours, PET showed a larger tumour or tumour tissue in additional areas, compared with enhancement on MR and CT, while in 2 cases the tumour extension was similar in the three modalities. In the low grade tumour group, the findings on PET differed from those on post-contrast MR or CT in 7 cases. In 3 of these cases, no disruption of the BBB was seen either on MR or on CT. In 2 of our 14 patients CT showed larger enhancement extension than MR and in 2 cases MR was superior to CT in this respect. The enhancement intensity was higher on MR in 4 patients and on CT in 2 patients. No definite difference in the delineation of tumour tissue between the T1 weighted SE sequences used was found. The gradient echo sequences FLASH and FISP gave limited information that was less than that provided by the T1 weighted SE sequences. A greater increase in signal intensity in T1 weighted images was usually seen 5 min post-contrast in the high-grade tumours than in the low-grade ones.

Ultrasound Guided Needle Biopsy of Brain Tumors Using an Automatic Sampling Instrument

All ultrasound (US) guided needle biopsies of brain tumors performed during an 8-year period were reviewed. Tissue samples were obtained in 112 of 115 biopsy procedures, and a histologic diagnosis was established in 99 cases (88.4%). The rate of major complications was 8.0%. The mortality is similar as in reports on stereotactic and CT-guided biopsy procedures while the morbidity is higher in our material. There are no large series available on US guided intracranial biopsy with adequate reports of complications. A modified biopsy technique is introduced here using a cutting needle and an automatic sampling instrument. The modified technique, which has been used in all cases since 1985, yielded diagnostic material in 91.5%. This method consistently provides a tissue core which is essential for a confident histopathologic diagnosis.

Effect of Sleep and Salivary Glucose on Gingivitis in Children

It has been shown that inadequate sleep has deleterious effects on health by suppressing immunity and promoting inflammation. The aim of this study was to investigate the effect of sleep and salivary glucose levels on the development of gingivitis in a prospective longitudinal study of Kuwaiti children. Data were collected from 10-y-old children ( N = 6,316) in 2012 and again in 2014. Children were approximately equally distributed from 138 elementary schools representing the 6 governorates of Kuwait. Calibrated examiners conducted oral examination, self-reported sleep evaluation interviews, anthropomorphic measurements, and unstimulated whole saliva sample collection. Salivary glucose levels were measured by a florescent glucose oxidase method; values of salivary glucose ≥1.13 mg/dL were defined as high glucose levels. A multilevel random intercept and slope analysis was conducted to determine the relationship between sleep duration and gingivitis on 3 levels: within schools, among children, and over time. The outcome was the progression of the extent of gingival inflammation in children over time. The main independent variables were the number of daily sleep hours and salivary glucose levels. Other explanatory variables and confounders assessed were governorate, dental caries and restorations, and obesity by waist circumference (adjusted for snacking and sex). Gingivitis increased over time in children who had shorter sleep duration ( P < 0.05). Salivary glucose levels >1.13 mg/dL predicted gingivitis ( P < 0.05). Children who had more decayed or filled teeth had more gingivitis ( P < 0.05). No significant association was found between gingivitis and obesity. The level of gingivitis was different among the 6 governorates of Kuwait. Additionally, there was a strong clustering effect of the observations within schools and among children across time. Longitudinal analysis of 6,316 Kuwaiti children revealed that shorter sleep duration and higher salivary glucose levels were both associated with increased gingival inflammation.

Abstract P5-08-46: Competing causes of death among women with breast cancer in South East Asia: Effects of ethnicity, and age at diagnosis and stage at diagnosis

Background: Over the past decades, breast cancer survival has improved substantially and many patients die of other, non-breast cancer related causes. In South East Asia, where large ethnic differences exist in stage at presentation and overall survival, causes of death of breast cancer patients have been understudied.

Aim: To examine cause-specific mortality among breast cancer patients in multi-ethnic Singapore and investigate effects of ethnicity, and age and tumor stage at diagnosis.

Methods: Data of women diagnosed with breast cancer between 1990 and 2011 at the National University Hospital in Singapore were retrieved from the hospital-based breast cancer registry. Cause of death was categorized as breast cancer (ICD8 174; ICD9 174; ICD10 C50), cardio- and cerebrovascular disease (ICD8 390 to 459; ICD9 390 to 459; ICD10 I00 to I99), other malignancies (ICD8 140 to 239; ICD9 140 to 239; ICD10 C00 to D48 except codes for death resulting from breast cancer), and death from other causes (all ICD codes except those already listed). Patients with unknown cause of death (n=6) were classified as death from other cause. Chi square statistics were used to compare cause of death distributions.

Results: Of 4108 patients, median age at diagnosis was 51 years (range 21- 98 years). The majority of women were Chinese (n=3223, 78%), followed by Malay (n=517, 12%), Indian (n=257, 6%) and other ethnicities (n=111, 3%). After a median follow-up of 7 years, 1125 (27%) patients died: 910 (81%) patients died of breast cancer, 70 (6%) of cardio- and cerebrovascular disease, 71 (6%) of other malignancies, and 83 (7%) of other causes. Compared with other ethnicities, Malay women most frequently died as a result of breast cancer (n=178, 90%). The highest percentage CVD deaths was observed among Indians (n=7, 11%). Breast cancer accounted for 92% of deaths in women younger than 50 years at diagnosis and for 60% in women older than 65. The proportion of deaths as a result of CVD, other cancer or other causes increased with age. Patients with higher tumor stages at diagnosis were more likely to die of breast cancer (96% of deaths of patients with TNM4 were breast cancer related).

Conclusion: The present study showed that breast cancer is the most important cause of death in breast cancer patients among all ethnic groups, and ages and stages in South East Asia. The highest risk of death due to breast cancer in Malay women might be explained by their presentation at advanced stages and young age at diagnosis. Breast cancer is less likely to be the cause of death in women of Chinese ethnicity, older age at diagnosis and early tumor stage. In these groups more attention for competing causes of death, in particular CVD, should be a priority for the future.

Citation Format: Ho P, Rijnberg N, Gernaat SAM, Emaus MJ, Grobbee RDE, Lee SC, Hartman M, Verkooijen HM. Competing causes of death among women with breast cancer in South East Asia: Effects of ethnicity, and age at diagnosis and stage at diagnosis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-46.

Is arterial base deficit still a useful prognostic marker in trauma? A systematic review

BACKGROUND

Arterial base deficit (BD) has been widely used in trauma patients since 1960. However, trauma management has also evolved significantly in the last 2 decades. The first objective of this study was to systematically review the literature on the relationship between arterial BD as a prognostic marker for trauma outcomes (mortality, significant injuries, and major complications) in the acute setting. The second objective was to evaluate arterial BD as a prognosis marker, specifically, in the elderly and in patients with positive blood alcohol levels.

METHODS

MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched from January 1, 1990, to August 6, 2015. Bibliographies of articles were also hand searched for relevant citations.

RESULTS

Thirty-four studies were included in this review. The studies consistently showed that a higher arterial BD was associated with increased mortality, significant injuries, and major complications. The threshold BD value of 6 mmol/L was also useful in discriminating for poorer outcomes. The presence of alcohol did not affect the ability of arterial BD to discriminate between major and minor injuries. Elderly patients had higher mortality in all arterial BD categories compared to the younger age group.

CONCLUSIONS

Despite the advances in trauma care in the last 2 decades, arterial BD remains a useful prognostic marker in trauma patients, even in elderly patients and in patients who had consumed alcohol. The threshold BD value of 6 mmol/L was useful to prognosticate poorer outcomes.

Prediction of lymph node involvement in patients with breast tumors measuring 3-5 cm in a middle-income setting: the role of CancerMath

BACKGROUND

In settings with limited resources, sentinel lymph node biopsy (SNB) is only offered to breast cancer patients with small tumors and a low a priori risk of axillary metastases.

OBJECTIVE

We investigated whether CancerMath, a free online prediction tool for axillary lymph node involvement, is able to identify women at low risk of axillary lymph node metastases in Malaysian women with 3-5 cm tumors, with the aim to offer SNB in a targeted, cost-effective way.

METHODS

Women with non-metastatic breast cancers, measuring 3-5 cm were identified within the University Malaya Medical Centre (UMMC) breast cancer registry. We compared CancerMath-predicted probabilities of lymph node involvement between women with versus without lymph node metastases. The discriminative performance of CancerMath was tested using receiver operating characteristic (ROC) analysis.

RESULTS

Out of 1,017 patients, 520 (51 %) had axillary involvement. Tumors of women with axillary involvement were more often estrogen-receptor positive, progesterone-receptor positive, and human epidermal growth factor receptor (HER)-2 positive. The mean CancerMath score was higher in women with axillary involvement than in those without (53.5 vs. 51.3, p = 0.001). In terms of discrimination, CancerMath performed poorly, with an area under the ROC curve of 0.553 (95 % confidence interval CI 0.518-0.588). Attempts to optimize the CancerMath model by adding ethnicity and HER2 to the model did not improve discriminatory performance.

CONCLUSION

For Malaysian women with tumors measuring 3-5 cm, CancerMath is unable to accurately predict lymph node involvement and is therefore not helpful in the identification of women at low risk of node-positive disease who could benefit from SNB.

Access to oncology consultation in a cancer cohort in northeastern Ontario

BACKGROUND

To enhance cancer symptom management for residents of Sudbury-Manitoulin District, an ambulatory palliative clinic (pac) was established at the Northeast Cancer Centre of Health Sciences North. The pac is accessed from a medical or radiation oncology consultation. The primary purpose of the present population-based retrospective study was to estimate the percentage of cancer patients who died without ever having a medical or radiation oncology consultation. A secondary purpose was to determine factors associated with never having received one of those specialized consultations.

METHODS

Administrative data was obtained through the Ontario Cancer Data Linkage Project. For each index case, we constructed a timeline, in days, of all Ontario Health Insurance Plan billing codes and associated service dates starting with the primary cancer diagnosis and ending with death.

RESULTS

Within the 5-year study period (2004-2008), 6683 people in the area of interest with a valid record of primary cancer diagnosis died from any cause. Most (n = 5988, 89.6%) had 1 primary cancer diagnosis. For that subgroup, excluding those with a disease duration of 0 days (n = 67), about 18.4% (n = 1088) never had a consultation with a medical or radiation oncologist throughout their disease trajectory. Patients who were older or who resided in a rural area were significantly less likely to have had a consultation.

CONCLUSIONS

Specific strategies directed toward older and rural patients might help to address this important access-to-care issue.

Prognostic information of a previously diagnosed sister is an independent prognosticator for a newly diagnosed sister with breast cancer

BACKGROUND

Breast cancer survival has been shown to be associated among relatives. In this study, we used a population-based cohort of Swedish sisters, both diagnosed with breast cancer, to determine whether prognostic information of a previously diagnosed sibling is useful for the clinical management of a newly diagnosed sibling.

PATIENTS AND METHODS

The population-based cohort included all sister pairs, 1617 sisters, diagnosed with breast cancer in Sweden, from 1 January 1992, through 31 December 2006, with complete follow-up. All information was collected manually from original pathology reports and patient records. The Kappa statistic was used to measure the agreement of primary tumor characteristics between the sisters. We modeled the breast cancer-specific survival using multivariate (Cox) proportional hazard analyses in two steps categorizing the older sister's survival.

RESULTS

Estrogen receptor status was the only tumor characteristic significantly associated between the sisters [κ 0.18 (95% confidence interval (CI) 0.089-0.27)]. Younger sisters with poor older sister survival showed significantly worse survival compared with patients with good older sister survival (log rank, P = 0.017). A twofold increased hazard ratio (HR) for death from breast cancer was found in younger sisters with poor older sister survival compared with patients with good sister survival [HR 2.56 (95% CI 1.16-5.65)], adjusting for age and calendar period of diagnosis, socioeconomic factors, number of children and hospital of primary tumor diagnosis. When further adjusting for primary tumor characteristics and adjuvant therapy, the risk for death from breast cancer in younger sisters with poor older sister survival became more pronounced [HR 3.35 (1.34-8.34)].

CONCLUSIONS

Our findings derived from a population-based cohort of Swedish sister pairs suggest that breast cancer-specific survival is inherited independent of tumor characteristics and treatment in the sibling later diagnosed with the disease. Prognostic information of a previously diagnosed sibling with breast cancer could be important in the clinical management.

Spectrum of very early breast cancer in a setting without organised screening

BACKGROUND

Within a setting without organised breast cancer screening, the characteristics and survival of very early breast cancer were determined.

METHODS

All 4930 women diagnosed with breast cancer in University Malaya Medical Center, Malaysia from 1993 to 2011 were included. Factors associated with very early presentation (stage I) at diagnosis were identified. Tumour characteristics, management patterns, and survival of very early breast cancer were described, and where appropriate, compared with other settings.

RESULTS

Proportion of women presenting with stage I breast cancer significantly increased from 15.2% to 25.2% over two decades. Factors associated with very early presentation were Chinese ethnicity, positive family history of breast cancer, and recent period of diagnosis. Within stage I breast cancers, median tumour size at presentation was 1.5 cm. A majority of stage I breast cancer patients received mastectomy, which was associated with older age, Chinese ethnicity, postmenopausal status, and larger tumours. Chemotherapy was administered in 36% of patients. Five-year age-adjusted relative survival for women with stage I breast cancer was 99.1% (95% CI: 97.6-99.6%).

CONCLUSIONS

The proportion of women presenting with very early breast cancer in this setting without organised screening is increasing. These women seem to survive just as well as their counterparts from affluent settings.

FGF receptor genes and breast cancer susceptibility: results from the Breast Cancer Association Consortium

BACKGROUND

Breast cancer is one of the most common malignancies in women. Genome-wide association studies have identified FGFR2 as a breast cancer susceptibility gene. Common variation in other fibroblast growth factor (FGF) receptors might also modify risk. We tested this hypothesis by studying genotyped single-nucleotide polymorphisms (SNPs) and imputed SNPs in FGFR1, FGFR3, FGFR4 and FGFRL1 in the Breast Cancer Association Consortium.

METHODS

Data were combined from 49 studies, including 53 835 cases and 50 156 controls, of which 89 050 (46 450 cases and 42 600 controls) were of European ancestry, 12 893 (6269 cases and 6624 controls) of Asian and 2048 (1116 cases and 932 controls) of African ancestry. Associations with risk of breast cancer, overall and by disease sub-type, were assessed using unconditional logistic regression.

RESULTS

Little evidence of association with breast cancer risk was observed for SNPs in the FGF receptor genes. The strongest evidence in European women was for rs743682 in FGFR3; the estimated per-allele odds ratio was 1.05 (95% confidence interval=1.02-1.09, P=0.0020), which is substantially lower than that observed for SNPs in FGFR2.

CONCLUSION

Our results suggest that common variants in the other FGF receptors are not associated with risk of breast cancer to the degree observed for FGFR2.

Abstract P6-06-28: Survival gain in patients with de novo metastatic breast cancer in past two decades is largely attributable to treatment

Background: In Asia, a substantial proportion of breast cancer patients present with distant metastases at diagnosis. We determined whether metastatic breast cancer survival has improved in a multi-ethnic Asian setting over a span of fifteen years, and disentangled the contribution of various factors on the observed survival trend.

Methods: Patients diagnosed with de novo metastatic breast cancer from three hospitals in Malaysia and Singapore (N = 856) were assigned to three cohorts by year of diagnosis: 1996-2000, 2001-2005 and 2006-2010. Time trends in disease characteristics, treatment, and relative survival rates (RSR) were compared. Adjusted relative excess risks of mortality in recent periods were estimated using a step-wise Poisson regression to assess the contributions of several prognostic factors towards the observed survival pattern.

Results: The proportion of patients presenting with de novo metastatic breast cancer remained fairly stable at 10% in 1996-2000, 7% in 2001-2005, and 9% in 2006 -2010. Recently diagnosed patients were older, and more likely to have multiple metastatic sites involved, and visceral metastases. Surgery of primary tumor became more prevalent over time, and this is also complemented with higher attainments of free surgical margins. Chemotherapy, and endocrine therapy administration also increased with time, with higher use of taxane-based regimens in recent periods. The three-year RSR in the above periods were 20.6% (95%CI: 13.9%-28.2%, median survival = 14 months), 28.8% (95%CI: 23.4%-34.2%, median survival = 18 months), and 33.6% (95%CI: 28.8%-38.5%, median survival = 21 months), respectively. Surgery of the primary tumor explained most of the observed survival gain in the latest period, followed by chemotherapy, and endocrine therapy.

Excess Mortality Risk in Patients with De Novo Metastatic Breast Cancer by Period of Diagnosis Period of diagnosisDeath1996-200012001-20052006-2010Relative excess risk (95%CI)21.000.86(0.68-1.09)0.68(0.54-0.86)7Relative excess risk (95%CI)31.000.82 (0.65-1.05)0.68(0.54-0.87)7Relative excess risk (95%CI)41.000.82 (0.64-1.05)0.66(0.52-0.84)7Relative excess risk (95%CI)51.000.89 (0.69-1.15)0.76(0.59-0.97)7Relative excess risk (95%CI)61.000.89 (0.69-1.16)0.79(0.62-1.01)1 Reference period, 2 Derived using Poisson regression model, matched to background population mortality based on country, year, and age, and adjusted for center, and follow-up time, 3 Similar as model 2, and additionally adjusted for age at diagnosis, and ethnicity, 4 Similar as model 3, and additionally adjusted for T stage at diagnosis, ER status, number of organs with metastatic involvement, and presence of visceral metastasis, 5 Similar as model 4, and additionally adjusted for surgery, and surgical margins, 6 Similar as model 5, and additionally adjusted for radiotherapy, chemotherapy, and endocrine therapy, 7 Statistically significant

Conclusion: The modest survival gain in patients with de novo metastatic breast cancer in Asian settings is largely attributable to improvement in treatment strategies, namely surgery of primary tumor and other treatment modalities.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-28.

Abstract P2-11-06: Mortality among offspring of women diagnosed with breast cancer; a population based study

Introduction: Survival after breast cancer has improved substantially over the past decades. As a result, an increasing number of breast cancer survivors is starting or extending their family post-diagnosis. We evaluated mortality risks of offspring from women with a history of breast cancer.

Methods: From the Swedish Multi-Generation Register and the Cancer Register we identified all 63,205 children whose mother had ever been diagnosed with invasive breast cancer. For these children, we calculated relative mortality risks as compared to the background population (Standardized Mortality Ratios [SMRs]). We compared SMRs according to the mother's parity status at diagnosis and timing of birth in relation to time of diagnosis, i.e. before (&gt;1 year before), around (between 1 year before and 1 year after) and after (&gt;1 year after) diagnosis.

Results: Children born around their mother's breast cancer diagnosis had an increased mortality risk as compared to the background population (SMR 2.70 95% CI [1.64–4.44]). This risk was particularly high for first-born children (SMR 11.07 (95% CI [2.09–27.13]), who had an absolute excess risk of 6.4% to die before the age of 5 years. Children born more than one year before or after their mother's breast cancer diagnosis had similar mortality risks as the background population.

Conclusion: Children born around their mother's breast cancer diagnosis have significantly increased mortality risks. Offspring of nulliparous women have a particularly high relative mortality risk, suggesting that pregnant breast cancer patients may be keen to keep their first child in spite of potential treatment toxicity.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-11-06.

Abstract P3-07-03: The impact of Carcinoma in situ of the breast and family history on risk of subsequent breast cancer events and mortality - a population based study from Sweden

Purpose: To evaluate the long-term risk of subsequent breast cancer and mortality among women diagnosed with carcinoma in situ of the breast.

Patients and Methods: Using the population-based Swedish Multi-Generation and Cancer Registers we selected 8,111 women diagnosed with in situ breast cancer between 1980 and 2004. We estimated the relative risks of subsequent ipsi- and contralateral invasive breast cancer or a contalateral in situ expressed as standardized incidence ratios (SIRs), in relation to age, year, time since diagnosis and family history (1st degree relative) for breast cancer. The relative risk of death was expressed as standardized mortality ratio, (SMR).

Results: Of 8,111 women identified with first in situ, 859 had a family history for breast cancer. The overall risk of a subsequent invasive breast cancer is over four fold and the risk for contralateral in situ breasts cancer was almost seven fold, compared with the risk in healthy women.

Prognostic implication of estramustine-binding protein in astrocytoma

Estramustine-binding protein (EMBP) is a glycoprotein shown to be expressed in the cytoplasm of astrocytoma cells. Originally, it was found in rat prostatic tissue and described as a secretory protein. Its expression has been demonstrated to positively correlate with the degree of neoplastic transformation in astrocytoma tissue. EMBP has been proposed to be responsible for a specific and high affinity binding of estramustine in astrocytoma tumor tissue. In this study the expression of EMBP was evaluated by immunohistochemistry and radioimmunoassay in a series of astrocytoma of different grades. Staining intensity and the number of stained cells increased with the degree of malignancy. The levels of EMBP were 1.3-6.2 ng/g tumor tissue with higher levels in tumors of grade III to IV compared to grade I and II. It was found that a high expression of EMBP always implied a short survival of the patients. On the other hand, a low expression of EMBP did not always assure a favorable prognosis. It is proposed that EMBP might have a value to predict survival in patients with astrocytoma, especially if estramustine is to be included in the treatment schedule. However, further extended studies are needed before final conclusions can be made.

Cytotoxic effect and uptake of estramustine in a rat glioma model

The cytotoxic effect of estramustine-phosphate (EMP) and the uptake in tumor tissue were investigated in a rat glioma model in vitro and in vivo. EMP, a combination of nornitrogen mustard and 17beta-estradiol, is a cytotoxic drug which main target is assumed to be the microtubule system. EMP and its metabolite estramustine (EaM) have a demonstrated anti-tumorous effect on human glioma cells in vitro. The drug uptake in tumor tissue and subsequently also the cytotoxic effect, is believed to depend, at least partially, on a specific estramustine-binding protein (EMBP) which is present in human glioma tissue. In this study we have examined the effects and pharmacokinetics of EaM in the nitrosourea induced BT4C rat glioma model. The tumor was characterized by infiltrative growth with a histopathological picture resembling gliosarcoma. The presence of EMBP was demonstrated by immunohistology. In vitro EMP caused a dose-related inhibition of BT4C-cell growth. In vivo, in the rat model, a significant inhibition of tumor growth was obtained after administration of EaM 20 mg/kg/d i.p. The pharmacokinetics of EaM resembled that found in the human clinical situation with EaM as the main metabolite accumulating in tumor tissue. The mean concentration ratio of EaM was 15.6 in tumor versus serum, and 1.8 in tumor versus normal brain of 1.8. The cytotoxic effect demonstrated in the rat glioma model justifies further evaluation of EMP/EaM in the treatment of malignant gliomas.

P3-07-29: Validating the Lymph Node Ratio as a Prognostic Indicator among South East Asian Breast Cancer Patients

Background: Several studies in Caucasian settings have suggested that the lymph node ratio (LNR, i.e. the ratio of the number of positive nodes to the total number of nodes excised) is a superior prognostic indicator for breast cancer as compared to the absolute number of nodes involved (pN stage). This study validates the prognostic performance of LNR in the South East Asian setting.

Methods: All patients diagnosed with non-metastatic invasive breast cancer at the National University Hospital (Singapore) or University of Malaya Medical Center (Kuala Lumpur) between 1990 and 2007 and with information on axillary nodes removed and involved were included for analysis (n = 1589). Multivariate Cox regression analysis was performed to evaluate the prognostic value of the LNR [low (&gt; 0 and &lt;0.2), intermediate (0.2 to 0.65) and high risk (&gt;0.65 to 1)] and pN staging [pN1, pN2 and pN3] for all cause mortality. Patients staged pN0/LNR 0 were excluded from analysis.

Results: According to the LNR classification, 758 patients were categorized as low risk, 574 as intermediate risk and 257 as high risk LNR. For classic pN staging, 879 were pN1, 447 pN2 and 263 pN3. Women in the intermediate risk category (0.2 to 0.65) had a 1.5 fold increased risk of death [Adjusted hazard ratio [HRadj] of 1.5 (95%CI, 1.2 to 1.9]), and women with high risk (&gt;0.65 to 1) LNR had a 3.2 fold increased risk of death [HRadj of 3.2 (95%CI, 2.6 to 4.1)] as compared to the low risk women (&gt;0 and &lt;0.2). Similarly, women with pN2 disease had a 1.9 fold increased risk of death [HRadj of 1.9 (95%CI, 1.5 to 2.4)], and women with pN3 disease had 3.1 fold increased risk of death [HRadj 3.1 (95%CI, 2.5 to 3.9)] compared to pN1 patients.

Conclusion: Among South East Asian breast cancer patients, both the Lymph Node Ratio and the pN Staging system seem to be equally good at predicting all cause mortality.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-29.

P2-12-20: Adjuvant! Online Is Overoptimistic in Predicting Survival of Asian Breast Cancer Patients

Background

Adjuvant! Online is a free web-based tool which predicts 10-year breast cancer outcomes and efficacy of adjuvant therapy in patients with breast cancer. As its prognostic performance has only been validated in high income Caucasian populations, the model was validated in a middle income Asian setting.

Material and Methods: Within the University Malaya Hospital-Based Breast Cancer Registry, all 631 women receiving standard surgery for invasive non-metastatic breast cancer between 1993 and 2000 were identified. Calibration of Adjuvant! Online was evaluated by comparing the predicted 10-year overall survival with observed 10-year survival. Discrimination of the model was tested by receiver operating characteristic (ROC) analysis.

Results: For the entire cohort, Adjuvant! Online predicted 10 year survival (70.3%) was significantly higher than the observed 10 years survival (63.6 %) by a difference of 6.7% (95%CI: 3.0%- 10.4%). The model was especially overoptimistic in women under 40 years and in women of Malay ethnicity, where survival was overestimated by approximately 20% (95%CI: 9.8- 29.8%) and 15% (95%CI: 5.3−24.5%) respectively.

P5-14-10: Ethnic Differences in the Association between Tumor Size and Lymph Node Status among Breast Cancer Patients in South East Asia

Background: South East Asia consists of three major ethnic groups, i.e. Chinese, Malays and Indians. Previous work from our breast cancer research group showed that Malay ethnicity is an independent predictor of poor survival. In this study we evaluate whether (part of) these ethnic survival disparities may be due to ethnic differences in the association of tumor size and lymph node involvement.

Methods: We included all patients diagnosed with breast cancer at the National University Hospital (Singapore) and University of Malaya Medical Center (Kuala Lumpur) between 1990 and 2007, for whom information on tumor size and axillary lymph node status was available (n = 3805). Ethnic differences in the association between tumor size and lymph node involvement were studied and logistic regression analysis was performed to determine the independent effect of ethnicity on the association of tumor size and lymph node involvement.

Results: 1474 patients were categorized as T1 (&gt;0 to 2 cm), 1777 as T2 (2.1 to 5 cm) and 554 as T3 (&gt;5 cm). Within the small tumor size range (&gt;0 to 2 cm) the Malays were significantly more likely to present with node positive disease as compared to the other ethnic groups (36.9% as compared to 24.5% for Chinese and 25.9% for Indians, p value &lt;0.001). Similarly, for tumors measuring 2.1-5 cm, Malays were more likely than Chinese and Indians to have lymph node involvement (59.5%, 50.2% and 52.1%, respectively p value 0.016). After adjustment for age, Progesterone Receptor (PR) status, grade and treatment received, Malay ethnicity was an independent predictor of lymph node involvement, with adjusted Odds Ratio's of 1.4 (95% CI 1.0 to 2.1) for T1 tumors and 1.4 (95% CI 1.1 to 1.9) for T2 tumors compared to Chinese women.

Conclusion: Malay patients are more likely to present with lymph node metastasis especially for the small and midsized tumors as compared to the Chinese and Indians. This could reflect differences in tumor biology between the three ethnic groups with the Malays possibly having more aggressive disease than the others.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-10.

Impact of breast surgery on survival in women presenting with metastatic breast cancer

BACKGROUND

Advanced breast cancer is common in less affluent parts of Asia. The impact of breast surgery on survival of women presenting with metastatic breast cancer in this setting was investigated.

METHODS

Women presenting with metastatic breast cancer at the initial diagnosis at the University Malaya Medical Centre (Malaysia) between 1993 and 2008 were included in the study. Mortality of patients who had primary breast surgery was compared with that of those without surgery, and adjusted for possible confounders by means of a propensity score.

RESULTS

Of 3689 patients, 375 (10·2 per cent) presented with metastatic disease. One hundred and thirty-nine patients (37·1 per cent) underwent surgery. A total of 330 deaths occurred during 6814 person-months of follow-up. The 2-year survival rate was 21·2 (95 per cent confidence interval (c.i.) 15·9 to 26·5) per cent in women who did not have surgery and 46·3 (37·7 to 54·9) per cent in those who had breast surgery. Breast surgery was associated with a 28 per cent lower risk of death (hazard ratio 0·72, 95 per cent c.i. 0·56 to 0·94), after adjustment for patient and tumour characteristics, metastatic profile and treatment.

CONCLUSION

Surgical resection of the primary breast tumour was independently associated with a survival advantage in patients presenting with metastatic breast cancer.

Autophagy controls IL-1beta secretion by targeting pro-IL-1beta for degradation

Autophagy is a key regulator of cellular homeostasis that can be activated by pathogen-associated molecules and recently has been shown to influence IL-1β secretion by macrophages. However, the mechanisms behind this are unclear. Here, we describe a novel role for autophagy in regulating the production of IL-1β in antigen-presenting cells. After treatment of macrophages with Toll-like receptor ligands, pro-IL-1β was specifically sequestered into autophagosomes, whereas further activation of autophagy with rapamycin induced the degradation of pro-IL-1β and blocked secretion of the mature cytokine. Inhibition of autophagy promoted the processing and secretion of IL-1β by antigen-presenting cells in an NLRP3- and TRIF-dependent manner. This effect was reduced by inhibition of reactive oxygen species but was independent of NOX2. Induction of autophagy in mice in vivo with rapamycin reduced serum levels of IL-1β in response to challenge with LPS. These data demonstrate that autophagy controls the production of IL-1β through at least two separate mechanisms: by targeting pro-IL-1β for lysosomal degradation and by regulating activation of the NLRP3 inflammasome.

Abstract P3-11-13: Impact of Young Age on the Presentation, Management and Outcome of Breast Cancer in a Multi-Ethnic Asian Setting: Results from the Singapore-Malaysia Hospital-Based Breast Cancer Registry

Background: The proportion of very young women with breast cancer is high in Asia, ranging between 10% and 25%. Material and methods: Within the multi-institutional Singapore-Malaysia hospital-based breast cancer registry, we compared tumor characteristics, treatment and survival of very young (&lt;35 years; n=210) and older (35-55 years; n=2,152) breast cancer patients diagnosed between 1990 and 2007. Overall survival (OS)was estimated by Kaplan-Meier analysis. Cox regression analysis was used to compute hazard ratios (HR) after splitting follow-up time along the age-axis and calendar-time axis.

Results: Compared to older breast cancer patients, young patients presented with larger tumor (median diameter 25mm vs 30mm respectively: P&lt;0.001), and less estrogen receptor positive (54% vs 46% respectively: P&lt;0.01), and progesterone receptor positive tumors (57% vs 47%: P&lt;0.01). Young women were more likely to receive chemotherapy (70% vs 61%: P&lt;0.01), and less likely to be given hormone therapy (36% vs 57%: P&lt;0.001).

Among those with stage 0 to stage II disease, 5-year OS was 71.3% (95%CI: 61.7%-80.9%) in young patients and 85.6% (95%CI: 83.2%- 88.0%) in older women. After adjustment for stage, tumor profile and treatment, young patients had approximately 50% higher risk of death than their older counterparts (HR:1.46; 95% CI: 1.23-1.73). Ethnicity, tumor size, pathological lymph node staging, loco-regional therapy, and chemotherapy, were significant independent predictors of overall survival among young patients with breast cancer.

Conclusion: Asian women diagnosed at a very young age, present with less favorable tumor characteristics and stage distribution. They have a 50% higher risk of death following their disease, which is independent of their stage at diagnosis, tumor characteristics and treatment.

Abstract P3-11-08: Incidence and Outcome of Male and Female Breast Cancer: A Multinational Population Based Study

Background: Male breast cancer is a rare disease as its incidence rate is about 0.5% to 1% of that of female breast cancer. Given its scarcity, few studies have assessed the risk and prognosis.

Methods: We performed a multi-national population based study of 569,771 female breast cancer patients and 3,615 male breast cancer patients diagnosed in Denmark, Finland, Switzerland, Norway, Singapore and Sweden from 1943 to 2007. We calculated incidence and mortality as well as overall survival for both sexes. Life table analysis and Cox proportional hazard model were used to analyze the survival.

Results: The overall incidence rates, adjusted to the World Standard Population, of breast cancer were 60.2 per 100,000 in women and 0.4 per 100,000 in men. Women were diagnosed with breast cancer at a younger median age (61.4 years) than men (68.9 years). Among the 203,093 patients (35%) with information on TNM stage, 50% of the women and 47% of men were classified as stage I whilst stage III and stage IV cases accounted for 11% and 20% for women and men respectively. The 5-year cumulative survival was 66.2% for women and 53.0% for men. The adjusted relative risk of death was 24% higher in men [HR 1.24 (95% CI, 1.19-1.28)] as compared to women after controlling for age and time at diagnosis. Men had an 18% higher relative risk of death [HR 1.18 (95% CI, 1.09-1.27)] compared to women after further adjustment for TNM stage. Conclusion: Male breast cancer patients have later onset and worse prognosis than female patients. This may be due to the difference in tumour characteristics and treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-11-08.

Abstract P4-09-06: Breast Cancer Prognosis Is Inherited Independently of Patient, Tumor and Treatment Characteristics

Fondation Jean Dausset, Paris, France; Karolinska Institute, Stockolm, Sweden; Geneva University Hospitals, Switzerland Introduction: Several studies have suggested that survival of breast cancer is inherited, but none has assessed if this observation is linked to shared tumor characteristics or type of treatment. We studied the association of survival among first-degree relatives (FDRs) with breast cancer, taking into account characteristics of patients, tumors and treatments. Methods: In the population-based Geneva Breast Cancer Registry, we identified 162 pairs of FDRs diagnosed with breast cancer. Based on the breast cancer specific survival status of their proband (i.e. the mother or older sister), we categorized FDRs into poor, medium and good familial survival risk groups. We compared patient, tumor and treatment characteristics between categories and calculated standardized mortality ratios (SMRs) and adjusted disease specific mortality for each group. Results: Breast cancer patients in the poor familial survival risk group were more likely to be diagnosed at later stages than those in the good familial survival risk group. Similarly, they had higher SMRs than those in the medium and good survival risk groups (18.7, 95% Confidence Interval [CI]: 9.4-33.5 versus 16.5 95% CI: 7.6-31.4 and 9.4, 95% CI: 3.4-20.3, respectively). After adjustment for prognostic factors, women in the poor familial survival risk group were almost five times more likely to die of breast cancer than those in the good survival risk group (adjusted Hazard Ratio 4.8, 95% CI: 1.4-16.4).

Conclusion: This study shows that breast cancer prognosis clusters within families, and suggests that the hereditary component is independent of patient, tumor characteristics and type of treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-09-06.

Abstract P3-13-03: Association between Ethnicity and Survival after Breast Cancer in a Multi-Ethnic Asian Setting: Results from the Singapore-Malaysia Hospital-Based Breast Cancer Registry

Background: Little is known on the impact of ethnicity on survival after breast cancer in the multi-ethnic Asian setting. Material and Methods: Using the multi-institutional Singapore-Malaysia hospital-based breast cancer registry, we investigated the association between ethnicity and risk of mortality after breast cancer in 3,366 patients diagnosed between 1990 and 2007 (Chinese: 77%, Malay: 15%, Indian: 8%). Kaplan-Meier analysis was used to estimate overall cumulative survival (OS). Multivariable hazard ratios (HR) adjusted for tumor and treatment characteristics were computed using Cox regression analysis after splitting follow-up time along the age-axis and calendar-time axis. Results: Malay patients presented at younger age compared to Chinese and Indians (47years vs 52years vs 53years, respectively, P&lt;0.001) with larger tumors (35mm vs 24mm vs 30mm, respectively, P&lt;0.001), and at later stages (TNM stage III or IV) (37% vs 23% vs 25%, respectively, P&lt;0.001). Malay women were least likely to have undergone surgery, and most likely to receive chemotherapy. Five-year OS was 71.9% (95% CI: 69.7%-74.1%) in Chinese, 47.2% (95%CI: 41.9%-52.5%) in Malays and 62.7% (56.0%- 69.4%) in Indians.

After adjustment for tumor and treatment characteristics, Malay patients had approximately 60% higher risk of death than the Chinese (HR:1.57; 95%CI:1.40-1.77). Indian ethnicity was not significantly associated with risk of mortality after breast cancer compared to Chinese (HR:1.12; 95%CI: 0.98-1.30).

Conclusion: In the Asian setting, Malay ethnicity seems to be associated with significantly poorer survival after breast cancer, independent of tumor and treatment profile. The underlying reasons for this association are unclear but may be explained by variations in susceptibility to treatment, co-morbidity and lifestyle after diagnosis of breast cancer.

Effect of childbirth after treatment on long-term survival from breast cancer

Background

This study quantified long-term absolute and relative mortality risks of survivors of breast cancer with subsequent childbirth.

Methods

The Singapore Birth Register (n = 319 437), Swedish Multi-Generation Register (n = 11 million) and population-based cancer registries were linked to identify 492 women with childbirth after breast cancer. For these women, cumulative mortality risks and standardized mortality ratios (SMRs) were calculated and compared with those of 8529 women aged less than 40 years with breast cancer without subsequent childbirth, and with those predicted by Adjuvant! Online.

Results

Women with subsequent childbirth had a lower 15-year cumulative overall mortality rate than other women with breast cancer (16·8 (95 per cent confidence interval (c.i.) 13·3 to 20·9) versus 40·7 (39·5 to 41·9) per cent), but a higher relative mortality risk than the background population (SMR 13·6, 95 per cent c.i. 10·6 to 17·3). Mortality risks decreased significantly with increasing interval between diagnosis and subsequent childbirth. Mean 10-year cumulative mortality risks of women with subsequent childbirth were within the range of 10-year mortality predicted by Adjuvant! Online for women with T1 N0 tumours in otherwise perfect health.

Conclusion

This study reinforced the view that pregnancy after breast cancer is not detrimental to survival. However, women who gave birth after this diagnosis had substantially higher mortality risks than young women in the general population. This information may be a valuable addition to routine mortality estimates.