The Effect of Black Cohosh on Ki67 expression and Tumor Volume: A Pilot Study of Ductal Carcinoma in Situ Patients

BACKGROUND

Black cohosh (BC) (Cimicifuga racemosa) may prevent and treat breast cancer through anti-proliferative, pro-apoptotic, anti-estrogenic, and anti-inflammatory effects. This study sought to evaluate the effect of BC on tumor cellular proliferation, measured by Ki67 expression, in a pre-operative window trial of ductal carcinoma in situ (DCIS) patients.

METHODS

Patients were treated pre-operatively for 2 to 6 weeks with BC extract. Eligible subjects were those who had DCIS on core biopsy. Ki67 was measured using automated quantitative immunofluorescence (AQUA) pre/post-operatively. Ki67, tumor volume, and hormone changes were assessed with 2-sided Wilcoxon signed-rank tests, α = .05.

RESULTS

Thirty-one patients were treated for an average of 24.5 days (median 25; range 15-36). Ki67 decreased non-significantly (n = 26; P = .20; median pre-treatment 1280, post-treatment 859; range pre-treatment 175-7438, post-treatment 162-3370). Tumor volume, estradiol, and FSH did not change significantly. No grade 3 or 4 adverse events were reported.

CONCLUSIONS

BC use showed no significant impact on cellular proliferation, tumor volume, or invasive disease upgrade rates in DCIS patients. It was well-tolerated, with no observed significant toxicities. Further study is needed to elucidate BC's role in breast cancer treatment and prevention.ClinicalTrials.gov Identifier: NCT01628536https://clinicaltrials.gov/ct2/show/NCT01628536.

Increased epigenetic age in normal breast tissue from luminal breast cancer patients

Background

Age is one of the most important risk factors for developing breast cancer. However, age-related changes in normal breast tissue that potentially lead to breast cancer are incompletely understood. Quantifying tissue-level DNA methylation can contribute to understanding these processes. We hypothesized that occurrence of breast cancer should be associated with an acceleration of epigenetic aging in normal breast tissue.

Results

Ninety-six normal breast tissue samples were obtained from 88 subjects (breast cancer = 35 subjects/40 samples, unaffected = 53 subjects/53 samples). Normal tissue samples from breast cancer patients were obtained from distant non-tumor sites of primary mastectomy specimens, while samples from unaffected women were obtained from the Komen Tissue Bank (n = 25) and from non-cancer-related breast surgery specimens (n = 28). Patients were further stratified into four cohorts: age < 50 years with and without breast cancer and age ≥ 50 with and without breast cancer. The Illumina HumanMethylation450k BeadChip microarray was used to generate methylation profiles from extracted DNA samples. Data was analyzed using the “Epigenetic Clock,” a published biomarker of aging based on a defined set of 353 CpGs in the human genome. The resulting age estimate, DNA methylation age, was related to chronological age and to breast cancer status.

The DNAmAge of normal breast tissue was strongly correlated with chronological age (r = 0.712, p < 0.001). Compared to unaffected peers, breast cancer patients exhibited significant age acceleration in their normal breast tissue (p = 0.002). Multivariate analysis revealed that epigenetic age acceleration in the normal breast tissue of subjects with cancer remained significant after adjusting for clinical and demographic variables. Additionally, smoking was found to be positively correlated with epigenetic aging in normal breast tissue (p = 0.012).

Conclusions

Women with luminal breast cancer exhibit significant epigenetic age acceleration in normal adjacent breast tissue, which is consistent with an analogous finding in malignant breast tissue. Smoking is also associated with epigenetic age acceleration in normal breast tissue. Further studies are needed to determine whether epigenetic age acceleration in normal breast tissue is predictive of incident breast cancer and whether this mediates the risk of chronological age on breast cancer risk.

Electronic supplementary material

The online version of this article (10.1186/s13148-018-0534-8) contains supplementary material, which is available to authorized users.

Abstract P2-04-02: Comparison of DNA methylation patterns in normal breast tissue from women with and without breast cancer

BACKGROUND: Increasing evidence suggests that epigenetic mechanisms play critical roles in the development of breast cancer. However, precise DNA methylation signatures associated with breast cancer susceptibility remain unknown. We sought to compare DNA methylation changes in the normal breast tissue of women with and without breast cancer to identify patterns of aberrant DNA methylation in women with breast cancer.

METHODS:Samples of normal breast tissue were collected from four cohorts of women: age &lt; 50 years with and without breast cancer, and age ≥50 years with and without breast cancer. Normal breast tissue from healthy women was obtained from the Komen Tissue Bank at IU Simon Cancer Center and from women presenting for reduction mammoplasty at Yale New Haven Hospital. Normal breast tissue from women with breast cancer was obtained from patients undergoing adjuvant total mastectomy at Yale Breast Center. DNA was extracted using Qiagen AllPrep Universal kit. Raw data files in idat format were imported to Partek Genomics Suite 6.6 for normalization and differential methylation analysis. Raw intensities were normalized using With Array Normalization (SWAN) method. Principal component analysis (PCA) were performed as quality control. Differentially methylated loci (DML) between control and breast cancer groups were detected when False discovery rate (FDR) &lt; 0.05 and fold change &gt; 1.5. Functional enrichment analysis of genes with DML in the gene body were conducted using METACORE™. Pathways with FDR &lt; 0.05 were selected.

RESULTS: Ninety-three normal breast tissue samples from 89 subjects were analyzed (breast cancer=40, unaffected=53). Comparison of DNA methylation patterns between women with and without breast cancer revealed 200 DMLs. The majority of DMLs (186) were hyper-methylated in breast cancer patients, and 48 DMLs locate in enhancers of genes. 170 DMLs locate in 134 genes, enriched in two pathways: (1) Cell adhesion_Endothelial cell contacts by junctional mechanisms, and (2) Neurophysiological process_Constitutive and regulated NMDA receptor trafficking. Genes associated with cell adhesion and cell contacts included: ACTN2, GJA4, GJA7 and MAGI1. Two hyper-methylated loci were found in enhancers of ACTN2. In addition, one hyper-methylated locus in GJA4, one hyper-methylated and one hypo-methylated loci in GJA7, and two hyper-methylated loci in MAGI1 were detected in breast cancer patients. Genes associated with NMDA receptor trafficking include: TPK1, ADCY4 and LIN7C. One and two loci were found in TPK1 and ADCY4, respectively, that were hyper-methylated in normal breast tissue from cancer patients in the gene body, while a hypo-methylated locus in breast cancer patients was identified in LIN7C.

CONCLUSIONS: Comparison of DNA methylation patterns of normal breast tissue from women with and without breast cancer reveal specific mechanistic pathways and genes that are differentially methylated in women with breast cancer. DNA methylation of normal breast tissue deserves further study as a potential biomarker for breast cancer risk stratification and may lend new insight into mechanisms of breast cancer development.

Citation Format: Hofstatter EW, Zhu Y, Horvath S, Chagpar AB, Wali VB, Bossuyt V, Storniolo AM, Hatzis C, Patwardhan G, Von Wahlde M-K, Butler M, Epstein L, Stavris K, Sturrock T, Au A, Kwei S, Pusztai L. Comparison of DNA methylation patterns in normal breast tissue from women with and without breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-04-02.

Abstract P3-13-01: Impact of routine cavity shave margins on time and money: Results from the SHAVE trial

INTRODUCTION: Taking routine cavity shave margins (CSM) reduces positive margin and re-excision rates by 50%, but the impact of this technique on operative time and overall costs have not been well-elucidated.

METHODS: The SHAVE trial randomized 235 Stage 0-3 breast cancer patients undergoing partial mastectomy 1:1 to either have further cavity shave margins resected ("shave") or not ("no shave"). Randomization occurred intraoperatively after surgeons had completed standard partial mastectomy. Intraoperative time as well as actual direct costs incurred by the hospital were measured, for both the index case as well as any surgeries over the subsequent 90 days.

RESULTS: Median patient age was 61 (range; 33-94). 54 patients (23%) had invasive cancer, 45 (19%) had DCIS, and 125 (53%) had both. Median invasive tumor size was 1.1 cm (range; 0-6.5), and median DCIS size was 1.0 cm (range; 0-9.3). The "shave" and "no shave" groups were well-matched in terms of baseline characteristics, including the proportion having a sentinel node biopsy (75.6% vs. 69.8%, p=0.32) and/or axillary node dissection (9.2% vs. 7.8%, p=0.68) at the time of the initial surgery. The median number of additional CSM in the "shave" group was 4 (range; 3-6). At the initial surgery, those in the "shave" group had a longer operative time (median 76 vs. 66 minutes, p=0.005), and higher OR, pathology and total costs (see table). 48 patients required a subsequent surgery; 45 (93.8%) for margin clearance, 3 for sentinel lymph node biopsy alone (2 in the "shave" and 1 in the "no shave" group, p=1.00). There was a significantly lower re-excision rate for margins in the "shave" group (10.9% vs. 27.6%, p=0.001). Median time to re-excision was 22 days (range; 10-62). The mean cost of additional surgeries for those who required them was no different between the "shave" and "no shave" groups ($2636 vs. $3453, p=0.12); however, given the overall lower reoperation rate in the "shave" group (12.6% vs. 28.4%, p=0.003), the mean cost per patient for additional surgeries was significantly lower in the "shave" vs. "no shave" group. Taking into account all surgeries (including the index case and any additional surgeries within 90 days), there was no significant difference in cost (from a hospital perspective) between the two groups.

Mean (± SE) Costs per patient"Shave" (n=119)"No Shave" (n=116)p-valueIndex surgery:   OR costs$1315 (± $69)$1138 (± $52)0.042Pathology costs$1195 (± $43)$795 (± $48)&lt; 0.001Total costs$4758 (± $123)$4133 (± $119)&lt; 0.001Additional surgery:   OR costs$94 (± $24)$247 (± $44)0.003Pathology costs$51 (± $18)$112 (± $21)0.031Total costs$332 (± $88)$983 (± $189)0.002Total 90 day surgery costs:   OR costs$1409 (± $76)$1385 (± $64)0.808Pathology costs$1247 (± $49)$909 (± $52)&lt; 0.001Total costs$5090 (± $166)$5116 (± $214)0.925

CONCLUSIONS: Taking routine CSM is associated with increased time and cost for the index surgery, but this is offset by the cost savings of reduced re-excision rates. While the strategies of "shave" and "no shave" are similar in terms of 90 day hospital-related costs, taking CSM is associated with a lower need for reoperative surgery, thereby reducing patient angst and improving utilization of surgeon and OR time.

Citation Format: Chagpar AB, Longley PB, Horowitz NR, Killelea BK, Tsangaris TN, Li F, Butler M, Stavris K, Yao X, Harigopal M, Bossuyt V, Lannin DR, Pusztai L, Loftus M, Davidoff AJ, Gross CP. Impact of routine cavity shave margins on time and money: Results from the SHAVE trial. [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 P3-13-01.

A Randomized, Controlled Trial of Cavity Shave Margins in Breast Cancer

BACKGROUND

Routine resection of cavity shave margins (additional tissue circumferentially around the cavity left by partial mastectomy) may reduce the rates of positive margins (margins positive for tumor) and reexcision among patients undergoing partial mastectomy for breast cancer.

METHODS

In this randomized, controlled trial, we assigned, in a 1:1 ratio, 235 patients with breast cancer of stage 0 to III who were undergoing partial mastectomy, with or without resection of selective margins, to have further cavity shave margins resected (shave group) or not to have further cavity shave margins resected (no-shave group). Randomization occurred intraoperatively after surgeons had completed standard partial mastectomy. Positive margins were defined as tumor touching the edge of the specimen that was removed in the case of invasive cancer and tumor that was within 1 mm of the edge of the specimen removed in the case of ductal carcinoma in situ. The rate of positive margins was the primary outcome measure; secondary outcome measures included cosmesis and the volume of tissue resected.

RESULTS

The median age of the patients was 61 years (range, 33 to 94). On final pathological testing, 54 patients (23%) had invasive cancer, 45 (19%) had ductal carcinoma in situ, and 125 (53%) had both; 11 patients had no further disease. The median size of the tumor in the greatest diameter was 1.1 cm (range, 0 to 6.5) in patients with invasive carcinoma and 1.0 cm (range, 0 to 9.3) in patients with ductal carcinoma in situ. Groups were well matched at baseline with respect to demographic and clinicopathological characteristics. The rate of positive margins after partial mastectomy (before randomization) was similar in the shave group and the no-shave group (36% and 34%, respectively; P=0.69). After randomization, patients in the shave group had a significantly lower rate of positive margins than did those in the no-shave group (19% vs. 34%, P=0.01), as well as a lower rate of second surgery for margin clearance (10% vs. 21%, P=0.02). There was no significant difference in complications between the two groups.

CONCLUSIONS

Cavity shaving halved the rates of positive margins and reexcision among patients with partial mastectomy. (Funded by the Yale Cancer Center; ClinicalTrials.gov number, NCT01452399.).

Does three-dimensional intraoperative specimen imaging reduce the need for re-excision in breast cancer patients?

107

Background: Intraoperative specimen radiography is used by surgeons to evaluate partial mastectomy specimens to ensure that the lesion in question has been adequately removed. We sought to determine whether three-dimensional (3D) specimen imaging would better predict margin status and reduce the need for re-excision than conventional two-dimensional (2D) imaging. Methods: A prospective study using standard 2D as well as 3D specimen imaging was undertaken. Surgeons were asked whether the additional orthogonal view would change their management (i.e., result in further margins being taken intraoperatively), and the impact of this on final margin status. Results: Of the 100 women participating in the study, pathology results were available in 99. Of these, 10 had no residual tumor in the definitive specimen (either due to neoadjuvant chemotherapy, or due to the entire tumor being removed in the core biopsy). The remaining 89 patients formed the cohort of interest. 21 (23.6%) had DCIS, 18 (20.2%) had invasive cancer, and 50 (56.2%) had both. The median tumor size of the largest component was 1.7 cm (range; 0.2 – 8.1 cm). Based on the conventional two-dimensional imaging, surgeons stated they would take more tissue in 26 patients (29.2%). Of the 63 patients in whom no further excision would have been indicated on 2D imaging, the 3D imaging changed management in 4 patients (6.3%). Two of these patients would have had positive margins if the intraoperative resection done on the basis of the 3D imaging would have been omitted. Patients who surgeons felt, either by 2D or 3D intraoperative imaging, warranted intraoperative re-excision tended to have a closer initial margin than those in whom re-excision was thought not to be needed on the basis of intraoperative imaging (median 1.0 vs. 2.0 mm, p=0.038). Furthermore, patients in whom an immediate intraoperative margin was taken (either due to imaging or as a matter of routine) were less likely to require subsequent re-excision (13.4% vs. 40.9%, p=0.012). Conclusions: While 3D specimen imaging changes management in only 6.3% of cases, these data highlight the role of intraoperative immediate re-excision in potentially reducing re-excision rates.

A pilot chemoprevention study of isopropanolic black cohosh extract in women with ductal carcinoma in situ

TPS1609

Background: Recent evidence suggests that black cohosh (Cimicifuga racemosa) may be a potential agent for breast cancer prevention. The active ingredients in black cohosh preparations appear to be triterpene glycosides. Recent preclinical data suggest several mechanisms by which triterpenes may prevent and treat breast cancer, including anti-proliferative, pro-apoptotic, anti-estrogenic, and anti-inflammatory effects. Epidemiologic data demonstrate a significant protective effect of black cohosh against the development of breast cancer in healthy women, and prolonged disease-free survival in breast cancer patients. There is also abundant evidence demonstrating the safety and tolerability of black cohosh in several clinical trials studying its use for treatment of hot flashes. We hypothesize that efficacy of black cohosh can be demonstrated in a pilot pre-operative window trial in a cohort of women with ductal carcinoma in situ (DCIS). Methods: In this trial, we treat women with a 2-5 week pre-operative course of commercial standardized isopropanolic black cohosh extract (20 mg orally twice per day). We aim to demonstrate a reduction in breast epithelial cell proliferation as measured by Ki-67 staining in regions of DCIS using traditional IHC staining and AQUA analysis. We also assess safety and tolerability of black cohosh through monitoring of patient adherence, liver function tests and serum hormone levels. 22 patients will be enrolled onto the trial. Sample size is based on power calculations for the specific study aim of determining the mean change in the levels of Ki67, using a targeted effect size. Assuming a 10% drop-out rate, a sample size of 20 patients will achieve 91% power to detect a 0.8 standard deviation of difference with a two-sided significance level at 0.05 using Wilcoxon signed-rank test. Eligible subjects are pre- and post-menopausal women ≥ 18 years of age newly diagnosed with DCIS histologically confirmed on breast core biopsy, prior to definitive excision. Women who have recently taken any agent known to affect Ki67 levels in the breast (e.g. hormone therapy) are excluded. Enrollment is currently ongoing with 10 of 22 patients accrued. Clinical trial registry number NCT01628536. Clinical trial information: NCT01628536.

SHAVE: A randomized controlled trial of routine shave margins versus standard partial mastectomy

TPS1145

Background: It is well known that partial mastectomy for breast cancer is associated with a positive margin rate of 20-40% in most series. This has led some surgeons to advocate for routine cavity shave margins as a means of reducing re-excision rates. Others, however, feel that such a practice may be unwarranted and question the volume of tissue removed, cosmetic outcome and increase in operative time. It is unclear which of these two approaches is optimal; therefore, a prospective randomized controlled trial was proposed. Methods: Given the primary endpoint of positive margin rates (defined as a margin of < 1mm), the study was powered to find a difference between 30% in the standard partial mastectomy group and 15% in the routine shave margin group. To reach a power of 80% with alpha of 5%, 122 patients were required in each arm; we therefore set N=250 with a 1:1 randomization scheme. Patients are evaluated preoperatively and all patients undergoing a partial mastectomy for stage 0-III breast cancer are eligible; including those who have completed neoadjuvant chemotherapy. Patients are stratified according to stage and randomized within strata. After informed consent, patients undergo a standard partial mastectomy (including specimen radiography as needed). Surgeons may resect additional tissue at that time according to their standard practice. At the completion of this procedure, the randomization envelope is opened in the operating room and surgeons are instructed to either shave (ie., take additional circumferential margins) or close (no shave). Patients will be followed for five years. Outcome measures include: positive margin/re-excision rate, local recurrence, volume of tissue resected, cosmetic outcome, and intraoperative time. To date, over 130 patients have accrued to this trial. Initial results are expected to be reported in 2014. Clinicaltrials.gov identifier: NCT01452399

Recruitment of participants to a clinical trial of botanical therapy for benign prostatic hyperplasia

OBJECTIVES

The timely recruitment of study participants is a critical component of successful trials. Benign prostatic hyperplasia (BPH), a common nonmalignant urologic condition among older men, is characterized by lower urinary tract symptoms (LUTS). Successful recruitment methods for a trial of medical therapy for BPH, Medical Therapy of Prostate Symptoms (MTOPS), were mass mailing and advertising. The Complementary and Alternative Medicines Trial for Urological Symptoms (CAMUS) was designed to evaluate a botanical therapy, saw palmetto, for the treatment of BPH. The objective of this study was to evaluate recruitment strategies for CAMUS and to contrast the baseline characteristics of CAMUS participants with those recruited to a similar trial using conventional medical therapy.

DESIGN

CAMUS is a randomized, double-blind, placebo-controlled trial designed to evaluate the effects of saw palmetto given at escalating doses over an 18-month period on relief from LUTS.

SUBJECTS

The target enrollment goal was 350 men with LUTS from 11 clinical centers over a 12-month period. The recruitment techniques used and participants contacted, screened, and randomized through each technique were obtained from the clinical centers. Baseline characteristics of the CAMUS participants were compared with participants in the MTOPS trial who met the CAMUS eligibility criteria for LUTS.

RESULTS

The target enrollment goal was achieved in 11 months. The overall monthly recruitment rate per site was 3.7 and ranged from 2.4 to 8.0. The most successful recruitment methods were mass mailing and advertising, which accounted for 39% and 35% of the study participants, respectively. In comparison to MTOPS participants, CAMUS participants were younger, more highly educated, more diverse, and had less severe urinary symptoms.

CONCLUSIONS

Successful recruitment methods for CAMUS were similar to those in MTOPS. The use of botanical therapy attracted a less symptomatic and more educated study population.