Dose tailoring of adjuvant chemotherapy for breast cancer based on hematologic toxicities: further results from the prospective PANTHER study with focus on obese patients

Background

Adjuvant chemotherapy (ACT) for breast cancer improves relapse-free survival (BCRFS) and overall survival. Differences in terms of efficacy and toxicity could partly be explained by the significant interpatient variability in pharmacokinetics which cannot be captured by dosing according to body surface area. Consequently, tailored dosing was prospectively evaluated in the PANTHER trial.

Patients and methods

PANTHER is a multicenter, open-label, randomized phase III trial which compared tailored, dose-dense (DD) epirubicin/cyclophosphamide (E/C) and tailored docetaxel (D) (tDD) with standard interval 5-fluorouracil/E/C and D. The primary end point was BCRFS and the primary efficacy analysis has been previously published. In this secondary analysis, we aimed to retrospectively explore the concept of dose tailoring. Our two hypotheses were that BCRFS would not vary depending on the cumulative administered epirubicin dose; and that dose tailoring would lead to appropriate dosing and improved outcomes for obese patients, who are known to have worse prognosis and increased toxicity after DD ACT.

Results

Patients treated with tDD had similar BCRFS regardless of the cumulative epirubicin dose (P = 0.495), while obese patients in this group [body mass index (BMI) ≥30] had improved BCRFS compared with nonobese ones (BMI <30) [hazard ratio (HR) = 0.51, 95% confidence interval (CI) 0.30-0.89, P = 0.02]. Moreover, tDD was associated with improved BCRFS compared with standard treatment only in obese patients (HR = 0.49, 95% CI 0.26-0.90, P = 0.022) but not in nonobese ones (HR = 0.79, 95% CI 0.60-1.04, P = 0.089). The differences were not formally statistically significant (P for interaction 0.175). There were no differences in terms of toxicity across the epirubicin dose levels or the BMI groups.

Conclusions

Dose tailoring is a feasible strategy that can potentially improve outcomes in obese patients without increasing toxicity and should be pursued in further clinical studies.

ClinicalTrials.gov identifier

NCT00798070.

Abstract P5-12-01: A novel gene expression signature prognostic for both locoregional and distant failure and predictive for adjuvant radiotherapy

Background: Most patients with early stage breast cancer (BC) are treated with adjuvant radiotherapy (RT) following breast conserving surgery (BCS) to prevent locoregional recurrences (LRR). No predictive tools are currently available to select patients for RT, resulting in considerable over- and under treatment. We aimed to create and validate a gene expression-based classifier to prognosticate for LRR and to stratify patients for treatment with RT.

Patients and methods: A 27-gene expression signature was developed using three publicly available early stage BC gene expression datasets where patients were treated with RT and had detailed local recurrence information. The largest of the datasets was used to train the signature, and the other two datasets were used for signature refinement. As age was the strongest clinical factor for the endpoint in the training dataset, it was included in the model, resulting in a final clinical-genomic classifier of 27 genes and age. The classifier was locked before external validation in the SweBCG91-RT trial. This phase III clinical trial included primary tumors from 765 patients and for which gene expression data was available. The trial randomized node-negative BC patients to +/- RT following BCS, with sparse use of adjuvant systemic treatment (9%) and a median follow-up of 14.0 years for LRR in patients free from event. The classifier was validated using Cox regression with LRR as the primary endpoint, and hazard ratios (HRs) were calculated using the raw continuous classifier score (range: 0.5 to 2.5).

Results: The novel classifier was highly prognostic for LRR in SweBCG91-RT patients treated with RT (HR=7.5[3.3-16.9], p&lt;0.001), and remained prognostic in multivariate analysis (MVA) that included systemic treatment, subtype and grade (HR=7.2[3.1-16.4], p&lt;0.001). To a lesser extent, the classifier was also prognostic for LRR in patients not treated with RT (HR=1.9[1.0-3.5], p=0.03; MVA HR=1.9[1.0-3.3], p=0.05). Patients at high risk of LRR had a smaller effect of RT, and the treatment predictive potential was confirmed by testing for interaction (pinteraction=0.008). In patients treated with RT, age and the genomic component of the model were both prognostic for LRR (p&lt;0.01) as well as predictive for RT response (pinteraction&lt;0.05) and provided independent information (p&lt;0.01). The combined classifier has increased performance over its individual components (10-year AUC=0.72, 0.67, 0.65 for the classifier, age, and genomic component, respectively). While the novel signature was prognostic for metastasis (HR=4.3[2.3-7.8], p&lt;0.0001), calculated scores from previously published signatures to the metastasis endpoint, including the Oncotype-like score, were not prognostic for LRR.

Conclusions: This novel gene expression signature is highly prognostic for LRR, can identify patients at risk of LRR despite RT, and appears to be treatment predictive for adjuvant RT. Furthermore, the current signature is highly prognostic for metastasis. In contrast, calculated scores of previously published signatures modeled for the metastasis endpoint had inferior performance for LRR. These results underscore both the importance of signatures prognostic for LRR and the similarities in the biology of LRR and distant failure.

Citation Format: Sjöström M, Chang SL, Fishbane N, Davicioni E, Zhao SG, Hartman L, Holmberg E, Feng FY, Speers CW, Pierce LJ, Malmström P, Fernö M, Karlsson P. A novel gene expression signature prognostic for both locoregional and distant failure and predictive for adjuvant radiotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-12-01.

Abstract P2-08-05: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Jaraj D, Ahlgren J, Arnesson L-G, Einbeigi Z, Höijer J, Klintman M, Malmström P, Vikhe Patil E, Sund M, Fredriksson I, Bergh J, Pettersson A. Withdrawn [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 P2-08-05.

Abstract P4-09-08: A targeted breast cancer radiosensitivity gene expression panel

Background: A majority of patients with early breast cancer is operated with breast conserving surgery (BCS) and adjuvant radiotherapy (RT) is administered to prevent ipsilateral breast tumor recurrence (IBTR), including a new ipsilateral cancer. The EBCTCG meta-analysis showed a majority of patients treated with surgery only to be recurrence free at 10 years, and more than 10% to suffer an IBTR despite RT, thus implying considerable over- and under treatment. A wide range of prognosticators, including multigene tests, are well established, but we lack predictive factors for RT, which is the aim in the present study.

Patients and methods: Fresh frozen tissue from 340 patients operated with BCS with or without RT and with or without IBTR was collected (without IBTR N=196, with IBTR n=144). Patients were stratified according to estrogen receptor (ER) status and RT, and divided into a training cohort (N=172) and a validation cohort (N=168). The training cohort was analyzed with whole transcriptome analysis (Illumina HT12 v4) and top discriminating genes for IBTR (N=155) were selected based on a random forest machine learning algorithm with recursive feature elimination and cross-validation. Further, genes described in the literature as associated with radioresistance were included in the panel to a total of 248 genes. A custom nCounter (Nanostring Technologies) gene expression panel was designed and both the training and validation cohorts were analyzed with the custom panel. Single-sample classifiers using a k-top scoring pairs algorithm were trained in the training cohort and validated in the validation cohort. Area under the curve (AUC) with a receiver operator characteristics (ROC) analysis were calculated and p-values were calculated with a log-rank test. All calculations were done using the R statistical environment.

Results: Our classifiers were prognostic for IBTR in the validation cohort among ER+ patients given RT (AUC 0.67, p=0.005), ER+ patients not given RT (AUC=0.89, p=0.015) and ER- patients given RT (AUC=0.78, p&lt;0.001), while the number of ER- patients not given RT was too small for subgroup analysis (N=4). We also created a sequential algorithm were a first classifier was applied to test the risk of IBTR without RT. If low, the tumor was classified as “surgery only”. If classified as high, a second classifier was applied to test the risk of recurrence when given RT. If the risk was predicted low after RT, the tumor was classified as “radiosensitive”. If high, the tumor was classified as “radioresistant”. Among ER+ patients in the validation cohort, the “radiosensitive” tumors had an excellent effect of RT (p&lt;0.001), the “radioresistant” had no effect of RT (p=0.4) and a very high risk of recurrence (55% at 10 years). The tumors predicted as “surgery only” had no effect of RT (p=0.4), and a lower risk of recurrence than the “radioresistant” patients (25% at 10 years).

Conclusions: Our targeted radiosensitivity gene expression panel could identify patients of high or low risk of LR, with or without RT. The most promising was however that it seems as the panel could be used as a predictive marker, i.e., finding patients that do, or do not, respond to RT. Further refinement and testing of the panel and models is ongoing.

Citation Format: Sjöström M, Staaf J, Edén P, Wärnberg F, Bergh J, Malmström P, Fernö M, Niméus E, Fredriksson I. A targeted breast cancer radiosensitivity gene expression panel [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 P4-09-08.

Abstract P1-09-03: Relative radioresistency in triple negative tumors in the SweBCG91-RT randomized clinical trial

Introduction: Breast-conserving surgery (BCS) with adjuvant whole breast radiation therapy (WBRT) is the standard treatment for a majority of early breast cancer patients. No predictive biomarkers for RT are in use and most patients are cured by surgery alone, and are thus over-treated. Further, some patients suffer a relapse despite WBRT, and may have benefited from mastectomy or more aggressive postoperative treatment. Gene expression tests can be used to predict risk of distant recurrence and effect of adjuvant systemic therapy, and can reveal the intrinsic subtype of the tumor. A surrogate method of determining intrinsic subtype based on high quality centralized immunohistochemistry (IHC) has been proposed with criteria set up by the St Gallen consensus group 2013. The intrinsic subtypes provide prognostic information and are treatment predictive for chemotherapy, but the predictive potential for WBRT has not been conclusively determined.

Aim: To evaluate the effect of WBRT on ipsilateral breast tumor recurrence (IBTR), in patients with tumors of different intrinsic subtypes.

Methods: Tumor tissue from FFPE blocks were collected from 1003 breast cancer patients with node negative, stage I-II disease, randomized to BCS with or without WBRT, in the randomized SweBCG RT-91 trial between 1991-1997. Systemic adjuvant treatment was administered according to regional guidelines, but was sparsely used. Median follow-up was 15.2 years. Tissue microarrays were constructed and stained for estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor 2 (Her2) and Ki-67. SISH was used to determine amplification of samples scored 2+ for Her2. Centralized evaluation was performed by two pathologists subspecialized in breast pathology. Endpoint IBTR within 10 years was considered with a cumulative incidence and competing risks approach. P-values were calculated with the cause-specific logrank test and hazard ratios (HR) with cause specific Cox regression. Multivariate models, with or without an interaction term between subtype and WBRT, were compared to formally test if the effect of RT differs between subtypes.

Results: We were able to stain and score 958 out of 1003 tumors. These were classified as Luminal A-like (n=554), Luminal B-like (Her2-negative, n=259), triple negative (n=81) and Her2-positive (any ER status, n=64). WBRT reduced the frequency of IBTR for Luminal A-like tumors (19% vs 9%, HR 0.46 (0.28-0.74), p=0.001), Luminal B-like tumors (24% vs 8%, HR 0.30 (0.14-0.61), p&lt;0.001) and triple negative tumors (21% vs 6%, HR 0.25 (0.05-1.12), p=0.05), but not for Her2-positive tumors (15% vs 19%, HR 1.29 (0.38-4.4), p=0.69). However, the overall difference in WBRT effect between subtypes was not formally statistically validated (p=0.17).

Conclusions: We found that WBRT reduced IBTRs among the Luminal A, Luminal B, and the triple negative subgroups, but not in the Her2-positive subgroup. Thus, intrinsic subtyping by IHC may give information on how tumors respond to adjuvant WBRT. Additional studies are required and it remains to study the effect on breast cancer specific survival.

Citation Format: Sjöström M, Lundstedt D, Hartman L, Holmberg E, Kovács A, Malmström P, Niméus E, Werner Rönnerman E, Fernö M, Karlsson P. Relative radioresistency in triple negative tumors in the SweBCG91-RT randomized clinical trial [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 P1-09-03.

No breast cancer subgroup can be spared postoperative radiotherapy after breast-conserving surgery. Fifteen-year results from the Swedish Breast Cancer Group randomised trial, SweBCG 91 RT

BACKGROUND

Breast-conserving surgery (BCS) followed by radiotherapy (RT) is an established treatment for women with T1-2N0 breast cancers. Since subgroups of patients have low ipsilateral breast tumour recurrence (IBTR) rates, it is important to study whether RT is necessary for all patients.

PATIENTS AND METHODS

A total of 1187 women with primary T1-2N0M0 breast cancer were randomised, after standardised sector resection, to postoperative whole breast RT or no local treatment. Adjuvant systemic therapy was offered to patients with stage II cancers. Patients were followed with clinical examinations and annual mammography for 10 years and thereafter referred to the Swedish mammography screening program.

RESULTS

After 15 years of follow-up, a higher cumulative incidence of IBTR was observed in control patients, 23.9%, versus irradiated patients, 11.5%, P<0.001. Recurrence-free survival was inferior, 51.7% versus 60.4%, P=0.0013. The main effect of RT was seen during the first 5 years. However, overall survival was not significantly lower 68.4% versus 71.1%, P=0.68, nor was breast cancer-specific mortality significantly higher.

CONCLUSIONS

RT after BCS significantly reduced the incidence of IBTR at 15 years of follow-up. We were unable to identify subgroups which could be spared RT. Breast cancer mortality was not significantly reduced after RT. Good predictive markers for radiation sensitivity and improved adjuvant systemic therapy are needed to omit RT after BCS.

Abstract P5-08-30: Androgen receptor in early breast cancer: Distribution and prognostic value

Purpose:

Androgen receptor (AR) status in breast cancer has received renewed interest over the last years especially in triple-negative disease (TNBC), but the prognostic value is still under debate. The aim of this study was to assess the distribution and prognostic value of AR in early breast cancer patients with or without adjuvant endocrine treatment.

Patients and methods:

AR was assessed on tissue microarray with the AR 441 antibody (Thermo Scientific) on a cohort consisting of 471 patients derived from two clinical studies: (1) 208 premenopausal node-negative patients of which 87% had received no adjuvant medical treatment and (2) 263 estrogen receptor (ER)+ and ER-, node-positive and –negative patients treated with 2 years of adjuvant tamoxifen. Nuclear AR was divided in 5 groups: 0-1%, 2-10%, 11-50%, 51-75%, and 76-100% positive cells, scored as 0-4. Cox proportional hazards regression, stratified by study, was used to model the impact of the prognostic factors on distant disease-free survival (DDFS), both using trend tests and a cut-off for positivity set at &gt;10%, and log-rank tests to compare survival in different strata. Due to non-proportional hazards, the analysis was restricted to the first 5 years after diagnosis, a time period during which 95 patients developed distant recurrences.

Results:

76% of all patients were AR+, and 89%, 48%, and 23% of the ER+, ER-, and TNBC, respectively. Positive associations were observed between AR, ER and progesterone receptor status (PgR), negative associations with Ki67, and histological grade, but no associations with tumour size, age or Human Epidermal Growth Factor Receptor 2 (HER2). In univariable analysis, when divided into 5 groups, AR was a prognostic factor for DDFS with a Hazard Ratio (HR) of 0.86 per step in fraction score (95% Confidence Interval (CI): 0.76-0.98, p=0.018), as was HER2, age, size, grade, node-status, PgR, and ER status. In the Kaplan-Meier curves for each study, a similar but weaker trend was found (log-rank test for trend p=0.14 and 0.057 for cohort 1 and 2, respectively). With a cut-off at 10%, a similar HR was found (HR=0.67, 95% CI:0.43-1.05, p=0.078). In multivariable analysis, adjusted for grade, tumour size, HER2, ER, node-status, and age, AR did not retain independent prognostic value (HR 1.04 95% CI:0.88-1.23, p=0.66). In the TNBC patients there were no significant differences in DDFS in the AR+ vs AR-patients, possibly due to few events and a small population (n=20/75).

Conclusion:

This study demonstrates that AR is a weak prognostic factor for recurrence in a cohort consisting of node-negative premenopausal patients without endocrine treatment and patients who have received adjuvant endocrine treatment. There was however no independent value in multivariable analyses. It is noteworthy that there were 23% AR positive TNBC patients, for whom there is currently no available targeted treatment. There are several ongoing studies with AR-targeted treatment in the metastatic setting, which if proven effective, may be transferred to studies in the adjuvant setting with the goal of improving long-term prognosis for TNBC. Taken together, AR may be clinically helpful for prognostic considerations and for selection of adjuvant treatment.

Citation Format: Werner-Hartman L, Folkesson E, Nodin B, Malmström P, Fernö M, Nimeus E, Klintman M. Androgen receptor in early breast cancer: Distribution and prognostic value. [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 P5-08-30.

Pathological complete response after neoadjuvant chemotherapy is an independent predictive factor irrespective of simplified breast cancer intrinsic subtypes: a landmark and two-step approach analyses from the EORTC 10994/BIG 1-00 phase III trial

BACKGROUND

Pathological complete response (pCR) following chemotherapy is strongly associated with both breast cancer subtype and long-term survival. Within a phase III neoadjuvant chemotherapy trial, we sought to determine whether the prognostic implications of pCR, TP53 status and treatment arm (taxane versus non-taxane) differed between intrinsic subtypes.

PATIENTS AND METHODS

Patients were randomized to receive either six cycles of anthracycline-based chemotherapy or three cycles of docetaxel then three cycles of eprirubicin/docetaxel (T-ET). pCR was defined as no evidence of residual invasive cancer (or very few scattered tumour cells) in primary tumour and lymph nodes. We used a simplified intrinsic subtypes classification, as suggested by the 2011 St Gallen consensus. Interactions between pCR, TP53 status, treatment arm and intrinsic subtype on event-free survival (EFS), distant metastasis-free survival (DMFS) and overall survival (OS) were studied using a landmark and a two-step approach multivariate analyses.

RESULTS

Sufficient data for pCR analyses were available in 1212 (65%) of 1856 patients randomized. pCR occurred in 222 of 1212 (18%) patients: 37 of 496 (7.5%) luminal A, 22 of 147 (15%) luminal B/HER2 negative, 51 of 230 (22%) luminal B/HER2 positive, 43 of 118 (36%) HER2 positive/non-luminal, 69 of 221(31%) triple negative (TN). The prognostic effect of pCR on EFS did not differ between subtypes and was an independent predictor for better EFS [hazard ratio (HR) = 0.40, P < 0.001 in favour of pCR], DMFS (HR = 0.32, P < 0.001) and OS (HR = 0.32, P < 0.001). Chemotherapy arm was an independent predictor only for EFS (HR = 0.73, P = 0.004 in favour of T-ET). The interaction between TP53, intrinsic subtypes and survival outcomes only approached statistical significance for EFS (P = 0.1).

CONCLUSIONS

pCR is an independent predictor of favourable clinical outcomes in all molecular subtypes in a two-step multivariate analysis.

CLINICALTRIALSGOV

EORTC 10994/BIG 1-00 Trial registration number NCT00017095.

Abstract P6-06-52: Increased expression of insulin-like growth factor-1 receptor is associated with better prognosis in a cohort of tamoxifen treated women

Background: Treatment resistance is a well-known problem in estrogen receptor (ER) positive breast cancer. Complementary therapies are investigated for women who do not respond or who develop resistance against standard ER targeted treatment. Insulin-like growth factor-1 receptor (IGF1R) and its signaling pathway has been suggested to cause estrogen-independent cell growth and survival. Therapy against targets within the pathway is currently investigated in clinical trials. The aim of this study was to investigate if the IGF1R/mTOR pathway was activated or deregulated in breast cancer patients and to explore if any of the markers were prognostic, with or without adjuvant tamoxifen.

Material and methods: Two patient cohorts were investigated by immunohistochemistry using tissue microarrays. The first cohort (N = 264) consisted of mainly post-menopausal women with stage II breast cancer treated with tamoxifen for 2 years irrespective of ER status. The second cohort (N = 206) consisted of mainly medically untreated, pre-menopausal patients with node-negative breast cancer. The protein expression of IGF1R, p-mTOR and p-S6rp were investigated. Cytoplasmic staining was evaluated for all markers and membrane staining was additionally evaluated for IGF1R. Statistical analyses were based on the intensity (0-3) of staining. Expression of IGF1R gave similar results in the cytoplasm and membrane, and p-values for cytoplasmic staining are reported below. Distant disease free survival (DDFS) at 5 years was used as end-point.

Results: IGF1R expression was positively associated with ERa (p&lt;0.001 in Mann-Whitney ranksum test), PgR (p&lt;0.001) and HER2 (p = 0.042) expression in cohort 1, and also with Ki67 (p = 0.006) in cohort 2. p-S6rp was positively associated with ERα in cohort 1 (p&lt;0.001) and HER2 (p = 0.004) in cohort 2. p-mTOR was positively associated only with Ki67 (p&lt;0.001) in cohort 1. High expression of IGF1R was associated with a significantly better prognosis in cohort 1 (HR = 0.7 per intensity step, 95% CI = 0.5-0.9, p = 0.016 using Cox regression). When stratifying for ER status the effect was found in ER negative (ER-) (N = 80, HR = 0.6, 95% CI = 0.4-1.0, p = 0.03) but not in ER positive (ER+) patients (N = 174, HR 1.2, 95% CI = 0.8-2.0, p = 0.40). Both the effect in the ER- subgroup as well as the difference between ER- and ER+ patients were confirmed in interaction analysis and remains after adjustment for age, tumor size, node status, HER2, Ki67, and menopausal status (p = 0.06 for interaction). In cohort 2, no relation to DDFS could be found for IGF1R. p-mTOR and p-S6rp showed no relationship to prognosis in either of the cohorts.

Conclusion: We found that high IGF1R expression was associated with a better prognosis for tamoxifen treated women. This effect could be seen in the ER- but not in the ER+ subgroup of patients. The lack of co-activation of downstream markers (p-mTOR and p-S6rp) in the IGF1R pathway shows that the prognostic effect is not due to complete activation of this pathway.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-52.

Abstract P2-11-15: Immunohistochemical assessment of Ki67 with the antibodies SP6 and MIB1 - A comparison of prognostic information and reproducibility

Background

Proliferation is a key feature in breast cancer and also a clinical important factor for prognosis and treatment prediction. In the St Gallen Consensus of 2011, immunohistochemically analysed Ki67 was adopted as a surrogate marker to distinguish the “luminal A” from the “luminal B” subtype, in order to select patients with estrogen receptor positive disease expected to benefit from adjuvant chemotherapy. The mouse monoclonal antibody MIB1 is the generally accepted antibody for assessment of Ki67. However, other antibodies have been developed, e.g. the rabbit monoclonal antibody SP6. The assessment of Ki67 with MIB1 is unfortunately associated with a considerable lack of reproducibility. Rabbit monoclonal antibodies generally tend to have higher specificity without loss of sensitivity, compared to corresponding mouse monoclonal antibodies. SP6 has also been found to have reduced background staining compared to MIB1. According to these advantages, SP6 may be an alternative to MIB1 for routine staining of Ki67. Any methodological modification should, according to international recommendations, be compared against a clinically validated assay and demonstrate acceptable concordance before being introduced in clinical routine. The analysis of Ki67 with SP6 therefore needs to be evaluated and compared to MIB1 in a cohort of breast cancer patients with clinical follow-up.

Aims

To compare the antibodies SP6 and MIB1 for immunohistochemical assessment of Ki67 in primary breast cancer regarding prognostic strength and reproducibility of the evaluation.

Methods

Tissue microarray from a cohort of 237 premenopausal women with node-negative breast cancer was used for assessment of Ki67, with both SP6 and MIB1, by three different investigators. The 7th decile was applied for defining cut-off. Distant disease-free survival (DDFS) was used as endpoint and the follow-up was restricted to 5 years.

Results

Ninety per cent of the samples were classified into the same group, either high or low Ki67, irrespective of antibody used. Ki67 (high vs. low), analysed with both antibodies was associated to DDFS (34 events) in the univariable analyses (SP6: HR 2.6, 95% CI 1.3-5.2, p = 0.01 and MIB1: HR 2.8, 95% CI 1.4-5.7 p = 0.004) and showed borderline significance for DDFS in the multivariable analyses, also including HER2, age, and tumour size (SP6: HR 2.0, 95% CI 0.93-4.5, p = 0.074 and MIB1: HR 2.2, 95% CI 0.97-4.8, p = 0.058). The agreement between different assessors was somewhat higher for MIB1 than for SP6 (kappa-values 0.83-0.88 vs. 0.72-0.77).

Conclusions

SP6 was not superior to MIB1 and the two antibodies were comparable in the assessment of Ki67 for prognostic considerations in primary breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-11-15.

Abstract P1-08-12: G protein-coupled estrogen receptor in the plasma membrane is prognostic in early breast cancer

Background: G protein-coupled estrogen receptor (GPER), also known as GPR30, is a novel putative estrogen receptor. Although contradictory results have been presented e.g. regarding the subcellular localization and function of the receptor, previous studies have shown a prognostic value in breast cancer and proposed treatment predictive information for tamoxifen (Tam). This study aimed at clarifying the prognostic and treatment predictive value for Tam of GPER, in different subcellular localizations, by using samples from a randomized clinical trial - the ideal population for assessing treatment prediction.

Material and Methods: GPER levels were assessed semi-quantitatively by immunohistochemistry in tissue microarrays from 742 postmenopausal breast cancer patients with no lymph node metastasis and tumor size ≤ 30mm. Patients were originally included in the STO-3 trial 1976-1990. After surgery, they were randomized to Tam treatment (40mg for 2 years or no systemic treatment), regardless of classical estrogen receptor α (ER) status. GPER staining was evaluated in carcinoma both as intensity in 5 levels regardless of subcellular localization, and in the plasma membrane in 3 levels. Due to statistical considerations regarding group size, the final analysis was made with intensity in 3 levels and plasma membrane as positive or negative. The Kaplan-Meier method and logrank test (for trend when applicable) were used for survival analysis and Cox regression analysis for obtaining hazard ratios (HR), interaction testing and multivariate modeling. Distant disease-free survival (DDFS) was used as endpoint.

Results: Analyzing all patients, we found no association between DDFS and GPER intensity. However, positive plasma membrane staining showed a strong correlation with poor prognosis (HR 1.8 p = 0.002). This was only observed in the ER+ subgroup (ER+ patients HR 2.1, p&lt;0.001, ER- patients HR 1.1 p = 0.79). The prognostic value, in untreated patients only, was analyzed with similar results (plasma membrane staining positive vs. negative: all untreated patients HR 1.8 p = 0.008, ER+ patients HR 2.1 p = 0.003, ER- patients HR 1.1 p = 0.83).

No obvious difference in tamoxifen response was observed across plasma membrane or intensity groups, and tests for interaction were not significant.

A multivariate model including GPER in plasma membrane, ER, histological grade, HER2, tamoxifen and tumor size showed that GPER was an independent prognostic factor (HR 1.6 p = 0.01). Finally we created a group with ER+, progesterone receptor (PR) + patients treated with Tam, as this group today is treated with Tam and thought to have a good response. GPER in the plasma membrane significantly separated this group into an excellent prognosis group and a poor prognosis group (HR 3.3, p = 0.01). The excellent prognosis group, which constitutes more than half of ER+ patients, had a 20 year DDFS of 91% (95% CI 84-95).

Conclusion: We found no treatment predictive value of GPER for Tam. However, GPER expressed in the plasma membrane was a strong independent prognostic factor for a poor prognosis in ER+ breast cancer. Used in ER+, PR+, tamoxifen treated patients, it can distinguish patients with an excellent prognosis from patients with a poor outcome that may benefit from additional treatment.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-08-12.

A prospective, multicenter validation study of a prognostic index composed of S-phase fraction, progesterone receptor status, and tumour size predicts survival in node-negative breast cancer patients: NNBC, the node-negative breast cancer trial

BACKGROUND

In a retrospective study on node-negative breast cancer, a prognostic index consisting of a proliferation factor, S-phase fraction (SPF), progesterone receptor status (PR), and tumour size identified one-third of patients as high risk, with a sixfold increased risk of breast cancer death. This prospective multicenter cohort study was set up to validate the index.

PATIENTS AND METHODS

In 576 T1-2N0 patients <60 years, prospective analyses of PR and SPF were carried out. High risk was defined as ≥2 of the following: size >20 mm, PR-negativity, and high SPF (in the absence of SPF, Bloom-Richardson grade 3). Median follow-up was 17.8 years.

RESULTS

Thirty-one percent were high risk. In univariate analysis, the index was prognostic for breast cancer-specific survival after 5 years [hazard ratio (HR) = 4.7, 95% confidence interval (95% CI) 2.5-8.9], 10 years (HR = 2.2, 95% CI 1.5-3.3), and 15 years (HR = 1.7, 95% CI 1.2-2.5), and remained significant after adjustment for adjuvant medical treatment and age. In the 37% of patients with no risk factors, only one patient died of breast cancer the first 5 years.

CONCLUSIONS

This prospective study validates a prognostic index consisting of a proliferation factor, PR-status, and tumour size. The index may be helpful for prognostic considerations and for selection of patients in need of adjuvant therapy.

Towards optimised information about clinical trials; identification and validation of key issues in collaboration with cancer patient advocates

Clinical trials are crucial to improve cancer treatment but recruitment is difficult. Optimised patient information has been recognised as a key issue. In line with the increasing focus on patients' perspectives in health care, we aimed to study patients' opinions about the written information used in three clinical trials for breast cancer. Primary data collection was done in focus group interviews with breast cancer patient advocates. Content analysis identified three major themes: comprehensibility, emotions and associations, and decision making. Based on the advocates' suggestions for improvements, 21 key issues were defined and validated through a questionnaire in an independent group of breast cancer patient advocates. Clear messages, emotionally neutral expressions, careful descriptions of side effects, clear comparisons between different treatment alternatives and information about the possibility to discontinue treatment were perceived as the most important issues. Patients' views of the information in clinical trials provide new insights and identify key issues to consider in optimising future written information and may improve recruitment to clinical cancer trials.

Long-term follow-up of the SBG 9401 study comparing tailored FEC-based therapy versus marrow-supported high-dose therapy

BACKGROUND

The purpose was to investigate adjuvant marrow-supportive high-dose chemotherapy compared with an equitoxicity-tailored comparator arm.

PATIENTS AND METHODS

Five hundred and twenty-five women below the age of 60 years with operated high-risk primary breast cancer were randomised to nine cycles of granulocyte colony-stimulating factor supported and individually tailored FEC (5-fluorouracil, epirubicin, cyclophosphamide), (n = 251) or standard FEC followed by marrow-supported high-dose therapy with CTCb (cyclophosphamide, thiotepa, carboplatin) therapy (n = 274), followed by locoregional radiotherapy and tamoxifen for 5 years.

RESULTS

There were 104 breast cancer relapses in the tailored FEC group versus 139 in the CTCb group (double triangular method by Whitehead, P = 0.046), with a median follow-up of all included patients of 60.8 months. The event-free survival demonstrated 121 and 150 events in the tailored FEC- and CTCb group, respectively [P = 0.074, hazard ratio (HR) 0.804, 95% confidence interval (CI) 0.633-1.022]. Ten patients in the tailored FEC regimen developed acute myeloid leukaemia (AML)/myelodysplasia (MDS). One hundred deaths occurred in the tailored FEC group and 121 in the CTCb group (P = 0.287, HR 0.866, 95% CI 0.665-1.129).

CONCLUSION

The update of this study shows an improved outcome linked to the tailored FEC treatment in relation to breast cancer relapse, but also an increased incidence of AML/MDS.

Breast conservation surgery, with and without radiotherapy, in women with lymph node-negative breast cancer: a randomised clinical trial in a population with access to public mammography screening

The effect of postoperative radiotherapy after sector resection for stage I-II lymph node-negative breast cancer was evaluated in a patient population with access to public mammographical screening. 1187 women were randomised to no further treatment or postoperative radiotherapy following a standardised sector resection and axillary dissection. Radiation was administered to a dose of 48-54 Gy. Median age was 60 years, and median size of the detected tumours was 12 mm. Of the women 65% had their tumours detected by mammographical screening. The relative risk (RR) of ipsilateral breast recurrence was significantly higher in the non-irradiated patients compared with the irradiated patients, RR=3.33 (95% Confidence Interval (CI) 2.13-5.19, P<0.001). The corresponding cumulative incidence at 5 years was 14% versus 4%, respectively. Overall survival (OS) was similar, RR=1.16 (95% CI 0.81-1.65, P=0.41), with 5 year probabilities of 93 and 94%, respectively. Recurrence-free survival (RFS) at 5 years was significantly lower in the non-irradiated women, 77% versus 88% (P<0.001). Although women above 49 years of age, whose tumours were detected with mammographical screening, had the lowest rate of ipsilateral breast recurrence in this study, the cumulative incidence of such event amounted to 10% at 5 years if radiotherapy was not given. Such a recurrence rate has been considered as unacceptably high, but is, however, in the same range as that reported after lumpectomy and postoperative radiotherapy in published series.

Prognostic value of quality of life scores for time to progression (TTP) and overall survival time (OS) in advanced breast cancer

The purpose of the study was to investigate whether baseline quality of life (QoL) and changes in QoL scores from baseline are prognostic for time to progression (TTP) and/or overall survival (OS) in patients with advanced breast cancer receiving docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). QoL was assessed at baseline and before each treatment using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30). Survival curves and probabilities were estimated using the Kaplan-Meier technique. The Cox proportional hazards regression model was used for both the univariate and multivariate analyses to explore relationships between baseline QoL variables and TTP, as well as OS. In the univariate analysis, more severe pain and fatigue at baseline were predictive for a shorter OS; global QoL, physical functioning and appetite loss had a borderline significance (P=0.0130 for global QoL; P=0.0256 for physical functioning: P=0.0149 for appetite loss). World Health Organization (WHO) performance status was significantly predictive for OS. In the multivariate analysis, more severe pain at baseline was predictive for a shorter OS. In contrast, baseline QoL had no prognostic value for the duration of TTP. QoL change scores from baseline QoL predicted neither OS nor TTP. Our findings suggest that while QoL measurements are important in evaluating patients' QoL, they have no great importance in predicting primary clinical endpoints such as TTP or OS in advanced breast cancer patients.

Tumour microvessel density as predictor of chemotherapy response in breast cancer patients

The aim of this study was to evaluate the predictive value of intratumoural microvessel density in breast cancer. We studied immunohistochemically primary tumours of 104 patients with metastasised breast cancer who took part in a randomised multicentre trial comparing docetaxel to sequential methotrexate and 5-fluorouracil. Vessels were highlighted with factor VIII staining and counted microscopically. Microvessel density was compared with clinical response to chemotherapy and patient survival. The microvessel density of the primary tumour was not significantly associated with patient's response to chemotherapy, time to progression or overall survival in the whole patient population or in the docetaxel or methotrexate and 5-fluorouracil groups. However, disease-free survival was longer in patients with low microvessel density (P=0.01). These findings suggest that microvessel density of the primary tumour cannot be used as a predictive marker for chemotherapy response in advanced breast cancer.

C-erbB-2 expression does not predict response to docetaxel or sequential methotrexate and 5-fluorouracil in advanced breast cancer

Breast cancer patients with c-erbB-2-positive tumours seem to benefit from anthracycline-based adjuvant chemotherapy. The predictive value of c-erbB-2 for taxane sensitivity is not yet clear. The purpose of this study was to assess whether c-erbB-2 expression is associated with clinical sensitivity to docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). A total of 283 patients with metastatic breast cancer were initially enrolled in a randomised multicentre trial comparing docetaxel with sequential MF in advanced breast cancer. Paraffin-embedded blocks of the primary tumour were available for 131 patients (46%). c-erbB-2 status was determined by immunohistochemistry using a polyclonal antibody to the c-erbB-2 protein. C-erbB-2 expression was scored in a semi-quantitative fashion using a 0 to 3+ scale. Staining scores 2+ or greater were considered positive. Response evaluation was performed according to World Health Organization (WHO) recommendations. Overall 54 (42%) patients had c-erbB-2-positive tumours. There was no association between treatment outcome and c-erbB-2 overexpression. The overall response rates (RR) (n=128) among c-erbB-2-negative and -positive patients were 35 and 44%, respectively (P=0.359). In the MF arm (n=62), the RR was somewhat higher in the c-erbB-2 overexpressors (33% versus 18%, P=0.18). In the docetaxel arm the RRs were very similar, regardless of the c-erbB-2 expression (53% versus 53%). While several studies have suggested a prognostic and putative predictive significance of c-erbB-2 overexpression in early breast cancer, the significance of c-erbB-2 expression as a predictive factor for response to various cytotoxic treatments in advanced breast cancer is still controversial. In this study, c-erbB-2 expression could not predict response to either MF or T. Thus, tumours over-expressing c-erbB-2 are not uniformly more sensitive to taxanes and c-erbB-2 expression cannot yet be applied clinically as a predictive factor for response in advanced breast cancer.

S-phase fraction and urokinase plasminogen activator are better markers for distant recurrences than Nottingham Prognostic Index and histologic grade in a prospective study of premenopausal lymph node-negative breast cancer

PURPOSE

Histologic grade, Nottingham Prognostic Index (NPI), estrogen receptor (ER) and progesterone receptor (PgR) status, and tumor size have previously been shown to be important prognostic indicators for distant recurrence of breast cancer. The purpose of this study was to compare the prognostic value of these factors with flow cytometric S-phase fraction (SPF), urokinase plasminogen activator (uPA), and plasminogen activator inhibitor type 1 (PAI-1) in premenopausal patients with lymph node-negative breast cancer.

PATIENTS AND METHODS

In 237 consecutive premenopausal patients with lymph node-negative breast cancer and freshly frozen tumor material available, SPF, ER and PgR status, uPA and its inhibitor PAI-1, histologic grade, and NPI were evaluated.

RESULTS

SPF was univariately the most powerful prognostic factor for distant recurrence, followed by uPA, histologic grade, PgR, age, ER, NPI, and PAI-1, the latter being nonsignificant. Multivariate analysis revealed that neither NPI nor histologic grade was significant after adjustment for SPF, a fact that may be explained by the strong association between these factors. uPA was, however, an independent prognostic factor in addition to SPF, NPI, or histologic grade.

CONCLUSION

In this prospective study, SPF and uPA were found to be independent prognostic factors in premenopausal women with lymph node-negative breast cancer. We suggest that SPF, if performed under standardized conditions, can replace histologic grade as a selection instrument for adjuvant medical treatment. The value of the combination of SPF and uPA needs to be confirmed in an independent prospective trial.

DNA-synthesizing enzymes in breast cancer (thymidine kinase, thymidylate synthase and thymidylate kinase): association with flow cytometric S-phase fraction and relative prognostic importance in node-negative premenopausal patients

S-phase fraction (SPF) is a reference for cell-kinetic analysis. In this study, the links between SPF and the essential enzymes participating in the pyrimidine synthesis were investigated in breast cancer and their relationships with the natural history of the disease were compared. We measured thymidine kinase (TK) for salvage synthesis, thymidylate synthase (TS) for de novo synthesis and thymidylate kinase (TMK), which is required for both pathways. Our study population consisted of 211 premenopausal women with node-negative tumors. SPF was assessed prospectively by flow cytometry, whereas enzyme activities were measured retrospectively in cytosols using radioenzymatic methods. Among the enzymes analyzed, only TK demonstrated a strong correlation with SPF (r(s) = 0.59). In univariate analysis, high SPF and high levels of TK were associated with increased risk of developing distant recurrences (p < 0.001). Correlations with other prognostic factors (histological grade, steroid receptors, DNA ploidy status, urokinase plasminogen activator and plasminogen activator inhibitor type 1) confirmed a parallel association of SPF and TK with the most aggressive tumors. In contrast, TS and TMK were not associated with prognosis. After adjustment for SPF, the risk of relapse increased significantly with TK values. Subgroup analysis showed that additional information was provided by TK in the tumors with low SPF. When urokinase plasminogen activator (uPA) was a candidate variable in multivariate analysis, TK remained significant. Combined with SPF and uPA, TK could be useful to define premenopausal node-negative patients with rapidly proliferating tumors at a high risk of metastatic disease.

ErbB2 status and the benefit from two or five years of adjuvant tamoxifen in postmenopausal early stage breast cancer

AIM

We aimed to study the importance of erbB2 status in early stage postmenopausal breast cancer for patients who participated in a trial of five vs. two years of adjuvant tamoxifen.

PATIENTS AND METHODS

We analysed the erbB2 status of the tumours from 577 patients participating in the trial, either by a DNA amplification assay (n = 181) or by measurement of the protein level with flow cytometry (n = 396).

RESULTS

ErbB2 was overexpressed or gene amplified in 102 of the patients (18%). Overall, erbB2-positive patients had a significantly lower recurrence-free probability than others, 62% at five years as compared to 83%, and showed a significantly decreased breast cancer survival rate (P = 0.0007). ErbB2 status was significantly associated with recurrence and death in Cox multivariate analysis, adjusting for nodal status, tumour size and estrogen receptor status. The relative risk of recurrence (RR) for five vs. two years of tamoxifen was analysed in relation to erbB2 status for patients still disease-free two years after surgery. Whereas erbB2-negative patients showed significant benefit from prolonged treatment (RR = 0.62, 95% confidence interval (95% CI): 0.42-0.93), no benefit was evident for erbB2-positive patients (RR = 1.1, 95% CI: 0.41-3.2). When the same analysis was restricted to ER-positive patients a similar difference in relative hazard was obtained but the difference was not strictly significant (P = 0.065).

CONCLUSIONS

For early stage breast cancer patients treated with adjuvant tamoxifen, overexpression of erbB2 is an independent marker of poor prognosis. The results suggest that overexpression decreases the benefit from prolonged tamoxifen treatment.

Tailored fluorouracil, epirubicin, and cyclophosphamide compared with marrow-supported high-dose chemotherapy as adjuvant treatment for high-risk breast cancer: a randomised trial. Scandinavian Breast Group 9401 study

BACKGROUND

Chemotherapy drug distribution varies greatly among individual patients. Therefore, we developed an individualised fluorouracil, epirubicin, cyclophosphamide (FEC) regimen to improve outcomes in patients with high-risk early breast cancer. We then did a randomised trial to compare this individually tailored FEC regimen with conventional adjuvant chemotherapy followed by consolidation with high-dose chemotherapy with stem-cell support.

METHODS

525 women younger than 60 years of age with high-risk primary breast cancer were randomised after surgery to receive nine cycles of tailored FEC to haematological equitoxicity with granulocyte colony-stimulating factor (G-CSF) support (n=251), or three cycles of FEC at standard doses followed by high-dose chemotherapy with cyclophosphamide, thiotepa, and carboplatin (CTCb), and peripheral-blood stem-cell or bone-marrow support (n=274). Both groups received locoregional radiation therapy and tamoxifen for 5 years. The primary outcome measure was relapse-free survival, and analysis was by intention to treat.

FINDINGS

At a median follow-up of 34.3 months, there were 81 breast-cancer relapses in the tailored FEC group versus 113 in the CTCb group (double triangular method p=0.04). 60 deaths occurred in the tailored FEC group and 82 in the CTCb group (log-rank p=0.12). Patients in the CTCb group experienced more grade 3 or 4 acute toxicity compared with the tailored FEC group (p<0.0001). Two treatment-related deaths (0.7%) occurred in the CTCb group. Six patients in the tailored FEC group developed acute myeloid leukaemia and three developed myelodysplastic syndrome.

INTERPRETATION

Tailored FEC with G-CSF support resulted in a significantly improved relapse-free survival and fewer grade 3 and 4 toxicities compared with marrow-supported high-dose chemotherapy with CTCb as adjuvant therapy of women with high-risk primary breast cancer.

Predictive value of p53, mdm-2, p21, and mib-1 for chemotherapy response in advanced breast cancer

p53 is a transcription factor that participates in cell cycle checkpoint processes and apoptosis. The protein product of the murine double minute gene 2 (mdm-2) plays a central role in the regulation of p53. In response to DNA-damaging agents, the wild-type p53-activated fragment 1 (WAF1 also known as p21) is an important downstream effector in the p53-specific growth arrest pathway. In breast cancer patients, it is unclear whether measuring p53, mdm-2, or p21 expression provides information on how patients will respond to chemotherapy. Mib-1 monoclonal antibody recognizes the proliferation-related antigen Ki-67. High tumor proliferation has previously been associated with response to chemotherapy. p53, mdm-2, p21, and mib-1 expression were assessed by immunohistochemical methods in primary tumors derived from 134 patients who took part in a randomized multicenter trial comparing docetaxel to sequential methotrexate and 5-fluorouracil (MF) in advanced breast cancer. Low mib-1 staining correlated with negative p53 staining (P = 0.001), and mdm-2 and p21 stainings correlated positively with each other (P < 0.001). p53, mdm-2, p21, and mib-1 expression were not significantly associated with response to chemotherapy, time to progression, or overall survival in the whole patient population or in the docetaxel group. However, in the MF group, a low mib expression (<25%) and a high mdm-2 expression (> or =10%) predicted a better response (P = 0.014 and P = 0.046, respectively) to treatment and a longer time to progression in both univariate and multivariate analyses. p53 staining status was not associated with response to treatment in either group. Interestingly, tumors with both negative mdm-2 and p21 expression, irrespective of p53 status, had a high response rate to docetaxel but no response to MF. Although highly preliminary, the findings suggest that different tumor biological factors may predict response to different chemotherapy regimens with distinct mechanisms of action. The results of our phenotype analysis also indicate that it is more likely that a panel of tumor biological factors instead of only one single factor may be needed for better prediction of chemotherapy response.

Quality of life in patients with metastatic breast cancer receiving either docetaxel or sequential methotrexate and 5-fluorouracil. A multicentre randomised phase III trial by the Scandinavian breast group

The purpose of this study was to evaluate the effects of two alternative chemotherapy regimes on the quality of life (QoL) of patients with advanced breast cancer. In a multicentre trial, 283 patients were randomised to receive either docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). QoL was assessed at baseline and before each treatment using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30). Initial compliance in the QoL study was 96% and the overall compliance 82%. QoL data were available for 245 patients (T 130 and 115 MF). Both treatment groups showed some improvement in emotional functioning during treatment, with a significant difference favouring the MF group at treatment cycles 5 and 6. In the T group, the scores on the other functional scales remained stable throughout the first six cycles. There were significant differences favouring the MF group on the social functioning scale at treatment cycle 6 and on the Global QoL scale at treatment cycles 5 and 6. On most symptom and single-item scales there were no statistically significant differences between the groups. However, at baseline, the T patients reported more appetite loss, at treatment cycles 2-4, the MF patients reported more nausea/vomiting, and at treatment cycle 6, the T patients reported more symptoms of fatigue, dyspnoea and insomnia. There were no statistically significant differences between the groups in the mean change scores of the functional and symptom scales. Interindividual variance was, however, larger in the T group. Differences in QoL between the two treatment groups were minor. Hence, given the expectancy of comparable QoL outcomes, the choice of treatment should be made on the basis of the expected clinical effect.

Improved patient outcomes with BCG immunotherapy vs. chemotherapy - Swedish and worldwide experience

Intravesical therapy of superficial bladder cancer has been in routine use since the introduction of thiotepa in 1961. An empirical approach has been used to optimize this kind of treatment - clinical data are, unfortunately, often lacking. Marker lesion studies indicate that BCG is more effective than cytostatic drugs. For the prophylaxis of recurring disease, the recurrence rate is lower with chemotherapy than in controls, but no effect on the risk of progression has been verified. None of the chemotherapy drugs used has proved superior to the others. Randomized trials have recently been performed with mitomycin C vs. BCG. Comparison of the different trials is difficult due to the use of different methodologies. The majority of the studies found BCG to be more effective in lowering the number of recurrences, but progression rates were not significantly different. Trials with combinations of BCG-mitomycin C or epirubicin-interferon have yielded promising results.

Quantitative 201Tl SPET imaging in the follow-up of treatment for brain tumour: a sensitive tool for the early identification of response to chemotherapy?

The aim of this study was to establish if repeated quantitative 201Tl SPET scanning during follow-up of astrocytoma therapy can provide information that is relevant for clinical management. Sixteen consecutive patients, with histopathologically verified highly malignant astrocytoma, were followed during PCV chemotherapy. Imaging with 201Tl SPET and CT was performed repeatedly over 8-16 weeks until treatment discontinuation, with a maximum follow-up of 74 weeks. Tumour uptake volume (TUV), a measure of metabolically active tumour tissue, was calculated from the SPET images. The reliability of early identification of treatment failure, defined as > 25% tumour volume increase, following one course (week 8) and three courses (week 24) of chemotherapy, was calculated for the two imaging methods. 201Tl SPET positive patients (> 25% tumour volume increase) were compared with 201Tl SPET negative patients in terms of time to treatment discontinuation (TTD) and survival time (ST). The patients were followed with a total of 59 SPET examinations, and treatment was continued for a median 27 weeks (range 16-78 weeks). The comparative reliability of SPET and CT showed the highest sensitivity and accuracy for SPET in the early identification of astrocytoma treatment failure at the week 24 assessment. Patients with positive 201Tl SPET after three courses of chemotherapy had a significantly reduced TTD (P = 0.040) but not significantly reduced ST. Of the ten patients who received concomitant radiation and chemotherapy, five had a small (0-10 ml) TUV at the week 24 assessment. Patients with a TUV > 10 ml at this assessment had a shorter TTD (P = 0.016) and a reduced ST (P = 0.024) compared to patients with a TUV < 10 ml. In conclusion, the assessment of progressive disease by quantitative 201Tl SPET appears to provide information on treatment response, earlier and with a higher reliability than CT. Repeated 201Tl SPET scanning during follow-up of astrocytoma treatment is an alternative tool for the early identification of treatment failure.

Results of two or five years of adjuvant tamoxifen correlated to steroid receptor and S-phase levels. South Sweden Breast Cancer Group, and South-East Sweden Breast Cancer Group

A Swedish cooperative trial demonstrated that 5 years of adjuvant tamoxifen was more beneficial than 2 years of tamoxifen in the treatment of postmenopausal women with estrogen receptor (ER) positive, early stage, invasive breast cancer. The main aim of the present study was to investigate the importance of progesterone receptor (PgR) and ER concentration levels for patients participating in the trial and still distant recurrence free two years after the primary operation. Subgroup analyses revealed that only patients with ER positive and PgR positive breast cancer had improved distant recurrence free survival (DRFS) by prolonged tamoxifen therapy (p = 0.0016). Patients with ER negative and PgR negative as well as ER positive and PgR negative tumors showed no significant effect of prolonged tamoxifen (p = 0.53 and p = 0.80, respectively). The percentage of ER negative and PgR positive breast cancers was too small (2.2%) for any meaningful subgroup analysis. There was a significant positive trend that the concentration level of PgR (high positive vs. low positive vs. negative) decreased the recurrence rate for those with prolonged therapy. No corresponding pattern was found for the ER content. S-phase fraction did not correlate to the recurrence rate of PgR positive breast cancers. Patients recurring during tamoxifen therapy had receptor negative tumors to a greater extent than those recurring after tamoxifen treatment. In conclusion, prolonged tamoxifen therapy for 5 years instead of 2 years was found to be beneficial for patients with ER positive and PgR positive breast cancer, whereas three extra years of tamoxifen had little or no effect for patients with ER positive but PgR negative tumors as well as for steroid receptor negative patients.

Postoperative prognosis in craniopharyngioma with respect to cardiovascular mortality, survival, and tumor recurrence

Specific causes of death, survival, and recurrence rates were assessed in a cohort of 60 patients who had undergone surgery for craniopharyngioma between 1951 and 1988. Compared to the general population, the standardized mortality ratio (SMR) was increased [5.55; 95% confidence interval (CI), 3.68-8.22], and it was higher among females (SMR, 11.4) than males (SMR, 4.79). The risk of cardio- and cerebrovascular mortality (SMR, 3.21; 95% CI, 1.29-6.61) was also enhanced. The cumulative survival rates 10 and 15 yr after the initial operation were 68% (95% CI 54-78) and 59% (95% CI 30-63), respectively. A multivariate survival analysis adjusting for age showed a protective effect of radiotherapy (hazard ratio, 0.3; 95% CI, 0.1-0.8) and an increased risk of death after recurrence (hazard ratio, 4.4; 95% CI, 1.4-14), but no obvious effect of radicality at surgery. However, when patients who had died within 6 months after surgery were excluded, no significant protective effect of radiotherapy remained. The cumulative frequency of recurrence after 10 yr was 33% (95% CI, 22-48%), and that after 15 yr was 40% (95% CI, 28-56%). The incidence of recurrence did not differ significantly with respect to age, radicality at surgery, or postoperative radiotherapy. The determinants for long term outcome in patients with craniopharyngioma are interrelated in a complex way, which calls for strict selection criteria in follow-up studies and the use of multivariate statistical models.

Psychological profile related to malignant tumours of different histopathology

In a previous preoperative study of patients with gliomas, we made the original observation that patients with high grade as opposed to those with low-grade gliomas have a psychological profile marked by extreme emotional reactivity. In this postoperative study of the psychological profiles of patients with breast cancer, the main funding was unexpectedly analogous with the findings in the brain tumour study. The patients with poorly differentiated ductal carcinomas showed a specific and, compared to the patients with well differentiated carcinomas, outstanding psychological profile marked by extreme emotional reactivity as well as by genuine creativity. Some of the present patients with well differentiated carcinomas showed personality profiles marked by compulsive inhibition, also described earlier in the literature of patients with breast cancer. The psychobiological relations between emotional reactivity and aggressiveness of tumour growth are discussed.

Dacarbazine-vindesine versus dacarbazine-vindesine-cisplatin in disseminated malignant melanoma. A randomised phase III trial

In a multicentre phase III study of disseminated malignant melanoma performed in Sweden and Norway, 326 patients were randomised to receive treatment with the combination dacarbazine [DTIC] (D) and vindesine (V) with or without the addition of cisplatin (P). D was given intravenously (i.v.) at a dose of 250 mg/m2 days 1-5 every 4 weeks and V was given i.v. at a dose of 3.0 mg/m2 day 1 weekly. P was given i.v. at a dose of 100 mg/m2 day 1 every 4 weeks. There was no statistically significant difference in overall survival between the treatment arms (P = 0.22). Increased toxicity was observed in the treatment arm containing P of which leucopenia, alopecia and nausea/vomiting were the most pronounced. The median time to progression was significantly longer in patients treated with DVP (4.2 versus 2.2 months, P = 0.007). In conclusion, adding P to DV did not change overall survival but did significantly increase toxicity.

Attitude towards aggression and creative functioning in patients with breast cancer

Three projective personality tests were used to assess attitude to aggression (The Identification Test), anxiety and defenses (The Meta-Contrast Technique) and creative functioning (The Creative Functioning Test) in 70 patients with breast cancer. Discriminant analyses were applied pro primo to characterize psychologically patients with a better prognosis and patients with a poorer prognosis. A second aim was to characterize psychologically older (postmenopausal) and younger (premenopausal) women. Generally, high scores on the Identification Test indicated maladaptive attitudes towards aggression among all the patients. Patients with a poorer prognosis showed responses that in healthy subjects indicate acknowledgement of aggressive impulses, perhaps suggesting lack of "defenses" against such impulses among those patients. Another way to describe it would be that patients with a better prognosis seem to have (normally nonadaptive) "defenses" against aggressive impulses while those with poorer prognosis have not. Surprisingly, the patients with a better prognosis (but not those with a poorer prognosis) gave responses classified as depression in the Meta-Contrast Technique. Typical of premenopausal patients were responses classified as anxiety as well as reaction formation on the Identification Test. Responses classified as adaptive defenses (isolation) were seen in the Meta-Contrast Technique. A surprising finding was that many of these patients were characterized by high scores on the creativity test. These original statistically significant findings of attitudes towards aggression and creative functioning in breast cancer patients are discussed in relation to the underlying nature of aggression and creativity.

Dosage of adjuvant G-CSF (filgrastim)-supported FEC polychemotherapy based on equivalent haematological toxicity in high-risk breast cancer patients. Scandinavian Breast Group, Study SBG 9401

BACKGROUND

Conventional dosages of cytostatics in mg/m2 will cause marked variations in systemic exposure, resulting in over- and under-treatment, at least with respect to side effects.

PATIENTS AND METHODS

We are conducting a randomized adjuvant study for breast cancer patients younger than 60 years of age with > or = 70% risk of recurrence within five years. The first 89 consecutive patients who have received nine courses q three weeks of individually dose-escalated and G-CSF (filgrastim)-supported FEC (5-fluorouracil (5-FU), epirubicin, and cyclophosphamide) therapy given with ciprofloxacin prophylaxis were included in this analysis. Six different FEC dose levels were used for treatment at equivalent haematological toxicity. Dose modifications were based on white blood cell and platelet counts on days 8, 11/12, 15, and 22.

RESULTS

Eighty-three of 89 patients completed all nine courses. The median epirubicin and cyclophosphamide doses were 782 mg/m2 (range 0-994 mg/m2) and 10.330 mg/m2 (range 0-14.460 mg/m2), respectively. Patients treated at the two highest dose levels experienced NCl grade 0 or 1 toxicities in 73% to 92% of the courses. Three patients have developed acute myeloid leukaemia, and two of them have demonstrated abnormalities compatible with topoisomerase II-poison-related karyotypic changes.

CONCLUSIONS

Tailored adjuvant G-CSF-supported FEC polychemotherapy will make it possible for all patients to be treated at equivalent levels of haematological toxicity with significantly higher doses without a marked increase in other organ toxicities.

Induction chemotherapy with versus without hormonal synchronisation in locally advanced breast cancer

Sixty-nine patients with locally advanced breast cancer were given induction chemotherapy with doxorubicin and cyclophosphamide (day 1) followed by methotrexate and 5-Fu (day 8). Thirty-two of these patients were also given tamoxifen (days 2-6) in an attempt to induce a G1 arrest in cancer cells, and oestrogen (days 7-8) to stimulate proliferation and thus induce a synchronized wave of proliferating cells. The induction therapy response rate was 61% in the series as a whole (n = 69), but was found to be significantly better in the group on the tamoxifen/oestrogen synchronization regimen than in the remainder on chemotherapy alone (82% vs. 43%). This difference was particularly marked in the respective receptor-positive subgroups [90% (9/10) vs. 30% (3/10); p < 0.001]. The findings suggest that, in combination with chemotherapy, tamoxifen/oestrogen therapy, given in the sequence outlined here, constitutes a promising regimen for the treatment of locally advanced receptor-positive breast cancer patients.

A phase I/II evaluation of metoclopramide as a radiosensitiser in patients with inoperable squamous cell carcinoma of the lung

The feasibility of administering metoclopramide (MCA) as a radiosensitizer has been evaluated in 23 patients with a pathological or cytological diagnosis of a squamous cell carcinoma of the lung, clinically evaluated as inoperable. All patients received 40-60 Gy radiotherapy fractionated into 1.8 Gy fractions 5 times per week (Monday-Friday). Two MCA treatment regimens were used: (i) MCA at 2 mg/kg administered by intravenous-infusion 1-2 h prior to radiotherapy 3 times per week (Monday, Wednesday, Friday); and (ii) MCA at 1 mg/kg administered by intravenous infusion 1-2 h prior to radiotherapy 5 times per week (Monday-Friday). 11 of the 23 patients treated with radiotherapy and MCA had none to mild pneumonitis or fibrosis and another 8 of the 23 had moderate levels. No patient had their therapy interrupted due to radiation-related side-effects. The MCA-related side-effects were as expected, i.e. 78% of the patients experienced sedation/tiredness and 48% expressed restlessness/anxiety symptoms. Both the total dose and serum levels of MCA were significantly associated to the MCA side-effect profile. Tumour response, duration of tumour response and survival were significantly positively correlated to the total and weekly doses of MCA administered to the patients during their radiotherapy treatment. These favourable phase II data have justified the initiation of a phase II/III randomised multicentred trial being carried out in Europe to evaluate MCA as a radiosensitiser.

CAVIAR: a tool to improve serial analysis of the 12-lead electrocardiogram

An important part of an electrocardiogram (ECG) interpretation is the comparison between the present ECG and earlier recordings. The purpose of the present study was to evaluate a combination of two computer-based methods, synthesized vectorcardiogram (VCG) and CAVIAR, in this comparison. The methods were applied to a group of 38 normal subjects and to a group of 36 patients treated with anthracyclines. A fraction of these patients are likely to develop cardiac injury during or after the treatment, since anthracyclines are known to cause heart failure and cardiomyopathy. Two ECGs were recorded on each patient, one before and one after the treatment. On each normal subject, two ECGs were recorded with an interval of 8-9 years. A synthesized VCG was calculated from each ECG and the two synthesized VCGs from each subject were analysed with the CAVIAR method. The CAVIAR analysis is a quantitative method and normal limits for four measurements were established using the normal group. Values above these limits were more frequent in the patient group than in the normal group. The conventional ECGs were also analysed visually by an experience ECG interpreter without knowledge of the result of the CAVIAR analysis. No significant serial changes were found in 10 of the patients with high CAVIAR values. Changes in the ECGs were found in two patients with normal CAVIAR values. In summary, synthesized VCG and CAVIAR could be used to highlight small serial changes that are difficult to find in a visual analysis of ECGs.

Reoperation for malignant astrocytomas: personal experience and a review of the literature

All patients in a randomized study comparing chemotherapy with chemotherapy plus radiotherapy for patients with astrocytomas grade 3 and 4, were considered for reoperation when tumour progression was established. Fifty-eight patients were reoperated and 85 were not. Different prognostic factors, such as age, sex, Karnofsky performance status and reoperation were evaluated univariately and simultaneously in a multivariate model. The Karnofsky index and age were found to be independent prognostic factors, while re-operation could not be demonstrated to prolong life when controlled for age and the Karnofsky index. We review the literature on re-operation of malignant astrocytomas.

Phase II study of tauromustine in malignant glioma

46 eligible patients with either anaplastic astrocytoma (AA) or glioblastoma (GBM) and clinical and computed-tomography-confirmed relapse following primary surgery and radiotherapy received oral tauromustine 130 mg/m2 every 5 weeks. A prospective design allowed for concurrent assessment of both clinical and radiological responses and drug toxicity. 41% of patients improved clinically whilst 46% improved radiologically with 3 complete, 7 partial and 7 minimal responses (WHO criteria). Toxicity included grade III or IV gastrointestinal side-effects (15%), grade III or IV leukopenia (24%) and grade III and IV thrombocytopenia (44%). In 9 clinically responding patients, haematological toxicity led to discontinuation of treatment. All patients were followed-up until death and second-line chemotherapy was not used. Median post-treatment survival was 26 weeks for patients with GBM and 57 weeks for patients with AA. Overall 2-year survival rate was 69% for AA and 23% for GBM. Tauromustine given at the time of relapse has demonstrable antitumour activity in patients not previously treated with chemotherapy.

A randomized study of chemotherapy with procarbazine, vincristine, and lomustine with and without radiation therapy for astrocytoma grades 3 and/or 4

The authors undertook a controlled, prospective, randomized study of 171 patients with supratentorial astrocytoma grades 3 and/or 4 (classified according to Kernohan). All patients were given chemotherapy consisting of procarbazine, vincristine, and lomustine (CCNU) (PVC). Half of the patients received whole-brain irradiation (RT) to a dose of 5800 cGy in the tumor-bearing hemisphere and 5000 cGy in the contralateral hemisphere. After diagnosis of progressive tumor growth, patients received individual treatment. The endpoint of the study was time to progression, but cases were followed until the patients died. Median time to progression (MTP) for the whole randomized population was 21 weeks. Median survival time (MST) was 53 weeks; 18% of patients survived for 2 years or longer. Survival analysis showed that patients less than 50 years of age treated with PVC plus RT had significantly longer MTP (81 weeks) and MST (124 weeks) than all other patients. For patients less than 50 years of age treated with PVC alone, MTP was 21 weeks and MST was 66 weeks. For patients more than 50 years of age treated with PVC plus RT, MTP was 23 weeks and MST was 51 weeks; in the PVC group, MTP was 17 weeks and MST was 39 weeks. Age, Karnofsky index, areas of Grade 2, and absence of extensive necrosis in the tumor were significant prognostic factors in the univariate analyses. Patients less than 50 years of age treated with PVC plus RT had significantly longer survival (P = 0.037) when correcting for these factors in a multi-variate analysis.

Immune functions in melanoma patients during treatment with interferon [HuIFN-alpha (Le)] alone or in combination with cimetidine

While leukocyte interferon was found therapeutically ineffective in a series of 20 patients with metastatic malignant melanoma, subsequent combination treatment with interferon and cimetidine induced 5 complete and 1 partial tumour remissions. Prior to interferon therapy initiation, regressor patients demonstrated a significantly greater ability to mediate antibody-dependent cellular cytotoxicity than progressor patients and also tended to have higher natural killer-cell activity. These differences were more pronounced following in vitro exposure of effector cells to interferon alone or in combination with cimetidine. During therapy the differences decreased to statistically nonsignificant levels. The number of immunoglobulin producing cells and lymphocyte proliferative responses to Con A were found to increase in both patient groups after interferon therapy initiation; but this augmentation vanished gradually upon combined treatment with cimetidine. A gradual decrease of the number of T lymphocytes and granulocytes was also recorded. None of the demonstrated alterations in the activities of circulating lymphocytes appears to be a relevant correlate to the efficacy of combined therapy compared to interferon alone.

Column separation of monocytes by adherence to gelatin beads

This investigation was performed to study whether the efficient binding of collagen to monocytes in the presence of fibronectin and heparin may be used for separation of monocytes from human peripheral blood. It was shown that monocytes adhere selectively to gelatin bead columns in the presence of fresh plasma and heparin. Mononuclear blood cells are rapidly depleted of monocytes by passage through a 5-10 ml column at a flow rate of 1.5-2.0 ml per min. Adhering lymphocytes are more loosely attached and may be detached by stirring and washing, while the monocytes can be eluted by 50 mM EDTA. This separation technique is suitable for combination with various other methods since it is rapid, allows convenient handling of large numbers and yields cells with very high viability. Although most B lymphocytes pass through the column without attaching, there is some enrichment of B cells and non-T, non-B cells among the adherent lymphocytes.

Natural killer cell activity and antibody-dependent cellular cytotoxicity in newborn infants

The ability of lymphocytes from the peripheral blood of preterm and term infants and adult women and men to mediate natural killing (NK) and K cell activity (antibody-dependent cellular cytotoxicity) was analysed in 4 hours 51Cr-release assays. K 562 cells were targets for NK activity. K cell activity was assayed on antibody-coated rat thymocytes. Lymphocytes from adult male donors were significantly more cytotoxic to K 562 cells than were lymphocytes from adult female donors. Lymphocytes from both preterm and term infants had significantly lower NK and K cell activity than lymphocytes from adult donors. During the first month of life no increase in NK activity or K cell activity occurred in 7 infants who were re-examined. It is concluded that neither NK nor K cell activities are fully developed during the first month of life.

ANAE staining pattern of rat lymphocytes: lack of correlation with lymphocyte subclasses

Lymphocytes from various lymphoid organs of WF and BN rats were isolated and stained for acid alpha-naphthyl acetate esterase (ANAE) activity. From all organs examined-peripheral blood, lymph nodes, and spleen-70-80% of the lymphocytes were stained for ANAE activity. After separation into B and non-B cells by affinity chromatography on anti-Ig columns, esterase-negative lymphocytes were detected in both populations, demonstrating that ANAE staining cannot be used as a lymphocyte subclass marker in rats, in contrast to the situation in human and mice.