1030 Did the COVID-19 Pandemic Impact on Medical Students Knowledge of Plastic Surgery Emergencies?

Aim

The aim of this study was to look at the teaching and knowledge of plastic surgery emergencies and referral criteria in medical students from 3rd to 5th year.

Method

400 students were sent a survey via email and invited to participate 278 replied (69.7%). Students were asked 20 questions including demographics, if they were interested in surgery/ED, if they had teaching in B+P and what type, if there was clinical exposure, how to classify TBSA and factors deciding considered in classifying the burn, if they were confident to treat a burn, when to make a referral and burn mechanisms, common complications of burns, what is a flap and types and how to assess, what a plastic surgeon does.

Results

58% (161) declared an interest in surgery or ED, 32% (88) had teaching in B+P with 63% (252) attending a lecture and 5% (13) a formal Placement, others were adhoc and 21% (59) had clinical exposure. 74% (205) identified depth as important, 42% (117) TBSA. 58% (161) could not classify TBSA, 97% (271) did not feel confident treating a burn + only 8% (32) knowing when to refer although most could identify mechanisms. 92% (368) knew infection was a complication but only 1 knew why smoking was contraindicated. 1 student knew what a flap was with non able to classify or assess. few could identify what B+P do.

Conclusions

There is a lack of consistent undergraduate education on plastic emergencies and knowledge, perhaps resulting from less experience from cancelled placement.

Autophagy of mucin granules contributes to resolution of airway mucous metaplasia

Exacerbations of muco-obstructive airway diseases such as COPD and asthma are associated with epithelial changes termed mucous metaplasia (MM). Many molecular pathways triggering MM have been identified; however, the factors that regulate resolution are less well understood. We hypothesized that the autophagy pathway is required for resolution of MM by eliminating excess non-secreted intracellular mucin granules. We found increased intracellular levels of mucins Muc5ac and Muc5b in mice deficient in autophagy regulatory protein, Atg16L1, and that this difference was not due to defects in the known baseline or stimulated mucin secretion pathways. Instead, we found that, in mucous secretory cells, Lc3/Lamp1 vesicles colocalized with mucin granules particularly adjacent to the nucleus, suggesting that some granules were being eliminated in the autophagy pathway rather than secreted. Using a mouse model of MM resolution, we found increased lysosomal proteolytic activity that peaked in the days after mucin production began to decline. In purified lysosomal fractions, Atg16L1-deficient mice had reduced proteolytic degradation of Lc3 and Sqstm1 and persistent accumulation of mucin granules associated with impaired resolution of mucous metaplasia. In normal and COPD derived human airway epithelial cells (AECs), activation of autophagy by mTOR inhibition led to a reduction of intracellular mucin granules in AECs. Our findings indicate that during peak and resolution phases of MM, autophagy activity rather than secretion is required for elimination of some remaining mucin granules. Manipulation of autophagy activation offers a therapeutic target to speed resolution of MM in airway disease exacerbations.

Economic impacts of implementing a national smoke-free prison policy

Background

Worldwide, over 600,000 non-smokers are killed annually due to exposure to secondhand smoke (SHS); the UK societal cost of SHS is estimated at £700million per annum. Prior to recent smoke free policy in Scottish prisons smoking rates were very high (70-75%), well above population rates, subjecting people in custody (PiC) and prison staff to high levels of SHS. Eradicating SHS exposure in prisons could lead to improved health in previous smokers and non-smokers alike, and decrease demand on the National Health Service. However, to date, there is little evidence relating to the economic impact of smoking bans in prisons.

Methods

An economic evaluation estimating the short-term and lifetime impacts of smokefree prison policy in Scotland policy used data from the TIPs study (Jun 2016-Nov 2019) for prison staff and PiC. The analyses adopted a public health and personal perspective and key resources included: implementation costs, cessation support services, health service use and personal costs. For the short-term analyses data were sourced from TIPs staff and PiC surveys, and routine data from the Scottish Prison Service and NHS National Services Scotland. Outcomes included SHS exposure, staff sickness absence, violent incidents and quality adjusted life years (QALYs). The life-time analysis used a Markov model to estimate cost per QALY for both staff and PiC.

Results

SHS exposure measures show a median reduction of 91%. Costs and economic outcome results (mean cost pre- and post-ban, cost-consequences balance sheet and incremental cost per QALYs) are confidential until May 2020 due to their sensitivity and will be available to present at EUPHA 2020.

Conclusions

Previous economic evaluations have focussed on smoking bans in public places and raising the smoking age. This is the first economic analysis of a national prison smoking ban and analysis will be of interest to prison services in other jurisdictions which have yet to implement smokefree policy.

Smokefree policy and medication dispensing for people in prison: interrupted time series analysis

Background

Previous evaluations of smokefree prison policies have suggested improvements in self-rated health and some smoking-related symptoms. No studies to date have investigated impacts on medication use as proxy measures of objective ill-health or as indicators of potential negative unintended consequences. These is limited evidence to date on these important outcomes.

Methods

We obtained from NHS National Services Scotland aggregate data on medication items dispensed in prisons, based on individual named patient medication records, and from the Scottish Prison Service data on the prison population, for the period Jan 2013-Nov 2019. Items of interest comprised those for smoking cessation (varenicline and buproprion); nicotine replacement; specific smoking-related health conditions (glyceryl trinitrate; inhaled bronchodilators and steroids; antibiotics; chloramphenicol eye drops; and proton pump inhibitors and H2 receptor antagonists), and potential unintended mental health consequences (anti-depressants). We also included a set of negative controls for which dispensing was not expected to be affected by the new smokefree policy (anticonvulsants, excluding pregabalin and gabapentin). Analyses were undertaken using AutoRegressive Integrated Moving Average (ARIMA) time series methods, with the dates of the policy's announcement and of implementation included as pre-specified breakpoints.

Results

The results of ARIMA modelling of medication dispensing are confidential until May 2020 due to their sensitivity and will be available to present at WCPH 2020.

Conclusions

The use of routinely available dispensing data as an indicator of objective health impacts and potential negative unintended consequences provides novel insights into the effectiveness of smokefree prison policies. Results will be of interest to international jurisdictions considering such policies and to those seeking to harness the potential of administrative data for natural experiments.

Opinions and experiences of a national smokefree prison policy: evidence from the TIPs study

Background

Removal of tobacco from prisons poses distinct challenges, as prisons are 'homes' and smoking rates are high. TIPs is unique in comprehensively studying a smoking ban using data collected before, during and after the ban. This paper presents opinions and experiences of people in custody (PiC) and staff in Scotland, and identifies implementation success factors and lessons that are highly relevant for other jurisdictions and areas of public health.

Methods

Surveys of staff and PiC (response rates) were conducted in Nov-Dec 2016 (27%, 34%), May-Jul 2018 (31%, 26%) and May-Jul 2019 (16%, 18%), with questions on smoking, smoking cessation/abstinence and smoking restrictions in the prison context. Topics were also explored qualitatively with staff/PiC at similar time points (34 focus groups, 99 interviews). Survey responses were analysed using descriptive statistics and logistic regression analyses. Qualitative data were thematically analysed to identify the diversity of views and experiences.

Results

Smokefree policy is widely accepted as the new 'norm', but support was higher among staff than PiC before, during and after implementation. Surveys and qualitative data suggest perceptions of some of the potential difficulties (e.g. 'hard to enforce') and negative consequences (e.g. 'cause a lot of trouble') of smokefree policy reduced post implementation. Participants identified several implementation success factors relating to: planning and communication, smoking abstinence/cessation products/services, and partnership working.

Conclusions

Smokefree prison polices can be successfully implemented, providing the removal of tobacco is well managed and support measures are available for smokers. Some factors shaping the successful introduction of smokefree prisons in Scotland are relevant to other areas of public health transformation e.g. setting clear objectives and timescales; collaboration and teamwork; and involving staff at all levels and end-users.

How does smokefree policy impact nicotine-related and other prisoner spend (e.g. HFSS foods)?

Background

People in custody (PiC) have poor health compared to the general population, in part due to high smoking rates. Scotland's prisons became smokefree in 2018. Rechargeable e-cigarettes became available a few weeks before the removal of tobacco from the 'canteen' (prison shop for PiC).

Methods

Routinely collected weekly 'canteen' purchase data (no of units of given product purchased by an individual by date) were available for 29-7-18 to 31-3-19 (2112638 rows of data, 645 unique products). Products were categorised into: tobacco; e-cigarettes; food/drink; communication; hygiene; NRT; other and graphed as mean/person/week, for 'smokers' and 'non-smokers' (at baseline). Spend by product type pre- and post-implementation was compared in PiC for 31+ weeks over this period, using mixed effects models.

Results

Mean weekly spend for 'smokers' in custody for 31+ weeks over the pre-post ban comparison period (n = 2541) decreased from £21.36 to £19.80; mean weekly nicotine-related spend reduced from £6.64 (pre-) to £5.55 (post-) (p < 0.001), but showed an increasing trend in nicotine-related spend (£0.08/week) post-ban. No changes were seen for 'non-smokers' (n = 342) overall) or in nicotine-related spend. Trends in mean spend for other products remained flat, suggesting positive transfers of spend noted in qualitative interviews over a comparable period were not evident at population level.

Conclusions

Whilst there are benefits of removing tobacco from prisons, for staff and PiC, previously heavy smokers may find (mandated) tobacco abstinence difficult. Some jurisdictions have made e-cigarettes available to support people quitting/managing without tobacco, but long-term implications of e-cigarette use in this population are as yet unknown. When the introduction of smokefree policy is facilitated by the introduction of e-cigarettes, nicotine spend by PiC may remain high; the implications for whether or not PiC return to smoking on release from custody are unclear.

Changes in exposure to second-hand smoke following a smoking ban across a national prison system

Background

Prisons were one of few workplaces where smoking was still permitted after the smoking ban in indoor public places in Scotland in 2006. This study compares SHS exposure assessments in Scotland's 15 prisons six months after smokefree policy was introduced (in Nov 2018) with levels measured in 2016 before the policy was announced.

Methods

In 2016, 128,431 mins of PM2.5 (marker of SHS) concentration data were collected from residential halls and 2,860 mins for 'task-based' measures; 2019 figures were 126,777 and 3,073 mins. Six days of fixed-site monitoring in halls in each prison commenced on 22.5.19. Task-based measurements were conducted to assess SHS for specific locations and activities (e.g. cell searches). Typical daily PM2.5 exposure profiles were constructed for the prison service and time-weighted average exposure concentrations were estimated for shift patterns for residential staff pre- and post-implementation of the policy. Staff self-reports of exposure to SHS were gathered via surveys.

Results

Measured PM2.5 in residential halls declined markedly; median fixed-site concentrations reduced by > 91% compared to baseline. Changes in the task-based measurements (89% average decrease for high-exposure tasks) and time-weighted average concentrations across shifts (>90% decrease across all shifts), provide evidence that staff exposure to SHS has significantly reduced. The percentage of staff reporting no exposure to SHS rose post-ban.

Conclusions

This is the first study to objectively measure SHS levels before, during and after implementation of smokefree policy across a country's prison system. The dramatic reduction in SHS exposures confirm complementary qualitative data and stakeholder reports of the ban's success in removing tobacco. The findings show that SHS can be effectively eliminated through a well-applied smoking ban in the challenging context of prisons; and are highly relevant for other jurisdictions considering changes to prison smoking rules.

A qualitative study exploring the factors that influence the uptake of pre-pregnancy care among women with Type 2 diabetes

AIM

To elicit the views and experiences of women with Type 2 diabetes and healthcare professionals relating to the pregnancy and pre-pregnancy care they have received or provided.

METHODS

A qualitative study using in-depth semi-structured interviews with women with Type 2 diabetes (n=30) and healthcare professionals (n=22) from primary and specialist care. Women were purposively sampled to include different experiences of pregnancy and pre-pregnancy care. Data were transcribed verbatim and analysed thematically using Framework Analysis.

RESULTS

The median age of the women was 37 years, and most were obese (median BMI 34.9 kg/m² ), of black or Asian ethnicity (n=24, 80%) and from areas of high deprivation (n=21, 70%). Participating healthcare professionals were from primary (n=14), intermediate (n=4) and secondary (n=4) care. Seven themes expressing factors that mediate reproductive behaviour and care in women with Type 2 diabetes were identified at the patient, professional and system levels. Type 2 diabetes was generally perceived negatively by the women and the healthcare professionals. There was a lack of awareness about the pre-pregnancy care needs for this population, and communication between both groups was unhelpful in eliciting the reproductive intentions of these women. The themes also reveal a lack of systemic processes to incorporate pre-pregnancy care into the care of women with Type 2 diabetes, and consequently, health professionals in primary care have limited capacity to provide such support.

CONCLUSION

If the current high levels of unprepared pregnancies in women with Type 2 diabetes are to be reduced, the reproductive healthcare needs of this group need to be embedded into their mainstream diabetes management.

Assessment of fecal steroid and thyroid hormone metabolites in eastern North Pacific gray whales

Baleen whale fecal samples have high potential for endocrine monitoring, which can be used as a non-invasive tool to identify the physiological response to disturbance events and describe population health and vital rates. In this study, we used commercial enzyme-linked immunosorbent assays to validate and quantify fecal steroid (progestins, androgens and glucocorticoids) and thyroid hormone metabolite concentrations in eastern North Pacific gray whales (Eschrichtius robustus) along the Oregon coast, USA, from May to October of 2016-2018. Higher mean progestin metabolite concentrations were observed in postweaning females, followed by pregnant females. Mean androgen, glucocorticoid and thyroid metabolites were higher in mature males. Progestin, glucocorticoids and thyroid fecal metabolites varied significantly by year, with positive correlations between progestin and androgen, and between glucocorticoid and thyroid metabolites. We also present two case studies of a documented injured whale and a mature male displaying reproductive competitive behavior, which provide reference points for physiologically stressed individuals and adult breeding males, respectively. Our methods and findings advance the knowledge of baleen whale physiology, can help guide future research on whale physiology and can inform population management and conservation efforts regarding minimizing the impact of anthropogenic stressors on whales.

Abstract PD4-05: Molecular breast imaging and tomosynthesis to eliminate the reservoir of undetected cancer in dense breasts: The Density MATTERS trial

Background

High mammographic breast density is the primary reason for missed cancers or delayed detection on mammography, and is associated with a higher rate of advanced and interval cancers which increase breast cancer mortality. Digital breast tomosynthesis (DBT) has been shown to reduce false positive findings relative to 2D mammography but does not eliminate the potential for tumor masking in dense breasts due to the similar x-ray attenuation characteristics of tumors and normal fibroglandular tissue. Molecular Breast Imaging (MBI) performed with a dedicated gamma camera to detect functional uptake of a radiotracer, Tc-99m sestamibi, has been shown to reveal breast cancers obscured by density on mammography. In single-institution studies, adding MBI to 2D mammography in women with dense breasts detected an additional 5 to10 invasive cancers per 1000 screened, with modest increases in recall rate (6 to 8%) at a lower cost-per-cancer detected than mammography alone. Despite this promising evidence, the lack of multicenter trial data has limited wider acceptance. Also, MBI has yet to be compared to DBT, which in some centers has replaced 2D mammography screening. We present interim results from a multicenter trial comparing cancer detection rate of DBT and MBI in screening of women with mammographically dense breasts.

Methods

In this ongoing, prospective, multicenter clinical trial, asymptomatic women aged 40-75 years with dense breasts on prior mammogram and no prior history of supplemental screening are invited to undergo two annual rounds of concurrent DBT and MBI. MBI is performed with injection of 300 MBq Tc-99m sestamibi with a dual-head semiconductor-based gamma camera. Screening tests are interpreted independently. Here, preliminary cancer detection rates (cancers per 1000 women screened), recall rates, and biopsy rates of DBT and MBI for initial screening are reported.

Results

In 537 women out of a planned 3000 who have completed the first round of screening, 7 cancers were detected: one by DBT only and 6 by MBI only, giving cancer detection rates of 1.9 for DBT vs. 11.2 for MBI and incremental cancer detection rate of 9.3 for MBI. The one DBT-only cancer was a node-negative 0.8 cm invasive lobular carcinoma. All 6 cancers detected by MBI were invasive; 5 of 6 were node negative (median size 1.0 cm; range 0.6 to 2.6 cm). Recall rate was 11% (60/537) for DBT alone; 16% (84/537) for MBI alone, and 21% (115/537) for the combination. Biopsy was prompted by DBT in 13 patients (PPV 8% [1/13]); by MBI in 23 patients (PPV 26% [6/23]); and by the combination of modalities in 33 (PPV 21% [7/33]).

Conclusion

These preliminary results demonstrate that MBI detects invasive breast cancers occult on DBT in dense breasts. Data from a second screening round will allow calculation of sensitivity and specificity, and determination of the impact of screening MBI in reducing advanced (> 2 cm) and interval cancers. Additional planned analyses will evaluate a denoising algorithm for further reduction in MBI radiation dose to match that of DBT.

Citation Format: Rhodes D, Hunt K, Conners A, Zingula S, Whaley D, Ellis R, Gasal Spilde J, Mehta R, Polley M-Y, O'Connor M, Hruska C. Molecular breast imaging and tomosynthesis to eliminate the reservoir of undetected cancer in dense breasts: The Density MATTERS trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD4-05.

A qualitative study exploring women's health behaviours after a pregnancy with gestational diabetes to inform the development of a diabetes prevention strategy

AIM

To inform targeted interventions for women with gestational diabetes mellitus (GDM) by exploring the factors that influence their health behaviours and their preferences for lifestyle support.

METHODS

Participants were women with previous GDM taken from a diverse inner-city UK population. Data collection involved focus groups (n = 35 women in six groups) and semi-structured interviews (n = 15 women). The transcribed data were analysed using framework analysis.

RESULTS

Eight themes relating to factors influencing health behaviour were identified: psychological legacy of pregnancy, relationships with healthcare professionals, physical impacts of pregnancy, social support and cultural norms, life-scheduling, understanding and risk perception, appetite regulation, and prioritization of the baby. The women's recommendations for intervention components included addressing the emotional stress of pregnancy; conveying personalized risk in a motivational way, adopting a family-centered approach, focusing on women's health rather than just the infant's, and developing flexible interventions. These recommendations were used to construct a model integrating the behaviour-regulating factors with a suggested framework for intervention.

CONCLUSIONS

This study identified some common drivers that may regulate the health behaviours of women following GDM, and recognized some ways to improve care to impact on this. Interventions for diabetes prevention in this population need to address factors at both the individual and systemic levels.

Abstract PD8-03: ESR1 gene fusions drive endocrine therapy resistance and metastasis in breast cancer

Background. Dysregulation of the estrogen receptor gene (ESR1) is an established mechanism of inducing endocrine therapy resistance. We previously discovered a chromosomal translocation event generating an estrogen receptor gene fused in-frame to C-terminal sequences of YAP1 (ESR1-YAP1) that contributed to endocrine therapy resistance in estrogen receptor positive (ER+) breast cancer models. This study compares functional, transcriptional, and pharmacological properties of additional ESR1 gene fusion events of both early stage (ESR1-NOP2) late stage (ESR1-YAP1 and ESR1-PCDH11x) breast cancers to gain a better understanding of therapeutic resistance and metastasis. Understanding the role of ESR1 fusions in inducing metastasis is critical, since the primary cause of death in breast cancer patients is through metastasis to distant sites.

Methods. RNA-seq screens identified ESR1 fusions from early and late stage, endocrine therapy resistant breast tumor samples. Functional experiments were conducted using ER+ breast cancer cell lines, xenograft, and PDX models to test the ability of ESR1 fusions to induce therapeutic resistance and metastasis. ChIP-seq and RNA-seq were performed to examine transcriptional properties and differential gene expression induced by the fusions which directed subsequent pharmacological experiments with a CDK4/6 inhibitor.

Results. ESR1-YAP1 and ESR1-PCDH11x promoted estrogen-independent and fulvestrant-resistant growth in vitro and induced greater tumor growth and increased metastatic capacity to the lungs of xenografted mice. In contrast, the ESR1-NOP2 fusion was sensitive to low estrogen conditions in vitro, and did not promote tumor growth. RNA-seq profiling revealed E2F targets pathway as the most highly enriched pathway induced by the ESR1 fusions. IHC revealed higher levels of pRb in ESR1-YAP1 and ESR1-PCDH11x xenograft tumors and subsequent CDK4/6 inhibition completely blocked tumor growth in an ESR1-YAP1 PDX model. Integrating RNA-seq with ChIP-seq data, we discovered a set of EMT and metastasis genes bound by all ESR1 fusions and WT-ER, but whose expression was strongly and uniquely up-regulated only by the ESR1-YAP1 and ESR1-PCDH11x fusions. These studies also revealed gained sites bound only by the ESR1-YAP1 and ESR1-PCDH11x fusions, not bound by WT-ER nor ESR1-NOP2. Genes mapping to these sites have a role in metastatic biology and were highly up-regulated by the YAP1 and PCDH11x fusions, potentially mediated by long range transcriptional activation.

Conclusion. ESR1-YAP1 and ESR1-PCDH11x are driver fusions that occur in drug-resistant, advanced stage breast cancer and are a new class of recurrent somatic mutation that can cause acquired endocrine therapy resistance, yet can be treated with CDK4/6 inhibition. These driver fusions also confer increased metastatic ability through their ability to drive expression of genes that contribute to EMT and metastasis. In contrast, ESR1-NOP2 did not produce functional protein and appears to be a passenger event. These studies may provide pre-clinical rationale for targeting ESR1 translocated breast tumors, since the presence of an ESR1 driver fusion places a patient in a therapeutic category where none of the currently available endocrine therapies are likely to be effective.

Citation Format: Lei JT, Shao J, Zhang J, Iglesia M, Chan DW, Cao J, Anurag M, Singh P, Haricharan S, Kavuri SM, Matsunuma R, Schmidt C, Kosaka Y, Crowder R, Hoog J, Phommaly C, Goncalves R, Ramalho S, Rodrigues-Peres RM, Lai W-C, Hampton O, Rogers A, Tobias E, Parikh P, Davies S, Ma C, Suman V, Hunt K, Watson M, Hoadley KA, Thompson A, Perou CM, Creighton CJ, Maher C, Ellis MJ. ESR1 gene fusions drive endocrine therapy resistance and metastasis in 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 PD8-03.

The intervention process in the European Fans in Training (EuroFIT) trial: a mixed method protocol for evaluation

BACKGROUND

EuroFIT is a gender-sensitised, health and lifestyle program targeting physical activity, sedentary time and dietary behaviours in men. The delivery of the program in football clubs, led by the clubs' community coaches, is designed to both attract and engage men in lifestyle change through an interest in football or loyalty to the club they support. The EuroFIT program will be evaluated in a multicentre pragmatic randomised controlled trial (RCT), for which ~1000 overweight men, aged 30-65 years, will be recruited in 15 top professional football clubs in the Netherlands, Norway, Portugal and the UK. The process evaluation is designed to investigate how implementation within the RCT is achieved in the various football clubs and countries and the processes through which EuroFIT affects outcomes.

METHODS

This mixed methods evaluation is guided by the Medical Research Council (MRC) guidance for conducting process evaluations of complex interventions. Data will be collected in the intervention arm of the EuroFIT trial through: participant questionnaires (n = 500); attendance sheets and coach logs (n = 360); observations of sessions (n = 30); coach questionnaires (n = 30); usage logs from a novel device for self-monitoring physical activity and non-sedentary behaviour (SitFIT); an app-based game to promote social support for physical activity outside program sessions (MatchFIT); interviews with coaches (n = 15); football club representatives (n = 15); and focus groups with participants (n = 30). Written standard operating procedures are used to ensure quality and consistency in data collection and analysis across the participating countries. Data will be analysed thematically within datasets and overall synthesis of findings will address the processes through which the program is implemented in various countries and clubs and through which it affects outcomes, with careful attention to the context of the football club.

DISCUSSION

The process evaluation will provide a comprehensive account of what was necessary to implement the EuroFIT program in professional football clubs within a trial setting and how outcomes were affected by the program. This will allow us to re-appraise the program's conceptual base, optimise the program for post-trial implementation and roll out, and offer suggestions for the development and implementation of future initiatives to promote health and wellbeing through professional sports clubs.

TRIAL REGISTRATION

ISRCTN81935608 . Registered on 16 June 2015.

Being the 'med reg': an exploration of junior doctors' perceptions of the medical registrar role

The role of the medical registrar is challenging and acknowledged as being a disincentive to a career in medicine for some junior doctors. We set out to build a broader understanding of the role through exploration of Foundation Doctors' and Core Medical Trainees' perceptions of the role. Data, gathered from focus groups, were analysed using a framework approach. Six key themes were identified, which were grouped under the headings 'perceptions of the medical registrar role' and 'transition into the role'. Our work builds on existing literature to inform a deeper understanding of how junior doctors perceive the medical registrar role. In light of our findings we offer suggestions on possible training initiatives to tackle the issues identified. We also highlight positive perceptions of the role and emphasise the key ambassadorial role that current medical registrars have in relation to attracting tomorrow's medical registrars to the specialty.

Abstract PD2-03: Recurrent functionally diverse in-frame ESR1 gene fusions drive endocrine resistance in breast cancer

Background. We previously reported an alternative ESR1 somatic gain-of-function chromosomal translocation event in a patient presenting with aggressive, endocrine therapy resistant estrogen receptor (ER) positive disease, producing an in-frame fusion gene consisting of N-terminal ESR1 and the C-terminus of the Hippo pathway coactivator YAP1 (ESR1-YAP1). We recently identified another ESR1 fusion through RNA sequencing (RNA-seq) in advanced stage ER+ disease from a chest wall recurrence in a male patient that was refractory to multiple lines of treatment. Two examples of fusions discovered in primary breast cancer samples include ESR1 fused in-frame to C-terminal sequences from NOP2 (ESR1-NOP2), identified in a resistant cohort from a RNA-seq screen focused on 81 primary breast cancers from aromatase inhibitor clinical trials, and a second ESR1 fusion, fused in-frame to the entire coding sequence of POLH (ESR1-POLH), that was identified from RNA-seq analysis of 728 Cancer Genome Atlas breast samples. This current study extends our previous characterization of ESR1-YAP1 by comparing functional and pharmacological properties of these three additional ESR1 gene fusion events of both early stage and advanced breast cancers.

Methods. In vitro and in vivo experiments were conducted to test ESR1 fusions to induce therapeutic resistance, and metastasis. The transcriptional and binding properties of each fusion was also examined. Pharmacological inhibition with Palbociclib, a cyclin-dependent kinase 4/6 inhibitor, was utilized to assess drug sensitivity in ESR1 fusion containing breast cancer cells and in a patient derived xenograft (PDX) model expressing ESR1-YAP1 (WHIM18).

Results. The YAP1 and PCDH11x fusions conferred estrogen-independent and fulvestrant-resistant growth. Immunohistochemistry revealed significantly higher numbers of ER+ cells in lungs of mice xenografted with T47D cells expressing the YAP1 and PCDH11x fusions compared to YFP control, NOP2 and POLH fusions. Results from ChIP-seq and microarray studies suggest that these two fusions promote proliferation and metastasis through genomic action by binding estrogen response elements (ERE) and subsequent gene activation. We thereby define these fusions as “canonical” fusions compared to “non-canonical” NOP2 and POLH fusions, which demonstrated dramatically decreased genomic binding ability. The non-canonical fusions induced genes associated with basal-like breast cancer and promoted HER2, EGFR, and MAPK gene expression signatures in contrast to genes associated with cell cycle/proliferation induced by canonical fusions. The proliferative ability of canonical fusion-containing ER+ cells was inhibited by Palbociclib in a dose-dependent manner. In vivo WHIM18 tumors in mice fed with Palbociclib-containing chow demonstrated significantly reduced tumor volume, growth rate, and weight compared to tumors in mice on control chow.

Conclusions. In-frame ERE activating canonical fusions occur in end-stage drug resistant advanced breast cancer and can be added to ESR1 point mutations as a class of recurrent somatic mutation that may cause acquired resistance. Growth induced by these fusions can be antagonized by Palbociclib and is potentially clinically helpful.

Citation Format: Lei JT, Shao J, Zhang J, Iglesia M, Cao J, Chan DW, He X, Kosaka Y, Schmidt C, Matsunuma R, Haricharan S, Crowder R, Hoog J, Phommaly C, Goncalves R, Ramalho S, Lai W-C, Hampton O, Rogers A, Tobias E, Parikh P, Davies S, Ma C, Suman V, Hunt K, Watson M, Hoadley KA, Thompson A, Chen X, Perou CM, Creighton CJ, Maher C, Ellis MJ. Recurrent functionally diverse in-frame ESR1 gene fusions drive endocrine resistance in breast cancer [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 PD2-03.

Abstract P2-01-11: SentimagIC: A non-inferiority trial comparing super paramagnetic iron oxide vs. Tc99 and blue dye in the detection of axillary sentinel nodes in patients with early stage breast cancer

Background: Sentinel lymph node biopsy (SLNB), performed using radioisotope tracer with or without blue dye, is a highly accurate method for staging the axilla in early breast cancer. A radioisotope tracer with or without blue dye is the most commonly used technique for SLNB. Superparamagnetic iron oxide mapping agents detected by a handheld magnetic probe have been explored to overcome the disadvantages of the standard technique which include the short half-life, availability, handling and disposal issues for radioisotope, and the risk of allergic reactions to blue dye. Iron oxide mapping agents have been shown to be non-inferior to the standard technique in European studies. The SentimagIC trial was designed to establish the non-inferiority of a new formulation of the magnetic tracer, SiennaXP, to the combination of radioisotope and blue dye and was required to support a US regulatory submission.

Methods: Between January and December 2015, 160 patients with clinically node negative early stage breast cancer were recruited from six centers in the United States. Subjects received radioisotope injection then an intraoperative subareolar injection of SiennaXP and isosulfan blue dye prior to SLNB being performed. The sentinel node identification rate was compared between SiennaXP and the standard technique to evaluate concordance and non-inferiority.

Results: 147 procedures were completed in 147 subjects. A total of 369 histologically confirmed nodes were excised. The nodal detection rate was 94.3% (348/369) with SiennaXP and 93.5% (345/369) with the standard technique (difference 0.8%, 95% binomial confidence interval lower bound -2.1%). The per-subject detection rate was 99.3% (145/146) with SiennaXP and 98.6% (144/146) with the standard technique (one subject excluded due to not contributing any analyzable nodes). There were 22 subjects with positive SLNs, of whom 21 (95.4%) were detected by both SiennaXP and the standard tracers. In one subject, a positive node was not identified by any tracer, but was removed as clinically suspicious. The number of nodes excised per subject was 2.4 for both SiennaXP and for the standard combined technique.

Conclusion: This study showed SiennaXP is non-inferior to the standard dual technique of radioisotope and blue dye for axillary sentinel lymph node detection in early stage breast cancer and this provides a potential alternative to radioisotope and blue dye.

Citation Format: Alvarado M, Bold R, Gittleman M, Beitsch P, Blair S, Harmer Q, Kivilaid K, Teshome M, Thompson A, Mittendorf E, Hunt K. SentimagIC: A non-inferiority trial comparing super paramagnetic iron oxide vs. Tc99 and blue dye in the detection of axillary sentinel nodes in patients with early stage breast cancer [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 P2-01-11.

Performance of the Xpert HPV assay in women attending for cervical screening

Objectives

This study evaluated the Xpert HPV Assay in women attending screening in general practice by comparing Xpert with two established HPV tests, cytology and histology.

Methods

A prospective study in women aged 20–60 years attending screening in Bristol, Edinburgh and London using residual Preservcyt cytology samples. Sample order was randomised between Roche cobas4800 and Cepheid Xpert assays with Qiagen hc2 third.

Results

3408 cases were included in the primary analysis. Positivity for Xpert was 19.6%, cobas 19.2% and hc2 19.9% with high concordance (kappa=86.8% vs cobas, 81.55 vs hc2). Xpert, cobas and hc2 showed similar sensitivity (98.7%, 97.5%, 98.7%) for CIN2+. All pairwise comparisons had high concordance (Kappa ≥0.78 with any abnormal cytology. Xpert and hc2 were positive for all cases of ≥moderate dyskaryosis (N=63)), cobas was negative in two. Histology was available for 172 participants. 79 reported CIN2+, 47 CIN3+. All CIN3+ was positive on Xpert and hc2 and one case negative for cobas. One case of CIN2 was negative for all assays.

Conclusions

The performance of Xpert HPV Assay in a general screening population is comparable to established HPV tests. It offers simplicity of testing, flexibility with non-batching of individual samples and rapid turnaround time.

•

This is the first study to report on the performance of the Xpert HPV Assay in a screening population.

•

Xpert HPV Assay׳s performance in detecting HPV is comparable to two clinically validated HPV tests.

•

Xpert HPV Assay showed a relative sensitivity of 98.73% for CIN 2 or higher and 100% for CIN3 or higher.

International study of the place of death of people with cancer: a population-level comparison of 14 countries across 4 continents using death certificate data

Background:

Where people die can influence a number of indicators of the quality of dying. We aimed to describe the place of death of people with cancer and its associations with clinical, socio-demographic and healthcare supply characteristics in 14 countries.

Methods:

Cross-sectional study using death certificate data for all deaths from cancer (ICD-10 codes C00-C97) in 2008 in Belgium, Canada, Czech Republic, England, France, Hungary, Italy, Mexico, the Netherlands, New Zealand, South Korea, Spain (2010), USA (2007) and Wales (N=1 355 910). Multivariable logistic regression analyses evaluated factors associated with home death within countries and differences across countries.

Results:

Between 12% (South Korea) and 57% (Mexico) of cancer deaths occurred at home; between 26% (Netherlands, New Zealand) and 87% (South Korea) occurred in hospital. The large between-country differences in home or hospital deaths were partly explained by differences in availability of hospital- and long-term care beds and general practitioners. Haematologic rather than solid cancer (odds ratios (ORs) 1.29–3.17) and being married rather than divorced (ORs 1.17–2.54) were most consistently associated with home death across countries.

Conclusions:

A large country variation in the place of death can partly be explained by countries' healthcare resources. Country-specific choices regarding the organisation of end-of-life cancer care likely explain an additional part. These findings indicate the further challenge to evaluate how different specific policies can influence place of death patterns.

Serial assessment of the physiological status of leatherback turtles (Dermochelys coriacea) during direct capture events in the northwestern Atlantic Ocean: comparison of post-capture and pre-release data

The physiological status of seven leatherback turtles (Dermochelys coriacea) was assessed at two time points during ecological research capture events in the northwestern Atlantic Ocean. Data were collected as soon as possible after securing each turtle onboard the capture vessel and again immediately prior to release. Measured parameters included sea surface temperature, body temperature, morphometric data, sex, heart rate, respiratory rate and various haematological and blood biochemical variables. Results indicated generally stable physiological status in comparison to previously published studies of this species. However, blood pH and blood potassium concentrations increased significantly between the two time points (P = 0.0018 and P = 0.0452, respectively). Turtles were affected by a mild initial acidosis (mean [SD] temperature-corrected pH = 7.29 [0.07]), and blood pH increased prior to release (mean [SD] = 7.39 [0.07]). Initial blood potassium concentrations were considered normal (mean [SD] = 4.2 [0.9] mmol/l), but turtles experienced a mild to moderate increase in blood potassium concentrations during the event (mean [SD] pre-release potassium = 5.9 [1.7] mmol/l, maximum = 8.5 mmol/l). While these data support the general safety of direct capture for study of this species, the observed changes in blood potassium concentrations are of potential concern due to possible adverse effects of hyperkalaemia on cardiac function. The results of this study highlight the importance of physiological monitoring during scientific capture events. The results are also likely to be relevant to unintentional leatherback capture events (e.g. fisheries interactions), when interactions may be more prolonged or extreme.

Abstract P5-14-07: Comparison of infectious complications between breast conserving therapy with catheter-based accelerated partial irradiation and whole breast irradiation

Standard treatment after breast conserving surgery (BCS) has been whole breast irradiation (WBI), however, accelerated partial breast irradiation (APBI) has recently been shown to be an alternative in a select group of patients. APBI has been associated with early postoperative as well as delayed infections. In the current study, we compared rates of infectious complications between patients treated with catheter-based APBI and WBI.

Patients were identified from a single-institution prospective registry from 2009 to 2011. Selection criteria included patients who underwent BCT with either single-entry APBI or WBI and fulfilled criteria for ABPI including ≥50 years, tumor size ≤ 3cm, pN0, and no lympho-vascular invasion. Data regarding treatment, patient comorbidities, and outcomes were obtained. Infectious complications were assessed from the date of APBI catheter insertion or from the date of surgery to start of WBI. Infectious complications were classified as early (≤ 30 days) or delayed (> 30 days). Fisher's exact test was used to compare the rate of infection between APBI and WBI.

91 patients were treated with single-entry catheter-based APBI and 267 patients were treated with WBI. Median follow-up time was 76.2 weeks for APBI patients and 115 weeks for WBI patients. Re-excision was required in 20 patients (21.7%) who underwent APBI and in 51 patients (19.1%) who underwent WBI. Overall, infection occurred in 13 patients (14.1%) who underwent APBI versus 39 patients (14.6%) who underwent WBI. In the APBI group, three (3.3%) patients had infection within 30 days and 10 (10.9%) had infection more than 30 days after catheter insertion. 24 (9.0%) patients had infections within 30 days after surgery and 15 (5.6%) patients occurred more than 30 days after surgery in the WBI group. Patients began WBI within an average of 84 days after surgery. In the APBI group, 4 patients required hospital admission, 5 patients had percutaneous aspiration, and one needed incision and drainage. 8 patients were managed with outpatient oral antibiotics. In the WBI group, 5 patients required hospital admission, 13 patients had percutaneous aspiration, and 30 patients were managed with outpatient oral antibiotics. Diabetes, smoking, and BMI >25 were factors commonly associated with infectious complications in both APBI and WBI but not statistically significant (P = 0.6, 0.09, 0.1. respectively).

In contrast to other studies showing that patients treated with catheter-based APBI have higher rates of infection than patients treated with WBI, our study found no statistically significant difference in infection rates between the two groups. A majority of infections following APBI or WBI can be medically managed as an outpatient basis.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-14-07.

Teenagers' understandings of and attitudes towards vaccines and vaccine-preventable diseases: a qualitative study

•

Explored understandings of diseases and knowledge and experiences of vaccination.

•

Teenagers had limited knowledge and little direct experience of the diseases.

•

Participants attitudes towards receiving vaccines’ varied.

•

The success of mass immunisation programmes is associated with disease perceptions.

•

Need to engage with teenagers to address misconceptions about vaccines and diseases.

Background

To examine immunisation information needs of teenagers we explored understandings of vaccination and vaccine-preventable diseases, attitudes towards immunisation and experiences of immunisation. Diseases discussed included nine for which vaccines are currently offered in the UK (human papillomavirus, meningitis, tetanus, diphtheria, polio, whooping cough, measles, mumps and rubella), and two not currently included in the routine UK schedule (hepatitis B and chickenpox).

Methods

Twelve focus groups conducted between November 2010 and March 2011 with 59 teenagers (29 girls and 30 boys) living in various parts of Scotland.

Results

Teenagers exhibited limited knowledge and experience of the diseases, excluding chickenpox. Measles, mumps and rubella were perceived as severe forms of chickenpox-like illness, and rubella was not associated with foetal damage. Boys commonly believed that human papillomavirus only affects girls, and both genders exhibited confusion about its relationship with cancer. Participants considered two key factors when assessing the threat of diseases: their prevalence in the UK, and their potential to cause fatal or long-term harm. Meningitis was seen as a threat, but primarily to babies. Participants explained their limited knowledge as a result of mass immunisation making once-common diseases rare in the UK, and acknowledged immunisation's role in reducing disease prevalence.

Conclusions

While it is welcome that fewer teenagers have experienced vaccine-preventable diseases, this presents public health advocates with the challenge of communicating benefits of immunisation when advantages are less visible. The findings are timely in view of the Joint Committee on Vaccination and Immunisation's recommendation that a booster of meningitis C vaccine should be offered to teenagers; that teenagers did not perceive meningitis C as a significant threat should be a key concern of promotional information. While teenagers’ experiences of immunisation in school were not always positive, they seemed enthusiastic at the prospect of introducing more vaccines for their age group.

Effects of exposure, diet, and thermoregulation on fecal glucocorticoid measures in wild bears

We examined fecal glucocorticoid (fGC) measures of nutrition and thermoregulatory demands on wild bears in Glacier National Park, Montana, and assessed how these measures changed in samples left in the field. Both ambient temperature and exposure can impact thermoregulation and sample degradation. Bear diets vary markedly with season, affecting body condition and thus fGC. We collected fecal samples during September and October, 2001, when ambient temperatures ranged from 30°C to -5°C. We collected half of each sample immediately and left the other half in its original location for 1-28 days. We used generalized linear models (GLM) to first predict fGC concentrations in fresh samples based on proxies of nutrition, ambient temperature, thermal exposure, and precipitation. These same covariates were then used to predict degradation-based differences in fGC concentrations between the paired sample halves. Variation in fGC was predicted by diet, Julian date, aspect, and the interaction between Julian date and aspect in both fresh and exposed samples. Cumulative precipitation was also a significant predictor of fGC concentrations in the exposed samples, independent of time, indicating that precipitation contributes to sample degradation but not enough to mask effects of other environmental factors on fGC concentrations. Differences between sample halves were only predicted by cumulative precipitation and exposure time; cumulative precipitation decreased, whereas exposure time increased, fGC concentrations in the exposed sample halves. Results indicate that fGC can provide reliable indices of nutrition and thermoregulatory demands in bears and that sample degradation impacts on these relations are minimal and can be virtually eliminated by controlling for cumulative precipitation over the estimated exposure times.

Intra- and extraluminal structural and functional venous anomalies in multiple sclerosis, as evidenced by 2 noninvasive imaging techniques

BACKGROUND AND PURPOSE

Chronic cerebrospinal venous insufficiency (CCSVI) is a vascular condition characterized by anomalies of the main extracranial cerebrospinal venous routes that interfere with normal venous outflow. Research into CCSVI will determine its sensitivity and specificity for a diagnosis of MS, its prevalence in MS patients, and its clinical, MRI, and genetic correlates. Our aim was to investigate the prevalence and number of intra- and extraluminal structural and functional extracranial venous abnormalities by using DS and MRV, in patients with MS and HCs.

MATERIALS AND METHODS

One hundred fifty patients with MS, 104 (69.3%) with RR and 46 (30.7%) with a progressive MS course, and 63 age- and sex-matched HCs were scanned with 3T MR imaging by using TOF and TRICKS sequences (only patients with MS). All subjects underwent DS examination for intra- and extraluminal structural and functional abnormalities of the IJVs. Absent/pinpoint IJV flow morphology on MRV was considered an abnormal finding. Prominence of collateral extracranial veins was assessed with MRV.

RESULTS

Patients with MS had a significantly higher number of functional (P < .0001), total (P = .001), and intraluminal (P = .005) structural IJV DS abnormalities than HCs. There was a trend for more patients with MS with extraluminal IJV DS abnormalities (P = .023). No significant differences were found on the MRV IJV flow morphology scale between patients with MS and HCs. Patients with progressive MS showed more extraluminal IJV DS abnormalities (P = .01) and more MRV flow abnormalities on TOF (P = .006) and TRICKS (P = .01) than patients with nonprogressive MS. There was a trend for a higher number of collateral veins in patients with MS than in HCs (P = .016).

CONCLUSIONS

DS is more sensitive than MRV in detecting intraluminal structural and functional venous abnormalities in patients with MS compared with HCs, whereas MRV is more sensitive in showing collaterals.

P5-03-01: Cytoplasmic Cyclin E and P-CDK2 Expression in Triple Negative Breast Carcinomas Measured by Immunohistochemistry Correlates with Poor Outcome

Background: Triple negative breast carcinomas (TNBCs) are aggressive malignancies that lack effective therapeutic targets but express low molecular isoforms of cyclin E (LMW-E). These LMW-E, generated primarily from NH2-terminal elastase cleavage of full length cyclin E (EL), preferentially accumulate in the cytoplasm of cancer cells. Using a transgenic mouse model system, our laboratory has recently shown that cyclin-dependent kinase 2 (CDK2) is required for LMW-E-mediated mammary tumorigenesis. These results lead us to hypothesize that immunohistochemical cytoplasmic detection of LMW-E and phospho-CDK2 in TNBC provides a valuable screening tool for those patients most likely to have a poor prognosis who could then be treated with anti-CDK2 therapy currently clinically available. Material and Methods: Tissue micro-arrays from 168 TNBC patients were IHC stained for cyclin E and p-CDK2. Cyclin E staining intensity and percentage of positivity were evaluated both in the nucleus and cytoplasm of cancer cells and four different phenotypes of cyclin E were distinguished with respect to predominant nuclear or cytoplasmic localization of staining: cyclin E negative, predominantly nuclear, both nuclear and cytoplasmic and predominantly cytoplasmic. p-CDK2 IHC was achived using an antibody, which recognizes phospho-threonine 160 on CDK2. Immunoreactive scores were determined by multiplying the intensity with the extent of staining of nuclei and cytoplasm. We sought correlations between different cyclin E and p-CDK2 expression patterns and disease-free survival (DFS). Results: Cytoplasmic cyclin E accumulation on IHC of TNBCs correlated with poor outcome. Within the median follow up of 7.3 years tumors with both nuclear and cytoplasmic cyclin E expression demonstrated higher recurrence rate compared to entirely negative for cyclin E (p=0.0117). In contrast patients with exclusively nuclear cyclin E showed only a trend toward decreased DFS compared to patients with cyclin E negative tumors (p=0.0896). Furthermore we identified the new phenotype of cyclin E immunoreactivity, which is characterized by negative nucleus and positive cytoplasmic staining. This phenotype was the most significantly associated with poor DFS compared to cyclin E negative phenotype (p=0.0026) and as the only one distinguished at high risk of early recurrence among TNBC patient without axillary nodes involvement (p=0.0105). The expression of p-CDK2 was significantly higher in this phenotype than the cytoplasmic cyclin E.negative tumors. High p-CDK2 tumors were also correlated to worse DFS then p-CDK2 low tumors (P=0.019). Lastly, our analyses revealed that tumors positive for both cytoplasmic cyclin E and p-CDK2 had higher recurrence rate compared to negative for both or positive for one of them (p=0.003).

Discussion: Cytoplasmic cyclin E may help to predict recurrence, especially in early stage, node negative TNBCs. We present a new concept in assessing cyclin E expression. Poor outcome due to TNBCs overexpressing LMW-E provide a rationale to investigate the treatment strategies that could specifically target high LMW-E tumors. These patients could particularly benefit from treatment with CDK2 inhibitors.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-03-01.

A novel staging system for disease-specific survival in patients with breast cancer treated with surgery as the first intervention

92

Background: American Joint Committee on Cancer (AJCC) staging of breast cancer is used to determine prognosis, yet survival of patients within each stage shows wide variation and remains unpredictable. We hypothesized that differences in underlying biology might influence some of this variation and that the addition of biologic markers to current AJCC staging parameters would improve predictions of prognosis.

Methods: We identified an initial cohort of 3,728 patients at our center who underwent surgery as the first intervention between 1997 and 2006. We used a Cox proportional hazards model, with backward stepwise exclusion of factors and stratified on pathologic stage (PS), to test the added significance of modified Black’s nuclear grade (G), the presence of lymphovascular invasion (L), estrogen receptor status (E), progesterone receptor status (P), or combined ER and PR status (EP), or combined receptor subtype (ER+PR+HER2 [M]). We assigned values 0-2 to these disease-specific survival (DSS)–associated factors and then used different combinations to assess different staging systems. Surveillance Epidemiology and End Results (SEER) data was used as the external cohort (n=26,711) to validate the scoring system.

Results: Median follow-up time for the initial cohort was 6.5 years, and the 5-year DSS rate was 97.4%. Six different staging systems were used to predict 5-year patient outcomes: PS, PS+G, PS+GL, PS+EG, PS+GEP, and PS+GM. We compared 5-year DSS rates, Akaike’s information criterion (AIC) and Harrell’s concordance index (C-index) for each staging system. We found that the PS+GEP staging system was most precise with lowest AIC (1927.3) and had the highest C-index (0.80). The ability of the PS+GEP system to stratify outcomes was confirmed in the internal bootstrapping samples and the external validation cohort.

Conclusions: Our results validate a new staging system that incorporates tumor grade, ER and PR status into current AJCC staging for breast cancer. We recommend that biologic markers be incorporated into revised versions of the AJCC staging system for patients undergoing surgery as their first intervention.

Impact of chemotherapy timing on local-regional failures in patients with breast cancer undergoing breast-conserving therapy

82

Background: Debate continues as to whether BCT after neoadjuvant chemotherapy (chemo) can achieve long-term local control rates similar to those experienced by patients undergoing surgery first, especially in those presenting with large tumors. This study was performed to evaluate long-term results of BCT for patients undergoing surgery first versus chemotherapy.

Methods: 2,984 patients underwent BCT with whole breast irradiation from 1987 to 2005. Clinicopathologic and outcomes data were reviewed and comparisons made between surgery first and chemotherapy patients.

Results: 2,331 (78%) patients underwent surgery first; 653 (22%) received chemotherapy first. Overall, chemotherapy patients had more adverse clinicopathologic features (Table). 5 and 10-yr local-regional recurrence (LRR)-free survival rates were 97% (95% CI: 96%-98%) and 94% (93%-95%) for surgery first patients. Chemotherapy downstaged patients presenting with clinical stage II/III disease (608/653; 93%) allowing for BCT, and pathologic findings revealed stage II/III disease in only 305/653 (46%) (p<.001). 5 and 10-yr LRR-free survival rates were 93% (91%-95%) and 90% (87%-93%) after chemotherapy. After adjusting for clinical stage at presentation, there were no differences in LRR between surgery first and chemotherapy patients. On multivariate analysis, age<50, clinical stage III, grade 3, ER neg status, associated DCIS on final pathology, and close/positive margins were associated with LRR.

Conclusions: LRR after BCT is driven by biologic factors and not the timing of chemotherapy. Chemotherapy downstages a significant number of patients with stage II/III disease allowing appropriately selected patients to achieve high rates of local-regional control with BCT.

[Table: see text]