Role of Bone-Modifying Agents in Metastatic Breast Cancer: An American Society of Clinical Oncology–Cancer Care Ontario Focused Guideline Update

Purpose

To update, in collaboration with Cancer Care Ontario (CCO), key recommendations of the American Society of Clinical Oncology (ASCO) guideline on the role of bone-modifying agents (BMAs) in metastatic breast cancer. This focused update addressed the new data on intervals between dosing and the role of BMAs in control of bone pain.

Methods

A joint ASCO-CCO Update Committee conducted targeted systematic literature reviews to identify relevant studies.

Results

The Update Committee reviewed three phase III noninferiority trials of dosing intervals, one systematic review and meta-analysis of studies of de-escalation of BMAs, and two randomized trials of BMAs in control of pain secondary to bone metastases.

Recommendations

Patients with breast cancer who have evidence of bone metastases should be treated with BMAs. Options include denosumab, 120 mg subcutaneously, every 4 weeks; pamidronate, 90 mg intravenously, every 3 to 4 weeks; or zoledronic acid, 4 mg intravenously every 12 weeks or every 3 to 4 weeks. The analgesic effects of BMAs are modest, and they should not be used alone for bone pain. The Update Committee recommends that the current standard of care for supportive care and pain management—analgesia, adjunct therapies, radiotherapy, surgery, systemic anticancer therapy, and referral to supportive care and pain management—be applied. Evidence is insufficient to support the use of one BMA over another. Additional information is available at www.asco.org/breast-cancer-guidelines and www.asco.org/guidelineswiki .

Subtype-Dependent Relationship Between Young Age at Diagnosis and Breast Cancer Survival

PURPOSE

Young women are at increased risk for developing more aggressive subtypes of breast cancer. Although previous studies have shown a higher risk of breast cancer recurrence and death among young women with early-stage breast cancer, they have not adequately addressed the role of tumor subtype in outcomes.

METHODS

We examined data from women with newly diagnosed stage I to III breast cancer presenting to one of eight National Comprehensive Cancer Network centers between January 2000 and December 2007. Multivariable Cox proportional hazards models were used to assess the relationship between age and breast cancer-specific survival.

RESULTS

A total of 17,575 women with stage I to III breast cancer were eligible for analysis, among whom 1,916 were ≤ 40 years of age at diagnosis. Median follow-up time was 6.4 years. In a multivariable Cox proportional hazards model controlling for sociodemographic, disease, and treatment characteristics, women ≤ 40 years of age at diagnosis had greater breast cancer mortality (hazard ratio [HR], 1.4; 95% CI, 1.2 to 1.7). In stratified analyses, age ≤ 40 years was associated with statistically significant increases in risk of breast cancer death among women with luminal A (HR, 2.1; 95% CI, 1.4 to 3.2) and luminal B (HR 1.4; 95% CI, 1.1 to 1.9) tumors, with borderline significance among women with triple-negative tumors (HR, 1.4; 95% CI, 1.0 to 1.8) but not among those with human epidermal growth factor receptor 2 subtypes (HR, 1.2; 95% CI, 0.8 to 1.9). In an additional model controlling for detection method, young age was associated with significantly increased risk of breast cancer death only among women with luminal A tumors.

CONCLUSION

The effect of age on survival of women with early breast cancer seems to vary by breast cancer subtype. Young age seems to be particularly prognostic in women with luminal breast cancers.

Ten-Year Outcomes of Patients With Breast Cancer With Cytologically Confirmed Axillary Lymph Node Metastases and Pathologic Complete Response After Primary Systemic Chemotherapy

IMPORTANCE

The long-term effect of axillary pathologic complete response (pCR) on survival among women with breast cancer treated with primary systemic chemotherapy (PST) is unknown.

OBJECTIVE

To assess the long-term effect of axillary pCR on relapse-free survival (RFS) and overall survival (OS) in women with breast cancer with cytologically confirmed axillary lymph node metastases treated with PST.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed the effect of axillary pCR on 10-year OS and RFS among all women who received a diagnosis of breast cancer stages II to III with cytologically confirmed axillary metastases between 1989 and 2007 who received PST at a large US comprehensive cancer center. Women were stratified by post-PST axillary status, and survival outcomes were estimated and compared according to response in the breast and axilla.

MAIN OUTCOMES AND MEASURES

Outcomes of interest were RFS and OS.

RESULTS

Of 1600 women treated, median (range) age at diagnisis was 49 (21-86) years. A total of 454 (28.4%) achieved axillary pCR. These patients were more likely to have human epidermal growth factor receptor 2 (HER2)-positive and triple-negative disease (P < .001), pCR in the breast (P < .001), high-grade tumors (P < .001), and lower clinical and pathologic T stage (P = .002). Ten-year OS rates were 84% (95% CI, 79%-88%) and 57% (95% CI, 54%-61%) (P < .001) and 10-year RFS rates 79% (95% CI, 74%-83%) and 50% (95% CI, 46%-53%) (P < .001) for patients with axillary pCR and residual axillary disease, respectively. For patients with axillary pCR, 10-year OS rates were 90% (95% CI, 84%-94%) for those with breast pCR and 72% (95% CI, 61%-80%) for those with residual breast disease (P < .001). For patients with residual axillary disease, 10-year OS rates were 66% (95% CI, 56%-74%) for patients with and 56% (95% CI, 52%-60%) for patients without breast pCR (P = .02). Of patients receiving HER2-targeted therapy for HER2-positive disease, 67.1% (100 of 149) achieved axillary pCR; 10-year OS rates were 92% (95% CI, 84%-96%) and 57% (95% CI, 20%-82%) (P = .003) and 10-year RFS rates 89% (95% CI, 81%-94%) and 44% (95% CI, 18%-68%) (P < .001) for those with axillary pCR and residual axillary disease, respectively.

CONCLUSIONS AND RELEVANCE

Axillary pCR was associated with improved 10-year OS and RFS. Patients with axillary and breast pCR after PST had superior long-term survival outcomes. Patients undergoing HER2-targeted therapy for HER2-positive disease had high rates of axillary pCR, and those with axillary pCR had excellent 10-year OS.

Contrast-Enhanced Computed Tomography Evaluation of Hepatic Metastases in Breast Cancer Patients Before and After Cytotoxic Chemotherapy or Targeted Therapy

PURPOSE

To evaluate change in size vs computed tomography (CT) density of hepatic metastases in breast cancer patients before and after cytotoxic chemotherapy or targeted therapy.

METHODS

A database search in a single institution identified 48 breast cancer patients who had hepatic metastases treated with either cytotoxic chemotherapy alone or targeted therapy alone, and who had contrast-enhanced CT (CECT) scans of the abdomen at baseline and within 4 months of initiation of therapy in the past 10 years. Two radiologists retrospectively evaluated CT scans and identified up to 2 index lesions in each patient. The size (centimeters) of each lesion was measured according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria, and CT density (Hounsfield units) was measured by drawing a region of interest around the margin of the entire lesion. The percent change in sum of lesion size and mean CT density on pre- and post-treatment scans was computed for each patient; results were compared within each treatment group.

RESULTS

Thirty-nine patients with 68 lesions received cytotoxic chemotherapy only; 9 patients with 15 lesions received targeted therapy only. The mean percent changes in sum of lesion size and mean CT density were statistically significant within the cytotoxic chemotherapy group before and after treatment, but not significant in the targeted therapy group. The patients in the targeted therapy group tend to have better 2-year survival. The patients who survived at 2 years tend to have more decrease in tumour size in the cytotoxic chemotherapy group.

CONCLUSION

Cytotoxic chemotherapy produced significant mean percent decrease in tumour size and mean CT density of hepatic metastases from breast cancer before and after treatment, whereas targeted therapy did not. Nonetheless, there is a trend that the patients in the targeted therapy group had better 2-year survival rate. This suggests that RECIST is potentially inadequate in evaluating tumour response in breast cancer liver metastases treated with targeted therapy alone, calling for an alternative marker for response evaluation in this subset of patients.

Variation in type of adjuvant chemotherapy received among patients with stage I breast cancer: A multi-institutional study

BACKGROUND

Among patients with stage I breast cancer, there is significant uncertainty concerning the optimal threshold at which to consider chemotherapy, and when considered, there is controversy regarding whether to consider non-intensive versus intensive regimens. The authors examined the types and costs of adjuvant chemotherapy received among patients with stage I breast cancer.

METHODS

The current study was a prospective cohort study including patients with stage I breast cancer who were treated at a National Comprehensive Cancer Network center from 2000 through 2009. Stage was defined according to the version of the American Joint Committee on Cancer Staging Manual applicable at the time of diagnosis. Stratifying by human epidermal growth factor receptor 2 (HER2), the authors examined the percentage of patients receiving intensive versus non-intensive chemotherapy regimens and the factors associated with type of chemotherapy administered using multivariable logistic regression. Costs of the most common regimens were estimated.

RESULTS

Of 8907 patients, 33% received adjuvant chemotherapy. Among those individuals, there was an increase in the use of intensive chemotherapy within the last decade, from 31% in 2000 through 2005 to 63% in 2008 through 2009 (including an increase in the use of the combination of docetaxel, carboplatin, and trastuzumab) among patients with HER2-positive disease and from 15% in 2000 through 2005 to 41% in 2008 through 2009 among patients with HER2-negative disease (32% of patients with hormone receptor-positive and 59% of patients with triple-negative disease). Among patients treated with non-intensive regimens, there was an increase in the use of the combination of docetaxel and cyclophosphamide noted, with a decrease in the use of the doxorubicin and cyclophosphamide combination. The choice of regimen varied significantly by institution. The major drivers of cost variation were the incorporation of biologics (eg, trastuzumab) and growth factors, with significant variation even within non-intensive and intensive regimens.

CONCLUSIONS

Over time, there was an increase in use of intensive regimens among Stage I breast cancer, with striking institutional and cost variations.

Racial and Ethnic Differences in Breast Cancer Survival: Mediating Effect of Tumor Characteristics and Sociodemographic and Treatment Factors

PURPOSE

To evaluate the relationship between race/ethnicity and breast cancer-specific survival according to subtype and explore mediating factors.

PATIENTS AND METHODS

Participants were women presenting with stage I to III breast cancer between January 2000 and December 2007 at National Comprehensive Cancer Network centers with survival follow-up through December 2009. Cox proportional hazards regression was used to compare breast cancer-specific survival among Asians (n = 533), Hispanics (n = 1,122), and blacks (n = 1,345) with that among whites (n = 14,268), overall and stratified by subtype (luminal A like, luminal B like, human epidermal growth factor receptor 2 type, and triple negative). Model estimates were used to derive mediation proportion and 95% CI for selected risk factors.

RESULTS

In multivariable adjusted models, overall, blacks had 21% higher risk of breast cancer-specific death (hazard ratio [HR], 1.21; 95% CI, 1.00 to 1.45). For estrogen receptor-positive tumors, black and white survival differences were greatest within 2 years of diagnosis (years 0 to 2: HR, 2.65; 95% CI, 1.34 to 5.24; year 2 to end of follow-up: HR, 1.50; 95% CI, 1.12 to 2.00). Blacks were 76% and 56% more likely to die as a result of luminal A-like and luminal B-like tumors, respectively. No disparities were observed for triple-negative or human epidermal growth factor receptor 2-type tumors. Asians and Hispanics were less likely to die as a result of breast cancer compared with whites (Asians: HR, 0.56; 95% CI, 0.37 to 0.85; Hispanics: HR, 0.74; 95% CI, 0.58 to 0.95). For blacks, tumor characteristics and stage at diagnosis were significant disparity mediators. Body mass index was an important mediator for blacks and Asians.

CONCLUSION

Racial disparities in breast cancer survival vary by tumor subtype. Interventions are needed to reduce disparities, particularly in the first 2 years after diagnosis among black women with estrogen receptor-positive tumors.

Outcomes of children exposed in utero to chemotherapy for breast cancer

INTRODUCTION

The incidence of breast cancer diagnosed during pregnancy is expected to increase as more women delay childbearing in the United States. Treatment of cancer in pregnant women requires prudent judgment to balance the benefit to the cancer patient and the risks to the fetus. Prospective data on the outcomes of children exposed to chemotherapy in utero are limited for the breast cancer population.

METHODS

Between 1992 and 2010, 81 pregnant patients with breast cancer were treated in a single-arm, institutional review board-approved study with 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) in the adjuvant or neoadjuvant setting. Labor and delivery records were reviewed for each patient and neonate. In addition, the parents or guardians were surveyed regarding the health outcomes of the children exposed to chemotherapy in utero.

RESULTS

In total, 78% of the women (or next of kin) answered a follow-up survey. At a median age of 7 years, most of the children exposed to chemotherapy in utero were growing normally without any significant exposure-related toxicity or health problems. Three children were born with congenital abnormalities: one each with Down syndrome, ureteral reflux or clubfoot. The rate of congenital abnormalities in the cohort was similar to the national average of 3%.

CONCLUSIONS

During the second and third trimesters, pregnant women with breast cancer can be treated with FAC safely without concerns for serious complications or short-term health concerns for their offspring who are exposed to chemotherapy in utero. Continued long-term follow-up of the children in this cohort is required.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00510367. Other Study ID numbers: ID01-193, NCI-2012-01578. Registration date: 31 July 2007.

Risk of marrow neoplasms after adjuvant breast cancer therapy: the national comprehensive cancer network experience

PURPOSE

Outcomes for early-stage breast cancer have improved. First-generation adjuvant chemotherapy trials reported a 0.27% 8-year cumulative incidence of myelodysplastic syndrome/acute myelogenous leukemia. Incomplete ascertainment and follow-up may have underestimated subsequent risk of treatment-associated marrow neoplasm (MN).

PATIENTS AND METHODS

We examined the MN frequency in 20,063 patients with stage I to III breast cancer treated at US academic centers between 1998 and 2007. Time-to-event analyses were censored at first date of new cancer event, last contact date, or death and considered competing risks. Cumulative incidence, hazard ratios (HRs), and comparisons with Surveillance, Epidemiology, and End Results estimates were obtained. Marrow cytogenetics data were reviewed.

RESULTS

Fifty patients developed MN (myeloid, n = 42; lymphoid, n = 8) after breast cancer (median follow-up, 5.1 years). Patients who developed MN had similar breast cancer stage distribution, race, and chemotherapy exposure but were older compared with patients who did not develop MN (median age, 59.1 v 53.9 years, respectively; P = .03). Two thirds of patients had complex MN cytogenetics. Risk of MN was significantly increased after surgery plus chemotherapy (HR, 6.8; 95% CI, 1.3 to 36.1) or after all modalities (surgery, chemotherapy, and radiation; HR, 7.6; 95% CI, 1.6 to 35.8), compared with no treatment with chemotherapy. MN rates per 1,000 person-years were 0.16 (surgery), 0.43 (plus radiation), 0.46 (plus chemotherapy), and 0.54 (all three modalities). Cumulative incidence of MN doubled between years 5 and 10 (0.24% to 0.48%); 9% of patients were alive at 10 years.

CONCLUSION

In this large early-stage breast cancer cohort, MN risk after radiation and/or adjuvant chemotherapy was low but higher than previously described. Risk continued to increase beyond 5 years. Individual risk of MN must be balanced against the absolute survival benefit of adjuvant chemotherapy.

Breast cancer, BRCA mutations, and attitudes regarding pregnancy and preimplantation genetic diagnosis

BACKGROUND

Women with premenopausal breast cancer may face treatment-related infertility and have a higher likelihood of a BRCA mutation, which may affect their attitudes toward future childbearing.

METHODS

Premenopausal women were invited to participate in a questionnaire study administered before and after BRCA genetic testing. We used the Impact of Event Scale (IES) to evaluate the pre- and post-testing impact of cancer or carrying a BRCA mutation on attitudes toward future childbearing. The likelihood of pursuing prenatal diagnosis (PND) or preimplantation genetic diagnosis (PGD) was also assessed in this setting. Univariate analyses determined factors contributing to attitudes toward future childbearing and likelihood of PND or PGD.

RESULTS

One hundred forty-eight pretesting and 114 post-testing questionnaires were completed. Women with a personal history of breast cancer had less change in IES than those with no history of breast cancer (p = .003). The 18 BRCA-positive women had a greater change in IES than the BRCA-negative women (p = .005). After testing, 31% and 24% of women would use PND and PGD, respectively. BRCA results did not significantly affect attitudes toward PND/PGD.

CONCLUSION

BRCA results and history of breast cancer affect the psychological impact on future childbearing. Intentions to undergo PND or PGD do not appear to change after disclosure of BRCA results. Additional counseling for patients who have undergone BRCA testing may be warranted to educate patients about available fertility preservation options.

Outcomes by tumor subtype and treatment pattern in women with small, node-negative breast cancer: a multi-institutional study

PURPOSE

Treatment decisions for patients with T1a,bN0M0 breast cancer are challenging. We studied the time trends in use of adjuvant chemotherapy and survival outcomes among these patients.

PATIENTS AND METHODS

This was a prospective cohort study within the National Comprehensive Cancer Network Database that included 4,113 women with T1a,bN0M0 breast cancer treated between 2000 and 2009. Tumors were grouped by size (T1a, T1b), biologic subtype defined by hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status, and receipt of chemotherapy with or without trastuzumab.

RESULTS

Median follow-up time was 5.5 years. Eight percent of patients with HR-positive/HER2-negative tumors were treated with chemotherapy. Fifty-two percent of those with HER2-positive or HR-negative/HER2-negative breast cancers received chemotherapy, with an increase over the last decade. Survival outcomes diverged by subtype and size, but the 5-year distant relapse-free survival (DRFS) did not exceed 10% in any subgroup. The 5-year DRFS for patients with T1a tumors untreated with chemotherapy ranged from 93% to 98% (n = 49 to 972), and for patients with T1b tumors, it ranged from 90% to 96% (n = 17 to 2,005). Patients with HR-positive/HER2-negative disease had the best DRFS estimates, and patients with HR-negative/HER2-negative tumors had the lowest. In this observational, nonrandomized cohort study, the 5-year DRFS for treated patients with T1a tumors was 100% for all subgroups (n = 12 to 33), and for patients with T1b tumors, it ranged from 94% to 96% (n = 88 to 241).

CONCLUSION

Women with T1a,b tumors have an excellent prognosis without chemotherapy. Size and tumor subtype may identify patients in whom the rate of recurrence justifies consideration of chemotherapy. These patients represent an optimal group for evaluating less toxic adjuvant regimens to maintain efficacy while minimizing short- and long-term risks.

Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer

PURPOSE

For patients with breast cancer (BC), the optimal time to initiation of adjuvant chemotherapy (TTC) after definitive surgery is unknown. We evaluated the association between TTC and survival according to breast cancer subtype and stage at diagnosis.

PATIENTS AND METHODS

Women diagnosed with BC stages I to III between 1997 and 2011 who received adjuvant chemotherapy at our institution were included. Patients were categorized into three groups according to TTC: ≤ 30, 31 to 60, and ≥ 61 days. Survival outcomes were estimated and compared according to TTC and by BC subtype.

RESULTS

Among the 6,827 patients included, the 5-year overall survival (OS), relapse-free survival (RFS), and distant RFS (DRFS) estimates were similar for the different TTC categories. Initiation of chemotherapy ≥ 61 days after surgery was associated with adverse outcomes among patients with stage II (DRFS: hazard ratio [HR], 1.20; 95% CI, 1.02 to 1.43) and stage III (OS: HR, 1.76; 95% CI, 1.26 to 2.46; RFS: HR, 1.34; 95% CI, 1.01 to 1.76; and DRFS: HR, 1.36; 95% CI, 1.02 to 1.80) BC. Patients with triple-negative BC (TNBC) tumors and those with human epidermal growth factor receptor 2 (HER2) -positive tumors treated with trastuzumab who started chemotherapy ≥ 61 days after surgery had worse survival (HR, 1.54; 95% CI, 1.09 to 2.18 and HR, 3.09; 95% CI, 1.49 to 6.39, respectively) compared with those who initiated treatment in the first 30 days after surgery.

CONCLUSION

TTC influenced survival outcomes in the overall study cohort. This finding was particularly meaningful for patients with stage III BC, TNBC, and trastuzumab-treated HER2-positive tumors who experienced worse outcomes when chemotherapy was delayed. Our findings suggest that early initiation of chemotherapy should be granted for patients in these high-risk groups.

Abstract P3-11-02: Women with pregnancy-associated early breast cancer achieve improved emotional well-being as a result of their cancer experience

Background: Pregnancy-associated early breast cancer (PAEBC) has increased in incidence as more women pursue childbearing at an older age. The objective of this study was to measure the impact of diagnosis and treatment on emotional health and evaluate the positive emotional outcomes in a group of women with PAEBC. Methods: Between 1989 and 2010, 81 patients were treated for PAEBC with 5-flurouracil, doxorubicin and cyclophosphamide (FAC) chemotherapy. Patients completed the Impact of Events Scale-Revised (IES-R), which is a questionnaire that measures subjective distress caused by traumatic events and the Post-traumatic Growth Inventory (PGI), which measures positive outcomes after a traumatic event. Results: Of the 81 women, 53% (43/81) completed the IES-R and 44% (36/81) also completed the PGI. The time since diagnosis ranged from 6 months to greater than 5 years. The median age of the participants was 33 years (range 26-43 years). Of the 43 patients who completed the IES-R, 91% (39/43) did not use avoidance as a primary coping strategy; they felt well equipped to deal with feelings about their diagnosis and treatment. Of patients who inadvertently thought about their diagnosis, 70% (30/43) noted that they avoided becoming upset by their thoughts. Less than 10% (9/43) of patients surveyed felt apathetic towards their diagnosis and subsequent treatment. In terms of positive outcomes, 94% (33/36) felt they were enabled to depend on others in times of crises and felt a greater appreciation for people and their kindness following their diagnosis of PAEBC. Eighty-six percent (31/36) had changed their priorities about what is important in life, felt more compassionate towards others, and felt a greater appreciation for the value of their own life. In addition, 86% (30/36) of patients indicated that they had discovered their inner strength and felt more inclined to change things in their life. Finally, 75% of patients surveyed felt they had developed a stronger religious faith because of their experience and had a better understanding of spiritual matters. The majority of patients reported improvement in interpersonal skills – placing more effort into their relationships and sharing a greater sense of closeness with others. Conclusions: Although women who experience PAEBC are thought to be at high risk for experiencing psychosocial distress, these findings suggest that most do not suffer negative emotional consequences; in fact, these data suggest that they often achieve improved emotional well-being as a result of their cancer experience. It is possible that these women have better emotional outcomes because they have successfully carried a pregnancy while facing a life-threatening illness. Comparisons to other premenopausal breast cancer survivors will be crucial in interpreting these findings.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-11-02.

Ethnic disparities in adherence to breast cancer survivorship care

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Background: Two major components of breast cancer survivorship care include surveillance with mammograms and clinic visits after completion of definitive treatment. Identifying disparities in adherence to survivorship care is critical for improving the care delivery and outcomes of patients. Methods: We evaluated adherence to survivorship care among 4,212 racially/ethnically diverse Texan residents who underwent surgery for stage I-III breast cancer at the MD Anderson Cancer Center between January, 1997 and December, 2006 and completed one year of survivorship care. We used generalized estimating equations (GEE) method to evaluate race/ethnicity differences in missed mammograms and clinic visits up to 4 years of survivorship care. Results: The mean age of the cohort was 53 years (range 22-91); 72% white, 11% black, 11% Hispanic and 5% other race/ethnicity. Over four years, 36% of patients missed an annual mammogram and 21% of patients did not have a minimum of 1 clinic visit per year. For the entire study cohort, the trend of missed annual mammograms per year of survivorship care follow-up was 6% (year 1), 17% (year 2), 19% (year 3) and 22% (year 4) (p-trend <0.0001). In multivariable GEE model adjusted for survivorship year, age, stage, chemotherapy, endocrine therapy, radiation therapy and county of residence, Hispanic (OR 1.48 95% CI 1.22-1.80) and black (OR 1.41, 95% CI 1.15-1.72) patients were more likely be nonadherent with annual mammograms compared to white patients. Hispanic (OR 1.58, 95% CI 1.25-2.00) and black (OR 1.45, 95% CI 1.14-1.84) patients were also more likely to be nonadherent with clinic visits compared to white patients. There was a significant interaction between ethnicity and non-receipt of adjuvant endocrine therapy on clinic visit nonadherence (p-interaction=0.04) and annual mammogram nonadherence (p-interaction=0.001) among Hispanic compared to white patients. Conclusions: Drop out of breast cancer survivorship care increases over time and black and Hispanic women are more likely to be nonadherent. Better characterization of the reasons for nonadherence is needed to design interventions to improve retention in breast cancer survivorship care, especially for patients not receiving adjuvant endocrine therapy.

The safety of chemotherapy for breast cancer patients with hepatitis C virus infection

BACKGROUND

Hepatitis C virus (HCV) infection is one of the major causes of chronic liver disease, and more than 880,000 people are estimated to be infected with HCV in Japan. Little information is available on the outcomes of HCV during chemotherapy for solid tumors, and the impact of HCV infection on toxicity of chemotherapy is unknown.

MATERIALS AND METHODS

We performed a retrospective survey of 1,110 patients diagnosed with breast cancer between January 2006 and March 2011 at our institution. All patients had been screened for hepatitis C serology at diagnosis of breast cancer. We retrospectively investigated the change in HCV load and the toxicities of chemotherapy, based on review of their medical records.

RESULTS

23 patients were identified as having a positive test for anti-HCV antibodies. Ten of these patients received chemotherapy. Their median age was 66 years. No patient had decompensated liver disease at baseline. Eight patients received cytotoxic agents with or without trastuzumab, and two patients received trastuzumab alone. Four of eight patients who received cytotoxic chemotherapy developed febrile neutropenia and one developed transaminases elevation. Serum HCV-ribonucleic acid (RNA) level before and after chemotherapy was evaluated in six patients. Median serum HCV-RNA level at baseline and after chemotherapy was 6.5 and 6.7 logIU/ml, respectively.

CONCLUSION

Chemotherapy for breast cancer patients with HCV infection is feasible, and viral load doesn't change during the chemotherapy.

Breast cancer, version 3.2013: featured updates to the NCCN guidelines

These NCCN Guidelines Insights highlight the important updates specific to the management of HER2-positive metastatic breast cancer in the 2013 version of the NCCN Clinical Practice Guidelines in Oncology for Breast Cancer. These include new first-line and subsequent therapy options for patients with HER2-positive metastatic breast cancer.

Time trends in the use of adjuvant chemotherapy (CTX) and outcomes in women with T1N0 breast cancer (BC) in the National Comprehensive Cancer Network (NCCN)

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Background: The role of adjuvant CTX in women with small BC is controversial. Here we analyze time trends of CTX use and outcomes in women with T1N0 BC treated at NCCN cancer centers. Methods: 8917 women were identified who received surgery or systemic therapy at an NCCN center with T1a, T1b or T1c N0 M0 BC between 2000-09. Tumors were grouped by biologic subgroups by hormone receptor (HR) and HER2 status and T subgroups (T1a, T1b, T1c). Primary endpoints were receipt of adjuvant CTX (± trastuzumab) and BC specific survival (BCSS). Chi-square, Cochran Armitage trend, Kaplan Meier estimates, log-rank test and Cox hazard proportional regression were used for analysis. In this report we focus on T1a/b results (N=4113). Results: Median follow up time was 5.5 years (range, 0.7-12.7). CTX use differed according to biologic and T subgroups, with significant changes over time (Table). In 2009, more than 50% of patients (pts) with HER2+ and HR-2- T1a/b breast cancers received CTX (± trastuzumab). The table lists use of CTX by year and subset and the 5 year BCSS for pts treated and not treated with CTX. Conclusions: A high proportion of pts with HER2+ and HR-HER2- T1N0 breast cancers received adjuvant CTX, with a sharp increase in use of CTX among HER2+ over the past decade. Use of CTX is higher in T1b compared to T1a tumors. In this study, women with T1a and T1b tumors have an excellent prognosis without CTX at 5 Yr. Careful examination of cutoffs for absolute benefit sufficient to recommend CTX is warranted. [Table: see text]

Impact of delaying initiation of adjuvant chemotherapy in breast cancer patients

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Background: The survival benefit of adjuvant chemotherapy in breast cancer is well established. However, the optimal timing to initiation of chemotherapy after definitive surgery is unknown. We evaluated the association between time to initiation of chemotherapy and survival outcomes according to breast cancer subtype and stage at diagnosis. Methods: Women diagnosed with stage I–III breast cancer between 1997-2011 who received adjuvant chemotherapy at our institution were included. Patients were categorized according to time from definitive surgery to adjuvant chemotherapy into one of three groups: ≤ 30 days, 31–60 days and more than 60 days. Descriptive statistics, Kaplan-Meier statistics and Cox proportional hazards models were used. Results: Among the 6,827 patients included, the 5-year Overall Survival (OS), Relapse-Free Survival (RFS) and Distant Relapse-Free Survival (DRFS) estimates were similar for the different time-to-chemotherapy categories. Among patients with stage I, there was no association between outcome and time to initiation of chemotherapy. Patients with stage II disease experienced an 18% and 22% increase in risk of RFS (HR 1.18; p=0.038) and DRFS (HR 1.22; p=0.02), when systemic treatment was started >60 days from surgery. Patients with stage III disease that started adjuvant chemotherapy >60 days after surgery had a 70% increase in the risk of death (HR 1.7; p=0.002), a 32% increase risk of relapse (HR 1.32; p=0.046) and a 34% increase risk of distant relapse (HR 1.34; p=0.044). Time to chemotherapy did not have a significant effect on outcome among Hormone Receptor (HR)-positive patients. Patients with triple negative (TNBC) and HER2-positive tumors treated with trastuzumab who started chemotherapy >60 days after surgery had lower 5 year-OS estimates (HR 1.52; p=0.016 and HR 2.62; p=0.005, respectively). Conclusions: Time to chemotherapy did not influence survival outcomes in the overall population. However, patients with stage III, TNBC and HER2-positive tumors treated with trastuzumab, experienced worse outcomes when chemotherapy was delayed. Among patients with tumors with aggressive biology and more advanced stages at diagnosis, early initiation of therapy should be favored.

Case control study of women treated with chemotherapy for breast cancer during pregnancy as compared with nonpregnant patients with breast cancer

BACKGROUND

The purpose of this analysis was to compare disease-free survival (DFS), progression-free survival (PFS), and overall survival (OS) between pregnant and nonpregnant patients with breast cancer.

METHODS

From 1989 to 2009, 75 women were treated with chemotherapy during pregnancy. Each pregnant case was matched on age and cancer stage to two nonpregnant patients with breast cancer (controls). Fisher's exact test, the Kaplan-Meier method, and Cox proportional hazards regression models were used.

RESULTS

Median follow-up time for patients who were alive at the end of follow-up (n = 159) was 4.20 years (range: 0.28-19.94 years). DFS at 5 years was 72% (95% confidence interval [CI]: 58.3%-82.1%) for pregnant patients and 57% (95% CI: 46.7%-65.8%) for controls (p = .0115). Five-year PFS was 70% (95% CI: 56.8%-80.3%) for pregnant patients and 59% (95% CI: 49.1%-67.5%) for controls (p = .0252). Five-year OS was 77% (95% CI: 63.9%-86.4%) for pregnant patients and 71% (95% CI: 61.1%-78.3%) for controls (p = .0461). Hazard ratio estimates favored improved survival for pregnant patients in univariate analyses and multivariate analyses, controlling for age, year of diagnosis, stage, and tumor grade.

CONCLUSIONS

For patients who received chemotherapy during pregnancy, survival was comparable to-if not better than-that of nonpregnant women. Pregnant patients with breast cancer should receive appropriate local and systemic therapy for breast cancer.

Time to adjuvant chemotherapy for breast cancer in National Comprehensive Cancer Network institutions

BACKGROUND

High-quality care must be not only appropriate but also timely. We assessed time to initiation of adjuvant chemotherapy for breast cancer as well as factors associated with delay to help identify targets for future efforts to reduce unnecessary delays.

METHODS

Using data from the National Comprehensive Cancer Network (NCCN) Outcomes Database, we assessed the time from pathological diagnosis to initiation of chemotherapy (TTC) among 6622 women with stage I to stage III breast cancer diagnosed from 2003 through 2009 and treated with adjuvant chemotherapy in nine NCCN centers. Multivariable models were constructed to examine factors associated with TTC. All statistical tests were two-sided.

RESULTS

Mean TTC was 12.0 weeks overall and increased over the study period. A number of factors were associated with a longer TTC. The largest effects were associated with therapeutic factors, including immediate postmastectomy reconstruction (2.7 weeks; P < .001), re-excision (2.1 weeks; P < .001), and use of the 21-gene reverse-transcription polymerase chain reaction assay (2.2 weeks; P < .001). In comparison with white women, a longer TTC was observed among black (1.5 weeks; P < .001) and Hispanic (0.8 weeks; P < .001) women. For black women, the observed disparity was greater among women who transferred their care to the NCCN center after diagnosis (P (interaction) = .008) and among women with Medicare vs commercial insurance (P (interaction) < .001).

CONCLUSIONS

Most observed variation in TTC was related to use of appropriate therapeutic interventions. This suggests the importance of targeted efforts to minimize potentially preventable causes of delay, including inefficient transfers in care or prolonged appointment wait times.

Time to diagnosis and breast cancer stage by race/ethnicity

We examined differences in time to diagnosis by race/ethnicity, the relationship between time to diagnosis and stage, and the extent to which it explains differences in stage at diagnosis across racial/ethnic groups. Our analytic sample includes 21,427 non-Hispanic White (White), Hispanic, non-Hispanic Black (Black) and non-Hispanic Asian/Pacific Islander (Asian) women diagnosed with stage I to IV breast cancer between January 1, 2000 and December 31, 2007 at one of eight National Comprehensive Cancer Network centers. We measured time from initial abnormal mammogram or symptom to breast cancer diagnosis. Stage was classified using AJCC criteria. Initial sign of breast cancer modified the association between race/ethnicity and time to diagnosis. Among symptomatic women, median time to diagnosis ranged from 36 days among Whites to 53.6 for Blacks. Among women with abnormal mammograms, median time to diagnosis ranged from 21 days among Whites to 29 for Blacks. Blacks had the highest proportion (26 %) of Stage III or IV tumors. After accounting for time to diagnosis, the observed increased risk of stage III/IV breast cancer was reduced from 40 to 28 % among Hispanics and from 113 to 100 % among Blacks, but estimates remained statistically significant. We were unable to fully account for the higher proportion of late-stage tumors among Blacks. Blacks and Hispanics experienced longer time to diagnosis than Whites, and Blacks were more likely to be diagnosed with late-stage tumors. Longer time to diagnosis did not fully explain differences in stage between racial/ethnicity groups.

A prospective study of bone tumor response assessment in metastatic breast cancer

BACKGROUND

In our previous study, new MD Anderson (MDA) bone tumor response criteria (based on computed tomography [CT], plain radiography [XR], and skeletal scintigraphy [SS]) predicted progression-free survival (PFS) better than did World Health Organization (WHO) bone tumor response criteria (plain radiography [XR] and SS) among patients with breast cancer and bone-only metastases. In this pilot study, we tested whether MDA criteria could reveal bone metastasis response earlier than WHO criteria in patients with newly diagnosed breast cancer with osseous and measurable nonosseous metastases.

METHODS

We prospectively analyzed bone metastasis response using each imaging modality and set of bone response criteria to distinguish progressive disease (PD) from non-PD and their association with PFS and overall survival (OS). We also compared the response of osseous metastases assessed by both criteria with the response of nonosseous measurable lesions.

RESULTS

The median follow-up period was 26.7 months (range, 6.1-53.3 months) in 29 patients. PFS rates differed at 6 months based on the classification of PD or non-PD using either set of criteria (MDA, P = .002; WHO, P = .014), but these rates, as well as OS, did not differ at 3 months. Response in osseous metastases by either set of criteria did not correlate with the response in nonosseous metastases.

CONCLUSION

MDA and WHO criteria predicted PFS of patients with osseous metastases at 6 months but not at an earlier time point. We plan a well-powered study to determine the role of MDA criteria in predicting bone tumor response by incorporating 18-fluorodeoxyglucose ((18)F) positron emission tomography (FDG-PET)/CT to see if findings using this modality are earlier than those with WHO criteria.

Impact of hormone receptor status on patterns of recurrence and clinical outcomes among patients with human epidermal growth factor-2-positive breast cancer in the National Comprehensive Cancer Network: a prospective cohort study

INTRODUCTION

In gene expression experiments, hormone receptor (HR)-positive/human epidermal growth factor-2 (HER2)-positive tumors generally cluster within the luminal B subset; whereas HR-negative/HER2-positive tumors reside in the HER2-enriched subset. We investigated whether the clinical behavior of HER2-positive tumors differs by HR status.

METHODS

We evaluated 3,394 patients who presented to National Comprehensive Cancer Network (NCCN) centers with stage I to III HER2-positive breast cancer between 2000 and 2007. Tumors were grouped as HR-positive/HER2-positive (HR+/HER2+) or HR-negative/HER2-positive (HR-/HER2+). Chi-square, logistic regression and Cox hazard proportional regression were used to compare groups.

RESULTS

Median follow-up was four years. Patients with HR-/HER2+ tumors (n = 1,379, 41% of total) were more likely than those with HR+/HER-2+ disease (n = 2,015, 59% of total) to present with high histologic grade and higher stages (P <0.001). Recurrences were recorded for 458 patients. HR-/HER2+ patients were less likely to experience first recurrence in bone (univariate Odds Ratio (OR) = 0.53, 95% Confidence Interval (CI): 0.34 to 0.82, P = 0.005) and more likely to recur in brain (univariate OR = 1.75, 95% CI: 1.05 to 2.93, P = 0.033). A lower risk of recurrence in bone persisted after adjusting for age, stage and adjuvant trastuzumab therapy (OR = 0.53, 95% CI: 0.34 to 0.83, P = 0.005) and when first and subsequent sites of recurrence were both considered (multivariable OR = 0.55, 95% CI: 0.37 to 0.80, P = 0.002).

CONCLUSIONS

Presenting features, patterns of recurrence and survival of HER2-positive breast cancer differed by HR status. These differences should be further explored and integrated in the design of clinical trials.

Abstract PR06: Racial/ethnic differences in breast cancer survival and mediating effects of tumor characteristics, sociodemographic, and treatment factors

Purpose: To evaluate the relationship between race/ethnicity and breast cancer specific survival and to investigate the mediating effects of tumor characteristics, treatment, anthropomorphic and sociodemographic factors on racial/ethnic disparities in survival.

Methods: Analysis included 19,480 women presenting to National Comprehensive Cancer Network centers with stage I-III breast cancer between January 2000 and December 2007 with National Death Index survival follow-up through December 2009. Multiple Cox proportional hazards regression models were used to compare breast cancer specific mortality by Non-Hispanic Asian-Pacific Islanders (Asian, n=634), Hispanics (Hispanic, n=1,291), Non-Hispanic Blacks (Black, n=1,500) as compared to Non-Hispanic Whites (White, n=16,055) respectively. Additionally models were analyzed overall and also stratified by tumor subtypes. Cox models were analyzed with control variables in steps: age adjusted, plus SES factors, plus tumor characteristics, plus treatment variables. Mediation analyses were performed to estimate the proportion of excess breast cancer mortality mediated through exposures.

Results: Median follow-up time was 6.9 years. Due to non-proportional hazards among Blacks, overall and within certain clinical subgroup models, analyses for total breast cancer, estrogen receptor positive and negative (ER+ and ER-) and basal tumors were performed in two time periods (0-3 years and 3 years to end of follow-up (EOF)). In multivariable fully adjusted models, Blacks had higher risk of breast cancer specific death overall (years 0-3: hazard ratio [HR] 1.48, 95% confidence interval [CI] 1.12-1.94; years 3 to EOF: HR 1.34, 95% CI 1.06-1.69), among ER+ tumors (years 0-3: HR 2.85, 95% CI 1.75-4.62; years 3 to EOF: HR 1.49, 95% CI 1.11-2.00), and for luminal B subtypes (HR 1.76, 95% CI 1.30-2.39) as well as for luminal A subtypes (HR 1.66, 95% CI 1.03-2.67) subtypes. After adjustment for age, SES factors, tumor characteristics and treatment variables there were no significant differences between Blacks and Whites for ER-, basal, or Her2 over expressed tumors. In fully adjusted models Asians were at significantly lower risk of death from breast cancer as compared to Whites (all cancers: HR 0.60, 95% CI 0.40-0.90; ER- tumors: HR 0.51, 95% CI 0.27-0.94; luminal A: HR 0.23, 95% CI 0.06-0.93; HER2 over expressed tumors: HR 0.25, 95% CI 0.07-0.92). There were no significant differences in breast cancer mortality between Hispanics and Whites. The estimated proportion of excess breast cancer mortality among Blacks that was mediated by tumor markers (estrogen, progesterone, and her2neu) and grade was 24.8% (p&lt;0.0001). Other mediators included stage at diagnosis (18.2%, p=0.002), comorbidity score (13.8%, p=0.02), body mass index (BMI) (9.8%, p=0.04), and insurance type (9.5%, p=0.04). Among Asians, BMI (13.9%, p=0.06) was an important mediator.

Conclusions: Blacks are at higher risk of breast cancer death as compared to Whites, particularly in the first three years after diagnosis and predominantly among ER+, luminal A and luminal B tumor subtypes. This excess risk is mediated through differences in tumor characteristics, stage at diagnosis, comorbid conditions, BMI, and insurance type. Asian women have better breast cancer survival than Whites somewhat mediated through their lower BMI at diagnosis.

This abstract is also presented as Poster B64.

Citation Format: Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Rebecca A. Ottesen, Yu-Ning Wong, Stephen B. Edge, Richard L. Theriault, Douglas W. Blayney, Joyce C. Niland, Eric P. Winer, Jane C. Weeks, Ann H. Partridge. Racial/ethnic differences in breast cancer survival and mediating effects of tumor characteristics, sociodemographic, and treatment factors. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr PR06.

Biology of bone metastases

BACKGROUND

Bone metastases cause morbidity and mortality in multiple malignancies. In addition to portending a dire prognosis, bone metastases cause bone pain, fractures, hypercalcemia, spinal cord compression, and other nerve compression syndromes. Improved understanding of the mechanisms that predispose tumor metastases to bone is needed to improve patients' therapeutic options, maintain their quality of life, and improve their survival.

METHODS

This review discusses selected preclinical and clinical data regarding bone metastasis development and cytokine/molecular interactions predisposing to bone metastases formation. Potential interventions for reducing bone metastases are also described.

RESULTS

Biologic mechanisms resulting in metastases of tumor cells to bone are being studied. Among these are the RANKL pathway, osteoclast activation via cytokines (produced by tumor cell and cells in the bone microenvironment), interactions with transient and stromal cells in the bone microenvironment, and molecules such as PTHrP and endothelin-1. These molecules offer important opportunities for targeted interventions to decrease bone metastases-associated morbidity.

CONCLUSIONS

Knowledge of the pathophysiology of bone and cancer is developing rapidly. Relationships among cancer cells, bone-derived cells, and cytokines provide opportunities for the development of new interventions. Therapy targeting osteoclast/osteoblast interactions has proven benefit for patients with bone metastases.

Metastatic breast cancer, version 1.2012: featured updates to the NCCN guidelines

These NCCN Guidelines Insights highlight the important updates/changes specific to the management of metastatic breast cancer in the 2012 version of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer. These changes/updates include the issue of retesting of biomarkers (estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2) on recurrent disease, new information regarding first-line combination endocrine therapy for metastatic disease, a new section on monitoring of patients with metastatic disease, and new information on endocrine therapy combined with an mTOR inhibitor as a subsequent therapeutic option.

Pathologic characteristics of second breast cancers after breast conservation for ductal carcinoma in situ

BACKGROUND

The number of women diagnosed with ductal carcinoma in situ (DCIS) is increasing. Although many eventually develop a second breast cancer (SBC), little is known about the characteristics of SBCs. The authors described the characteristics of SBC and examined associations between the pathologic features of SBC and index DCIS cases.

METHODS

Women were identified in the National Comprehensive Cancer Network Outcomes Database who were diagnosed with DCIS from 1997 to 2008 and underwent lumpectomy and who subsequently developed SBC (including DCIS or invasive disease that occurred in the ipsilateral or contralateral breast). The Fisher exact test and the Spearman test were used to examine associations between the pathologic characteristics of SBC and index DCIS cases.

RESULTS

Among 2636 women who underwent lumpectomy for DCIS, 150 (5.7%) experienced an SBC after a median of 55.5 months of follow-up. Of these 150 women, 105 (70%) received adjuvant radiotherapy, and 50 (33.3%) received tamoxifen for their index DCIS. SBCs were ipsilateral in 54.7% of women and invasive in 50.7% of women. Among the index DCIS cases, 60.6% were estrogen receptor (ER)-positive, and 54% were high grade, whereas 77.5% of SBCs were ER-positive, and 48.2% were high grade. Tumor grade (P = .003) and ER status (P = .02) were associated significantly between index DCIS and SBC, whereas tumor size was not (P = .87).

CONCLUSIONS

After breast conservation for DCIS, SBC in either breast exhibited pathologic characteristics similar to the index DCIS, suggesting that women with DCIS may be at risk for developing subsequent breast cancers of a similar phenotype.

Pregnancy outcomes in women with cancer

6116

Background: Parenthood after cancer is a critical concern for many cancer patients (pts). Pregnancy (prg) during cancer is an emotional time for about 1/1000 pregnant women. No randomized controlled studies exist examining the impact of cancer treatment (tx) on the developing fetus nor on the woman with cancer. Methods: From 2002-2011, women presenting for cancer tx during prg were approached for this IRB-approved prospective database study. All pts provided written consent. Results: To date 143 pts are evaluable. The median age at diagnosis was 32.1 years and median gestational age (GA) at enrollment was 18.2 weeks. 95/143 (66.4%) are White, 19 (13.3%) are African American, 17 (11.9%) are Hispanic and 12 (8.4%) are Asian/Other. Primary cancers included breast (n=59, 41.3%), hematologic (n=29, 20.3%), melanoma (n=13, 9%), GYN (n=11, 8%), GI (n=8, 5.6%), head/neck (n=7, 6%) and other (n=16, 11%) (brain=4, GU=1, thyroid=3, head/neck=7, thoracic=1, sarcoma=6, unknown primary=1). 111/143 (77.6%) of prgs resulted in live births. Median birth weight was 6.5 lbs. Median follow-up time for pts was 32.3 months. To date, 3/19 pts who terminated prgs have died (1.6%). Most terminations occurred in the 1st trimester. To date, 79 pts (55.2%) are NED and 23 pts have died; of these 19 (1.7%) had live births. No major malformations were observed in the 74/143 (52%) of pts who received chemotherapy (CTx) during pregnancy. 57% received FAC/FEC; other regimens included ABVD (n=5), cytarabine (n=5), CHOP/R-CHOP, and platinum-based regimens. Median GA at the start of CTx was 19.7 wks. Median number of CTx cycles during prg was 4. Other pts underwent surgery (n=32), no tx (n=14), deferred tx until after delivery (n=17), radiation (2), transplant (3), other (1). Conclusions: Cancer diagnosis during prg is compatible with successful tx and prg outcome. Cancer tx during the 2nd and 3rd trimester can be safely given and in our pts did not result in adverse prg outcomes. Tx during the 1st trimester is usually not recommended. Thus cancer pts in their 1st trimester need to be extensively counseled about their disease as well as about the risks to the prg. In our pts continuation or termination of prg were not associated with an increased risk of death.

Impact of hormone receptor (HR) status on clinicopathological features, patterns of recurrence, and clinical outcomes among patients (pts) with human epidermal growth factor receptor-2 positive (HER2) breast cancer (BC) in the National Comprehensive Cancer Network (NCCN)

599

Background: According to gene expression profiling, HER2+ BC is heterogeneous and appears to diverge by HR status. Methods: We evaluated 3394 pts who presented to NCCN centers with stage I-III HER2+ BC between 2000-07. Pts were classified as HR+ (ER+ and/or PR+) and HR- (ER- and PR-). Chi-square, univariate logistic regression, log-rank test, and Cox hazard proportional regression were used for analysis. Results: Median follow-up was 51 months. 59% of patients had HR+ and 41% HR- disease respectively. Pts with HR- BC were more likely to be postmenopausal and to present with higher stage and high grade disease (p<0.001). Most pts received adjuvant or neoadjuvant therapy; 44% received adjuvant trastuzumab. Recurrences were recorded for 458 pts. HR- patients were more likely to recur first in the central nervous system (CNS) (OR: 1.8, 95% CI: 1.1, 2.9; p= 0.03) and less likely to recur in bone (OR: 0.5, 95% CI: 0.3, 0.8; p<0.01). No differences in risk of lung or liver recurrence were observed. Combining first and subsequent sites of recurrence, the difference in CNS involvement was lost (p=0.107) but HR- were more likely to experience lung involvement (OR: 1.5, 95% CI: 1.0, 2.2; p= 0.05). After adjusting for age, year of diagnosis (y), race, stage, and grade, HR- had worse survival after initial BC diagnosis than HR+ pts (Hazard Ratio of death [HRd] 1.4, 95% CI: 1.14, 1.7; p<0.01). However, the risk of death was not proportional over time with HR- having significantly increased hazard in the first five years: HRd 0-2 y 1.9 [1.3, 2.9]; p< 0.01; HRd 2-5y 1.5, [1.2, 2.0]; p<0.01; HRd 5+ y, 0.8, [ 0.6, 1.2], p=0.29. Conclusions: Clinicopathological features, sites of recurrence, and risk of death over time for HER2+ BC differed by HR status. This suggests that HR status in HER2+ BC is clinically relevant. These differences should be further explored from a mechanistic and therapeutic standpoint.

The effect of age on delay in diagnosis and stage of breast cancer

BACKGROUND

Young women with breast cancer are more likely to present with more advanced disease and are more likely to die as a result of breast cancer than their older counterparts. We sought to examine the relationship among young age (≤40 years), the likelihood of a delay in diagnosis, and stage.

METHODS

We examined data from women with newly diagnosed stage I-IV breast cancer presenting to one of eight National Comprehensive Cancer Network centers in January 2000 to December 2007. Delay in diagnosis was defined as time from initial sign or symptom to breast cancer diagnosis >60 days.

RESULTS

Among 21,818 women with breast cancer eligible for analysis, 2,445 were aged ≤40 years at diagnosis. Young women were not more likely to have a delay in diagnosis >60 days (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.98-1.19) after adjustment for type of initial sign or symptom. Young women were only modestly more likely to present with higher stage disease after a similar adjustment (OR, 1.18; 95% CI, 1.07-1.31). Women presenting with symptomatic disease, more common in younger women, were more likely to have a delay in diagnosis (OR, 3.31; 95% CI, 3.08-3.56) and higher stage (OR, 4.31; 95% CI 4.05-4.58).

CONCLUSION

Young age is not an independent predictor of delay in diagnosis of breast cancer and only modestly is associated with higher stage disease. Presenting with symptoms of breast cancer predicts delay and higher stage at diagnosis.

Clinicopathologic features, patterns of recurrence, and survival among women with triple-negative breast cancer in the National Comprehensive Cancer Network

BACKGROUND

The objective of this study was to describe clinicopathologic features, patterns of recurrence, and survival according to breast cancer subtype with a focus on triple-negative tumors.

METHODS

In total, 15,204 women were evaluated who presented to National Comprehensive Cancer Network centers with stage I through III breast cancer between January 2000 and December 2006. Tumors were classified as positive for estrogen receptor (ER) and/or progesterone receptor (PR) (hormone receptor [HR]-positive) and negative for human epidermal growth factor receptor 2 (HER2); positive for HER2 and any ER or PR status (HER2-positive); or negative for ER, PR, and HER2 (triple-negative).

RESULTS

Subtype distribution was triple-negative in 17% of women (n = 2569), HER2-positive in 17% of women (n = 2602), and HR-positive/HER2-negative in 66% of women (n = 10,033). The triple-negative subtype was more frequent in African Americans compared with Caucasians (adjusted odds ratio, 1.98; P < .0001). Premenopausal women, but not postmenopausal women, with high body mass index had an increased likelihood of having the triple-negative subtype (P = .02). Women with triple-negative cancers were less likely to present on the basis of an abnormal screening mammogram (29% vs 48%; P < .0001) and were more likely to present with higher tumor classification, but they were less likely to have lymph node involvement. Relative to HR-positive/HER2-negative tumors, triple-negative tumors were associated with a greater risk of brain or lung metastases; and women with triple-negative tumors had worse breast cancer-specific and overall survival, even after adjusting for age, disease stage, race, tumor grade, and receipt of adjuvant chemotherapy (overall survival: adjusted hazard ratio, 2.72; 95% confidence interval, 2.39-3.10; P < .0001). The difference in the risk of death by subtype was most dramatic within the first 2 years after diagnosis (overall survival for 0-2 years: OR, 6.10; 95% confidence interval, 4.81-7.74).

CONCLUSIONS

Triple-negative tumors were associated with unique risk factors and worse outcomes compared with HR-positive/HER2-negative tumors.

P2-13-05: Breast Cancer, BRCA Mutations and Attitudes Regarding Pregnancy and Preimplantation Genetic Diagnosis

Background: Breast cancer is associated with treatment-related infertility and has been demonstrated to be a major concern for premenopausal survivors. Detection of a BRCA deleterious mutation may also affect attitudes regarding future childbearing. Preimplantation genetic diagnosis (PGD) allows women to use in vitro fertilization (IVF) to implant only those embryos without a BRCA mutation. The ability to test the fetus for BRCA mutations is also available through amniocentesis and chorionic villus sampling (CVS). The objective of this study was to evaluate attitudes about childbearing and fertility in women being evaluated for a BRCA mutation. Methods: Women with childbearing potential who were referred to the Clinical Cancer Genetics Clinic to be evaluated for a BRCA mutation were invited to participate in this survey. The questionnaire was administered prior to genetic counseling. A follow-up was administered after the BRCA results were disclosed. The survey queried participants regarding their attitudes on fertility, pregnancy as it may relate to cancer and the potential of a BRCA mutation. Other questions detailed attitudes regarding IVF, PGD, and CVS in these instances. Descriptive statistics were used. Results: One hundred and twenty-eight women completed pre-questionnaires and to date 76 have completed post results disclosure questionnaires. The mean age was 33 (range 21–44) with 69.5% with a diagnosis of breast cancer, 39.8% received chemotherapy and 60.9% already had at least 1 biological child. A future child was desired by 45.3% although 53.1% worried that their children would have an increased risk of cancer. Regarding PGD, although only 30.9% (38/123) said that they would use PGD, 80.2% felt that the testing should be available to families with inherited cancers. Regarding fetal testing via amniocentesis or CVS, 29.7% would have the fetus tested and 7% would consider termination if a genetic mutation was identified. Additionally, 69.5% felt it was important to receive fertility counseling and treatment at the same place where they receive their cancer care. To date 8 women have been diagnosed with a BRCA1 mutation and 4 with a BRCA2 mutation. When asked similar questions after their genetic results were disclosed, 2 women who had previously stated they would not use PGD changed their mind. Conclusions: Future pregnancies are important to many breast cancer survivors. BRCA mutation carriers have the option to have children without passing on their genetic risk for cancer. Although few would use these interventions, a large majority felt it was important to have information about these choices and to have options for fertility preservation options addressed at the center where cancer care is delivered.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-13-05.

P1-11-02: Racial/Ethnic Differences in Adjuvant Trastuzumab Receipt for Women with Breast Cancer within the National Comprehensive Cancer Network

Background Racial/ethnic disparities in breast cancer care are well documented. Although adjuvant trastuzumab has been shown to improve disease outcomes for women with Human Epidermal Growth Factor Receptor 2 (HER2)-positive cancers, the ‘real world’ utilization and toxicity of adjuvant trastuzumab are unknown. Because therapy involves one year of treatment and the costs of treatment are high, a risk for treatment disparity exists. We examined differences in receipt and completion of adjuvant trastuzumab by race/ethnicity, education, employment, and insurance for women diagnosed with HER2−positive breast cancer.

Methods Using the National Comprehensive Cancer Network (NCCN) Breast Cancer Outcomes Database, we identified 1,146 women with stage I-III HER-2 positive breast cancer who presented to participating NCCN institutions during 2005–2008. In multivariable logistic analyses, we assessed the effect of race/ethnicity on the likelihood of trastuzumab therapy, and among women who initiated trastuzumab, the likelihood of completing ≥ 270 days of therapy, adjusting for center, diagnosis year, age, insurance, comorbidity, education, employment, and tumor characteristics. We also examined reasons for discontinuation of therapy among those who stopped treatment prematurely.

Results Among patients eligible for this analysis, 75% women were Caucasian, 9% were African-American, and 9% were Hispanic. Most women had managed care insurance (71%) and were employed/student (52%). About one-third (36%) had a college degree and 39% had a high school education or less. Overall, most women (82%) received neo/adjuvant trastuzumab and there were no racial/ethnic differences in receipt of therapy (adjusted odds ratio [OR] 1.11, 95% confidence interval [CI] .72-1.71 for African-American and OR 1.39, 95% CI .76-2.54 for Hispanic, versus Caucasian women). Among the 769 women who initiated neo/adjuvant trastuzumab and had ≥ 365 days of follow-up, 84% completed ≥ 270 days of trastuzumab. Rates of completion were lower for African-American (72%) and Hispanic (82%) women than Caucasian women (85%). In adjusted analyses, African-American women but not Hispanic women had lower odds of completing therapy compared with Caucasian women (OR .45, 95% CI .29-.70, p=0.0003). Indemnity insurance (versus managed care) was associated with lower odds of trastuzumab completion, as was having a high school education or less (versus college education). Among the 123 women who did not complete trastuzumab, 26% stopped early for toxicity, and this occurred more frequently for African-American women than Caucasian women (50% vs. 21%), but small sample precluded a meaningful test for statistical significance.

Conclusion: Compared with Caucasian women, African-American women had similar rates of initiation of adjuvant trastuzumab but much lower rates of completion that were not explained by differences in education, employment, or insurance. Because of the significant benefits conferred by adjuvant trastuzumab therapy for HER2−positive breast cancer, interventions to assure completion of therapy could lead to improved outcomes. Further exploration of racial differences in toxicity and tolerance of therapy are also warranted.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-02.

P1-08-05: Age and Survival in Women with Early Stage Breast Cancer: An Analysis Controlling for Tumor Subtype

Background: Previous research has suggested that young age at diagnosis is an independent risk factor for breast cancer recurrence and death in women with early stage breast cancer. However, young women are more likely to have aggressive subtypes of breast cancer. No prior studies have adequately controlled for tumor phenotype, including HER-2/neu (HER2) status, in particular. Recent evidence has suggested that the prognostic effect of young age varies by tumor subtype.

Methods: We examined data from women with newly diagnosed Stage 1–3 breast cancer presenting to one of 8 NCCN centers between January 2000 and December 2007. Multivariate Cox proportional hazards models were used to assess the relationship between age and breast cancer specific survival, controlling for known prognostic factors and treatment. In addition, we conducted stratified analyses by estrogen receptor (ER) and HER2 status.

Results: 19,633 women with Stage 1–3 breast cancer eligible for analysis including 2,177 (11%) who were age 40 years or younger at diagnosis. Younger women were more likely to be non-white or Hispanic, more educated, employed, and to have higher stage, high grade, ER-negative, progesterone receptor (PR) negative, and HER2−positive disease, and treated with chemotherapy and trastuzumab (all variables P&lt; 0.0001 by Chi-Square test). 5-year survival among younger women was 94.1 (95% Confidence Interval [CI] 92.9−95.3) and 96.3 (95% CI 95.9−96.6) for older women. In a multivariate Cox proportional hazards model controlling for sociodemographic, disease, and treatment characteristics, women age &lt; 40 or younger at diagnosis had increased mortality compared to older women (Hazard Ratio [HR] 1.26, 95% CI 1.02−1.56). In stratified analyses, age 40 or less was associated with increased mortality among women with ER-positive disease (HR 1.44, 95% CI 1.01−2.05), but was not among those with ER-negative disease (HR 1.15, 95% CI 0.85−1.55). Younger age was associated with a statistically significant increase in mortality among women with HER2−negative disease (HR 1.29, 95% CI 1.00−1.68), but this difference did not reach statistical significance among those with HER2−positive disease (HR 1.30, 95% CI 0.82−2.09). Conclusions: The effect of age on short-term survival of women with early breast cancer appears to vary by breast cancer subtype, particularly ER status. Further research to elucidate differences in breast cancer biology and efficacy of therapy within tumor types by age is warranted.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-05.

Retrospective analysis of antitumor effects of zoledronic acid in breast cancer patients with bone-only metastases

BACKGROUND

Bisphosphonates have been used successfully in the treatment of hypercalcemia and to reduce skeletal complications of bone metastasis, but have not been shown to prevent bone metastasis or to prolong survival time in metastatic breast cancer patients. The aim of this study was to determine whether the progression-free survival (PFS) and overall survival (OS) of patients with bone-only breast cancer metastasis differed based on whether patients received zoledronic acid, pamidronate, or no bisphosphonate upon diagnosis of their metastases.

PATIENTS AND METHODS

We retrospectively identified 314 patients diagnosed with bone-only metastasis at the time of initial staging or who developed bone metastasis as the first recurrence site during follow-up from January 1, 1997 to December 31, 2008, at The MD Anderson Cancer Center. Univariate and multivariate Cox hazards models were used to assess the effects of each treatment on PFS and OS.

RESULTS

Patients who had more than 1 bone metastasis and Eastern Cooperative Oncology Group (ECOG) performance status of 2 and 3 were more likely to receive zoledronic acid in this analysis. Compared with no bisphosphonate use, the use of zoledronic acid was not significantly associated with longer PFS (hazard ratio [HR] = 0.72, P = .058 in univariate analysis, and HR = 0.80, P = .235 in multivariate analysis) nor with longer OS (HR = 1.04, P = .863 in univariate analysis and HR = 1.34, P = .192 in multivariate analysis).

CONCLUSION

Our study demonstrates that for patients with bone-only metastases, zoledronic acid did not prolong PFS or OS. In patients with bone-only metastasis, we could not demonstrate antitumor effects of zoledronic acid.

Phase III randomized trial of dose intensive neoadjuvant chemotherapy with or without G-CSF in locally advanced breast cancer: long-term results

OBJECTIVE

To compare the pathologic complete response (pCR) rate of patients treated with 5-fluorouracil (5-FU), doxorubicin, and cyclophosphamide (FAC) versus dose-intense FAC plus G-CSF in the neoadjuvant setting and to compare the delivered dose intensity, disease-free survival (DFS) and overall survival (OS) times, and toxicity between treatment arms in patients with breast cancer.

METHODS

Patients were randomized to receive preoperative FAC (5-FU, 500 mg/m(2); doxorubicin, 50 mg/m(2); cyclophosphamide, 500 mg/m(2)) every 21 days for four cycles or dose-intense FAC (5-FU, 600 mg/m(2); doxorubicin, 60 mg/m(2); cyclophosphamide, 1,000 mg/m(2)) plus G-CSF every 18 days for four cycles.

RESULTS

Two hundred two patients were randomly assigned. The median follow-up was 7.5 years. Patients randomized to FAC plus G-CSF had a higher pCR rate as well as clinical complete response rate; however, these differences were not statistically different from those with the FAC arm. Patients in the FAC + G-CSF arm had a higher delivered dose intensity of doxorubicin in the neoadjuvant and adjuvant settings than those in the standard FAC arm. DFS and OS times were not significantly different between the two groups. However, the OS and DFS rates were significantly higher for patients who achieved a pCR than for those who did not. Thrombocytopenia, febrile neutropenia, and infection rates were higher in the FAC + G-CSF arm.

CONCLUSIONS

A higher delivered dose intensity of doxorubicin with the FAC + G-CSF regimen did not result in a statistically significant higher pCR rate. However, patients who achieved a pCR experienced longer DFS and OS times.

FDG-PET/CT compared with conventional imaging in the detection of distant metastases of primary breast cancer

PURPOSE

Evidence from studies with small numbers of patients indicates that (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) accurately detects distant metastases in the staging of primary breast cancer. We compared the sensitivity and specificity of PET/CT and conventional imaging (CT, ultrasonography, radiography, and skeletal scintigraphy) for the detection of distant metastases in patients with primary breast cancer.

PATIENTS AND METHODS

We performed a retrospective review that identified 225 patients with primary breast cancer seen from January 2000 to September 2009 for whom PET/CT data were available for review. Imaging findings were compared with findings on biopsy, subsequent imaging, or clinical follow-up. Sensitivity and specificity in the detection of distant metastases were calculated for PET/CT and conventional imaging. Fisher's exact tests were used to test the differences in sensitivity and specificity between PET/CT and conventional imaging.

RESULTS

The mean patient age at diagnosis was 53.4 years (range, 23-84 years). The sensitivity and specificity in the detection of distant metastases were 97.4% and 91.2%, respectively, for PET/CT and 85.9% and 67.3%, respectively, for conventional imaging. The sensitivity and specificity of PET/CT were significantly higher than those of conventional imaging (p = .009 and p < .001, respectively). Eleven cases of distant metastases detected by PET/CT were clinically occult and not evident on conventional imaging.

CONCLUSION

PET/CT has higher sensitivity and specificity than conventional imaging in the detection of distant metastases of breast cancer. A prospective study is needed to determine whether PET/CT could replace conventional imaging to detect distant metastases in patients with primary breast cancer.

Initial staging impact of fluorodeoxyglucose positron emission tomography/computed tomography in locally advanced breast cancer

PURPOSE

Fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) may reveal distant metastases more accurately than conventional imaging (CT, skeletal scintigraphy, chest radiography). We hypothesized that patients diagnosed with stage III noninflammatory breast cancer (non-IBC) and IBC by conventional imaging with PET/CT have a better prognosis than patients diagnosed without PET/CT.

PATIENTS AND METHODS

We retrospectively identified 935 patients with stage III breast cancer in 2000-2009. We compared the relapse-free survival (RFS) and overall survival (OS) times of patients diagnosed by conventional imaging with those of patients diagnosed by conventional imaging plus PET/CT. Univariate and multivariate Cox proportional hazards regression models were used to assess associations between survival and PET/CT.

RESULTS

RFS and OS times were not significantly different between patients imaged with PET/CT and those imaged without PET/CT. However, the RFS time in IBC patients was significantly different between patients imaged with PET/CT and those imaged without PET/CT on both univariate (hazard ratio [HR], 0.43; p = .014) and multivariate (HR, 0.33; p = .004) analysis. There was a trend for a longer OS duration in IBC patients imaged with PET/CT.

CONCLUSION

Among IBC patients, adding PET/CT to staging based on conventional imaging might detect patients with metastases that were not detected by conventional imaging. The use of conventional imaging with PET/CT for staging in non-IBC patients is not justified on the basis of these retrospective data. The use of conventional imaging plus PET/CT in staging IBC needs to be studied prospectively to determine whether it will improve prognosis.

American Society of Clinical Oncology Executive Summary of the Clinical Practice Guideline Update on the Role of Bone-Modifying Agents in Metastatic Breast Cancer

Purpose

To update the recommendations on the role of bone-modifying agents in the prevention and treatment of skeletal-related events (SREs) for patients with metastatic breast cancer with bone metastases.

Methods

A literature search using MEDLINE and the Cochrane Collaboration Library identified relevant studies published between January 2003 and November 2010. The primary outcomes of interest were SREs and time to SRE. Secondary outcomes included adverse events and pain. An Update Committee reviewed the literature and re-evaluated previous recommendations.

Results

Recommendations were modified to include a new agent. A recommendation regarding osteonecrosis of the jaw was added.

Recommendations

Bone-modifying agent therapy is only recommended for patients with breast cancer with evidence of bone metastases; denosumab 120 mg subcutaneously every 4 weeks, intravenous pamidronate 90 mg over no less than 2 hours, or zoledronic acid 4 mg over no less than 15 minutes every 3 to 4 weeks is recommended. There is insufficient evidence to demonstrate greater efficacy of one bone-modifying agent over another. In patients with a calculated serum creatinine clearance of more than 60 mg/min, no change in dosage, infusion time, or interval of bisphosphonate administration is required. Serum creatinine should be monitored before each dose. All patients should receive a dental examination and appropriate preventive dentistry before bone-modifying agent therapy and maintain optimal oral health. Current standards of care for cancer bone pain management should be applied at the onset of pain, in concert with the initiation of bone-modifying agent therapy. The use of biochemical markers to monitor bone-modifying agent use is not recommended.

Treatment outcome and prognostic factors for patients with bone-only metastases of breast cancer: a single-institution retrospective analysis

PURPOSE

Limited information is available about the optimal management and clinical outcome of bone-only metastases in breast cancer patients. The objective of this study was to define prognostic factors for patients with bone-only metastases. Our second objective was to compare progression-free survival (PFS) and overall survival (OS) between patients with hormone receptor (HR)(+) tumors and bone-only metastases who received combinatory therapy (chemotherapy followed by endocrine therapy, or endocrine therapy combined with molecular targeted therapy) and those treated with endocrine or chemotherapy alone.

PATIENTS AND METHODS

We retrospectively identified 351 breast cancer patients diagnosed with bone-only metastasis in 1997-2008 at our institution.

RESULTS

Patients with metastasis detected at the time of their primary breast cancer diagnosis (rather than at recurrence), a single metastasis, or asymptomatic bone disease had a longer PFS interval, and patients with a performance status of 0-1, a single metastasis, or asymptomatic bone disease had a longer OS time. Among patients with HR(+) human epidermal growth factor receptor (HER)-2(-) disease, combinatory therapy was associated with longer PFS and OS times than with endocrine therapy. In multivariate analyses, combinatory therapy was not associated with longer PFS or OS times than with endocrine therapy. Among patients with HER-2(+) disease, trastuzumab led to a longer PFS interval but no difference in the OS time.

CONCLUSION

Our results indicate that, for HR(+) disease, a prospective trial of chemotherapy followed by endocrine therapy is warranted to determine whether it prolongs survival more than endocrine therapy alone in patients with bone-only metastases.

Abstract P5-01-02: Role of FDG-PET/CT in Metastatic Staging of Newly Diagnosed Primary Breast Cancer

Background

FDG positron emission tomography/computed tomography (PET/CT) may accurately detect distant metastases during staging of primary breast cancer. However, the evidence is very limited. We retrospectively compared the sensitivity and specificity of PET/CT and conventional imaging (CT, ultrasonography, radiography, and skeletal scintigraphy) for the detection of distant metastases in patients with primary breast cancer. We also retrospectively tested the hypothesis that stage III disease detected by conventional imaging + PET/CT has a better prognosis than that detected by conventional imaging only.

Methods

To determine sensitivity and specificity, we used a database of 225 patients with primary breast cancer (2000-2009) for which PET/CT data existed. The presence or absence of distant metastases was determined based on histopathologic findings, subsequent imaging findings, or clinical follow-up. To determine prognosis, we studied 935 patients newly diagnosed with stage III breast cancer (2000-2009). In 82 of these patients, stage III disease was detected by conventional imaging + PET/CT. We studied 171 IBC patients newly diagnosed with stage III breast cancer. In 51 of these patients, stage III disease was detected by conventional imaging + PET/CT; we compared their relapse-free survival (RFS) and overall survival (OS) rates with those for 853 patients diagnosed using conventional imaging only. Univariate and multivariate Cox Proportional Hazard regression models were used to assess PEC/CT.

Results

Among 225 pts with primary breast cancer, the sensitivity and specificity for PET/CT in the detection of distant metastases were 97.4% and 91.2%, respectively; This was significantly higher (p=0.009 and P&lt;0.001) than the sensitivity and specificity rates for conventional imaging only (85.9% and 67.3%, respectively). Eleven patients of distant metastases detected by PET/CT were clinically occult and not evident on conventional imaging. Among patients with stage III disease, RFS (hazard ratio [HR]=1.10, p=0.7) and OS (HR=1.14, p=0.673) did not significantly differ based on whether PET/CT was used. RFS also did not show significant difference in multivariate analysis (HR=0.70, p=0.213). However, in inflammatory breast cancer (IBC), patients diagnosed with conventional imaging + PET/CT had longer RFS than patients diagnosed with conventional imaging only in both univariate (HR=0.43, p=0.014) and multivariate analysis (HR=0.33, p=0.004). There was a trend for OS improvement among patients who had PET/CT (HR=0.55, p=0.122). Conclusion

PET/CT had higher sensitivity and specificity than conventional imaging in the detection of distant metastases of breast cancer. Among patients with stage III disease, there was no difference in OS or RFS between patients diagnosed with conventional imaging + PET/CT and patients diagnosed with conventional imaging only. IBC patients staged with conventional imaging + PET/CT had better prognosis than those staged with conventional imaging only. Based on our results, the use of PET/CT as a staging tool to detect metastasis is not justified in stage III non-IBC. Conversely, the use of conventional imaging + PET/CT in patients with IBC appears promising, but needs prospective confirmation.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-01-02.

Breast cancer and pregnancy: current concepts in diagnosis and treatment

The treatment of breast cancer diagnosed during pregnancy presents a challenging situation for the patient, family, and caregivers. Case series have demonstrated the efficacy and safety of using anthracycline-based chemotherapy during the second and third trimesters. Additionally, patients should be seen, evaluated, and treated in a multidisciplinary setting with facilitated communication among the medical oncologist, surgical oncologist, obstetrician, radiation oncologist, pathologist, and radiologist. This review details the available data regarding the diagnosis and management of the pregnant breast cancer patient.

Addition of GM-CSF to trastuzumab stabilises disease in trastuzumab-resistant HER2+ metastatic breast cancer patients

Background:

One of the proposed mechanisms of trastuzumab-induced regression of human epidermal growth factor receptor 2-positive (HER2+) tumours includes facilitation of antibody-dependent cell-mediated cytotoxicity (ADCC). Granulocyte-macrophage colony-stimulating factor (GM-CSF) mediates ADCC. We presented our pilot study of adding GM-CSF to trastuzumab in patients with trastuzumab-resistant HER2+ metastatic breast cancer.

Methods:

Patients with HER2+ metastatic breast cancer that progressed after trastuzumab +/− chemotherapy were continued on trastuzumab 2 mg kg^–1 intravenous weekly and GM-CSF 250 μg m^–2 subcutaneous daily. Patients were assessed for response every 8 weeks. Treatment was continued until disease progression or intolerable toxicity.

Results:

Seventeen patients were evaluable (median age 48 years, range 27–75 years). The median number of metastatic sites was 2 (range 1–3); the most common site was the liver (n=10). The median number of prior regimens for metastatic disease was 2 (range 1–5). No objective disease response was observed, but five patients (29%) had stable disease for a median duration of 15.8 (range 10–53.9) weeks. The most common adverse event was rash at the injection site. No grade 4 or irreversible adverse event was seen.

Conclusion:

The addition of GM-CSF to trastuzumab alone had a modest clinical benefit and acceptable safety profile in heavily pretreated patients with trastuzumab-resistant HER2+ metastatic breast cancer.