Addressing the risk of infertility in young women with breast cancer (BC): A quality improvement (QI) intervention

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Background: Many young women with early BC require systemic therapy (ST) which can result in ovarian damage leading to infertility. Fertility preservation (FP) can be performed prior to ST, however uptake is low. Data suggest oncology providers do not routinely discuss the risk of treatment related infertility (TRI) or FP with young women with BC. Methods: We created a QI protocol to ensure providers address fertility needs of young women with early BC. Non-pregnant women age 18-44 years with stage I-III BC who have not initiated ST are identified by screening clinic schedules. Clinicians are asked to follow a QI protocol requiring assessment of patients’ childbearing potential (CBP), risk for TRI and fertility goals (FG). If appropriate, FP is discussed and consultation with a fertility specialist arranged. A clinical team member completes a provider documentation form (PDF) summarizing the QI protocol steps accomplished. Results: Since implementation of the QI protocol, there have been 80 eligible women (mean age 38.6). At least one PDF was completed for 56 (70%), with the majority completed by breast surgeons. Among those with a completed PDF, 48 (86%) were of CBP, all but one of whom planned ST associated with a risk of infertility. According to the PDF, the risk of TRI was discussed in 34 (72%) while FG were assessed in 44 (94%), with 8 (18%) desiring fertility and 8 (18%) undecided about FG. Discussion of FP by the provider and/or a fertility specialist was documented in the PDF for 85% of those who desired fertility or who were undecided. In comparison to the PDF, discussion of FG was recorded in provider notes in 36 (45%) women with documentation in both provider notes and the PDF for 29 (36%). Provider notes documented discussion of FG in 94% of the women who desired fertility or who were undecided according to the PDF. Conclusions: Implementation of a QI protocol with required documentation ensures providers address fertility needs of young women with BC. Providers do not discuss the risk of TRI as frequently as assessing FG. Efforts are ongoing to increase completion rate of our PDF and to incorporate it into the electronic medical record. Follow-up regarding ST and uptake of FP in our cohort is ongoing.

Abstract P3-07-62: Association of overexpression of hypoxia inducible factor 1α with response to neoadjuvant chemotherapy in early stage breast cancer

Background: Hypoxia inducible factor 1 alpha (HIF-1α) is a master transcription factor involved in multiple oncogenic processes. In breast cancer, HIF-1α overexpression is associated with increased resistance to radiation therapy, chemotherapy, and inferior disease-free and overall survival. Patients who achieve a pathologic complete response (pCR) following neoadjuvant therapy have improved survival outcomes. Limited data are available regarding the association between HIF-1α expression and rates of pCR. We investigated the relationship between HIF-1α overexpression and pCR rates following neoadjuvant chemotherapy for early breast cancer.

Methods: Eligible women were those with HER2-negative, stage II-III breast cancer, who received anthracycline- and taxane-based neoadjuvant chemotherapy from 2002 to 2012, and were included in an institutional review board-approved Integrated Breast Cancer Research Database at Johns Hopkins. The database includes patient age, sex, menopausal status, breast cancer diagnosis, tumor histopathology, treatment history, laboratory data, and outcomes. Both diagnostic and surgical tissue blocks were retrieved from pathology archives. Whole section slides were prepared and analyzed by immunohistochemical staining with appropriate negative and positive controls. The intensity of cells positive for HIF-1α was estimated visually by a pathologist blinded to clinical data. A semi-quantitative scoring of nucleus expression was used to score HIF-1α expression: score 0 is defined as less than 1%, 1 is defined as 1-5%, 2 as 5-20% and 3 as >20% tumor cells positive for HIF-1α. Overall tumor HIF-1α negativity was defined as (0, 1) and positivity as (2, 3). We compared baseline HIF-1α status among responders (pCR defined as no invasive tumor in the breast or lymph nodes) and non-responders (no pCR) using Fisher's exact test, and evaluate the association between baseline and surgical specimens in those who did not achieve pCR using NcNemar's test.

Results: A total of 122 women meeting the eligibility criteria underwent a definitive surgical procedure following neoadjuvant chemotherapy. Of those, 50 patients had no tissue blocks available at baseline and additional 16 patients' blocks did not contain sufficient tissue for analysis. Thus, tumors from 56 women were available for analysis. Median age was 50 (range 33-78), 54% were White and 35% Black; 41% and 59% of women had triple negative and hormone receptor-positive tumors, respectively; 71% women had Ki67>30%, and 80% were node-positive. Overall pCR was observed in 12 women (21%). We did not detect a significant association between HIF-1α score on the diagnostic specimen with pCR status (p=0.627). However, a positive HIF-1α score was significantly associated with positive lymph nodes (p=0.01). We observed a significant decrease in HIF-1α score following chemotherapy (p<0.001).

Conclusions: We did not observe a clear association between HIF-1α expression and response to neoadjuvant chemotherapy. However, HIF-1α expression on a diagnostic specimen was statistically higher than following chemotherapy and was associated with lymph node positivity. Our study is limited by its retrospective nature and a small sample size.

Citation Format: Zhi WI, Huang C-Y, Gabrielson E, Tully E, Cimino-Mathews A, Santa-Maria C, Jeter S, Kai C, Semenza G, Stearns V. Association of overexpression of hypoxia inducible factor 1α with response to neoadjuvant chemotherapy in early stage breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-62.

Abstract PD6-08: IMAGE: Individualized molecular analyses guide efforts in breast cancer with comprehensive genomic profiling of tissue and plasma tumor DNA

Background: Standard treatment options for patients with metastatic triple negative breast cancer (TNBC) are limited to chemotherapy. Molecular profiling of tumors may allow for novel treatment recommendations.

Methods: We initiated a prospective study designated IMAGE. Women with newly progressing metastatic TNBC who received at least one line of prior chemotherapy were eligible. New metastatic biopsies were obtained for molecular profiling at study entry. Archived metastatic biopsy specimens were allowed if patients had not commenced new systemic therapy. The specimens were reviewed by the study pathologist and stained for ER, PR, HER2, and androgen receptor (AR) by immunohistochemistry. Specimens underwent hybrid-capture based comprehensive genomic profiling (CGP) (Foundation Medicine Inc., Cambridge, MA). Clinical data and genomic profiling reports were reviewed by the GAITWAY (Genomic Alterations in Tumors with Actionable Yields) Molecular Profile Tumor Board. Recommendations were communicated to the treating oncologist and patients were followed for treatment decision and clinical outcomes. Peripheral blood was also analyzed by an investigational assay for circulating plasma tumor DNA (ptDNA) (Foundation Medicine Inc.) at study entry, and when obtainable, from serial blood draws at time of progression. The primary objective was to assess feasibility of completing the process from consent to GAITWAY recommendations within 28 days for at least 80% of patients.

Results: From September 2013 to April 2015, we enrolled 26 eligible women. Median age was 55 (range 25-67); patients identified as white 12 (46%), black 11 (42%), or other 3 (12%); median number of prior lines of treatment was 3; and 65.4% of patients had visceral disease. Twenty (77%) eligible patients received CGP of a metastatic site biopsy. Six patients did not undergo CGP due to either absence of a metastatic site amenable for biopsy or inadequate tissue for CGP. The study met the predefined statistical endpoint for futility and was closed after 20 patients had undergone CGP. Twelve (60%) evaluable patients received treatment recommendations within 28 days of study consent. Failure to meet this time frame was due to difficulties in accessing archival tumor tissue (N=5) and need for additional tissue for molecular analysis (N=3). Preliminary results demonstrate high concordance between mutations in metastatic biopsies and ptDNA in 15/17 patients.

Enrolled in IMAGE26Successful NGS20Potentially actionable mutation identified15GAITWAY recommended targeted therapy as possible next treatment13Received targeted therapy4

Conclusions: CGP of patients with metastatic TNBC can provide additional information that may help direct treatment. However, difficulties in obtaining adequate tumor tissue may hinder this approach. Use of a well-validated ptDNA profiling assay could be an alternative to overcome these limitations.

Citation Format: Parsons HA, Beaver JA, Cimino-Mathews A, Zorzi J, Slater S, Clark T, Lipson D, Ali SM, Kennedy M, Otto GA, Young LE, Jeter S, VanDenBerg DA, Rosner GL, Park BH, Stearns V. IMAGE: Individualized molecular analyses guide efforts in breast cancer with comprehensive genomic profiling of tissue and plasma tumor DNA. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD6-08.

Diagnostic accuracy of sentinel node identification is maintained with the addition of local lidocaine and subareolar radioactive colloid injection

Preoperative sentinel node localization (SNL) using a subareolar injection of radiotracer technetium-99m-sulfur colloid (Tc(99m)SC) is associated with significant pain. Lidocaine use during SNL is not widely adopted partly due to a concern that it can obscure sentinel node identification and reduce its diagnostic accuracy. We prospectively identified women with a biopsy-proven infiltrating breast cancer who were awaiting a SNL. The women completed the McGill pain questionnaire, Visual Analog Scale, and Wong-Baker FACES Pain Rating Scale prior to and following SNL. We identified a retrospective cohort of women with similar demographic and tumor characteristics who did not receive lidocaine before SNL. We compared sentinel lymph node identification rates in the two cohorts. We used Wilcoxon rank sum tests to compare continuous measures and Fisher's exact test for categorical measures. Between January 2011 to July 2012, 110 women consented, and 105 were eligible for and received lidocaine prior to Tc(99m)SC injection. The post-lidocaine identification rate of SNL was 95 % with Tc(99m)SC, and 100 % with the addition of intraoperative methylene blue dye/saline. Pain range prior to and following the SNL was unchanged (P = 0.703). We identified 187 women from 2005 to 2009 who did not receive lidocaine during preoperative SNL. There was no significant difference in the success rate of SNL, with or without lidocaine (P = 0.194). The administration of lidocaine during SNL prevents pain related to isotope injection while maintaining the success rate. We have changed our practice at our center to incorporate the use of lidocaine during all SNL.

Novel methylated biomarkers and a robust assay to detect circulating tumor DNA in metastatic breast cancer

The ability to consistently detect cell-free tumor-specific DNA in peripheral blood of patients with metastatic breast cancer provides the opportunity to detect changes in tumor burden and to monitor response to treatment. We developed cMethDNA, a quantitative multiplexed methylation-specific PCR assay for a panel of ten genes, consisting of novel and known breast cancer hypermethylated markers identified by mining our previously reported study of DNA methylation patterns in breast tissue (103 cancer, 21 normal on the Illumina HumanMethylation27 Beadchip) and then validating the 10-gene panel in The Cancer Genome Atlas project breast cancer methylome database. For cMethDNA, a fixed physiologic level (50 copies) of artificially constructed, standard nonhuman reference DNA specific for each gene is introduced in a constant volume of serum (300 μL) before purification of the DNA, facilitating a sensitive, specific, robust, and quantitative assay of tumor DNA, with broad dynamic range. Cancer-specific methylated DNA was detected in training (28 normal, 24 cancer) and test (27 normal, 33 cancer) sets of recurrent stage IV patient sera with a sensitivity of 91% and a specificity of 96% in the test set. In a pilot study, cMethDNA assay faithfully reflected patient response to chemotherapy (N = 29). A core methylation signature present in the primary breast cancer was retained in serum and metastatic tissues collected at autopsy two to 11 years after diagnosis of the disease. Together, our data suggest that the cMethDNA assay can detect advanced breast cancer, and monitor tumor burden and treatment response in women with metastatic breast cancer.

Detection of cancer DNA in plasma of patients with early-stage breast cancer

PURPOSE

Detecting circulating plasma tumor DNA (ptDNA) in patients with early-stage cancer has the potential to change how oncologists recommend systemic therapies for solid tumors after surgery. Droplet digital polymerase chain reaction (ddPCR) is a novel sensitive and specific platform for mutation detection.

EXPERIMENTAL DESIGN

In this prospective study, primary breast tumors and matched pre- and postsurgery blood samples were collected from patients with early-stage breast cancer (n = 29). Tumors (n = 30) were analyzed by Sanger sequencing for common PIK3CA mutations, and DNA from these tumors and matched plasma were then analyzed for PIK3CA mutations using ddPCR.

RESULTS

Sequencing of tumors identified seven PIK3CA exon 20 mutations (H1047R) and three exon 9 mutations (E545K). Analysis of tumors by ddPCR confirmed these mutations and identified five additional mutations. Presurgery plasma samples (n = 29) were then analyzed for PIK3CA mutations using ddPCR. Of the 15 PIK3CA mutations detected in tumors by ddPCR, 14 of the corresponding mutations were detected in presurgical ptDNA, whereas no mutations were found in plasma from patients with PIK3CA wild-type tumors (sensitivity 93.3%, specificity 100%). Ten patients with mutation-positive ptDNA presurgery had ddPCR analysis of postsurgery plasma, with five patients having detectable ptDNA postsurgery.

CONCLUSIONS

This prospective study demonstrates accurate mutation detection in tumor tissues using ddPCR, and that ptDNA can be detected in blood before and after surgery in patients with early-stage breast cancer. Future studies can now address whether ptDNA detected after surgery identifies patients at risk for recurrence, which could guide chemotherapy decisions for individual patients.

Patient-reported outcomes in women with breast cancer enrolled in a dual-center, double-blind, randomized controlled trial assessing the effect of acupuncture in reducing aromatase inhibitor-induced musculoskeletal symptoms

BACKGROUND

Aromatase inhibitors (AIs) have been associated with decrements in patient-reported outcomes (PROs). The objective of this study was to assess whether real acupuncture (RA), compared with sham acupuncture (SA), improves PROs in patients with breast cancer who are receiving an adjuvant AI.

METHODS

Postmenopausal women with a stage 0 through III breast cancer who received an AI and had treatment-associated musculoskeletal symptoms were randomized to receive 8 weekly RA versus SA in a dual-center, randomized controlled trial. The National Surgical Adjuvant Breast and Bowel Project (NSABP) menopausal symptoms questionnaire, the Center for Epidemiological Studies Depression (CESD) scale, the Hospital Anxiety and Depression Scale (HADS), the Pittsburgh Sleep Quality Index (PSQI), the hot flash daily diary, the Hot Flash-Related Daily Interference Scale (HFRDI), and the European quality-of-life survey (EuroQol) were used to assess PROs at baseline and at 4weeks, 8 weeks, and 12 weeks.

RESULTS

The intention-to-treat analysis included 23 patients in the RA arm and 24 patients in the SA arm. There were no significant differences in baseline characteristics between the 2 groups. Compared with baseline, scores in the RA arm improved significantly at week 8 on the CESD (P = .022), hot flash severity (P = .006), hot flash frequency (P = .011), the HFRDI (P = .014), and NSABP menopausal symptoms (P = .022); scores in the SA arm improved significantly on the EuroQol (P = .022),the HFRDI (P = .043), and NSABP menopausal symptoms (P = .005). Post-hoc analysis indicated that African American patients (n = 9) benefited more from RA than SA compared with non-African American patients (n = 38) in reducing hot flash severity (P < .001) and frequency (P < .001) scores.

CONCLUSIONS

Both RA and SA were associated with improvement in PROs among patients with breast cancer who were receiving AIs, and no significant difference was detected between arms. Racial differences in response to acupuncture warrant further study.

Abstract P2-06-01: cMethDNA is a quantitative circulating methylated DNA assay for detection of metastatic breast cancer and for monitoring response to therapy

Background- The ability to consistently detect cell-free tumor-specific DNA in peripheral blood of patients with metastatic breast cancer provides the opportunity to detect changes in tumor burden and to monitor response to treatment. Studies of cell-free DNA in the peripheral blood of breast cancer patients suggest that methylated DNA markers in serum or plasma could be used for detection of advanced disease, monitoring of therapeutic response, and for early detection of disease recurrence.

Methods- A genome-wide serum DNA methylome array (Illumina HumanMethylation27 BeadChip) analysis was conducted on cell-free circulating DNA in serum from women with stage IV recurrent breast cancer, and 232 key CpG loci were identified. Methylation for this panel of 10 gene loci was evaluated using our newly developed cMethDNA assay to detect miniscule amounts of methylated DNA in Training and Test sets of sera from a total of 112 women (n = 55 normal, n = 57 metastatic breast cancer). The clinical sensitivity and specificity of the assay, along with technical reproducibility, was determined. To evaluate the concordance of DNA methylation patterns, the 10 gene panel was tested on 22 DNA sets of primary tumor, metastases and serum from the same patient. Finally, the ability of cMethDNA to monitor response to therapy was evaluated in 28 patients with metastatic disease.

Results- A normal laboratory threshold of 7 cumulative methylation units was set and assay parameters were locked, based on Receiver Operating Characteristic (ROC) analyses of DNA from 300 ul of patient sera in the Training set (normal, n = 28; cancer, n = 24; 92% sensitivity, 96% specificity, and AUC = 0.950). Evaluation of the Test set of patient sera (normal, n = 27; cancer n = 33) resulted in detection of metastatic breast cancer with 91% sensitivity, 100% specificity, and AUC = 0.994 (0.984-1.005, p&lt;0.0001). Reproducibility of the cMethDNA assay increased with copy number; with the highest variation at 50 copies (CV = 29.1%) and the lowest at 3,200 copies (CV = 2.5%) of methylated DNA. The test was shown to be operator independent (ICC = 0.99). Evaluation of concordance between primary and disseminated tumor methylation showed that the methylation pattern from any given individual is highly conserved between serum, primary tissue and their metastases, and poorly conserved between different individuals. cMethDNA analysis of 28 patients before and after initiation of therapy showed a decrease in cumulative methylation in women with stable/responsive disease and a correlation with disease progression free survival (p&lt;0.0001).

Conclusion- Together, our data suggest that the cMethDNA test 1) can detect tumor DNA shed into blood, 2) reflect the methylation alterations typical of the primary tumor and its metastatic lesions, and 3) reflect response to treatment after chemotherapy. Next, we will test the clinical utility of cMethDNA in independent clinical trial sample sets where it's complementary and independent roles will be examined against CA15.3 and CTC assays.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-06-01.

A PIK3CA mutation detected in plasma from a patient with synchronous primary breast and lung cancers

Digital polymerase chain reaction is a new technology that enables detection and quantification of cancer DNA molecules from peripheral blood. Using this technique, we identified mutant PIK3CA DNA in circulating ptDNA (plasma tumor DNA) from a patient with concurrent early stage breast cancer and non-small cell lung cancer. The patient underwent successful resection of both her breast and lung cancers, and using standard Sanger sequencing the breast cancer was shown to harbor the identical PIK3CA mutation identified in peripheral blood. This case report highlights potential applications and concerns that can arise with the use of ptDNA in clinical oncology practice.

Sensitivity for detecting PIK3CA mutations in early-stage breast cancer with droplet digital PCR

11019

Background: PIK3CA is mutated in up to 30% of breast cancers. Classically somatic mutations are identified by Sanger sequencing of the primary tumor specimen. However third generation droplet digital PCR technologies offer a novel platform for quantitative mutation detection with improved sensitivity. Methods: Thirty stage I-III breast cancer patients were consented on an IRB-approved prospective repository study at Johns Hopkins for collection of their primary breast tumor specimen. Formalin-fixed paraffin embedded (FFPE) samples were analyzed by standard sequencing for three PIK3CA hotspot mutations. The DNA from these samples was then analyzed using the RainDrop digital PCR platform with TaqMan probes in a triplex format to simultaneously detect and quantitate hotspot mutations and genome equivalents. Results are expressed as a percentage of mutant to wild-type PIK3CA molecules for each sample. Results: Standard sequencing of all tumors (n=30) identified seven PIK3CA Exon 20 mutations (H1047R) and three Exon 9 mutations (E545K). Samples were scored as PIK3CA mutation positive by digital PCR if the tumor DNA contained at least 5% mutant molecules. All ten mutations identified by sequencing were verified by digital PCR with quantities of mutant molecules ranging from 20.3-55.6% in a given sample. Digital PCR identified additional PIK3CA mutations that were wild type by standard sequencing including three mutant Exon 20 samples, two mutant Exon 9 samples and one sample with an Exon 20 and Exon 9 mutation. Quantities of mutant molecules in these additional samples ranged from 5-28.9%. Conclusions: RainDrop digital PCR offers improved sensitivity and quantification for detecting PIK3CA mutations in FFPE samples using nanograms of DNA. Additional mutations identified by digital PCR may reflect genetic heterogeneity or possibly tissue contamination. The clinical utility of identifying a small proportion of mutations is unknown but may impact eligibility for targeted therapies and clinical trials. Ongoing studies will also address whether the identification of solid tumor mutations in circulating cell-free plasma DNA by digital PCR can improve diagnostics and aid in therapeutic decisions.

Digoxin as an inhibitor of global hypoxia inducible factor-1α (HIF1α) expression and downstream targets in breast cancer: Dig-HIF1 pharmacodynamic trial

TPS1144

Background: Unlike normal cells, tumor cells thrive in a hypoxic microenvironment, and intratumoral hypoxia correlates with increased tumor invasiveness, metastasis, and poor prognosis in cancer. The hypoxic microenvironment is primarily mediated through HIF1α, a transcription factor for over 200 genes involved in cellular metabolism, proliferation, and angiogenesis. In pre-clinical models, cardiac glycosides, including digoxin, act as potent inhibitors of HIF1α protein synthesis and expression of HIF1α target genes (Zhang et al, PNAS 09). Methods: Trial design: The proposed study is a randomized, controlled, two arm, pre-surgical study. Eligible patients include women with stage I-III carcinoma of the breast scheduled to undergo definitive surgery, tumor size ≥ 1cm, grade 2/3 or Ki-67 ≥ 10%, normal organ function, and no known cardiac arrhythmias. Participants will receive oral digoxin daily, or no therapy, for 14 days (±4 days) prior to scheduled surgery. Trial Objectives: 1) To evaluate whether daily oral digoxin therapy, as compared to no study drug, reduces HIF1α expression by IHC and mRNA or its target genes (VEGF, CA-9, and GLUT1) in breast cancer tissue. 2) To evaluate whether daily oral digoxin therapy, as compared to no study drug, reduces levels of serum VEGF & PAI-1, reduces tissue Ki-67 expression, and modulates proteomic profiles of breast cancer tissue. 3) To assess safety and tolerability of digoxin therapy in the pre-surgical setting. Statistical methods: The primary hypothesis is that 2 weeks of digoxin therapy will reduce the level of HIF1α expression in breast cancer tissue assessed by pathologists blinded to the treatment assignment. Our preliminary study shows the mean HIF1α expression level is 2.43. A 33% reduction would be considered clinically relevant. Allowing for up to 20% attrition, a total sample size of 64 will provide more than 85% power to detect 33% reduction with a two-sided significance level of 0.05. Target accrual: 64 (32 each arm). Funding and Acknowledgement: Dept. of Defense, Commonwealth Foundation, ASCO YIA. Contact Person: Dr. Vered Stearns, Email: vstearn1@jhmi.edu .ClinicalTrials.gov Identifier: NCT01763931. Clinical trial information: NCT01763931.

A dual-center randomized controlled double blind trial assessing the effect of acupuncture in reducing musculoskeletal symptoms in breast cancer patients taking aromatase inhibitors

Up to 50 % of women receiving aromatase inhibitor (AI) complain of AI-associated musculoskeletal symptoms (AIMSS) and 15 % discontinue treatment. We conducted a randomized, sham-controlled trial to evaluate whether acupuncture improves AIMSS and to explore potential mechanisms. Postmenopausal women with early stage breast cancer, experiencing AIMSS were randomized to eight weekly real or sham acupuncture sessions. We evaluated changes in the Health Assessment Questionnaire Disability Index (HAQ-DI) and pain visual analog scale (VAS) following the intervention compared to baseline. Serum estradiol, β-endorphin, and proinflammatory cytokine concentrations were measured pre and post-intervention. We enrolled 51 women of whom 47 were evaluable, including 23 randomized to real and 24 to sham acupuncture. Baseline characteristics were balanced between groups with the exception of a higher HAQ-DI score in the real acupuncture group (p = 0.047). We did not observe a statistically significant difference in reduction of HAQ-DI (p = 0.30) or VAS (p = 0.31) between the two groups. Following eight weekly treatments, we observed a statistically significant reduction of IL-17 (p ≤ 0.009) in both groups. No significant modulation was seen in estradiol, β-endorphin, or other proinflammatory cytokine concentrations in either group. We did not observe a significant difference in AIMSS changes between real and sham acupuncture. As sham acupuncture used in this study may not be equivalent to placebo, further studies with a non-acupuncture arm may be required to establish whether acupuncture is beneficial for the treatment of AIMSS.

Abstract P2-02-01: Accurate identification of metastatic breast cancer using methylated gene markers in circulating free DNA in peripheral blood

Background: Preliminary studies from our lab have shown that a panel of methylation markers in tissue identifies 100% of tested breast cancer and 95% of tested DCIS, and has high accuracy in cells from ductal fluid and spontaneous nipple discharge1,2. Other groups have reported on the use of a single marker or a panel of markers to detect breast cancer in serum or plasma. Cell-free DNA studies in the peripheral blood of breast cancer patients with advanced disease or with early-stage disease after completion of local therapy support the hypothesis that methylated DNA markers in serum or plasma could be used to monitor response to therapy and for long-term surveillance. Validation studies to test these hypotheses have been hampered by assay methodological issues such as the very small amount of DNA shed in the serum by tumor compared to the total DNA shed by normal cells.

Methods: To overcome this problem, we developed a modified quantitative methylation-specific PCR that directly measures the number of copies of methylated DNA markers in a small aliquot of serum (Serum-QM-MSP) and robustly detects less than 25 copies of DNA in 300 µL of serum. We then conducted a genome-wide methylome analysis to identify key markers that are preferentially methylated in serum from women with breast cancer and compared the profiles to those from women with no breast cancer. We then analyzed 300 µL each of sera from 55 normal women (single time point) and 43 women with metastatic breast cancer using this newly developed panel of markers and the Serum-QM-MSP assay. We also examined changes after therapy in a subset of patients with metastatic disease.

Results: Methylation markers were quantitatively detected in sera of 39 out of 43 (91% sensitive) metastatic breast cancer patients with varying tumor burdens, and not in sera of any of 55 women (100% specific) for an AUC=0.95, using a laboratory threshold of 7.2 cumulative methylation units. 28 of the 43 patients had sampling repeated 3–5 weeks after therapy started. Sera from patients whose tumors regressed and from those that had stable disease showed a quantitative reduction, while those with progressive disease showed an increase in methylation levels of several genes.

Conclusion: Our results suggest that methylated DNA in serum accurately discriminates between blood samples from normal women and from metastatic breast cancer patients. Also, early changes after therapy initiation for metastatic disease may correlate with subsequent clinical outcome. Assay analytical validation studies are ongoing. Studies examining a potential role in surveillance in the adjuvant setting and therapeutic benefit in the metastatic setting are warranted.

1. Fackler MJ et al. Genome-wide methylation analysis identifies genes specific to breast cancer hormone receptor status and risk of recurrence. Cancer Res. 2011 Oct 1;71(19):6195–207. PMCID: PMC3308629. 2. Fackler MJ, et al. Hypermethylated genes as biomarkers of cancer in women with pathologic nipple discharge. Clin Cancer Res. 2009 Jun 1;15(11):3802–11. PMID: 19470737

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-02-01.

Gene methylation in random FNA samples as biomarkers for breast cancer

518

Background: Current methods to determine breast cancer risk are insufficiently sensitive to select women most likely to benefit from preventive strategies. We hypothesized that candidate gene promoter hypermethylation may provide an individualized risk profile. We performed a prospective study to determine whether DNA cumulative methylation index (CMI) varies by menstrual phase or menopausal status, and to correlate CMI with established risk factors. Methods: We obtained random fine needle aspiration (rFNA) samples from healthy women age 35-60 and determined their menopausal and menstrual status, lifetime Gail risk, mammographic breast density, and cytologic atypia assessed as the Masood score. We evaluated CMI of 11 candidate genes in rFNA cells using the Quantitative Multiplex Methylation-Specific PCR (QM-MSP) technique. We used Wilcoxon test and ANOVA model to compare CMI across menopausal and menstrual (follicular, mid-cycle, luteal) categories, respectively. We used linear regression model to adjust for age and BMI. Methylation scores were log-transformed in the analysis. Results: We enrolled 390 women at the Avon Breast Centers at Johns Hopkins and Northwestern, the majority through the Love/Avon Army of Women, and 380 completed study procedures. Median age 50 (36-60), mean BMI 28 (18.7-50.8), 52% were postmenopausal. Mean life-time Gail risk 14.6 (5.6-54.1), mean percent mammographic density 19.6 (2.5-72.8), and mean Masood score (N=354) 13.6 (7-18). QM-MSP analysis was completed on 229 samples. We did not observe differences in CMI among menopausal (P=0.4895) or menstrual categories (P=0.2333). There was no association between CMI and life-time Gail risk (P=0.706) or breast density (P=0.4116). We observed a significant correlation between CMI and Masood score (P=0.0167). Conclusions: CMI correlates with degree of cytologic atypia and is potentially a robust indicator of breast cancer risk since it does not vary with menstrual or menopausal status. Next, we will select genes that best reflect changes in the clinical parameters to create a gene methylation signature that will be validated in other studies and correlated with breast cancer risk.

Changes in patient-reported outcomes in women with breast cancer in a multicenter double-blind randomized controlled trial assessing the effect of acupuncture in reducing aromatase inhibitor-induced musculoskeletal symptoms (AIMSS)

9103

Background: Aromatase Inhibitors (AIs) have been associated with worsening of patient related outcomes (PROs) such as AIMSS, menopausal symptoms and depression. Acupuncture has been reported to alleviate such symptoms. We hypothesized that real acupuncture (RA) would improve PROs more than sham acupuncture (SA). Methods: We collected PROs at baseline, 4, 8, and 12 weeks (wks), from women enrolled in a multi-center double blind RCT designed to assess the effect of acupuncture in reducing PROs. Patients were randomized to 8 wkly RA or SA. PROs were measured by the revised National Surgical Adjuvant Breast and Bowel Project (NSABP) menopausal symptoms questionnaire, Center for Epidemiological Studies Depression Scale (CESD), Hospital Anxiety and Depression Scale (HADS), Pittsburgh Sleep Quality Index (PSQI), Hot Flash Daily Diary, Hot Flash Related Daily Interference Scale (HFRDI) and EuroQoL survey. We measured estrogen and cytokines concentrations at baseline and wk 8. We used Wilcoxon rank sum and signed-rank tests to make comparisons between and within group, respectively. Results: We included 23 patients from RA and 24 from SA arms in the intent-to-treat analysis. We have previously reported no significant difference in reduction of AIMSS between two arms. RA caused reduction of CESD scores compared to SA (median: -2 vs 0, p = 0.057). When compared to baseline, there were statistically significant improvements at wk 8 in hot flash severity score (p=0.006), hot flash frequency (p=0.011), HFRDI (p=0.014) and NSABP menopausal symptoms (p=0.022) scores in RA arm; for EuroQoL (p=0.022), HFRDI (p=0.043) and NSABP menopausal symptoms (p=0.005) scores in SA arm. The majority of patients’ estradiol concentrations were undetectable at baseline and wk 8. Changes in other time points, data and analysis of cytokines changes will be presented at the meeting. Conclusions: Real and sham acupuncture were both associated with improvement in PROs in breast cancer patients taking AIs. We detected no significant difference in the change of PROs between real and sham acupuncture, except for CESD.

Early change in 18-fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET) to predict response to preoperative systemic therapy (PST) in HER2-negative primary operable breast cancer: Translational breast cancer research consortium (TBCRC008)

10509

Background: PST allows for improved surgical outcomes and response assessment without compromising long term outcomes. PST is an attractive model for assessing surrogate markers of response to therapy. We hypothesized that changes in tumor standardized uptake values corrected for lean body mass (SUL) max on FDG- PET by cycle 1 day 15 (C1D15) of therapy would predict pathological complete response (pCR) to PST in women with stage 2-3, grade 2-3, HER2-negative breast cancer. Methods: TBCRC008 is a multicenter placebo-controlled trial that investigates pCR following 12 weeks of preoperative carboplatin and albumin-bound paclitaxel with or without vorinostat. FDG-PET followed by tumor biopsies were performed at baseline and C1D15. We correlated % reduction in SULmax on FDG-PET (PERCIST 1.0; Wahl RL, J Nuc Med 2009) with pCR (no invasive cancer in breast/axilla). We compared % reduction in SULmax between responders (pCR) and non responders (no pCR) using nonparametric Wilcoxon rank sum test. We explored association of % reduction in SULmax at pre-specified cutoff with response using Fisher’s exact test and logistic regression. We correlated baseline, C1D15, and % change in Ki67 at C1D15 with pCR. Results: Accrual is complete. Of 62 women enrolled (10/2009-11/2011), 40 have completed study PST and surgery (median age 47.5 [range 30-68], ER-positive 67%). Overall pCR was 26%. In an intent to treat analysis (n=39), we observed a significant difference in median % reduction in SULmax between responders vs not (66.6% vs 32.4%, p <0.001). We observed a higher proportion of reduction in SULmax ≥ 60% in responders vs not (80% vs 3.5%, p <0.001). The differences in baseline, C1D15 and % change in Ki67 were not significant between responders and non-responders. Conclusions: Change in SULmax on FDG-PET 15 days after initiating PST was significantly greater in patients with pCR versus no pCR. Future studies will determine whether altering therapy based on early changes in SULmax will improve pCR. Unblinded data from all participants will be presented at the meeting.

Preclinical and clinical evaluation of intraductally administered agents in early breast cancer

Most breast cancers originate in the epithelial cells lining the breast ducts. Intraductal administration of cancer therapeutics would lead to high drug exposure to ductal cells and eliminate preinvasive neoplasms while limiting systemic exposure. We performed preclinical studies in N-methyl-N'-nitrosourea-treated rats to compare the effects of 5-fluorouracil, carboplatin, nanoparticle albumin-bound paclitaxel, and methotrexate to the previously reported efficacy of pegylated liposomal doxorubicin (PLD) on treatment of early and established mammary tumors. Protection from tumor growth was observed with all five agents, with extensive epithelial destruction present only in PLD-treated rats. Concurrently, we initiated a clinical trial to establish the feasibility, safety, and maximum tolerated dose of intraductal PLD. In each eligible woman awaiting mastectomy, we visualized one ductal system and administered dextrose or PLD using a dose-escalation schema (2 to 10 mg). Intraductal administration was successful in 15 of 17 women with no serious adverse events. Our preclinical studies suggest that several agents are candidates for intraductal therapy. Our clinical trial supports the feasibility of intraductal administration of agents in the outpatient setting. If successful, administration of agents directly into the ductal system may allow for "breast-sparing mastectomy" in select women.

P4-12-13: A Multi-Center Randomized Controlled Double Blind Trial Assessing the Effect of Acupuncture in Reducing Musculoskeletal Symptoms in Breast Cancer Patients Taking Aromatase Inhibitors: First Interim Analysis

Background: Aromatase inhibitors (AIs) are recommended as first-line adjuvant hormonal therapy in postmenopausal women with hormone-receptor-positive breast cancer, as monotherapy or sequential therapy after tamoxifen. AI-associated musculoskeletal symptoms (AIMSS) occur in approximately 50% of women receiving AIs and in some may result in discontinuation of treatment. Symptom management is essential to ensure that breast cancer patients receive the full recommended duration of AI therapy. We conducted a randomized, placebo-controlled trial to evaluate the effect of acupuncture on AIMSS and report the first interim analysis.

Method: Postmenopausal women with early stage breast cancer, experiencing AIMSS, who had not had acupuncture in the year prior to the study, were eligible. Patients were randomized to 8 weekly acupuncture or sham acupuncture. Health assessment questionnaire disability index (HAQ-DI ranging 0–3.0) and pain visual analog scale (VAS ranging 0–100) were used to assess clinical musculoskeletal disorder severity at weeks 0, 4, 8, and 12 or 24. Change in HAQ-DI (ΔHAQ-DI) and VAS scores (ΔVAS) from baseline were compared between patients receiving acupuncture versus sham acupuncture using exact Wilcoxon rank sum test. Serum samples were collected for measurements of estrogens and beta endorphin concentrations and cytokine profile before and after the intervention to evaluate the etiology of AIMSS and the mechanism of acupuncture in treating AIMSS.

Results: Between May 2008 and June 2011, 48 patients were enrolled, 2 patients were not evaluable due to noncompliance to treatment and lost to follow up, 10 were still receiving treatment and therefore not evaluable. Thirty-six were evaluable, and were equally distributed between the real and sham acupuncture groups. Baseline characteristics were balanced between the two groups with regard to age, race, and body mass index (BMI) with the exception that baseline mean HAQ-DI was higher in the acupuncture group (0.9 vs 0.55, p=0.04). White/Black/Asian: 26/7/3, Median (range): age: 61 (45-82); BMI (kg/m2): 31.1 (22.9−59.6). At week 8, both groups showed a wide range of ΔHAQ-DI (ΔHAQ-DI =HAQ-DIweek8-HAQ-DIbaseline): from −1.38 to 0.5 in the acupuncture group versus from −1 to 0.12 in sham acupuncture group. There was no statistically significant difference in mean ΔHAQ-DI between the real and sham acupuncture groups (−0.33 vs −0.33, p=0.87). Eleven patients in each group (61%) reported decreased HAQ-DI scores, which correlated with improved function. There was no difference in mean ΔVAS between the real and sham acupuncture groups (−9.27 vs −13.82, p=0.67). No significant side effects were reported. Changes in other time points and in serum biomarkers will be presented at the meeting.

Conclusions: The majority of breast cancer patients experiencing AIMSS who participated in our study reported a reduced HAQ-DI score both from acupuncture and sham acupuncture. We did not observe significant differences between responses to real versus sham acupuncture after 8 weekly treatments. The study remains open to accrual to reach 50 evaluable patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-13.

OT1-01-01: Prospective Clinical Trial Evaluating Efficacy of Zoledronic Acid (ZA) Prophylaxis for Prevention of Aromatase Inhibitor Associated Musculoskeletal Symptoms: ZAP-AIMSS Trial

Brief background: Aromatase inhibitor associated musculoskeletal symptoms (AIMSS) occur in approximately 50% of patients receiving AIs (Henry 08). However, interventions to prevent or treat AIMSS have not been established. In a retrospective study (Muslimani 09), patients receiving bisphosphonates along with AIs were less likely to report AIMSS compared to those not taking bisphosphonates (35% vs. 60%). However, the efficacy of bisphosphonates in reducing incidence of AIMSS has not been studied prospectively, so it cannot be recommended for routine clinical practice.

Trial design: We are conducting a single arm, phase II clinical trial of 4 mg intravenous zoledronic acid (ZA) given at baseline and at 6 months, in combination with letrozole 2.5 mg daily for one year. Development of AIMSS will be assessed using the standardized Health Assessment Questionnaire (HAQ-DI) and pain Visual Analog Scale (VAS) at baseline,1, 3, 6, and 12 months. Secondary endpoints include mammographic breast density (when intact contralateral breast), bone mineral density, bone turnover metabolites, circulating inflammatory markers, and patient reported quality of life measures. Prevalence of AIMSS will be compared to historical controls from a recently completed multi-institutional study designated Exemestane and Letrozole Pharmacogenetics (ELPh trial, ClinicalTrials.gov #NCT00228956). The current study has the same eligibility criteria, method and intervals of outcome assessment, and AI medication, as the ELPh trial, ensuring that the two cohorts are comparable.

Eligibility criteria: Postmenopausal women who have completed local therapy and chemotherapy for hormone receptor positive DCIS or stage I-III breast cancer and who are scheduled to receive adjuvant AI. Prior tamoxifen therapy is permitted.

Specific aims:

1. Percentage of women experiencing AIMSS at 1, 3, 6, and 12 months after initiation of ZA and letrozole, as compared to historical controls.

2. Change in bone mineral density and breast density between baseline and 12 months for those receiving ZA and letrozole, as compared to historical controls.

3. Change in bone turnover markers and inflammatory markers between baseline and 1, 3, 6 and 12 months for those receiving ZA and letrozole, as compared to historical controls.

Statistical methods: Allowing for a 20% dropout rate, a total sample size of 59 patients yields 80% power to detect reduction in AIMSS incidence from 50% to 30% with a two sided type I error rate of 5%. The rates of AIMSS and other endpoints at each time point and across all time points between controls and patients will be compared with a logistic regression model that adjusts for potential confounding variables and include random effects as appropriate to account for correlation between outcomes in the same patient.

Present accrual and target accrual: The Johns Hopkins Institutional Review Board approved the study and it opened to accrual in January 2011. Since that time, 12 participants have signed consent and started therapy, and 2 have completed the 3 month evaluation.

Funding: Trial supported by BCRF. ZA and letrozole kindly supplied by Novartis.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-01-01.

Comparison of breast cancer recurrence risk and cardiovascular disease incidence risk among postmenopausal women with breast cancer

The majority of breast cancers are diagnosed in postmenopausal women. Competing comorbidities, particularly cardiovascular disease (CVD), should be considered when individualizing adjuvant therapies for these women. We compared the 10-year predicted breast cancer recurrence risk with CVD risk among postmenopausal women with hormone receptor-positive (HR+), non-metastatic breast cancer. CVD risk factor data were prospectively collected from postmenopausal women with stage I-III, HR+ breast cancer initiating adjuvant aromatase inhibitor therapy. We compared predicted 10-year CVD risk, including the composite index heart age, computed from modified Framingham risk score, with predicted 10-year risk of breast cancer recurrence using Adjuvant! Online. We created multivariable logistic regression models to estimate the odds ratios (OR) and 95% confidence intervals (CI) for greater CVD risk than breast cancer recurrence risk. Among 415 women, mean age and heart age were 60 and 67 years, respectively. Overall, 43% of women had a predicted 10-year CVD risk equivalent to breast cancer recurrence risk and 37% had CVD risk higher than breast cancer recurrence risk. Predicted CVD risk was higher than breast cancer recurrence risk for stage I disease (OR: 6.1, 95% CI: 3.4-11.2) or heart age >65 (OR: 12.4, 95% CI: 7.0-22.6). The majority of postmenopausal women with HR+ early breast cancer had a predicted 10-year CVD risk that was equivalent to or higher than breast cancer recurrence risk. Physicians should weigh competing risks and offer early screening and cardiac prevention strategies for women at a greater risk for CVD.

In vitro and in vivo oxidative metabolism and glucuronidation of anastrozole

AIMS

Little information is available regarding the metabolic routes of anastrozole and the specific enzymes involved. We characterized anastrozole oxidative and conjugation metabolism in vitro and in vivo.

METHODS

A sensitive LC-MS/MS method was developed to measure anastrozole and its metabolites in vitro and in vivo. Anastrozole metabolism was characterized using human liver microsomes (HLMs), expressed cytochrome P450s (CYPs) and UDP-glucuronosyltransferases (UGTs).

RESULTS

Hydroxyanastrozole and anastrozole glucuronide were identified as the main oxidative and conjugated metabolites of anastrozole in vitro, respectively. Formation of hydroxyanastrozole from anastrozole was markedly inhibited by CYP3A selective chemical inhibitors (by >90%) and significantly correlated with CYP3A activity in a panel of HLMs (r= 0.96, P= 0.0005) and mainly catalyzed by expressed CYP3A4 and CYP3A5. The K(m) values obtained from HLMs were also close to those from CYP3A4 and CYP3A5. Formation of anastrozole glucuronide in a bank of HLMs was correlated strongly with imipramine N-glucuronide, a marker of UGT1A4 (r= 0.72, P < 0.0001), while expressed UGT1A4 catalyzed its formation at the highest rate. Hydroxyanastrozole (mainly as a glucuronide) and anastrozole were quantified in plasma of breast cancer patients taking anastrozole (1 mg day⁻¹); anastrozole glucuronide was less apparent.

CONCLUSION

Anastrozole is oxidized to hydroxyanastrozole mainly by CYP3A4 (and to some extent by CYP3A5 and CYP2C8). Once formed, this metabolite undergoes glucuronidation. Variable activity of CYP3A4 (and probably UGT1A4), possibly due to genetic polymorphisms and drug interactions, may alter anastrozole disposition and its effects in vivo.

Abstract P2-14-09: Prospective Evaluation of Change in 2-Point Discrimination of Index Finger as a Potential Early Predictive Marker for Carpal Tunnel Syndrome among Women Receiving Adjuvant Aromatase Inhibitor Therapy for Postmenospausal Breast Cancer in the Exemestane and Letrozole Pharmacogenomics (ELPh) Trial

Introduction: Third generation aromatase inhibitors (AIs) represent an integral part of hormonal therapy in postmenopausal women with hormone receptor (HR)-positive breast cancer. AIs are associated with musculoskeletal symptoms in up to 50% of women. Post-hoc analyses of adjuvant AI trials (ATAC and IES) have suggested that AIs might be associated with carpal tunnel syndrome (CTS), a pressure-induced neuropathy disorder caused by compression on the median nerve. The clinical diagnosis of CTS is made with typical symptoms of pain, weakness, and paresthesias in affected arm. A variety of tests, including change in 2-point discrimination (2PD) can be used to aid in diagnosis. However, the actual incidence of CTS and clinical utility of diagnostic tests such as 2PD have not been prospectively examined among women receiving AIs. Methods: Postmenopausal women with stage 0-III HR-positive breast cancer, who had completed local therapy and, if indicated, adjuvant chemotherapy, and who were enrolled in the multi-center Exemestane and Letrozole Pharmacogenetics (ELPh) trial underwent prospective evaluation of 2PD with the Disc-criminator™ (sliding aesthesiometer) at baseline, and 3 months, following initiation of the AI. The end of the Disc-criminator™ was applied at the two points at same time to the skin on the volar tip pulp of the index fingers, and the threshold value (in mm) was determined as the shortest distance between the two points a woman was able to differentiate. The exercise was repeated thrice at each point. Abnormal 2PD thresholds were defined using standard criteria (outside 95 percentile for age). The differences in mean 2PD from baseline to 3 months were analyzed using a multivariate mixed effects model where the correlations from repeated measures were accounted for by assuming an unstructured covariance structure. A p value &lt; 0.05 was considered statistically significant.

Results: A total of 104 women underwent baseline 2PD testing. The mean age was 59 years, 55.8% had stage I disease, and 42.3% received adjuvant chemotherapy. We observed abnormal 2PD thresholds in 1.9% and 3.5% of women at baseline and 3 months respectively. There was a significant worsening in the adjusted mean 2PD from baseline (3.4 mm) to 3 months (4 mm, p=0.01). The increase in mean 2PD following 3 months of AI therapy was higher among women with age &gt; 55 (p=0.02), BMI &gt; 25 (p=0.002), African Americans (p=0.02), and those who received adjuvant chemotherapy (p=0.05), as compared to their counterparts. Conclusion: Adjuvant AI therapy was associated with a significant worsening of 2PD at 3 months, particularly among older women, overweight women, and those receiving adjuvant chemotherapy. Correlation with CTS symptoms and need for surgical release will be presented at the meeting. Our results suggest that 2PD is a non-invasive method that may potentially allow for early detection of CTS. If confirmed, change in 2PD could serve as an objective early predictor for subsequent CTS in postmenopausal women with breast cancer initiating AI therapy.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-14-09.

Modeling hot flushes and quality of life in breast cancer survivors

OBJECTIVES

To evaluate the relationships among measures of hot flushes, perceived hot flush interference, sleep disturbance, and measures of quality of life while controlling for potential covariates (patient and treatment variables).

METHODS

Breast cancer survivors (n = 395) due to receive aromatase inhibitor therapy provided demographic information, physiological hot flush data via sternal skin conductance monitoring, hot flush frequency via written diary and electronic event marker, hot flush severity and bother via written diary, and questionnaire data via the Hot Flash Related Daily Interference Scale, Pittsburgh Sleep Quality Index, the EuroQOL, Hospital Anxiety and Depression Scale and the Center for Epidemiologic Studies Depression Scale.

RESULTS

Confirmatory factor analysis supported a two-factor model for hot flush symptoms (frequency and severity). Although there was strong convergence among self-reported hot flush measures, there was a high degree of unexplained variance associated with physiological measures. This suggests that self-report and physiological measures do not overlap substantially. The structural model showed that greater hot flush frequency and severity were directly related to greater perceived interference with daily life activities. Greater perceived interference, in turn, directly predicted greater sleep disruption, which predicted lower perceived health state and more symptoms of anxiety and depression.

CONCLUSIONS

Findings suggest hot flush interference may be the most appropriate single measure to include in clinical trials of vasomotor symptom therapies. Measuring and ameliorating patients' perceptions of hot flush interference with life activities and subjective sleep quality may be the most direct routes to improving quality of life.

Pathologic complete response to preoperative sequential doxorubicin/cyclophosphamide and single-agent taxane with or without trastuzumab in stage II/III HER2-positive breast cancer

BACKGROUND

Four major clinical trials have established that trastuzumab added to adjuvant systemic chemotherapy for women with HER2+ breast cancer significantly improves disease-free and overall survival compared with chemotherapy alone. We evaluated pathologic complete response (pCR) rate and cardiac safety of preoperative doxorubicin and cyclophosphamide followed by a taxane with or without trastuzumab.

PATIENTS AND METHODS

We reviewed pCR rate and change in left ventricular ejection fraction in women with operable HER2+ breast cancer (defined as immunohistochemical 3+ or fluorescence in situ hybridization ratio > or = 2.2) who were treated between 2002 and 2008 with doxorubicin and cyclophosphamide followed by a taxane with or without trastuzumab before definitive breast surgery.

RESULTS

We identified 33 patients, of whom 42.4% received preoperative chemotherapy without trastuzumab and 57.6% of whom received trastuzumab with chemotherapy. The pCR rates were 28.6% and 52.6% in the group that received chemotherapy alone or with trastuzumab, respectively (odds ratio, 2.78; 95% CI, 0.64-12.1; P = .173). Severe cardiac events or treatment delays as a result of cardiac toxicity were not observed. With a median follow-up time of 14 months, 21.4% of patients in the non-trastuzumab group and 10.5% in the trastuzumab group had disease recurrence.

CONCLUSION

Sequential administration of preoperative doxorubicin and cyclophosphamide followed by a taxane and trastuzumab combination is safe in women with primary operable HER2+ breast cancer and is associated with a high pCR rate. Large randomized phase III clinical trials are evaluating the role of preoperative trastuzumab when added to anthracycline- and/or taxane-based regimens.

A phase I study assessing the feasibility and safety of intraductal pegylated liposomal doxorubicin (PLD) in women with breast cancer

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Background: Most breast cancers originate in epithelial cells lining the breast ducts. Preclinical data suggest that intraductal administration of chemotherapy including PLD decrease tumor volume, prevent the development of new lesions, and eradicate pre-malignant disease. We initiated a clinical trial to determine the feasibility, safety, and maximum tolerated dose of PLD administered into one duct of women awaiting mastectomy. Methods: Women 18 or older awaiting mastectomy for breast cancer were eligible. Preoperative chemotherapy was allowed. T4 tumors, prior breast irradiation, or surgeries that may have altered the ductal system were excluded. Nipple aspiration and ductal cannulation were completed and the first 3 women received 5 mL of intraductal dextrose. PLD was administered to subsequent participants on a dose escalation schema based on preclinical pharmacokinetic and safety data. Serial doxorubicin (Dox) and doxorubicinol (Doxol) concentrations were determined in plasma by LC/MS/MS. At mastectomy (completed at least 2 weeks after intraductal administration of PLD), blue dye was injected into the treated duct and tissue was obtained for pharmacokinetic and biomarker analysis. Results: From 2/06 to 6/08, 14 women enrolled, and 12 underwent all study procedures. All dose levels up to 10 mg PLD per one duct were completed without serious adverse events. Median pain score was 0.9 (0–2.3). Intraductal PLD resulted in a dose-dependent increase in both systemic and local exposure to dox and doxol. Neither dox nor the metabolite was detected in the contralateral breast. Systemic exposure was lower than with conventionally administered PLD. Inflammatory changes were not observed on histopathological review of mastectomy specimens. Conclusions: We have established the logistics of intraductal administration of agents in an outpatient setting and it is feasible in women with and without prior chemotherapy. Biomarker data will be completed prior to the meeting. Future studies will evaluate other agents administered to one or more ducts.

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Promoter hypermethylation in sentinel lymph nodes as a marker for breast cancer recurrence

PURPOSE

Promoter methylation of tumor suppressor genes in histologically negative sentinel lymph nodes (HNSN) of early stage breast cancer patients has not been extensively studied. This study evaluates the methylation frequency and pattern in HNSN to determine if detection of hypermethylation of one or more genes is associated with an increased recurrence risk in node negative breast cancer.

EXPERIMENTAL DESIGN

In 1998, a prospective study of patients with early stage breast cancer and HNSN was initiated in order to correlate sentinel node analysis with clinical outcome. Nodal tissue was selected from 120 HNSN patients for methylation analysis in at least one and up to six sentinel nodes using a panel of nine genes. Corresponding primary breast tumors from 79 patients were also evaluated for hypermethylation. Methylation analysis was performed using nested Methylation Sensitive PCR (n-MSP). Logistical regression was used to evaluate the relationship between clinical recurrence and methylation status.

RESULTS

Over a median follow-up of 79 months, 13 of the 120 patients had clinical recurrence. Hypermethylation of genes was frequently observed in HNSN, but there was no correlation of methylation pattern and clinical recurrence. However, increased frequency of gene methylation of the primary tumor correlated with clinical recurrence.

CONCLUSIONS

Although hypermethylation of multiple genes occurs frequently in HNSN of breast cancer patients, it is not associated with breast cancer recurrence in the first 7 years of clinical follow-up.