Distinct genomic and immunologic tumor evolution in germline TP53-driven breast cancers

Pathogenic germline TP53 alterations cause Li-Fraumeni Syndrome (LFS), and breast cancer is the most common cancer in LFS females. We performed first of its kind multimodal analysis of LFS breast cancer (LFS-BC) compared to sporadic premenopausal BC. Nearly all LFS-BC underwent biallelic loss of TP53 with no recurrent oncogenic variants except ERBB2 (HER2) amplification. Compared to sporadic BC, in situ and invasive LFS-BC exhibited a high burden of short amplified aneuploid segments (SAAS). Pro-apoptotic p53 target genes BAX and TP53I3 failed to be up-regulated in LFS-BC as was seen in sporadic BC compared to normal breast tissue. LFS-BC had lower CD8+ T-cell infiltration compared to sporadic BC yet higher levels of proliferating cytotoxic T-cells. Within LFS-BC, progression from in situ to invasive BC was marked by an increase in chromosomal instability with a decrease in proliferating cytotoxic T-cells. Our study uncovers critical events in mutant p53-driven tumorigenesis in breast tissue.

Selection of appropriate biomarkers to monitor effectiveness of ovarian function suppression in pre-menopausal patients with ER+ breast cancer

Use of gonadotropin-releasing hormone (GnRH) agonists has been widely adopted to provide reversible ovarian function suppression for pre-menopausal breast cancer patients who are also receiving aromatase inhibitor or tamoxifen therapy based on results of 25 randomized trials representing almost 15,000 women demonstrating a survival benefit with this approach. Past clinical trials designed to establish the efficacy of GnRH agonists have monitored testosterone in the prostate cancer setting and estradiol in the breast cancer setting. We explore the merits of various biomarkers including estradiol, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) and their utility for informing GnRH agonist treatment decisions in breast cancer. Estradiol remains our biomarker of choice in ensuring adequate ovarian function suppression with GnRH agonist therapy among pre-menopausal women with breast cancer. We recommend future trials to continue to focus on estradiol levels as the primary endpoint, as they have in the past.

Contrast-enhanced mammography in the assessment of residual disease after neoadjuvant treatment

PURPOSE

To investigate the utility of contrast-enhanced mammography (CEM) as an alternative to breast MRI for the evaluation of residual disease after neoadjuvant treatment (NAT).

METHODS

This prospective study enrolled consecutive women undergoing NAT for breast cancer from July 2017-July 2019. Breast MRI and CEM exams performed after completion of NAT were read independently by two breast radiologists. Residual disease and lesion size on MRI and CEM recombined (RI) and low-energy images (LEI) were compared. Histopathology was considered the reference standard. Statistical analysis was performed using McNemar's and Leisenring's tests. Multiple comparison adjustment was made using Bonferroni procedure. Lesion sizes were correlated using Kendall's tau coefficient.

RESULTS

There were 110 participants with 115 breast cancers. Residual disease (invasive cancer or ductal carcinoma in situ) was detected in 83/115 (72%) lesions on pathology, 71/115 (62%) on MRI, 55/115 (48%) on CEM RI, and 75/115 (65%) on CEM LEI. When using multiple comparison adjustment, no significant differences were detected between MRI combined with CEM LEI and CEM RI combined with CEM LEI, in terms of accuracy (MRI: 77%, CEM: 72%; p ≥ 0.99), sensitivity (MRI: 88%, CEM: 81%; p ≥ 0.99), specificity (MRI: 47%, CEM: 50%; p ≥ 0.99), PPV (MRI: 81%, CEM: 81%; p ≥ 0.99), or NPV (MRI: 60%, CEM: 50%; p ≥ 0.99). Size correlation between pathology and both MRI combined with CEM LEI and CEM RI combined with CEM LEI was moderate: τ = 0. 36 vs 0.33 (p ≥ 0.99).

CONCLUSION

Contrast-enhanced mammography is an acceptable alternative to breast MRI for the detection of residual disease after neoadjuvant treatment.

Abstract P6-05-02: PRESENCE OF BRCA MUTATIONS AND PRE-CHEMOTHERAPY SERUM ANTI-MULLERIAN HORMONE LEVELS PREDICT RISK OF AMENORRHEA IN WOMEN WITH BREAST CANCER

OBJECTIVE: The likelihood of post-chemotherapy (ChT) amenorrhea is still empirically determined. Our aim was to determine the predictors of amenorrhea risk post- ChT in women with breast cancer(ca). As acute amenorrhea (< 12mo post-ChT) can be temporary, we used amenorrhea status 12 and 18 months post-ChT as the primary endpoint.

MATERIALS AND METHODS: 102 women aged 18-44, with regular cycles and stage I-III breast ca were prospectively and longitudinally followed for their menstrual pattern changes at 6, 12, and 18mo after the completion of adjuvant ChT with an Anthracycline-Cyclophosphamide-based (AC) or Cyclophosphamide-Methotrexate +5-Fluorouracil regimen on an IRB-approved protocol. Prior ChT, ovarian surgery, pelvic RT, family history of POI, and infertility diagnosis were the exclusion criteria. AMH was measured pre- and immediately post- ChT. Amenorrhea was defined as no bleeding for 4 consecutive cycles. Preand/or post-ChT AMH levels, age and BMI at the onset of ChT, BMI, tamoxifen use, regimen type (AC-based vs. not), and BRCA mutation (m) status (positive vs. not) were evaluated for the prediction of amenorrhea risk.

RESULTS: In multivariable-adjusted logistic regression models, age (p=0.03) and AMH (p=0.03) were significant predictors of amenorrhea at 12mo, and BRCAm status (p=0.03) at 18 mo; these models yielded areas under the ROC curve of 0.77 and 0.76, respectively. An undetectable AMH post-ChT was best predictive of amenorrhea with shorter follow-up, but not at 18mo. In longitudinal analysis (with data at 0, 6, 12, and 18 months) estimating ‘time-trends’, a baseline AMH < 2.0 ng/ml (optimal cut-off from ROC curve) and BRCAm status were associated with the risk of amenorrhea. The baseline AMH ≥2.0 group showed attenuated time-trend vs. the AMH < 2.0 ng/ml group (ratio of ORs=0.91, 95% CI=0.86-0.97, p=0.002), while the BRCA-positive group showed a steeper time-trend in the odds ratio (OR) of amenorrhea, compared to the non-positive group (ratio of ORs=1.12,95% CI=1.04-1.20, p=0.003) (Table 1). Sensitivity analyses demonstrated the robustness of these findings, for example, yielding an 8-10% increased risk of amenorrhea for BRCAm carriers, with p-values of 0.008- 0.04.

CONCLUSIONS: Age, pre-and post-ChT AMH levels, and BRCAm status are potential predictors of amenorrhea at 12 and 18mo post-ChT. These predictors may help better guide fertility preservation decision-making in women with breast ca. The higher likelihood of amenorrhea in women with BRCAm suggests that they may be more prone to lose their ovarian function post-ChT and should be accordingly counseled.

Table 1. Longitudinal analysis at 0, 6, 12 and 18 months for the difference in amenorrhea trend between groups dichotomized by baseline factors.

Citation Format: Shari B. Goldfarb, Volkan Turan, Giuliano Bedoschi, Nadia Abdo, Cassandra Chang, heejung Bang, KUTLUK H. OKTAY. PRESENCE OF BRCA MUTATIONS AND PRE-CHEMOTHERAPY SERUM ANTI-MULLERIAN HORMONE LEVELS PREDICT RISK OF AMENORRHEA IN WOMEN WITH BREAST CANCER [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-02.

Abstract P5-08-10: Safety and Tolerability of Paxman Scalp Cooling at Lower Temperatures to Improve Efficacy with Anthracycline Chemotherapy

Background: Chemotherapy induced alopecia is one of the most distressing side effects of cancer therapy since it is a constant reminder of the underlying malignancy. Anthracycline chemotherapy induces total alopecia. Although scalp cooling devices have been used to prevent this alopecia, there is still a need to improve efficacy with anthracycline therapy. This study was performed to evaluate if the Paxman Scalp Cooling System is safe, tolerable, and more efficacious at lower temperatures.

Objectives: The primary end point is to assess the safety and tolerability of the Paxman Scalp Cooling System at lower temperatures (-7.5 Celsius and -10 Celsius), defined as the ability of patients to undergo scalp cooling without any DLTs during the treatment period. The secondary end point is successful hair preservation assessed using the Common Terminology Criteria for Adverse Events version 4.0 scale (grade 0 [no hair loss] or grade 1 [< 50% hair loss not requiring a wig] were considered to have hair preservation) after anthracycline chemotherapy.

Methods: 34 women with stage I-III breast cancer who were receiving anthracycline-based neoadjuvant or adjuvant therapy were enrolled on study. The first 7 patients received scalp cooling at -7.5 Celsius and the subsequent 27 patients received scalp cooling at -10 Celsius. Patients completed safety and tolerability assessments at each visit. In addition, participants had standardized scalp photography to assess the superior, vertex and frontal scalp views, trichoscopic assessments, alopecia grading and completed PROs (CADS, Tolerability, Change in scalp coverage).

Results: Thirty-four women (56% White, 18% Black, 8% Asian, 18% other) with a mean age of 44 (range 20-68) were enrolled on this IRB-approved pilot study. Seventy-four percent received ddAC-T, 18% received ddAC-THP and 8% received ddAC/Pembro-T/Carbo/Pembro. Twenty-six patients were evaluable for the DLT end point. Three patients are still on study and five patients left the study before completion (2 due to lack of efficacy, 1 shaved her head, 1 was removed from study due to hospitalization for sepsis and 1 patient changed her mind and never started scalp cooling). There were no DLTs in any patient throughout the study. Both the -7.5 and -10 Celsius temperatures were found to be tolerable with no difference in tolerability. The most common reported AEs were headaches 48%, discomfort 13%, scalp pain 9.7%, dizziness 9.6%, scalp coldness 6%, feeling cold 3% and lightheadedness 3%. Twenty-nine percent of patients reported that scalp cooling triggered a headache and the average level of pain was mild. Only 16% of patients reported pain killer use due to scalp cooling, which effectively resolved headaches or discomfort. Sixty-one percent of patients reported hair preservation at the primary end point. Hair regrowth was reported in patients after they experienced grade 2 alopecia and while still on study. More detailed data on hair preservation will be forthcoming once all of the photos and trichoscopic measures are assessed.

Conclusions: Paxman Scalp Cooling System is safe, tolerable and even more efficacious at lower temperatures. The -10 Celsius is more efficacious and as tolerable as -7.5 in patients being treated with anthracycline therapy. When using the Paxman Scalp Cooling System in patients being treated with anthracycline therapy, you should consider performing scalp cooling at lower temperatures

Table 1: Demographics

Citation Format: Shari B. Goldfarb, Victoria Blinder, Devika Gajria, Cassandra Chang, Analisa Dacunto, Jinae Park, Monica Fornier, Mario Lacouture. Safety and Tolerability of Paxman Scalp Cooling at Lower Temperatures to Improve Efficacy with Anthracycline Chemotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-08-10.

Fertility Preservation in Young Women with Breast Cancer: Impact on Treatment and Outcomes

BACKGROUND

The impact of chemotherapy timing on the fertility preservation (FP) decision is poorly understood. Here we evaluate factors associated with FP completion among women age ≤ 45 years with breast cancer who received chemotherapy and consulted with a reproductive endocrinology and infertility (REI) specialist, and report pregnancy and oncologic outcomes.

PATIENTS AND METHODS

This retrospective review included all women age ≤ 45 years diagnosed with stage I-III unilateral breast cancer at Memorial Sloan Kettering Cancer Center between 2009 and 2015 who received chemotherapy and consulted with an REI specialist. Clinicopathologic features and factors associated with the decision to undergo FP were analyzed, and comparisons were made with the Wilcoxon rank-sum test, Chi-square test, or Fisher's exact test. Survival curves were constructed using the Kaplan-Meier method.

RESULTS

Among the 172 women identified, median age was 34 years (interquartile range 31-37 years). The majority of women were single (n = 99, 57.6%) and nulliparous (n = 134, 77.9%). Most women underwent FP (n = 121, 70.3%). Factors associated with the decision to undergo FP included younger median age (33 vs. 37 years, p < 0.001), having private insurance (p < 0.001), nulliparity (p < 0.001), and referral from Breast Surgery (p = 0.004). Tumor characteristics and treatments were similar between women who underwent FP and those who declined. Overall survival and recurrence-free survival were also similar between groups. Women who underwent FP were more likely to have a biological child after breast cancer treatment.

CONCLUSIONS

Women underwent FP at high rates independent of timing of chemotherapy and oncologic factors. FP is associated with having a biological child and does not compromise oncologic outcomes.

Phase 1/2 study of topical submicron particle paclitaxel for cutaneous metastases of breast cancer

Purpose

This Phase 1/2 study evaluated safety and efficacy of a topical submicron particle paclitaxel (SPP) in an anhydrous ointment base (SOR007), primarily in breast cancer patients with cutaneous metastases (CM).

Methods

One of three concentrations of SOR007 SPP (0.15%, 1.0%, or 2.0%) was applied twice daily over an area of 50 cm² under a 3 + 3 phase 1 design for up to 28 days, with the option for expansion to an additional 28 days at the highest dose under a Phase 2a once safety was established. Efficacy was analyzed by lesion measurements and photographs to determine overall response rate (ORR), complete response (CR), and progression free survival by day 28 or 56.

Results

Twenty-three subjects were enrolled, 21 with cutaneous metastases of breast cancer (CMOBC). Four subjects received SOR007 0.15% for a median of 28 days (range = 17–29), three at a dose of 1.0% for a median of 28 days (range = 6–29), and sixteen at 2.0% for a median of  55 days (range = 6–60). All doses were well tolerated, and 19 subjects were evaluable for efficacy. At day 28 across all dose levels, 16% (95% CI 3.4 to 39.6%) of subjects achieved an ORR and another 63% (95% CI 34.9–96.8%) had stable disease (SD). The proportion of patients being progression free at 28 days across all treatments was 79% (95 CI 54–94%).

Conclusion

Application of SOR007 0.15%, 1.0%, and 2.0% to CM was safe and well tolerated with some reduction in lesion pain, and minimal systemic absorption of paclitaxel. Lesion stabilization was observed in most subjects over the study period. A randomized, placebo-controlled trial to confirm these findings is warranted.

ClinicalTrials.gov identifier

NCT03101358.

Timing of Presentation and Outcomes of Women with Stage IV Pregnancy-Associated Breast Cancer (PABC)

BACKGROUND

Pregnancy-associated breast cancer (PABC) and concurrent, or early development of, stage IV disease is uncommon. Given this rarity, and complexities surrounding pregnancy, data are limited regarding PABC treatment and outcomes. We evaluated oncologic, obstetric, and fetal outcomes of women with stage IV PABC in relation to presentation timing and treatment.

PATIENTS AND METHODS

Our retrospective review of an institutional database identified women with stage IV PABC from 1998 to 2018. PABC was defined as diagnosis during pregnancy or ≤ 1 year postpartum. Clinicopathologic, treatment, and outcome variables were compared between women diagnosed during pregnancy versus postpartum.

RESULTS

We identified 77 women (median age 35 years; interquartile range [IQR] 32-37 years): 51 (66%) in the postpartum group and 26 (34%) in the pregnant group, including 9 with therapeutic or spontaneous abortion. Among 17 women who continued pregnancy, no obstetric or fetal complications were noted. Clinicopathologic and treatment variables did not differ between groups. Of 43 women dead from disease, 15 had triple negative (TN) tumors. Median overall survival (OS) of TN tumors was 14 months (range 5-39 months); OS was associated with hormone receptor-positive and human epidermal growth factor receptor 2 (HER2) positive tumors (p < 0.01). At 31 months (range 0-137 months) median follow-up, the 5-year OS was 34% (95% confidence interval 21-46%), and did not differ among pregnant and postpartum groups (p = 0.2).

CONCLUSIONS

Women with stage IV TN PABC had high mortality rates despite multimodality therapy. Timing of presentation did not affect management decisions or OS, even for women who completed pregnancy. Further research to understand PABC biology, focusing on TN tumors, is warranted.

Abstract P4-11-03: Decisions and outcomes of young women with breast cancer regarding fertility preservation before cancer treatment and family building after treatment

Background: More than 12,000 new diagnoses of breast cancer occur annually in women &lt;40 years old and most will become survivors. It is recommended that young women with breast cancer be counseled about fertility preservation (FP) options prior to initiation of systemic therapy if they are interested in having biologic children in the future. Decisions to pursue FP are multifactorial and current data suggest only a small proportion of women pursue FP before breast cancer treatment. This study examines the decisions and outcomes of women who pursue FP before treatment and family building after therapy. Methods: An IRB approved web-based cross-sectional survey examining decisions about FP, factors influencing decisions, and post-decision regret was administered to young (age 18-45) breast cancer survivors with stage I-III breast cancer who were either English or Spanish speaking. All women received counseling by a MSK Fertility Nurse Specialist prior to initiating cancer treatment at MSKCC in 2009-2017. Clinical data was also extracted from the medical record .Results: Our sample consisted of 211 women with a mean and median age of 34 (age range was 20-45) and 82% had ER+ disease, 19% had HER-2+ disease and 12% had triple negative breast cancer. At the time of diagnosis, 46 women (22%) had children and 173 women (61%) were married or living with a partner. 151 (72%) of study participants wanted to have (more) children, 48 (23%) were unsure and 12 (6%) did not want additional children. Prior to treatment, 172 (82%) women met with a reproductive endocrinologist (RE), and 122 (58%) underwent FP: 73 froze eggs and 49 froze embryos. After treatment, 28 (13%) women met with a RE, and 13 underwent FP: 9 froze eggs and 4 froze embryos. 26 (12%) patients opted to just use a GnRH agonist during chemotherapy. For women who froze eggs, the average number obtained was 14 pre-treatment and 18 post-treatment. Of those who froze embryos, the average number obtained was 7 both pre- and post-treatment. Concern with financial burden was noted in 58% of women. Insurance did not cover any FP treatment for 56/122 (46%) of women. 32% (39/122) of women paid $10,000 or more for their FP. Women reported that the most important factor that contributed to their FP decision was the ability to feel hopeful about their future followed by concern that they would have regrets if they did not undergo FP. Additional factors that contributed to the FP decision were the desire to have biologic children, feeling overwhelmed by the cancer diagnosis, the cost of freezing eggs or embryos and concern about taking hormone medication. Reflecting back 176 women (83%) believe they made the right decision regarding FP. After completing primary breast cancer treatment, 61 women (29%) opted to try to build their family and 42 had children: 35 gave birth and 7 used a surrogate. Currently 3 women are pregnant, and 10 are pursuing pregnancy. 19 (31%) women conceived without fertility treatment and 22 (36%) women used or are currently pursuing assisted reproduction. 1 woman used a donor egg and 15 successfully used frozen eggs/embryos harvested prior to treatment. Delay of endocrine therapy to pursue pregnancy was uncommon, reported by only 6 women. However, 23 women interrupted endocrine therapy to conceive. Conclusions: The majority of women who attempted family building after treatment were able to have children. Many of these women used eggs/embryos frozen before breast cancer treatment either by getting pregnant themselves or via surrogacy. These data stress the importance of early discussion with a fertility nurse specialist regarding risks and preservation options followed by prompt referral to a reproductive endocrinologist. In addition, FP helped women to feel hopeful about their future and the majority of women believe they made the right decision.

Citation Format: Shari B Goldfarb, Bridgette Thom, Cassandra Chang, Nadia Abdo, Andrea Carpio, Rosemary Semler, Catherine Benedict, Patricia Hershberger, Joanne F Kelvin, Mary L Gemignani. Decisions and outcomes of young women with breast cancer regarding fertility preservation before cancer treatment and family building after treatment [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-03.

Abstract PD12-05: Fertility preservation in young women with breast cancer: Impact on treatment and outcomes

Background. The American Society of Clinical Oncology guidelines recommend timely referral to reproductive endocrinology and infertility (REI) specialists for young women diagnosed with breast cancer. There is a paucity of data evaluating the impact of FP on oncologic outcomes and timely initiation of chemotherapy.

Methods. This retrospective review included all women age ≤ 45y diagnosed with stage I-III unilateral breast cancers at Memorial Sloan Kettering Cancer Center between 2009-2015 who received chemotherapy and consulted with an REI specialist. Factors associated with the decision to undergo FP were analyzed. Survival curves were constructed using the Kaplan-Meier method.

Results. A total of 172 women were identified. Median age was 34y (interquartile range 31-37). The majority of women were single (n = 99, 58.1%) and nulliparous (n = 134, 77.9%). Most women underwent FP (n = 121, 70.3%). Tumor characteristics and treatments were similar between women who underwent FP and those who declined (Table 1). While white race was associated with decision to pursue FP, this association did not persist on multivariable analysis (MVA). Young age (p = 0.003), nulliparity (p = 0.001), referral from Breast Surgery (p = 0.009), and private insurance (p &lt; 0.001) were independent predictors of FP on MVA. Timing of chemotherapy (adjuvant vs neoadjuvant) was not associated with decision to undergo FP. FP was not associated with breast cancer treatment delays.

A total of 25.5% (n = 44) of women had a biological child following breast cancer treatment (Table 2). Women who underwent FP were more likely to have a biological child after breast cancer treatment. Race and insurance type were also associated with having a biological child after treatment, with white women and women with private insurance being more likely to have a biological child. MVA revealed that undergoing FP, being married, and being white were independent predictors of having a biological child.

The 5-year overall survival (OS) was 97.5% (95% CI: 93.5-99.1%) and the 5-year recurrence-free survival (RFS) was 91.4% (95% CI: 85.9%-94.8%) with a median follow-up of 70 months (range 4-127). Five-year overall survival (OS) and recurrence-free survival (RFS) were similar between women who underwent FP and those who declined (OS: FP 98.2%, 95% CI 92.9%-99.5% vs 95.9%, 95% CI 84.6-98.9%, p = 0.20 and RFS: FP 92.1%, 95% CI: 85.4-95.8% vs declined 89.7%, 95% CI 76.9-95.6%, p = 0.42). Disease stage, race, and pregnancy were not associated with differences in OS or RFS. Private insurance was associated with improved OS but not with improved RFS.

Conclusions. Most women underwent FP. Women pursued FP at high rates independent of the timing of chemotherapy and oncologic factors. These findings indicate that timely consultation with REI specialists is the key factor in completing FP, and highlight opportunities for improved education and counseling regarding FP. They also identify FP as a possible area of racial disparities within breast cancer care, and serve as a reminder of the complex interplay between socioeconomic factors, reproductive choices, and pregnancy outcomes.

Table 1. Factors associated with decision to pursue cryopreservationFactorsDeclined Cryopreservation (n = 51)Cryopreservation (n = 121)p valueMedian Age, years (IQR)37 (32-40)33 (30-37)&lt; 0.001RaceWhite26 (56.5%)86 (78.2%)0.015Black10 (21.7%)7 (6.3%)Asian9 (19.6%)15 (13.6%)Other1 (2.2%)2 (1.8%)Unknown511Insurance TypePrivate39 (76.5%)114 (94.2%)&lt; 0.001Government11 (21.6%)4 (3.3%)Uninsured1 (2.0%)3 (2.5%)Single29 (56.9%)70 (57.9%)&gt; 0.99Nulligravid21 (41.2%)80 (66.1%)0.004Nulliparous31 (60.8%)103 (85.1%)&lt; 0.001Referring ServiceBreast Surgery24 (47.1%)87 (71.9%)0.004Breast Medicine26 (51.0%)33 (27.3%)Genetics/GYN1 (2.0%)1 (0.8%)Tumor GradeI2 (4.0%)2 (1.7%)0.52II7 (14.0%)14 (11.8%)III41 (82.0%)103 (86.6%)Unknown12Receptor ProfileER/PR+ HER2-31 (60.8%)64 (52.9%)0.74ER/PR+ HER2+8 (15.7%)27 (22.3%)ER/PR- HER2+2 (3.9%)4 (3.3%)Triple Negative10 (19.6%)26 (21.5%)StageI12 (23.5%)44 (36.4%)0.074II27 (52.9%)63 (52.1%)III12 (23.5%)14 (11.6%)Breast SurgeryLumpectomy19 (37%)38 (31.4%)0.57Mastectomy32 (63%)83 (68.6%)Systemic TherapyAdjuvant Chemotherapy43 (84.3%)104 (86.0%)0.97Median Time from Surgery to Chemotherapy, weeks (range)7 (4-19)7 (2-18)0.9Delay &gt; 12 Weeks to Chemotherapy2 (4.7%)3 (2.9%)0.63Neoadjuvant Chemotherapy8 (15.7%)17 (14.0%)0.97Median Time from Diagnosis to NAC, weeks (range)3 (1-8)3 (2-12)0.29Delay &gt; 6 weeks to chemotherapy start1 (12.5%)2 (11.8%)&gt; 0.99Endocrine Therapy41 (80.4%)92 (76.0%)0.67Radiation TherapyAdjuvant Whole Breast Radiation Therapy16 (31.4%)38 (31.4%)0.99PMRT16 (31.4%)43 (35.5%)0.73IQR interquartile range, IDC invasive ductal carcinoma, ILC invasive lobular carcinoma, DCIS ductal carcinoma in situ, ER estrogen receptor. “Unknowns” were not included in percentage calculations or in univariate analysis.

Table 2. Factors associated with having a biological child after breast cancer treatmentFactorsHad a biological child (n = 44)Did not have a biological child (n = 128)p valueCompleted fertility preservation40 (90.9%)81 (63.3%)0.001RaceWhite36 (90.0%)76 (65.5%)0.029Black1 (2.5%)16 (13.8%)Asian3 (7.5%)21 (18.1%)Other03 (2.6%)Unknown412Insurance TypePrivate40 (90.9%)113 (88.3%)0.020Government1 (2.3%)14 (10.9%)Uninsured3 (6.8%)1 (0.8%)Married30 (68.2%)43 (33.6%)&lt;0.001Nulligravid24 (54.5%)77 (60.2%)0.64Nulliparous32 (72.7%)102 (79.7%)0.45Referring ServiceBreast Surgery33 (75.0%)48 (37.5%)0.22Breast Medicine11 (25.0%)78 (60.9%)Genetics/GYN02 (1.6%)Tumor FactorsTumor GradeI1 (2.4%)3 (2.3%)&gt; 0.99II5 (11.9%)16 (12.6%)III36 (85.7%)108 (85.0%)Unknown21StageI19 (43.2%)37 (28.9%)0.21II19 (43.2%)71 (55.5%)III6 (13.6%)20 (15.6%)Breast Cancer TreatmentMastectomy32 (72.7%)83 (64.8%)0.44ALND15 (34.1%)51 (39.8%)0.62Systemic TherapyAdjuvant Chemotherapy39 (88.6%)108 (84.4%)0.66Neoadjuvant Chemotherapy5 (11.4%)20 (15.6%)Radiation Therapy26 (59.1%)87 (68.0%)0.38IDC invasive ductal carcinoma, ILC invasive lobular carcinoma, DCIS ductal carcinoma in situ, ER estrogen receptor. “Unknowns” were not included in percentage calculations or in univariate analysis.

Citation Format: Angelena Crown, Shirin Muhsen, Varadan Sevilimedu, Joanne Kelvin, Shari B Goldfarb, Mary L Gemignani. Fertility preservation in young women with breast cancer: Impact on treatment and outcomes [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 PD12-05.

Abstract PS1-18: Pregnancy-associated breast cancer: Does timing of presentation affect outcome?

Background: Pregnancy-associated breast cancer (PABC) comprises breast cancer diagnosed during the gestational period or within the first year post-partum. PABC is associated with worse prognosis, especially for women diagnosed in the postpartum period.

Methods: This is an IRB-approved retrospective review of an institutional database of women with stage 0-III PABC diagnosed between 1992 and 2019. Clinicopathologic features, treatments, and clinical outcomes were compared between women who were diagnosed with PABC during pregnancy and those who were diagnosed during lactation (1-12 months after delivery). Comparisons were made using Fisher’s exact tests and chi-square tests of independence.

Results: A total of 341 women were identified; 131 (38%) diagnosed during pregnancy (pregnancy associated, PA) and 210 (62%) diagnosed post-partum during lactation (lactation associated, LA). Median age for the cohort was 36 (25-46). Median follow-up was 73 months (range, 11-325). Among women with PA diagnoses, 35% (n = 46) presented with breast masses during first trimester, 32% (n = 42) and 33% (n = 43) presented during second and third trimester, respectively; 28% (n = 36) of pregnancies ended in miscarriage or abortion. Fifty-five percent (n = 116) of LA diagnoses were within 6 months of delivery while 44% (n = 92) were between 6-12 months of delivery. The study population was Caucasian (n = 272, 80%), Black (n=26, 7.6%) and Asian (n = 27, 7.9%). Presenting T-stage, N-stage, and AJCC stage were similar between groups. HR+/HER-2-was the most common subtype in both groups (PA n = 49, 37% vs LA n = 71, 34%, p = 0.6). Distribution of other breast cancer receptor profiles were similar between groups (Table). Chemotherapy was administered to 94% (n = 321) of women; 229, 67% as adjuvant and 92, 27% as neoadjuvant (NAC). 72% of women received ddAC-T. Median time to chemo was 3 weeks (range 1-13) for NAC compared to 4 weeks (range 1-16) for adjuvant. Breast cancer treatment was deferred until after delivery for the PA group in 85 women, 65%. Median time from histologic diagnosis to any treatment was 4 weeks (range, 1-22) for PA group and 4 weeks (range 1-17) for LA group. Radiation therapy was received by most women (n = 194, 57%). Endocrine therapy receipt was also common (n = 168, 93% of women with hormone receptor (HR) positive tumors). Patterns of recurrence were similar between groups with most patients in both groups experiencing no recurrence (PA n = 82, 63% vs LA n = 158, 75%, p = 0.10). Differences were observed in disease status with PA having higher rates of women alive with disease (PA n = 16, 12% vs LA n = 12, 5.7%, p = 0.002) and a lower rate of women with no evidence of disease (PA n = 87, 66% vs LA n = 172, 82%, p = 0.002).

Conclusions: Clinicopathologic features were similar between women in both PA and LA groups. Despite these similarities, PA appeared to be associated with higher rates of women alive with disease and lower rates of women with no evidence of disease. Although median time from histologic diagnosis to treatment was similar between PA and LA groups, 65% of women in the PA group had treatment delayed until after delivery, which could potentially impact oncologic outcomes. This highlights the balance between fetal and maternal factors in treatment decisions including possible patient or physician reluctance to treat during pregnancy. Further study is necessary to evaluate this finding.

Table 1. Clinicopathologic features and outcomes associated with PABCCharacteristicPregnancy Associated, n=131*Lactation Associated, n=210*p-value**Presenting T02 (1.5%)2 (1.0%)0.3147 (36%)98 (47%)267 (51%)85 (40%)310 (7.6%)19 (9.0%)45 (3.8%)6 (2.9%)Presenting N Stage054 (41%)97 (46%)0.2177 (59%)109 (52%)20 (0%)4 (1.9%)AJCC Stage02 (1.5%)2 (1.0%)0.5126 (20%)54 (26%)261 (47%)99 (47%)342 (32%)55 (26%)SubtypeTN45 (34%)59 (28%)0.3HR+/HER2-49 (37%)71 (34%)0.6HR+/HER2+21 (16%)30 (14%)0.8HR-/HER2+10 (7.6%)31 (15%)0.072RecurrenceContralateral Breast3 (2.3%)5 (2.4%)0.10Distant33 (25%)31 (15%)Ipsilateral LRR9 (6.9%)13 (6.2%) No Recurrence82 (63%)158 (75%)Simultaneous LRR and Distant4 (3.1%)3 (1.4%)Disease StatusAWD16 (12%)12 (5.7%)0.002DOC3 (2.3%)0 (0%)DOD25 (19%)26 (12%) NED87 (66%)172 (82%)*Statistics presented: n (%); **Statistical tests performed: Fisher's exact test; chi-square test of independence

Citation Format: Angelena Crown, Damian McCartan, Michael Curry, Maya Feldman, Sujata Patil, Sabrina Kamer, Shari B Goldfarb, Mary Gemignani. Pregnancy-associated breast cancer: Does timing of presentation affect outcome? [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 PS1-18.

Surgical ovarian suppression for adjuvant treatment in hormone receptor positive breast cancer in premenopausal patients

OBJECTIVE

Ovarian suppression is recommended to complement endocrine therapy in premenopausal women with breast cancer and high-risk features. It can be achieved by either medical ovarian suppression or therapeutic bilateral salpingo-oophorectomy. Our objective was to evaluate characteristics of patients with stage I-III hormone receptor positive primary breast cancer who underwent bilateral salpingo-oophorectomy at our institution.

MATERIALS AND METHODS

Premenopausal women with stage I-III hormone receptor positive primary breast cancer diagnosed between January 2010 and December 2014 were identified from a database. Patients with confirmed BRCA1/2 mutations were excluded. Distribution of characteristics between treatment groups was assessed using χ² test and univariate logistic regression. A multivariate model was based on factors significant on univariate analysis.

RESULTS

Of 2740 women identified, 2018 (74%) received endocrine treatment without ovarian ablation, 516 (19%) received endocrine treatment plus ovarian ablation, and 206 (7.5%) did not receive endocrine treatment. Among patients undergoing ovarian ablation 282/516 (55%) received medical ovarian suppression, while 234 (45%) underwent bilateral salpingo-oophorectomy. By univariate logistic analyses, predictors for ovarian ablation were younger age (OR 0.97), histology (other vs ductal: OR 0.23), lymph node involvement (OR 1.89), higher International Federation of Gynecology and Obstetrics (FIGO) stage (stage II vs I: OR 1.48; stage III vs I: OR 2.86), higher grade (grade 3 vs 1: OR 3.41; grade 2 vs 1: OR 2.99), chemotherapy (OR 1.52), and more recent year of diagnosis (2014 vs 2010; OR 1.713). Only year of diagnosis, stage, and human epidermal growth factor receptor 2 (HER-2) treatment remained significant in the multivariate model. Within the cohort undergoing ovarian ablation, older age (OR 1.05) was associated with therapeutic bilateral salpingo-oophorectomy. Of 234 undergoing bilateral salpingo-oophorectomy, 12 (5%) mild to moderate adverse surgical events were recorded.

CONCLUSIONS

Bilateral salpingo-oophorectomy is used frequently as an endocrine ablation strategy. Older age was associated with bilateral salpingo-oophorectomy. Perioperative morbidity was acceptable. Evaluation of long-term effects and quality of life associated with endocrine ablation will help guide patient/provider decision-making.

A phase I safety study of topical calcitriol (BPM31543) for the prevention of chemotherapy-induced alopecia

PURPOSE

Chemotherapy-induced alopecia (CIA) negatively affects psychosocial health and quality of life (QoL). Currently, there are no approved pharmacologic agents to prevent CIA. Here, we evaluated the safety, tolerability, and potential signal of efficacy of topical calcitriol (BPM31543) on CIA prevention.

MATERIALS AND METHODS

This Phase 1 trial included 23 female patients with breast cancer, gynecologic cancer, or sarcomas receiving a taxane-based chemotherapy. Patients received a 3 + 3 dose-escalation regimen at 5, 10, 20, 40, 60, and 80 μg/mL, with 3-6 patients per group. Patients applied topical BPM31543 to the scalp twice a day for 2 weeks prior to chemotherapy and continued until chemotherapy treatment was completed. The maximum tolerated dose (MTD) during first 28 day application was determined. Adverse event (AE) monitoring, pharmacokinetics, blinded photographic assessments, and patient self-assessment were evaluated.

RESULTS

Out of 23 patients treated with BPM31543, 8 patients experienced at least 1 treatment-related adverse event (AE). The majority of AEs were mild to moderate in severity. Only 1 patient experienced SAEs (vomiting, nausea, fever, and flank pain) considered treatment related. Alopecia < 50% from baseline was observed in 8 patients at Week 7, and, of which 2 patients had < 50% alopecia maintained at Week 15. There were no detectable effects of topical BPM31543 on serum levels of calcitriol.

CONCLUSIONS

BPM31543 applied topically twice daily to the scalp is safe and well tolerated in patients receiving taxane-based chemotherapy. No DLT was observed at up to 80 µg/mL, and MTD was not reached. Based on the data from this trial, BPM31543 represents a promising therapy and warrants further investigation in Phase 2/3 trials.

Does Use of Neoadjuvant Chemotherapy Affect the Decision to Pursue Fertility Preservation Options in Young Women with Breast Cancer?

BACKGROUND

The American Society of Clinical Oncology guidelines recommend early referral to reproductive endocrinology and infertility (REI) specialists for young women diagnosed with breast cancer. Current practice patterns demonstrate an increased utilization of neoadjuvant chemotherapy (NAC). We evaluated premenopausal women with breast cancer after consultation with a Fertility Nurse Specialist (FNS) and determine factors associated with referral to REI specialists.

METHODS

This retrospective review included all premenopausal women diagnosed at our institution with stage 0-III unilateral breast cancers between 2009 and 2015 who completed an FNS consultation. Clinicopathologic features and factors associated with referral to REI after FNS consultation were analyzed.

RESULTS

A total of 334 women were identified. Median age was 35 years (interquartile range 32-38). The majority of women were single (n = 198, 59.3%) and nulliparous (n = 239, 71.6%). REI referrals were common (n = 237, 71.0%). The Breast Surgery service was the most frequent referring service (n = 194, 58.1%), with significantly more REI referrals compared to Breast Medicine and Genetics services (p = 0.002). Nulliparity was associated with REI referral (p < 0.0001). Adjuvant chemotherapy (p = 0.003) was associated with pursuing REI referral, whereas NAC (p < 0.001) was associated with declining REI referral.

CONCLUSIONS

Most women elected to consult with an REI specialist, confirming strong interest in fertility preservation among premenopausal women with breast cancer. However, women receiving NAC more frequently declined referral to REI, suggesting that the need to start NAC may influence decisions regarding fertility preservation. With increasing utilization of NAC, our study supports the need for further counseling and education regarding fertility preservation for women undergoing NAC.

Increased chemotherapy-induced ovarian reserve loss in women with germline BRCA mutations due to oocyte deoxyribonucleic acid double strand break repair deficiency

OBJECTIVE

To assess whether woman who have BRCA mutations (WBM) experience more declines in ovarian reserve after chemotherapy treatment, as it induces oocyte death by deoxyribonucleic acid (DNA) damage, and BRCA mutations result in DNA damage repair deficiency.

DESIGN

Longitudinal cohort study.

SETTING

Academic centers.

PATIENT(S)

The 108 evaluable women with breast cancer were stratified into those never tested (negative family history; n = 35) and those negative (n = 59) or positive (n = 14) for a pathogenic BRCA mutation.

INTERVENTION(S)

Sera were longitudinally obtained before and 12-24 months after chemotherapy treatment, assayed for antimüllerian hormone (AMH), and adjusted for age at sample collection.

MAIN OUTCOME MEASURE(S)

Ovarian recovery, defined as the geometric mean of the after chemotherapy age-adjusted AMH levels compared with baseline levels.

RESULT(S)

Compared with the controls, the before chemotherapy treatment AMH levels were 24% and 34% lower in those negative or positive for BRCA mutations, consistent with accelerated ovarian aging in WBM. The WBM had a threefold difference in AMH recovery after chemotherapy treatment (1.6%), when compared with BRCA negative (3.7%) and untested/low risk controls (5.2%). Limiting the analysis to the most common regimen, doxorubicin and cyclophosphamide followed by paclitaxel, showed similar results. These findings were mechanistically confirmed in an in vitro mouse oocyte BRCA knockdown bioassay, which showed that BRCA deficiency results in increased oocyte susceptibility to doxorubicin.

CONCLUSION(S)

Women who have pathogenic BRCA mutations are more likely to lose ovarian reserve after chemotherapy treatment, suggesting an emphasis on fertility preservation. Furthermore, our findings generate the hypothesis that DNA repair deficiency is a shared mechanism between aging, infertility, and cancer.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00823654.

Abstract PD6-06: Impact of BRCA mutations on chemotherapy-induced loss of ovarian reserve: A prospective longitudinal study

Background: The BRCA1/2 genes are key members of the ataxia-telangiectasia mutated (ATM)-mediated DNA double strand break (DSB) repair pathway. Recent research showed that germline mutations in these genes result in DNA repair deficiency in oocytes, leading to accelerated ovarian aging as manifested by lower ovarian reserve and earlier age at natural menopause. Because we discovered that oocyte DNA repair is similarly critical in chemotherapy-induced ovarian follicle loss, we hypothesized that women with pathogenic mutations in BRCA1/2 genes may experience larger declines in ovarian reserve after chemotherapy. To gauge the degree of the chemotherapy-induced ovarian damage, we utilized serum anti-mullerian hormone (AMH), which is the most reliable current marker for assessing oocyte reserve.

Methods: Women with early stage breast cancer were enrolled before chemotherapy (Trial registration number: NCT00823654) between January 2009 and November 2017. Sera were obtained at baseline, before the initiation of treatment, and 18 to 24 months after the completion of chemotherapy. Stored sera were assayed at once for anti-mullerian hormone (AMH) and the results were adjusted for the women's age at sample collection. Of the 235 enrolled, 117 evaluable women were stratified into three groups, those never tested (based on NCCN Guidelines V 1.2018 ; n=38) and those negative (n=65) or positive (n=14) for a pathogenic BRCA mutation. Ovarian recovery was defined as the geometric mean of the post chemotherapy age-adjusted AMH levels compared to baseline.

Results: Compared to the lower risk (BRCA-untested) control group, AMH levels averaged 76% and 66% in those negative or positive for BRCA mutations (p=0.078). The geometric mean recoveries for the three groups (not tested, BRCA negative and BRCA positive) were 3.7%, 5.2% and 1.6%, respectively. The mean recovery in the BRCA mutation positive group was about one-third the 4.6% recovery in the other two groups combined (two group ANOVA, p=0.034, F=4.89). Given the potential of the ovarian recovery to be dependent on type of chemotherapy, the data were reanalyzed for all three BRCA groups after restriction to those treated with the AC-T (doxorubicin and cyclophosphamide followed by paclitaxel) regimen. Of the 108 women in the previous analysis, 83 (77%) were treated with AC-T; 25, 46 and 12 women in the three groups, respectively. The geometric mean AMH recoveries for these new groups were 3.2%, 4.7% and 1.3%. When the BRCA mutation positive group was compared with other two groups, the former had significantly worse recovery of serum AMH levels (ANOVA, p=0.044, F=4.2).

Conclusions: These data show that women with breast cancer and pathogenic BRCA mutations have striking liability to chemotherapy-induced ovarian reserve loss and may have to be preferentially counselled on fertility preservation methods. In addition, taken together with the previous data showing that women with BRCA mutations may have accelerated ovarian aging, even unaffected reproductive age individuals may have to be proactive about family building or early preservation of their fertility (Supported by NIH R01HD053112).

Citation Format: Oktay K, Bedoschi G, Goldfarb SB, Taylan E, Titus S, Palomaki GE, Cigler T, Robson M, Dickler MN. Impact of BRCA mutations on chemotherapy-induced loss of ovarian reserve: A prospective longitudinal study [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 PD6-06.

Abstract P5-11-11: A preliminary assessment of knowledge, attitudes, and awareness surrounding ESR1 mutations and biomarker testing amongst medical oncologists

Background: Estrogen receptor gene (ESR1) mutations present in breast cancer patients are associated with resistance to endocrine therapy and worse patient outcomes. Recent findings suggest ESR1 mutations are present in up to 40% of metastatic breast cancer (mBC) patients' tumors. The objective of this study was to evaluate the perceptions of precision medicine and biomarker testing specific to ESR1 mutations among medical oncologists.

Methods: Ten 60-minute web-assisted, telephone interviews were conducted with medical oncologists. Each physician was prescreened prior to being interviewed to ensure board certification and practice experience between 2 and 35 years. Each participant spent greater than 30% of their time on direct patient care and managed the treatment of more than 30 different cancer patients per month, with a minimum of 15 breast cancer patients, including at least five who had metastatic breast cancer and at least one patient with an ESR1 mutation.

Results: A 10-20% prevalence of ESR1 mutation was estimated by the oncologists. However, the practitioners did accept the possibility of a 40% prevalence. Physician knowledge of ESR1 mutations included the relationship between ESR1 mutations and efficacy of endocrine therapies and its association with poorer outcomes. None of the medical oncologists interviewed were highly satisfied with the existing armamentarium of treatments for patients with an ESR1 mutation.

In general, the interview participants were highly comfortable ordering ESR1 companion diagnostics to test for an ESR1 mutation, pending viable treatment options are available. Nonetheless, most physicians will wait until the patient has progression of disease before ordering a biomarker test. Several areas of unmet need in the mBC arena were offered by the survey participants, including more efficacious hormonal options for later-line therapies, better durability of remission, improved drug tolerability profiles, and lower treatment costs.

Conclusion: Most oncologists acknowledged that personalized treatment is beneficial because it allows for better efficacy than a “one size fits all” approach. The study results also suggest that there are few barriers and drawbacks to the use of personalized medicine in the mBC arena, as most physicians expect precision medicine to account for the majority of advances in breast cancer treatments in the foreseeable future.

Support: Sermonix Pharmaceuticals

Citation Format: Goldfarb SB, Goetz MP, Plourde PP, Attias E, Portman DJ. A preliminary assessment of knowledge, attitudes, and awareness surrounding ESR1 mutations and biomarker testing amongst medical oncologists [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 P5-11-11.

Abstract P6-12-12: Improvement in sexual function over time in premenopausal women with breast cancer

Background: There is evidence that many cancer survivors live with sexual dysfunction that impacts their quality of life. It is essential to identify factors that influence the development of sexual symptoms and understand their trajectory over time in order to guide potential interventions to treat sexual dysfunction. Most studies to date have been cross-sectional and longitudinal studies are needed to understand the change of sexual function over time. This study aims to investigate and describe the factors that impact sexual health and dysfunction in breast cancer patients during and after their cancer treatment.

Methods: A longitudinal prospective trial is being conducted in premenopausal women 18-50 years of age with breast cancer being treated at MSKCC. Validated questionnaires on sexual health and function were administered to patients after they were diagnosed with breast cancer, but before they initiated cancer treatment and at one-year follow-up after initiation of primary breast cancer therapy. Demographic and treatment information was also collected. The female sexual function index (FSFI) total and individual domain scores were calculated. Baseline and 12-month scores were compared using paired t-tests. Multivariable linear regression was used to assess individual variable associations with 12-month FSFI total scores controlling for baseline scores.

Results: 127 women were eligible for analysis at the time of this abstract and had a median age of 41. Eighty-nine percent of tumors were estrogen receptor positive and 24.4% were HER-2 overexpressing. Eighty-nine percent of patients received chemotherapy, 61.4% received Tamoxifen and 23% received a LHRH agonist in combination with an aromatase inhibitor. Mean FSFI total score was 20.4 at baseline and 21.2 at 12-months post diagnosis. More than half of women met FSFI criteria for sexual dysfunction (FSFI score&lt;26) at baseline (57.5%) and 12-months (55.2%). Small increases in sexual activity were seen with 27.8% of patients inactive at baseline compared to 23.2% at 12 months. Similarly, women engaging in sexual activity more than once a week increased from 9.5% to 16.8%. Desire (libido) significantly improved (p = 0.023) from baseline to 12 months. Controlling for baseline score, younger age and treatment with tamoxifen were associated with better 12-month scores (p &lt; 0.05).

Conclusions: Mean FSFI scores in our patients with breast cancer before and after treatment are consistent with scores from other studies looking at cancer patients and are lower than those of healthy women. In the peri-diagnosis period patients had worse sexual function that showed signs of small improvements 12 months after initiation of treatment, especially in the desire domain. Patients are being followed to see if sexual function continues to improve over time, to better understand the factors causing sexual dysfunction in these patients and to determine the best time to intervene in order to improve symptoms.

Citation Format: Goldfarb SB, Kamer S, Baser R, Quistorff J, Gemignani ML, Dickler M. Improvement in sexual function over time in premenopausal women with breast cancer [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 P6-12-12.

Abstract P5-11-11: A phase I safety study of topical calcitriol (BPM31543) for the prevention of chemotherapy-induced alopecia (CIA)

Background: Chemotherapy induced alopecia (CIA) may lead to significant psychosocial and quality of life issues. Currently there are no FDA approved oral or topical agents available to prevent CIA. In murine studies, topical calcitriol reduced CIA, due to arrest of cell cycle in healthy hair follicles, and reduction in the sensitivity of follicular epithelium to chemotherapy.

Methods: A prospective dose escalation study is being performed in up to 31 women with breast cancer, gynecologic cancer and sarcomas. Each patient is applying 1mL of BPM31543 to her scalp bid, ≥ 5 days prior to initiation of taxane-based chemotherapy for at least 3 months or until the completion of chemotherapy. The study cohorts are: 5/10/20/40/60/80μg/mL. The first 5 cohorts are completely enrolled and the final cohort is currently being enrolled. Each patient undergoes pk analysis, adverse event (AE) monitoring, patient self-assessment diaries (1-10 scale), and blinded photographic assessments. Efficacy and pK data are still being collected and analyzed for the patients on study, but will be available by December.

Results: Twenty-four subjects have been enrolled so far (evaluable at this time, n = 13). Pk data (n = 16; 5-40μg/mL) showed inter-individual variability, but no significant dose-dependent increase in systemic absorption (range, &lt; 20-110 pg/mL). Treatment-related AEs (probably/possibly) were mild/moderate in nature and included scalp pain (n = 1; 5 μg/mL), elevated vitamin D levels in 1 patient (20μg/mL) and passage of renal calculus in another (n = 1; 40μg/mL). All subjects reported changes in overall hair fullness, thickness, and volume of hair during chemotherapy. At the 5/10 μg/mL dose level, ≥ 75% hair loss was reported in 85% of patients. At the ≥ 20 μg/mL dose level, ≥ 75% hair loss was seen only in 43% of patients. Hair loss/ thinning caused all subjects to change their hair style (onset, week 2; peak, weeks 5-6).

Conclusions: Data have shown that the twice daily application of BPM31543 in patients receiving taxane-based chemotherapy was safe and well-tolerated. Efficacy data from the preliminary analysis was promising and led to the amendment of the study to evaluate two additional higher dose cohorts: 60 and 80 μg/ml.

Citation Format: Goldfarb SB, Konner J, Stevens J, Brouwer S, Narain NR, Ye R, Ravipaty S, Sarangarajan R, Akmaev VR, Jimenez JJ, Belum VR, 'Kitts S, Ciccolini K, Berman B, Lacouture ME. A phase I safety study of topical calcitriol (BPM31543) for the prevention of chemotherapy-induced alopecia (CIA) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-11-11.

Cold thermal injury from cold caps used for the prevention of chemotherapy-induced alopecia

INTRODUCTION

The use of scalp cooling for the prevention of chemotherapy-induced alopecia (CIA) is increasing. Cold caps are placed onto the hair-bearing areas of the scalp for varying time periods before, during, and after cytotoxic chemotherapy. Although not yet reported, improper application procedures could result in adverse events (AEs). At present, there are no evidence-based scalp cooling protocols, and there is no regulatory oversight of their use.

OBJECTIVE

To report the occurrence of cold thermal injury (frostbite) on the scalp, following the use of cold caps for the prevention of CIA.

MATERIALS AND METHODS

We identified four patients who developed cold thermal injuries on the scalp following the application of cold caps. Medical records were analyzed to retrieve the demographic and clinical characteristics.

RESULTS

The cold thermal injuries in our patients were grade 1/2 in severity and improved with topical interventions and interruption of cold cap use, although grade 1 persistent alopecia ensued in 3 patients. The true incidence of such injuries in this setting, however, remains unknown.

CONCLUSIONS

Cold thermal injuries are likely infrequent and preventable AEs that may result from improper device application procedures during cold cap use. Although these untoward events are usually mild to moderate in severity, the potential occurrence of long-term sequelae (e.g., permanent alopecia and scarring) or the need to discontinue cold cap use, are not known. Prospective studies are needed to further elucidate the risk and standardize healthcare delivery methods, and to improve patient/supportive/healthcare provider education.

Cancer and Fertility Program Improves Patient Satisfaction With Information Received

PURPOSE

A cancer and fertility program was established at a large cancer center to support clinicians in discussing treatment-related fertility risks and fertility preservation (FP) options with patients and in referring patients to reproductive specialists. The program provides resources, clinician education, and fertility clinical nurse specialist consultation. This study evaluated the program's impact on patient satisfaction with information received.

PATIENTS AND METHODS

Retrospective cross-sectional surveys assessed satisfaction before (cohort 1 [C1]) and after (cohort 2 [C2]) program initiation. Questionnaires were investigator-designed, gender-specific, and anonymous.

RESULTS

Most C1 (150 males, 271 females) and C2 (120 males, 320 females) respondents were 2 years postdiagnosis; the most frequently reported cancers were testicular, breast, and lymphoma. A significant difference in satisfaction with the amount of information received was seen between C1 and C2. For males, satisfaction with information on fertility risks was high in both cohorts but significantly greater in C2 for information on sperm banking (χ(2) = 9.3, P = .01) and finding a sperm bank (χ(2) = 13.3, P = .001). For females, satisfaction with information was significantly greater in C2 for information on fertility risks (χ(2) = 62.1, P < .001), FP options (χ(2) = 71.9, P < .001), help with decision making (χ(2) = 80.2, P < .001), and finding a reproductive endocrinologist (χ(2) = 60.5, P < .001). Among patients who received and read information materials, 96% of males and 99% of females found them helpful. Among C2 females, fertility clinical nurse specialist consultation was associated with significantly greater satisfaction with information on FP options (χ(2) = 11.2, P = .004), help with decision making (χ(2) = 10.4, P = .006), and finding a reproductive endocrinologist (χ(2) = 22.6, P < .001), with 10% reporting lack of knowledge as a reason for not pursuing FP.

CONCLUSION

Improvements in patient satisfaction with information received demonstrate the potential for fertility programs in cancer care settings to improve the quality of clinician-patient discussions about fertility.

Fertility Preservation for the Young Breast Cancer Patient

BACKGROUND

The American Society of Clinical Oncology (ASCO) guidelines include incorporation of fertility preservation guidelines in the care of breast oncology patients. This study aimed to examine the baseline knowledge and preferences concerning fertility preservation among women of childbearing age with newly diagnosed breast cancer at the time of their initial visit to Memorial Sloan Kettering Cancer Center (MSKCC).

METHODS

A questionnaire on reproductive history, fertility knowledge, and preservation options was administered to women 18-45 years of age with newly diagnosed breast cancer at MSKCC between May and September 2011.

RESULTS

The inclusion criteria were met by 60 women eligible for analysis who had a median age of 40 years (range 20-45 years). The findings showed that 50 % of the women either desired children in the future or were unsure whether they wanted children, with 9 % reporting that they received information about fertility preservation options before their MSKCC visit. Women who had never been pregnant were more likely than those with prior pregnancies to consider having children in the future (p = 0.001) and to contemplate fertility preservation options both before (p = 0.001) and after (p = 0.0002) cancer treatment.

CONCLUSION

Early referral allows patients to take advantage of fertility preservation options while preventing delay in the initiation of systemic therapy. Referral by the breast surgical oncologist at the time of the initial visit has the potential to increase fertility knowledge because it appears that many women have not yet received fertility information at this early treatment stage.

Abstract P2-16-12: An exploratory analysis of the role of dasatinib in preventing progression of disease in bone in patients with metastatic breast cancer

Introduction: The role of dasatinib, an oral SRC inhibitor is being explored for the treatment of metastatic breast cancer. In a phase I study, we previously established that the combination of dasatinib and weekly paclitaxel was feasible. The activity of this combination is currently being explored in an ongoing phase II trial. Since Src kinase has a major role in osteoclast function and dasatinib has established anabolic and anti-resorptive effects in bone in vitro, we hypothesized that patients receiving this combination would have good control of osseous metastases and primarily develop progression of disease in sites other than bone.

Patients and methods: Patients were included in this analysis if they participated in the phase I or II metastatic breast cancer studies and received dasatinib at or above the recommended phase II dose of 120mg with paclitaxel (80mg/m2 day 1 and 8 of each 21day cycle). Patients who discontinued therapy for reasons other than progression were excluded. Per protocol, patients were required to discontinue bisphosphonates or other bone modulating agents for the first 8 weeks of study due to the potential for hypocalcaemia. Thereafter, they were permitted to receive these agents at the discretion of their treating physician. Patients provided serum samples for correlative studies. Assessment of N-telopeptide of type 1 collagen (NTX), a product of mature bone collagen that reflects bone specific resorption, is planned.

Results: The median age of the 24 patients who met criteria for analysis was 50y (37 - 66y). Of these, 15 (63%) had ER+ disease, and 24 (100%) were negative for human epidermal growth factor receptor (HER2). At study entry, 17 (71%) patients had bone involvement. Following the initial eight week moratorium, 7 (29%) patients received a bisphosphonate or rank ligand inhibitor during treatment with dasatinib + paclitaxel. Patients received a median 2 months (range 1-23) of dasatinib + paclitaxel therapy. To date, 3 (13%) continue on therapy, and 21 (88%) have had progression of disease. Among patients who progressed, 18 (86%) have progressed in visceral sites and only 3 (14%) progressed in bone. Analyses of serum NTX levels are ongoing and will be compared by site of progression.

Conclusion: The potential role of serum NTX as a predictive biomarker of benefit from dasatinib and paclitaxel is being explored and updated results will be presented.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-12.

A national network to advance the field of cancer and female sexuality

INTRODUCTION

Understanding sexual health issues in cancer patients is integral to care for the continuously growing cancer survivor population.

AIM

To create a national network of active clinicians and researchers focusing on the prevention and treatment of sexual problems in women and girls with cancer.

METHODS

Interdisciplinary teams from the University of Chicago and Memorial Sloan-Kettering Cancer Center jointly developed the mission for a national conference to convene clinicians and researchers in the field of cancer and female sexuality. The invitee list was developed by both institutions and further iterated through suggestions from invitees. The conference agenda focused on three high-priority topics under the guidance of a professional facilitator. Breakout groups were led by attendees recognized by collaborators as experts in those topics. Conference costs were shared by both institutions.

MAIN OUTCOME MEASURE

Development of Scientific Working Groups (SWGs).

RESULTS

One hundred two clinicians and researchers were invited to attend the 1st National Conference on Cancer and Female Sexuality. Forty-three individuals from 20 different institutions across 14 states attended, including representation from eight National Cancer Institute (NCI)-funded cancer centers. Attendees included PhD researchers (N = 19), physicians (N = 16), and other healthcare professionals (N = 8). Breakout groups included (i) Defining key life course sexuality issues; (ii) Building a registry; and (iii) Implementing sexual health assessment. Breakout group summaries incorporated group consensus on key points and priorities. These generated six SWGs with volunteer leaders to accelerate future research and discovery: (i) Technology-based interventions; (ii) Basic science; (iii) Clinical trials; (iv) Registries; (v) Measurement; and (vi) Secondary data analysis. Most attendees volunteered for at least one SWG (N = 35), and many volunteered for two (N = 21).

CONCLUSION

This 1st National Conference demonstrated high motivation and broad participation to address research on cancer and female sexuality. Areas of need were identified, and SWGs established to help promote research in this field.

PD04-03: Sexual Dysfunction in Premenopausal Women with Breast Cancer: Prevalence and Severity

Background: Sexual dysfunction is reported after chemotherapy and endocrine therapies. However, the prevalence and severity of sexual dysfunction in premenopausal women undergoing therapy for both local and metastatic disease is not well defined. This study was performed in order to understand the impact of contemporary breast cancer treatment on the prevalence and severity of sexual health in premenopausal women.

Methods: We developed a survey that includes a previously validated questionnaire, the Female Sexual Function Index (FSFI), as well as an established measure of health-related quality of life (the EuroQol EQ-5D), and disease-specific items to characterize sexual dysfunction and its causes based on literature review and expert consultations. Anonymous administration of the surveys was conducted in outpatient clinic waiting areas of the Breast Cancer Center at Memorial Sloan-Kettering Cancer Center (MSKCC), under an IRB waiver of consent.

Results: 372 consecutively approached premenopausal women with breast cancer of any stage, undergoing treatment were each queried once. The mean age was 47. 87% reported current or past hormonal treatment, and 86% reported current or past chemotherapy (76% adjuvant; 24% for metastatic disease). Sexual dysfunction attributed to breast cancer or its treatment, defined as an FSFI score &lt;26, was reported by 75% of respondents with a mean score of 16.3. Among these women, 79% of patients considered their sexual symptoms to be bothersome, with 51% noting moderate or severe levels of bother (score &gt;=5/10). In a multivariate analysis, metastatic disease, development of amenorrhea from cancer treatment, antidepressant use and poorer overall health were each significantly associated with worse FSFI scores. Lower FSFI scores were also significantly associated with worse health-related quality of life.

Conclusion: Sexual dysfunction is prevalent in premenopausal women treated for breast cancer and should be discussed with patients as a potential adverse effect of therapy. Assessment of sexual symptoms throughout treatment and beyond may facilitate the use of potential interventions such as lubricants, dilators, treatment modification and counseling.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD04-03.

P2-08-01: Impact of Aromatase Inhibitors on Background Parenchymal Enhancement and Amount of Fibroglandular Tissue on Breast MRI

Background: On breast MRI, background parenchymal enhancement (BPE) and volume of fibroglandular tissue (FGT) have been shown to reflect a patient's hormonal status. Tamoxifen has been shown to reduce mammographic breast density and may serve as an early predictor of response in the prevention setting (Cuzick, JNCI 2011). We have shown that adjuvant tamoxifen can reduce BPE in the unaffected breast in women with breast cancer. We hypothesize that aromatase inhibitor (AI) induced endocrine changes in breast tissue should also be evident and therefore we performed a study to evaluate whether adjuvant AI therapy influences BPE or amount of FGT in the contralateral breast.

Methods: An electronic medical record review identified 856 postmenopausal women with stage I-III breast cancer who had at least two breast MRIs and took adjuvant AI treatment. A retrospective chart review was conducted to select those patients without a history of prior tamoxifen or raloxifene treatment who had a MRI of the contralateral breast both before and during 6 to 12 months of AI treatment. After exclusion of all irradiated breasts, 168 women were eligible. MRIs were performed between August 1999 and June 2010. Two radiologists who were blind to AI treatment status, independently rated level of BPE and amount of FGT using categorical scales: BPE — Minimal, Mild, Moderate, Marked; FGT — Fatty, Scattered, Heterogeneously Dense, Dense (based on proposed BIRADS criteria for BPE and on ACR criteria for FGT). Blinded side-by-side direct comparison evaluated whether there was a category change between the two MRIs. A consensus was reached in cases of disagreement. The Wilcoxon signed-rank test was used to assess changes in rating categories for BPE and FGT between before and during AI breast MRIs. A waiver of authorization was granted by the institutional review board for this study.

Results: In this study 127/168 (76%) women were treated with anastrozole, 33/168 (20%) with letrozole and 8/168 (5%) with exemestane. Based on the blinded side-by-side comparison, a category (or more) decrease in BPE occurred during treatment with AIs (p&lt;0.0001). There was an overall shift from higher to lower degree of BPE in 35% (45/127) of the women taking anastrozole while a category increase occurred in only one woman (1%; p &lt;0.0001). A similar result was seen in the women taking letrozole [45% (15/33) had a decrease versus 3% (1/33) an increase; p=0.0003] and exemestane [25% (2/8) had a decrease versus 12.5% (1/8) an increase; p=0.50]. For FGT a category decrease occurred in 5% (6/127) of anastrozole users while no increase occurred [0% (0/127), p=0.016]. The respective numbers for letrozole were 3% (1/33) and 0% (0/33), and nobody on exemestane had a change in FGT.

Conclusions: After 6 to 12 months of treatment with adjuvant AIs, there was a statistically significant category (or more) decrease in BPE. BPE is more sensitive than FGT to changes in normal breast stroma that occur during adjuvant treatment with AIs and BPE may be a marker of anti-hormonal activity in the breasts.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-01.

Bevacizumab in metastatic breast cancer: when may it be used?

Tumor angiogenesis, which is necessary for breast cancer growth, invasion and metastases, is regulated by pro-angiogenic factors such as vascular endothelial growth factor (VEGF). Bevacizumab is a recombinant humanized monoclonal antibody that targets VEGF. The addition of bevacizumab to chemotherapy has improved progression-free survival in the first- and second-line treatment of patients with advanced-stage breast cancer. In this article we review the clinical trials testing the utility of bevacizumab for the treatment of metastatic disease.

Abstract P2-14-08: Patient Perspectives on Information Communicated Regarding Effects of Treatment on Fertility

Background: Many breast cancer survivors diagnosed during their reproductive years desire to have children after treatment and are distressed about the possibility of treatment-induced infertility. Informing patients about fertility preservation options before therapy may optimize quality of life after treatment. This study was undertaken to evaluate the information patients received about effects of therapy on fertility, early menopause, and fertility preservation options. Methods:

An IRB approved cross-sectional study was performed to evaluate patient perceptions of the impact of treatment on fertility and early menopause. The survey was developed at Memorial Sloan-Kettering Cancer Center (MSKCC) for patients ages 18-45, with items derived from existing surveys in the literature and input from a multidisciplinary committee. We evaluated two groups of patients, one who had completed treatment and the other who was currently undergoing therapy. Surveys were mailed to 395 women who began treatment (all modalities) for breast cancer at MSKCC between 7/1/07 and 6/30/08. A second cohort of patients (n=35) completed surveys during patient visits to breast cancer medicine ambulatory clinics

between 3/22/2010 and 4/8/2010.

Results:

The survey was completed by 159 pts. (129/395 and 30/35). At the time of diagnosis, 69% (110/159) had children and 45% (70/156) were interested in having children. 79% (123/155) reported that the impact of treatment on fertility was discussed with them before initiating therapy. A healthcare provider initiated the discussion 54% (83/155) of the time. However, only 35% (54/152) and 47% (71/150) of women felt they received an adequate amount of information about the effect of cancer treatment on fertility and menopause, respectively. Based on their ranking, patients preferred to receive fertility information in person either from their physician or a fertility specialist, or through written material. After treatment, 5 patients attempted pregnancy (7 naturally, 1 with assisted technology), yielding 8 live births. Conclusions:

Many breast cancer survivors wish to have children after treatment. To optimize success, patients should be adequately informed about the effects of therapy on fertility, early menopause, and options for fertility preservation. These findings are informing an institution-wide fertility program.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-14-08.

Abstract P5-08-01: Oncology Clinicians’ Knowledge, Attitudes and Practices Regarding Fertility Preservation

Background:

Many breast cancer survivors of child-bearing age wish to become parents after therapy and are concerned about the possibility of treatment-induced infertility. Educating patients about the effects of therapy on fertility, early menopause, and fertility preservation options prior to treatment may optimize a survivor's quality of life after treatment. It is unclear whether oncologists feel qualified to discuss fertility issues with their patients, and if not, what barriers prevent such discussions.

Methods:

An IRB approved cross-sectional survey was developed at Memorial Sloan-Kettering Cancer Center (MSKCC) in order for clinicians to self-evaluate their knowledge, attitudes, and behaviors regarding fertility preservation. Survey items were derived from existing surveys in the literature and input from a multidisciplinary committee. The web-based survey was systematically administered to all MSKCC ambulatory clinicians. Repeated email reminders were sent to optimize responses.

Results:

76 breast cancer clinicians at MSKCC and our regional network sites completed the survey between 2/9/09 and 2/25/09. Among respondents, there was widespread agreement (97% (70/72)) that patients should be informed of fertility preservation options, but fewer respondents (51% (37/72)) consistently discussed effects of treatment on fertility with their patients. Only 47% of clinicians (35/74) reported access to information about effects of treatment on fertility. Many physicians cited lack of training in fertility preservation, time constraints, and lack of referral information as barriers to educating patients. No significant difference existed in practice or knowledge between physicians who were practicing for ≤ 5 years vs ≥ 5 years.

Conclusions:

Physicians report that lack of education, resources and insufficient time hinder fertility preservation discussions with patients. Physicians might benefit from educational efforts regarding the effects of treatment on fertility and new fertility preservation techniques in order to effectively counsel their patients. Time limitations may be overcome by developing educational resources and collaborating with other clinical staff (e.g., nurses) to provide this vital information to patients. These findings are informing an institution-wide educational fertility program.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-08-01.

Bevacizumab for advanced breast cancer

Tumor angiogenesis is an important step in breast cancer development, progression, invasion and metastasis. Pro-angiogenic factors such as VEGF regulate angiogenesis and are targets for drug development. Bevacizumab, an anti-VEGF antibody, has demonstrated significant clinical benefit in several solid tumors, including breast cancer. Its use in combination with either paclitaxel or docetaxel has prolonged progression-free survival and increased response rates in the first-line treatment of patients with metastatic breast cancer. This review article discusses the clinical trials establishing the use of bevacizumab for the treatment of advanced breast cancer.

Double minute chromosomes contain amplified c-myc oncogene sequences in acute myeloid leukemia

We describe two elderly male patients with acute myeloid leukemia transformed from myelodysplastic bone marrow. Neither patients had a history of prior exposure to mutagenic agents or other malignancies. Chromosome analysis at the time of initial diagnosis revealed 47,XY,del(5)(q14q33),+21 in patient 1 and 45,XY,add(1)(q23),-5,del(8)(p11.2p23),der(17)t(5;17)(p12;p11.2) in patient 2. In addition, numerous copies of double minute chromosomes were seen in both patients. We used fluorescence in situ hybridization to identify the amplified sequences presumed to represent the dmins in the leukemic cells. In both cases, it appeared that the dmins were derived from specific amplification of c-myc oncogene.