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PURPOSE: Patients with triple negative breast cancer (TNBC) who do not achieve pathological complete response (pCR) following neoadjuvant chemotherapy have a high risk of recurrence and death. Molecular characterization may identify patients unlikely to achieve pCR. This neoadjuvant trial was conducted to determine the pCR rate with docetaxel and carboplatin, and to identify molecular alterations and/or immune gene signatures predicting pCR. EXPERIMENTAL DESIGN: Patients with clinical stages II/III TNBC received 6 cycles of docetaxel and carboplatin. The primary objective was to determine if neoadjuvant docetaxel and carboplatin would increase the pCR rate in TNBC compared to historical expectations. We performed whole exome sequencing (WES) and immune profiling on pre-treatment tumor samples to identify alterations that may predict pCR. Thirteen matching on-treatment samples were also analyzed to assess changes in molecular profiles. RESULTS: Fifty-eight of 127 (45.7%) patients achieved pCR. There was a non-significant trend towards higher mutation burden for patients with residual cancer burden (RCB) 0/I versus RCB II/III (median 80, versus 68 variants, p 0.88). TP53 was the most frequently mutated gene, observed in 85.7% of tumors. EGFR, RB1, RAD51AP2, SDK2, L1CAM, KPRP, PCDHA1, CACNA1S, CFAP58, COL22A1, and COL4A5 mutations were observed almost exclusively in pre-treatment samples from patients who achieved pCR. Seven mutations in PCDHA1 were observed in pre-treatment samples from patients who did not achieve pCR. Several immune gene signatures including IDO1, PD-L1, interferon gamma signaling, CTLA4, cytotoxicity, tumor inflammation signature, inflammatory chemokines, cytotoxic cells, lymphoid, PD-L2, exhausted CD8, Tregs, and immunoproteosome were upregulated in pre-treatment samples from patients who achieved pCR. CONCLUSIONS: Neoadjuvant docetaxel and carboplatin resulted in a pCR of 45.7%. WES and immune profiling differentiated patients with and without pCR. TRIAL REGISTRATION: Clinical trial information: NCT02124902, Registered 24 April 2014, & NCT02547987, Registered 10 September 2015.

Background: Cyclin-dependent kinases 4 and 6 inhibitors (CDK4/6i) are now standard of care (SOC) for pts with HR+/HER2- MBC. However, aside from HR positivity, there are no biomarkers for pt selection. Although mutations (muts) in genes such as RB1, FAT1, or FGFR, are associated with CDK4/6i resistance, they are rare events in HR+/HER2- MBC. The goal of this study is to examine the ctDNA mut profile, and the impact of commonly mutated genes (ESR1, TP53 and PIK3CA) on progression free survival (PFS) in pts received pal as SOC in a real world experience. Methods: Chart review was performed for pts with HR+/HER2- MBC who received pal and ctDNA Guardant360® (G360) testing between 01/2015 and 06/2020 at Siteman Cancer Center. The Kaplan-Meier method was used to generate time-to-event curves with calculated mPFS. A stratified log-rank test was used for all comparisons with P-values reported. Hazard ratios (HRs) and associated 95% confidence intervals (CI) were calculated with a stratified Cox proportional-hazards model. Results: Among the 73 pts identified, median age was 61.5 years (range 33.7-83.3). 15 (20.5%) pts received pal as 1st-line, 22 (30.1%) pts as 2nd-line, and 36 (49.3%) pts as 3rd-line and beyond. All 73 pts had muts by G360. Top 3 mutated genes are PIK3CA (n=25, 34.2%), TP53 (n=20, 27.4%) and ESR1 (n=17, 23.3%), followed by GATA3 (n=12, 16.4%) and MYC (n=6, 8.2%). For association analysis with PFS, 17 pts were excluded from further analysis due to having had multiple interim therapies between G360 testing and pal therapy, leaving 56 pts who had G360 immediately prior to pal (n=11), during pal (n=13), at progressive disease (PD) on pal (n=20), or had 1 additional therapy after PD on pal (n=12). Among the 56 pts, the median age on pal was 62.8 years (36.6-78.4). Median duration on pal was 7.7 months (mo). Pal was received as 1st-line in 14 (25.0%), 2nd-line in 17 (30.4%) and 3rd-line plus in 25 (44.6%) pts. Muts in PIK3CA, TP53 and ESR1, were identified in 18 (32.1%), 16 (28.6%), and 13 (23.2%) pts, respectively, with rates similar to the entire 73-pt cohort. Among 13 ESR1 mutant pts, 7 had letrozole and 6 had fulvestrant as pal’s endocrine partner. Concurrent muts in 2 of 3 genes were observed in 11 (19.6%) pts (6 with PIK3CA and TP53, and 5 with ESR1 and TP53). The mPFS was 7.4 and 12.6 mo (p=0.03) in pts with or without PIK3CA mut, 7.9 and 12.8 mo (p=0.85) with or without ESR1 mut, and 16.0 and 13.3 mo (p=0.46), with or without TP53 mut, respectively. mPFS for pts with concurrent muts in 2 of the 3 genes was 7.4 mo, compared to 11.7 mo and 13.3 mo in pts with 1 or no mut in these 3 genes (p=0.46). In multivariate analysis that included age, visceral mets and line of therapy, the HRs for PFS were 10 muts, respectively. Conclusions: In this retrospective real world experience, ctDNA muts in PIK3CA and ESR1 as well as higher number of muts in ctDNA were associated with worse outcome in pts received pal. Although several studies have shown CDK4/6i benefit regardless of PIK3CA or ESR1 mut status, our data indicates that muts in these genes render worse prognosis on CDK4/6i and supports PIK3CA and ESR1 muts as driver events in HR+ MBC. PI3Ki or novel ER targeted agents are combined with CDK4/6i in clinical trials and results are eagerly awaited. In addition, further study for pts with higher ctDNA mut number is warranted. Multivariate Cox Proportional Hazards Regression Model on PFSVariablesPFSHR (95% CI)P-valueESR1 (non-mut vs. mut)0.64 (0.26-1.56)0.32TP53 (non-mut vs. mut)1.70 (0.80-3.60)0.16PIK3CA (non-mut vs. mut)0.42 (0.17-1.02)0.06Age (=65 yo)0.92 (0.45-1.87)0.81No. Lines of pal (1st- vs. 3rd-line)0.61 (0.25-1.48)0.28No. Lines of pal (2nd- vs. 3rd-line)0.46 (0.20-1.04)0.06No. of muts (1-5 vs. >10)0.74 (0.24-2.33)0.61No. of muts (6-10 vs. >10)0.64 (0.20-2.07)0.46Visceral mets (no vs. yes)1.25 (0.52-2.98)0.61 Citation Format: Jing Xi, Nusayba Bagegni, Foluso Ademuyiwa, Ashley Frith, Rama Suresh, Anna Roshal, Caron Rigden, Leonel Hernandez-Aya, Lindsay Peterson, Mateusz Opyrchal, Katherine Clifton, Katherine Weilbaecher, Ron Bose, Cynthia Ma. Circulating tumor DNA (ctDNA) mutation (mut) profile in relation to paboclicib (pal) efficacy in hormone receptor positive (HR+) and HER2 negative (HER2-) metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-18.

Background: With advances in next generation sequencing (NGS) and now approved targeted therapy in breast cancer, genomic testing to identify potentially actionable mutations has become a common practice in patients (pts) with advanced breast cancer using both ctDNA and traditional tissue-based assays. Less is known regarding physician practice patterns in obtaining NGS testing and the practical implications of testing in older adults with breast cancer.Methods: Pts with advanced breast cancer underwent molecular profiling using a plasma-based ctDNA NGS assay (Guardant360® or Tempus®) between 5/2015 and 5/2020 at Siteman Cancer Center. Pts with advanced breast cancer who underwent genomic profiling using a tissue-based NGS assay (Tempus®) between 12/2017 and 5/2020 at this institution were also included. Clinicopathological histories were obtained from the medical record. Correlations were examined using a Fisher’s exact test.Results: During 5/15-5/20, 244 pts underwent ctDNA testing and 147 pts had a tissue-based NGS assay performed. There was no significant difference between the number of pts ≥ 65 years-old who underwent ctDNA testing (n=78, 32.0%) and tissue testing (n=37, 25.2%). There was no statistically significant difference between date of metastatic diagnosis and date of NGS testing between the older and younger cohorts. In pts who underwent tissue-based NGS testing, there was no significant difference between site of tissue tested (distant recurrence vs local) in the older and younger cohorts. The most common clinical managements following both ctDNA and tissue-based testing are presented in Table 1. Out of the 391 pts who underwent testing, 27 pts had both ctDNA and tissue-based NGS performed. Pts ≥ 65 were less likely to have both assays performed (n=3, 11.1%; p Conclusion: Older adults, who are typically less likely to be included in clinical trials, may still benefit from NGS to reveal potentially targetable mutations. It is reassuring in our cohort that older adults had ctDNA and tissue-based NGS performed at similar rates as part of standard of care treatment. The clinical management following NGS testing was also not significantly different in the older adult cohort. Older adults were less likely to have both tissue and ctDNA testing performed however, given the high concordance rates between tests, this may be less clinically relevant. Table 1clinical management following NGS testing≥65 years-old Citation Format: Katherine K Clifton, Jingqin Luo, Yu Tao, Jennifer Saam, Thereasa Rich, Timothy Rearden, Anna Roshal, Ashley Frith, Caron Rigden, Foluso Ademuyiwa, Katherine Weilbaecher, Leonel Hernandez Aya, Lindsay Peterson, Nusayba Bagegni, Rama Suresh, Ron Bose, Tanya Wildes, Mateusz Opyrchal, Cynthia Ma. Next generation sequencing (NGS) in older adults with breast cancer using tissue-based and circulating tumor DNA (ctDNA) assays [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-09.

1089 Background: Although the noninvasive nature of ctDNA testing is attractive in an older adult population, less is known regarding the mutation profiles of ctDNA in the older adult breast cancer population as this population is often excluded from studies. Previous tissue testing has shown differences in mutation profiles between older and younger adults with breast cancer. The objective of this study is to assess differences in mutation profiles in the older and younger adult breast cancer population using a ctDNA assay. Methods: Patients (pts) with advanced breast cancer underwent molecular profiling using a plasma-based ctDNA NGS assay (Guardant360) between 5/2015-10/2019 at Siteman Cancer Center. Clinicopathological histories were obtained from the medical record. The results of a multicenter database of pts with advanced breast cancer who had undergone molecular profiling using Guardant360 were obtained. Associations between mutations and age were measured using a Fisher’s exact test. Results: In the single institution cohort, of the 214 patients who underwent testing, 148 (69.16%) were < 65 and 66 (30.84%) ≥ 65 years-old. The most frequently mutated genes in age < 65 pts were TP53 (48.65%), PIK3CA (35.81%), and ESR1 (30.41%) while the most frequently mutated genes in age≥65 pts were PIK3CA (56.06%), TP53 (51.52%), ESR1 (25.76%), and ATM (21.21%). ATM, BRAF and PIK3CA mutations were found more frequently in age≥ 65 pts with ER+ HER2- breast tumors (p < 0.01). MYC and ESR1 mutations were not significantly associated with age, overall or within subtype. Overall ctDNA resulted in change in management in 19.8% pts (40/202). In the larger multicenter cohort, of the 8803 pts who underwent testing, 5367 (61.0%) were < 65 and 3417 (38.8%) ≥ 65 years-old. ATM, ESR1 and PIK3CA mutations were more common in age≥65 pts (p < 0.0001) and MYC mutations were less common in age≥65 pts (p < 0.0001). Conclusions: This study found that ctDNA is a feasible, attractive alternative to traditional biopsies and may identify actionable mutations in older adults with breast cancer. When controlling for subtype, results from a single institution were similar to the larger multicenter cohort showing ATM and PIK3CA were more common in the older adult population. This data suggests there may be additional molecular differences between breast cancer in older compared to younger adults that warrants further investigation.

Introduction: Palbo is approved in combination with an aromatase inhibitor or fulvestrant (FUL) for the treatment of HR+ HER2- MBC. The incidence of grade (G) 3/4 neutropenia (ANC) approaching 66% has been observed in phase 3 trials of palbo. We hypothesize that an alternative schedule of palbo, 5 days on/2 days off every 7 days, reduces the severity of neutropenia, therefore allowing continued weekly dosing and less dose reduction and discontinuation. Methods: A single arm phase II study (Alt Dose Palbo) was conducted in patients (pts) with HR+ HER2- MBC who had ≤1 prior systemic therapy in the metastatic setting (NCT03007979). Pts were treated with palbo 125 mg daily on a 5 days on/2 days off every 7-day schedule, along with letrozole (LET) or FUL per treating physician. Goserelin was administered if premenopausal. The primary objective was to determine the rate of G3/4 ANC within the first 29 days of treatment. Secondary objectives included determining the rate of G3/4 ANC during all cycles, rate of palbo dose reduction/interruption/discontinuation, adverse event (AE) profile per CTCAE v5, progression free survival (PFS), objective response rate (ORR) and clinical benefit rate (CBR) by RECIST 1.1. The sample size of 47 was calculated to provide 90% power based on one-sample binomial exact test at a 5% alpha level to test the one-sided null hypothesis of G3/4 ANC rate >62% versus the alternative of Table 1C1 D1-29 AEG1G2G3TotalWBC decreased26%50%17%93%ANC decreased10%43%21%74%Anemia38%12%0%50%Fatigue29%0%0%29%Platelets decreased14%0%2%17%Nausea12%2%0%14%All cycle AEG1G2G3TotalWBC decreased19%50%26%95%ANC decreased5%40%36%81%Anemia50%21%2%74%Fatigue36%5%0%40%Nausea26%2%0%29%Platelets decreased24%0%2%26%Alopecia21%0%0%21%Mucositis19%0%0%19%Hot flashes17%2%0%19%Constipation14%0%0%14%Arthralgia12%2%0%14%AST elevated10%0%2%12%Anorexia12%0%0%12%ALT elevated7%0%5%12% Citation Format: Jairam Krishnamurthy, Jingqin Luo, Foluso Ademuyiwa, Rama Suresh, Caron Rigden, Timothy Reardon, Katherine Weilbaecher, Ashley Frith, Anna Roshal, Pavan Tandra, Mathew Cherian, Tracy Summa, Shana Thomas, Leonel Hernandez-Aya, Lindsay Peterson, Cynthia Ma. A phase II trial assessing the safety of an alternative dosing schedule of palbociclib (palbo) in hormone receptor positive (HR+), HER2 negative (HER2-) metastatic breast cancer (MBC): Alt Dose Palbo [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-19-13.

Half of hormone receptor-positive (HR+) breast cancer patients will develop joint pain, termed aromatase inhibitor-induced arthralgia (AIA), while taking aromatase inhibitor therapy. Though there is no universally accepted effective treatment for AIA, there has been some evidence to support high-dose vitamin D as a treatment. We randomized post-menopausal women who were beginning adjuvant AI therapy to receive standard-dose vitamin D3 (800 IU daily for 52 weeks), or high-dose vitamin D3 (50,000 IU weekly for 12 weeks, followed by 2000 IU daily for 40 weeks). The primary end point was development of AIA. The trial was designed to enroll 184 patients. This futility analysis was performed after 93 patients were enrolled. The high-dose vitamin D regimen was effective in raising serum vitamin D levels, but there was no significant difference in development of AIA between the two arms. In the high-dose arm, 25 patients (54%) developed AIA, compared to 27 patients (57%) in the standard-dose arm. The planned futility analysis was positive; thus, the study was terminated. Neither baseline vitamin D nor 12-week vitamin D level was predictive of AIA development. Although vitamin D levels were increased in the high-dose arm, there was no significant signal for benefit of high-dose vitamin D supplementation for AIA prevention in this unblinded trial. This study, along with several others, implies that vitamin D likely does not play a significant role in AIA for the majority of patients.

Objectives Macropinocytosis promotes internalization of albumin into cells to serve as a nutrient supply and is constitutively driven by signaling pathways frequently hyperactivated in head and neck squamous-cell carcinoma (HNSCC). In this way, drugs bound to albumin may selectively target HNSCC. nab-paclitaxel is a nanoparticle albumin-bound formulation of paclitaxel that improves drug delivery into tumor compared to paclitaxel. The primary aim of this single-arm, multicenter, phase 2 trial was to determine if nab-paclitaxel, cetuximab, and carboplatin (CACTUX regimen) would result in longer progression-free survival (PFS) than the historical regimen (EXTREME: 5-fluorouracil, cetuximab, and a platinum). Materials and methods Patients with untreated recurrent or metastatic HNSCC received six, three-week cycles of nab-paclitaxel, cetuximab, and carboplatin, followed by maintenance nab-paclitaxel and cetuximab until progression. We hypothesized the median PFS with CACTUX would be 35% longer than with EXTREME (corresponding to 7.6 vs 5.6 months; power 0.80, α = 0.05, one-sided test, n = 70). Secondary outcomes included objective response rate (ORR) and overall survival (OS). Results Seventy-four patients enrolled into the trial; seventy were evaluable. The median PFS was 6.1 months (95% CI, 4.1–7.4). The ORR was 60%. Median follow-up was 18 months (IQR: 4.7–23). The median OS was 17.8 months (95% CI, 8.5–21.7) for all patients, and 19.8 months (95% CI, 10.9–22.0) for human papillomavirus (HPV)-related oropharynx SCC and 14.0 months (95% CI, 4.6–23.3) for HPV-unrelated HNSCC. Conclusion Among patients with recurrent or metastatic HNSCC, CACTUX did not result in a longer PFS than historical EXTREME. However, CACTUX did result in a more favorable ORR and OS.

Background: The approved 3 weeks (wks) on/1 wk off schedule of PAL results in grade (G)3+ neutropenia (ANC) up to 66%. We hypothesized that an alternative schedule (Alt Dose Pal), 5 on/2 off every 7 days, reduces the rate of G3+ ANC, allowing continued weekly dosing. In addition, based on our previous study supporting sTK1, an E2F-dependent enzyme critical for DNA synthesis, as a pharmacodynamic indicator of CDK4/6 inhibition, we hypothesized that Alt Dose Pal inhibits sTK1 and sTK1 dynamics predicts PAL response. Methods: A single arm phase II trial was conducted in HR+ HER2- MBC, ≤1 prior endocrine therapy (ET) for MBC (NCT03007979). Pts received PAL 125 mg daily, 5 on/2 off weekly, plus letrozole (LET) or fulvestrant (FUL) per physician choice, on a 28-day cycle (C). Goserelin was added if premenopausal. Complete blood count and chemistry panel were done at baseline (BL), C1&2D15, and D1 of C2+. The primary objective was to determine the rate of G3+ ANC in C1 D1-D29. Secondary objectives were to assess the rate of all cycle G3+ ANC, PAL dose reduction/discontinuation, adverse events (AE) per CTCAE v5, progression free survival (PFS), objective response rate (ORR: CR+PR (complete and partial responses)) and clinical benefit rate (CBR: no progression (PD) in 24 wks) by RECIST 1.1. The sample size of 47 provides 90% power, 1-sample binomial exact test, 5% alpha, to test the 1-sided null hypothesis of G3+ ANC rate >62% vs the alternative of 10% or G3+. The ORR was 50% (2 CR, 13 PR, 95% CI: 33.15%-66.85%) in 30 pts with measurable disease (n=29) or non-measurable but CR (n=1). The CBR was 81.63% (95% CI: 67.5%-90.76%) in 40 (2CR, 13 PR, 25 SD ≥24 wks) of 49 evaluable pts. The median PFS (mPFS) was 24.3 mo (95% CI 15~not reached (NR)) overall. The mPFS was 33.5 mo (95% CI 17.3~NR) and 12 mo (95% CI: 10.4~NR), in ET sensitive and resistant population, respectively. sTK1 was significantly reduced, 80% down to undetectable, as early as C1D15 (p=7.77E-07). BL sTK1 levels correlated with PD vs non-PD (p=0.003) as best response and negatively correlated with PFS (p=0.002). sTK1 rose significantly at PD (p=0.0003). A median lead time of 80.6 (IQ range 6.8-189.2) days was observed for rising TK before RECIST PD. Conclusion: The Alt Dose Pal trial met its primary endpoint with reduced G3+ ANC. The efficacy data is comparable to prior reports. sTK1 shows promise for PAL response prediction and monitoring. Table 1 AEAEG1G2G3G4TotalC1 D1-29 (n=47)Leukopenia13 (27.6%)22 (46.8%)7 (14.9%)042 (89%)Neutropenia6 (12.8%)18 (38.3%)10 (21.3%)034 (72%)Anemia18 (38.3%)5 (10.6%)0023 (49%)Lymphopenia6 (12.8%)8 (17%)2 (4.3%)016 (34%)Fatigue13 (27.7%)00013 (28%)Hot flashes7 (14.9%)0007 (15%)Nausea6 (12.8%)1 (2.1%)007 (15%)Thrombocytopenia5 (10.6%)1 (2.1%)006 (13%)Alopecia5 (10.6%)0005 (11%)Dizziness1 (2.1%)01 (2.1%)02 (4%)All cycles (n=54)Leukopenia10 (18.5%)22 (40.7%)21 (38.9%)053 (98%)Neutropenia4 (7.4%)21 (38.9%)21 (38.9%)1 (1.9%)47 (87%)Anemia29 (53.7%)12 (22.2%)3 (5.6%)044 (82%)Lymphopenia8 (14.8%)16 (29.6%)10 (18.5%)034 (63%)Fatigue19 (35.2%)4 (7.4%)0023 (43%)Nausea19 (35.2%)3 (5.6%)0022 (41%)Alopecia18 (33.3%)00018 (33%)Thrombocytopenia15 (27.8%)01 (1.9%) *016 (30%)ALT elevated3 (5.6%)02 (3.7%)05 (9%)AST elevated4 (7.4%)01 (1.9%)05 (9%)*pt died from subdural hematoma (G5) Citation Format: Jairam Krishnamurthy, Jingqin Luo, Rama Suresh, Foluso Ademuyiwa, Caron Rigden, Timothy Reardon, Katherine Clifton, Katherine Weilbaecher, Ashley Frith, Anna Roshal, Pavan Tandra, Mathew Cherian, Tracy Summa, Shana Thomas, Leonel Hernandez-Aya, Mattias Bergqvist, Lindsay Peterson, Cynthia X Ma. Safety and efficacy of an alternative schedule of palbociclib (PAL) in hormone receptor positive (HR+), HER2 negative (HER2-) metastatic breast cancer (MBC) and the utility of serum thymidine kinase 1 (sTK1) activity in predicting PAL response [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS12-02.

Background: Pemetrexed is an antifolate chemotherapeutic agent approved for use in non-small cell lung cancer (NSCLC). The mammalian target of rapamycin (mTOR) pathway is implicated in lung cancer development and inhibited by temsirolimus. Methods: We performed a phase I study evaluating the combination of pemetrexed and temsirolimus in advanced non-squamous NSCLC. Results: Eight patients were enrolled in this study. The dose-limiting toxicities included grade 4 thrombocytopenia, grade 3 leukopenia and grade 3 neutropenia. The maximum tolerated dose was determined to be pemetrexed 375 mg/m2 intravenously on day 1 and temsirolimus 25 mg intravenously on days 1, 8 and 15. No objective responses were noted and 3 patients had stable disease as the best response. Conclusion: The combination of pemetrexed and temsirolimus is feasible and well tolerated. This combination may be further evaluated in patients with mTOR pathway activation, particularly in those with TSC1 or STK11 mutations.

One of the principle unresolved questions in adjuvant endocrine therapy for breast cancer is whether it is more beneficial for women to receive aromatase inhibitor (AI) monotherapy or start with tamoxifen and then switch to AI therapy. This review will compare the current available efficacy, safety, and cost-effectiveness data for AIs in the initial adjuvant and switch adjuvant settings.A search of the Medline database from 1976 through 2006 was performed for the following terms: breast cancer, adjuvant, aromatase inhibitors, anastrozole, letrozole, exemestane, tamoxifen, sequential, switching. A search for relevant abstracts from the EBCC, ECCO, ASCO, and SABCS conferences was also performed.In the upfront adjuvant setting, anastrozole and letrozole have both demonstrated a significant disease-free survival (DFS) benefit over tamoxifen. Upfront therapy with a nonsteroidal AI appears to be most critical for patients at risk of an early relapse, illustrated by the finding that upfront letrozole provided a significant early DFS advantage over tamoxifen only in patients with node-positive disease (hazard ratio = 0.71, p0.001). With respect to safety, both strategies have similar adverse event profiles. From an economic perspective, AIs, whether used upfront or sequentially, are considered cost-effective compared with tamoxifen due to the cost savings associated with a reduction in the breast cancer event rate. From the efficacy standpoint, modeling studies have produced inconsistent results and do not produce definitive data.Differences in patient populations, definitions of end points, and prior tamoxifen usage between the trials discussed necessitates a careful interpretation but may provide insights in the treatment decision-making process. The BIG 1-98 trial was designed to compare letrozole monotherapy versus a letrozole-to-tamoxifen or reverse-sequence approach and should provide insights to the question of optimal therapy. Until results are available, for higher-risk patients (i.e., those with positive lymph nodes), initiation of treatment with a non-steroidal AI may be beneficial to avoid tamoxifen-associated early relapses that occur in the first 2 years after diagnosis.

Preoperative radiation therapy with 5-fluorouracil chemotherapy is a standard of care for cT3-4 rectal cancer. Studies incorporating additional cytotoxic agents demonstrate increased morbidity with little benefit. We evaluate a template that: (1) includes the benefits of preoperative radiation therapy on local response/control; (2) provides preoperative multidrug chemotherapy; and (3) avoids the morbidity of concurrent radiation therapy and multidrug chemotherapy.Patients with cT3-4, any N, any M rectal cancer were eligible. Patients were confirmed to be candidates for pelvic surgery, provided response was sufficient. Preoperative treatment was 5 fractions radiation therapy (25 Gy to involved mesorectum, 20 Gy to elective nodes), followed by 4 cycles of FOLFOX [5-fluorouracil, oxaliplatin, leucovorin]. Extirpative surgery was performed 4 to 9 weeks after preoperative chemotherapy. Postoperative chemotherapy was at the discretion of the medical oncologist. The principal objectives were to achieve T stage downstaging (ypTcT) and preoperative grade 3+ gastrointestinal morbidity equal to or better than that of historical controls.76 evaluable cases included 7 cT4 and 69 cT3; 59 (78%) cN+, and 7 cM1. Grade 3 preoperative GI morbidity occurred in 7 cases (9%) (no grade 4 or 5). Sphincter-preserving surgery was performed on 57 (75%) patients. At surgery, 53 patients (70%) had ypT0-2 residual disease, including 21 (28%) ypT0 and 19 (25%) ypT0N0 (complete response); 24 (32%) were ypN+. At 30 months, local control for all evaluable cases and freedom from disease for M0 evaluable cases were, respectively, 95% (95% confidence interval [CI]: 89%-100%) and 87% (95% CI: 76%-98%). Cases were subanalyzed by whether disease met requirements for the recently activated PROSPECT trial for intermediate-risk rectal cancer. Thirty-eight patients met PROSPECT eligibility and achieved 16 ypT0 (42%), 15 ypT0N0 (39%), and 33 ypT0-2 (87%).This regimen achieved response and morbidity rates that compare favorably with those of conventionally fractionated radiation therapy and concurrent chemotherapy.

553 Background: Preoperative radiotherapy (RT) with 5FU chemotherapy (CT) is a standard of care for cT3-4 rectal cancer. Studies incorporating additional cytotoxic agents have resulted in increased morbidity with little benefit. We evaluate a template that seeks to (1) include the known benefits of preoperative RT on local response/control, (2) provide for preoperative multi-drug CT, (3) avoid the morbidity of concurrent RT and multi-drug CT. Methods: Patients with cT3-4, any N, any M rectal cancer were eligible. Patients were confirmed to be candidates for surgery, provided the response was sufficient. Preoperative treatment was 5 fractions RT (25 Gy to involved mesorectum, 20 Gy to elective nodes), followed by 4 cycles of mFOLFOX6. Postoperative CT was at the discretion of the medical oncologist. The principal objectives are to demonstrate that this regimen can achieve T stage down staging (ypT < cT) and acute grade 3+ gastrointestinal (GI) morbidity equal to or better than historical controls. Results: Accrual opened late 2009, with 60 patients enrolled through 8/2011. Forty-six have had sufficient time to proceed to surgery with 4 having grade 3 preoperative GI morbidity. Two cases are inevaluable for response: one withdrew consent prior to CT and one received no surgery due to progression of cM1 disease (with local response). The 44 evaluable cases included 4 cT4 and 40 cT3; 32 (73%) cN+, 4 cM1. At surgery 33 (75%) had ypT0-2 residual disease including 13 (30%) ypT0, 14 (32%) were ypN+. Cases were sub-analyzed by whether disease was too advanced for the upcoming ACOSOG preoperative FOLFOX vs. 5FU-RT trial. By ACOSOG eligibility, response rates were (eligible first, ineligible second) ypT0: 10/22 (45%) vs. 3/22 (14%) (p = 0.05), ypT0-2: 19/22 (86%) vs. 14/22 (64%) (p = NS). Conclusions: This regimen achieves high response rates with acceptable morbidity. The response for ACOSOG eligible cases meets pre-determined stopping criteria for proceeding to a randomized trial. Our successor study will randomize to this regimen vs. FOLFOX alone for ACOSOG eligible cases, while initially continuing as a single arm trial for ACOSOG ineligible cases.