The Predictive Utility of MammaPrint and BluePrint in Identifying Patients with Locally Advanced Breast Cancer Who are Most Likely to Have Nodal Downstaging and a Pathologic Complete Response After Neoadjuvant Chemotherapy

BACKGROUND

Neoadjuvant chemotherapy (NCT) increases the feasibility of surgical resection by downstaging large primary breast tumors and nodal involvement, which may result in surgical de-escalation and improved outcomes. This subanalysis from the Multi-Institutional Neo-adjuvant Therapy MammaPrint Project I (MINT) trial evaluated the association between MammaPrint and BluePrint with nodal downstaging.

PATIENTS AND METHODS

The prospective MINT trial (NCT01501487) enrolled 387 patients between 2011 and 2016 aged ≥ 18 years with invasive breast cancer (T2-T4). This subanalysis includes 146 patients with stage II-III, lymph node positive, who received NCT. MammaPrint stratifies tumors as having a Low Risk or High Risk of distant metastasis. Together with MammaPrint, BluePrint genomically (g) categorizes tumors as gLuminal A, gLuminal B, gHER2, or gBasal.

RESULTS

Overall, 45.2% (n = 66/146) of patients had complete nodal downstaging, of whom 60.6% (n = 40/66) achieved a pathologic complete response. MammaPrint and combined MammaPrint and BluePrint were significantly associated with nodal downstaging (p = 0.007 and p < 0.001, respectively). A greater proportion of patients with MammaPrint High Risk tumors had nodal downstaging compared with Low Risk (p = 0.007). When classified with MammaPrint and BluePrint, more patients with gLuminal B, gHER2, and gBasal tumors had nodal downstaging compared with HR+HER2-, gLuminal A tumors (p = 0.538, p < 0.001, and p = 0.013, respectively).

CONCLUSIONS

Patients with genomically High Risk tumors, defined by MammaPrint with or without BluePrint, respond better to NCT and have a higher likelihood of nodal downstaging compared with patients with gLuminal A tumors. These genomic signatures can be used to select node-positive patients who are more likely to have nodal downstaging and avoid invasive surgical procedures.

Impact on Radiation Therapy Recommendation and Treatment Modality for Patients with Ductal Carcinoma In Situ Using the 7Gene Biosignature: Analysis of the PREDICT Study

PURPOSE/OBJECTIVE(S)

Breast conserving surgery (BCS) followed by adjuvant radiotherapy (RT) has been a mainstay in the treatment of DCIS based on multiple randomized trials demonstrating a local recurrence benefit with RT. However, these studies have failed to identify subsets of patients who did or did not benefit from adjuvant RT after BCS, raising concerns regarding both over and undertreatment. Thus, better prognostic and predictive tools are needed to appropriately risk stratify patients and understand their benefit of RT. The 7-gene predictive DCIS biosignature provides a validated score (DS) for women undergoing BCS that assesses their 10-year risk of in-breast and invasive recurrence with and without adjuvant RT. This trail was designed to evaluate the decision impact of the 7-gene predictive biosignature score on DCIS treatment recommendations.

MATERIALS/METHODS

The PREDICT study is a prospective, multi-institutional trial for patients who received DCISionRT testing as part of their routine care. The registry includes females 26 and older who are diagnosed with DCIS, are candidates for BCS, and eligible for RT. Treating physicians completed treatment recommendation forms before and after receiving test reports to capture surgical, radiation and hormonal treatment (HT) recommendations and patient preferences. Analysis was performed in 2,012 patients treated at 63 clinical sites.

RESULTS

Median age was 62 years old with 32% grade 3 and 10% size 2.5 cm or greater. Post-test, RT recommendation changed for 38% of patients (p<0.001), with a net reduction of 20% in patients recommended to receive RT(p<0.001). The DCISionRT test results had the greatest impact (OR 26.2, 95% CI 19.1-36.4, when analyzed categorically using DS>3 cut-off; 2.3 per DS, 95% CI 2.1-2.6, when evaluated continuously) on post-test RT recommendation in multivariable analysis when compared to all other factors including patient preference, patient clinical and tumor pathological factors, patient race/ethnicity, treatment facility, physician specialty. The post-test RT recommendation rate increased with increasing DS (0-2, 2-4, 4-10) on a categorical basis, with odds ratios of 6.8 DS (2-4 vs 0-2), and 35.0 for DS (4-10 vs 0-2). After DCISionRT test result, patient preference was the second most important factor in post-testing RT recommendation. There was also a significant change in the modality of RT recommended to 34% of those patients recommended RT pre-test and post-test by radiation oncologists (n = 937), with intensified RT modality for higher DS (p<0.001) and de-escalation for lower DS (p<0.001).

CONCLUSION

This analysis of over 2,000 patients demonstrates significant changes in recommendations to add or omit RT based on the 7-gene predictive. The integration of DCISionRT into clinical decision processes has substantial impact on recommendations aimed at optimal management to prevent over- or under-treatment.

Abstract OT1-09-02: The PREDICT Registry: A prospective registry to evaluate the effect of a predictive assay on treatment decisions in patients with DCIS following breast conserving therapy

Background. The benefits of adjuvant radiation therapy (RT) in patients with ductal carcinoma in situ (DCIS) treated with breast conserving surgery (BCS) remains controversial. Although there is level-I evidence supporting the role of RT in reducing the risk of local recurrence, the absolute benefit is variable. Current guidelines generally recommend RT for all patients having BCS, but it is important to develop prognostic and predictive tools to better assess risk and understand the impact such a tool would have on treatment decisions. The DCISionRT Test(PreludeDx, Laguna Hills, CA) is a biologic signature that provides a validated score for assessing 10-year risk of recurrence and RT benefit using individual tumor biology as assessed by clinical and pathologic biomarkers. Methods. This is a prospective cohort study for patients diagnosed with DCIS of the breast. Treating physicians complete a treatment recommendation survey before and after receiving DCISionRT test results. Test results, treatment recommendations, patient preferences and clinico-pathologic features are stored in a de-identified registry for participating institutions from a variety of geographic regions across the US. The study will also collect 5- and 10-year recurrence and survival data. The study includes females over age 25 who are candidates for BCS and eligible for RT and/or systemic treatment with sufficient tissue to generate test results. Subjects must not have been previously treated for DCIS or have previous or current invasive or micro-invasive breast cancer. The primary endpoints are changes in treatment recommendations for surgical, radiation and hormonal therapy. Secondary endpoints are identification of key drivers for treatment recommendations, including age, size, grade, necrosis, hormone receptor status and other clinico-pathologic factors. Changes in treatment recommendations will be assessed using McNemar's test with an alpha level of 0.05. Differences in recurrence-free and overall survival will be evaluated by Kaplan-Meier survival analysis using the log-rank test and/or the Cox Proportional Hazards model. A planned early interim analysis based on the first 200 patients has been recently completed and reported. Results. As of July 9, 2021, 1,986 patients have been accrued from 64 institutions. Ten additional institutions are currently in the process of joining the study. We are planning to enroll up to 2,500 patients from up to 100 institutions.

Citation Format: Steven C Shivers, Pat W Whitworth, Rakesh Patel, Troy Bremer, Charles E Cox. The PREDICT Registry: A prospective registry to evaluate the effect of a predictive assay on treatment decisions in patients with DCIS following breast conserving therapy [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 OT1-09-02.

Abstract P2-08-12: Interim analysis of the PREDICT Registry: Changes in treatment recommendation for a biologic signature predictive of radiation therapy (RT) benefit in patients with DCIS

Background: The role of adjuvant RT following breast conserving surgery (BCS) for women with ductal carcinoma in situ (DCIS) remains controversial. Although there is level I evidence supporting the role of RT in reducing the risk of local recurrence, prognostic and predictive tools are needed to better stratify individual risks and benefits of RT. The DCISionRT® Test (PreludeDx, Laguna Hills, CA) is a biosignature that uses individual tumor biology in conjunction with clinical and pathologic risk factors. The test provides a validated score (DS) for women receiving BCS that assesses 10-year risk of DCIS recurrence and development of invasive breast cancer with and without adjuvant RT. We established a registry to evaluate the decision impact of DCISionRT on DCIS treatment recommendations. Methods: The PREDICT study is a prospective, multi-institutional registry for patients who received DCISionRT testing as part of their routine care. The registry includes females 26 and older who are diagnosed with DCIS and are candidates for BCS and eligible for RT or systemic therapy. Treating physicians completed treatment recommendation forms before and after receiving test reports to capture surgical, radiation and hormonal treatment (HT) recommendations and patient preferences. The primary endpoint is to identify the proportion of patients where testing led to a change in RT recommendation. Additional analyses include changes in recommendations in patient subgroups based on clinicopathologic factors or type of treating physician. Results: Analysis was performed in 969 patients treated at 55 sites who had definitive BCS and subsequent DCISionRT testing. The median age of patients was 62 years, 19% were 50 or younger, nuclear grade was high in 31% and tumor size was 2.5 cm or greater for 11%. Test results were DS Low risk (DS ≤ 3) for 63% of women and 37% were DS Elevated risk (DS &gt; 3). Overall, RT recommendation (yes/no) was changed for 40% of women after DCISionRT testing and HT recommendation was changed for 11%. There was a net decrease in RT recommendation from 69% pre-assay to 50% post-assay (p&lt;0.001). RT recommendation decreased by 42% in DS Low risk patients, but increased 22% in DS Elevated risk patients. Among physicians, surgeons were more likely to change their RT recommendation (49%) than radiation oncologists (38%). When test results indicated DS Elevated risk, both surgeons (82%) and radiation oncologists (91%) were likely to recommended RT, but when the results were low risk, surgeons were more likely than radiation oncologists to recommend omitting RT (83% vs. 68%, respectively). Conclusions: This interim analysis demonstrates a significant percent change in recommendations to add or omit RT based on DCISionRT results in 969 patients. Compared to traditional clinicopathologic features, the factor most strongly associated with RT recommendation was the DCISionRT result with other factors of importance being patient preference, tumor size and grade. The integration of DCISionRT into clinical decision processes has substantial impact on recommendations aimed at optimal management to prevent over- or under-treatment.

TABLE 1. Impact of DCISionRT on adjuvant radiation recommended by clinicopathologic features.RT recommendedPre- to post-test change in RT recommendedTotal change in RT recommendedClinical factorNPre-test(%)Post-test(%)Net change (%)Yes to no (%)No to yes (%)Overall change (%)95% CIp-ValueAge, years&lt; 501648148-3243133730-45%&lt;0.001≥ 508056651-1642374137-44%&lt;0.001Grade1 or 26656144-1650354440-47%&lt;0.00133048764-2332333227-37%&lt;0.001Tumor size≤ 2.5 cm8596648-1845354238-45%&lt;0.001&gt; 2.5 cm1109269-2327222619-35%&lt;0.001RTOG 9804 criteria‘Good risk’5005541-1452344440-49%&lt;0.001Not ‘good risk’4598460-2436353632-40%&lt;0.001

Citation Format: Steven C Shivers, Pat W Whitworth, Rakesh Patel, Troy Bremer, Charles E Cox. Interim analysis of the PREDICT Registry: Changes in treatment recommendation for a biologic signature predictive of radiation therapy (RT) benefit in patients with DCIS [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 P2-08-12.

Simulating the Cortical Microcircuit Significantly Faster Than Real Time on the IBM INC-3000 Neural Supercomputer

This article employs the new IBM INC-3000 prototype FPGA-based neural supercomputer to implement a widely used model of the cortical microcircuit. With approximately 80,000 neurons and 300 Million synapses this model has become a benchmark network for comparing simulation architectures with regard to performance. To the best of our knowledge, the achieved speed-up factor is 2.4 times larger than the highest speed-up factor reported in the literature and four times larger than biological real time demonstrating the potential of FPGA systems for neural modeling. The work was performed at Jülich Research Centre in Germany and the INC-3000 was built at the IBM Almaden Research Center in San Jose, CA, United States. For the simulation of the microcircuit only the programmable logic part of the FPGA nodes are used. All arithmetic is implemented with single-floating point precision. The original microcircuit network with linear LIF neurons and current-based exponential-decay-, alpha-function- as well as beta-function-shaped synapses was simulated using exact exponential integration as ODE solver method. In order to demonstrate the flexibility of the approach, additionally networks with non-linear neuron models (AdEx, Izhikevich) and conductance-based synapses were simulated, applying Runge–Kutta and Parker–Sochacki solver methods. In all cases, the simulation-time speed-up factor did not decrease by more than a very few percent. It finally turns out that the speed-up factor is essentially limited by the latency of the INC-3000 communication system.

Abstract PS6-17: Clinical utility of a biologic signature to assess DCIS recurrence risk in patients meeting ‘good-risk’ criteria (RTOG 9804, ECOG 5194): Interim analysis of the DCISionRT PREDICT study

BACKGROUND: When considering health-related, quality-of-life and monetary costs associated with post-surgical treatments for women diagnosed with Ductal Carcinoma In Situ (DCIS), there remains a need for prognostic and predictive tools to help design individual treatment planning. DCISionRT (PreludeDx, Laguna Hills, CA) is a validated biologic signature to assess the 10-year event risk for DCIS patients managed with breast conserving surgery (BCS). The 10-year risks are provided separately for patients treated with and without adjuvant radiation therapy (RT) after BCS. The study was designed to measure the change in adjuvant RT recommendation. This is a planned interim analysis of the study, which will eventually comprise up to 2,500 patients and 100 sites.

METHODS: The registry includes females over the age of 25 who are candidates for breast conserving surgery and eligible for RT. Survey forms are completed pre- and post-DCISionRT test to capture treatment recommendations and patient preferences. This interim analysis was performed to assess changes in RT recommendation for patients treated with BCS in different clinicopathologic subgroups. Specifically, ‘good risk’ profiles were based on the RTOG 9804 and ECOG 5194 study designs. RTOG 9804 like criteria was screening detected tumors with nuclear grade of 1 or 2, size of ≤ 2.5 cm, and clear (≥ 2 mm) surgical margins. ECOG 5194 like criteria was tumors with nuclear grade of 1 or 2, size of ≤ 2.5 cm, and clear surgical margins, or nuclear grade of 3, size of ≤ 1 cm, and clear surgical margins. Statistics were provided as percentages and counts, and McNemar’s test was used to assess change in RT with a p-value of &lt;0.05 considered statistically significant.

RESULTS: There were 513 patients from 32 sites with testing completed after treatment with BCS. Of these patients, 16% were ≤ 50 years of age, 60% were ≥ 60 years of age, and 26% were ≥ 70 years of age. The DCIS tumor nuclear grade was high in 32% of patients, and the size of the tumor was ≤ 1 cm for 68% of patients. There were 49% of patients who met RTOG 9804 like criteria, 51% who met the ECOG 5194 (grade 1 or 2) criteria, and 45% of patients who met the ECOG 5194 (grade 3) criteria. RT was recommended to 52% and 53% patients for RTOG 9804/ECOG 5194 (grade 1 or 2) criteria pre-testing, and 42% post-testing. For ECOG 5194 (grade 3) like criteria, 64% of patients were recommended RT pre-test, and 40% were recommended RT post-test. In all criteria groups, for patients whom were initially recommended RT pre-test, 51% to 54% were not recommended RT post-test, while patients initially not recommended RT pre-test, 25% to 37% were recommended RT post-test. Overall, the post-test RT recommendation was significantly changed from between 42% and 46% for patients with ‘good-risk’ clinicopathologic criteria.

CONCLUSIONS: The PREDICT study interim analysis demonstrates a significant absolute overall change post DCISionRT testing for RT recommendation in patients with ‘good-risk’ clinicopathology. RT recommendations were changed post-test for 42% to 46% of patients meeting RTOG 9804/ECOG 5194 like criteria. Integration of DCISionRT testing had a significant impact on the RT recommendations aimed at reducing overtreatment and minimizing undertreatment.

Table 1. Pre-Post DCISionRT Impact by ‘good-risk’ criteria.n% RTPre-testYes% RTPost-test Yes% RTPre-Yes, Post-No% RTPre-No, Post-Yes% Total Decision Change95% CIp-valueRTOG 9804 criteriaGrade 1 or 2, Size ≤ 2.5 cm, screen detected, wide margins2525242543746%40 - 52%1.2E-02ECOG E5194 criteriaGrade 1 and 2, Size ≤ 2.5 cm, wide margins2625342533645%39 - 51%0.010Grade 3, Size ≤ 1 cm, wide margins2316440512542%36 - 48%2.4E-08

Citation Format: Chirag Shah, Frank Vicini, Steven C Shivers, Pat W Whitworth, Rakesh Patel, Charles E Cox, Troy Bremer. Clinical utility of a biologic signature to assess DCIS recurrence risk in patients meeting ‘good-risk’ criteria (RTOG 9804, ECOG 5194): Interim analysis of the DCISionRT PREDICT study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-17.

Abstract PS6-30: Combined use of MammaPrint and BluePrint assays to evaluate patients for response to neo-adjuvant chemotherapy for locally advanced breast cancer

Background: The main goal of the Multi-Institutional Neo-Adjuvant Therapy MammaPrint (MINT) project was to determine the predictive power of the combination of the molecular assays MammaPrint and BluePrint (Agendia Inc., Irvine, CA) for chemosensitivity as measured by complete pathological response (pCR) in patients with locally advanced breast cancer (LABC). MammaPrint is a 70-gene microarray-based assay that classifies each breast cancer patient as low or high risk to develop metastases within 10 years after diagnosis. The BluePrint test is an 80-gene molecular subtyping profile that discriminates between luminal, basal and HER-2 subtypes.

Methods: After appropriate IRB approval, 270 female patients with histologically-proven invasive breast cancer and no distant metastases were enrolled in this study. Patients had a clinical tumor classification of T2-T4 with 0-3 positive lymph nodes. DCIS or LCIS was allowed in addition to invasive cancer at the T2 or T3 levels. At least one lesion had to be accurately measured in two dimensions utilizing mammogram, ultrasound, or MRI images to define specific size and validate pCR. Patients were required to have adequate bone marrow reserves, renal function and hepatic function, as determined by standard blood and serum measurements. Patients under 18 years of age or those with confirmed metastatic disease, inflammatory breast cancer, any serious uncontrolled intercurrent infections, or other serious uncontrolled concomitant disease were excluded. Patients with any prior chemotherapy, radiotherapy, or endocrine therapy for the treatment of breast cancer were also excluded. Tumor samples were collected via incisional or core needle biopsy and shipped to Agendia for processing of the MammaPrint and BluePrint gene panels, as well as whole human genome expression microarrays. Comparison of response rates between MammaPrint and BluePrint molecular subtypes was conducted using Pearson Chi-square test with chemo-responsiveness measured as a binary response: pCR or residual disease.

Results: Of 270 patients enrolled, 56 did not have TNM or RCB staging information reported in the case report form and/or were not submitted for central pathology review. Of 214 patients evaluated by central pathology review, 68 (32%) exhibited a pCR. Patients with a high risk MammaPrint result had a higher pCR rate (37%) compared to patients with a low risk MammaPrint (0%). And patients with a HER-2 or basal molecular subtype by BluePrint had significantly higher rates of pCR (62%, 37%, respectively).

Conclusion: Upfront evaluation of LABC tumors using the combination of MammaPrint and BluePrint can help in the clinico-pathologic evaluation to determine which patients are more likely to benefit from neo-adjuvant chemotherapy, ranging from expected minimal response in Luminal A to substantial responses for HER2-type and Basal-type tumors. Additional studies to evaluate the prognostic and/or predictive values of additional gene panels from the whole human genome microarrays are underway.

Rate of pCR in MammaPrint and MammaPrint/BluePrint groupsGroupsResidual DiseasepCRP valueMP Risk GroupLow Risk27 (100%)0 (0%)0.0004High Risk114 (63%)67 (37%)BP subtypeBasal42 (63%)25 (37%)2 x 10-9HER220 (38%)33 (62%)Luminal A26 (100%)0 (0%)Luminal B53 (85%)9 (15%)

Citation Format: Brian Longbottom, Steven C Shivers, Geza Acs, Charles E Cox. Combined use of MammaPrint and BluePrint assays to evaluate patients for response to neo-adjuvant chemotherapy for locally advanced breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-30.

Abstract PS6-41: Mammaprint and blueprint as prognostic indicators for elderly patients with early stage breast cancer

Background: Elderly breast cancer (BC) patients are an understudied population, with limited evidence regarding treatment options and outcomes and a lack of research involving prognostic multigene assays for this group. One study in patients 65-89 years old with an Oncotype DX Recurrence Score ≥ 26 concluded that gene expression profiling tests have limited utility in elderly patients, and should only be used for patients aged 65-74 with no/low to moderate comorbidities and not for patients ≥ 75. In this study, the 70-gene risk of distant recurrence signature, MammaPrint (MP), and 80-gene molecular subtyping signature, BluePrint (BP), were evaluated in both the neoadjuvant and adjuvant settings in elderly patients with early stage BC.

Methods: This analysis included 211 BC patients classified as cT2-4N0-3M0 (T2 &gt; 3.5 cm if N0) who received neoadjuvant chemotherapy and enrolled in the Multi-Institutional Neoadjuvant Therapy MammaPrint Project (MINT) study from 2011-2016. Lymph node (LN) involvement was established following neoadjuvant treatment. The second analysis included 517 early stage BC patients with 0-3 positive LNs who enrolled in the community based cohort study (COPPER) from 2009-2016. Patients were given adjuvant treatment following standard of care. Patients from both cohorts were divided into age at diagnosis groups: &lt; 65, 65-74, and &gt; 74. MP stratified patients into either Low Risk (LR) or High Risk (HR) groups. BP classified patient samples into Luminal, HER2, or Basal subtype. Kaplan Meier analysis and log-rank test were used to assess differences in overall survival (OS) and distant metastasis free survival (DMFS). Clinical risk assessment based on the MINDACT trial algorithm was performed.

Results: From MINT, 35 patients were ≥ 65 years old; 80% were HR and 20% were LR. Pathological complete response (pCR) was achieved in 36% (10/28) of elderly HR patients, of whom 70% were HER2 and 30% were Basal by BP. Nodal downstaging occurred in 55% (11/20) of LN positive elderly HR patients, of whom 64% (7/11) achieved pCR. BP classified patients with nodal downstaging as HER2 (55%), Basal (36%), or Luminal (9%). Importantly, pCR and nodal downstaging were more likely to be achieved in HR tumors and correlated with BP subtype in both young and elderly patients. From the COPPER cohort, 77% of HR patients 65-74 years old received chemotherapy (CT), whereas 74% of LR patients omitted CT. Of patients &gt; 74, 49% of HR patients received CT, whereas 75% of LR patients omitted CT. OS and DMFS probabilities indicated good survival outcomes in LR patients that omitted CT and HR patients that received CT, with no significant difference between age groups. A majority of HR patients treated with CT and over 1/3 of LR patients that omitted CT had high clinical risk. Interestingly, among all patients that had a metastasis event, mortality was less likely to occur in patients that received dose dense AC (doxorubicin and cyclophosphamide).

Conclusion: MP and BP may identify HR elderly patients who are likely to achieve nodal downstaging and pCR. Elderly patients were safely spared or assigned adjuvant CT based on MP results independent of clinical risk. Furthermore, these data are in line with previous studies that suggest similar survival benefits between older and younger patients who are candidates for aggressive CT regimens. MP and BP elucidate information about tumor biology and provide prognostic value, which may help inform treatment decisions, independent of patient age.

MINTAge group&lt; 6565-74&gt; 74MP resultHRLRHRLRHR# of patients152242177% of patients with pCR35% (53/152)033% (7/21)043% (3/7)# of LN+ patients103181456% of LN+ patients with nodal downstaging49.5% (51/103)22% (4/18)50% (7/14)067% (4/6)% of LN+ patients with pCR & nodal downstaging65% (33/51)071%(5/7)050%(2/4)COPPERAge group&lt; 6565-74&gt; 74MP resultHRLRHRLRHRLR# of patients1409988665569# of patients received CT121256813278# of patients omitted CT116717492052# of patients with unknown treatment873489Groups treated based on MPHR treated with CTLR omitted CTAge group&lt; 6565-74&gt; 74&lt; 6565-74&gt; 745-yr DMFS probability (95% CI)91% (80.2-96.7)87% (60.2-91.4)87% (55.2-96.6)100%98% (84.3-99.7)94% (75.9-98.5)5-yr OS probability (95% CI)94% (80.2-98.2)96% (83.4-98.9)86% (54.7-96.5)100%98% (84.3-99.7)97% (80.4-99.6)% Clinical high risk83% (100/121)76% (52/68)63% (17/27)34% (23/67)37% (18/49)35% (18/52)

Citation Format: Peter W. Blumencranz, Mehran Habibi, Lisa Blumencranz, Andrea Menicucci, Shiyu Wang, Amy Truitt, William Audeh, Jolanta L. Baginski, Steven Shivers, Geza Acs, Charles E. Cox, MINT Investigators Group. Mammaprint and blueprint as prognostic indicators for elderly patients with early stage breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-41.

Abstract OT-08-01: The PREDICT registry: A prospective registry to evaluate the effect of a predictive assay on treatment decisions in patients with DCIS following breast conserving therapy

Background. The benefits of adjuvant radiation therapy (RT) in patients with ductal carcinoma in situ (DCIS) treated with breast conserving surgery (BCS) remains controversial. Although there is level-I evidence supporting the role of RT in reducing the risk of local recurrence, the absolute benefit is variable. Current guidelines generally recommend RT for all patients having BCS, but it is important to develop prognostic and predictive tools to better assess risk and understand the impact such a tool would have on treatment decisions. The DCISionRT Test (PreludeDx, Laguna Hills, CA) is a biologic signature that provides a validated score for assessing 10-year risk of recurrence and RT benefit using individual tumor biology as assessed by clinical and pathologic biomarkers.Methods. This is a prospective cohort study for patients diagnosed with DCIS of the breast. Treating physicians complete a treatment recommendation survey before and after receiving DCISionRT test results. Test results, treatment recommendations, patient preferences and clinico-pathologic features are stored in a de-identified registry for participating institutions from a variety of geographic regions across the US. The study will also collect 5- and 10-year recurrence and survival data. The study includes females over age 25 who are candidates for BCS and eligible for RT and/or systemic treatment with sufficient tissue to generate test results. Subjects must not have been previously treated for DCIS or have previous or current invasive or micro-invasive breast cancer. The primary endpoints are changes in treatment recommendations for surgical, radiation and hormonal therapy. Secondary endpoints are identification of key drivers for treatment recommendations, including age, size, grade, necrosis, hormone receptor status and other clinico-pathologic factors. Changes in treatment recommendations will be assessed using McNemar's test with an alpha level of 0.05. Differences in recurrence-free and overall survival will be evaluated by Kaplan-Meier survival analysis using the log-rank test and/or the Cox Proportional Hazards model. A planned early interim analysis based on the first 200 patients has been recently completed and reported. Results. As of July 6, 2020, 1,000 patients have been accrued from 49 institutions. Twenty additional institutions are currently in the process of joining the study. We are planning to enroll up to 2,500 patients from up to 100 institutions.

Citation Format: Steve C Shivers, Pat W Whitworth, Rakesh Patel, Troy Bremer, Charles E Cox. The PREDICT registry: A prospective registry to evaluate the effect of a predictive assay on treatment decisions in patients with DCIS following breast conserving therapy [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 OT-08-01.

12-chemokine gene expression score in breast cancer patients treated with neoadjuvant chemotherapy

591

Background: Although advances in immunotherapy for the treatment of breast cancer have been minimal compared with other cancers, studies demonstrating tumor-infiltrating lymphocytes and immunomodulatory gene activation in the tumor microenvironment suggest the importance of antitumor immune responses in clinical outcomes. A 12-chemokine gene score has been shown to predict the presence of ectopic lymph node-like structures (ELN) in the tumor microenvironment and improved survival in melanoma, colon cancer, and breast cancer patients (Prabhakaran, 2017). Here, we evaluated this signature in an independent dataset of breast cancer patients treated with neoadjuvant chemotherapy. Methods: Tumor specimens used in this retrospective analysis (n = 92) were from breast cancer patients enrolled in either MINT (NCT0151487) or NBRST (NCT01479101) neoadjuvant registry trials from 2011 to 2016. Clinical data were captured with informed consent, and 70-gene signature (70-GS), 80-gene signature (80-GS), and full transcriptome data were generated by Agendia, Inc. Gene expression data were quantile normalized using R limma package. Principal component analysis (PCA) was performed on the normalized dataset using R princomp package. Chemokine score (CS) was defined as the first principal component values resulting from PCA. 70-GS/80-GS and clinical data were evaluated in relation to CS. CS were compared using Mann-Whitney test. Results: Of 92 breast tumors available for analysis, 84% were 70-GS High Risk (HR). Tumors were 39% Luminal-type, 24% HER2-type, and 32% Basal-type by 80-GS. HR tumors had higher CS than 70-GS Low Risk (LR) tumors (p < 0.001). 80-GS Basal-type, HER2-type, and Luminal B tumors had higher CS than Luminal A tumors (p < 0.01 for each comparison). High grade and ER-negative tumors seemed to have a high CS, although not significantly. Tumors from patients who achieved a pathological complete response (pCR) following neoadjuvant chemotherapy had higher CS than patients with residual cancer burden (p = 0.048). Conclusions: The current study demonstrated a significantly higher CS in 70-GS HR tumors and those which achieved pCR following neoadjuvant chemotherapy. Although further study is needed to evaluate the association of high CS with tumor-associated ELN, these results support previous work demonstrating that, although high CS is associated with aggressive clinical features, it also predicts superior clinical outcomes. The current study suggests validation of the 12-chemokine gene score in an independent dataset of breast cancer patients.

Abstract OT3-09-03: The PREDICT registry: A prospective registry study to evaluate the effect of the DCISionRT test on treatment decisions in patients with DCIS following breast conserving therapy

Background: The benefits of adjuvant radiation therapy (RT) in DCIS patients treated with breast conserving surgery (BCS) remains controversial. Although there is level I evidence supporting the role of RT in reducing the risk of local recurrence, the incremental absolute benefit is variable. Current treatment guidelines generally recommend RT for all patients having BCS. When considered in the context of the economic, health-related, and quality-of-life costs associated with RT, it is critical to identify patients who are at low enough risk to consider foregoing RT. It is important to develop prognostic tools to better assess risk and understand the impact such a tool would have on treatment decisions. The DCISionRT™ Test (PreludeDx, Laguna Hills, CA) is a biologic signature that provides a validated score for assessing 10-year risk of recurrence and RT benefit using individual tumor biology in conjunction with clinical and pathologic risk factors.

Trial Design: This is a prospective cohort study for patients diagnosed with ductal carcinoma in situ (DCIS) of the breast. Treating physicians complete a treatment recommendation survey before and after receiving DCISionRT test results. Test results, treatment recommendations, patient preferences and clinicopathologic features are stored in a de-identified registry for future analysis of data across participating institutions from a variety of geographic regions in the US. The study will also collect 5- and 10-year recurrence and survival data.

Eligibility Criteria: The study includes females over the age of 25 who are candidates for BCS and eligible for RT and/or systemic treatment with sufficient tissue to generate test results. Subjects must not have been previously treated for DCIS or have previous or current invasive or micro-invasive breast cancer.

Specific Aims: The primary objective of this study is to create a de-identified database of patients, test results, treatment decisions and outcomes that can be queried to determine the clinical utility of the DCISionRT Test in actual clinical use for the management of DCIS. The primary endpoints are changes in treatment recommendations for surgical, radiation and hormonal therapy after the physician and patient have reviewed the DCISionRT test results, including subgroup analysis by physician type (surgeon, radiation oncologist or tumor board). Secondary endpoints are identification of the key drivers for treatment recommendations, including age, size, grade, architecture, necrosis, palpability, presentation, hormone receptor status, race, ethnicity, family history, etc.

Statistical Methods: Study results will be analyzed by summary descriptive statistics, such as patient counts, percentages, means, etc. Changes in treatment recommendations will be assessed using McNemar's chi-squared test for symmetry of rows and columns in a two-dimensional contingency table with an alpha level of 0.05. Differences in recurrence-free and overall survival will be evaluated by Kaplan-Meier survival analysis using the logrank test and/or the Cox Proportional Hazards model. A planned early interim analysis based on the first 200 patients has been recently completed and reported - data are available upon request (contact Steven Shivers, PhD, sshivers@preludedx.com.)

Accrual: As of July 1, 2019, 319 patients have been accrued from 56 physicians at 25 institutions. Twenty-two additional institutions are currently in the process of joining the study. We are planning to accrue up to 2,500 patients from up to 100 institutions.

Contact Information: We are actively recruiting institutions for participation. For more information, please contact: Mary Kay Hardwick, mkhardwick@tmebcn.com.

Citation Format: Steve C Shivers, Pat Whitworth, Rakesh Patel, Troy Bremer, Charles E Cox. The PREDICT registry: A prospective registry study to evaluate the effect of the DCISionRT test on treatment decisions in patients with DCIS following breast conserving therapy [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT3-09-03.

Clinical Trial in Progress: The FLEX Big Data Platform explores new gene expression profiles and investigator-initiated protocols in early-stage breast cancer

TPS3155

Background: Genomic signatures are revolutionizing the definition, identification, and treatment of breast cancer. To precisely stratify breast cancers into actionable subgroups, full genome expression data and matching clinical data must be aggregated into a large data set. Such a data set will accelerate research and discovery, especially for smaller patient subsets who are not as widely represented within the current body of literature. Methods: FLEX is a multicenter, prospective, population-based, observational trial for patients with Stage I, II, and III breast cancer. All patients with stage I to III breast cancer who receive MammaPrint, with or without BluePrint on a primary breast tumor are eligible for enrollment. The study’s primary aim is to create a large scale, population-based registry of full genome expression data matched with clinical data to investigate new gene associations with prognostic and/or predictive value. Secondary objectives include utilizing the shared study infrastructure to examine and generate hypotheses for targeted subset analyses and/or trials based on full genome expression data. The design of FLEX allows targeted sub-studies and sub-analyses to be added as appendices after the initial baseline study is opened. Patients enrolled in the initial study are also eligible for inclusion in sub-studies where they meet all criteria and additional consent is not required. Additional clinical data will be collected as specified in the appendix protocols. The FLEX collaborative platform allows participating investigators the opportunity to author their own sub-study protocols, as approved by the FLEX Steering Committee of their peers. 13 sub-studies have already been identified and are under development. Eligibility: The study will enroll a minimum of 10000 patients aged ≥18 years with histologically proven invasive stage I-III breast cancer who signed informed consent. Enrollment began April 2017 and 1506 patients have been enrolled. Clinical trial information: NCT03053193.

Multi-institutional comparison of breast cancer risk stratification by 70-gene signature and 21-gene assay

522

Background: Breast cancer risk stratification with the 70-gene signature (70-GS) provides a binary low risk (LR) or high risk (HR) result; by contrast the 21-gene assay (21-GA) provides LR, intermediate (IR), and HR results. Results from these two assays were compared for 769 patients from 5 institutions. Methods: The study included patients from McGill University (n = 86), UPMC (n = 437), USF (n = 135), Morton Plant North Bay Hospital (n = 79), and Cleveland Clinic (n = 32, all 21-GA IR). Results: With the 70-GS, 487 (63%) patients had a LR and 282 (37%) patients had a HR result. Excluding 32 cases selected for 21-GA IR results (n = 737), the 21-GA gave 369 (50%), 250 (34%), and 118 (16%) patients with LR, IR, and HR scores, respectively. Using the TAILORx cutoff, there were 134 (18%), 432 (59%), and 171 (23%) patients with LR, IR, and HR scores, respectively. There were 329 (45%) and 486 (66%) patients who were not classified in the same risk category by both assays using the clinical and TAILORx cutoffs for IR, respectively. Conclusions: In a large multi-institutional study the 70-GS and 21-GA results were discordant in 45-66% of patients, and the proportion of patients with a 21-GA score in the IR range varied from 34-59%. The 70-GS provided clinically actionable results for all patients. [Table: see text]

Abstract P6-09-45: Long-term follow-up of early stage breast cancer patients with results of MammaPrint®, Oncotype DX® and MammoStrat® risk classification assays

Introduction: The use of genomic tests for the prediction of breast cancer recurrence is becoming more common. MammaPrint® (MP, Agendia Inc.) is a 70-gene microarray assay designed to assess the 10-year risk of recurrence in an untreated population that was not selected for ER/HER2 results. The Oncotype DX® Recurrence Score® (RS, Genomic Health, Inc.) is a 21-gene RT-PCR assay that is clinically validated to predict the 10-year risk of distant recurrence in ER+ patients treated with Tamoxifen. MammoStrat® (MS, Clarient, Inc.) is an IHC assay that uses 5 antibodies and has been validated in a similar population as RS. Several recent reports show that these assays classify patients differently with significant discordances for all risk groups (Shivers, et al., SABCS 2013; Denduluri, et al., ASCO Breast 2011; Poulet, et al., SABCS 2012; Schneider, et al., ASCO 2013). The present study is an analysis of long-term follow-up in a cohort of patients who have results for all three of these risk-stratifying assays side by side in the same samples.

Methods: Patients with ER+ N0-N1 early-stage breast cancer with an MP result obtained as part of their routine clinical care were identified at the University of South Florida (USF, N=65) and Morton Plant Hospital (N=83). After local IRB approval, slides and/or blocks were cut and de-identified at USF and sent to Genomic Health and Clarient for blinded testing. Clinicopathological features were also reviewed by 3 breast pathologists.

Results: 148 patients with an MP result had tissue available to send for RS and MS assays. These patients had a median age of 62 years; median tumor size 1.8 cm; 9% low grade, 59% intermediate grade and 32% high grade. In our previous analysis of this study, of 148 patients with MP results, 53% were low risk and 47% were high risk. Of 135 samples that yielded enough RNA to produce an RS result, 53% were low risk, 26% were intermediate risk and 21% were high risk. Of 129 samples that yielded an MS result, 44% were low risk, 28% were moderate risk and 28% were high risk. Of 121 patients with results for all 3 assays, only 22% were concordant for low risk and 9% were concordant for high risk across all 3 assays. Overall, 30% of cases showed a major discordance such as low risk for one assay and high risk for another. After median follow-up of 54 months, 9 patients have had a distant metastasis and/or 8 patients have died (11 patients total). One patient who had bone metastasis and died had been classified as low risk by all 3 assays. Three patients with distant metastases had a major discordance between assays, with two high risk and one low risk result. Seven patients were classified as high or intermediate/moderate risk by all 3 assays.

Conclusions: This direct comparison demonstrates that although the assays classify a large proportion of patients differently, the patients who ended up with a distant metastasis and/or died of breast cancer had been classified as high risk by at least two of the three assays. This study has important clinical implications since these assays are used to help make treatment decisions regarding which patients might benefit from chemotherapy.

Citation Format: Shivers SC, Russell S, Blumencrancz L, Mehindru A, Acs G, Ellis D, Vrcelj V, Zanchi A, Blumencrancz PW, Carter E, King J, Cox CE. Long-term follow-up of early stage breast cancer patients with results of MammaPrint®, Oncotype DX® and MammoStrat® risk classification assays [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 P6-09-45.

Abstract P5-16-05: MINT trial yields MammaPrint High1/High2 risk classes associated with significant differences in pCR and receptor subtype

Background: Previous clinical trials have validated that the 70-gene signature MammaPrintTM provides prognostic and predictive information for early stage breast cancer patients and can identify low risk patients who may safely avoid adjuvant chemotherapy. Additionally, the neo-adjuvant I-SPY 1&2 TRIALs demonstrated that further stratification of patients into MammaPrint High 1 (MP1) and MammaPrint High 2 (MP2) risk groups may help predict chemo-sensitivity. There were significant differences in pathological complete response (pCR) rates for early stage, locally advanced breast cancer patients who were not HR+HER2- MammaPrint Low Risk. Specifically, the PARP inhibitor veliparib in combination with carboplatin recently graduated the I-SPY 2 phase 2 screening trial, having met the 85% predictive probability criterion with a triple-negative breast cancer signature, which was the subset recommended for this regimen's subsequent development. Given these data, we wanted to determine whether the Multi Institutional Neo Adjuvant Therapy MammaPrint Project (MINT) patient population confirmed the MP1/MP2 risk stratification, clarify if there is an associated receptor subtype for MP1/MP2 risk classes, and conclude if the stratification correlates to a significant difference in pCR. Methods: Array data from pre-treatment samples were obtained from 180 patients classified as MammaPrint High Risk, subtyped by IHC and treated with neo-adjuvant chemotherapy according to protocol. Response was measured by centrally assessed residual cancer burden pursuant to guidelines. Patients were then further stratified based on the MammaPrint Index per their classification threshold between MP1/MP2. Fisher's exact test was used to assess significance of association with pCR overall and within hormone receptor (HR) and HER2 subtypes. Results: MP1 vs MP2 risk classes yielded subsets with significant (p=0.007) differences in pCR. 44% (40/92) of MP2 patients achieved a pCR, compared to 24% (21/88) of MP1 patients. Next, we investigated whether the MP1 and MP2 risk classes were associated with receptor subtype. MP1 demonstrated a significant association and MP2 near significance. 32% (21/66) of triple-negative patients were classified as MP2 vs only 3% (2/66) MP1. Similarly, in the overall population, 28% (51/180) HR+HER2- are classified as MP1 vs 4% (8/180) MP2. Results in the pCR population were reflective of these subtype trends. 63% (58/92) of MP2 patients were classified triple-negative, of which nearly one quarter (21/92) had a measured pCR, whereas 58% (51/88) of MP1 patients were HR+HER2- with 3% (3/88) achieving pCR (Table1). Conclusion: This analysis in the MINT patient population supports previously published data and suggests that the MammaPrint High 1/2 risk classification may help predict chemo-sensitivity. Given the statistical significance of these data, we are currently investigating the biological mechanisms distinguishing the MP1/MP2 subgroups that may account for its use as a specific biomarker of response to chemotherapy treatment in future trials.

Table 1.MP1MP2HER2+HER2-HER2+HER2-HR+HR-HR+HR-HR+HR-HR+HR-793241322185486456371514518818858Row#1= pCR, #2= RD, #3= Total

Citation Format: Blumencranz LE, Shivers SC, Untch S, Treece TD, Yoder E, Blumencranz PW, Cox CE. MINT trial yields MammaPrint High1/High2 risk classes associated with significant differences in pCR and receptor subtype [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 P5-16-05.

Abstract P1-11-06: Learning curve for the SAVI SCOUT breast localization and surgical guidance system

Background: The gold standard for localizing non-palpable breast lesions for surgical excision is wire localization (WL). Multiple disadvantages for WL include complicated scheduling and migration of the wire after placement. Radioactive seed localization (RSL) mitigates these disadvantages, but regulatory requirements regarding radiation limit more universal adoption. The SAVI SCOUT surgical guidance system (an FDA cleared medical device) eliminates the drawbacks of WL without the regulatory requirements of RSL. SCOUT utilizes electromagnetic wave technology and infrared light to provide intra-operative guidance during surgical excision. The purpose of this study is to describe the learning curve associated with adoption of this new technology.

Method: An IRB-approved prospective, single-arm, multi-site trial enrolled women with non-palpable breast lesions requiring localized surgical excision. After informed consent, a radiologist or surgeon used imaging guidance to implant the SCOUT reflector into the target lesion. Intraoperatively, the surgeon used SCOUT for localization of the reflector and removal of the target lesion. We evaluated the association of several independent variables with respect to successful localization and surgical excision including: tumor side, tumor quadrant, distance of reflector from the skin, and the number of SCOUT localized breast excisions performed by operating surgeon up to the 1st five cases. We studied the relationship between these independent variables and the following dependent variables: reflector detection post-placement, reflector detection pre-incision, and reflector localization post-incision.Statistical analysis utilized the z-test to perform a two-sided test of equality at an alpha level of 0.05 with adjustment for multiple comparisons by the Bonferroni method. T-tests were used to perform two-sided tests of equality for numeric variables.

Results: Across 11 institutions, 16 surgeons performed a total of 153 surgical excisions. Overall success rates of reflector detection pre-incision and post-incision were 98% (150/153) and 99% (151/153), respectively. The reflectors were successfully removed in 100% (153/153) of cases. Difficulty with reflector detection immediately post placement was significantly associated with reflectors more than 4 cm (P=0.034) or 5 cm (P=0.007) from the skin, or the procedure being the 1st SCOUT case by the operating surgeon (P=0.036). Operating surgeons performing their 1st SAVI localization procedure were significantly associated with difficult reflector detection post-incision (p=0.044). Subsequent procedures, up to the first five SCOUT localizations, noted no significant difficulty with reflector detection.

Conclusions: The SAVI SCOUT surgical guidance system is a viable surgical localization procedure for non-palpable breast lesions. Surgeons were 100% successful at removing the reflectors during surgical excision. Difficulty with reflector detection was not noted after the surgeon's 1st SCOUT procedure. Overall, it appears the learning curve for reflector placement and localization for non-palpable breast lesions is relatively short. However, depth of the reflector in relation to skin likely affects reflector detection during this early learning period.

Citation Format: Shukla SC, Shivers SC, Mattingly A, Russell S, Mehindru A, Carter E, Cox CE. Learning curve for the SAVI SCOUT breast localization and surgical guidance system [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 P1-11-06.

Mindfulness-Based Stress Reduction in Post-treatment Breast Cancer Patients: Immediate and Sustained Effects Across Multiple Symptom Clusters

CONTEXT

Breast cancer survivors (BCS) face adverse physical and psychological symptoms, often co-occurring. Biologic and psychological factors may link symptoms within clusters, distinguishable by prevalence and/or severity. Few studies have examined the effects of behavioral interventions or treatment of symptom clusters.

OBJECTIVES

The aim of this study was to identify symptom clusters among post-treatment BCS and determine symptom cluster improvement following the Mindfulness-Based Stress Reduction for Breast Cancer (MBSR(BC)) program.

METHODS

Three hundred twenty-two Stage 0-III post-treatment BCS were randomly assigned to either a six-week MBSR(BC) program or usual care. Psychological (depression, anxiety, stress, and fear of recurrence), physical (fatigue, pain, sleep, and drowsiness), and cognitive symptoms and quality of life were assessed at baseline, six, and 12 weeks, along with demographic and clinical history data at baseline. A three-step analytic process included the error-accounting models of factor analysis and structural equation modeling.

RESULTS

Four symptom clusters emerged at baseline: pain, psychological, fatigue, and cognitive. From baseline to six weeks, the model demonstrated evidence of MBSR(BC) effectiveness in both the psychological (anxiety, depression, perceived stress and QOL, emotional well-being) (P = 0.007) and fatigue (fatigue, sleep, and drowsiness) (P < 0.001) clusters. Results between six and 12 weeks showed sustained effects, but further improvement was not observed.

CONCLUSION

Our results provide clinical effectiveness evidence that MBSR(BC) works to improve symptom clusters, particularly for psychological and fatigue symptom clusters, with the greatest improvement occurring during the six-week program with sustained effects for several weeks after MBSR(BC) training.

TRIAL REGISTRATION

Name and URL of Registry: ClinicalTrials.gov. Registration number: NCT01177124.

Examination of Broad Symptom Improvement Resulting From Mindfulness-Based Stress Reduction in Breast Cancer Survivors: A Randomized Controlled Trial

PURPOSE

The purpose of this randomized trial was to evaluate the efficacy of the Mindfulness-Based Stress Reduction for Breast Cancer (MBSR[BC]) program in improving psychological and physical symptoms and quality of life among breast cancer survivors (BCSs) who completed treatment. Outcomes were assessed immediately after 6 weeks of MBSR(BC) training and 6 weeks later to test efficacy over an extended timeframe.

PATIENTS AND METHODS

A total of 322 BCSs were randomly assigned to either a 6-week MBSR(BC) program (n = 155) or a usual care group (n = 167). Psychological (depression, anxiety, stress, and fear of recurrence) and physical symptoms (fatigue and pain) and quality of life (as related to health) were assessed at baseline and at 6 and 12 weeks. Linear mixed models were used to assess MBSR(BC) effects over time, and participant characteristics at baseline were also tested as moderators of MBSR(BC) effects.

RESULTS

Results demonstrated extended improvement for the MBSR(BC) group compared with usual care in both psychological symptoms of anxiety, fear of recurrence overall, and fear of recurrence problems and physical symptoms of fatigue severity and fatigue interference (P < .01). Overall effect sizes were largest for fear of recurrence problems (d = 0.35) and fatigue severity (d = 0.27). Moderation effects showed BCSs with the highest levels of stress at baseline experienced the greatest benefit from MBSR(BC).

CONCLUSION

The MBSR(BC) program significantly improved a broad range of symptoms among BCSs up to 6 weeks after MBSR(BC) training, with generally small to moderate overall effect sizes.

Abstract P3-13-08: A prospective, single-arm, multi-site, clinical evaluation of the SAVI SCOUT® surgical guidance system for the location of non-palpable breast lesions during excision

Background and Objectives: The standard preoperative technique for localizing non-palpable breast lesions is wire localization (WL). Radioactive seed localization (RSL) is an alternative approach that addresses a number of clear disadvantages associated with WL but, the adoption of RSL has been impacted by considerable regulatory requirements for the handling of radioactive materials. To advance the progress made with RSL and eliminate issues associated with radioactive components, the SAVI SCOUT® surgical guidance system was developed. SAVI SCOUT is an FDA-cleared medical device that utilizes non-radioactive electromagnetic wave technology to provide real-time guidance during excisional breast procedures. The purpose of this study is to evaluate the performance of SAVI SCOUT in guiding the removal of non-palpable breast lesions.

Methods: Following a 50 patient pilot study that showed SAVI SCOUT to be safe and effective, IRB approval was granted for this prospective, single-arm, multi-site study for women with a non-palpable breast lesion. Pts underwent localization and excision with the SAVI SCOUT system, which consists of an electromagnetic wave reflective device (reflector), handpiece and console. Using mammographic or ultrasound guidance, the reflector was implanted into the target tissue. Before making an incision, the surgeon used the handpiece, which emits electromagnetic waves and infrared light, to detect the location of the reflector and subsequently plan the surgical incision. During the procedure, the surgeon used the handpiece to guide the localization and removal of the reflector along with the surrounding breast tissue. The console provides audible feedback of reflector proximity to the handpiece. Successful reflector placement, localization and retrieval were the primary endpoints.

Results: A total of 61 pts have participated in the study to date, along with 7 surgeons and 9 radiologists across 6 institutions. The reflectors were successfully placed in all pts, including 27 under mammographic guidance and 34 under ultrasound guidance. In 28 cases, the reflectors were placed on the same day as surgery. Otherwise, the reflectors were placed up to 7 days (average 2.9 days) before surgery. Thirteen pts underwent excisional biopsy and 48 pts had a lumpectomy. The intended lesion and reflector were successfully removed in all pts. Reflector migration did not occur and no adverse events occurred. Final pathology is currently available for 52 pts: 8/10 excisional biopsy pts had no invasive or in situ carcinoma identified. For pts with cancer and complete data, 39/39 had clear margins, but one patient was recommended for re-excision due to a close margin (1 mm) for DCIS.

Conclusions: The preliminary data from this prospective, multi-site study show that real-time surgical guidance with SAVI SCOUT is an accurate technique for directing the removal of non-palpable breast lesions and is reproducible at multiple clinical sites. At present, the study has yielded 100% surgical success with a re-excision rate of 3.0%. Ongoing accrual to this clinical evaluation study will validate these findings with planned enrollment of 150 pts at up to 15 total sites.

Citation Format: Cox CE, Prati R, Blumencranz P, Allen K, Banull C, Cline M, Howard T, Portillo M, Whitworth P, Funk K, Police A, Lin E, Combs F, Anglin B, King J, Shivers SC. A prospective, single-arm, multi-site, clinical evaluation of the SAVI SCOUT® surgical guidance system for the location of non-palpable breast lesions during excision. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-08.

Abstract OT3-2-02: MINT I: Multi-Institutional Neo-adjuvant Therapy, MammaPrint Project I

Background:

Women with locally advanced breast cancer (LABC) are often treated with neo-adjuvant chemotherapy to reduce the size of the tumor prior to surgery, to enable breast conserving surgery and to observe the clinical effect of therapy in real time. Studies have shown that the 25–27% of individuals who have a pathologic complete response (pCR) to neoadjuvant therapy have a survival advantage of 80% in 5 years, which is double the expected survival of the remaining patients without pCR. If patients who are likely to show a pCR could be identified prior to initiation of therapy, it would enable more informed treatment decisions – patients likely to respond would be served well by current neoadjuvant chemotherapy protocols, while those unlikely to respond may be better suited to innovative new strategies for drug discovery [von Minckwitz et al. JCO 2006]. Genomic assays, which are widely used to provide prognostic and predictive information in early breast cancer, have the potential to provide information on the likelihood of a patient with LABC responding to neo-adjuvant therapy [Glück et al. BRCRT2013].

Trial design:

MINT I is a prospective study designed to test the ability of molecular profiling, as well as traditional pathologic and clinical prognostic factors, to predict response to neo-adjuvant chemotherapy in patients with LABC. MammaPrint risk profile, BluePrint molecular subtyping profile, TargetPrint estrogen receptor (ER), progesterone receptor (PR) and HER2 single gene readout, and TheraPrint Research Gene Panel will be analyzed on a fresh tumor specimen using the whole genome array. Patients will receive neo-adjuvant chemotherapy pre-specified in the protocol. Response will be measured centrally. pCR is defined as the absence of invasive carcinoma in both the breast and axilla at microscopic examination of the resection specimen, regardless of the presence of carcinoma in situ.

Eligibility:

The study will include women ≥18 years with histologically-proven invasive breast cancer T2 (≥3.5cm)-T4, N0M0 or T2-T4N1M0, adequate bone marrow reserves and normal renal and hepatic function who signed an IRB approved informed consent.

Objectives:

The objectives of the study are to:

1. Determine the predictive power of MammaPrint and BluePrint for sensitivity to neo-adjuvant chemotherapy as measured by pCR.

2. Compare TargetPrint ER, PR and HER2 with local and centralized IHC and/or CISH/FISH assessment.

3. Identify correlations between TheraPrint and response to neo-adjuvant chemotherapy.

4. Identify and/or validate predictive gene expression profiles of clinical response or resistance to neo-adjuvant chemotherapy.

5. Compare BluePrint with IHC-based subtype classification.

Statistical methods:

Standard statistical tests such as the Pearson Chi-square test will be used to characterize and evaluate the relationship between chemoresponsiveness and gene expression patterns.

Accrual:

A total of 226 eligible patients will be enrolled from multiple institutions. To date (June 06, 2014), 103 patients have been enrolled.

Citation Format: Charles E Cox, Peter Blumencranz, Ruben Saez, Robert Wesolowski, William Dooley, Lisette Stork-Sloots, Femke de Snoo, Sarah Untch, Eli Avisar. MINT I: Multi-Institutional Neo-adjuvant Therapy, MammaPrint Project I [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT3-2-02.

Baseline immune biomarkers as predictors of MBSR(BC) treatment success in off-treatment breast cancer patients

Researchers focused on patient-centered medicine are increasingly trying to identify baseline factors that predict treatment success. Because the quantity and function of lymphocyte subsets change during stress, we hypothesized that these subsets would serve as stress markers and therefore predict which breast cancer patients would benefit most from mindfulness-based stress reduction (MBSR)-facilitated stress relief. The purpose of this study was to assess whether baseline biomarker levels predicted symptom improvement following an MBSR intervention for breast cancer survivors (MBSR[BC]). This randomized controlled trial involved 41 patients assigned to either an MBSR(BC) intervention group or a no-treatment control group. Biomarkers were assessed at baseline, and symptom change was assessed 6 weeks later. Biomarkers included common lymphocyte subsets in the peripheral blood as well as the ability of T cells to become activated and secrete cytokines in response to stimulation with mitogens. Spearman correlations were used to identify univariate relationships between baseline biomarkers and 6-week improvement of symptoms. Next, backward elimination regression models were used to identify the strongest predictors from the univariate analyses. Multiple baseline biomarkers were significantly positively related to 6-week symptom improvement. The regression models identified B-lymphocytes and interferon-γ as the strongest predictors of gastrointestinal improvement (p < .01), +CD4+CD8 as the strongest predictor of cognitive/psychological (CP) improvement (p = .02), and lymphocytes and interleukin (IL)-4 as the strongest predictors of fatigue improvement (p < .01). These results provide preliminary evidence of the potential to use baseline biomarkers as predictors to identify the patients likely to benefit from this intervention.

Abstract OT1-2-01: MINT I: Multi-institutional neo-adjuvant therapy, MammaPrint project I

Background: Women with locally advanced breast cancer (LABC) are often treated with neo-adjuvant chemotherapy to reduce the size of the tumor prior to surgery, to enable breast conserving surgery and to observe the clinical effect of therapy in real time. Studies have shown that the 25–27% of individuals who have a pathologic complete response (pCR) to neoadjuvant therapy have a survival advantage of 80% in 5 years, which is double the expected survival of the remaining patients without pCR. If patients who are likely to show a pCR could be identified prior to initiation of therapy, it would enable more informed treatment decisions – patients likely to respond would be served well by current neoadjuvant chemotherapy protocols, while those unlikely to respond may be better suited to innovative new strategies for drug discovery [von Minckwitz et al. JCO 2006]. Genomic assays, which are widely used to provide prognostic and predictive information in early breast cancer, have the potential to provide information on the likelihood of a patient with LABC responding to neo-adjuvant therapy [Glück et al. ASCO 2012].

Trial design: MINT I is a prospective study designed to test the ability of molecular profiling, as well as traditional pathologic and clinical prognostic factors, to predict response to neo-adjuvant chemotherapy in patients with LABC. MammaPrint risk profile, BluePrint molecular subtyping profile, TargetPrint estrogen receptor (ER), progesterone receptor (PR) and HER2 single gene readout, and TheraPrint Research Gene Panel will be analyzed on a fresh tumor specimen using the whole genome array. Patients will receive neo-adjuvant chemotherapy pre-specified in the protocol. Response will be measured centrally. pCR is defined as the absence of invasive carcinoma in both the breast and axilla at microscopic examination of the resection specimen, regardless of the presence of carcinoma in situ.

Eligibility: The study will include women ≥18 years with histologically-proven invasive breast cancer T2 (≥3.5cm)-T4, N0M0 or T2-T4N1M0, adequate bone marrow reserves and normal renal and hepatic function who signed an IRB approved informed consent.

Objectives: The objectives of the study are to:

1. Determine the predictive power of MammaPrint and BluePrint for sensitivity to neo-adjuvant chemotherapy as measured by pCR.

2. Compare TargetPrint ER, PR and HER2 with local and centralized IHC and/or CISH/FISH assessment.

3. Identify correlations between TheraPrint and response to neo-adjuvant chemotherapy.

4. Identify and/or validate predictive gene expression profiles of clinical response or resistance to neo-adjuvant chemotherapy.

5. Compare BluePrint with IHC-based subtype classification.

Statistical methods: Standard statistical tests such as the Pearson Chi-square test will be used to characterize and evaluate the relationship between chemoresponsiveness and gene expression patterns.

Accrual: A total of 226 eligible patients will be enrolled from multiple institutions. To date (June 06, 2013), 57 patients have been enrolled.

Clinical trial registry number: NCT01501487.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-2-01.

The prospective MammaPrint MINT (Multi-Institutional Neo-adjuvant Therapy) study

TPS11122

Background: Patients with locally advanced breast cancer (LABC) are often treated with neo-adjuvant chemotherapy to reduce the size of the tumor before definitive surgery. Complete pathologic Response (pCR) predicts better long term outcome. Genomics assays that measure specific gene expression patterns in a patient's primary tumor have become important prognostic and predictive tools for early breast cancer. This study is designed to test the ability of molecular profiling, as well as traditional pathologic and clinical prognostic factors to predict responsiveness to neo-adjuvant chemotherapy in patients with LABC. Methods: Women ≥ 18 yrs with histologically-proven invasive breast cancer T2(≥3.5cm)-T4,N0M0 or T2-T4N1M0, with measurable disease, adequate bone marrow reserves and normal renal and hepatic function who signed informed consent are enrolled. Axillary lymph nodes will be staged according to protocol. MammaPrint risk profile, BluePrint molecular subtyping profile, TargetPrint ER, PR and HER2 single gene readout, and the 56-gene TheraPrint Research Gene Panel will be analysed using the whole genome expression array. Patients will receive neo-adjuvant chemotherapy treatment according to protocol. Response will be measured by centrally assessed Residual Cancer Burden (RCB). Objectives are: (1) To determine the predictive power of MammaPrint and BluePrint for sensitivity to neo-adjuvant chemotherapy as measured by pCR. (2) To identify and/or validate predictive gene expression profiles of clinical response or resistance to neo-adjuvant chemotherapy. (3) To compare TargetPrint ER, PR and HER2 with local and centralized IHC and/or CISH/FISH assessment. (4) To identify correlations between TheraPrint and response to neo-adjuvant chemotherapy. (5) To compare BluePrint molecular subtype with IHC-based subtype classification. To achieve a difference of 20% in chemotherapy sensitivity for patients stratified by MammaPrint, a total of 226 samples is needed (significance level 0.05 and power of 0.90). So far 45 patients have been enrolled from multiple institutions. Clinical trial information: NCT01501487.

Presentation of contralateral axillary involvement from breast cancer

49

Background: Metastatic breast cancer to the contralateral axilla is defined as stage IV disease. We postulate that metastatic disease to the contralateral axilla is secondary to extension of aggressive, local regional disease rather than distant metastatic disease and may have a better outcome. Methods: An IRB-approved retrospective review of breast cancer cases presenting to a single institution between January 2005 and December 2011 was performed to identify cases with contralateral axillary disease. Eligibility for the study included unilateral primary breast cancer at presentation with synchronous/metachronous documented metastasis to the contralateral axilla without a documented primary invasive breast cancer within the contralateral breast by surgery or MRI. Clinicopathologic data was recorded for these patients (pts). Results: Thirteen pts were identified that fulfilled eligibility criteria. The average age was 53 years (range 26.3-72.2) with 12/13 (92%) pts presenting with a locally advanced breast tumor or an ipsilateral in-breast recurrence. 10/13 (77%) pts had documented dermal involvement of tumor either at presentation or local recurrence. Contralateral metastatic disease occurred synchronously with the initial primary tumor (3pts, 23%), concomitant with a local recurrence (5 pts, 38%), metachronously with the initial tumor in (3pts, 23%), and metachronously with a local recurrence in (2pts, 15%). Resection of involved contralateral nodes was performed in 10/13 (77%) pts; 5/13 (38%) patients received contralateral axillary radiation; all 13 (100%) received systemic therapy. 9/13 pts (69%) developed distant metastatic disease with a mean follow up of 2.6 years (range 0.3-6.8 years). 3/13 pts (23%) have no evidence of disease at a mean follow up of 4.7 years (range 1.5-6.8). Conclusions: Contralateral axillary spread of breast cancer carries a poor prognosis but may have different prognostic implications than metastatic disease. Contralateral axillary metastatic disease may occur through dermal lymphatic spread and requires multidisciplinary management. Further study is warranted on the prognosis and management of these challenging and rare cases.

Randomized trial using gonadotropin-releasing hormone agonist triptorelin for the preservation of ovarian function during (neo)adjuvant chemotherapy for breast cancer

PURPOSE

Chemotherapy-induced amenorrhea is a serious concern for women undergoing cancer therapy. This prospective randomized trial evaluated the use of gonadotropin-releasing hormone (GnRH) analog triptorelin to preserve ovarian function in women treated with chemotherapy for early-stage breast cancer.

PATIENTS AND METHODS

Premenopausal women age 44 years or younger were randomly assigned to receive either triptorelin or no triptorelin during (neo)adjuvant chemotherapy and were further stratified by age (< 35, 35 to 39, > 39 years), estrogen receptor status, and chemotherapy regimen. Objectives included the resumption of menses and serial monitoring of follicle-stimulating hormone (FSH) and inhibin A and B levels.

RESULTS

Targeted for 124 patients with a planned 5-year follow-up, the trial was stopped for futility after 49 patients were enrolled (median age, 39 years; range, 21 to 43 years); 47 patients were treated according to assigned groups with four cycles of adriamycin plus cyclophosphamide alone or followed by four cycles of paclitaxel or six cycles of fluorouracil, epirubicin, and cyclophosphamide. Menstruation resumed in 19 (90%) of 21 patients in the control group and in 23 (88%) of 26 in the triptorelin group (P= .36). Menses returned after a median of 5.8 months (range, 1 to 19 months) after completion of chemotherapy in the triptorelin versus 5.0 months (range, 0 to 28 months) in the control arm (P= .58). Two patients (age 26 and 35 years at random assignment) in the control group had spontaneous pregnancies with term deliveries. FSH and inhibin B levels correlated with menstrual status.

CONCLUSION

When stratified for age, estrogen receptor status, and treatment regimen, amenorrhea rates on triptorelin were comparable to those seen in the control group.

Carmine red (E-120)-induced occupational respiratory allergy in a screen-printing worker: a case report

Here we present a case report of a patient suffering from occupational rhinoconjunctivitis and asthma due to IgE-mediated carmine red allergy. This is the first description of carmine red allergy in a screen-printing worker in which the diagnosis was documented by quantification of specific IgE antibodies, by skin tests, by a flow-assisted basophil activation test, and by a carmine red challenge test.

Consequences of axillary ultrasound in patients with T2 or greater invasive breast cancers

BACKGROUND

Axillary ultrasound (AUS) with needle biopsy is used to detect metastasis in patients with invasive breast cancers. Our hypothesis is that preoperative AUS significantly reduces sentinel node biopsy (SLNB) use in patients with invasive breast tumors >2 cm upon clinical examination.

METHODS

A single-institution database of patients with breast cancer and AUS was reviewed. Patients with incomplete records, clinical tumor <2 cm, or postoperative AUS were excluded. A control cohort of non-AUS patients with clinical T2 (cT2) or greater disease was identified. Clinicopathologic data were collected. Simple Kappa coefficient and chi-square statistical analyses were performed.

RESULTS

AUS was performed in 153 patients vs. 370 controls. Of AUS patients, 112 (73.2%) had cT2 disease vs. 272 (73.5%) controls. Median AUS patient age was 53.7 (range, 22.8-85.8) years vs. 53.8 (range, 26.7-91.6) years; median pathologic tumor was 3.8 (range, 1.0-20.0) cm in AUS patients vs. 2.5 (range, 0.1-11.0) cm. Among AUS patients, 78% had needle biopsy; 85 of 120 (70.8%) were positive. Sixty-eight patients had SLNB: 33 after negative AUS and 35 after negative needle biopsy. Twenty-three SLNB (37.3%) were positive; 15 of 33 after negative AUS and 8 of 35 after a negative needle biopsy. Axillary dissection was performed in 102 of 153 vs. 225 of 370 controls. Sensitivity and specificity of AUS was 86.2% and 40.5%. Sensitivity of AUS plus needle biopsy was 89.3% with 100% specificity. Neoadjuvant chemotherapy was given to 49.7% of AUS patients. AUS reduced costs by more than $4,000 per patient.

CONCLUSIONS

AUS reduces SLNB use and affects treatment in patients with cT2 or greater breast cancer. Routine AUS should be considered in this population.

Erratum to: Axillary recurrence rate following negative sentinel node biopsy for invasive breast cancer: long-term follow-up

OBJECTIVE

Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the staging procedure for breast cancer. SLN biopsy causes less morbidity and is more cost effective than complete ALND. Lymphatic mapping and SLN biopsy have a low false-negative rate, but long-term outcomes in large consecutive series of patients are unavailable.

METHODS

Retrospective review of a prospectively accrued institutional breast cancer database was performed. The initial mapping of 1,528 patients with invasive breast cancer that demonstrated negative sentinel node biopsy and no axillary dissection in 1,530 cases between January 1995 and June 2003 were collated and reviewed to achieve a long-term follow-up. These 1,528 patients were reviewed for follow-up time, local recurrences, distant metastases, and survival.

RESULTS

A total of 1,530 consecutively mapped invasive breast cancer cases had negative SLN biopsy and no ALND. The mean invasive tumor size of was 1.40 cm. Of patients, 1,212 (79.2%) underwent lumpectomy and 318 (20.8%) underwent mastectomy. Median follow-up was 63 months (range 0.1-144 months). There have been 4 (0.26%) cases presenting with local axillary recurrences, 54 (3.53%) cases presenting with local recurrences in the ipsilateral breast/chest wall, and 24 (1.57%) cases presenting with distant metastases.

CONCLUSION

These data confirm that SLN biopsy is an effective and safe alternative to ALND for detection of nodal metastases in patients with invasive breast cancer and validates its use as the standard tool for nodal staging.

Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer

OBJECTIVES

Considerable morbidity persists among survivors of breast cancer (BC) including high levels of psychological stress, anxiety, depression, fear of recurrence, and physical symptoms including pain, fatigue, and sleep disturbances, and impaired quality of life. Effective interventions are needed during this difficult transitional period.

METHODS

We conducted a randomized controlled trial of 84 female BC survivors (Stages 0-III) recruited from the H. Lee Moffitt Cancer and Research Institute. All subjects were within 18 months of treatment completion with surgery and adjuvant radiation and/or chemotherapy. Subjects were randomly assigned to a 6-week Mindfulness-Based Stress Reduction (MBSR) program designed to self-regulate arousal to stressful circumstances or symptoms (n=41) or to usual care (n=43). Outcome measures compared at 6 weeks by random assignment included validated measures of psychological status (depression, anxiety, perceived stress, fear of recurrence, optimism, social support) and psychological and physical subscales of quality of life (SF-36).

RESULTS

Compared with usual care, subjects assigned to MBSR(BC) had significantly lower (two-sided p<0.05) adjusted mean levels of depression (6.3 vs 9.6), anxiety (28.3 vs 33.0), and fear of recurrence (9.3 vs 11.6) at 6 weeks, along with higher energy (53.5 vs 49.2), physical functioning (50.1 vs 47.0), and physical role functioning (49.1 vs 42.8). In stratified analyses, subjects more compliant with MBSR tended to experience greater improvements in measures of energy and physical functioning.

CONCLUSIONS

Among BC survivors within 18 months of treatment completion, a 6-week MBSR(BC) program resulted in significant improvements in psychological status and quality of life compared with usual care.

Indications for sentinel lymph node biopsy in the setting of prophylactic mastectomy

BACKGROUND

Bilateral/contralateral prophylactic mastectomy (PM) is offered to high-risk women to decrease their actual or perceived breast cancer risk. When an invasive occult cancer is identified, prevailing wisdom suggests that an axillary dissection be performed. This single-institution study aims to identify patients who may benefit from sentinel node biopsy (SLNB) at the time of prophylactic mastectomy.

STUDY DESIGN

We performed a retrospective review of a prospective database of patients treated at our institution with bilateral/contralateral PM between 1995 and 2006. We examined patients' clinicopathologic characteristics in comparison with their incidence of occult cancer in the contralateral breast or axilla.

RESULTS

There were 449 patients who underwent PM and SLNB. Twenty-eight underwent bilateral PM. Of the 28, no occult cancers were identified. Occult cancers were identified in 18 of 420 (4.3%) contralateral prophylactic specimens; they were invasive in 6 (1.4%). In cases of occult carcinoma, the primary established tumor was more likely to be of invasive lobular histology. Eight of 420 (2%) patients had a positive contralateral sentinel node, and within this subset of 8 patients the majority had locally advanced disease on the known tumor side. Other features associated with a positive contralateral sentinel node included the presence of lymphovascular involvement or skin or nipple involvement and grade 2 to 3 invasive primary established tumors.

CONCLUSIONS

Overall, SLNB in patients undergoing bilateral PM or contralateral PM associated with early-stage disease is not indicated. But patients with locally advanced primary breast cancers have a significantly increased risk of occult cancer in the contralateral axilla, likely due to crossover metastasis; this select group of patients may benefit from SLNB at the time of surgery.

Axillary recurrence rate following negative sentinel node biopsy for invasive breast cancer: long-term follow-up

OBJECTIVE

Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the definitive nodal staging procedure for breast cancer. SLN biopsy has been proven to cause less morbidity and be more cost effective than complete ALND. Short-term follow-up has shown that lymphatic mapping and SLN have a low false-negative rate, but there is limited data demonstrating long-term outcomes within a large consecutive series of patients.

METHODS

Retrospective review of a prospective database of breast cancer patients at our institution was performed. The initial mapping of 1,530 patients with invasive breast cancer who demonstrated a negative sentinel node biopsy and no axillary dissection between January 1995 and June 2003 were collated and reviewed to achieve a long-term follow-up. These 1,530 patients were reviewed for follow-up time, local recurrences, distant metastases, and survival.

RESULTS

1,530 consecutively mapped invasive breast cancer patients had a negative SLN biopsy and no ALND. The mean invasive tumor size was 1.40 cm. Of 1,530 patients, 73% (1,121) underwent lumpectomy and 27% (409) underwent mastectomy. Mean follow-up was 4.92 years (range 0-12.0 years). There have been 4 (0.26%) patients presenting with local axillary recurrences, 54 (3.53%) patients presenting with local recurrences in the ipsilateral breast/chest wall, and 24 (1.57%) presenting with distant metastases.

CONCLUSION

These data confirm that SLN biopsy is an effective and safe alternative to ALND for detection of nodal metastases in patients with invasive breast cancer and should be used as the standard tool for nodal staging.