Culturally adapted psychosocial interventions (CaPSI) for early psychosis in a low-resource setting: study protocol for a large multi-center RCT

BACKGROUND

Psychosis treatment guidelines recommend cognitive behaviour therapy (CBT) and family intervention (FI), for all patients with first episode psychosis (FEP), though guidance borrows heavily from literature in adults from high income countries. To our knowledge, there are few randomized controlled trials (RCTs) examining the comparative effect of these commonly endorsed psychosocial interventions in individuals with early psychosis from high-income countries and no such trials from low and middle-income countries (LMICs). The present study aims to confirm the clinical-efficacy and cost-effectiveness of delivering culturally adapted CBT (CaCBT) and culturally adapted FI (CulFI) to individuals with FEP in Pakistan.

METHOD

A multi-centre, three-arm RCT of CaCBT, CulFI, and treatment as usual (TAU) for individuals with FEP (n = 390), recruited from major centres across Pakistan. Reducing overall symptoms of FEP will be the primary outcome. Additional aims will include improving patient and carer outcomes and estimating the economic impact of delivering culturally appropriate psychosocial interventions in low-resource settings. This trial will assess the clinical-efficacy and cost-effectiveness of CaCBT and CulFI compared with TAU in improving patient (positive and negative symptoms of psychosis, general psychopathology, depressive symptoms, quality of life, cognition, general functioning, and insight) and carer related outcomes (carer experience, wellbeing, illness attitudes and symptoms of depression and anxiety).

CONCLUSIONS

A successful trial may inform the rapid scale up of these interventions not only in Pakistan but other low-resource settings, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority groups with FEP.

TRIAL REGISTRATION

NCT05814913.

Kynurenine pathway of tryptophan metabolism in pathophysiology and therapy of major depressive disorder

Serotonin deficiency in major depressive disorder (MDD) has formed the basis of antidepressant drug development and was originally attributed to induction of the major tryptophan (Trp)-degrading enzyme, liver Trp 2,3-dioxygenase (TDO), by cortisol, leading to decreased Trp availability to the brain for serotonin synthesis. Subsequently, the serotonin deficiency was proposed to involve induction of the extrahepatic Trp-degrading enzyme indoleamine 2,3-dioxygenase (IDO) by proinflammatory cytokines, with inflammation being the underlying cause. Recent evidence, however, challenges this latter concept, as not all MDD patients are immune-activated and, when present, inflammation is mild and/or transient. A wide range of antidepressant drugs inhibit the activity of liver TDO and bind specifically to the enzyme, but not to IDO. IDO induction is not a major event in MDD, but, when it occurs, its metabolic consequences may be masked and overridden by upregulation of kynurenine monooxygenase (KMO), the gateway to production of modulators of immune and neuronal functions. KMO appears to be activated in MDD by certain proinflammatory cytokines and antidepressants with anti-inflammatory properties may block this activation. We demonstrate the ability of the antidepressant ketamine to dock (bind) to KMO. The pathophysiology of MDD may be underpinned by both the serotonin deficiency and glutamatergic activation mediated respectively by TDO induction and N-methyl-D-aspartate receptor activation. Inhibition of TDO and KMO should be the focus of MDD pharmacotherapy.

Effects of Anti-inflammatory Medication on Indoleamine 2,3 Dioxygenase Activity

Objective: To study the effects of anti-inflammatory medication on Indoleamine 2,3 dioxygenase activity. Research Design: This was an investigational study. Methodology: Eighteen fully grown albino rats separated into control and two treated sets, both treated sets were given indomethacin (50mg/1000g) orally. For acute treatment first treated set was sacrificed after 3.5 hrs & for chronic treatment second set was sacrificed after 3 days. However, control set animals were given an equivalent amount of vehicle. Results: Outcomes shows that serum Indoleamine 2,3 dioxygenase (IDO) enzyme activity was suppressed after acute treatment while serum IDO activity were increased after chronic treatment however no significant effect was seen on brain IDO. Conclusion: It is concluded that indomethacin has not shown any significant effect on brain IDO. But inhibits serum IDO activity.

Evaluating paediatric dermatology telephone clinics during COVID-19 from a dual clinician and patient perspective: a prospective study

BACKGROUND

The landscape of dermatology services, already rapidly evolving into an increasingly digital one, has been irretrievably altered by the COVID-19 (SARS-CoV-2) pandemic. Data are needed to assess how best to deliver virtual dermatology services in specific patient subgroups in an era of ongoing social distancing and beyond. Initial studies of teledermatology in paediatric populations suggest that many of the problems experienced in adult telemedicine are more apparent when treating children and come with additional challenges.

AIM

To evaluate the efficacy of a virtual paediatric dermatology telephone clinic in comparison to traditional face-to-face (FTF) clinics, both from the clinician and patient/parental perspective.

METHODS

We carried out a prospective service evaluation examining a single centre cohort of paediatric dermatology patients managed during the COVID-19 pandemic via a telephone clinic supported by images. The study period covered June-September 2020. Data on outcomes were collected from clinicians and a qualitative patient/parental telephone survey was undertaken separately. A five-point Likert scale was used to assess both satisfaction and levels of agreement regarding whether a telephone clinic was more convenient than an FTF clinic.

RESULTS

Of 116 patients included, 24% were new and 76% were follow-up patients, with a mixture of inflammatory dermatoses (75%) and lesions (25%). From the clinician's perspective, most consultations (91%) were successfully completed over the telephone. However, qualitative patient and parent feedback paradoxically illustrated that although nearly all (98%) respondents had no outstanding concerns, 52% felt highly unsatisfied and only 22% agreed that telephone clinics were more convenient. Most (65%) preferred FTF follow-up in the future. Statistical analysis using χ² test showed that among those with established follow-ups, the preference for future consultation type was independent of specific reasons for follow-up.

CONCLUSIONS

Our study demonstrates a clear discrepancy between the practical successes of a virtual service from the clinician's perspective compared with the patient/parental perspective. Parental anxiety appears to be less effectively allayed virtually than with FTF. This raises the question of whether there is a role for virtual paediatric telephone clinics in the postpandemic future, which may be better left to patients/parents to decide on an individual basis.

Practical consensus recommendaton for adjuvant bone-modifying agents in breast cancer

Bone-modifying therapy is a primary research interest in breast cancer. Several features contribute to the importance of the bone environment in the management of breast cancer. Firstly, bone metastases represent the most common site of breast cancer metastases and secondly, the emergence of cancer treatment-induced bone loss (CTIBL) among breast cancer survivors and patients is of increasing concern. In the adjuvant setting, bisphosphonates can be given to prevent and treat tumor therapy-induced bone loss in premenopausal and postmenopausal women and, owing to their beneficial effect on bone turnover, have also been evaluated for prevention of bone metastases occurrence. Expert oncologists discusses on the update on the approaches of Bone-modifying Agents and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Mathematical modeling for the outbreak of the coronavirus (COVID-19) under fractional nonlocal operator

A mathematical model for the spread of the COVID-19 disease based on a fractional Atangana-Baleanu operator is studied. Some fixed point theorems and generalized Gronwall inequality through the AB fractional integral are applied to obtain the existence and stability results. The fractional Adams-Bashforth is used to discuss the corresponding numerical results. A numerical simulation is presented to show the behavior of the approximate solution in terms of graphs of the spread of COVID-19 in the Chinese city of Wuhan. We simulate our table for the data of Wuhan from February 15, 2020 to April 25, 2020 for 70 days. Finally, we present a debate about the followed simulation in characterizing how the transmission dynamics of infection can take place in society.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Abstract P1-15-21: The molecular characterisation of early and advanced breast cancer in a Middle-Eastern breast cancer cohort treated with neo/adjuvant anthracycline+/-taxane-based chemotherapy

Neoadjuvant therapy for breast cancer enables improved conservative operative approaches for breast cancer with similar survival. In addition, it may be used to define clinical as well as molecular systemic therapy sensitivity, aid molecular subtyping analysis of residual disease as well as incorporating potential mechanisms of resistance. Breast cancer in women in the Middle East is characterized by younger median age, more advanced stage at presentation and a higher proportion of patients with triple-negative disease. Recently, Symmans et al. published the results of neoadjuvant anthracycline+/-taxane-based chemotherapy demonstrating a strong association between residual cancer burden (RCB) and overall survival. In this and other cohorts e.g. TCGA, ICGC molecular data of pts from the Middle-East is under-represented.

Aim:

The aim of this project was to define the above parameters in a cohort of women treated with systemic therapy from June 2016 to October 2017 in a Middle Eastern breast cancer referral centre treated in the neo/adjuvant setting. In the neoadjuvant setting we are examining the association between primary biopsy and pathological response tissue (RCB criteria) integrating molecular pathology using massive parallel sequencing (MPS) analyses.

Methodology:

We designed a custom 1000 gene panel using Illumina IDT capture-based assay design and sequenced tumour samples to greater than 500X coverage. Sequencing analysis and variant calling were performed using Broad GAKT best practice; BWA, Mutect2, Oncotator pipeline.

Results:

We present a cohort of 57 pts with median age of 45(26-66), presenting with clinical stage I 2(4%), stageII 30(53%), stage III 25(44%) breast cancer for neoadjuvant (20) or adjuvant (37) anthracycline +/- taxane-based chemotherapy. Standard immunohistochemical (IHC) analysis revealed ER-pos PR-pos HER2-neg 38(67%) ER-pos PR-neg HER2-neg 2(4%) ER-neg PR-neg HER2-pos 3(5%), ER-pos PR-pos HER2-pos 5(9%), TNBC 9(16%). In the neoadjuvant cohort (20) pts, 7 were clinical stage II and 12 stage 3 at presentation. Anthracycline+/-taxane-based chemotherapy achieved pCR/RCB 0 7(35%), RCB I 3(15%), RBC II 4(20%), RCB III 6(30%). All Her2 positive patients received concurrent taxane-trastuzumab.

Implications:

Predictive molecular expression algorithms for response to systemic chemotherapy in the neoadjuvant setting have been published (Hatzis JAMA 2011; Masuda Clin Ca Res 2013).Molecular characterisation of RCB after neoadjuvant chemotherapy has looked at DNA mutations (Jiang PLOS Med 2016) and RNA expression (Lehmann J PLOS One 2016; Echavarria Clin Ca Res 2018). Integration of both provides insight into mechanisms of sensitivity and relapse using pathway analysis. We present genomic data on 20 of the neoadjuvant samples with sufficient quality DNA analysed using a custom designed 1000 gene panel using Illumina IDT capture-based assay design to greater than 500X coverage. The most commonly aberrant genes TP53, PIK3CA, GATA3, KMT2Dwere observed, with notable differences in PAX3, BRCA2, CHD2, FGFR4. Using integrated comprehensive tumour molecular comparisons pre- and post-treatment in the neoadjuvant patients and circulating tumour DNA analyses of the whole cohort will be presented.

Citation Format: Dawood S, Korbie D, Pheasant M, Kazim H, Al Hamadi A, Lloyd C, Dent R, Mainwaring PN. The molecular characterisation of early and advanced breast cancer in a Middle-Eastern breast cancer cohort treated with neo/adjuvant anthracycline+/-taxane-based chemotherapy [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 P1-15-21.

Treatment of patients with metastatic pancreatic cancer: Experience from a tertiary Indian cancer center

BACKGROUND

The aim of this study was to look at the outcome of patients with metastatic pancreatic cancer treated at a tertiary cancer center in India.

PATIENTS AND METHODS

A total of 101 patients with locally advanced and metastatic pancreatic cancer diagnosed between May 2012 and July 2013 were identified from a prospectively maintained database at the tertiary cancer center. Overall survival (OS) was computed using the Kaplan-Meir product limit method and compared across groups using the log-rank statistics. Cox proportional hazards model, adjusted for a number of patient and tumor characteristics, was then used to determine factors prognostic for OS.

RESULTS

Median age at diagnosis was 55 years (range: 21-81 years). 57.4% (n = 58) of patients were male, 22% (n = 22) had performance status (PS) of <2 at diagnosis and 89% received first-line chemotherapy, while the rest received best supportive care. For the whole cohort, 6 month and 1-year OS was 57% (95% confidence interval [CI]: 46-66%) and 47% (95% CI: 35-57%), respectively. In a multivariable model, PS <2 and oligometastatic disease were associated with a significantly decreased risk of death.

CONCLUSION

Results from our analysis indicate that the prognostic outcome among Indian patients with metastatic pancreatic cancer is poor with survival outcomes similar to those reported in North America and Europe.

Prevalence of HIV and HIV-related diseases in the adult medical wards of a tertiary hospital in Durban, South Africa

Our objective was to determine the prevalence of HIV and the distribution of HIV-related diseases among adult, medical inpatients. Consecutive admissions were recruited and a single ELISA assay was used to determine HIV infection. Demographic and clinical details were extracted from clinical records. Of 507 patients, 54% were infected with HIV of which 84% had AIDS. HIV-infected patients were significantly younger (34.9 years) than uninfected patients (47.1 years) and had significantly higher risks for oral/oesophageal candidiasis (risk ratio [RR] 18.6), generalized lymphadenopathy (RR 7.1), unexplained fever (RR 7.0), chronic diarrhoea (RR 6.2) and pulmonary tuberculosis (RR 3.1). Pulmonary tuberculosis was present in 56% of HIV cases. Mortality was 22% for HIV cases and 9% ( P=0.016) for others. The mean length of hospital stay was the same for HIV-infected and uninfected patients. AIDS is the most common reason for admission to adult medical wards and will increasingly limit the number of beds available for non-AIDS patients.

Docking studies of antidepressants against single crystal structure of tryptophan 2, 3-dioxygenase using Molegro Virtual Docker software

Tryptophan 2, 3-dioxygenase (TDO) a heme containing enzyme found in mammalian liver is responsible for tryptophan (Trp) catabolism. Trp is an essential amino acid that is degraded in to N-formylkynurenine by the action of TDO. The protein ligand interaction plays a significant role in structural based drug designing. The current study illustrates the binding of established antidepressants (ADs) against TDO enzyme using in-silico docking studies. For this purpose, Fluoxetine, Paroxetine, Sertraline, Fluvoxamine, Seproxetine, Citalopram, Moclobamide, Hyperforin and Amoxepine were selected. In-silico docking studies were carried out using Molegro Virtual Docker (MVD) software. Docking results show that all ADs fit well in the active site of TDO moreover Hyperforin and Paroxetine exhibited high docking scores of -152.484k cal/mol and -139.706k cal/mol, respectively. It is concluded that Hyperforin and Paroxetine are possible lead molecules because of their high docking scores as compared to other ADs examined. Therefore, these two ADs stand as potent inhibitors of TDO enzyme.

Survival of women with inflammatory breast cancer: a large population-based study

BACKGROUND

Our group has previously reported that women with inflammatory breast cancer (IBC) continue to have worse outcome compared with those with non-IBC. We undertook this population-based study to see if there have been improvements in survival among women with stage III IBC, over time.

PATIENT AND METHODS

We searched the Surveillance, Epidemiology and End Results Registry to identify female patients diagnosed with stage III IBC between 1990 and 2010. Patients were divided into four groups according to year of diagnosis: 1990-1995, 1996-2000, 2001-2005, and 2006-2010. Breast cancer-specific survival (BCSS) was estimated using the Kaplan-Meier method and compared across groups using the log-rank test. Cox models were then fit to determine the association of year of diagnosis and BCSS after adjusting for patient and tumor characteristics.

RESULTS

A total of 7679 patients with IBC were identified of whom 1084 patients (14.1%) were diagnosed between 1990 and 1995, 1614 patients (21.0%) between 1996 and 2000, 2683 patients (34.9%) between 2001 and 2005, and 2298 patients (29.9%) between 2006 and 2010. The 2-year BCSS for the whole cohort was 71%. Two-year BCSS were 62%, 67%, 72%, and 76% for patients diagnosed between 1990-1995, 1996-2000, 2001-2005, and 2006-2010, respectively (P < 0.0001). In the multivariable analysis, increasing year of diagnosis (modeled as a continuous variable) was associated with decreasing risks of death from breast cancer (HR = 0.98, 95% confidence interval 0.97-0.99, P < 0.0001).

CONCLUSION

There has been a significant improvement in survival of patients diagnosed with IBC over a two-decade time span in this large population-based study. This suggests that therapeutic strategies researched and evolved in the context of non-IBC have also had a positive impact in women with IBC.

Abstract P6-06-16: Young age as a good prognostic factor in de novo metastatic breast cancer

Background

While breast cancer is relatively rare in young women under the age of 40, its incidence is increasing and accounts for up to 40% of all female cancers. Young age at diagnosis is associated with a poorer prognosis in early breast cancers; however little is known about the natural history of young women with metastatic breast cancer. We aim to evaluate the effect of age on breast-cancer specific survival (BCS) and overall survival (OS) for patients with de novo metastatic breast cancer using data from the SEER registry.

Methods

We retrospectively analyzed 14155 patients with de novo metastatic breast cancer from the SEER registry between 2000 and 2009. Young women were defined as 50 years and below and further subdivided into three groups: 20-34, 35-39, and 40-49 years. Age 50-69 years served as a comparison group. Unadjusted overall survival (OS) and breast cancer specific survival (BCS) were accessed using Kaplan-Meier plots and compared across groups using log-rank tests. Cox proportional hazards models were then fitted to determine the association between survival end point and age after adjusting for patient and tumor characteristics.

Results

546 (3.9%) patients were age 20-34 years, 750 (5.3%) were 35-39 years, 3049 (21.5%) were 40-49 years and 9810 (69.3%) patients were 50-69 years. Median BCS among patients age 20-34, 35-39, 40-49 and 50-69 years was 30, 33, 35, 28 months respectively (P&lt;0.0001). Median BCS among patients with estrogen receptor positive disease who were age 20-34, 35-39, 40-49 and 50-69 years was 43, 42, 51, 37 months respectively (P&lt;0.0001). Similarly median BCS among patients with estrogen receptor negative disease who were age 20-34, 35-39, 40-49 and 50-69 years was 21, 18, 18, 17 months respectively (P&lt;0.0001). In the multivariable model compared to patients who were age 50 -69 years those aged 20-34 years (HR 0.88, 95% CI 0.78-0.99), 35-39 years (HR 0.82, 95% CI 0.74-0.91) and 40-49 years (HR 0.84, 95% CI 0.79-0.89) had a significantly decreased risk of death from breast cancer. Similar results were obtained for OS.

Conclusion

Younger patients defined by age less than 50 years had a better BCS and OS when compared against older age group in the setting of de novo metastatic breast cancer. This may be explained by lack of important comorbidities, relatively good performance status as well as ability to tolerate more lines of chemotherapies.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-16.

Abstract P6-12-01: Survival of women with inflammatory breast cancer: A large population based study

Background

The introduction of efficacious polychemotherapy regimens and targeted biologicals has contributed to significant improvements in survival of women with breast cancer. However, our group has previously reported that women with inflammatory breast cancer (IBC) continue to have worse outcome compared to those with non-inflammatory breast cancer. We undertook this population based study to see if there have been improvements in survival among women with stage III IBC, over time.

Methods

We searched the Surveillance, Epidemiology and End Results Registry to identify female patients diagnosed with stage III IBC between 1990 and 2010. Follow up cut off was December 31st 2010. Patients were defined as having IBC according to the AJCC 6th edition criteria. Patients were divided into 4 groups according to year of diagnosis: 1990-1995, 1996-2000, 2001-2005 and 2006-2010. Breast cancer specific survival (BCSS) was estimated using the Kaplan-Meier method and compared across groups using the log rank statistic. Cox models were then fitted to determine the association of year of diagnosis and BCSS after adjusting for patient and tumor characteristics.

Results

7,679 patients with IBC were identified of whom 1,084 patients (14.1%) were diagnosed between 1990-1995, 1,614 patients (21.0%) between 1996 -2000, 2,683 patients (34.9%) between 2001-2005 and 2,298 patients (29.9%) between 2006-2010. Median follow-up was 30 months. The 2-year BCSS for the whole cohort was 71%. 2-year BCSS were 62%, 67%, 72%, and 76% for patients diagnosed between 1990-1995, 1996-2000, 2001-2005 and 2006-2010 respectively (p&lt;0.0001). The absolute increase in 2-year BCSS over the immediately preceding time period were 5%, 5%, and 4%, respectively. Significant improvements in survival over time were also observed among patients younger and older than age 35 years. In a multivariable cox regression analysis increasing year of diagnosis (modeled as a continuous variable) was associated with decreasing risk of death from breast cancer (HR = 0.98, 95% CI: 0.97 – 0.99, P &lt; 0.0001).

Conclusion

There has been a significant improvement in survival of patients diagnosed with IBC over a two decade time span in this large population based study. This suggests that therapeutic strategies researched and evolved in the context of non inflammatory breast cancer have also had a positive impact in women with IBC.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-12-01.

Gene regulation of pteridine reductase 1 in leishmania promastigotes and amastigotes using a full-length antisense construct

BACKGROUND

Pteridine metabolic pathway is unusual features of Leishmania, which is necessary for the growth of parasite. Leishmania has evolved a complex and versatile pteridine salvage network which has the ability of scavenging a wide area of the conjugated and unconjugated pteridines especially folate and biopterin. In this study, we focus on the inhibition of ptr1 gene expression.

METHODS

L. major ptr1 gene was cloned into pcDNA3 and digested using KpnI and BamHI. The gene was subcloned so that antisense will transcribe and called pcDNA-rPTR. Leishmania major was cultured and late logarithmic-phase promastigotes were harvested. The promastigotes were divided into two groups. One group was transfected with 50 µg of pcDNA-rPTR, whereas the other group was transfected with pcDNA3. Transfected cells were cultured and plated onto semi-solid media. Mouse pritonean macrophages were transfected using pcDNA-rPTR-tansfected promastigotes. Western blotting was performed on mouse transfected pritonean macrophages and extracts from transfected promastigotes of L. major using a L. major ptr1 antibody raised in rabbits.

RESULTS

The PTR1 protein was not expressed in pcDNA-rPTR- tansfected promastigotes and mouse macrophage transfected with pcDNA-rPTR- tansfected promastigotes.

CONCLUSION

This approach might be used to study the pteridine salvage pathway in Leishmania or to assess the possibility of using gene expression inhibition in the treatment of leishmaniasis.

Abstract P6-07-25: Annexin expression and survival outcomes in women with breast cancer

Background: The annexin superfamily of proteins has been implicated in several cellular processes. In particular, annexin A1 is known to have anti-inflammatory, anti-proliferative and pro-apoptotic functions. The expression and precise role of annexin A1 in breast cancer have been conflicting. The goal of this retrospective study was to explore the association of annexin A1 expression and survival outcome among women with breast cancer.

Methods: 426 women with breast cancer whose tumor samples and associated data was available were identified. Annexin A1 expression was measured using RPPA and was considered as a categorical and continuous variable. Range of annexin A1 levels for the cohort was −1.90 to 2.36. Patients were divided into four groups according to the annexin A1 level: a) negative (annexin A1 &lt;-0.84), b) low (annexin A1 &gt; = −0.84 and &lt;0.23), c) medium (annexin A1 &gt;=0.23 and &lt; 1.29) and d) high (annexin A1 &gt;=1.29). Recurrence free survival (RFS) was estimated using the Kaplan-Meier product limit methods and compared across groups using log rank statistic. Cox proportional hazards models were used to determine the association of survival outcomes and annexin expression (continuous variable) adjusted by patient and tumor characteristics.

Results: Median age at diagnosis was 62 years. 41 (9.6%), 245 (57.5%), 25 (5.9) and 115 (27.0%) patients had Her2 positive, hormone receptor (HR) positive, metaplastic and triple negative (TNBC) disease respectively. For the whole cohort 44 (10%), 235 (55.2%), 119 (27.9%), 28 (6.6%) breast tumors were classified as having negative, low, medium and high annexin expression respectively. High annexin A1 levels were associated with hormone receptor positive disease, increased age, post-menopausal status, low grade and lower disease stage. Median annexin A1 level was −0.19, 0.0, −0.34, −0.2 among tumors that were HER2 positive, HR positive, metaplastic and TNBC disease respectively. 5-yearRFS was 65.8% and 84.9% respectively among women with negative/low and medium/high annexin A1 levels respectively (p &lt; 0.0001). Among women with Her2 positive, HR positive, metaplastic or TNBC disease 5-year RFS was significantly higher among tumors with medium/high annexin A1 levels. In the multivariable model an increase in annexin was associated with a 13% reduction in the risk of recurrence (HR = 0.87, 95% CI 0.60–1.26, p = 0.46).

Conclusion: In this large dataset with long follow up our results indicate that high annexin A1 expression among women with breast cancer was associated with favorable patient and tumor characteristics and an improved RFS. Annexin A1 should be explored further as a potential prognostic biomarker.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-07-25.

Adverse events risk associated with bevacizumab addition to breast cancer chemotherapy: a meta-analysis

BACKGROUND

Bevacizumab is a monoclonal antibody against vascular endothelial growth factor with the ability to increase progression-free survival in metastatic breast cancer (MBC). A systematic review and meta-analysis was conducted to determine the risk of the most clinically relevant adverse outcomes associated with the use of bevacizumab in the treatment of breast cancer.

PATIENTS AND METHODS

We included phase III clinical trials that used bevacizumab alone or in combination with chemotherapy as for MBC or locally recurrent. Statistical analyses were conducted to calculate summary odds ratio (OR) of the eight most relevant adverse outcomes related with bevacizumab.

RESULTS

Five clinical trials were included in the meta-analysis. Summary odds ratios obtained showed a statistically significant bevacizumab-associated increased risk in four of the adverse outcomes studied: proteinuria (OR = 27.68), hypertension (OR = 12.76), left ventricular dysfunction (LVD) (OR = 2.25), and hemorrhagic events (OR = 4.07). No statistically significant differences were found for gastrointestinal (GI) perforation, vascular events, fatal events, or febrile neutropenia.

CONCLUSIONS

Bevacizumab did increase the risk of LVD and hemorrhagic events. The addition of bevacizumab to chemotherapy in patients with metastatic breast cancer was not associated with a significant increase in grade ≥ 3 arterial or venous thromboembolic events, GI perforation, or fatal events.

Mechanisms and management of doxorubicin cardiotoxicity

Doxorubicin is an effective anti-tumor agent with a cumulative dose-dependent cardiotoxicity. In addition to its principal toxic mechanisms involving iron and redox reactions, recent studies have described new mechanisms of doxorubicin-induced cell death, including abnormal protein processing, hyper-activated innate immune responses, inhibition of neuregulin-1 (NRG1)/ErbB(HER) signalling, impaired progenitor cell renewal/cardiac repair, and decreased vasculogenesis. Although multiple mechanisms involved in doxorubicin cardiotoxicity have been studied, there is presently no clinically proven treatment established for doxorubicin cardiomyopathy. Iron chelator dexrazoxane, angiotensin converting enzyme (ACE) inhibitors, and β-blockade have been proposed as potential preventive strategies for doxorubicin cardiotoxicity. Novel approaches such as anti-miR-146 or recombinant NRG1 to increase cardiomyocyte resistance to toxicity may be of interest in the future.

Identifying factors that impact survival among women with inflammatory breast cancer

BACKGROUND

The objective of this retrospective study was to determine factors impacting survival among women with inflammatory breast cancer (IBC).

METHODS

The Surveillance, Epidemiology and End Results Registry (SEER) was searched to identify women with stage III/IV IBC diagnosed between 2004 and 2007. IBC was identified within SEER as T4d disease as defined by the sixth edition of the American Joint Committee on Cancer. The Kaplan-Meier product-limit method was used to describe inflammatory breast cancer-specific survival (IBCS). Cox models were fitted to assess the multivariable relationship of various patient and tumor characteristics and IBCS.

RESULTS

Two thousand three hundred and eighty-four women with stage IIIB/C and IV IBC were identified. Two-year IBCS among women with stage IIIB, IIIC and IV disease was 81%, 67% and 42%, respectively (P < 0.0001). In the multivariable model, patients with stage IIIB disease and those with stage IIIC disease had a 63% [hazard ratio (HR) 0.373, 95% confidence interval (CI) 0.296-0.470, P < 0.001] and 31% (HR 0.691, 95% CI 0.512-0.933, P = 0.016) decreased risk of death from IBC, respectively, compared with women with stage IV disease. Other factors significantly associated with decreased risk of death from IBC included low-grade tumors, being of white/other race, undergoing surgery, receiving radiation therapy and hormone receptor-positive disease. Among women with stage IV disease, those who underwent surgery of their primary had a 51% decreased risk of death compared with those who did not undergo surgery (HR = 0.489, 95% CI 0.339-0.704, P < 0.0001).

CONCLUSIONS

Although IBC is an aggressive subtype of locally advanced breast cancer, it is heterogeneous with various factors affecting survival. Furthermore, our results indicate that a subgroup of women with stage IV IBC may benefit from aggressive combined modality management.

Abstract P1-17-01: Differences in Survival among Women with Stage III Inflammatory and Non-Inflammatory Locally Advanced Breast Cancer Appear Early: A Large Population Based Study

Background

Significant improvements in the survival of women with breast cancer have been observed and are attributed to a multidisciplinary approach and the introduction of polychemotherapy regimens. The objective of this population based study was to determine if differences, if any, in survival exist among women with inflammatory (IBC) and non-IBC locally advanced breast cancer (LABC) diagnosed in this era.

Methods

The Surveillance, Epidemiology and End Results Registry was searched to identify women with stage IIIB and C breast cancer who were diagnosed between 2004 and 2007 who had undergone surgery and radiation therapy. Patients were categorized as either having IBC or non-IBC LABC according the AJCC 6th edition criteria. Breast cancer specific survival (BCS) was estimated using the Kaplan-Meier product limit method and compared across groups using the log rank statistic. Cox models were then fitted to compare the association between breast cancer type and BCS after adjusting for patient and tumor characteristics.

Results

Eight hundred and twenty eight (19.2%) women and 3476 (80.8%) women had stage IIIB/C IBC and non-IBC LABC respectively. Median follow up was 19 months. 2-year BCS was 90% (95% CI 88-91%) for the whole cohort and 84% (95% CI 80%-87%) and 91% (95% CI 90%-91%) among women with IBC and non-IBC LABC respectively. In the multivariable model compared to women with non-IBC LABC women with IBC had a 43% increased risk of death from breast cancer that was statistically significant (HR=1.43, 95% CI 1.10-1.86, p=0.008). Conclusion

In the era of multidisciplinary management and anthracycline and taxane based polychemotherapy regimens women with IBC continue to have inferior survival outcomes compared to women with non-IBC LABC with differences in survival appearing early.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-17-01.

International expert panel on inflammatory breast cancer: consensus statement for standardized diagnosis and treatment

BACKGROUND

Inflammatory breast cancer (IBC) represents the most aggressive presentation of breast cancer. Women diagnosed with IBC typically have a poorer prognosis compared with those diagnosed with non-IBC tumors. Recommendations and guidelines published to date on the diagnosis, management, and follow-up of women with breast cancer have focused primarily on non-IBC tumors. Establishing a minimum standard for clinical diagnosis and treatment of IBC is needed.

METHODS

Recognizing IBC to be a distinct entity, a group of international experts met in December 2008 at the First International Conference on Inflammatory Breast Cancer to develop guidelines for the management of IBC.

RESULTS

The panel of leading IBC experts formed a consensus on the minimum requirements to accurately diagnose IBC, supported by pathological confirmation. In addition, the panel emphasized a multimodality approach of systemic chemotherapy, surgery, and radiation therapy.

CONCLUSIONS

The goal of these guidelines, based on an expert consensus after careful review of published data, is to help the clinical diagnosis of this rare disease and to standardize management of IBC among treating physicians in both the academic and community settings.

Incidence of and survival following brain metastases among women with inflammatory breast cancer

BACKGROUND

The purpose of this study was to determine the incidence of and survival following brain metastases among women with inflammatory breast cancer (IBC).

PATIENTS AND METHODS

Two hundred and three women with newly diagnosed stage III/IV IBC diagnosed from 2003 to 2008, with known Human epidermal growth factor receptor 2 (HER2) and hormone receptor status, were identified. Cumulative incidence of brain metastases was computed. Survival estimates were computed using the Kaplan-Meier product limit method. Multivariable Cox proportional hazards models were fitted to explore the relationship between breast tumor subtype and time to brain metastases.

RESULTS

Median follow-up was 20 months. Thirty-two (15.8%) patients developed brain metastases with a cumulative incidence at 1 and 2 years of 2.7% and 18.7%, respectively. Eleven (5.3%) patients developed brain metastases as the first site of recurrence with cumulative incidence at 1 and 2 years of 1.6% and 5.7%, respectively. Compared with women with triple receptor-negative IBC, those with hormone receptor-positive/HER2-negative disease [hazard ratio (HR) = 0.55, 95% confidence interval (CI) 0.19-1.51, P = 0.24] had a decreased risk of developing brain metastases, and those with HER2-positive disease (HR = 1.02, 95% CI 0.43-2.40, P = 0.97) had an increased risk of developing brain metastases, although these associations were not statistically significant. Median survival following a diagnosis of brain metastases was 6 months.

CONCLUSION

Women with newly diagnosed IBC have a high early incidence of brain metastases associated with poor survival and may be an ideal cohort to target for site-specific screening.

Survival differences among women with de novo stage IV and relapsed breast cancer

BACKGROUND

The objective of this retrospective study was to determine whether differences in survival exist between women with de novo stage IV and relapsed breast cancer.

PATIENTS AND METHODS

Three thousand five hundred and twenty-four women with de novo stage IV or relapsed breast cancer diagnosed from 1992 to 2007 were identified. Disease-free interval (DFI) was defined as the time from the diagnosis of primary nonmetastatic breast cancer to the date of the first distant metastases. Kaplan-Meier product limit method was used to estimate overall survival (OS). Cox proportional hazards model was fitted to determine the association between metastatic disease (relapsed versus de novo) and OS after controlling for other patient/tumor characteristics.

RESULTS

Six hundred and forty-three (18.2%) women had de novo stage IV disease and 2881 (81.8%) had relapsed disease. Median follow-up was 19 months. Median OS among patients with de novo stage IV and relapsed disease was 39.2 and 27.2 months, respectively (P < 0.0001). In the multivariable model, women with relapsed disease had an increased risk of death compared with patients with de novo disease (HR = 1.75, 95% confidence interval 1.47-2.08, P < 0.0001). When the multivariable model was stratified by DFI, women with relapsed disease with DFI <6 months, ≥6 months to <2 years, or ≥2 to <5 years each had a significantly higher risk of death compared with women with de novo stage IV disease. The risk of death was not statistically different among patients with relapsed disease with DFI >5 years compared with those with de novo disease.

CONCLUSIONS

This large cohort study provides further insight into the natural history of relapsed and de novo stage IV breast cancer. DFI plays an important role in the prognosis for patients with relapsed breast cancer.

Predictive Value of Circulating Tumor Cells (CTCs) in Metastatic Breast Cancer Patients Treated by Bevacizumab-Based Therapy

Background:Circulating tumor cells (CTC) are involved in cancer dissemination and are an independent prognostic factor in metastatic breast cancer (MBC). Antiangiogenic, bevacizumab-based chemotherapy improves response rate and progression free survival in patients with metastatic breast cancer (MBC), without impact on overall survival. Preclinical data suggest the possibility of increased metastatic potential of tumor cells pretreated by anti-angiogenic therapy (Ebos et al. Cancer Cell 2009,15: 232–9). The aim of this study was to determine the prognostic value of CTC in MBC patients treated by bevacizumab-based therapy.Patients and Methods: This retrospective study included 48 MBC treated with bevacizumab combined chemotherapy regimens and 46 patients treated with chemotherapy alone between January 2004 and December 2008 at M.D.Anderson Cancer Center. CTCs were detected and enumerated before patients started therapy using the CellSearch™ system (Veridex, LLC, NJ, USA). Progression free survival (PFS) and overall survival (OS) were calculated from the date of CTC measurement, estimated by the Kaplan-Meier product limit method, and compared between groups with the log-rank test.Results: At a median follow up of 10.1 months (range: 1-26 months), 22 patients (45.8%) had died. The estimated medians of PFS in bevacizumab-treated patients were 8.1 vs. 5.2 months (p = 0.42) in patients with baseline &lt; 5 CTCs vs. ≥ 5 CTCs. Moreover, the OS for the two subgroups were 18.3 vs. 12.4 months (p = 0.41), respectively. Twenty-three patients had CTC measurements at the time of progression. Median CTC counts at baseline and at time of disease progression were 6 (range: 0-230) and 7 (range: 0-359) respectively in the bevacizumab-treated group. The median CTC counts in the control group at same time points were 7 (range: 0-724) and 2 (range:0-999), respectively. Thirteen (56.5%) and 12 (52.2%) patients had CTC ≥ 5 at baseline and at time of disease progression in bevacizumab-treated group compared to CTC counts of 24 (52.2%) and 17 (37%) in control group treated with chemotherapy without bevacizumab. Post progression overall survival in patients with CTC &lt; 5 and CTC ≥ 5 measured at time of disease progression were 11.0 and 10.4 months (p = 0.36), in the bevacizumab treated group vs. 27 and 12.4 months (p = 0.04), in the control group respectively.Conclusion: Our data support the prognostic value of CTC measured before therapy in MBC. The detection of higher CTC counts at time of disease progression and the limited prognostic value of CTC after failure of bevacizumab-based chemotherapy although intriguing, warrants further prospective investigations. Moreover, a comparison between the differential effects of monoclonal antibodies and tyrosine kinases inhibitors on CTCs detection and monitoring will better clarify the role of specific targeted therapies on micrometastatic disease.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3013.

Characterization of Metastatic Breast Cancer Patients with Non-Detectable Circulating Tumor Cells

Background: Circulating tumor cells (CTC) are independent predictor of progression free and overall survival in metastatic breast cancer patients, with superior prognosis for patients with CTC &lt;5 per 7.5mL of peripheral blood. However, 30-50% of patients have non-detectable CTC. The aim of this study was to assess the prognostic factors in MBC patients with non-detectable CTC.Methods: This retrospective study included 271 MBC patients evaluated between January 2004 and December 2007. Median age of patients was 56 years (range: 23-82 years). CTCs were enumerated before patients started a new line of treatment using the CellSearchTM. Overall survival (OS) was calculated from the date of CTC measurement, estimated by the Kaplan-Meier product limit method, and compared between groups with the log-rank test.Results: Median CTC count was 2 (range: 0-1780) per 7.5 mL. CTCs were not detected in 99 (36.5%) patients, while 112 (41.3%) patients had CTC ≥ 5. Median OS for patients with 0 CTC; 1-4 CTC and ≥ 5 CTC was 29.3; 26.4; and 19.4 months (p = 0.04), respectively. Patients with brain metastasis have the highest probability of non-detectable CTC (71.4% vs. 33.6%; p = 0.001), while patients with bone metastasis are more likely to have CTC ≥ 1 (48.2% vs. 31.8%; p = 0.01). There was no association between other tumor characteristics (ER, PR, HER2, number and localization of tumor metastasis) and non-detectable CTC status. Patients with CTC = 0 have non-significantly better OS compared to patients with CTC ≥ 1 (29.3 vs. 23.3 months; p = 0.09) and have superior survival in all but one analyzed subgroups; only inflammatory breast cancer (IBC) patients with CTC = 0 have inferior OS compared with patients with CTC ≥ 1 (26 vs. 37 months; p = 0.67). In a subgroup of patients with non-detectable CTC, triple negative MBC has the poorest survival (median OS = 18.8 months), while hormone receptor positive MBC, without visceral metastases and non-inflammatory breast cancer has the best survival (median OS = 36.9 months). In multivariate analysis, hormone receptor status and line of therapy were only independent prognostic factors for OS in patients with non-detectable CTC (Table 1).Conclusion: Patients with non-detectable CTC before start of new line of therapy comprise a heterogeneous group of patients with substantially different prognosis. Triple negative and IBC patients represent poor prognosis subgroups. These data suggest heterogeneity of microscopic disease in advanced cancer and indicate the need to investigate combining additional detection technologies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3006.

Brain Metastases in Women with Inflammatory Breast Cancer (IBC): Incidence, Treatment and Outcome

Background: Brain metastases are an uncommon metastatic recurrence site in breast cancer with a median incidence of approximately 6% in unselected populations. Inflammatory breast cancer (IBC) is an aggressive disease associated with dismal outcome. The purpose of this study was to determine the incidence of and survival following brain metastases among women with IBC.Material and Methods: Two hundred and six women with newly diagnosed stage III or IV IBC diagnosed between the period of between 2003 and 2008 were identified in a prospectively maintained IBC database at the MD Anderson Cancer Center. Cumulative incidence of brain metastases was computed. Cox proportional hazards models were fitted to explore factors that predict for the development of brain metastases. Survival was computed using the Kaplan-Meier product limit method.Results: Median follow-up was 20 months. Eighty three (40.3%) women had de-novo stage IV disease and 123 (59.7%) had stage III disease at diagnosis. Thirty-three (16%) patients developed brain metastases with a cumulative incidence at 1 and 3 years of 2.7% and 22% respectively. Eleven (5.3%) patients developed brain metastases as the first site of recurrence with cumulative incidence at 1 and 3 years of 1.6% and 6.7% respectively. In the multivariable model, no specific factor was observed to be significantly associated with time to brain metastases, including HER-2 status. Median overall survival for the whole cohort was not reached. 3-year overall survival for the whole cohort was 78% (95% CI 69%-86%). Median survival following a diagnosis of brain metastases for all women who developed brain metastases or those who developed brain metastases as the first site of recurrence was 6 months.Conclusion: In this single-institutional study, women with IBC demonstrated a high early incidence of brain metastases associated with poor survival. As such IBC may be an ideal cohort to target screening procedures for brain metastases and/or enrollment of these women in clinical trials evaluating additional adjuvant preventive strategies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2102.

Circulating tumour cells are associated with increased risk of venous thromboembolism in metastatic breast cancer patients

BACKGROUND

Cancer is a risk factor for venous thromboembolism (VTE). Circulating tumour cells (CTCs) are an independent predictor of survival in metastatic breast cancer (MBC) patients. The aim of this study was to test the hypothesis that CTCs are associated with the risk of VTE in MBC patients.

METHODS

This retrospective study included 290 MBC patients treated in the MD Anderson Cancer Center from January 2004 to December 2007. Circulating tumour cells were detected and enumerated using the CellSearch system before starting new lines of therapy.

RESULTS

At a median follow-up of 12.5 months, 25 patients experienced VTE and 53 patients died without experiencing thrombosis. Cumulative incidence of thrombosis at 12 months was 8.5% (95% confidence interval (CI)=5.5%, 12.4%). Patients with CTCs > or = 1 and > or = 5 had a higher incidence of VTE compared with patients with 0 and <5 CTCs (12-month estimate, 11.7 and 11.6% vs 3 and 6.6%; P=0.006 and P=0.076, respectively). In the multivariate model, patients with CTCs > or = 1 had a hazard ratio of VTE of 5.29 (95% CI=1.58, 17.7, P=0.007) compared with patients with no CTCs.

CONCLUSION

These results suggest that CTCs in MBC patients are associated with increased risk of VTE. These patients should be followed up more closely for the risk of VTE.

Circulating tumor cells and risk of venous thromboembolism in metastatic breast cancer patients

1060

Background: Cancer is well-recognized risk factor for venous thromboembolism (VTE), and VTE is associated with a higher risk of death in cancer patients. Coagulation activation by tissue factor (TF) is associated with cancer growth and disease progression. Circulating tumor cells (CTCs) are an independent predictor of survival in metastatic breast cancer (MBC) patients. The aim of this study was to test the hypothesis that CTCs are associated with the risk of VTE in MBC patients. Methods: This retrospective study included 362 MBC patients treated in M. D. Anderson Cancer Center between January 2004 and December 2007. CTCs were detected and enumerated using the CellSearch system. Patients were assigned to cohorts based on the highest CTC counts during the course of the disease. All venous thrombosis and/or pulmonary embolism in the presence of unequivocal medical documentation were classified as events. Results: At a median follow up of 11.1 months (range 0–38 months) 30 patients (8.3%) experienced VTE. Median survival was 16.3 months vs. 37.2 months (p = 0.003) in patients with and without VTE, respectively. Patients with ≥ 3 CTCs had an elevated risk of VTE in comparison to patients with < 3 CTCs (12.1% vs 3.7%; p = 0.003). In multivariate analysis, the presence of visceral metastasis, increased number of metastatic sites and ≥ 3 CTCs were associated with the risk of VTE. Conclusions: This retrospective study showed that CTCs are associated with increased risk of VTE in MBC. Prospective assessment of coagulation status and its correlation to CTC counts and clinical outcome are warranted.

No significant financial relationships to disclose.

Value of adjuvant radiation therapy in breast cancer patients with one to three positive lymph nodes undergoing a modified radical mastectomy and systemic therapy

507

Background: Whether adjuvant radiation therapy should be utilized for patients (pts) with early stage breast cancer with up to 3 positive axillary lymph nodes treated with mastectomy and systemic therapy is controversial. This retrospective study was performed to determine if adjuvant radiation therapy had an impact on survival for this cohort of pts. Methods: 4240 pts with T1–2N0–1 breast cancers, diagnosed between 1980–2007, who underwent either mastectomy without adjuvant radiation therapy or segmental mastectomy with adjuvant radiation therapy were identified. All pts received systemic treatment. Women with >3 positive axillary lymph nodes were excluded. Overall (OS) and distant disease free survival (DDFS) were estimated using the Kaplan-Meir product method. Cox proportional hazards were used to determine associations between OS/DDFS and type of surgery after controlling for pt and disease characteristics. Results: 1336 (18.8%) had T1N0 disease, 1114 (26.27%) had T2N0 disease, 989 (23.33%) had T1N1 disease and 801 (18.89%) had T2N1 disease. Median follow-up was 54 months.5- year DDFS among women who underwent mastectomy and segmental mastectomy was 81% (95% 78%-83%) and 86% (95% CI 84%-87%), respectively (p < 0.0001). In the Cox analysis, pts who had mastectomy without radiation had a significantly increased risk of distant recurrence (HR= 1.39, 95% CI 1.14–1.70, p= 0.0013) than pts treated with segmental mastectomy and radiation. When looking at subgroups, no significant difference in DDFS was observed between the two groups in pts with lymph node negative disease. However, for pts with 1–3 positive lymph nodes, pts treated with mastectomy without radiation had significantly increased risk of distant recurrence compared to pts treated with segmental mastectomy with radiation (HR=1.614, 95% CI 1.198–2.177, p= 0.002). This difference was most pronounce in the subset of patients with T2N1 disease (HR= 1.794, 95% CI 1.220–2.637, p=0.003). Similar trends were observed for OS. Conclusions: This study provides provocative evidence for benefit of radiation therapy among pts with 1–3 positive axillary lymph nodes who are treated with surgery and systemic therapy.

No significant financial relationships to disclose.

Defining breast cancer prognosis based on molecular phenotypes: results from a large cohort study

Abstract #1068

Aim&#x2028; Identification at the molecular level of breast cancers sub-types associated with different clinical outcomes would be of great value to help individualize therapeutic strategies and, in turn, improve survival. With large sample size, long follow-up, and geographical spread of the population any results derived from analysis of the Nurses' Health Study (NHS) data set may be more generalizable to the U.S population. Thus the purpose of this study was to define the survival outcomes associated with distinct molecular phenotypes of invasive breast cancer in women identified from the NHS.&#x2028; Methods&#x2028; 2013 women enrolled in the NHS (1976-1996) with invasive non-metastatic breast cancer whose breast tumor samples were available for inclusion in tissue microarrays and subsequent immunohistochemical (IHC) analysis form the study population. Tumors were classified into one of 5 categories based on results of IHC assays for estrogen receptor (ER), progesterone receptor (PR), HER2, cytokeratin (CK) 5/6, and epidermal growth factor receptor (EGFR) as follows: 1) Luminal-A (ER and/or PR +ve and HER2 -ve), 2) Luminal-B (ER and/or PR +ve and HER2 +ve), 3) HER2 subtype (HER2 +ve with both ER and PR -ve), 4) Basal-like (-ve for ER, PR and HER2 and +ve for either CK5/6 and/or EGFR), 5) unclassifiable (-ve for all markers). Overall survival (OS), breast-cancer-specific survival (BCS) and recurrence-free survival (RFS) were estimated using the Kaplan-Meir product limit method and compared across groups using the log rank statistic. Cox-proportional hazards models were fitted to determine the association of molecular phenotype with survival outcomes after adjusting for age at diagnosis, stage, lymph nodes, tumor size, grade and body mass index at diagnosis.&#x2028; Results&#x2028; Median age at diagnosis was 57 years (34 – 75 years) with a median follow-up of 14 years. 1490 (74%) tumors were classified as luminal-A, 99 (4.9%) were classified as luminal-B, 106 (5.27%) were of HER2 subtype, 219 (10.9%) were classified as basal-like and 99 (4.9%) tumors were unclassifiable.726 (36%) patients had died of any cause, 433 (21.5%) had died of a breast cancer related event, and 459 (22.8%) experienced a recurrence. Five-year BCS for patients with luminal-A, luminal-B, HER2 , basal-like and unclassifiable tumors was 94%, 82%, 73%, 82% and 75% respectively (p&lt;0.001). In the fully adjusted multivariable model compared to patients with luminal-A tumors patients with luminal-B (HR 1.73, 95% 1.18-2.53), HER2 (HR 1.39, 95% CI 0.97-1.20), basal-like (HR 1.50, 95% 1.32-1.20) and unclassifiable (HR 1.89, 95% CI 1.30-2.74) tumors had lower BCS. Similar trends were observed for OS and RFS.&#x2028; Conclusions&#x2028; Compared to women who have luminal-A tumors those with luminal-B, HER2 subtype, basal-like and unclassifiable tumors had a worse prognosis. A fifth, unclassifiable sub-group was identified that has survival outcomes similar to and may represent a subtype of basal-like tumors.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1068.

Survival differences among women with newly diagnosed stage IV and recurrent breast cancer

Abstract #2077

Background &#x2028; The objective of this retrospective study was to determine whether differences in survival exist between women with newly diagnosed stage IV disease and those with recurrent breast cancer.&#x2028; Methods&#x2028; Women with newly diagnosed stage IV disease or recurrent breast cancer with distant metastases diagnosed between 1992 and 2007 were identified from the Breast Cancer Management System Database at UTMDACC. Among women with recurrent breast cancer, distant disease-free interval (DDFI) was defined as the time from diagnosis of primary breast cancer to the date of the first distant metastases. For all patients, overall survival (OS) was measured from the date of first distant metastases to the date of death from any cause or last follow-up. The Kaplan-Meier product limit method was used to estimate OS, and OS was compared across groups using log-rank statistic. Cox-proportional hazards models were fit to determine the association between stage IV breast cancer (recurrent versus newly diagnosed) and OS after controlling for other patient and tumor characteristics.&#x2028; Results&#x2028; The analysis included 3524 patients of whom 643 (18.2%) had newly diagnosed disease and 2881 (81.8%) had recurrent disease. Median follow-up was 19 months. Median OS among patients with newly diagnosed stage IV disease and recurrent disease was 39.2 and 27.2 months, respectively (p&lt;0.0001). Patients with recurrent disease with DDFI &lt; 5 years had worse OS compared to those with newly diagnosed disease (p&lt;0.0001). Patients with DDFS &gt;5years had better OS compared to those with newly diagnosed stage IV disease (p&lt;0.005). In the multivariable model patients with recurrent disease had an increased risk of death compared to patients with newly diagnosed stage IV disease (HR=1.75, 95% CI 1.47-2.08, p&lt;0.0001). When the multivariable model was stratified by DDFI, patients with recurrent disease with DDFI &lt;5 years had 1.74 times the risk of death compare to those with newly diagnosed stage IV disease (95% CI 1.44-2.10, p&lt;0.0001). The risk of death was not statistically different among patients with recurrent disease with DDFI &gt;5 years compared to those with newly diagnosed stage IV disease (HR=1.11, 95% CI 0.88-1.41, p=0.38).&#x2028; ConclusionThis large cohort study provides further insight into the natural history of recurrent and newly diagnosed stage IV breast cancer. Compared to women with newly diagnosed stage IV disease, those with recurrent disease whose DDFI was &gt;5 years and &lt;5 years had similar and worse OS respectively.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2077.

Survival among women with triple receptor-negative breast cancer and brain metastases

Abstract #6077

Background&#x2028; The purpose of this study was to determine the incidence of brain metastases in a cohort of women with early stage triple-receptor negative breast cancer and to evaluate the survival outcomes of these patients.&#x2028; Method&#x2028; Six hundred and seventy nine patients with early stage triple-receptor negative breast cancer diagnosed between 1980 and 2006 were identified. Cumulative incidence of brain metastases at 2- and 5-years following a diagnosis of early-stage triple receptor-negative breast cancer considering death as a competing risk was computed. Time to brain metastases was computed from the date of breast cancer diagnosis to the date of development of brain metastases. Cox proportional hazards models, adjusted for various patient and tumor characteristics, were then fitted to explore factors that could predict for the subsequent development of brain metastases in this cohort. Survival following a diagnosis of brain metastases was measured from the date of brain metastases diagnosis to the date of death from any cause. All survival outcomes were computed using the Kaplan – Meier product limit method and compared across groups using log rank statistic.&#x2028; Results&#x2028; Median age was 50 years (range 22 to 97 years) and median follow-up was 26.9 months (range 1.1 to 321.3 months. Overall 42 (6.2%) patients developed brain metastases of whom 16 (38.1%) had 3 brain lesions or less, 19 (45.2%) had more than 3 brain lesions and number of brain lesions was unknown in 7 (16.7%) patients. Overall cumulative incidence at 2- and 5-years was 5.6% (95% CI 3.8%-7.9%) and 9.6% (95% CI 6.8% - 13%) respectively. Twenty –four (3.5%) patients developed brain metastases as the first site of recurrence with cumulative incidence at 2- and 5-years observed to be 2.0% (95% CI 2.6% -6.0%) and 4.9% (95% CI 3.2%-7.0%) respectively. In the multivariable model factors such as age at primary tumor diagnosis, initial clinical stage, histological tumor grade, number of lymph nodes examined and tumor lymph-vascular invasion were not significantly associated with time to brain metastases. For the whole group of patients who developed brain metastases median survival was 2.9 months (95% CI 2.0 – 7.6 months). Among those who developed brain metastases as the first site of recurrence median survival was 5.8 months (95% CI 1.7 – 11.0 months).&#x2028; Conclusion&#x2028; Data from published studies have reported a 5-year cumulative incidence of brain metastases of approximately 5 % in an unselected breast cancer population. In our large single institutional study patients with triple-receptor-negative breast tumors we report higher early cumulative incidence compared to historical controls associated with poor survival. Patients with triple-receptor negative breast tumors may be an ideal cohort to target brain metastases preventive strategies.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6077.

Survival among women with triple receptor-negative breast cancer and brain metastases

BACKGROUND

The purpose of this study was to determine the incidence of and survival following brain metastases among women with triple receptor-negative breast cancer.

PATIENTS AND METHODS

In all, 679 patients with nonmetastatic triple receptor-negative breast cancer diagnosed from 1980 to 2006 were identified. Cumulative incidence of brain metastases was computed. Cox proportional hazards models were fitted to explore factors that predict for development of brain metastases. Survival was computed using the Kaplan-Meier product limit method.

RESULTS

Median follow-up was 26.9 months. In all, 42 (6.2%) patients developed brain metastases with a cumulative incidence at 2 and 5 years of 5.6% [95% confidence interval (CI) 3.8% to 7.9%] and 9.6% (95% CI 6.8% to 13%), respectively. A total of 24 (3.5%) patients developed brain metastases as the first site of recurrence with cumulative incidence at 2 and 5 years of 2.0% (95% CI 2.6% to 6.0%) and 4.9% (95% CI 3.2% to 7.0%), respectively. In the multivariable model, no specific factor was observed to be significantly associated with time to brain metastases. Median survival for all patients who developed brain metastases and those who developed brain metastases as the first site of recurrence was 2.9 months (95% CI 2.0-7.6 months) and 5.8 months (95% CI 1.7-11.0 months), respectively.

CONCLUSION

In this single-institutional study, patients with nonmetastatic triple receptor-negative breast tumors have a high early incidence of brain metastases associated with poor survival and maybe an ideal cohort to target brain metastases preventive strategies.

Serotonergic mediation effects of St John's wort in rats subjected to swim stress

Present study shows the effects of St John's Wort (SJW) (20 mg/kg) on swim stress induced changes in tryptophan (TRP) metabolism and disposition in rats. The results show that after forced swim test (FST) hepatic tryptophan pyrrolase (holo and total) activities were significantly decreased (P<0.001). Liver TRP was increased (P<0.001) while serum TRP was decreased (P<0.01). Brain TRP, 5-hydroxytryptamine (5-HT, Serotonin) and 5-hydroxyindole acetic acid (5-HIAA) concentrations were increased (P<0.001), similarly immobility time during swim test was also increased. SJW pretreated FS group of rats showed reduced holo enzyme activity (P<0.001) while increase in total and apo enzyme activities (P<0.001). There was significant decrease in liver TRP (P<0.01), serum TRP (P<0.05), brain TRP (P<0.001), 5-HT (P<0.001) and 5-HIAA (P<0.001) concentrations with reduction in immobility time during swim test when compared with saline injected FS group. SJW injected group but when compared with untreated controls showed significant increase in total and apo enzyme activities (P<0.001) while holo enzyme activity was decreased (P<0.001), serum TRP, brain TRP and 5-HIAA levels were significantly decreased (P<0.001). Changes in 5-HT concentrations were not significant. It is concluded that SJW treatment alter stress induced augmented 5-HT levels by decreasing precursor availability to the brain and that serotonergic system is involve in the mechanism of action of the drug.