P5-01-06: Gene Copy Number and Expression of TYMP and TYMS Are Predictive of Outcome in Breast Cancer Patients Treated with Capecitabine

Background: The efficacy of the pro-drug capecitabine (C) may be affected by the expression of thymidylate synthase (TYMS) and thymidine phosphorylase (TYMP), respectively the target and the activating enzyme of C, as well as dihydrofolate reductase (DHFR) that provides a key intermediate.

Method: In this retrospective study, expression and gene copy number (GCN) of the above enzymes were assessed and correlated with time-to progression (TTP) and progression-free survival (PFS) of adult female patients with pathologically confirmed breast cancer and locally advanced or metastatic disease treated with C 1000 mg/m2 BID days 1–14 of a 21-day cycle. TYMS, TYMP and DHFR GCN were scored using custom made FISH probes (Dako, Denmark) in at least 60 morphologically intact non-overlapping nuclei. FISH markers dichotomized as high/low by the median were correlated with TTP and PFS using Cox proportional hazard models in 65, 57 and 24 patients for TYMS, TYMP and DHFR probes respectively. Gene expression was analyzed using the whole genome cDNA-mediated annealing, selection extension and ligation (DASL) platform on total RNA extracted from FFPE tissue samples and correlated with TTP and PFS using Cox models in 75 patients. Correlations between GCN and expression were measured using both Pearson's and Spearman's correlation coefficients.

Results: Our interim results (ASCO 2011) showed that higher TYMS GCN was significantly associated with both decreased TTP (HR 1.76, 95% CI 1.07 to 2.90, p=0.026) and PFS (HR 1.86, 95% CI 1.14 to 3.04, p=0.036) in the overall patient population. We now observe 1) a statistically significant positive correlation between TYMS GCN and expression (Pearson 0.26, p=0.049; Spearman 0.25, p=0.056); 2) a trend towards worse outcome with higher TYMS expression in a) the overall population (TTP-HR 1.23, 95% CI 0.93 to 1.64, p=0.148), b) in ER+ patients (TTP-HR 1.46, 95% CI 0.97 to 2.19, p=0.07) as well as in c) HER2− patients (TTP-HR 1.17, 95% CI 0.85 to 1.61, p=0.343), 3) a statistically significant association between higher TYMP expression and longer PFS, but not TTP in ER+ and HER2− patients (table).

Selective Effects of Glucose, Insulin and Leptin by Molecular Breast Cancer Subtype

Background: Type II diabetes and obesity are important risk factors for post-menopausal luminal A (LA) and triple negative (TN) pre-menopausal breast cancers, particularly in African American (AA) and Hispanic women. Breast cancer patients with these chronic metabolic diseases also have a worse prognosis, independent of other factors. We have published that metformin inhibits cell growth (S phase arrest) and induces apoptosis, only in TN cell lines in vivo and in vitro. It is less active, growth inhibitory (G1 arrest) and does not induce apoptosis in other breast cancer cell subtypes (Cell Cycle, 2009).Methods: We investigated the effects of glucose as a mitogen at physiologic (5mM), metabolic syndrome (7mM) or diabetic levels (10mM), with or without insulin (100 ng/ml) or leptin (100 ng/ml) using cell lines representing all molecular subtypes of breast cancer. Metformin was then used in combination with the above, to determine whether it would block the mitogenic or signaling effects of supraphysiological glucose, insulin or leptin.Results: The LA (MCF-7) and 2 of 5 TN cell lines (derived from AA patients; HCC 1806 and MDA 468) showed the most cell growth in response to glucose >5mM (75% for MCF-7, 30-50% for AA TN lines). Three TN cell lines from Caucasians (MDA231, HCC1937, BT20), the HER2 (SKBR3) and luminal B (BT-474) cells showed less growth induction with glucose >5mM. In TN lines only, glucose associated mitogenesis was associated with increased EGFR, pEGFR, IGF1R, pIGF1R, AKT and pAKT and decreases in AMPK, pAMPK, p38, IRS2, and the cyclins D1, E and A in a dose dependent manner. Metformin abrogated glucose induced cell growth and the aforementioned protein expression/phosphorylation changes involving EGFR, IGF1R, and AKT, increased AMPK and pAMPK and induced a profound reduction in Cyclin D1 across all glucose concentrations in TN cell lines from AA women. It reduced but did not eliminate glucose associated mitogenesis in the TN cell lines from Caucasian patients. Metformin had a more variable effect on cell lines of other molecular subtypes grown under high glucose conditions. The 5 TN breast cancer cell lines were uniformly resistant to both leptin and insulin associated mitogenesis, across a wide range of glucose concentrations. In contrast, both leptin and insulin significantly promoted LA breast cancer cell growth. These effects were resistant to metformin treatment. Leptin and insulin had the least growth promoting effects on HER2 breast cancer cell lines, whereas they induced modest growth induction in LB cell lines.Conclusions: All TN cell lines showed significant mitogenesis in response to glucose >5mM, whereas they were uniformly resistant to both leptin and insulin. The glucose associated mitogenesis was more pronounced in lines derived from AA patients, as were the anti-mitgenic effects of metformin. LA cells showed marked growth induction by glucose, leptin and insulin, whereas HER2 cell lines showed general resistance to all of these factors. These data suggest that metabolic and hormonal shifts with obesity and diabetes, as well as metformin response vary by the molecular subtype of breast cancer cells and ethnicity.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5154.

Metformin Enhances Trastuzumab Efficacy and Overcomes Resistance in HER2 Type Breast Cancer Cells

Background: HER2 alterations occur in one-fourth of breast cancers and are associated with an aggressive tumor phenotype. The anti-HER2 agent trastuzumab reduces cell proliferation, angiogenesis, DNA repair and induces antibody-dependent cellular cytotoxicity. Objective response rates and median duration of response for eligible patients given trastuzumab alone is low (12-34% and 9 months respectively), hence, it is administered in combination with other agents. Mechanisms of trastuzumab resistance include: altered receptor antibody interactions, increased signaling through other EGFR type I growth factor receptors, modulation of p27 kip1 and increased insulin-like growth factor 1 receptor (IGF-1) signaling. We have reported that metformin inhibits HER2 expression, tyrosine kinase activity (phosphorylated HER2 at both auto- and Src- phosphorylation sites), AKT/mTOR signaling, Cyclin D1 and E2F1 with G1 arrest in HER2 overexpressing breast cancer cells. We sought to determine if metformin would enhance trastuzumab associated cytotoxicity and modulate acquired resistance in vitro.Methods: We used trastuzumab sensitive (SKBR3, BT474) and resistant cell lines (BT-474/HR20, SKBR3/P2, MCF-7/713 and MCF-7/HER2Δ16) to study the effects of metformin, metformin + trastuzumab and trastuzumab alone. Assays included MTS for proliferation, clonogenicity studies, Western blots, and pull down experiments with Western blots.Results: Trastuzumab sensitive breast cancer cells were less sensitive to metformin alone, compared to trastuzumab resistant HER2 subtype breast cancer cell lines. Trastuzumab sensitive cells showed enhanced growth and clonogenicity inhibition when treated by both metformin and trastuzumab. At the molecular level, these bi-treated cells showed decreases in HER2/pHER2, erbB3/perbB3, and inactivation of AKT and MAPk signaling. Metformin as low as 20mM increased the efficacy of trastuzumab. All HER2 resistant cell lines showed higher levels of IGF1R and HER2/IGF1R complexes, as compared to sensitive parental lines. In these resistant lines Metformin decreased cell proliferation and clonogenicity, HER2/IGF1R complexes (identified through pull down experiments) and protein expression of HER2/pHER2, erbB3/perbB3, IGF1R/pIGF1R as well as downstream signaling via Akt and IGF1 pathways. Metformin overcame trastuzumab resistance as demonstrated by growth and clonogenicity assays.Conclusions: HER2 amplified trastuzumab resistant breast cancer cells showed greater sensitivity to metformin than sensitive parental lines. Metformin reversed trastuzumab resistance and decreased HER2:IGF1R complexes, HER2/pHER2 and IGF1R expression, whereas sensitive parental lines showed no complex formation. These preclinical data suggest a combination of metformin and trastuzumab may have clinical benefit, improving the efficacy and reducing the emergence of or reversing trastuzumab resistance in HER2 positive breast cancer patients.Herceptin graciously provided by Genentech

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1133.

Thymidilate synthase (TS), thymidine phosphorylase (TP), dihydropyrimidine dehydrogenase (DPD), and dihydrofolate reductase (DHFR) as predictive markers of capecitabine efficacy in breast cancer patients

11033

Background: The efficacy of 5-FU and the pro-drug capecitabine (C) is mediated through the thymidylate synthase pathway and may be affected by expression of key enzymes in this pathway. The expression and/or gene copy number of TS, TP, DPD and DHFR was assessed and correlated with time-to progression (TTP) and progression-free survival (PFS). Methods: Adult female patients with pathologically confirmed breast cancer and locally advanced or metastatic disease were treated with C 1000 mg/m2 BID days 1–14 of a 21-day cycle. Formalin-fixed, paraffin-embedded (FFPE) specimens from C-treated patients were processed for RNA extraction. Total RNA was isolated from 32 FFPE tissue samples containing at least 70% tumor cells and RNA levels for TS, TP, DPD and DHFR were quantified using real time RT-PCR and Affymetrix GeneChip microarrays. Custom made TS and TP FISH probes (Dako, Glostrup, Denmark) were used to evaluate gene copy number and gene to reference ratios in at least 60 morphologically intact non-overlapping nuclei. Markers were correlated with TTP and PFS using Cox proportional hazard models in 24 patients. Results: Higher TS gene copy number was significantly associated with a decrease in PFS (HR 1.46, 95% CI 1.08 to 1.96, p=0.014) and TTP (HR 1.49, 95% CI 1.05 to 2.13, p=0.028). However, the association between TS RNA levels (expressed as Ct values) and PFS (HR 0.82, 95% CI 0.61 to 1.11, p=0.198) or TTP (HR 0.74, 95% CI 0.49 to 1.14, p=0.172) failed to reach statistical significance. RNA levels, determined by Affymetrix, were significantly correlated with RT-PCR for TS (r= -0.5073, p=0.0004) and DHFR (r=-0.50994, p=0.003). Neither TP gene copy number nor RNA levels were significantly associated with PFS (HR 099, and HR 0.93) or TTP (HR 1.07 and HR 1.029), respectively. The association between RNA levels and PFS or TTP did not reach statistical significance for both DPD (HR 1.17 and HR 1.13) and DHFR (HR 0.68 and HR 0.63), respectively. Conclusions: These data indicate that TS gene copy number, assessed by FISH with proper standardization, might be a useful and easily accessible marker for C sensitivity in human breast cancer and warrants further investigation.

[Table: see text]

Docetaxel Combined With Trastuzumab Is an Active Regimen in HER-2 3+ Overexpressing and Fluorescent In Situ Hybridization–Positive Metastatic Breast Cancer: A Multi-Institutional Phase II Trial

Purpose

To determine the efficacy and safety of weekly docetaxel and trastuzumab as first- or second-line therapy in women with HER-2–overexpressing metastatic breast cancer and to correlate the efficacy of trastuzumab with HER-2 status as determined by immunohistochemistry assay and fluorescent in situ hybridization (FISH).

Patients and Methods

Twenty-six women with HER-2–positive (HercepTest [Dako Corp, Carpenteria, CA]2 to 3+) metastatic breast cancer were enrolled onto this study of trastuzumab (4 mg/kg load; 2 mg/kg/wk administered intravenously) and docetaxel (35 mg/m2/wk for 6 weeks).

Results

Using an intent-to-treat analysis, the overall response rate was 50% (13 of 26 patients). Eight patients (31%) had a period of stable disease posttherapy. Among HER-2 3+ patients, the overall response rate was 63% (12 of 19 patients) compared with a 14% response rate (one of seven patients) for HER-2 2+ patients (P = .07). Patients with FISH-positive tumors experienced an overall response rate of 64%. Median time to progression was 12.4 months for the entire cohort (HER-2 3+ tumors, 12.3 months; HER-2 2+ lesions, 9.5 months) and median survival was 22.1 months. All HER-2 3+ patients were FISH-positive; the only HER-2 2+ patient responding to treatment was also FISH-positive. Grade 4 toxicities occurred in four patients; most toxicities were mild.

Conclusion

Trastuzumab plus docetaxel is an active and well-tolerated regimen in women with HER-2 3+ overexpressing or FISH-positive metastatic breast cancer.

Basic statistics of PM2.5 and PM10 in the atmosphere of Mexico City

The high levels of fine particulate matter in Mexico City are of concern since they may induce severe public health effects as well as the attenuation of visible light. Sequential filter samplers were used at six different sites from 23 February to 22 March 1997. The sampling campaign was carried out as part of the project 'Investigación sobre Materia Particulada y Deterioro Atmosferico-Aerosol and Visibility Evaluation Research'. This research was a cooperative project sponsored by PEMEX and by the US Department of Energy. Sampling sites represent the different land uses along the city, the northwest station, Tlalnepantla, is located in a mixed medium income residential and industrial area. The northeast station, Xalostoc, is located in a highly industrialized area, Netzahualcoyotl is located in a mixed land use area, mainly commercial and residential. Station La Merced is located in the commercial and administrative district downtown. The southwest station is located in the Pedregal de San Angel, in a high-income neighborhood, and the southeast station located in Cerro de la Estrella is a mixed medium income residential and commercial area. Samples were collected four times a day in Cerro de la Estrella (CES), La Merced (MER) and Xalostoc (XAL) with sampling periods of 6 h. In Pedregal (PED), Tlalnepantla (TLA) and Netzahualcoyot1 (NEZ) sampling periods were every 24 h. In this paper the basic statistics of PM2.5 and PM10 mass concentrations are presented. The average results showed that 49, 61, 46, 57, 51 and 44% of the PM10 consisted of PM2.5 for CES, MER, XAL, PED, TLA and NEZ, respectively. The 24-h average highest concentrations of PM25 and PM10 were registered at NEZ (184 and 267 microg/m3) and the lowest at PED (22 and 39 microg/m3). The highest PM10 correlations were between XAL-CES (0.79), PED-TLA (0.80). In contrast, the highest PM2.5 correlations were between CES-PED (0.74), MER-CES (0.73) and TLA-PED (0.72), showing a lower correlation than the PM10 one. The results of the PM10 from 12.00 to 18.00 h at CES and MER presented the highest variability and also the highest median concentrations, meanwhile XAL showed them from 06.00 to 12.00 h. The highest variability and median concentrations of PM2.5 were from 06.00 to 12.00 h for the three stations.

Activation (tyrosine phosphorylation) of ErbB-2 (HER-2/neu): a study of incidence and correlation with outcome in breast cancer

PURPOSE

We hypothesize that phosphorylated ErbB-2 (P-ErbB-2, identified by a novel antibody PN2A) may provide either more significant or additional prognostic marker data for breast cancer patients. This study was designed to compare the incidence and prognostic value of ErbB-2 (HER-2/neu) and P-ErbB-2 immunoexpression in archival breast cancer samples.

MATERIALS AND METHODS

Eight hundred sixteen invasive breast cancers with a median of 16.3 years of follow-up were immunostained for ErbB-2 (using antibody CB11) and P-ErbB-2 (using antibody PN2A). ErbB-2 and P-ErbB-2 data were compared with clinical, histologic, immunohistochemical, and outcome variables.

RESULTS

Of 816 primary breast cancers, 307 (38%) were positive for ErbB-2 and 37 (12% of ErbB-2 positive and 5% of the study population) expressed P-ErbB-2. P-ErbB-2 was not detected in ErbB-2-negative cases (n = 509). ErbB-2 immunohistochemical data were bimodal; patients with > or = 80% cellular expression had the shortest disease-free and disease-specific survival. P-ErbB-2 was associated with a higher percentage of ErbB-2-positive cells, a higher number of positive lymph nodes, and cellular proliferation. ErbB-2 and P-ErbB-2 were indicators of poor prognosis in node-positive patients in both univariate and multivariate analyses. We found that either P-ErbB-2 expression or high (> or = 80%) ErbB-2 expression provided the most significant prognostic value in node-positive cases by multivariate analyses. There were too few P-ErbB-2-positive cases and events in the node-negative patient group to allow statistical analysis of P-ErbB-2 in that subgroup.

CONCLUSION

PN2A immunostaining identified a subset (approximately 12% of ErbB-2-positive breast cancers) with activation (phosphorylation) of the receptor ErbB-2. P-ErbB-2 expression was strongly associated with higher levels of ErbB-2 expression (> or = 80%), although it was not a surrogate. Identification of cases with a high percentage of invasive breast cancer cells expressing ErbB-2 or determination of receptor activation via P-ErbB-2 may provide additional prognostic value in node-positive breast cancers.

Nurses' recognition of depression in their patients with cancer

PURPOSE/OBJECTIVES

To determine the degree to which nurses recognize levels of depressive symptoms in their patients with cancer and to describe patient characteristics that influence the accuracy of nurses' perceptions of depressive symptoms.

DESIGN

Descriptive, prospective correlational design.

SETTING

25 community-based ambulatory oncology clinics affiliated with Community Cancer Care of Indiana.

SAMPLE

40 clinic nurses rated the depression levels of 1,109 patients.

METHODS

Patients completed the Zung Self-Rating Depression Scale (ZSDS) prior to their medical oncology clinic appointment. Nurses rated their patients' level of depressive symptoms, anxiety, and pain on a 0-10 numerical scale along with determining a performance status score.

MAIN RESEARCH VARIABLES

Patient-rated depression and the nurse depression rating.

FINDINGS

The most frequent agreement between nurses and patients was observed when patients reported little or no depressive symptoms. They were only concordant 29% and 14% of the time in the mild and moderate/severe ranges, respectively. Nurses' ratings were influenced most by patients' endorsement of frequent and obvious mood symptoms and nurse ratings of patients' anxiety and pain.

CONCLUSIONS

A marked tendency existed to underestimate the level of depressive symptoms in patients who were more severely depressed. Nurses' ratings were most influenced by symptoms such as crying, depressed mood, and medical factors that are useful but perhaps not the most reliable indicators of depression in this population.

IMPLICATIONS FOR NURSING PRACTICE

Nurse assessment of depression might be improved if greater emphasis were placed on the more diagnostically reliable symptoms of depression and if screening tools for depression were incorporated into nursing practice.

Use of the Zung Self-Rating Depression Scale in cancer patients: feasibility as a screening tool

The feasibility, utility and reliability of the Zung Self-Rating Depression Scale (ZSDS) was examined in a large sample of ambulatory cancer patients. This tool and a brief 11-item version of the ZSDS (excluding nine items concerning somatic symptoms), which was developed during the course of the survey, were used to estimate the prevalence of self-reported depressive symptoms. Patient characteristics that may be associated with an increased risk of clinically significant depressive symptoms were also explored. Twenty-five ambulatory oncology clinics affiliated with Community Cancer Care, Inc. enrolled and surveyed 1109 subjects. The alpha coefficients for the ZSDS (0.84) and the Brief ZSDS (0.84) indicated high levels of internal consistency. The overall prevalence of clinically significant depressive symptoms as defined by the ZSDS was 35.9% and by the Brief ZSDS was 31.1%. The ZSDS and the Brief ZSDS were highly correlated (r = 0.92). The medical and demographic variables most associated with clinically significant depressive symptoms were more advanced stage of disease at time of diagnosis, lung cancer as primary tumor type, higher ECOG rating (greater degree of physical disability), and having been prescribed antidepressant medications. The high prevalence of depressive symptoms observed in this study is consistent with rates found in other studies of self-report depression instruments in cancer patients. The initial indicators of internal consistency and validity suggest that the Zung SDS or the brief version may be useful screening tools to identify depressive symptoms in oncology patients.

Use of the Zung Self-Rating Depression Scale in cancer patients: feasibility as a screening tool

The feasibility, utility and reliability of the Zung Self-Rating Depression Scale (ZSDS) was examined in a large sample of ambulatory cancer patients. This tool and a brief 11-item version of the ZSDS (excluding nine items concerning somatic symptoms), which was developed during the course of the survey, were used to estimate the prevalence of self-reported depressive symptoms. Patient characteristics that may be associated with an increased risk of clinically significant depressive symptoms were also explored. Twenty-five ambulatory oncology clinics affiliated with Community Cancer Care, Inc. enrolled and surveyed 1109 subjects. The alpha coefficients for the ZSDS (0.84) and the Brief ZSDS (0.84) indicated high levels of internal consistency. The overall prevalence of clinically significant depressive symptoms as defined by the ZSDS was 35.9% and by the Brief ZSDS was 31.1%. The ZSDS and the Brief ZSDS were highly correlated (r = 0.92). The medical and demographic variables most associated with clinically significant depressive symptoms were more advanced stage of disease at time of diagnosis, lung cancer as primary tumor type, higher ECOG rating (greater degree of physical disability), and having been prescribed antidepressant medications. The high prevalence of depressive symptoms observed in this study is consistent with rates found in other studies of self-report depression instruments in cancer patients. The initial indicators of internal consistency and validity suggest that the Zung SDS or the brief version may be useful screening tools to identify depressive symptoms in oncology patients.

erbB-2, p53, and efficacy of adjuvant therapy in lymph node-positive breast cancer

BACKGROUND

We have previously reported that high expression of the erbB-2 gene (also known as HER-2/neu and ERBB2) in breast cancer is associated with patient response to dose-intensive treatment with cyclophosphamide, doxorubicin (Adriamycin), and 5-flurouracil (CAF) on the basis of short-term follow-up of 397 patients (set A) with axillary lymph node-positive tumors who were enrolled in Cancer and Leukemia Group B (CALGB) protocol 8541.

METHODS

To validate those findings, we conducted immunohistochemical analyses of erbB-2 and p53 protein expression in an additional cohort of 595 patients (set B) from CALGB 8541, as well as a molecular analysis of erbB-2 gene amplification in tumors from all patients (sets A and B). Marker data were compared with clinical, histologic, treatment, and outcome data.

RESULTS

Updated analyses of data from set A (median follow-up, 10.4 years) showed an even stronger interaction between erbB-2 expression and CAF dose, by use of either immunohistochemical or molecular data. A similar interaction between erbB-2 expression and CAF dose was observed in all 992 patients, analyzed as a single group. However, for set B alone (median follow-up, 8.2 years), results varied with the method of statistical analysis. By use of a proportional hazards model, the erbB-2 expression-CAF dose interaction was not significant for all patients. However, in the subgroups of patients randomly assigned to the high- or the moderate-dose arms, significance was achieved. When patient data were adjusted for differences by use of a prognostic index (to balance an apparent failure of randomization in the low-dose arm), the erbB-2 expression-CAF dose interaction was significant in all patients from the validation set B as well. An interaction was also observed between p53 immunopositivity and CAF dose.

CONCLUSIONS

The hypothesis that patients whose breast tumors exhibit high erbB-2 expression benefit from dose-intensive CAF should be further validated before clinical implementation. Interactions between erbB-2 expression, p53 expression, and CAF dose underscore the complexities of predictive markers where multiple interactions may confound the outcome.

ErbB-2 protein in sera and tumors of breast cancer patients

We compared levels of erbB-2 oncoprotein among three groups: Group I included 60 asymptomatic women; Group II had 51 women with benign breast biopsies; and Group III had 67 women with node-negative breast cancer. Serological levels of erbB-2 protein were measured in all participants; tumor levels were measured for Groups II and III. Forty-three percent of usable tumors (25/58), including three of seven lobular tumors, were erbB-2 positive. Tumor and blood oncoprotein levels were unrelated. Blood levels, however, were positively related to tumor volume, but only when the tumor had both a ductal carcinoma in situ (DCIS) component and an invasive component, suggesting a role for erbB-2 protein in progression of DCIS to invasive carcinoma. In Groups I and II serological levels of erbB-2 protein were directly related to age, and inversely related to having had a live birth. Therefore, a model that determined the threshold levels of serological erbB-2 positivity in Group III included age and nulliparity as independent variables. Only three of the 67 women (4.5%) in Group III were positive for serological erbB-2. In a multivariate model, with serological erbB-2 as the dependent variable, and in which the independent variables included Study Group, there was a statistical trend for younger women, in which Group III had the highest serological levels of erbB-2, followed by Group II, and then Group I. In women who were over the age of 50 years the trend was reversed; i.e., levels of erbB-2 tended to be lowest in Group III, followed by Group II, and finally Group I.

Oncologists' recognition of depression in their patients with cancer

PURPOSE

This study was performed as part of a large depression screening project in cancer patients to determine the degree of physician recognition of levels of depressive symptoms in cancer patients and to describe patient characteristics that influence the accuracy of physician perception of depressive symptoms.

METHODS

Twenty-five ambulatory oncology clinics affiliated with Community Cancer Care, Inc of Indiana enrolled and surveyed 1,109 subjects treated by 12 oncologists. Subjects completed the Zung Self-Rating Depression Scale (ZSDS) and physicians were asked to rate their patients' level of depressive symptoms, anxiety, and pain using numerical rating scales. Subjects' sex, age, primary tumor type, medications, primary caregiver, and disease stage at diagnosis were also recorded.

RESULTS

Physician ratings of depression were significantly associated with their patients' levels of endorsement of depressive symptoms on the ZSDS. However, agreement between physicians and patients is most frequently clustered when patients report little or no depressive symptoms. While physician ratings are concordant with patient endorsement of no significant depressive symptomatology 79% of the time, they are only concordant 33% and 13% of the time in the mild-to-moderate/severe ranges, respectively. Physician ratings were most influenced by patient endorsement of frequent and obvious mood symptoms, ie, sadness, crying, and irritability. Physician ratings also appeared to be influenced by medical correlates of patients' level of depressive symptoms (functional status, stage of disease, and site of tumor). Additionally, patients whose depression was inaccurately classified reported significantly higher levels of pain and had higher levels of disability. Physicians' ratings of depression were most highly correlated with physicians' ratings of patients' anxiety and pain.

CONCLUSION

Physicians' perceptions of depressive symptoms in their patients are correlated with patient's ratings, but there is a marked tendency to underestimate the level of depressive symptoms in patients who are more depressed. They are most influenced by symptoms such as crying and depressed mood, and medical factors that are useful, but not the most reliable, indicators of depression in this population. Physicians' ratings of their patients' distress symptoms seem to be global in nature--they are highly correlated with anxiety, pain, and global dysfunction. Physician assessment might be improved if they were instructed to assess and probe for the more reliable cognitive symptoms such as anhedonia, guilt, suicidal thinking, and hopelessness. Screening instruments and the use of brief follow-up interviews would help to identify patients who are depressed.

HER2/Neu and the Ets transcription activator PEA3 are coordinately upregulated in human breast cancer

HER2/Neu is overexpressed in 25-30% of all human breast cancers as a result of both gene amplification and enhanced transcription. Transcriptional upregulation of HER2/neu leads to a 6-8-fold increased abundance of its mRNA per gene copy and likely results from the elevated activity of transcription factors acting on the HER2/neu promoter. Here we report that transcripts of PEA3, an ETS transcription factor implicated in oncogenesis, were increased in 93% of HER2/Neu-overexpressing human breast tumor samples. Analyses to uncover the molecular basis for elevated PEA3 transcripts in HER2/Neu-positive breast tumors revealed that the HER2/Neu receptor tyrosine kinase initiated an intracellular signaling cascade resulting in increased PEA3 transcriptional activity; transcriptionally-activated PEA3 stimulated HER2/neu and PEA3 gene transcription by binding to sites in the promoters of these genes. PEA3 also activates transcription of genes encoding matrix-degrading proteinases, enzymes required for tumor cell migration and invasion. These findings implicate PEA3 in the initiation and progression of HER2/Neu positive breast cancer, and suggest that PEA3 and signaling proteins affecting its regulation are appropriate therapeutic targets.

Determining the effectiveness of a clinical-practice intervention in improving the control of pain in outpatients with cancer

PURPOSE

To determine the effectiveness of a clinical-practice intervention in improving the control of pain in outpatients with cancer.

METHOD

Between July 5 and September 30, 1995, a randomized, controlled trial of 510 cancer outpatients and 13 oncologists was conducted at 23 clinics in Indiana. All the patients completed assessments of their pain, their pain regimens, and the degrees of relief received; they were surveyed again by mail four weeks after their clinic visits. The intervention group's clinical charts contained a summary of the completed pain scales; the oncologists who treated these patients were instructed to review the summary sheet prior to an evaluation. This summary was not available for the oncologists treating the patients in the control group. Each patient's pain management index (PMI) was calculated: the patient's pain medication level was rated on a scale of 0 to 3; the patients's pain level was rated on a scale of 0 to 3 and then subtracted from the first rating. A negative PMI was interpreted as representing insufficient treatment. Data were analyzed with several statistical tests.

RESULTS

In all, only 320 patients who reported cancer-related pain were used in the analysis: 160 to 260 in the control group and 160 of 250 in the intervention group. The groups were similar with respect to demographics, cancer sites, and performance status. A significant difference (p = .0162) in the physicians' prescription patterns was found. In the control group, prescriptions for 86% of the patients did not change, with no decrease in analgesic prescriptions; for 14% of the patients analgesic prescriptions increased. In the intervention group, analgesic prescriptions changed for 25% of the patients, decreasing for 5% and increasing for 20%. A decrease in the incidence of pain described as more than life's usual aches and pains was found for the intervention group (p = .05). No significant difference was found between the groups for the patients undertreated for pain, as measured by PMIs.

CONCLUSION

Although analgesic regimens were altered significantly when the physicians understood more about the patient's pain, cancer pain management remains a complex problem. Future studies should focus on the long-term systematic incorporation of simple pain-assessment tools into daily outpatient oncology practices as well as on innovative ways to address other aspects of managing cancer pain.

p53 mutations in benign breast tissue

PURPOSE

Patients with benign breast biopsies that exhibit atypical epithelial proliferation or fibroadenoma may be at increased risk for invasive breast cancer. We hypothesized that molecular markers might also be useful to evaluate the malignant potential of nonneoplastic breast tissue.

PATIENTS AND METHODS

Study subjects belonged to a cohort of 6,805 women who underwent biopsy for nonmalignant breast disease at the Mayo Clinic and Rochester-affiliated hospitals between 1967 and 1981. As part of a nested case-control study that compared subjects who developed invasive breast cancer with those who did not, we analyzed a sample of 60 benign breast biopsies for the following markers: HER-2/neu and p53 over-expression by immunohistochemistry, HER-2/neu and PRAD-1 amplification using differential polymerase chain reaction (PCR), and p53 mutation using single-strand conformation analysis (SSCA) and direct DNA sequencing by asymmetric PCR.

RESULTS

None of 60 biopsies showed amplification of HER-2/neu or PRAD-1. Five samples exhibited low-level immunoreactivity to the HER-2/neu protein product. Fourteen samples exhibited focal or diffuse immunoreactivity to the p53 protein. Point mutations in the p53 gene were found in five samples: three of these samples exhibited mutations that altered the amino acid sequence. Only two of five samples with p53 mutation exhibited p53 overexpression. Histologic diagnoses on three samples with nonconservative p53 mutation were, respectively, nonproliferative fibrocystic change, papillomatous hyperplasia, and fibroadenoma.

CONCLUSION

The clinical significance of p53 mutation, p53 overexpression, and low-level HER-2/neu expression in benign breast tissue remains to be determined. Further research will be necessary to evaluate whether these markers could serve as useful adjuncts to histology in evaluation of the malignant potential of benign breast tissue.

Proliferating cell nuclear antigen and Ki-67 immunohistochemistry in brain tumors: a comparative study

Proliferating cell nuclear antigen (PCNA) is a 36-kDa DNA polymerase-delta auxiliary protein which accumulates in the nucleus during S phase of the cell cycle. Immunohistochemical labeling indices (LI) of PCNA and Ki-67 were compared using an avidin-biotin complex method on frozen sections of 27 nervous system tumors. 3 normal cerebral cortices, and 3 peripheral nerves. In glial tumors, PCNA and Ki-67 LI increased with increasing tumor grade (Daumas-Duport system). In 5 low-grade glial tumors, PCNA and Ki-67 LI were less than or equal to 1%, except for one optic nerve glioma (Ki-67 LI = 6%). In 7 grade 3 astrocytomas and 1 mixed glioma, PCNA LI were less than or equal to 1-1.5%, while Ki-67 LI were 2%-10%. In 7 grade 4 astrocytomas and 1 metastatic carcinoma, PCNA LI ranged from 6%-15% while Ki-67 LI ranged from 17%-30%. In 5 of 6 schwannomas, focally high PCNA LI (4%-65%) were noted, despite low LI with Ki-67 (less than or equal to 1.6%). Scattered normal schwann cell nuclei also stained with PCNA, but normal cerebral cortex did not.(ABSTRACT TRUNCATED AT 250 WORDS)

Stress response protein (srp-27) determination in primary human breast carcinomas: clinical, histologic, and prognostic correlations

Expression of an estrogen-regulated protein known as the 27,000-d heat-shock or stress-response protein (srp-27) was evaluated in human breast carcinomas and established breast cancer cell lines. Results obtained by Northern and Western blot analyses and immunohistochemical methods were concordant. Immunohistochemical assessment of srp-27 expression in 300 breast carcinomas (with median patient follow-up of 8 years) was performed. Twenty-six percent of lymph node-negative and 45% of lymph node-positive tumors were overexpressors. Univariate analysis demonstrated significant correlations between srp-27 overexpression and estrogen receptor (ER) content, pS2 protein expression, nodal metastases, advanced T stage, lymphatic/vascular invasion, and a shorter disease-free survival period (but not a shorter overall survival) for the study population as a whole. Regression tree analysis showed that srp-27 expression was an independent prognostic indicator for disease-free survival only in patients with one to three positive lymph nodes. The Cox proportional hazards model confirmed the independent prognostic significance of nodal involvement, T stage, and ER content but failed to recognize srp-27 overexpression as a significant independent parameter predictive of patient outcome in the patient population as a whole. The observed associations between srp-27 overexpression and more aggressive tumors suggest a biologic role for srp-27 in human breast carcinomas.

Evaluation of in vitro bromodeoxyuridine labeling of breast carcinomas with the use of a commercial kit

The prognostic significance of S-phase fraction analyses of breast carcinomas has been reported by several investigators. The Cell Proliferation Kit (Amersham Corporation, Arlington Heights, IL), which uses in vitro bromodeoxyuridine (BRDU) labeling to evaluate cell cycle kinetics without a flow cytometer or radioisotopes, simplifies this assay for the clinical-based laboratory by providing standardized reagents and recommended methods. This study was performed to determine whether data derived from its use were comparable to published S-phase data from the use of thymidine labeling, BRDU, or other methods on breast carcinomas. Primary infiltrating ductal carcinomas (n = 142) and primary lobular carcinomas (n = 6) showed mean and median BRDU labeling of 4.63% and 3%, 1.3% and 1%, respectively, with a range of 0-28%. Benign lesions always had less than 3% BRDU uptake (n = 21). Estrogen receptor (ER) and progesterone receptor (PR) status correlated with BRDU labeling (P less than 0.05), with the highest S-phase fractions in ER- and PR-negative tumors. Correlations between BRDU uptake and histologic tumor type or size were observed. Significant correlations between BRDU uptake and lymph node status, patient age, or histologic tumor grade were not observed. S-phase studies of breast carcinomas using other techniques have shown similar data, therefore, the Cell Proliferation Kit appears to be a practical and useful method for in vitro S-phase analysis that allows concomitant histologic examination of the same tumor tissue sample.