Factors associated with COVID-19 booster vaccine hesitancy: a nationwide, cross-sectional survey in Japan

OBJECTIVES

COVID-19 vaccine hesitancy/fatigue is increasing as the pandemic enters the endemic phase. The present study aimed to explore current perceptions about COVID-19 booster vaccination among the Japanese public.

STUDY DESIGN

This was a cross-sectional study.

METHODS

This cross-sectional study used data from the Japan COVID-19 and Society Internet Survey conducted in September 2021 and September 2022. The public's perceptions of COVID-19 vaccination and factors associated with COVID-19 booster vaccine hesitancy were analyzed.

RESULTS

In total, 56,735 respondents were included. In the Japan COVID-19 and Society Internet Survey 2021, 75.1% of the participants (21,126/28,118) had completed the primary vaccination series. In the 2022 survey, 74.1% of the respondents (21,216/28,617) completed the primary series of vaccination with booster doses. The proportion of fear toward COVID-19 and obtaining information about COVID-19 has decreased from 2021 to 2022. Factors independently associated with booster vaccine hesitancy were young age (range: 18-29 years; adjusted odds ratio [aOR]: 6.56), history of COVID-19 (aOR: 1.82), distrust of the Japanese government's COVID-19 prevention measures (aOR: 1.55), lack of confidence in COVID-19 vaccine efficacy (aOR: 1.30), lack of confidence in COVID-19 vaccine safety (aOR: 1.62), low reliance on the COVID-19 vaccine (aOR: 1.92), and belief in COVID-19 conspiracy theories (aOR: 1.77).

CONCLUSIONS

Providing clear and trustworthy information is critically important, especially targeted and tailored messages for the young generation, to promoting COVID-19 booster vaccination. Policymakers should therefore develop consistent and transparent communication strategies and the ability to respond promptly and flexibly to mitigate the negative impact of COVID-19 on the public while preparing for the next pandemic.

Albuminuria predicts worsening renal function at 1 month after transcatheter aortic valve implantation

Background

Worsening renal function (WRF) at short term after transcatheter aortic valve replacement (TAVR) is reportedly associated with subsequent poor clinical outcomes. We previously reported preoperative albuminuria predicted mid-term WRF after TAVR. However, the impact of albuminuria on short-term WRF after TAVR is unknown.

Methods

Overall, 206 patients who underwent TAVR for severe aortic stenosis were investigated retrospectively. Patients were divided into two groups according to the preoperative urinary albumin-to-creatinine ratio (ACR): high (ACR ≥30 mg/g) and low (ACR <30 mg/g). The incidence of 1-month WRF, defined as a decrease in estimated glomerular filtration rate (eGFR) ≥10% from baseline after TAVR, was investigated.

Results

More than half of the examined patients (n=106/206 [51.5%]) had a high ACR. Patients with a high ACR had significantly lower eGFR at baseline than those with a low ACR (49.3 [32.5–57.8] vs. 51.4 [37.7–65.8] mL/min/1.73 m2, p=0.03). Patients with a high ACR more frequently had acute kidney injury (8.5% vs. 1.0%, p=0.01) and 1-month WRF than those with a low ACR (29.2% vs. 12.0%, p=0.002). Multivariate analysis showed a high ACR was independently associated with 1-month WRF (odds ratio, 3.72; 95% confidence interval, 1.72–8.08; p<0.001). Meanwhile, eGFR <60 mL/min/1.73 m2 was not an independent predictor of 1-month WRF (odds ratio, 0.48; 95% confidence interval, 0.22–1.04, p=0.06).

Conclusions

Patients with preoperative albuminuria (ACR ≥30 mg/g) more frequently developed AKI and 1-month WRF after TAVR. Albuminuria was independently associated with 1-month WRF, suggesting albuminuria to be a universal predictor of deterioration of renal function at various time points.

Funding Acknowledgement

Type of funding sources: None.

De-Training Effects Following Leucine-Enriched Whey Protein Supplementation and Resistance Training in Older Adults with Sarcopenia: A Randomized Controlled Trial with 24 Weeks of Follow-Up

OBJECTIVES

This study aimed to evaluate the effectiveness of de-training after a combined intervention of leucine-enriched whey protein supplementation and resistance training on skeletal muscle mass and strength in older adults with sarcopenia.

DESIGN

A randomized controlled trial.

SETTING

A community in Hyogo, Japan.

PARTICIPANTS

The study included older adults aged ≥ 65 years who were screened for sarcopenia at the Care Center from, a community in Hyogo, Japan. The participants were randomly allocated to one of three groups: whey protein supplementation after resistance training (RT + PRO; n = 27), resistance training only (RT; n = 27), and whey protein supplementation only (PRO; n = 27).

INTERVENTIONS

An intervention program was conducted over a period of 24 weeks. The program included RT and/or PRO supplementation twice a week for 24 weeks, followed by a de-training period for another 24 weeks. PRO supplementation included 11.0 g of protein and 2,300 mg of leucine. The total energy and protein intake amounts for the participants in all groups were controlled to achieve at least 30 kcal/kg ideal body weight (IBW)/day and 1.2 g/kg IBW/day, respectively, during the intervention and de-training periods.

MEASUREMENTS

The primary outcomes, such as mean change of appendicular skeletal muscle mass index (ΔASMI), and secondary outcomes, such as handgrip strength (ΔHGS), were measured at baseline, the end of intervention, and at 12 and 24 weeks of de-training.

RESULTS

Compared to baseline, ASMI and HGS increased significantly at the end of the intervention period in the RT+PRO group (ASMI and HGS, p < 0.01); however, there were no significant differences in ΔASMI and ΔHGS between each group. At 24 weeks of the de-training period, ΔASMI and ΔHGS were higher in the RT + PRO group than in the RT group (p < 0.05 and p < 0.01, respectively).

CONCLUSION

We demonstrated that combined intervention of RT and PRO showed long-term maintenance in treating sarcopenia than RT only at 24 weeks after de-training. Therefore, PRO intake after RT may be useful in the treatment of sarcopenia in older adults.

Incidental findings on computed tomography for preoperative assessment before transcatheter aortic valve implantation in japanese patients

Background

Extra-cardiovascular incidental findings (IFs) on preoperative computed tomography (CT) are frequently observed in transcatheter aortic valve implantation (TAVI) candidates. However, the backgrounds of TAVI candidates and comorbidities differ based on the race and/or country, and data on IFs in a specific population are not always applicable to another.

Objective

To assess the prevalence, type, and clinical impact of IFs in Japanese TAVI candidates.

Methods

This was a retrospective, single-center, observational study. CT reports of 257 TAVI candidates were reviewed, and IFs were classified as (a) insignificant: findings that did not require further investigation, treatment, or follow-up; (b) intermediate: findings that needed to be followed up or were considered for further investigation but did not affect the planning of TAVI; and (c) significant: findings that required further investigation immediately or affected the planning of TAVI.

Results

At least one IF was found in 254 patients (98.8%). Insignificant, intermediate, and significant IFs were found in 253 (98.4%), 153 (59.5%), and 34 (13.2%) patients, respectively. Newly indicated significant IFs were found in 19 patients (7.4%). In 2 patients (0.8%), TAVI was canceled because of significant IFs. In patients who consequently underwent TAVI, the presence of significant IFs was not associated with the duration from CT performance to TAVI [28 (19–40) days vs. 27 (19–43) days, p=0.74] and all-cause mortality during the median follow-up period of 413 (223–805) days (p=0.44).

Conclusion

Almost all Japanese TAVI candidates had at least one IF, and the prevalence of significant IFs was not negligible. Although the presence of significant IFs was not associated with mid-term mortality, appropriate management of IFs was considered important.

Funding Acknowledgement

Type of funding sources: None.

Regression of electrocardiographic left ventricular hypertrophy after transcatheter aortic valve replacement for aortic stenosis

Background

The changes in electrocardiographic left ventricular hypertrophy (ECG-LVH) after transcatheter aortic valve replacement (TAVR) are not fully elucidated.

Methods

This retrospective single-center study investigated 156 patients who underwent TAVR for severe aortic stenosis. Twelve-leads ECGs obtained before and at 2 days and 1, 6 and 12 months after TAVR were analyzed. Patients with an implanted pacemaker, with a bundle branch block before or after TAVR or whose electrocardiogram at any measuring point was not available were excluded. As an assessment of ECG-LVH, Sokolow-Lyon voltage, Cornell voltage, Cornell product and Peguero–Lo Presti voltage were evaluated.

Results

Finally, 64 patients were included. Sokolow-Lyon voltage, Cornell voltage, Cornell product and Peguero–Lo Presti voltage significantly decreased between 1 and 6 months after TAVR compared to baseline. The prevalence of ECG-LVH criteria for each parameter decreased as well. QRS duration significantly decreased at 6 months after TAVR and the number of patients with strain pattern decreased significantly at 1 month when compared to baseline. When the patients were divided into two groups, those with and without ECG-LVH at baseline, ECG-LVH parameter values decreased significantly, especially in patients with ECG-LVH at baseline.

Conclusion

Regression of ECG-LVH after TAVR was demonstrated as per various criteria of ECG-LVH. The voltages and prevalence of ECG-LVH decreased significantly between 1 and 6 months after TAVR.

Funding Acknowledgement

Type of funding sources: None.

Abstract P1-13-09: Long-term follow-up of two randomized controlled trials (N-SAS-BC01 trial and CUBC trial) comparing oral tegafur-uracil (UFT) versus classical cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) as adjuvant therapy in early breast cancer

Background: Two randomized controlled trials comparing the efficacy of oral tegafur-uracil (UFT) (2 years) with that of classical cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) (6 courses) were conducted in patients with resected early breast cancer. UFT is an oral fluoropyrimidine that combines tegafur, a prodrug of 5-fluorouracil, with uracil in a 1:4 molar ratio. One study was the N-SAS-BC01 trial (Watanabe et al, J Clin Oncol 2009), which was conducted in patients with high-risk node-negative breast cancer (n=733). The other was the CUBC trial (Park et al, Br J Cancer 2009), which was performed in patients with node-positive breast cancer (n=377). We reported the pooled analysis of these two randomized control trials using individual patient data (Ohashi et al, Breast Cancer Res Treat 2010). This pooled analysis showed that UFT was non-inferior to CMF in terms of inhibiting recurrence of estrogen receptor (ER)-positive early breast cancer. In addition, an exploratory subgroup analysis showed that UFT may be more effective in ER-positive patients who were 50 years or older. The present study was conducted to investigate the long-term efficacy of UFT or CMF in patients with early breast cancer.

Methods: Long-term follow-up data for disease recurrence and survival were collected. Hazard ratios (HR) were determined using the Cox model stratified by study and adjusted for clinical characteristics, namely age, tumor size, nodal status, histological type, ER, and progesterone receptor (PgR). Survival curves were estimated by the Kaplan-Meier method. Hochberg multiplicity adjustment was applied in the previous pooled analysis, and non-inferiority of UFT versus CMF was shown in terms of relapse-free survival (RFS) in the ER-positive patient group. We investigated the non-inferiority of UFT in the same patient group with updated data. Restricted mean survival time (RMST) was calculated to consider the relative efficacy of UFT. This study is registered with JapicCTI-163321.

Results: In total, 1,057 patients were analyzed (CMF, n=528; UFT n=529). The median follow-up time was 11.1 years (12.1 years in the N-SAS-BC 01 trial and 8.3 years in the CUBC trial). Table 1 shows the 10-year RFS and overall survival (OS) in all patients and ER-positive patients. The difference in RMST between arms at 20 years in terms of RFS was -2.7 months in all patients and 3.4 months in ER-positive patients. Table 2 shows the HR for RFS according to ER status and age.

 UFT (%)CMF (%)UFT to CMF; HR (95% CI)10-year RFSall patients74.477.11.02 (0.81–1.30)ER-positive patients75.075.10.91 (0.66–1.27)10-year OSall patients86.886.90.98 (0.72–1.34)ER-positive patients89.987.90.86 (0.54–1.37)

 Age &lt;50 yearsAge ≥50 yearsER negative1.76 (0.95–3.26)0.93 (0.58–1.51)ER positive1.29 (0.74–2.23)0.76 (0.50–1.16)

Conclusion: This study shows that UFT was shown to be non-inferior to CMF in terms of RFS in ER-positive early breast cancer. This result is similar to that of the previous pooled analysis.

Sponsor: Taiho Pharmaceutical Co., LTD

Citation Format: Yonemori K, Ohsumi S, Takao S, Tokuda Y, Ito Y, Nakagami K, Takahashi M, Yoshidome K, Nakayama T, Yamaguchi Y, Ohashi Y, Inaji H, Watanabe T. Long-term follow-up of two randomized controlled trials (N-SAS-BC01 trial and CUBC trial) comparing oral tegafur-uracil (UFT) versus classical cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) as adjuvant therapy in early breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-13-09.

Abstract P2-11-11: Role of postmastectomy radiotherapy after neoadjuvant chemotherapy in breast cancer patients: A study from the Japanese breast cancer registry

Background:

Postmastectomy radiotherapy (PMRT) has been shown to be beneficial in node-positive breast cancer patients. However, the role of PMRT for patients receiving modern neoadjuvant chemotherapy (NAC) are controversial. We aimed to evaluate the efficacy of radiotherapy for breast cancer patients treated with NAC and mastectomy in the Japanese Breast Cancer Registry.

Methods:

Patients who received NAC and mastectomy for cT1-4 cN0-2 M0 breast cancer were included in this analysis. We assessed locoregional recurrence (LRR), distant disease-free survival (DDFS), and overall survival (OS) using the Kaplan-Meier method and compared them between the groups with and without PMRT by nodal status after NAC; ypN0, ypN1, and ypN2-3. We also performed multivariable cox regression analysis to evaluate the association of radiotherapy and these outcomes adjusting for baseline patient and cancer characteristics.

Results:

Of the 145,530 patients registered from 2004 to 2009, we identified 3,226 patients who met our inclusion criteria with the 5-year follow-up information including 1,299 ypN0, 1,036 ypN1, and 879 ypN2-3 cases. PMRT was performed in 185 patients (14.2%) with ypN0, 265 patients (25.6%) with ypN1, and 543 patients (61.8%) with ypN2-3. There was no difference in LRR, DDFS, and OS between the groups with and without radiotherapy for ypN1 patients who received NAC (P=0.72, P=0.29, and P=0.36, respectively). For patients with ypN2-3 breast cancer, radiotherapy significantly improved LRR (P&lt;0.001), DDFS (P=0.01), and OS (P&lt;0.001) on univariate analysis. No difference in LRR, DDFS, and OS was observed for ypN0 patients (P=0.81, P=0.15, and P=0.05, respectively). In multivariable analysis, the use of radiotherapy was independently associated with improved LRR [hazard ratio (HR): 0.608, 95% confidence interval (CI): 0.452–0.818, P=0.001] and OS [HR: 0.685, 95% CI: 0.531–0.885, P=0.004] for ypN2-3 patients.

Effect of PMRT on locoregional recurrence by the ypN subgroupsypN subgroupHazard ratio95%CI Low95%CI HighP valueypN00.8550.4581.5960.623ypN10.8320.5491.2620.387ypN2-30.6080.4520.8180.001

Abstract P2-04-13: Difference of immune microenvironment between primary and recurrent tumours in breast cancer patients

Background

Immune checkpoint therapy only benefits a fraction of patients, thus huge efforts have been made to develop predictive biomarkers to identify those patients. Immune biomarkers like PD-L1 expression are extremely dynamic and the timing of evaluation, on primary or metastatic disease, may be critical. We have already shown that tumour-infiltrating lymphocytes (TILs) decrease during metastatic progression in triple-negative (TN) and human epidermal growth factor-2 positive (HER2+) breast cancers (Ogiya R, ASCO 2015), suggesting that mechanisms of immune escape contribute and favour the metastatic progression. In this work we aimed to characterize the modulation and changes of specific immune markers during the metastatic spread comparing paired samples from primary and recurrent breast cancers.

Methods

We retrospectively identified 25 patients with HER2+ (n = 14) and TN (n = 11) early breast cancer diagnosed between 1990 and 2009 at Tokai University Hospital, and who subsequently experienced a first regional or distant recurrence confirmed by tumour biopsy/resection. Haematoxylin and eosin-stained slides of these paired samples were evaluated for stromal TILs. Immunohistochemical staining was performed using primary antibodies against CD4, CD8, Foxp3, PD-L1, PD-L2, and HLA-class I.

Results

The sites of first recurrence was the skin (n = 7), brain (n = 6), lymph node (n = 4), lung (n = 3), bone (n = 2), and one of each of bone marrow, liver and muscle. Immunohistochemical evaluations could not be performed in 5 primary tumours and 2 recurrent tumours because of the small quantity of the specimens. The percentage of CD8+ T cells staining in the primary tumours was significantly higher (median 16%) than that in recurrent tumours (median 10%) (paired t-test, p = 0.008) Similarly, the percentage of CD4+ T cells staining in the primary tumours was significantly higher (median 40%) than that in recurrent tumours (median 25%) (p = 0.026). The percentage of Foxp3+ T cells was low (&lt;10%) and similar in both primary and recurrent tumours (p = 0.16). PD-L1, PD-L2, and HLA class I antibody expression was not statistically different between primary and recurrent tumours, but conversions from positive to negative and vice versa were observed. PD-L1+ staining (≥1%) was 90% and 85% in primary and metastatic tumours, respectively.

Comparison of positivity rate between primary and recurrent tumours for each antibody Primary tumourRecurrent tumourPTotal breast tumours (N)2023 TILs positivity rate, median (%)   CD440%25%.03CD816%10%.01Foxp3&lt;10%&lt;10%.16Expression in tumour cells (N)   PD-L1   Strong85.46Weak1015 Negative23 PD-L2   Strong69.78Weak1011 Negative43 HLA   Strong46.89Weak1415 Negative22 

Conclusions

Tumours at first metastatic recurrence in HER2+ and TN breast cancers have a lower percentage of both CD8+ and CD4+ T cells compared to primary tumours, confirming a potential role of immune escape in tumour progression. Other immune markers, including PD-L1, were not found to change significantly, but negative/positive conversions were observed. This suggest that an evaluation of disease at the time of immunotherapy administration might be more informative. These findings warrant larger confirmation studies.

Citation Format: Ogiya R, Niikura N, Kumaki N, Bianchini G, Kitano S, Iwamoto T, Hayashi N, Yokoyama K, Oshitanai R, Terao M, Morioka T, Tsuda B, Okamura T, Saito Y, Suzuki Y, Tokuda Y. Difference of immune microenvironment between primary and recurrent tumours in breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-04-13.

Abstract P3-13-11: Utility of LigaSureTM vessel-sealing device in axillary dissection for breast cancer surgery: A randomized single center study

Introduction

Axillary lymph node dissection is standard therapy for patients with positive-node breast cancer, and can be performed with an electrocautery scalpel and suture ligation in most cases. However, knot slipping can occur during suture ligation and this can spread thermal damage to peripheral tissues. The LigaSureTM Small Jaw vessel-sealing system was developed as an alternative to suture ligatures, staplers, and other energy-dependent devices for sealing blood and lymphatic vessels, but its use in axillary dissection for breast cancer is limited. We prospectively compared the duration until drain removal after surgery, total lymph fluid drainage volume, intraoperative blood loss, and incidence of complications after axillary dissections, between this device and conventional methods.

Methods

This prospective randomized study was conducted at the Department of Breast and Endocrine Surgery at Tokai University School of Medicine, Kanagawa, Japan, between October 2011 and March 2015. Major eligibility criteria included (1) pathologically confirmed breast cancer diagnosis, (2) age ≥20 and ≤80 years, and (3) a signed informed consent form. The primary endpoint was duration until drain removal after surgery. The secondary endpoints were total lymph fluid drainage volume, intraoperative blood loss, and incidence of postoperative surgical complications. We defined the criterion for drain removal as a lymph fluid drainage volume of &lt;40 mL/day for two consecutive days.The target accrual was 100 patients, with a two-sided error rate of 5%, and 90% power. The assumed duration until drain removal after surgery was 7.2 days in the control group (conventional use of an electrocautery scalpel and suture ligation) and 5.8 days in the study group (use of the LigaSureTM Small Jaw). This clinical study was approved by the Institutional Review Board of the Tokai University School of Medicine and is registered with UMIN (No. 000013034).

Results

Initially, 100 patients were assigned as eligible; however, two patients were later excluded because of the exclusion criteria. Of 98 patients, 49 were randomized to the study group, and 49 to the control group. The mean duration until drain removal after surgery was 5.2 days in the study group and 5.0 days in the control group (p=0.573). The mean total lymph fluid drainage volumes were 260.3 and 233.5 mL (p=0.502), and the mean intraoperative blood loss volumes were 17.8 and 18.0 mL (p=0.949), for the study and control groups, respectively. No significant differences were found between the two groups regarding drain removal duration, total drainage volume, and intraoperative blood loss volume. Both groups had low incidence rates of postoperative hematoma, wound infection, lymphedema, and pain, and had similar incidence rates of seroma formation after drain removal.

Conclusion

Our study results indicated that the use of the LigaSureTM Small Jaw in axillary dissection for breast cancer was as safe as conventional methods. However, using the LigaSureTM Small Jaw did not improve surgical outcomes such as duration until drain removal and total lymph fluid drainage volume compared with conventional methods.

Citation Format: Okamura T, Niikura N, Yokoyama K, Ogiya R, Oshitanai R, Terao M, Morioka T, Tsuda B, Saito Y, Suzuki Y, Tokuda Y. Utility of LigaSureTM vessel-sealing device in axillary dissection for breast cancer surgery: A randomized single center study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-11.

Abstract P5-16-04: A randomized phase II neoadjuvant study comparing docetaxel and cyclophosphamide (TC) with 5-fluorouracil, epirubicin, and cyclophosphamide followed by docetaxel (FEC-D) for hormone receptor-negative breast cancer: The Kanagawa breast oncology group (KBOG) 1101 study

Purpose: This study aimed to evaluate response to neoadjuvant chemotherapy (NAC) for patients with hormone receptor-negative (HR-negative) breast cancer (BC) to identify subtypes that require anthracycline treatment.

Methods: In total, 103 patients with operable HR-negative BC were registered. They were randomely assigned to administration of 6 cycles of docetaxel (75mg/m2) and cyclophosphamide (600 mg/m2) (TC6) or 3 cycles of 5-fluorouracil (500 mg/m2), epirubicin (100mg/m2), and cyclophosphamide (500mg/m2) followed by 3 cycles of docetaxel (100mg/m2) (FEC-D). Cytokeratin (CK) 5/6 and EGFR expression were used to identify basal and non-basal triple-negative (TN) BC. The primary endpoint was pathological complete response (pCR); secondary endpoints were safety, breast-conserving surgery, disease-free survival, and overall survival. Predictive factors of pCR for each regimen were also evaluated.

Results:

The pCR rate was 36% for FEC-D and 25.5% for TC6, which did not differ significantly (P=0.265). When TN BC was subdivided into basal and non-basal subtypes, the pCR rate in the basal subtype was significantly lower for TC6 (13.6%) than for FEC-D (42.9%) (P=0.033), but did not significantly differ in the non-basal (TC6, 36.4%; FEC-D, 25.0%) and HER2-positive (TC6, 41.7%; FEC-D, 35.7%) cases.

The relative dose intensities of epirubicin and docetaxel in FEC-D and docetaxel in TC6 were 96.3±13.0%, 93.5±14.6%, and 93.9±16.3% (mean±SD), respectively. Occurrence of grade ≥2 adverse events was significant in FEC-D-treated patients. Poor appetite (P&lt;0.001), nausea (P&lt;0.001), vomiting (P&lt;0.001), dysgeusia (P=0.03), and fatigue (P=0.05) were significantly more common for FEC-D than TC6. Patients treated with FEC-D experienced significantly more febrile neutropenia and anemia (P=0.016 and 0.017, respectively).

The rates of breast-conserving surgery were 68.0 and 72.3% for FEC-D and TC6, respectively (P=0.641).

Patients achieved pCR had better DFS (log rank test, P = 0.287) and OS (log rank test, P = 0.069), though not significant. Patients treated with FEC-D had better DFS (log rank test, P = 0.107) and OS (log rank test, P = 0.159), though not significant. Among patients with TN BC, those treated with FEC-D had significantly better DFS (log rank test, P = 0.016) and OS (log rank test, P = 0.034) than treated with TC6.

Low ALDH1 expression and high topo IIα protein expression were strongly correlated with pCR in FEC-D, with odds ratios (ORs) of 4.33 [95% CI, 1.02–18.38] and 4.08 [0.97–17.2], respectively. ALDH1 was also associated with pCR in TC, OR=3.50 [0.84–14.6]. Other factors, including age, tumor size, nodal status, tumor grade, Ki67, p53, and TOP 2A status were not associated with pCR in either regimen.

Conclusions:We found that TC6 was less effective than FEC-D for treating HR-negative BC because it was insufficient for TNBC, particularly for basal BC. This suggests that anthracycline is more important than taxane for basal BC. Additionally, ALDH1 could be a marker for resistance to conventional chemotherapy.

Citation Format: Narui K, Ishikawa T, Shimizu D, Tanabe M, Sasaki T, Oba MS, Morita S, Nawata S, Kida K, Mogaki M, Doi T, Tsugawa K, Ogata H, Ota T, Kosaka Y, Sengoku N, Kuranami M, Saito Y, Suzuki Y, Suto A, Arioka H, Chishima T, Ichikawa Y, Endo I, Tokuda Y. A randomized phase II neoadjuvant study comparing docetaxel and cyclophosphamide (TC) with 5-fluorouracil, epirubicin, and cyclophosphamide followed by docetaxel (FEC-D) for hormone receptor-negative breast cancer: The Kanagawa breast oncology group (KBOG) 1101 study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-16-04.

Professionalism of physicians at a major teaching hospital during the Fukushima nuclear disaster

It poses a serious problem if physicians leave a hospital without having a replacement or without permission. A huge earthquake followed by a devastating tsunami seriously damaged the Fukushima-Daiichi nuclear power plant. This disaster overwhelmed a major teaching hospital in the local area and many hospital employees, including some resident physicians, left the premises. Since the threat of severe radiation exposure poses a potentially greater lifetime risk to younger individuals, letting the young resident physicians leave the hospital was not only allowed, it was actually recommended by many attending physicians and hospital administrators. The hospital administrator was required to make the difficult decision of whether to make all efforts to provide the highest level of medical care, including keeping all of the physicians on the premises, or to evacuate the resident physicians in order to preserve their health and their potential future contributions to healthcare. Consideration and compassion needed to be provided to all people, regardless of the reason they wanted to leave. From an ethical perspective, the roles of performance under these complex circumstances should be understood and embraced by us as individuals, professionals, supervisors and society as a whole.

Multi-frequency force-detected electron spin resonance in the millimeter-wave region up to 150 GHz

In this article, a novel technique is developed for multi-frequency force-detected electron spin resonance (ESR) in the millimeter-wave region. We constructed a compact ESR probehead, in which the cantilever bending is sensitively detected by a fiber-optic Fabry-Perot interferometer. With this setup, ESR absorption of diphenyl-picrylhydrazyl radical (<1 μg) was clearly observed at multiple frequencies of up to 150 GHz. We also observed the hyperfine splitting of low-concentration Mn(2+) impurities(∼0.2%) in MgO.

Abstract P5-08-14: Tumor Infiltrating lymphocytes (TIL) related genomic signature associated with chemotherapy response and prognosis in subtypes of breast cancer

Background: Tumor infiltrating lymphocytes (TIL) in subtypes of breast cancer may provide clinically important information on chemotherapy response and prognosis. However, the standardized methodology for immunohistochemical (IHC)-TIL has not yet been established, reproducible and objective method of evaluation of TIL such as gene expression profiles is warranted. We evaluated whether IHC-TIL level was associated with gene expression profiles and whether such profiles could be used to predict chemotherapy response and prognosis according to subtypes of breast cancers.

Methods: To select TIL associated genes, we used 40 samples with both IHC-TIL information and gene expression profiling data. The degree of TIL at the edges of the tumor mass, in the tumor mass, or in the stroma surrounding the expanding mammary ducts packed by carcinoma cells was evaluated as score 0, 1, and 2, when TIL was not unrecognizable (0%), sparse (0 &lt;&lt; 50%) and dense (50% ≤), respectively. We selected 22 genes as the TIL-gene signature (GS), by comparing expression profiles between TIL score 2 and 0 tumors. We showed the associations between the TIL-GS levels and subtypes of breast cancers (Estrogen receptor: ER / Human Epidermal growth factor 2: HER2). The chemotherapy sensitivity analysis was performed on cohorts of 625 patients with stage I–III breast cancer who received neo adjuvant chemotherapy (NAC) based on Anthracycline and Taxane containing regimen. Data from 1,586 tumors were used to evaluate the association between distant metastasis free survival (DMFS) and the TIL-GS in a Kaplan-Meier analysis.

Results: The TIL-GS for ER negative (-)/HER2- and HER2 positive (+) cases were significantly higher expression level than luminal types (p-value &lt;0.001). All breast cancer subtypes except luminal-low proliferation had significantly higher differential TIL-GS level in cases with pathological complete response (pCR) after NAC than residual disease (luminal-high: p-value = 0.013, HER2+: 0.005, and ER-/HER2-: 0.016). With no adjuvant chemo or only tamoxifen treated breast cancer data set, the TIL-GS had no prognostic power in luminal cases regardless of proliferative level. In HER2+ breast cancers, cases with the high TIL-GS had significantly better prognosis than low cases (p-value =0.001), but no significance in ER-/HER2- cases (p-value = 0.621).

Conclusions: Higher TIL-gene signature of 22 genes appeared to be associated with aggressive subtypes and pCR rate (except luminal-low) of breast cancers. This approach may improve the reproducibility of assessment on tumor TIL level and thus serve the clinical applications for breast cancers.

Citation Format: Kochi M, Niikura N, Iwamoto T, Bianchini G, Mizoo T, Nogami T, Shien T, Motoki T, Taira N, Masuda S, Doihara H, Fujiwara T, Tokuda Y, Matsuoka J. Tumor Infiltrating lymphocytes (TIL) related genomic signature associated with chemotherapy response and prognosis in subtypes of 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 P5-08-14.

Abstract P1-01-09: Ductal carcinoma in situ: A comparative study between histopathological characteristics and imaging findings

Background: The treatment policy for ductal cancer in situ (DCIS) of the breast greatly depends on the spreading diagnosis. However, a problem is that we cannot compare imaging findings with the histopathology of DCIS. The purpose of this study was to investigate the histopathological characteristics of DCIS and the association with imaging findings.

Methods: Subjects were 128 patients from Tokai University Hospital, diagnosed with DCIS. A positive finding on ultrasonography (USG) was defined as Breast Imaging Reporting and Data System (BI-RADS) of US category 3 or above, in mammography (MMG) it was Japan Breast Cancer Society category 2 or above, and in MRI it was BI-RADS-MRI category 3 or above. Histopathologically, we re-classified DCIS into 3 subtypes.

Table. Histopathological classification of the 3 DCIS subtypesSubtypesArchitectures of DCISType 1Flat and/or micropapillaryType 2Cribriform and/or papillaryType 3Solid and/or comedo, solid or comedo with any other architecture patterns, e.g. solid and cribriform or papillary, etc.

The microscopic examination items included the nuclear grade, necrosis and calcification, stromal reactions surrounding DCIS, distribution of DCIS, and with or without adenosis or other benign changes in the background breast. The automated image analysis using figures captured from virtual system are planned to evaluate concentration of DCIS distribution.

Results: 1) The clinical characteristics and association between imaging findings and histopathological classification of the 3 subtypes of DCIS are summarized as: a) Histopathologically, in type 3, there was a higher frequency of necrosis and calcification in the ducts of DCIS (χ2, p&lt;0.001), the number of dilated peri-ductal capillaries was greater than in type 1 (p=0.023), and the distribution of DCIS was concentrated in type 3 (p=0.020); b) In imaging findings, type 3 was easier to detect than type 1 on USG (p=0.008), but there were no significant differences in MMG and MRI. 2) The 14 DCIS cases that could not be detected by USG, showed slight edematous or myxoid change in the stroma histopathologically (p&lt;0.001), and were less likely to be detected by MRI (p=0.004). 3) The 6 MRI un-detected cases were less likely to be detected by USG (p=0.004), and the occurrence of adenosis or other benign changes in the background breast interfered with MRI (p=0.010). Peri-ductal capillaries seemed to be an important factor for MRI detection (p=0.007). 4) The results of automated image analysis will be presented.

Conclusion: USG imaging reflected the histopathological subtypes of DCIS, myxoid changes of the stroma, and the concentration of DCIS ducts. MRI was correlated with the peri-ductal capillaries of DCIS and the changes in the background breast, while MMG can make up for the shortcomings of USG and MRI. It is important for us to keep the histopathological type in mind and interpret the imaging findings comprehensively, when we do a spreading diagnosis of DCIS.

Citation Format: Tang X, Yamashita T, Kumaki N, Tokuda Y, Masuda S. Ductal carcinoma in situ: A comparative study between histopathological characteristics and imaging findings. [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 P1-01-09.

Abstract P3-14-08: A randomized phase II trial comparing docetaxel plus cyclophosphamide with epirubicin plus cyclophosphamide followed by docetaxel as neoadjuvant chemotherapy for hormone receptor-negative breast cancer. Kanagawa breast oncology group (KBOG) 1101 study

Background: Taxane-based regimens have been developed and used widely to treat breast cancer. It has therefore become important to identify subgroups of patients in which anthracyclines are indispensable. Pathological response to neoadjuvant chemotherapy (NAC) predicts prognosis in hormone-negative subtypes. We therefore initiated a randomized phase II NAC study to compare a taxane with and without an anthracycline in these breast-cancer subtypes.

Aim: To determine the safety and activity of six cycles of docetaxel and cyclophosphamide (TC6) compared with 5-fluorouracil, epirubicin, and cyclophosphamide followed by docetaxel (FEC-D), and to examine the predictive factors for each regimen.

Methods: Eligibility criteria were operable hormone-receptor-negative breast cancer, age younger than 75 years and ECOG PS0-1. According to HER2 status, patients were randomly assigned to TC (75/600 mg/m2) every 3 weeks X 6 or FEC (500/100/500 mg/m2) every 3 weeks X 3 followed by D (100 mg/m2) every 3 weeks X 3. The primary endpoint was the rate of pathological complete response (pCR; grade 3). Triple-negative (TN) breast cancer was subdivided by cytokeratin 5/6 and epidermal growth factor receptor into basal- and non-basal subtypes. Secondary endpoints were safety, breast-conserving surgery, disease-free survival, overall survival, and predictive factors: Ki-67, p53, aldehyde dehydrogenase (ALDH) 1 and topoisomerase 2A by both immunohistochemistry and fluorescence in situ hybridization for each regimen.

Results: Ninety-seven of 103 patients were analyzed successfully (50 for FEC-D and 47 for TC6). Significantly more severe adverse events (grade 2) were observed in FEC-D-treated patients (poor appetite, nausea and vomiting: p = 0.001; febrile neutropenia: p = 0.016). The pCR rate tended to be higher in FEC-D-treated patients compared with TC6-treated patients (pCR: 36.0 vs. 25.5%, n.s.). FEC-D treatment was significantly more effective than TC6 in basal-type (p = 0.033) but not in non-basal and HER2 subtypes. ALDH1 was associated with resistance to both regimens (FEC-D: p = 0.047, TC6: p = 0.085)

Conclusions: TC6 was safer, but not more effective than FEC-D. TC6 was significantly less active than FEC-D in basal subtype, and equivalent to FEC-D in HER2 and non-basal subtypes. Concurrent use of trastuzumab with TC could thus represent a reasonable option for NAC in HER2-subtype patients. ALDH1 could provide a marker for novel strategies such as stem cell-based therapies for breast cancer. Analyses on pathological factors in surgical specimens after NAC will be presented at the meeting.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-08.

Abstract P5-01-11: A new anti-HER2 peptide “CH401MAP” can stimulate the immunity of breast cancer patients

In previous decades, numerous attempts have been made to develop therapeutic peptide vaccines for cancer. However, the HLA (Human Leukocyte Antigen) types are limited because most peptide vaccines are specific to the major HLA types of the area. Peptide vaccines specific for Caucasians thus may not be specific to Japanese. Moreover, they are not designed to stimulate both helper and killer T cells. We are trying to make a peptide vaccine specific to the MHC of Japanese patients that stimulates both helper and killer T cells. We selected a new-HER2 peptide including a B-cell epitope which has anti-tumor effects in a mouse system. The B-cell epitope was determined for a H401 monoclonal antibody (mAb) specific for HER2. As for epitope mapping of the chimera mAb CH401, enzyme-linked immunosorbent assay was employed with 20mer MAPs carrying a partial HER2 sequence. The CH401 epitope was determined as N:163-182, and the CH401MAP including the epitope induced anti-tumor effects in HER2-overexpressing tumor cells in a mouse system. We predicted the peptide MHC affinity and examined the in vitro reaction of PBMCs from Japanese breast cancer patients. The study enrolled 173 female breast cancer patients who underwent surgery between October 2010 and July 2012 at Tokai University Hospital. We used SYFPEITHI, BIMAS and IEDB algorithms to estimate peptide and HLA affinity. Lymphocyte proliferation ability, cell surface marker expression, cytokine (interleukin (IL)-2, IL-4 and interferon (IFN)-g) secretion and specific antibody production were analyzed in vitro. According to the algorithms, 97.1% of patients showed high to intermediate affinity of the CH401 epitope peptide to Japanese major HLA class I. Similarly, 34.5% of patients showed high to moderate affinity to HLA class II. The proliferative ability of patient groups was significantly higher than that of the HD group (HER2 0 group, p&lt;0.05; HER2 1+2+ group, p&lt;0.01; HER2 3+ group, p&lt;0.01). Cell percentages of CD8+ cells were significantly increased after 21 days of CH401MAP stimulation. In the HER2 0 patient group, CD4+CD25+ cell ratio was also increased, while no significant increase was seen in the other groups. Foxp-3 expression was not increased in any groups, suggesting that these cells were not regulatory T cells. Concentrations of IL2 in stimulated supernatant tended to increase in all patient groups. In particular, concentration in the HER2 1+2+ group at 48 h was significantly increased (p&lt;0.001). IL-4 and IFN-g secretion also tended to increase. CH401MAP-specific antibodies were measured for all breast cancer patient groups and HD, showing significant differences. However, within each patients’ group, no significant differences were observed irrespective of CH401MAP stimulation (p&lt;0.001). As a result, reactivity with CH401MAP and breast cancer patient PBMCs activated immunity in the total breast cancer patient group, and the association with HER2 expression level of the primary cancer was poor overall. Collectively, CH401MAP may become a promising peptide vaccine to prevent recurrent breast cancer in Japanese patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-01-11.

Abstract P3-13-02: Safety and Efficacy of Zoledronic Acid Beyond 24 Months in Breast Cancer Patients

Background: Bisphosphonate therapy has decreased the risk of skeletal complications associated with osteolytic bone lesions in patients with breast cancer and multiple myeloma. The large prospective studies have used 21 to 24 months of treatment. We studied the safety and efficacy of Zoledronic acid in a subset of patients who received therapy for more than 24 months.

Patients and Methods: Patients who received Zoledronic acid were identified. Data on skeletal events and laboratory parameters were gathered by chart review. The treatment regimen is 4 mg of Zolendronic acid at 3- to 4-week intervals, and concurrent chemotherapy, hormonal therapy, and radiation therapy was included. Before approval of Zoledronic acid, we were using Pamidronate and Incadronate.

Results: We used the Zoledronic acid in 221 patients from June 2006 until December 2011 (range, 1–69 times of administration). We analyzed 71 cases in which the treatment could be continued for more than 24 months (range, 24–69 times of administration). No significant calcium, phosphorus, electrolyte abnormalities were encountered. There were no significant differences between the long-term treatment patients with Zoledronic acid and all the other patients in the range of pain felt at the time of the bone metastasis diagnosis, or the bone metastases sites. In addition, by March 2012, more than 50% patients of long-term usage of Zoledronic acid had continued receiving treatment. And in all of the patients, as well, the most cited reason for discontinuing treatment was a disease progression, adverse effect was few. In long-term treatment patients, 4 cases of fractures and 2 cases of spinal compression were encountered. The median time until an SRE occurred was 37 months. There were fewer occurrences of SREs in our investigation than in the 12 months of a clinical trial conducted in Japan with Zoledronic acid and a placebo. As for adverse effects, BRONJ appeared in 4 (1.8%) out of a total of 221 cases, and in 3 (4.2%) at prolonged treatment patients. The other adverse effects were fever in 4 cases and fatigue in 2 cases.

Conclusion: Prolonged treatment with Zoledronic acid seems to be well tolerated and should be studied in prospective, randomized studies to document prolonged skeletal efficacy and survival.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-13-02.

Abstract P2-05-08: Determination of HER2 amplification by dual-color in situ hybridization before and after neoadjuvant chemotherapy

Background: HER2-targeted therapies such as trastuzumab neoadjuvant chemotherapy for patients with HER2-positive breast cancer can increase pathological complete response (pCR) better than non-HER2-targeted therapies. Previous studies have suggested that trastuzumab may convert HER2-positive (HER+) primary breast tumors to HER2 negative (HER−) after neoadjuvant chemotherapy. We compared the HER2 status in breast cancer patients before and after neoadjuvant treatment by using dual-color in situ hybridization (DISH).

Methods: We retrospectively identified 46 patients from the Breast Cancer database at Tokai University Hospital, in whom HER2-positive primary breast cancer was diagnosed between 2000 and 2010, and who were treated with neoadjuvant chemotherapy or endocrine therapy with or without trastuzumab. Surgical specimens from patients achieving less than pCR were assessed to determine if there was enough residual tissue to evaluate the post-treatment HER2 status by DISH. HER2 status was defined as positive if DISH demonstrated a gene copy ratio of HER2:CEP17 &gt;2.0. Paraffin tissue sections (4-μm thick) were mounted on glass slides (New Sliane III, Catalog No. 5126–25; MUTO PURE CHEMICALS, CO. LTD., Tokyo, Japan) and stained using the newly developed, fully automated HER2 Dual ISH assay on a BenchMark® XT slide stainer according to the recommended procedure (Ventana Medical Systems Inc., Tucson, AZ). Thereafter, the stained slides were rinsed with tap water containing neutral detergent and then rinsed again with distilled water. The slides were dried at room temperature for at least 60 min and cover-slipped with cover grass for SGC (MUTO PURE CHEMICALS). HER2 Dual ISH and H&E images were obtained using an Olympus BX51 microscope.

Results: A pCR was achieved in 9 of the 46 patients (19.6%). Specimens from core needle biopsy were not sufficient to assess the pretreatment HER2 status in 3 patients. In 9 patients, the post-treatment HER2 status could not be assessed because residual tumors were DCIS only in 4 patients and there were less than 20 invasive cells in 5 patients. Residual tumor was sufficient to assess the post-treatment HER2 status in 25 patients. In pretreatment specimens, of the 25 patients identified as HER2 + by immunohistochemical analysis, 3 patients were identified as HER2− by DISH. No post-treatment specimens were found to be HER2− by DISH among the tumors identified as HER2+ by DISH at pretreatment. Among the 3 pretreatment tumors identified as HER2− by DISH, 1 tumor was found to be HER2+ by DISH at post-treatment, and 2 showed a stable HER2 status.

Conclusion: DISH revealed a stable HER2 status in pretreatment breast tumors and in residual tumors. However, we found a discrepancy in the HER2 status between the immunohistochemical analysis and DISH.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-05-08.