bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract PD02-01: Her2 expression measured by AQUA analysis on BCIRG-005 and BCIRG-006 predicts the benefit of Herceptin therapy
Authors: Christiansen J , Barakat N , Murphy D , Rimm DL , Dabbas B , Nerenberg M , Beruti S , Quinaux E , Hall J , Press M , Slamon D
Published: August 2014

Introduction: There have been disparate results reported in breast cancer testing for HER2 assessment as measured by protein expression or DNA amplification, yet both tests are routinely used to prescribe the drug Herceptin (trastuzumab, Genentech, So San Francisco, CA). Typically, immunohistochemistry (IHC) staining intensity of 3+ or FISH copy ratio of ≥2.0 are used to establish the cutoff between a negative and a positive result. However, it is unclear whether positivity is correlated with differential response to therapy. We used Automated Quantitative Analysis (AQUA) and a fluorescent immunohistochemical assay to measure HER2 expression in cases scored by central laboratory FISH and also receiving Herceptin therapy. The intentions of the study were two-fold: first, to provide further validation of the AQUA technology as applied to the clinical measurement of HER2 expression in breast cancer and second, to examine the potential of drug response stratification within those patients that are considered positive.

Methods: AQUA fluorescence IHC staining was performed on a multi-cohort tissue microarray (TMA) set. The assay was constructed in the Genoptix CLIA laboratory per ASCO/CAP guidelines and with a cutpoint that was validated against IHC (with FISH reflex). The trial specimens tested were from the BCIRG-005/006 studies. BCIRG-005 had n=1544 cases all assessed as FISH- while the 006 cohort had n=1477 cases all assessed as FISH+. Disease free survival (DFS) was used as the variable in subsequent modeling and analysis.

Results: The BCIRG 005 and 006 cohorts, examined in aggregate, allowed for an initial examination of agreement relationships between HER2 levels as assessed by AQUA scoring and HER2 levels as assessed by central lab FISH. Results indicated a 77% negative agreement, a 97% positive agreement and an 87% overall concordance agreement for a total of n=3021 cases. Additional Cox modeling of the patients that were enrolled as FISH+ and stratified for those who did or did not receive Herceptin treatment demonstrated a significant overall hazard ratio (HR = 0.75, CI=0.60,0.93) and when stratified for response to Herceptin, cases determined to be positive by AQUA showed significant benefit from treatment (HR = 0.66, CI = 0.52,0.85) in contrast to those who were scored as negative by AQUA that did demonstrate benefit from therapy (HR = 1.19, CI=0.71,1.97).

Conclusions: Analysis of the cases in this study originally determined to be HER2+ by FISH indicates that AQUA may improve predictions of which patients will benefit from Herceptin therapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD02-01.
Abstract PD04-06: Molecular Phenotypes of DCIS predict Invasive and DCIS recurrence
Authors: Williams KE , Barnes NLP , Cheema K , Dimopoulos N , Bundred NJ , Landberg G
Published: August 2014

Introduction: Molecular phenotypes of invasive breast cancer predict early recurrence and survival. DCIS exhibits similar phenotypes but their frequency and clinical significance remain uncertain. To determine whether molecular phenotypes of DCIS predict recurrence, 273 women (median age 57 years) with primary DCIS who were screened for or entered DCIS trials (Iressa/Lapatinib/ERISAC) in one unit from 1990–2010 were studied.

Methods: HER2, oestrogen receptor (ER) and progesterone receptor (PR) expression within primary DCIS were established using immunohistochemistry within the trial protocols. HER2 was scored 0 (absent) to 3 (maximum). Scores ≥2 were taken as positive if amplified on FISH testing. ER and PR scored positive if ≥5% of cells stained. 64.2% patients were ER positive, 43.3% were HER2 positive and 31.8% were high-grade lesions. 94 underwent mastectomy whilst 185 had BCS.

Results: There was an overall recurrence rate of 20.14% after a median follow-up period of 74 months (range 12–240). Of these recurrences, 36.4% were invasive. Conservation surgery (BCS) was used in 185 women who suffered 47 recurrences. Molecular phenotype predicted local recurrence by Log Rank analysis (P < 0.01) and invasive recurrences (P < 0.016) overall and in the BCS group remained predictive of invasive recurrence (p <0.005) and overall recurrence (p < 0.001).

ER negative DCIS had higher invasive recurrence (p < 0.01: Chi-squared). Grade 3 was a weak predictor of overall (p < 0.02) but not invasive recurrence. HER2 positive DCIS had poorer cumulative 5-year disease-free survival than HER2 negative cases (p = <0.001, Kaplan-Meier), irrespective of ER status. On multivariate COX regression analysis, HER2 positivity was an independent predictor of increased recurrence risk (p = 0.01) H.R. 7.39, 95% CI 1.61–33.8)

Discussion: Determination of molecular phenotypes of DCIS aids identification of women at high-risk of recurrence. ER-HER2+ patients need maximal adjuvant treatment to avoid invasive recurrence whereas lower-risk ER+HER2− patients might avoid adjuvant radiotherapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD04-06.
Abstract PD05-09: Whole-genome progression of breast cancer from early neoplasia to invasive carcinoma
Authors: West RB , Kashef-Haghighi D , Newburger D , Weng Z , Brunner A , Salari R , Guo X , Troxell M , Zhu S , Varma S , Sidow A , Batzoglou S
Published: August 2014

Cancer evolution involves cycles of genomic damage, epigenetic deregulation, and increased cellular proliferation that eventually culminate in the carcinoma phenotype. Early breast neoplasias include usual ductal hyperplasia, columnar cell lesions, and flat epithelial atypia and some are thought to represent precursor stages. To elucidate their role in cancer evolution we performed comparative whole genome sequencing of early neoplasias, matched normal tissue, and carcinomas from six patients. The identified somatic mutations served as lineage markers to build trees that relate the tissue samples. On the basis of the lineage trees we inferred the order, timing, and rates of mutational events. We find that in a subset of cases, the last common ancestor of an early neoplasm and a carcinoma was hypermutated and had several aneuploidies, and that evolution further accelerated in the carcinoma lineage. In contrast to highly advanced tumors that are the focus of much of current cancer genome sequencing, the early neoplasia genomes, and the carcinomas as well, harbor a striking paucity of potentially functional somatic point mutations. The earliest significant events we could detect, those changes that occurred in common ancestors of neoplastic and tumor cells, are aneuploidies. Several aneuploidies are recurrent, suggesting that they are among the earliest genomic events that predispose breast tissue to eventual development of invasive carcinoma.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD05-09.
Abstract PD07-06: NEO-ZOTAC: Toxicity data of a phase III randomized trial with NEOadjuvant chemotherapy (TAC) with or without ZOledronic acid (ZA) for patients with HER2-negative large resectable or locally advanced breast cancer (BC)
Authors: van de Ven S , Liefers G-j , Putter H , van Warmerdam LJ , Kessels LW , Dercksen W , Pepels MJ , Maartense E , van Laarhoven HWM , Vriens B , Smit VTHBM , Wasser MNJM , Meershoek-Klein Kranenbarg EM , van Leeuwen-Stok E , van de Velde CJH , Nortier JWR , Kroep JR
Published: August 2014

Background: The role of bisphosphonates (BP) when added to the (neo)adjuvant treatment of BC in enhancing the efficacy of therapy is still unknown. NEOZOTAC investigates the efficacy of ZA added to neoadjuvant chemotherapy in patients with HER2-negative BC.

Trial design: NEOZOTAC is a Dutch multicenter study. Patients are 1:1 randomized to 3-weekly TAC (docetaxel 75mg/m2, adriamycin 50 mg/m2 and cyclophosphamide 500 mg/m2 i.v., day 1) chemotherapy supported by pegfilgrastim (6 mg sc), day 2 with or without ZA (4 mg i.v. within 24 hr after chemotherapy) q3 weeks.

Eligibility criteria: Main inclusion criteria: stage II or III, measurable, HER2-negative BC, age ≥18 years, WHO 0–2, adequate bone marrow-, renal-, and liver function, absence of prior BP usage and absence of active dental problems.

Study endpoint: The primary endpoint is the pathologic complete response (pCR) rate. Secondary endpoints are toxicity, clinical response, tumor heterogeneity in core biopsy vs. operation specimen, and (disease free) survival. Optional side studies include fluorescent imaging (SoftScan®), changes in bone markers, single nucleotide polymorphisms and the insulin-like growth factor pathway, circulating tumor and endothelial cells and the false-negative rate of the sentinel node biopsy after neoadjuvant chemotherapy.

Statistical Methods: Using a 5% significance level based on the two-sided Fishers exact test with a power of 80%, 250 patients (125/arm) are needed to show an improvement of the pCR-rate from 17% to 34% in the experimental arm. Randomization was done according to the Pococks minimisation technique stratified by cT, cN, and estrogen receptor status. Toxicity is analyzed using the Exact (2-sided) Chi-Square test.

Results: From July 2010 to April 2012, 250 patients from 25 participating sites were randomized. Toxicity data of 173 patients are currently available and data of all 250 patients will be presented at SABCS. Patient characteristics are presented in table 1.

Hematological and non-hematological toxicities were not significantly different between both treatment arms. Main grade 3/4 NCI-CTCv4 toxicities were neutropenia (8%), followed by febrile neutropenia (7%), fatigue (6%), diarrhea, hypertension, nausea (3%) and vomiting (1.2%). Bone pain, myalgia, and hypocalcemia occurred in one patient in the TAC-ZA arm (0.6%). Osteonecrosis of the jaw was not observed.

Conclusions: Neoadjuvant TAC supported by pegfilgrastim plus ZA is feasible. No significant difference in toxicity are reported compared with the control arm.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD07-06.
Abstract PD10-05: HLA-DQA1*02:01/DRB1*07:01 as a biomarker for lapatinib-induced hepatotoxicity: prospective confirmation in a large randomised clinical trial (TEACH, EGF105485)
Authors: Spraggs CF , Schaid DJ , Parham LR , McDonnell SK , Briley LP , King KS , Rappold E , Goss PE
Published: August 2014

Hepatotoxicity is associated with small molecule tyrosine kinase inhibitors (TKI) in use for the treatment of a variety of cancers. Retrospective studies have identified and confirmed that specific Class II Human Leukocyte Antigen (HLA) alleles are strongly associated with ALT elevation in women treated with the TKI lapatinib for breast cancer. This study aimed to further evaluate and validate the role of the specified HLA alleles as predictors of elevated ALT in a pre-defined analysis of a large, randomized, double-blind, placebo-controlled study of lapatinib monotherapy in early stage HER2 positive breast cancer, the TEACH study (Tykerb Evaluation After Chemotherapy, EGF105485).

This prospectively defined pharmacogenetic study compared the frequency of hepatobiliary adverse events between pre-specified Major Histocompatibility Complex (MHC) genetic variants, including the HLA alleles DQA1*02:01 and DRB1*07:01. The primary focus was on elevated ALT, as well as rare cases of concurrent ALT (>3x ULN) and bilirubin (>2x ULN) elevation, which represent possible Hy's Law cases and a high risk of acute liver failure, among 1194 patients randomized to lapatinib treatment from whom pharmacogenetic data was available.

This study prospectively validated prior reports of the association of the specified MHC variants with elevated ALT among women treated with lapatinib. The strongest effects were observed for carriers of the HLA alleles DQA1*02:01 and DRB1*07:01, with odds ratios of 20 (95% CI: 8–40) between cases (n = 34) and controls (n = 807–808). These two HLA alleles are highly correlated, inherited together in most individuals and are consistent with a single genetic association. The overall risk of patients having an ALT (>3xULN) elevation was 3.0% and 0.7% during treatment with lapatinib and placebo respectively. Carriers of either HLA allele had a 12% chance (positive predictive value) of having an elevated ALT (>3xULN), in contrast to a 0.9% risk (negative predictive value, 99.1%) for non-carriers of the specified HLA alleles. These associations were maintained for higher ALT elevation thresholds and for cases of concurrent ALT and TBL elevation, consistent with possible Hy's Law cases. These results strongly support the role of Class II HLA-modulated immune mechanisms in lapatinib-induced hepatotoxicity.

Our results validate the large strength of association of the HLA alleles DRB1*07:01 and DQA1*02:01 with hepatotoxicity and provide the possibility of managing the risk of hepatotoxicity in women receiving lapatinib for early or late stage HER2 positive breast cancer. This association with immune mechanisms may have implications for toxicities with other TKIs in current use in cancer patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD10-05.
Abstract PL-1: Hormones and the Breast: Local and Environmental Interactions
Authors: Brisken C , Rajaram R , Ayyannan A , Beleut M , Yalcin O
Published: August 2014

A woman's reproductive history affects her risk to get breast cancer. In particular, the number of menstrual cycles she experiences correlates with risk. We use tissue recombination experiments and different mouse mutant models to discern the roles of the ovarian hormones estrogens and progesterone act in the mammary gland. While estrogens drive pubertal development, progesterone is the major driver of proliferation in the adult mammary epithelium. Both steroids rely strongly on paracrine signaling to elicit cell proliferation and other biological effects.

Perinatal exposure to environmentally relevant concentrations of a high production volume chemical, bisphenol A, that is detected in human due to exposure through consumer products, results in persistent changes in the mammary gland. The cell number is increased in in adult females as is the response to progesterone.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PL-1.
Abstract S1-2: ATLAS – 10 v 5 years of adjuvant tamoxifen (TAM) in ER+ disease: Effects on outcome in the first and in the second decade after diagnosis
Authors: Davies C , Pan H , Godwin J , Gray R , Peto R ,   ATLAS Collaborators Worldwide
Published: August 2014

Background: In ER+ early breast cancer, 5 years of tamoxifen greatly reduces recurrence throughout the first decade (years 0–9) with little further gain later, and reduces breast cancer mortality (BCM) substantially throughout years 0–14 (EBCTCG, Lancet 2011; 378: 771–84 – see Table). It is not known how 10 years TAM compares with the current standard of just 5 years TAM.

Methods: In 1996–2005 the international ATLAS trial randomized 6846 women with ER+ disease who had had ∼5 years of adjuvant TAM to continue another 5 years (to year 10) or stop at year 5 (control). Annual follow-ups recorded compliance, hospital admissions, breast cancer recurrence (including new contralateral), any other new primary cancer and cause of death.

Results: Compliance was ∼80%, as after 2 years 84% of those allocated continue and 4% of those allocated stop were still taking endocrine treatment (>99% TAM). With mean 7.1 woman-years follow-up (30,000 w-y in years 5–9, 16,000 in years 10–14, 2000 later), 1328 recurrences were reported (900 in years 5–9, 379 in years 10–14). Recurrence was significantly lower with10 than 5 years TAM (Table: logrank 2p = 0.002, rate ratio (RR)=0.90 se 0.06 in years 5–9 and 0.75 se 0.08 in years 10+). So were both BCM (2p = 0.01, RR = 0.97 se 0.10 in years 5–9 and 0.71 se 0.09 in years 10+) and all-cause mortality (2p = 0.01, with no increase in non-BCM). Proportional risk reductions were homogeneous by country, age and stage. Kaplan-Meier risks in years 5–14 (K-M) were: recurrence 21.4 vs 25.1%, BCM 12.2 vs 15.0%. Uterine cancer K-Ms in those randomized at age 50+ were: incidence 2.6 vs 1.6% (2p = 0.08), mortality 0.2 vs 0.2%. In pre-menopausal women (where AIs are not an alternative to TAM) there was no apparent excess of uterine cancer.

Discussion: Compared with just 5 years TAM, continuing TAM to year 10 safely protects further against recurrence and, particularly during the second decade, BCM. Combining results from ATLAS and the EBCTCG meta-analyses of 5 years TAM vs none (both had ∼80% compliance), in a hypothetical trial of 10 vs 0 years TAM with ∼80% compliance, 15-year BCM would be reduced by at least one-third. Hence, full compliance with 10 years TAM would yield even greater benefit (Table). Further follow-up of ATLAS will assess more reliably the apparently substantial mortality reduction in the second decade after diagnosis.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S1-2.
Abstract S1-6: Results of a randomized phase 2 study of PD 0332991, a cyclin-dependent kinase (CDK) 4/6 inhibitor, in combination with letrozole vs letrozole alone for first-line treatment of ER+/HER2− advanced breast cancer (BC)
Authors: Finn RS , Crown JP , Lang I , Boer K , Bondarenko IM , Kulyk SO , Ettl J , Patel R , Pinter T , Schmidt M , Shparyk Y , Thummala AR , Voytko NL , Breazna A , Kim ST , Randolph S , Slamon DJ
Published: August 2014

Background: PD 0332991, a selective inhibitor of CDK 4/6, prevents cellular DNA synthesis by blocking cell cycle progression. Preclinical studies in a BC cell line panel identified the luminal ER subtype, elevated expression of cyclin D1 and Rb protein, and reduced p16 expression as being associated with sensitivity to PD 0332991 (Finn et al. 2009). Synergistic activity was also observed in vitro when combined with tamoxifen. After determination of the recommended phase 2 dose in combination with letrozole (letrozole 2.5 mg QD plus PD 0332991 125 mg QD on Schedule 3/1), a randomized phase 2 study comparing letrozole alone (L) to letrozole plus PD 0332991 (L+P) was initiated.

Methods: The phase 2 portion of the study was designed as a two-part study; Part 1 enrolled post- menopausal women with ER+/HER2− advanced BC; Part 2 in addition to ER+/HER2− as eligibility criteria, screened for CCND1 amplification and/or loss of p16 by FISH. The primary endpoint is progression-free survival (PFS); secondary endpoints include response rate, overall survival, safety, and correlative biomarker studies. In both parts, post-menopausal women with ER+/HER2− advanced BC were randomized 1:1 to receive letrozole either with or without PD 0332991. Pts continue on assigned study treatment until disease progression, unacceptable toxicity, or consent withdrawal, and are followed for tumor assessments every 2 months.

Results: 66 pts were randomized in Part 1 and 99 pts in Part 2. Preliminary results from Part 1 of this study have been previously reported (IMPAKT Breast Cancer Conference, Abstract #292, Finn et al. May 2012) demonstrating a significant improvement in median PFS in the L+P vs. L arm (HR = 0.35; 95% CI, 0.17 to 0.72; p = 0.006). With the additional 99 pts randomized in Part 2 (N = 165), the statistically significant improvement in median PFS (26.2 vs. 7.5 months, respectively) continues to be observed with a HR=0.32 (95% CI, 0.19 to 0.56) with p <0.001. The response rate for the L+P arm (n = 84) was 31% vs. 26% for the L arm (n = 81) and the clinical benefit rate was 68% vs. 44%, respectively. The most commonly reported treatment-related AEs in the combination arm were neutropenia, leukopenia, anemia, and fatigue. The updated results from the combined Part 1 and Part 2 group will be presented in December 2012.

Conclusions: The combination of PD 0332991 and letrozole is well tolerated and shows encouraging clinical benefit, confirming the sensitivity of ER+ BC to PD 0332991 observed in preclinical models. A phase 3 trial in this setting will commence in 2013.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S1-6.
Abstract S3-2: Chemotherapy prolongs survival for isolated local or regional recurrence of breast cancer: The CALOR trial (Chemotherapy as Adjuvant for Locally Recurrent breast cancer; IBCSG 27-02, NSABP B-37, BIG 1-02)
Authors: Aebi S , Gelber S , Láng I , Anderson SJ , Robidoux A , Martín M , Nortier JWR , Mamounas EP , Geyer CE , Maibach R , Gelber RD , Wolmark N , Wapnir I
Published: August 2014

Introduction Patients with isolated local and regional recurrences (ILRR) of breast cancer (BC) have a high risk of developing distant metastasis and dying from BC. We investigated the impact of chemotherapy (C) on disease-free survival (DFS) and overall survival (OS) after ILRR.

Methods Patients with resected ILRR were stratified according to prior chemotherapy (yes vs. no), ER and/or PgR status of the recurrent tumor (both negative vs. either positive), and location of recurrence (breast vs. scar/chest wall vs. lymph nodes). Radiation, hormone and HER2 directed therapies were delineated in the protocol. Participants were randomly assigned to receive C or none. Multidrug C for at least 4 courses was recommended. Drug selection was at the discretion of the investigator. Slow accrual led to premature closure of the trial before achieving the planned sample size of 265.

Results The trial accrued 162 patients (C, 85; control, 77) from 2002–2010. The groups were balanced in regard to the characteristics listed in the table below.

At a median follow up of 4.9 years, there were 24 (28%) DFS events and 9 (11%) deaths in the C group compared with 34 (44%) DFS events and 21 (27%) deaths in the control group, corresponding to a 5-year DFS of 69% vs. 57%, [DFS HR (C/control) = 0.59, 95% CI (0.35, 0.99)], p =0.046] and a 5-year OS of 88% vs. 76%, [OS HR (C/control) = 0.41, 95% CI (0.19, 0.89)], p =0.02]. The results remained significant for both DFS and OS in multivariable Cox proportional hazards modeling controlling for ILRR location, disease-free interval, ER status and prior adjuvant chemotherapy. Adjuvant C was particularly effective for women with ER-negative ILRR: 5-year DFS 67% vs. 35%, [DFS HR (C/control) = 0.32, 95% CI (0.14, 0.73)], p =0.007] and OS 79% vs. 69%, [OS HR (C/control) = 0.43, 95% CI (0.15, 1.24)], p =0.12]. Results for the ER-positive ILRR cohort were: 5-year DFS 70% vs. 69%, [DFS HR (C/control) = 0.94, 95% CI (0.47, 1.89)], p =0.87] and OS 94% vs. 80%, [OS HR (C/control) = 0.40, 95% CI (0.12, 1.28)], p =0.12].

Conclusion Adjuvant chemotherapy should be recommended for patients with completely resected isolated loco-regional recurrences of breast cancer, in particular, if the recurrence is not sensitive to endocrine therapy.

Funding NCI PHS grants U10-CA-37377, -69974, -12027, -69651, CA-75362.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S3-2.
Abstract S5-4: EGFR expression measured by quantitative immunofluorescense is associated with decreased benefit from trastuzumab in the adjuvant setting in the NCCTG (Alliance) N9831 trial.
Authors: Rimm D , Ballman KV , Cheng H , Vassilakopoulou M , Chen B , Gralow J , Hudis C , Davidson NE , Psyrri A , Fountzilas G , Perez EA
Published: August 2014

Background: Epidermal Growth Factor Receptor (EGFR, HER1) is known to heterodimerize with HER2 and may impact the effectiveness of trastuzumab. Historically, EGFR has been difficult to measure; thus there is no evidence regarding its effects on trastuzumab clinical therapy. Here we use a new, standardized, quantitative immunofluorescence assay and a novel EGFR antibody to evaluate the correlation between EGFR expression and clinical outcome in a cohort from the North Central Cancer Treatment Group (NCCTG, Alliance) N9831 trial.

Methods: Of the 3505 women in the N9831 trial, tissue microarrays were constructed that allowed analysis of 1,444 patients randomly assigned to receive chemotherapy alone (Arm A), sequential trastuzumab after chemotherapy (Arm B) or concurrent trastuzumab with chemotherapy (Arm C). Fluorescence-based, standardized measurement of EGFR was done using the rabbit monoclonal EGFR antibody D38B1 on the AQUA platform (HistoRx). EGFR expression levels were analyzed as a continuous variable and dichotomized using recursive partitioning to define an optimal cut point. The cut point was validated on an independent retrospective cohort comprised of 130 patients with HER2-positive metastatic breast cancer who received trastuzumab.

Results: EGFR assessed as a continuous variable shows an association with disease free survival (DFS) in Arm C (p = 0.002) but not in Arms A or B. Dichotomizing EGFR expression shows that high level expression is associated with worse outcome (HR = 2.2; 95% CI 1.33–3.59, p = 0.002) in arm C. Five year DFS within the low level EGFR expression group was 71%, 74% and 90% for Arms A, B and C, respectively (log-rank p-value=0.02) and within the high level EGFR expression (n = 213) group was 62%, 76% and 74% respectively (log-rank p-value 0.22). As validation, the same cut-point was used to define high EGFR expression in a retrospective metastatic breast cancer cohort. The median progression free survival difference between EGFR high group and EGFR low group was 6.1 months (p = 0.0063) and the hazard ratio of high EGFR was 1.92 (p = 0.0073).

Conclusions: High expression of EGFR by the AQUA platform appears to be associated with decreased benefit from adjuvant concurrent (not sequential) trastuzumab and shorter PFS in the metastatic setting. The biological underpinning for these observations is being considered. Since there are other treatment options for HER2-driven tumors, this marker, once validated, could help select patients for alternative or additive therapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S5-4.
Abstract S5-6: Activating HER2 mutations in HER2 gene amplification negative breast cancers.
Authors: Bose R , Kavuri SM , Searleman AC , Shen W , Shen D , Koboldt DC , Monsey J , Li S , Ding L , Mardis ER , Ellis MJ
Published: August 2014

Background: Breast cancer genome sequencing projects, performed by the genome sequencing centers in the U.S., Canada, and the U.K., are elucidating the somatic mutations and other genomic alterations that occur in human breast cancer. These studies recently identified somatic HER2 mutations in breast cancers lacking HER2 gene amplification.

Results: Compilation of data from seven sequencing studies documented 22 patients with somatic HER2 mutations. These mutations clustered in three regions. The first cluster was at amino acid (aa) 309–310 (exon 8), located in the extracellular domain. These aa residues form part of the HER2 dimerization interface. The second cluster was at aa 755–781, located in the kinase domain (exons 19–20). This was the most common location for HER2 mutations, with 17 out of 22 patients having somatic mutations here. The third region was at aa 835–896, also in the kinase domain (exons 21–22). Using multiple experimental approaches (cell line experiments, in vitro kinase assays, protein structure modeling, and xenograft experiments), we tested seven of these HER2 mutations and showed that 4 of them are activating mutations that are sensitive to lapatinib and trastuzumab. Another 2 mutations were found to be lapatinib resistant and we determined their sensitivity to neratinib, canertinib, and gefitinib.

Conclusions: These findings biologically validate somatic HER2 mutations as good targets for breast cancer treatment, but the appropriate choice of targeted drug is dependent on the precise mutation present. This study is among the first to functionally characterize mutations identified by breast cancer genome sequencing. A prospective, multi-institutional clinical trial has been launched to screen for HER2 mutation positive patients and determine the clinical outcome of treatment with HER2 targeted drugs.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S5-6.
Abstract S6-5: Primary results of BEATRICE, a randomized phase III trial evaluating adjuvant bevacizumab-containing therapy in triple-negative breast cancer
Authors: Cameron D , Brown J , Dent R , Jackisch C , Mackey J , Pivot X , Steger G , Suter T , Toi M , Parmar M , Bubuteishvili-Pacaud L , Henschel V , Laeufle R , Bell R
Published: August 2014

Background: Bevacizumab (BEV), an anti-VEGF antibody, significantly enhanced progression-free survival in metastatic breast cancer (BC) (E2100, AVADO, RIBBON-1, RIBBON-2) and pathologic complete response rates in the neoadjuvant setting (GeparQuinto, NSABP B-40) when combined with chemotherapy (CT). The dependence of micro-metastases on angiogenesis [Holmgren 1995] suggests that patients might benefit from anti-angiogenic strategies applied in the adjuvant setting. The BEATRICE trial was designed to test this hypothesis in patients with triple-negative BC, who have a poor prognosis and lack targeted options for treatment.

Methods: In this open-label randomized multinational phase III trial, patients with centrally confirmed triple-negative operable primary invasive BC (pT1a-pT3) were randomized 1:1 after definitive surgery to receive ≥4 cycles of either CT alone or the same CT + 1 year of BEV 5 mg/kg/wk equivalent. CT was anthracycline [anth] and/or taxane-based. Patients were stratified by nodal status (0 vs 1–3 vs ≥4 involved nodes), CT backbone (anth vs anth + taxane vs taxane), hormone receptor status (negative vs low), and surgery (breast-conserving vs mastectomy). The primary objective is to compare invasive disease-free survival (IDFS) [Hudis 2007] with adjuvant CT ± 1 year of BEV. Secondary outcome measures are overall survival (OS), breast cancer-free interval, disease-free survival (DFS), distant DFS, and safety (NCI CTCAE v3.0). The sample size was calculated to provide 80% power for a HR=0.75 at α=0.05 assuming 5-year IDFS of 72.0% with CT vs 78.2% with CT + BEV with 388 events. BEATRICE also includes evaluation of potential predictive and prognostic biomarkers.

Results: Between Dec 2007 and Mar 2010, 2591 patients were randomized. At data cut-off (Feb 29, 2012), median follow-up was 32 months.

The mean CT exposure was balanced between treatment arms. Median BEV duration was 11.7 months. BEV was associated with an increased incidence of grade ≥3 congestive heart failure/left ventricular dysfunction (3% vs <1% with CT), grade ≥3 hypertension (12% vs <1%), and treatment discontinuation (BEV and/or CT: 20% vs 2%) but no increase in the risk of fatal adverse events (0.3% vs 0.2%). No new safety signals were observed.

Conclusion: There was no statistically significant improvement in IDFS with the addition of 1 year's BEV to adjuvant CT for triple-negative BC. Further follow-up is required to assess the impact of BEV on OS. The safety profile was consistent with previous reports in metastatic BC with a low incidence of fatal adverse events. Protocol-specified biomarker analyses are ongoing. Updated OS results are expected in 2013.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S6-5.
Abstract BS01-2: Moving breast cancer stem cell therapies to the clinic
Authors: Wicha MS
Published: August 2014

The realization that many cancers, including breast cancer, are driven by cells which display stem cell properties has significant clinical implications. Furthermore, the demonstrated role of these cells in mediating tumor metastasis and treatment resistance suggests the need to develop strategies to specifically target CSC populations. Cancer stem cell self-renewal and survival pathways represent potential therapeutic targets. These self-renewal pathways are regulated by an interacting network of cell intrinsic pathways, as well as extrinsic factors from the tumor microenvironment. These mircroenvironmental factors include cytokines such as IL-6, IL-8 and TGFb. CSCs maintain the plasticity to transition between epithelial-like MET and mesenchymal-like EMT states, a process regulated by the tumor microenvironment through microRNA circuits. We have demonstrated that previously identified cancer stem cell markers are cancer stem cell state specific. CD44+/CD24- CSCs represent mesenchymal-like stem cells capable of tissue invasion which are largely quiescent. In contrast, Aldehyde dehydrogenase expression identifies a more epithelial-like cancer stem cell state associated with self-renewal. Reversible EMT/MET transitions play a crucial role in mediating tumor metastasis.

Preclinical breast cancer models predict that the greatest efficacy of CSC targeting therapeutics will occur when they are used in the adjuvant setting, a concept supported by preclinical models and clinical trials. Tumor regression may reflect effects on bulk cell populations explaining the lack of correlation between tumor shrinkage and patient survival. In contrast, recurrence following adjuvant therapy may be mediated by CSCs, which possesses sufficient self-renewal to form clinically significant metastasies. The important role of HER2 signaling in regulating breast cancer stem cell self-renewal may account for the remarkable clinical efficacy of targeting HER2 in the adjuvant setting. Furthermore, the clinical benefit of such therapies in classically defined HER2-negative breast cancers may be due to selective expression of HER2 in CSCs in the absence of HER2 gene amplification. The clinical benefit of adjuvant trastuzumab in women whose breast cancers are currently classified as HER2-negative is currently being assessed in the randomized national clinical trial B47. These studies may demonstrate the need for reevaluating currently used clinical endpoints and clinical trial designs. Promising new technologies including the isolation and molecular characterization of circulating cancer stem cells may provide the opportunity for real time assessment of the efficacy of CSC targeting agents. A number of agents regulating BCSCs have entered early phase clinical trials which will determine whether effective targeting of CSCs improves patient outcome.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr BS01-2.
Abstract BS03-1: Tumor-derived exosomes promote pre-metastatic niche formation and organotropism
Authors: Lyden DC , Peinado-Selgas H , Nitadori A , Shen T-L , Aleckovic M , Kang Y , Bromberg J
Published: August 2014

Metastasis is the most deadly aspect of cancer due to a lack of appropriate therapies. Tumor-secreted factors have been recently recognized to be one of the main culprits for metastatic progression. Tumor-secreted factors such as VEGF-A, PlGF, TGFb, TNF-a, and LOX have been shown to play active roles in the recruitment of bone marrow (BM)-derived cells to the primary tumor microenvironment and pre-metastatic niches. We have found that tumor-derived exosomes are abundantly secreted into the circulation in highly metastatic murine models and in patients with stage IV metastatic disease. Tumor-derived exosomes induce vascular leakiness, and hypoxic and pro-inflammatory changes at pre-metastatic sites. Moreover, tumor-derived exosomes preferentially fuse and “educate” BM-derived progenitor cells to a pro-vasculogenic phenotype characterized by upregulation of Tie-2, VEGF-A, VEGFR2, TSP1 and ADAM10. We found that B16-F10 melanoma-derived exosomes help establish pre-metastatic niches, including the recruitment of “educated” BM cells, in specific organs destined to be involved in future metastasis whereas LLC lung cancer-derived exosomes predominant in the lung as the main organ of metastasis. These results suggest that tumor-derived exosomes may have a role in metastatic organotropism, whereby cancer metastasizes to specific organs, as proposed by Stephen Paget's ‘seed and soil’ hypothesis more than a 100 years ago. We believe that the identification of exosomes proteins, with their prognostic and therapeutic potential, may also partially explain the specific receptor-ligand binding of exosomes to a pre-metastatic niche defining an organotropic site for future metastasis.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr BS03-1.
Abstract ES05-2: Divergent trends in breast cancer subtypes, a manifestation of cancer heterogeneity
Authors: Anderson WF
Published: August 2014

Recent studies in the United States show an unexpected divergence of ER positive and ER negative breast cancer incidence rates (JNCI 103: 1397-1402, 2011). ER positive cancers have risen while ER negative cancers have declined over the long-term. Divergent ER-specific trends might reflect statistical anomalies, lower assay thresholds for classifying breast cancers as ER positive, and/or the implementation of widespread screening mammography with increased sensitivity for ER positive cancers. However, the analysis of secular trends in Denmark, where there was better control of these potentially confounding factors, showed similar trends as in the United States (IJC 133: 2201-2206, 2013). ER positive cancers had increased among middle-aged and older Danish women in earlier birth-cohorts (or generations), implying a confluence of risk factor exposures during the peri- and the post-menopausal time periods of a woman's lifetime. In contrast, ER negative cancers had decreased among younger women in more recent birth-cohorts during the premenopausal time periods.

Divergent ER-specific trends among different birth-cohorts in younger and older generations is consistent with breast cancer heterogeneity due to distinct etiologic pathways for ER positive and ER negative breast cancers, which could be due to trends in environmental and lifestyle risk factors with dual effects by ER expression. Two such possible risk factors are pregnancy (or parity) and obesity, which are decreasing and increasing, respectively, in both the United States and Denmark. For example, parity tends to reduce breast cancer risk for ER positive cancer and to increase risk for ER negative cancers. In fact, new breast cancer cases appear to be rising worldwide due to the consequences of changing reproductive, hormonal, and dietary risk factors. For this reason, it is plausible that the same risk factors or at the least risk factors acting through common mechanisms in the United States and Denmark may foreshadow a common pattern worldwide. This is good news since ER negative breast cancers are the most difficult to treat subtypes of breast cancer, especially the so-called triple negative cancers.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr ES05-2.
Abstract ES08-3: MR imaging for predicting response to neoadjuvant treatment
Authors: Hylton NM
Published: August 2014

Magnetic Resonance Imaging (MRI) of the breast is a sensitive and non-invasive method for assessing both tumor morphology and physiology. In comparison to mammography and ultrasound, MRI has particular advantages for demonstrating the anatomic extent of disease and it is effective for assessing the response of primary breast tumors to pre-operative (neoadjuvant) treatment. Dynamic contrast-enhanced (DCE)-MRI and diffusion-weighted MRI (DWI) are two approaches that provide quantitative in vivo information about the state of disease and have been used to measure breast tumor changes associated with treatment. These techniques add functional information about breast cancer by sensitizing the MRI signal to tumor vascularity, known to be associated with tumor grade and aggressiveness, and water diffusion, a property affected by cell density that can reflect tumor growth as well as cell death from cytotoxic treatment, respectively. MR spectroscopic imaging (MRSI) has also been applied in the breast to study tumor metabolism, although the low spatial resolution currently limits the utility of this technique. This talk will discuss the emerging applications of functional MRI techniques for assessing breast tumor response to treatment in the neoadjuvant setting. The various roles for use of quantitative imaging in assessing neoadjuvant treatment will be considered. Imaging criteria can be the basis for patient inclusion or continuation on therapy, and can also be used as a biomarker to quantify response. Depending on how well the efficacy of an imaging biomarker has been established, it can also serve as the endpoint for evaluating the benefit of treatment, or as a surrogate endpoint for other clinically meaningful outcomes. A promising but more speculative role for imaging biomarkers is for prediction of therapeutic response. Current findings will be presented from the I-SPY (ACRIN 6657/CALGB 150007) trial, a multi-center study integrating biomarkers and imaging to maximize effectiveness of neoadjuvant treatment for patients with locally-advanced breast cancer. The experience implementing standardized MRI protocols in the multi-center setting will be discussed. This talk is intended for imaging scientists and clinical researchers involved in the diagnosis and treatment of breast cancer. It is expected that the audience will gain knowledge leading to the appropriate application of breast MRI techniques in the neoadjuvant treatment setting.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr ES08-3.
Abstract OT1-2-04: PAM50 HER2-enriched (HER2E) phenotype as a predictor of early-response to neoadjuvant lapatinib plus trastuzumab in stage I to IIIA HER2-positive breast cancer
Authors: Vidal M , de la Peña L , Oliveira M , Cortés J , Llombart A , Prat A
Published: August 2014

Background: The efficacy of trastuzumab in different regimens and settings has been well established, including its benefit as neoadjuvant therapy for early HER2-positive disease. Combinations of two different anti-HER2 therapies without chemotherapy have generated great expectations. However, it is unclear which group of patients benefits the most from this strategy. Within HER2-positive breast cancer, the PAM50 assay identifies a HER2-Enriched (HER2-E) intrinsic subtype characterized by high activation of the EGFR/HER2 pathway and low expression of luminal-related genes, and therefore should obtain the greatest benefit from anti-HER2 therapy.

Trial Design: This non-randomized, open-label, multicentric phase II translational research study will evaluate the ability of the PAM50 HER2-E subtype to predict pathological complete response (pCR) to dual HER2 blockade with lapatinib and trastuzumab for a total of 18 weeks. Patients with hormone receptor (HR)-positive disease will also receive endocrine therapy (letrozol or tamoxifen).

Eligibility Criteria: Untreated, histologically confirmed invasive breast carcinoma eligible for definitive surgery (stage I-IIIA), HER2-positive invasive breast cancer by central assessment, premenopausal or postmenopausal, ECOG performance status of 0 or 1, adequate organ function and baseline LVEF >50% measured by echocardiography or MUGA scan.

Specific Aims: The primary objective is to evaluate the ability of the PAM50 assay to predict pCR in the breast at the time of surgery. Secondary objectives are to (1) assess the correlation of HER2-E with pCR in the breast and axilla, (2) assess the correlation of HER2-E with Residual Cancer Burden (RCB) (3) evaluate the gene expression changes from Day 0 to Day 14 and the correlations with Ki67-IHC at Day 14, (4), identify additional gene expression signatures predictive of pCR, and (5) evaluate safety and tolerability.

Statistical Methods: The statistical plan is based on the assumption that breast pCR rate will be 35.0% for HER2-E tumors and 8.0% for non-HER2E. The study will have a 95% power with a significance level of 5% (two-sided) and an assumed drop-out rate of 15%. Biomarker Analyses: Baseline, 14-day treated and post-treatment (surgical) formalin–fixed, paraffin–embedded tissues will be obtained. The expression of 547 genes will be explored with the nCounter platform. Subtype will be identified using the PAM50 predictor (Parker et al. J Clin Oncol 2009). Ki-67-IHC will also be evaluated on pre-treatment and Day-14 samples.

Target Accrual: 150 patients with a maximum of 75 HR-positive patients across Spain and Portugal. Patient enrollment will begin in July 2013.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-2-04.
Abstract OT2-4-02: Young and strong: A randomized trial to evaluate a program for young women with breast cancer
Authors: Partridge AH , Ruddy KJ , Barry WT , Greaney M , Sprunck-Harrild K , Meyer ME , Baker EL , Ligibel J , Emmons KM
Published: August 2014

Young women with newly diagnosed breast cancer face substantial challenges including higher risk of disease recurrence and likelihood of harboring a genetic mutation compared with older women. Many young women are also very concerned about their future fertility and this population often feels isolated from other breast cancer survivors due to their age and life stage. Some worry that their doctors are unsure of how to treat them. To address these issues, we developed a comprehensive program at our institution to coordinate and enhance the care, support, and education for young women with breast cancer. The Young and Strong study is a randomized clinical trial (RCT) to evaluate a virtual, exportable, scalable version of this program designed to improve the quality of care and the psychosocial well-being of this vulnerable population.

The specific aims of this program are:

1) To develop, pilot, and refine an exportable and sustainable educational and support intervention for young women with breast cancer and their oncology providers (Young Women's Intervention; YWI).

2) To determine the effect of the YWI compared to a contact-time control intervention focused on promoting physical activity (Physical Activity Intervention; PAI) on attention to fertility issues in a RCT: “Young and Strong”.

We initially conducted 4 focus groups (n = 36) and 20 key informant interviews, and developed, piloted, and refined the YWI as well as the PAI. Based on this successful work, we launched the Young and Strong study in June 2012 as a cluster-randomized trial at a total of 54 sites (40 community and 14 academic sites across the United States). Randomization is 1:1 between sites, and stratified by practice type (community vs. academic). Each community site will enroll 5-10 participants, each academic site 15 participants. Total recruitment will be 410-610 pts. The primary objective is to evaluate whether YWI, as compared to PAI, is associated with greater attention to fertility issues, assessed via medical record review. In addition, participants will complete assessments at baseline, 3, 6, and 12 months that assess satisfaction with care, psychosocial well-being, physical activity and anthropomorphic changes.

Young and Strong activated in June 2012 and all sites have been identified. As of 6/11/2013 the study has been initiated at 53 out of 54 sites, and total of 282 women have enrolled on the study.

Eligibility Criteria:

1. Women age 18-45 years at diagnosis

2. Stage I-III invasive breast cancer without known recurrence or metastatic disease

3. Newly-diagnosed (within 3 months of initial diagnosis)

4. Have 1st appt. with a medical oncologist at participating site after the site opens to enrollment

5. Able to read and write in English

For further information, contact Ann Partridge, MD, MPH at 888-814-3324.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-4-02.