Immunological Landscape of HER-2 Positive Breast Cancer

Understanding the biological aspects of immune response in HER2+ breast cancer is crucial to implementing new treatment strategies in these patients. It is well known that anti-HER2 therapy has improved survival in this population, yet a substantial percentage may relapse, creating a need within the scientific community to uncover resistance mechanisms and determine how to overcome them. This systematic review indicates the immunological mechanisms through which trastuzumab and other agents target cancer cells, also outlining the main trials studying immune checkpoint blockade. Finally, we report on anti-HER2 vaccines and include a figure exemplifying their mechanisms of action.

Impact of the COVID-19 Pandemic on a Cancer Fast-Track Programme

Introduction

The COVID-19 pandemic has disrupted many aspects of clinical practice in oncology, particularly regarding early cancer diagnosis, sparking public health concerns that possible delays could increase the proportion of patients diagnosed at advanced stages. In 2009, a cancer fast-track program (CFP) was implemented at the Clinico-Malvarrosa Health Department in Valencia, Spain with the aim of shortening waiting times between suspected cancer symptoms, diagnosis and therapy initiation.

Objectives

The study aimed to explore the effects of the COVID-19 pandemic on our cancer diagnosis fast-track program.

Methods

The program workflow (patients included and time periods) was analysed from the beginning of the state of alarm on March 16th, 2020 until March 15th, 2021. Data was compared with data from the same period of time from the year before (2019).

Results

During the pandemic year, 975 suspected cancer cases were submitted to the CFP. The number of submissions only decreased during times of highest COVID-19 incidence and stricter lockdown, and overall, referrals were slightly higher than in the previous 2 years. Cancer diagnosis was confirmed in 197 (24.1%) cases, among which 33% were urological, 23% breast, 16% gastrointestinal and 9% lung cancer. The median time from referral to specialist appointment was 13 days and diagnosis was reached at a median of 18 days. In confirmed cancer cases, treatment was started at around 30 days from time of diagnosis. In total, 61% of cancer disease was detected at early stage, 20% at locally advanced stage, and 19% at advanced stage, displaying time frames and case proportions similar to pre-pandemic years.

Conclusions

Our program has been able to maintain normal flow and efficacy despite the challenges of the current pandemic, and has proven a reliable tool to help primary care physicians referring suspected cancer patients.

A prognostic miRNA based signature in early-stage HER2-positive breast cancer patients

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Background: In early-stage HER2+ breast cancer (BC), escalation or de-escalation of systemic treatment is an unmet need. Integration of promising biomarkers into risk scoring will further help progressing in the field. We aim to develop a prognostic signature that integrates two miRNAs (A and B) and quantitative and qualitative clinical variables in patients diagnosed with HER2+ BC. Methods: This study was conducted in a retrospective cohort of 45 HER2+ BC patients. Patients received standard treatment for localized disease. We calculated a prognostic signature for disease-free survival (DFS) using principal components analysis for mixed data combining clinicopathological data (Ki67 and axillary lymph node [pN0, pN1, pN2, pN3]) and expression of two microRNAs (we used mir-16 as housekeeping). Multiple DFS prognostic signatures were calculated and goodness of fit was evaluated by means of Akaike’s Information Criterion (AIC) to perform Cox model selection. Signature was then dichotomized into “high risk” and “low risk” using maximally selected Log-Rank statistics by Hothorn and Lausen, as method for optimal cut-off. Kaplan-Meier curves, Log-Rank test and Breslow test were used to ascertain statistical differences in the probability of DFS between high and low risk groups. MiRNA targeted genes were selected and used to perform functional enrichment analysis with the KEGG pathway database. To select significant terms/pathways, p-values were adjusted by the Benjamini-Hochberg method (p < 0.05). Results: MiR-A and miR-B expression was higher in primary tumor of patients who relapse compared to those free of disease after treatment (p = 0.018 and 0.004, respectively). Both miRNAs were strongly correlated (r = 0.84). This signature was significantly associated with relapse of the disease (HR 1.72; CI 95%: 1.243–2.382; p < 0.01, AIC = 114.02). The optimal cut-off of this score was obtained and patients were classified into high and low risk groups. Median DFS of the high-risk was 44 months while it has been not reached yet across the low risk after a median follow-up of 67 months (HR 8.39; p = 0.005, AIC = 111.784). Significant differences in survival between both groups were found (log rank test p < 0.001; Breslow test p = 0.002). miR-A and miR-B functional enrichment analysis returned 55 significant pathways. Interestingly, P53 pathway, apoptosis and cell cycle which are closely related to tumorigenesis and treatment response, were in the top 5 enriched pathways. Conclusions: Both miRNAs included in this signature are related to important biological pathways associated to BC progression. Our new prognostic signature identifies patients with early-stage, HER2+ BC who might be candidates for escalated or de-escalated systemic treatment. This signature was able to classify patients for DFS in high or low risk groups at the moment of BC diagnosis. Further investigations to validate the value of this new signature are on-going.

Ten-year assessment of a cancer fast-track programme to connect primary care with oncology: reducing time from initial symptoms to diagnosis and treatment initiation

Background

Cancer is the second leading cause of mortality worldwide. Integrating different levels of care by implementing screening programmes, extending diagnostic tools and applying therapeutic advances may increase survival. We implemented a cancer fast-track programme (CFP) to shorten the time between suspected cancer symptoms, diagnosis and therapy initiation.

Patients and methods

Descriptive data were collected from the 10 years since the CFP was implemented (2009-2019) at the Clinico-Malvarrosa Health Department in Valencia, Spain. General practitioners (GPs), an oncology coordinator and 11 specialists designed guidelines for GP patient referral to the CFP, including criteria for breast, digestive, gynaecological, lung, urological, dermatological, head and neck, and soft tissue cancers. Patients with enlarged lymph nodes and constitutional symptoms were also considered. On identifying patients with suspected cancer, GPs sent a case proposal to the oncology coordinator. If criteria were met, an appointment was quickly made with the patient. We analysed the timeline of each stage of the process.

Results

A total of 4493 suspected cancer cases were submitted to the CFP, of whom 4019 were seen by the corresponding specialist. Cancer was confirmed in 1098 (27.3%) patients: breast cancer in 33%, urological cancers in 22%, gastrointestinal cancer in 19% and lung cancer in 15%. The median time from submission to cancer testing was 11 days, and diagnosis was reached in a median of 19 days. Treatment was started at a median of 34 days from diagnosis.

Conclusions

The findings of this study show that the interval from GP patient referral to specialist testing, cancer diagnosis and start of therapy can be reduced. Implementation of the CFP enabled most patients to begin curative intended treatment, and required only minimal resources in our setting.

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Our CFP easily connects GPs and hospital specialists.

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Our CFP shortens assessment time in patients with suspected cancer, adding to quality care.

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Our CFP decreases emotional stress in patients without cancer.

Abstract PS7-71: Breast cancer fast-track programme to shorten time between initial symptoms, diagnosis and initiation of treatment. 10 years update

Background: Breast cancer (BC) is one of the most serious health problems worldwide. The implementation of screening programs as well as advances in diagnosis and therapeutics have achieved an increase in survival. However, there are patients who do not benefit from screening programs: very young or older than 69 years old patients and interval cancers.The main aim of this breast cancer fast-track program (BCFP) is to reduce the time from the onset of breast cancer signs and symptoms until the beginning of treatment.

· Methods: The programme began in June 2009; we hereby present data from the first ten years (June 2009-June 2019) in the Clinico-Malvarrosa Health Department in Valencia, Spain. Breast surgeons, primary care (PC) physicians, radiologists who are experts in breast cancer and oncology coordinators regularly met to discuss suspected cases of BC, and initially set guidelines with the criteria to be used by PC physicians in order to refer patients to BCFP. On the same day that the PC physician identified a patient with suspected BC, an index card was sent to the oncology coordinator, who reviewed these cases and referred those meeting previously defined criteria to either breast surgeons or breast radiologists.

· Results: 1849 proposals were sent to the hospital from which 1778 patients came to the first visit at the specialist. 312 (16.9%) referred cases were diagnosed with BC. 206 (66%) women were diagnosed of BC in the age range in which screening with mammography is not recommended in our general population (between 45-69 years old). 296 patients had a localized BC (94%) and 16 (6%) an advanced BC. The median time from submission of a proposal until the specialist assessment was 13 days for diagnosed patients, 2 days from the first visit to histopathological diagnosis, and 29 days from the histopathological diagnosis until a treatment is initiated (either oncological or surgical). It took a median of 18 days to confirm the absence of BC in 1466 patients with initial suspicion of it.

• Conclusions: Our data show that the time interval between patient referral by the PC physician to the specialist, diagnosis of breast cancer, and start of therapy can be reduced. We optimized existing resources with no additional costs associated with the implementation of this programme.

Keywords: Breast Cancer, Clinical Guidelines, Early diagnosis

Authors: M.T. Martinez1*, S. Moragon1*, S. Simón1, B. Ortega1, J.V. Montón1, J. Navarro2, A. Sanmartin2, A. Julve3, E. Buch4, O. Burgues5, C. Hernando1, J. M. Cejalvo1, A. Lluch1, B. Bermejo1, A. Cervantes1, I. Chirivella1.1Medical Oncology Department, INCLIVA Biomedical Research Institute, Valencia, Spain, 2Management department, Hospital Clinico Universitario de Valencia, Valencia, Spain3 Radiodiagnosis Department, Hospital Clinico Universitario de Valencia, Valencia, Spain4 Senology Department, Hospital Clinico Universitario de Valencia, Valencia, Spain5 Pathological Anatomy Department. Hospital Clinico Universitario de Valencia, Valencia, Spain

Citation Format: Maria Teresa Martínez, Santiago Moragon, Soraya Simon, Belen Ortega, Jose Vicente Monton-Bueno, Jorge Navarro, Ana Sanmartin, Ana Julve, Elvira Buch, Octavio Burgués, Cristina Hernando, Juan Miguel Cejalvo, Ana Lluch, Begoña Bermejo, Andrés Cervantes, Isabel Chirivella. Breast cancer fast-track programme to shorten time between initial symptoms, diagnosis and initiation of treatment. 10 years update [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-71.