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Background:Multi-parameter tumour gene expression assays (MPAs) are widely used to estimate individual patient residual risk and to guide chemotherapy use in hormone-sensitive, HER2-negative early breast cancer. The TAILORx trial supports MPA use in a node-negative population. Evidence for MPA use in node-positive breast cancer is limited. OPTIMA (Optimal Personalised Treatment of early breast cancer usIng Multi-parameter Analysis) (ISRCTN42400492) aims to validate MPAs as predictors of chemotherapy sensitivity in a largely node-positive breast cancer population where prospective RCT (Randomised Controlled Trial) evidence is lacking. Methods: OPTIMA is a partially blinded multi-center RCT with an adaptive two-stage design. The main eligibility criteria are women and men age 40 or older with resected ER-positive, HER2-negative invasive breast cancer and up to 9 involved axillary lymph nodes. Randomisation is to standard management (chemotherapy and endocrine therapy) or to MPA-directed treatment using the Prosigna (PAM50) test. Those with a Prosigna tumour score (ROR_PT) >60 receive standard management whilst those with a low score (≤60) are treated with endocrine therapy alone. Endocrine therapy for pre-menopausal women includes ovarian suppression. The co-primary outcomes are (1) Invasive Disease Free Survival (IDFS) and (2) cost-effectiveness of test-directed treatment. Secondary outcomes include IDFS in patients with low-score tumours and quality of life. An integrated qualitative recruitment study addresses challenges to consent and recruitment and will build on experience from the feasibility study that a multidisciplinary approach at sites is important for recruitment success. Tumour blocks will be banked to allow evaluation of additional MPA technologies. Recruitment of 4500 patients over 5 years will permit demonstration of 3% non-inferiority of test-directed treatment, assuming 5-year IDFS of 85% with standard management, equivalent to a HR of 1.22. Inclusion of patients from the feasibility study will increase the power to test for non-inferiority. Results: The OPTIMA main trial opened in January 2017. Overall recruitment (including the feasibility study) will reach 1000 in August 2018. Recruitment in Norway will commence in July 2018. Characteristics of the OPTIMA main participants recruited to 31st May 2018 are shown in the table. Main study patient characteristicsCharacteristic %Median age in years (range)57 (40-80) Menopause statusPre34 Post66 Male1Tumour size=30mm42Node statuspN04 pN1mi(sn)7 pN1(sn)20 pN155 pN214Historic grade16 258 336 Conclusion: OPTIMA is one of two large scale prospective trials validating the use of test-guided chemotherapy decisions in node-positive early breast cancer. It is expected to have a global impact on breast cancer treatment. Experience from the preliminary study and close engagement with centres will aid trial success. Funding: OPTIMA is funded by the UK NIHR HTA Programme (10/34/501). Views expressed are those of the authors and not those of the HTA Programme, NIHR, NHS or the DoH. Citation Format: Stein RC, Hughes-Davies L, Makris A, Macpherson IR, Conefrey C, Rooshenas L, Pinder SE, Thomas J, Hall PS, Cameron DA, Earl HM, Naume B, Poole CJ, Rea DW, MacIntosh SA, Harmer V, Morgan A, Hulme C, McCabe C, Stallard N, Higgins H, Donovan JL, Bartlett JM, Marshall A, Dunn JA. OPTIMA: A prospective randomized trial to validate the clinical utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in high clinical risk 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 OT1-05-02.

Background: Multi-parameter gene expression assays (MPAs) are widely used to estimate individual patient residual risk in hormone-sensitive HER2-negative node-negative early breast cancer, allowing patients with low risk to safely avoid chemotherapy. Evidence for MPA use in node-positive breast cancer is limited. OPTIMA (Optimal Personalised Treatment of early breast cancer usIng Multi-parameter Analysis) aims to validate MPA's as predictors of chemotherapy sensitivity in a largely node-positive breast cancer population. Methods: OPTIMA is a partially blinded multi-center, phase 3 randomized controlled trial with an adaptive two-stage design. The main eligibility criteria are women or men aged 40 or older with resected ER-positive, HER2-negative breast cancer and up to 9 involved axillary lymph nodes. Randomization is to standard management (chemotherapy and endocrine therapy) or to MPA-directed treatment. Those with a “high risk” tumor MPA score receive standard management whilst those at “low risk” are treated with endocrine therapy alone. The preliminary phase (OPTIMA prelim) evaluated the performance of several MPAs to select a test to be used in the main efficacy trial based on economic analysis, and assessed the feasibility and acceptability of a large UK trial. OPTIMA prelim used Oncotype DX as the primary discriminator; the main trial will use Prosigna (PAM50) with Prosigna Score ≤60 defined as “low-risk”. The co-primary outcomes are (1) Invasive Disease Free Survival (IDFS) and (2) cost-effectiveness of test-directed therapy. Secondary outcomes include IDFS in “low-risk” patients, quality of life and additional survival measures. An integrated qualitative recruitment study will identify and address challenges to recruitment and informed consent. Tumor blocks from all consenting participants will be banked allowing the performance of alternative MPA technologies to be evaluated. Recruitment of 4500 patients will permit demonstration of 3% non-inferiority of test-directed treatment, with 5% significance and 85% power, assuming 3 years follow-up and a control arm 5-year IDFS of at least 85%. The addition of patients from OPTIMA prelim will allow non-inferiority to be assessed with 2.5% significance. Results: OPTIMA-prelim recruited 412 patients in 23 months from 35 sites with a 47% acceptance rate. The main study opened in January 2017. Early progress indicates that the recruitment target is achievable in the intended 46-month timescale through the participation of >100 sites Conclusion: OPTIMA, as one of two large scale prospective trials validating the use of test-guided chemotherapy decisions in node-positive early breast cancer, is expected to have a global impact on breast cancer treatment. Experience from OPTIMA prelim showed that patient advocate support and close engagement with sites will aid trial success. Funding: The project is funded in the UK by the NIHR HTA Programme (10/34/501). Views expressed are those of the authors and not those of the HTA Programme, NIHR, NHS or the DoH. Citation Format: Stein RC, Makris A, Hughes-Davies L, Macpherson IR, Hall PS, Cameron DA, Earl HM, Pinder SE, Poole CJ, Rea DW, McIntosh S, Harmer V, Morgan A, Rooshenas L, Conefrey C, Donovan JL, Hulme C, McCabe C, Stallard N, Campbell A, Higgins H, Bartlett JMS, Marshall A, Dunn JA. OPTIMA: A prospective randomized trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-06-01.

Large-scale sequencing initiatives have revealed a wealth of common and novel variants as well as copy-number aberrations, across different malignancies. This growing list of variants/aberrations can sometimes be matched to specific therapeutics. Such “actionable mutations/changes” hold promise for personalized treatment in the future, with treatments tailored to molecular abnormalities. Presently, women with hormone positive early breast cancer continue to experience improved survival on adjuvant anti-hormone therapy, but a significant number of women continue to progress. Therefore, there is a need to identify those women for whom current therapies are insufficient and to identify alternative therapeutic interventions. We explored the used of genetic profiling using a comprehensive solid tumor next generation sequencing (NGS) assay (the Oncomine Comprehensive Assay, OCA) to characterize early invasive breast cancer. The OCA is based on the Ion Torrent™ NGS platform and Ion AmpliSeq™ library preparation technology, coupled to the Oncomine™ Knowledgebase, for target selection, variant calling, and data annotations. The OCA includes 87 genes for hotspot mutation detection, 48 genes for full length sequencing and 43 genes for focal copy number assessment. The OCA provides a standardized informatics workflow and quality control (QC) parameters to process samples in a translational clinical research setting. To explore the application of the OCA to early invasive breast cancers, we performed a retrospective pilot study in a subset of cases from the TEAM trial. From the TEAM pathology samples, 420 were chosen in a case-control fashion, 413 samples were analyzed, 388 samples passed standard QC metrics, and 254 samples (65%) were found to contain 368 variants with Oncomine Knowledgebase annotations. Briefly, variants of PIK3CA were most frequent at 42.7% (157/368), followed by TP53 at 27.2% (100/368), PTEN at 5.7% (21/368), BRCA2 at 3.8% (14/368), SF3B1 (12/368), AKT1 (11/368) and PTCH1 (11/368) at 3.3%, 3.0%, 3.0%; respectively. Other variants were detected in ATM, ERBB2, RB1, FGFR2, NF1, CDKN2A, PIK3R1 and others. Amongst the 43 genes assessed for copy-number, 23 showed copy-number changes across 132 samples totalling 167 CNVs. 256 samples showed no copy-number alterations in any of the genes on the panel. ERBB2 was most frequently altered at 28.1% (47/167), followed by FGFR1 at 23.4% (39/167), CCND1 at 15.0% (25/167) and MDM2 at 10.2% (17/167). Copy-number losses were identified in TP53, RB1, PTEN, BRCA2 at 0.6% each; as well as CDKN2A at 1.8% (3/167). Analytical validation of a subset of gene variants and copy-number changes will be presented in addition to the evidence of potential future application of the Oncomine Comprehensive Assay to precision oncology goals. Citation Format: Bayani J, Crozier C, Quintayo MA, Amemiya Y, Zhang X, Larivière M, Sadis S, Smith JM, Hasenburg A, Kieback D, Markopoulos C, Dirix L, Yaffe M, Seth A, Feilotter H, Rea D, Bartlett JMS. Evaluation of the oncomine comprehensive assay for the identification of actionable mutations for therapeutic stratification from the TEAM pathology cohort [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-17.

Background Ductal carcinoma in situ (DCIS) now represents 20-25% of all breast neoplasia due to large-scale detection by widely adopted population-based breast cancer screening programs. As a result, thousands of women are confronted with DCIS each year: more than 8,000 in the UK, 2,500 in the Netherlands, and some 50,000 in the US. Conventional management includes surgery, supplemented by radiotherapy and/or endocrine therapy, but overtreats the majority of DCIS as ˜1% recur annually and breast cancer mortality is ˜3% at 20 years. Uncertainty as to which DCIS lesions will progress to invasive cancer or, after excision, which will return with recurrent DCIS or invasive breast cancer drives this overtreatment. This urges us to learn how to distinguish DCIS that may progress to invasive breast cancer from the majority of indolent DCIS. Such distinction may be best achieved by synergistic international collaboration between leading global experts from various disciplines, driven by the essential input from patient voices as full members of the research team. Aim PRECISION (PREvent ductal Carcinoma In Situ Invasive Overtreatment Now) aims to save thousands of women with low risk DCIS the burden of intensive inappropriate treatment of DCIS (surgery, radiation therapy, hormonal therapies) through the discovery of new data and development of novel tests that promote informed and shared decision-making between patients and clinicians, without compromising the excellent outcomes for DCIS management presently achieved. Methods First, three large DCIS cohorts and supplementary resources will be collected enabling in depth molecular studies. Second, extensive genomic characterization, immune profiling and imaging analysis will be performed. In vivo and in vitro modeling will be performed to study the biology of DCIS in detail. Finally, all clinical, immune, and molecular data will be incorporated into a clinical risk prediction model. This risk prediction model will be validated in three prospective randomized DCIS trials in the US (COMET trial), UK (LORIS trial), and mainland Europe (LORD trial). How the results of this research will be used The discoveries from our laboratory studies, including a risk stratification model, will be cross-validated in three prospective trials of DCIS active surveillance versus conventional treatment (the COMET, LORIS and LORD trials). As such, the main result of this study will be that we can identify a group of women for which active surveillance for DCIS could be a safer alternative to intensive treatment. Ultimately, this may also contribute to a more reassuring perception of risk regarding non-life threatening precancerous lesions in general, reducing anxiety and preserving quality of life. * The PRECISION Team is a Cancer Research UK Grand Challenge Award 2017 winning team and will be jointly funded by Cancer Research UK and the Dutch Cancer Society. Citation Format: Wesseling J, Thompson A, Nik-Zainal S, Futreal A, Hwang S, Jonkers J, Lips E, Rea D, On Behalf of the PRECISION Team. When is cancer not really cancer? The PREvent ductal carcinoma in situ invasive overtreatment now (PRECISION)* initiative [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-13.

Hormone receptor positive breast cancer remains an ongoing therapeutic challenge. Despite optimal anti-endocrine therapies, most breast cancer deaths follow a diagnosis of early luminal cancer. Data describing molecular events in breast cancer has yet to be translated into actionable information to inform medical management and benefit patients. To understand the impact of multiple aberrations in the context of current therapy, we assessed the prognostic ability of genomic signatures as a putative stratification tool to targeted therapies. The analysis was performed based on an a priori hypothesis relating to molecular pathways which might predict response to targeted therapies currently under evaluation in late-stage clinical trials. In a case-control fashion, 420 patients from the Tamoxifen vs Exemstane Adjuvant Multinational Trial (TEAM) pathology cohort, were analysed to determine the prognostic, ability for these mutational and copy-number biomarkers representing the CCND/CDK, FGFR/FGF and AKT/PIK3CA to inform potential response to therapies targeting these pathways. Copy number analysis was performed using the Affymetrix Oncoscan™ Assay. Targeted sequencing was performed in a subset of samples for genes based on signaling cassettes mined from the ICGC. Pathways were identified as aberrant if there were copy number aberrations (CNAs) and/or mutations in any of the predetermined pathway genes: 1) CCND1/CCND2/CCND3/CDK4/CDK6 2) FGFR1/FGFR2/FGFR2/FGFR4 and 3) AKT1/AKT2/PIK3CA/PTEN. Kaplan Meier and log rank analyses were used for DRFS between groups. Hazard ratios were calculated using the Cox proportional hazard models adjusted for age, tumour size, grade, lymph node and HER2 status. 390/420 samples passed informatics QC filters. For the CCND/CDK pathway, patients with no CNA changes experienced a better DRFS (HR=1.94, 95% CI 1.45-2.61, p< 0.001). For the FGFR/FGF pathway, a similar outcome is seen among patients without CNAs (HR = 1.43, 95% CI 1.07-1.92 p=0.017). For AKT/PIK3CA, a decrease in DRFS was seen in those with aberrations (H=1.34, 95% CI 1.00-1.81, p=0.053). We demonstrated that CNAs of genes within CDK4/CCND, PIK3CA/AKT and FGFR pathways are independently linked to high risk of relapse following endocrine treatment. In this way, improving the clinical management of early breast cancers could be made, firstly by identifying those patients for whom current endocrine therapies are sufficient, thus reducing unnecessary treatment; and secondly, identifying those patients who are at high-risk for recurrence despite optimal endocrine therapy and the linking molecular features driving these cancers to treatment with targeted therapies. Citation Format: Bayani J, Kornaga EN, Crozier C, Jang GH, Kalatskaya I, Trinh QM, Yao CQ, Livingstone J, Hasenburg A, Kieback DG, Markopoulos C, Dirix L, Boutros PC, Spears M, Stein LD, Rea D, Bartlett JMS. Copy-number and targeted sequencing analyses to identify distinct prognostic groups: Implications for patient selection to targeted therapies amongst anti-endocrine therapy resistant early breast cancers [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD4-11.

BACKGROUND Patients receiving neoadjuvant chemotherapy for breast cancer go on to have surgery regardless of their response. Women with HER-2 positive ER negative tumours (7.5% of all operable breast cancers in the UK) respond so well to neoadjuvant treatment with dual anti-HER2 therapy in combination with chemotherapy that pathological complete response rates of 80% can be achieved. This means that for patients receiving this treatment surgery is being performed to remove a cancer that isn't there in the large majority. A study is planned in the UK (NOSTRA ) to assess if it is feasible to treat patients with HER-2 positive ER negative breast cancer who achieve a pCR after neoadjuvant chemotherapy with trastuzmab and pertuzumab with radiotherapy alone. The first phase of the trial will be a feasibility study commencing in 2017 where all patients will have image guided tumour bed biopsies post treatment and all patients will have surgery. If the group of patients where a pCR is achieved can be accurately identified then a phase III trial randomising to surgery and radiotherapy or radiotherapy alone is planned. The NOSTRA PRELIM study reported here assessed the ability of post neoadjuvant chemotherapy tumour bed biopsies to detect residual disease to provide experience to inform the much larger NOSTRA feasibility trial biopsy protocol. METHODS 23 consecutive patients with operable primary breast cancer scheduled for neoadjuvant chemotherapy were approached to take part in the study and 20 gave consent. All 20 patients had a clip inserted into the tumour bed under ultrasound(USS) guidance at diagnosis as is standard procedure. The number of cores taken ranged from 2-6. The median number of biopsies was 4 Tumour size range at diagnosis was 15-61mm with USS. All received neo-adjuvant chemotherapy and those who were Her2 positive received neoadjuvant trastusumab. At completion all patients had USS guided tumour bed biopsy. They then went on to have surgery, after which pathology was assessed and an RCB score calculated for each patient. For this study patients all tumour types were included as non pCR outcomes were required to determine accuracy and inform changes to the biopsy protocol for future use. RESULTS Only 2 patients in this study achieved a pCR Residual disease was correctly identified in 16/20 patients. Four patients had no tumour in their post treatment biopsies but had small residual invasive tumour at surgery. The size of residual disease in these patients ranged from 0.5 -9mm and all these patients had 3 core biopsies. One patient had negative post treatment biopsies and a PCR of their invasive tumour. This patient had a diagnostic biopsy that confirmed separate area of DCIS several centimetres from the invasive component. This area did not undergo post treatment tumour bed biopsies (although both areas were clipped at diagnosis). CONCLUSION A protocol for biopsy in the upcoming NOSTRA feasibility study has been designed to both take more biopsies and sample a larger area of the tumour bed in order minimise the false negative rate. Citation Format: Francis A, Herring K, Molyneux R, Jafri M, Trivedi S, Shaaban A, Rea DW. NOSTRA PRELIM: A non randomised pilot study designed to assess the ability of image guided core biopsies to detect residual disease in patients with early breast cancer who have received neoadjuvant chemotherapy to inform the design of a planned trial [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 P5-16-14.

Background: Marked variation in mastectomy rates exists across the UK. Identification of variation in practice is a key step towards standardisation of service. The rationale for advising mastectomy by multi-disciplinary teams (MDTs) has not been previously explored in the UK. The main aim of this multicentre observational study was to describe current practice in MDT decision-making for patients undergoing mastectomy. A secondary aim was to determine utilisation of neoadjuvant therapies. Methods: A multicentre, protocol-driven, prospective cohort study, led by trainees of the West Midlands Research Collaborative was performed during July and September 2015. Data was collected securely using Research Electronic Data Capture. Inclusion criteria were: women >18 years undergoing mastectomy for in situ/invasive disease; presenting with symptomatic or screen detected disease; performed as a primary procedure or following failure of breast conserving surgery (BCS); with or without immediate breast reconstruction (IR). Results: A total of 1776 patients (1823 mastectomies; 47 bilateral procedures) from 68 units were included. Median age was 63 years (range 20-99). In total 481 (26%) IRs were performed; median IR rate was 22% (range 0-67%). Mastectomy was advised by the MDT in 1402 (77%) cases. Reasons for advising mastectomy are shown in Table 1. Table 1. MDT rationale for advising mastectomyRationaleNumber of mastectomiesProportion (%)Large tumour to breast size ratio making BCS unsuitable53029.1Multi-centric disease on imaging37220.4Extensive malignant microcalcification1799.8Previous radiotherapy (Breast/Mantle)1638.9Requiring further surgery for positive margins following BCS1588.7Central tumour1136.2Large primary tumour, patient not suitable for neoadjuvant endocrine or chemotherapy treatment1126.1Neoadjuvant therapy failed to downsize tumour to allow BCS884.8Neoadjuvant therapy apparently successful but mastectomy advised anyway794.3Family History-High Risk512.8 In total 153 patients with oestrogen receptor positive (ER+) tumours were offered neoadjuvant endocrine treatment (NET); 131 (86%) received treatment. A total of 293 post-menopausal women with uni-focal, ER+ tumours, >20mm were not offered NET; mastectomy was advised by MDTs in 202 patients and the rationale for advising mastectomy in 173 patients (86%) was large tumour to breast size ratio. In total 104 patients with Human Epidermal Growth Factor Receptor 2 over-expressing (HER2+) tumours were offered neoadjuvant chemotherapy and trastuzumab (NACT); 89 (86%) received treatment. A total of 88 women 20mm were not offered NACT; mastectomy was advised by MDTs in 75 patients and rationale for advising mastectomy in 45 women (60%) was large tumour to breast size ratio. Conclusions: Although most mastectomies are advised for large tumour to breast size ratio, there is inconsistency in the utilisation of neoadjuvant therapies with many potentially eligible patients with large tumours not being given the opportunity to be downsized. Application of standardised recommendations for neoadjuvant treatment resulting in increased and appropriate use of neoadjuvant therapies could reduce the number of mastectomies advised by MDTs. Citation Format: Singh JK, McEvoy K, Marla S, Wilcox M, Rea D, Hallissey MT, Francis A, West Midlands Research Collaborative. Multicentre observational study evaluating why mastectomies are advised by UK multi-disciplinary teams [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 P3-13-05.

Introduction The LORIS Trial is a UK randomized clinical trial comparing active monitoring with surgery for low risk ductal carcinoma in situ (DCIS), defined as low or low-intermediate grade DCIS without comedo necrosis, as diagnosed on vacuum-assisted (wide bore) core needle samples. Because of the inconsistency of grading DCIS, we have underpinned this trial with a Central Histopathology Review (CHR) before randomisation. The process of the CHR for the first 22 months of a two year pilot study between July 2014 and May 2016 is reported here. Patients and methods Patients were eligible for CHR if they satisfied all of the eligibility criteria and had locally reported low or intermediate grade DCIS. Patients were identified at 28 pilot sites and were registered for potential trial entry following written informed consent before being subjected to CHR. CHR comprised online examination of digitally scanned histology slides of all material from all diagnostic biopsies and was performed by at least two of the three LORIS specialist breast pathologists. Histology slides were submitted using Royal Mail Safebox® to the University of Birmingham where they were digitally scanned and made available for review via the Leica digital image hub. The outcome of the review was reported in a separate secure online database by completion of a Central Pathology Review Form. Access to both online systems is password protected. Eligibility was confirmed if two pathologists agreed that there was low or low to intermediate grade DCIS and no comedo necrosis. A maximum of 7 calendar days from receipt of the diagnostic material was allowed for the central review process. The digital images of the histology slides are stored by the Leica system for future reference. Results 100 patients were registered and their slides reviewed. 55 of these were deemed eligible by CHR; of these 38 have been randomised. 45 patients were deemed ineligible, most commonly due to grade being in the upper half of the intermediate category and/or comedo necrosis. In addition, 9 patients were deemed not to have DCIS and 1 patient had invasive disease. Grouping the grade categories as low and low to intermediate grade (low risk and eligible for randomisation) Vs intermediate to high and high cytonuclear grade (ineligible for randomisation) showed 91% agreement on grade category amongst the reviewing pathologists. Results of the central review were made available to sites within 7 days for 97% of cases submitted. On average, central review was completed within 4 days. Average time between registration and randomisation was 3 weeks. The LORIS central review pathologists found online viewing and reporting of sections acceptable. Conclusions Central Histopathology Review using online viewing of digital slides provides timely and efficient pathology Quality Assurance in this clinical trial setting, with acceptable turnaround times and good agreement between reviewing specialist breast pathologists. This process will be continued in the main phase of the trial. Citation Format: Thomas J, Hanby A, Pinder S, Pirrie S, Rea D, Gaunt C, Young J, Francis A. LORIS trial of active monitoring for DCIS: How does the online pathology eligibility review process work? [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 P3-17-06.

Optimal endocrine therapy for postmenopausal, hormone-receptor positive (HR+) early breast cancer remains a point of discussion. The Tamoxifen Exemestane Adjuvant Multinational (TEAM) phase III trial showed no significant differences for disease free survival (DFS) and overall survival (OS) at 5 years between exemestane monotherapy and sequential treatment (tamoxifen followed by exemestane). We now report disease related outcomes at 10 years of follow-up (FU), and an explorative analysis to assess the predictive value of clinicopathological and immune-related biomarkers. In the TEAM trial, postmenopausal women with HR+ positive early breast cancer were randomly assigned to exemestane alone or sequential therapy. For this analysis, TEAM patients from countries that completed 10 years of FU were included. The primary endpoint was DFS at ten years, analyzed by intention to treat. Secondary outcomes were OS and cumulative incidence of relapse. An explorative per protocol analysis for relapse free survival (RFS) was performed to identify predictive pathological and immunological biomarkers, including centrally determined ER (ER-poor 0-6 vs ER-rich 7-8) and PR (0-4 vs 5-8) Allred scores, and the immunological markers CD8, FoxP3, classical HLA class 1 and HLA-G which were described earlier (Engels et al, Breast Cancer Treat Res, 2015). In total, 6120 patients were eligible for the current analysis, 3075 patients with exemestane monotherapy and 3045 patients randomized to sequential treatment. Median follow up was 9.83 years. DFS was 66.8% in the exemestane group and 66.8% in the sequential group (hazard ratio (HR) 0.96, 95% CI 0.88-1.05, p=0.389). OS was 74% in the exemestane, and 73% in the sequential group, respectively (HR 0.98, 95% CI 0.89-1.09, p=0.737). The cumulative incidence of relapse was 20% and 22% in the exemestane and sequential groups, respectively (HR 0.88, 95% CI 0.79-0.99, p=0.031). In the explorative per protocol analysis (n=4041), Allred score were available for 2996 patients; immunological markers for 1754 patients. Patients with above median numbers of FoxP3-positive T-cells showed a benefit of exemestane monotherapy for RFS (HR 0.56, 95% CI 0.42-0.75, p After ten years of follow up, both exemestane monotherapy and sequential therapy remain appropriate options for postmenopausal HR+ early breast cancer patients. Interestingly, the number of regulatory T-cells was a predictive factor for the benefit of exemestane monotherapy, which implies a role of the local immune system in endocrine therapy. Furthermore, data suggested that patients with a higher differentiation grade or ER-rich tumor derive more benefit from exemestane monotherapy. Citation Format: Blok EJ, Derks MGM, Kuppen PJK, Meershoek-Klein Kranenbarg EM, Engels CC, Liefers G-J, Putter H, Seynaeve CM, Kroep JR, Nortier JWR, Rea DW, Hasenburg A, Markopoulos CJ, Paridaens R, Bartlett JMS, van de Velde CJH. 10-year follow-up and biomarker discovery for adjuvant endocrine therapy; results of the TEAM trial [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 PD2-07.

Background UK breast cancer incidence rates suggest that upper outer quadrant (UOQ) cancers have risen disproportionately compared with other areas over time. We aimed to provide a comparison of the trend in quadrant-specific breast cancer incidence between the United States (US) and England, and determine whether a disproportionate UOQ increase is present. Methods Surveillance Epidemiology and End Results (SEER) cancer registry data were obtained on 630,007 female breast cancers from 1975 to 2013. English cancer registry data were obtained on 1,121,134 female breast cancers from 1979 to 2013. Temporal incidence changes were analysed using negative binomial regression. Interaction terms determined whether incidence changes were similar between sites. Results English breast cancer incidence in the UOQ rose significantly from 13% to 28% from 1979 to 2013 whereas no significant increase was observed among SEER data. The significant interaction between quadrant and year of diagnosis (p

Background The immunotherapy has revolutionized the world of oncology in the last decades with considerable advantages in terms of overall survival in cancer patients. The association of Pembrolizumab and Trastuzumab was recently proposed in clinical trials for the treatment of Trastuzumab-resistant advanced HER2-positive breast cancer. Although immunotherapies are frequently associated with a wide spectrum of immune-related adverse events, the cardiac toxicity has not been properly studied. Purpose We studied, for the first time, the putative cardiotoxic and pro-inflammatory effects of Pembrolizumab associated to Trastuzumab. Methods Cell viability, intracellular calcium quantification and pro-inflammatory studies (analyses of the production of Interleukin 1β, 6 and 8, the expression of NF-kB and Leukotriene B4) were performed in human fetal cardiomyocytes. Preclinical studies were also performed in C57BL6 mice by analyzing fibrosis and inflammation in heart tissues. Results The combination of Pembrolizumab and Trastuzumab leads to an increase of the intracellular calcium overload (of 3 times compared to untreated cells) and to a reduction of the cardiomyocytes viability (of 65 and 20–25%, compared to untreated and Pembrolizumab or Trastuzumab treated cells, respectively) indicating cardiotoxic effects. Notably, combination therapy increases the inflammation of cardiomyocytes by enhancing the expression of NF-kB and Interleukins. Moreover, in preclinical models, the association of Pembrolizumab and Trastuzumab increases the Interleukins expression of 40–50% compared to the single treatments; the expression of NF-kB and Leukotriene B4 was also increased. Conclusion Pembrolizumab associated to Trastuzumab leads to strong cardiac pro-inflammatory effects mediated by overexpression of NF-kB and Leukotriene B4 related pathways.

Introduction: There are a number of commercially-available tests to stratify risk for women diagnosed with early breast cancer. While such "Generation I" tests are increasingly being used, a consensus is growing that these tests are moderately accurate in assessing risk. Moreover, Generation I tests fail to direct more personalized treatment. Therefore, there is a clear need for more informative "Generation II" tests that better assess risk, also on the long term, and provide theranostic targets. To this end, we have performed an mRNA abundance-based analysis trained in the 790 patients of the UK TEAM cohort to identify a signature of residual risk , to be validated in the remaining 3000 patients from the TEAM pathology study. Methods: RNA extracted from the tumors of respective TEAM pathology study patients were profiled using a 165-gene NanoString code set. The gene list was compiled from targets that comprise many of the existing risk assessment tests, in addition to genes known to be of importance for breast cancer pathogenesis. Signal intensities were normalized using the R statistical environment; 336 different combinations of preprocessing methods were assessed and the most optimal method selected using unbiased criteria. A10-fold cross-validation approach, in combination with a network-based patient risk score calculation formula, was used to derive a 95-gene signature. Briefly, genes were first filtered based on a Cox regression p-value threshold of 0.25; the sum of the weighted mRNA abundance levels of the result genes was calculated for each patient as the risk score. Patient-wise risk scores were then used in a multivariate Cox proportional hazards model along with clinical covariates such as age, grade, HER2 status and nodal status, using DRFS truncated to 10 years as an end-point. Results: Univariate survival analysis revealed a number of significantly prognostic candidates. The resulting 95-gene signature identified in the training set, stratified patients into high and low risk with an HRhigh of 2.74 (p Conclusions: The impact of test-guided therapy using multi-parametric tests is increasingly being felt in the clinic, and is reshaping modern health-care economics. A successful Generation II multi-parametric test will better discriminate those that are truly at high risk for recurrence following endocrine therapy and indicate potential therapeutic options for intervention for those who would not benefit from current modalities. Citation Format: Bayani J, Yao CQ, Quintayo MA, Haider S, Brookes CL, Yan F, van de Velde CJH, Hasenburg A, Kieback DG, Markopoulos C, Dirix L, Seynaeve C, Boutros PC, Rea DW, Bartlett JMS. Defining a signature of residual risk following endocrine treatment in the tamoxifen and exemestane adjuvant multinational (TEAM) trial. [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 P2-08-29.

Background: The independent review of the UK National Health Service Breast Screening Programme reported (The Lancet, Volume 380, Issue 9855, Page 1778, 17 Nov 2012) on the benefits and harms of breast screening. It concluded that breast screening saves lives and acknowledged the existence of overtreatment. It encouraged randomized trials to elucidate the appropriate treatment of screen-detected DCIS to gain a better understanding of its natural history. The LORIS trial addresses the possible overtreatment of low and low/intermediate grade screen-detected (low risk) DCIS by randomizing patients to standard surgical treatment or active monitoring, each with long term follow up. Trial Design: LORIS is a phase III, multicentre, 2 arm study, with a built in 2 year Feasibility Phase, in patients confirmed to have low risk DCIS defined by strict criteria and determined by central pathology review. Patients will be randomized between standard surgery and active monitoring with annual mammography. Patients will be followed up for a minimum of 10 years. Eligibility Criteria: 1) Female, age ≥ 46 years 2) Screen-detected or incidental microcalcification (with no mass lesion clinically or on imaging) 3) Low risk DCIS on large volume vacuum-assisted biopsy, confirmed by central pathology review 4) Patient fit to undergo surgery 5) No previous breast cancer or ipsilateral DCIS diagnosis 6) Written informed consent Specific Aims: The LORIS Trial aims to establish whether patients with newly diagnosed low risk DCIS can safely avoid surgery without detriment to their wellbeing (psychological and physical) and whether those patients that do require surgery can be identified by pathological and radiological means. Primary endpoint: Ipsilateral invasive breast cancer free survival time Secondary endpoints: Overall survival; mastectomy rate; time to mastectomy; time to surgery; patient reported outcomes; health resource utilisation and assessment of predictive biomarkers. A digital image data repository and tissue bank will provide a prospective resource for both translational and imaging studies. Statistical Methods: A total of 932 patients will be randomized to a non-inferiority design to test the null hypothesis that active monitoring of women diagnosed with low risk DCIS is not non-inferior in terms of ipsilateral invasive breast cancer free survival (iiBCFS) time compared to treatment with surgery. The iiBCFS time will be compared across the two arms on a per protocol and intent-to-treat basis, using a 1-sided (α=0.05) log-rank test for non-inferiority. The iiBCFS rate is assumed to be 97.5% in the surgery arm at 5 years, utilizing 80% power to exclude a difference of more than 2.5% in the active monitoring arm. Present Accrual and Target Accrual: 32 UK centres are open for the Feasibility Phase of the trial which is nearing completion. The web-based central pathology review process is functioning efficiently, with a one week maximum turn around. Registrations and sites randomizing patients are on or above target. Randomizations are currently approximately 70% of target. A total of 60 centres will open in the main trial. Contact Information: For further information, please email the LORIS Trial Office LORIS@trials.bham.ac.uk. Citation Format: Francis A, Bartlett J, Billingham L, Bowden S, Brookes C, Dodwell D, Evans A, Fairbrother P, Fallowfield L, Gaunt C, Hanby A, Jenkins V, Matthews L, Pinder S, Pirrie S, Rea D, Reed M, Roberts T, Thomas J, Wallis M, Wilcox M, Young J. The UK LORIS trial: Randomizing patients with low or low intermediate grade ductal carcinoma in situ (DCIS) to surgery or active monitoring [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 OT1-03-01.

Background Recently, the world of oncology has been revolutionized by immunotherapy which has shown considerable advantages in terms of overall survival in cancer patients. The association of Pembrolizumab and Trastuzumab was recently proposed in clinical trials for the treatment of Trastuzumab-resistant advanced HER2-positive breast cancer. Although immunotherapies are frequently associated with a wide spectrum of immune-related adverse events, the cardiactoxicity has not been properly studied. Methods In human fetal cardiomyocytes exposed to Trastuzumab and Pembrolizumab alone or in combination, we studied: the cell viability (through MTS assay), the quantification of intracellular calcium, Interleukin 1β, 6 and 8; the expression of NF-kB and Leukotrienes. Preclinical studies were also performed in C57BL6 mice dividing them in 4 groups (6/group: untreated mice (control) ; mice treated with Pembrolizumab at 10 mg/Kg for the first dose, followed by 5 mg/Kg dose every 5 days until the study end point, according to literature; mice treated with Trastuzumab at 10 mg/kg/day; mice treated with both drugs in combination. After the administration period, we analyzed the fibrosis and inflammation in heart tissues. Results The combination of Pembrolizumab and Trastuzumab increases the intracellular calcium overload (of 3 times compared to untreated cells) and reduces the cardiomyocytes viability (of 65 and 20-25%, compared to untreated and Pembrolizumab or Trastuzumab treated cells, respectively; p Conclusions The association of Pembrolizumab and Trastuzumab exerts pro-inflammatory and pro fibrotic effects in the heart; these effects are mainly mediated by overexpression of NF-kB and Leukotriene B4 related pathways and pro-inflamamtory cytokines. Legal entity responsible for the study The authors. Funding This work was funded by the “Ricerca Corrente” grant from the Italian Ministry of Health. Disclosure All authors have declared no conflicts of interest.

There is now significant evidence emerging from the pivotal trials of AIs versus Tamoxifen (AIOG) demonstrating the value of meta-analysis of key clinical questions. The "Trans-AIOG" group has been tasked with the exploration of key molecular/biomarker questions that are pertinent to meta-analyses of biomarkers (past/present/future) in AIOG trials. HER2 has been long proposed as a marker of endocrine "resistance". Data from three trials, before the era of HER-directed therapy, suggest a potential role for HER2 to select patients for treatment with upfront AIs. However the individual trials lack power to test treatment-by-HER2 interaction due to sample size and low HER2+ve rates. A meta-analysis of the predictive value of HER2 status, specifically within the first 3 years of endocrine therapy, has the potential to inform patient selection for upfront or sequential strategies with AIs. The pre-existing standardization of methodology for HER2 (IHC/FISH) facilitates analysis of existing data from BIG-1-98, TEAM and ATAC for this key marker. Analysis plan: Following a prospectively-designed analysis plan, patient-level data from 3 randomized phase III trials (ATAC, BIG 1-98, TEAM) comparing AIs to tamoxifen during the first 2-3 years of adjuvant treatment were collected at the CRCTU (Birmingham UK), accounting for both the established time-dependency of relapse in HER2+ve, anti-endocrine treated patients and to address the clinical question of "upfront" vs "sequential" strategies for AIs. For each trial, covariate-adjusted Cox models estimated HER2-by-treatment (AI vs Tam) interaction on distant recurrence-free interval-censored at 2-2.75 years follow-up. A meta-analysis of the HER2-by-treatment interaction terms and of treatment effects according to HER2 status was performed. Results: 12129 patients with centrally-confirmed ER and HER2 status, 1092 (9%) HER2+ve, with 473 (4%; 111 among HER2+ve) distant recurrences were analyzed. The meta-analysis estimated a pooled HER2-by-treatment interaction of 1.61 (95% CI 1.01,2.57), reflecting treatment effect hazard ratio(AI/Tam) of HR=1.13 (0.75,1.71) among HER2+ve and HR=0.70 (0.56,0.87) among HER2-ve. There was heterogeneity among interaction terms (I-squared=59%, p=.09) that resulted from treatment effect heterogeneity among HER2+ve subgroup (I2=71%, p=.03), not the HER2-ve subgroup (I2=0%). The results for disease-free survival were similar. Conclusion: An individual patient data meta-analysis across 3 trials (ATAC, BIG 1-98, TEAM) conducted prior to standard use of HER2-directed adjuvant therapy demonstrated a marginally-significant interaction between HER2 status and treatment with AIs vs Tamoxifen in the 2-2.75 years prior to potential "switching" between Tamoxifen and AIs. Patients with HER2-ve cancers experienced improved outcomes when treated with AIs vs Tamoxifen whilst patients with HER+ve cancers fared no better, or slightly worse, during AI treatment. However, the small number of HER2+ve cancers and events even in this meta-analysis may explain a large degree of heterogeneity in the treatment effects within the HER2+ve subgroups across the 3 trials. Other causes, perhaps related to subtle differences between AIs, cannot be excluded. Citation Format: Bartlett JMS, Ahmed I, Regan MM, Sestak I, Mallon EA, Dell'Orto P, Thürlimann BJK, Seynaeve C, Putter H, Brookes CL, Forbes JF, Colleoni MA, Bayani J, van de Velde CJH, Viale G, Cuzick J, Dowsett M, Rea DW, On Behalf of the Translational Aromatase Inhibitor Overview Group (Trans-AIOG). HER2 status as predictive marker for AI vs Tam benefit: A TRANS-AIOG meta-analysis of 12129 patients from ATAC, BIG 1-98 and TEAM with centrally determined HER2. [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 S4-06.

Background: Postmenopausal early breast cancer patients, treated with endocrine therapy, have approximately 90% five year disease free survival (DFS). However, for patients at higher risk of relapse, additional adjuvant chemotherapy may be indicated. The challenge is to prospectively identify such patients. The Mammostrat test uses five immunohistochemical markers to stratify patients on tamoxifen (T) therapy into various risk groups potentially guiding treatment choices. We tested the efficacy of this panel in the TEAM trial (exemestane (E) versus T→E) to determine the relevance in patients treated with an AI. Patients & Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. The cohort overall was 47% node positive, and 36% also received adjuvant chemotherapy. Samples were stained, using triplicate 0.6mm2 TMA cores, and positivity for p53, HTF9C, CEACAM5, NDRG1, SLC7A5 assessed. Each case was assigned a Mammostrat risk score and analysed for disease free survival (DFS) by marker positivity and risk score. Results: Preliminary results on the UK TEAM cohort (1059 cases) showed 18.9% stained positive for p53 (184/972), 21.3% for NRDG1 (204/956), 26.4% for SLC7A (253/957), 21.9% for HTF9C (220/1004), 18.3% for CEACAM5 (185/1009). Complete data was available for 919 cases including patients treated with chemotherapy, with 447 (49%) designated low risk, 213 (23%) medium and 259 (28%) high risk. In univariate analysis, Mammostrat scores were prognostic (p=0.02), with 5 year DFS (see comment above) results being 86.9±1.7%, 80.1±3.0% and 80.8±2.6% for patients with low, medium and high Mammostrat scores respectively. Analyses on the entire TEAM pathology cohort are ongoing, and further data with sufficient power to evaluate the impact of Mammostrat in multivariate regression analyses will be presented. Conclusion: Preliminary analysis of the impact of the Mammostrat score in both tamoxifen and exemestane treated patients suggests it retains its prognostic value in this context. Further analysis with the power to evaluate the impact of Mammostrat in multivariate regression analyses will be presented. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-33.

Background: SECRAB is a large multicentre randomised controlled trial designed to determine the optimal sequence of CT and RT for women with EBC. The second objective of this trial was to determine if CT and RT treatment modalities could be given together without increased toxicity or compromising either modality. See abstract no 851519 for details of CT and RT scheduling. Methods: Data on acute skin reaction was collected on completion of RT and graded as mild, moderate or severe. Late toxicity data was collected annually and included lymphoedema, telangiectasia, severe subcutaneous fibrosis, brachial plexopathy, rib fracture, ischaemic heart disease, symptomatic lung fibrosis, and clinical radiation pneumonitis. Results: Between Jul 98 and Mar 04, 2296 women were randomised. Acute toxicity data was collected on 2267 patients who received RT. The distribution of RT schedules was balanced across treatment arms, with the majority of patients (67%) receiving 40Gy/15F (15F). Significantly more patients in the Syn arm experienced a delay of >10 days in CT delivery (11% vs 5%, p < 0.0001). Very few patients experienced a >7 days delay in RT in either arm (Syn n=12 vs Seq n=3). In a sub-set of 880 patients dose intensity of CT was not significantly different between the two arms. Percentage skin toxicities for the Syn and Seq arms respectively were: None 22.9 vs 36.3; Mild 52.4 vs 48.1; Moderate 20.2 vs 13.6; Severe 3.8 vs 1.1. A significantly (p < 0.001) higher proportion of patients on the Syn arm suffered a moderate or severe skin reaction compared to those on the Seq arm. An unplanned exploratory analysis by duration of RT showed that patients receiving >15F (45Gy/20F or 50Gy/25F) had a significantly worse acute skin reaction than those receiving 15F (25% vs 16%, p=15F. Acute radiation pneumonitis was 0.3% in both arms (n=5 in total). Percentage late toxicities for the Syn and Seq arms respectively were not significantly different for: moderate/severe lymphoedema 6.1 (n=70) vs 5.5 (n=64); severe subcutaneous fibrosis 1.3 (n= 15) vs 0.6 (n=7); brachial plexopathy 0.2 (n=2) vs 0.1 (n=1); rib fracture 0.6 (n=7) vs 0.4 (n=5); ischaemic heart disease 0.4 (n=5) vs 0.4 (n=2); symptomatic lung fibrosis 0.3 (n=15) vs 0.3 (n=7); and late clinical radiation pneumonitis 0.1 (n=1) vs 0.1 (n=1). Howevermoderate/severe telangiectasia was 2.5% vs 1.3% in the Syn and Seq arms respectively (p =0.05). This difference was not seen in patients receiving 15F. Conclusions: The delivery of Syn CT-RT in the adjuvant treatment of EBC is associated with an increase in acute skin toxicity however the percentage of severe reactions is less than 5%. These skin reactions were seen predominantly in patients treated with concurrent RT (>15F). An increase in late skin telangiectasia was also seen in patients receiving >15F. There was no difference in other late toxicities recorded. Syn CT-RT is feasible in the adjuvant treatment of EBC and does not result in a reduction in dose intensity of delivered CT. The optimal schedule is 40Gy/15F which is now the standard regime used in the UK. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-05.

Background: We have previous data showing that quantitation of hormone receptors can be highly informative in determining risk of early relapse in ER positive early breast cancer treated with tamoxifen or exemestane. Both quantitative immunohistochemistry (QIHC) and flouresecent immunohistochemistry (F-IHC as measured by AQUA technology) are highly prognostic over a wide expression range. We have explored the results of both assays to determine if current assays provide maximum information using current approaches. Patients & Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative AQUA and IHC analysis (using image quantitation) of ER and PgR was performed centrally (Edinburgh & HistoRx). Results from both assays were compared and their prognostic impact on DFS at 2.75 years examined. Results: Both AQUA and QIHC demonstrated linear relationships between intensity of staining for either ER or PgR and DFS at 2.75 years. For both PgR and ER AQUA provided significantly greater prognostic information that QIHC. However AQUA staining explained only 29% and 68% of the variability in ER and PgR QIHC results by logistic regression. Using both AQUA and QIHC data in a forward stepwise selection survival model demonstrated that AQUA and QIHC provided similar prognostic information over 70% and 50% of the range for ER and PgR respectively. High ER QIHC and low ER AQUA scores, and low PgR IHC and high PgR AQUA scores provided prognostic information unique to either platform. Conclusion: Both QIHC and AQUA analysis of HR expression provides significant and highly important information on DFS risk in early breast cancer. It appears that these two platforms provide overlapping prognostic information and that the range of ER and PgR expression which impacts patient outcome is wider than measured by either system alone. Further investigation of the clinical significance of this broader range of hormone receptor expression in treatment decisions is warranted. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-08-02.

Background: Recent evidence confirms the importance of both biological and pathological risk markers in predicting early relapse for breast cancer patients treated with endocrine therapy. Most studies use a two step process integrating biological markers into a “biological predictor (e.g. Oncotype Dx, “IHC4” etc) followed by assessment of the predictive value of such tests in the context of pathological markers (grade, nodal status etc). We have taken a one step process integrating both biological and pathological markers into a single model to assess key factors for predicting outcome at 2.75 years and 5 years of endocrine therapy; to inform choices between switching, upfront and extended adjuvant treatment with AIs. Patients & Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative analysis ER, PgR, Ki67, HER1, HER2, and HER3 was performed centrally. A prognostic model, integrating data from biological and pathological markers was created to assess risk (disease-free survival) after 2.75 and 5 years of follow up in the TEAM trial. Results: Of 4595 eligible cases samples received, 16 were excluded, and 3993 had complete biomarker data for all markers for the final biomarker analysis. In univariate analysis nodal status, grade, size, age at diagnosis, HER1, HER2, PgR, ER and Ki67 were all prognostic. At 2.75 years nodal status, age, PgR histoscore, size, grade, HER2, ER histoscore and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), Ki67 and HER3 were not included in this model. At 5 years median follow up; age, nodal status, size, PgR histoscore, grade, Ki67, HER2, and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), ER and HER3 were not included in this model. Conclusion: Combined biological and pathological marker panels are of significant value in predicting early relapse in breast cancer patients treated with endocrine therapy, however duration of follow-up may impact on the inclusion of variables in the model. This provides significant information relevant to the choice of different adjuvant endocrine therapies. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-04.

Inflammatory breast cancer: time to standardise diagnosis assessment and management, and for the joining of forces to facilitate effective research

We previously reported high activity for oxaliplatin and a modified de Gramont regimen (OxMdG) in a single centre study of patients with metastatic colorectal cancer. We now report results with a further 56 patients treated at 14 centres. Low rates of grade 3 and 4 toxicity were seen, with no toxic deaths. Objective response rates were CR/PR=53%; NC=34.7%; PD=12.2%. Median time to progression was 8.3 months and overall survival was 14.5 months. This regimen is more convenient than those based around the conventional de Gramont regimen but is highly active and well tolerated; it forms part of a current UK MRC phase 3 trial.

Surgery is an obligatory component of treatment for early breast cancer. The last 20 years developments in systemic neoadjuvant therapy have progressively increased pathological complete response (pCR). Pathological complete response is associated with excellent prognosis especially for hormone receptor negative cancers. Therapeutic advances and recognition of the importance of pathological subtype in predicting pCR facilitate identification of subgroups with very high pCR rates. Treatment of HER2 positive hormone receptor negative cancers with combination chemotherapy and multiple targeted anti-HER2 agents results in consistently high pCR rates of 60-83%. Routine surgery in this setting where most patients have no potential to benefit is of questionable value and the option of omitting surgery in these patients should now be explored in a randomized trial. For HER2 positive disease not achieving pCR after neoadjuvant treatment the outcomes are poor. Trials are underway to determine if outcomes for these patients can be improved with alternative targeted therapy.

Background:\ud The National Epirubicin Adjuvant Trial (NEAT) and BR9601 trials tested the benefit of epirubicin when added to cyclophosphamide, methotrexate and 5-fluorouracil (E-CMF) compared with standard CMF in adjuvant chemotherapy for women with early breast cancer. This report details longer follow-up with interesting additional time-dependent analyses.\ud \ud Methods:\ud National Epirubicin Adjuvant Trial used epirubicin (E) 3-weekly for four cycles followed by classical (c) CMF for four cycles (E-CMF) compared with cCMF for six cycles. BR9601 used E 3-weekly for four cycles followed by CMF 3-weekly for four cycles, compared with CMF 3-weekly for eight cycles.\ud \ud Results:\ud In all, 2391 eligible patients were randomised and with a median 7.4-year follow-up, E-CMF confirmed a significant benefit over CMF in both relapse-free survival (RFS) (78% vs 71% 5 years RFS, respectively, hazard ratio (HR)=0.75 (95% CI: 0.65–0.86), P

Background: Patients with high risk early breast cancer undergoing chemotherapy are frequently treated with both anthracycline and taxane-based chemotherapy exposing patients to multiple toxicities. Molecular predictors of response to specific chemotherapy agents are emerging. Abnormal duplication of the centromeric region of chromosome 17 (CEP17) and either Topoisomerase 2A (TOP2A) gene amplification or deletion, have been identified in a recent meta-analysis as potent markers of anthracycline sensitivity (Bartlett et al JCO 2015). The ROSCO study has been designed to prospectively test the utility of these markers to select anthracycline or taxane based chemotherapy in the neoadjuvant setting. Key entry criteria: Confirmed invasive breast cancer; centrally confirmed CEP17 duplication and TOP2A status; primary tumour>2cms or documented axillary node metastasis Exclusion criteria include breast cancer with good risk features i.e. Grade 1/2 ER PR rich (Q score 7/8), HER2 negative tumours. Study treatment: Patients will undergo central testing for CEP-17 and TOP2A and be randomised to 4 cycles of FEC100 (5-Flourouracil 500mg/m2 Epirubicin 100mg/m2 cyclophosphamide 600mg/m2) or 4 cycles of TC (Docetaxel 75mg/m2 Cyclophosphamide 600 mg/m2). Following chemotherapy patients will undergo surgical resection, (Institutional standard). Patients with residual invasive cancer will receive 4 cycles of the alternative chemotherapy to that received in the neoadjuvant setting. HER2 positive patients will receive concurrent trastuzumab and continue standard adjuvant trastuzumab. . Patients with biopsy proven axillary node metastases will undergo combined blue dye and radioisotope tracer guided sentinel lymph node biopsy (SLNB) and axillary lymph node clearance as a single procedure during breast surgery. Adjuvant endocrine and radiation therapy will be Institutional standard Endpoints: The primary endpoint is pathological complete response (no invasive disease in breast or axilla (pCR)). Secondary endpoints include: clinical and radiological response; rate of breast conservation; patient reported outcomes; safety, tolerability and long term outcomes. In patients with proven nodal involvement the false negative rate of a negative post treatment SLNB compared to axillary node clearance will be reported. Sample size and stratification: 1050 patients will be randomised in a 1:1 ratio stratified by nodal status, ER, HER2, and biomarker status (CEP-17 amplified or TOP2A amplified/deleted) vs normal (CEP-17 normal TOP2A normal). Analysis: The primary analysis will assess the interaction between the treatment effect and CEP17/TOP2A status to determine if a differential treatment effect exists between CEP17/TOP2A Normal and CEP17/TOP2A Abnormal patients. pCR will be analysed using a logistic regression model including co-variates for treatment, CEP17/TOP2A status and an interaction term of the two effects Sample size is based on the ability to detect an absolute improvement in pCR in the biomarker abnormal group from 21% in the TC treated group to 30% in the FEC treated group. With 90% power at 10% significance level. Contact Information: the ROSCO Trial Office ROSCO@trials.bham.ac.uk. Citation Format: Rea DW, Haywood L, Francis AM, Bowden SJ, Brookes CM, MacKenzie M, Cameron D, Stein R, Earl HM, Thomas J, Abraham J, Stanley A, Starczinski J, McGoldrick T, Treharne-Jones P, Billingham L, Bartlett JM. ROSCO: A randomised phase III, stratified CEP17/TOP2A biomarker trial of neo-adjuvant 5-flourouracil, epirubicin and cyclophosphamide vs docetaxel and cyclophosphamide chemotherapy. [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 OT3-02-02.

Background: Multi-parameter gene expression assays (MPAs) are widely used to estimate individual patient residual risk and to guide chemotherapy use in hormone-sensitive HER2-negative node-negative early breast cancer. These uses of MPAs have not yet been prospectively validated. OPTIMA aims to validate the use of MPA testing to predict chemotherapy sensitivity in a largely node-positive breast cancer population. Methods: OPTIMA is a partially blinded multi-center, phase 3 randomized controlled trial with an adaptive two-stage design. The preliminary phase (OPTIMA prelim) evaluated the performance of MPAs to identify a suitable test(s) to be used in the main efficacy trial and assessed the feasibility and acceptability of a large UK trial. Eligible patients are men or women aged 40 years or older who have surgically resected early stage breast cancer, which is ER-positive and HER2-negative and who have either 1-9 involved axillary lymph nodes or tumors of at least 30mm diameter. Randomization is to standard management (chemotherapy followed by endocrine therapy) or to MPA-directed treatment. Those with a tumor categorized as "high-risk" by the test will be assigned to standard management whilst those at "low-risk" will be treated with endocrine therapy alone. OPTIMA prelim used Oncotype DX as the primary discriminator; the main trial will use Prosigna (PAM50). The co-primary outcomes are (1) Invasive Disease Free Survival (IDFS) and (2) cost-effectiveness of test-directed therapy compared to standard practice. Secondary outcomes include IDFS in "low-risk" patients, distant disease free survival, breast cancer specific survival, overall survival and quality of life. An integrated qualitative recruitment study will identify and address challenges to recruitment and informed consent. Tumor blocks from all consenting participants will be banked allowing the performance of alternative MPA technologies to be evaluated. Recruitment of 4500 patients over 4 years will permit demonstration of 3% non-inferiority of test-directed treatment, with 5% significance and 85% power, assuming 3 years follow-up and a control arm 5-year IDFS of at least 85%. The addition of patients from OPTIMA prelim will allow non-inferiority to be assessed with 2.5% significance. Results: OPTIMA-prelim recruited 412 patients in 23 months from 35 sites. It confirmed the acceptability of randomization to patients with a 47% acceptance rate, and to clinicians and hence the feasibility of a large prospective trial of test-directed treatment running in 100-plus UK sites. It showed that investment into research on test-directed therapy, especially with Prosigna, should be of substantial value to the NHS. Conclusion: OPTIMA, as one of two large scale prospective trials validating the use of test-guided chemotherapy in node-positive hormone-sensitive early breast cancer will have a global impact on patient treatment. Recruitment into the main efficacy trial will commence in October 2015. Funding: Project funded by the UK NIHR HTA Programme (10/34/501). Views expressed are those of the authors and not those of the HTA Programme, NIHR, NHS or the DoH. Citation Format: Stein RC, Marshall A, Hall PS, Bartlett JMS, Rooshenas L, Campbell A, Cameron DA, Rea D, Macpherson I, Earl HM, Poole CJ, Francis A, Morgan A, Harmer V, Pinder SE, Stallard N, Donovan J, Hulme C, McCabe C, Hughes-Davies L, Makris A, Dunn JA. OPTIMA (optimal personalised treatment of early breast cancer usIng multi-parameter analysis), a prospective trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions. [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 OT3-02-12.

COX2 has been implicated in breast tumorigenesis, tumour proliferation & invasion. The role of COX2 in carcinogenesis is thought to be related to its abilities to increase production of prostaglandins, convert pro-carcinogens to carcinogens, inhibit apoptosis, promote angiogenesis, modulate inflammation & immune function & increase tumour cell invasiveness. COX2 inhibition may synergise with aromatase inhibition in controlling endocrine responsive breast cancer. The COX2 product prostaglandin E2 (PGE2) & cytokines such as interleukin-6 (IL6) can up regulate aromatase expression suggesting that aromatase inhibition may be more effective in combination with a COX2 inhibitor. There may be additional COX2 mediated anticancer activity. The hypothesis addressed is that activity of aromatase inhibitors(AI) as neoadjuvant endocrine therapy for early breast cancer may be enhanced by the addition of a COX2 inhibitor. TRIAL OBJECTIVES To determine whether the activity of AIs as neo-adjuvant endocrine therapy for ER positive breast cancer in postmenopausal women may be enhanced by the addition of the selective COX2 inhibitor celecoxib. TRIAL DESIGN Prospective phase III multicentre randomised trial. Patients were randomised to receive 16 weeks of exemestane 25 mg daily or letrozole 2.5 mg daily (open label) and celecoxib 400 mg twice daily or matched placebo (double blinded). Translational research tumour samples were collected before, during & after therapy. KEY ELIGIBILITY CRITERIA Post menopausal, ER positive, invasive cancer, 2cms or greater with calipers & visible on USS. PRIMARY OUTCOME MEASURE Objective clinical response to neoadjuvant treatment by RECIST criteria. RESULTS Primary Outcome; Response to treatment has been calculated for 266 patients (Table 1). Response rate was 73% in the celecoxib arm & 55% in the placebo arm (p=0.0022). The response rates 4 arm comparison are shown in Table 2. After adjustment for AI effect the significant difference in response rates remained (p=0.0023); the difference in response rates was greater in the exemestane treated group (29%) compared to the letrozole group (7%) although heterogeneity between AI arms was statistically non-significant (p=0.06). Table 1 Primary Outcome Results: response ratesOUTCOMEPLACEBO N (%)CELECOXIB N (%)TOTAL N (%)X2statisticP-valueRESPONSE73(55)97(73%)170 (64%)9.38820.0022NO RESPONSE60 (45%)36 (27%)96 (36%) TOTAL133133266 Table 2: Response Rates 4 Arm Comparison EXEMESTANELETROZOLERESPONSEPLACEBO n(%)CELECOXIB n(%)TOTAL n(%)PLACEBO n(%)CELECOXIB n(%)TOTAL n(%)RESPONSE33 (49)52(78)85(63)40(61)45(68)85(64)NO RESPONSE34(51)15(22)49(37)26(39)21(32)47(36)TOTAL67671346666132 Secondary outcome; There was an USS response rate of 42% v 37% for celecoxib & placebo arms respectively (p=0.2513) CONCLUSION The addition of the COX2 inhibitor celecoxib to an AI significantly & substantially increased the clinical response from 55% to 73%. Effect on tumour size assessed with USS is less marked with a non-significant increase in responses from 37% to 42%. This work was supported by CRUK: CRUK/06/005 and Pfizer. Citation Format: Rea D, Francis A, Poole C, Brookes C, Stein R, Bartlett J, Dunn J, Canney P, Sutton R, Daoud R, Hallissey M, Achuthan R, Grant M, Babrah J, Smith S, Fraser J, Desai A, Al Dubaisi M, Patel A, Bristol J, Chandrasekharan S, Prest C, Jewkes A. NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early 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 PD2-02.

Background: The independent review of the UK National Health Service Breast Screening Programme reported recently on the benefits and harms of breast screening (The Lancet, Volume 380, Issue 9855, Pages 1778 - 1786, 17 November 2012). This concluded that breast screening saves lives but acknowledged the existence of overtreatment. Consequently, randomized trials were recommended to elucidate the appropriate treatment of screen-detected ductal carcinoma in situ (DCIS) and to gain a better understanding of its natural history. The LORIS trial will address these issues in low and low/intermediate grade screen detected (low risk) DCIS. Trial Design: LORIS is a phase III, multicentre, 2 arm study, with a built in 2 year feasibility phase, in women confirmed by central pathology review to have low risk DCIS. Comprehensive site training will be complimented by a patient friendly DVD designed to ensure consistent and appropriate use of terminology. Patients will be randomised between standard surgery and active monitoring with annual mammography. Follow-up will be for a minimum of 10 years. Eligibility Criteria: 1) Female, age ≥ 46 years 2) Screen-detected or incidental microcalcification (with no mass lesion clinically or on imaging) 3) Low risk DCIS on large volume vacuum-assisted biopsy, confirmed by central pathology review 4) Patient fit to undergo surgery 5) No previous breast cancer or DCIS diagnosis 6) Written informed consent Specific Aims: The LORIS Trial aims to establish whether patients with newly diagnosed low risk DCIS can safely avoid surgery without detriment to their wellbeing (psychological and physical) and whether those patients who do require surgery can be identified by pathological and radiological means. Primary endpoint: Ipsilateral invasive breast cancer free survival rate at 5 years Secondary endpoints: Overall survival; mastectomy rate; time to mastectomy; time to surgery; patient reported outcomes; health resource utilisation and assessment of predictive biomarkers. A digital image data repository and tissue bank will provide a prospective resource for both translational and imaging studies. Statistical Methods: A total of 932 patients will be randomized to a non-inferiority design to test the null hypothesis that active monitoring of women diagnosed with low risk DCIS is not non-inferior in terms of 5 year ipsilateral invasive breast cancer free survival (iiBCFS) rate compared to treatment with surgery. The iiBCFS rate will be compared across the two arms on a per protocol and intent-to-treat basis, using a 1-sided (α = 0.05) log-rank test for non-inferiority. The iiBCFS rate is assumed to be 97.5% in the surgery arm giving 80% power to exclude a difference of more than 2.5% in the active monitoring arm at 5 years. Present Accrual and Target Accrual: 20 UK sites have been identified to contribute to the feasibility phase of the trial. Enrolment of the first patient is expected in late 2013/early 2014. A further 40 sites will be recruited upon successful completion of the feasibility phase. For further information, please contact the LORIS Trial Office LORIS@trials.bham.ac.uk. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-3-01.

Aim: For early stage HR + , HER2– BC pts with intermediate risk by clinical/pathologic criteria, treatment decisions should be based on sensitivity to endocrine therapy, risk of recurrence, and predicted benefit from CT. The ESMO guidelines highlight that multigene assays (MGA) may be used in these cases (Ann Oncol. 2013;suppl6:vi7-23). The MAGIC survey evaluated criteria considered for CT decisions and simulated CT recommendations for pts with different characteristics. We present CT recommendations for intermediate-risk BC pts based on characteristics of respondents. Methods: The online survey was completed by physicians working in multidisciplinary BC teams, having ≥5 year experience. A conjoint analysis was used to model CT recommendations for simulated pts. Results: Overall recommendations (n = 911, 52 countries) showed that BC pt profiles associated with a request for more information tended to have an intermediate/high age (>50 yr), intermediate/small tumor size, grade 1/2, low ER/intermediate Ki67 expression, and node-negative status. The table summarizes CT recommendations for 4 selected intermediate-risk BC pts. On average, CT was recommended for the 4 pt profiles by 29%, 42%, 31%, and 44% of responders. CT recommendation varied greatly among different countries for each pt profile. Physicians who always use international guidelines tended to prescribe CT more often, while those who use MGA, as expected, recommended CT less frequently for each pt profile. More-experienced physicians (ie, those who prescribe CT personally or who treat >200 pts/year) showed a slight trend to fewer CT recommendations. Conclusions: There is high variation in CT recommendations for intermediate-risk BC pts, primarily according to country of residence. There is a need for more broadly available tools, such as MGA, to help make more-informed treatment decisions in this pt population. Table: 261PD . Selected MAGIC survey respondent groups recommending CT for selected patient profiles Patient profile 1 ( age 35–50 , tumor size 1–2 cm, tumor grade 2, high ER, high PR , 14%–20% Ki67, node negative) Patient profile 2 ( age 35–50 , tumor size 1–2 cm, tumor grade 2, high ER, low PR , 14%–20% Ki67, node negative) Patient profile 3 ( age 51–70 , tumor size 2.1–3 cm, tumor grade 2, high ER, high PR , 14%–20% Ki67, node negative) Patient profile 4 ( age 51–70 , tumor size 2.1–3 cm, tumor grade 2, high ER, low PR , 14%–20% Ki67, node negative) All physicians (excluding pathologists, n = 877) 29% 42% 31% 44% All physicians – range between countries with >30 respondents 15%–41% 33%–50% 14%–48% 28%–56% Physicians personally prescribing CT (n = 610)/not prescribing CT (n = 267) 27%/31% 42%/44% 30%/34% 43%/46% Physicians treating 1–50 pts per year (n = 310)/ > 200 pts per year (n = 86) 32%/26% 45%/38% 36%/26% 49%/38% Physicians always (n = 482)/often (n = 377) using international guidelines 31%/25% 45%/39% 34%/27% 47%/40% Physicians using (n = 487)/not using (n = 390) MGA 26%/31% 39%/46% 29%/34% 41%/48% Medical oncologist (n = 485)/surgeons or gynecologists (n = 324)/radiation oncologists (n = 38) 27%/30%/32% 42%/42%/46% 30%/32%/33% 45%/44%/46% Physicians working in an academic hospital (n = 540)/community-based or private hospital (n = 240)/office-based or private practice (n = 77) 29%/27%/34% 42%/43%/45% 31%/31%/36% 43%/47%/47% ER, estrogen receptor; PR, progesterone receptor Disclosure: M. De Laurentiis: Advisory board: Genomic Health; M. Aapro: Advisory board: Genomic Health Corporate-sponsored research: Genomic Health; C. Markopoulos: Other substantive relationships: Genomic Health – Speaker's Honoraria; T. Mamounas: Advisory board: Genomic Health Inc. Other substantive relationships: Speaker's Bureau: Genomic Health Inc.; R. Rouzier: Advisory board: consultant for Genomic Health; C. Thomssen: Advisory board: Genomic Health Other substantive relationships: Speaker for Genomic Health; D. Rea: Advisory board: Genomic Health; B. Linderholm: Board of directors: Steering Committee for the BIG/EORTC/NABCG Male breast cancer project; V. Smit: Advisory board: Genomic Health Inc.; C. Svedman: Other substantive relationships: I am an employee of Genomic Health working in the medical department.All other authors have declared no conflicts of interest.

Aim: Anthracyclines are first line drugs against cancer, but produce a well-known cardiomyopathy through multiple mechanisms, which also include, among many, Ca2+ overload due to reduced SERCA2a activity and inappropriate opening of the RyR2, and impaired myocardial energetics. Anthracyclines generate Reactive Oxigen and Nitrogen Species (ROS and RNS), posing the heart at increased demand for oxygen, thus setting the stage for a metabolic ischemia that also activates late INa, the target of Ranolazine (RAN). Here, we aim at assessing whether RAN, diminishing intracellular Ca2+ through its inhibition of late INa blunts anthracyclines cardiotoxicity. Methods: To evaluate cardiac function in vivo, fractional shortening (FS) and ejection fraction (EF) were measured by M/B mode echocardiography and radial and longitudinal strain (RS and LS) were measured using 2D speckle-tracking ecocardiography, in C57/BL6 mice, 2-4 mo old, at day 0, and after 2 and 7 days of daily administration of Doxorubicin (Doxo, 2.17 mg/kg/day, ip). These measurements were repeated after 5 days of RAN treatment (750 mg/kg/day, a dose comparable to the one used in humans) iniziated at the end of Doxo treatment. Results: In our in vivo studies, after 7 days with Doxo, FS decreased to 50.5 ± 8.4%, p Conclusions: RAN post-treatment blunts cardiotoxic effects due to anthracyclines, as demonstrated by the normalization of the values of FS, EF and RS. It remains to explain the persistent abnormality of the LS. Disclosure: All authors have declared no conflicts of interest.

Aim: The MAGIC survey aimed to identify how physicians use the most common traditional parameters and histopathology markers in clinical treatment decisions in early stage HR + , HER2– breast cancer. The data presented here describe how physicians use tumor size, grade, nodal status, estrogen receptor (ER), progesterone receptor (PR), and Ki67 expression, and age for CT recommendations. Methods: The online MAGIC survey was available to physicians working in multidisciplinary breast cancer teams (≥5 years' experience). The survey evaluated respondent demographics, criteria considered for CT decisions, and treatment recommendations in a wide variety of patient cases and captured how physicians use traditional parameters for making CT recommendations. Results: Between August 2013 and January 2014, 911 respondents (52 countries) completed the survey. The results for key parameters are presented in the table. There was substantial heterogeneity in how all parameters were considered for decisions about CT, with a majority of respondents reaching agreement to strongly consider CT only in patients with Grade 3 tumors (70.1%), tumors larger than 3 cm (63.7%), and in patients with 2 or more positive nodes (63.1%). A majority would strongly consider CT in patients with low ER and high Ki67 expression but there was no consensus on the definition of low ER expression ( 20% [33.9%], > 30% [31.9%]). Conclusions: The results reveal substantial differences in how physicians use traditional prognostic parameters for CT decisions. The data highlight the need for implementation of additional criteria or biomarkers that are predictive of CT benefit and can help physicians and patients make more informed treatment decisions. Is there a specific tumor size above which you would strongly consider CT? > 1 cm 13.8% > 2 cm 35.5% > 3 cm 14.4% > 4 cm 4.7% > 5 cm 9.4% Not considered 22.2% Is there a specific tumor grade above which you would strongly consider CT? Grade 1 or above 0.6% Grade 2 or above 20.9% Grade 3 or above 70.1% Not considered 8.4% Would you be inclined to give CT to most patients with low expression of ER? Yes 83.4% No 8.4% Not considered 8.2% Would you be inclined to give CT to patients with low PR? Yes 41.9% No 21.3% Not considered 36.9% What percentage of ER+ cells would you consider low and would make you strongly consider CT? 26.2% 46.8% 20.0% Not considered 7.1% At which Ki67 percentage would you strongly consider giving CT? ≥ 14% 27.2% > 20% 33.9% > 30% 31.9% Not considered 7.1% What number of positive nodes would make you strongly consider CT? Node negative 3.6% 1 (including isolated tumor cells or nodal micrometastases) 38.6% 2 20.9% 3 10.8% 4 or more 21.0% Not considered 5.0% Is there an age above which you would strongly consider not giving adjuvant CT? > 50 years 1.4% > 60 years 0.7% > 70 years 16.8% > 80 years 48.4% Age is not considered 32.8% Disclosure: M. Aapro: Advisory board: Genomic Health Corporate-sponsored research: Genomic Health; C. Markopoulos: Other substantive relationships: Genomic Health – Speaker's Honoraria; T. Mamounas: Advisory board: Genomic Health Inc. Other substantive relationships: Speaker's Bureau: Genomic Health Inc.; R. Rouzier: Advisory board: consultant for Genomic Health; C. Thomssen: Advisory board: Genomic Health Speaker for Genomic Health (under other substantive relationships); D. Rea: Advisory board: Genomic Health; B. Linderholm: Board of directors: Steering Committee for the BIG/EORTC/NABCG Male breast cancer project; V. Smit: Advisory board for Genomic Health Inc.; C. Svedman: Other substantive relationships: I am an employee of Genomic Health working in the medical department; M. De Laurentiis: Advisory board: Genomic Health. All other authors have declared no conflicts of interest.

Aim: ErbB2 is overexpressed in about 25% of breast cancers. It modulates myocardial development and function in the heart. Trastuzumab (T), an anti-ErbB2 inhibitor, has improved the prognosis of patients with breast cancer, but is related to an increased risk of asymptomatic left ventricular (LV) dysfunction (3–34%) and heart failure (2–4%). The mechanisms of T cardiotoxicity are not entirely known and can include changes in Ca2+ regulation related to blockade of ErbB2. Here, we aim at assessing whether ranolazine (RAN), diminishing intracellular Ca2+ through its inhibition of late Ina, blunts T cardiotoxicity in vivo. Methods: To evaluate cardiac function in vivo, fractional shortening (FS) and ejection fraction (EF) were measured by echocardiography M-Mode in C57BL6 mice, 2-4 mo old, pretreated with RAN (750mg/kg/day, a dose comparable to the one used in humans) per os for 3 days. RAN was then administered for additional 7 days, alone and together with T (2.25 mg/kg/day ip), according to our well established protocol. Results: In our in vivo studies, after 7 days with T, FS decreased to 49 ± 1.5%, p < 0.01 vs 60 ± 0.5% (sham), and EF to 81 + 2%, p < 0.01 vs 91 ± 1% (sham). RAN alone did not change FS (59 ± 2%) nor EF 89 ± 1%. Interestingly, in mice treated with RAN and T, RAN prevents the reduction of EF and FS vs T alone (FS was 58 ± 1%, EF was 90 ± 1%, p = 0.01 and p < 0.01 respectively). Conclusions: In our mouse model, T produces LV dysfunction and RAN blunts T cardiotoxic effects. We plan to test RAN as a cardioprotective agent with other target-therapy drugs in our experimental models and to define the mechanisms of cardioprotection.

Background: Obesity is associated with an increased risk of breast cancer (BC) recurrence and decreased survival, also in case of adjuvant endocrine therapy. It is still not clear whether the activity of aromatase inhibitors and tamoxifen (T) given as adjuvant therapy is affected by body mass index (BMI), although both drugs are widely prescribed. In this analysis, we explored the outcome of TEAM patients (pts) treated with exemestane (E) versus T (2.75 yrs), and with E versus T followed by E (T/E) (5 yrs) in relation to BMI. Patients and Methods: The TEAM trial is a randomized, international phase III study in postmenopausal hormone sensitive early BC pts comparing the activity and safety of adjuvant E (25 mg daily) or the sequence of T (20 mg daily) followed by E (T/E), both regimens given for five years. WHO BMI definitions were used: normal 18.5-24.9 kg/m2, overweight 25-30 kg/m2, obese >30 kg/m2. Disease-free survival (DFS) and overall survival (OS) were calculated by Kaplan-Meier method; results were compared by using the log-rank test and Cox proportional hazard modelling adjusted for country. Results: Weight and height was known in 4741 pts. Mean BMI was 26.9 kg/m2 (SD 4.9); 39% had a normal BMI, 36.9% overweight, and 23.3% of pts was obese. Underweight pts (n=41, 0.9%) were excluded from further analysis. At 2.75 yrs (E vs T) disease relapse in normal weight, overweight and obese pts using E was observed in 8.1%, 6.8% and 7.5% respectively (p=0.57), and in 9.1%, 8.8%, and 12.5%, respectively (p=0.06) of pts using T. The hazard ratio (HR for risk of relapse on E vs T) in the three subgroups was 0.91 (95%CI 0.66-1.24), 0.78 (95%CI 0.55-1.089), and 0.57 (95%CI 0.39-0.84, p=0.004), respectively. At a median follow-up of 5.1 years, disease relapse in normal weight, overweight and obese pts using E occurred in 14.8%, 15.1% and 15.1%, respectively; and in pts using T in 17.0%, 16.9%, and 18.3%, respectively. Regarding DFS, the HR in normal weight, overweight, and obese pts was 0.87 (95%CI 0.69-1.10), 0.88 (95%CI 0.70-1.11), and 0.75 (95%CI 0.56-1.01, p=0.058), respectively, and with respect to OS 0.87 (95%CI 0.65-1.15, p= 0.32), 0.89 (95%CI 0.67-1.18, p= 0.43), and 0.71 (95% CI 0.51-1.01, p= 0.053), respectively. Conclusions: After 2.75 years more disease events were observed in obese women using tamoxifen, which was not seen in obese exemestane users, whereas at 5 years these differences in disease recurrences disappeared in this group. In contrast to recent reports, there seems to be a difference regarding the influence of a high BMI on recurrence rate between tamoxifen and the aromatase inhibitor exemestane. Further research on this topic is warranted. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S2-3.

Background Abiraterone irreversibly inhibits 17-hydroxylase/c-17-20 lyase (CYP17), reducing androgen and estrogen levels and improves overall survival from castration resistant prostate cancer. We hypothesized that: A) Postmenopausal ERα+ MBC continue to be ERα + /AR driven; and, B) Postmenopausal ERα- AR+ MBC can be driven by AR. Methods This Phase I/II trial of AA with hydrocortisone evaluated tolerability, pharmacokinetic (PK)-pharmacodynamic (PD) profile and anti-tumor activity. Two parallel but non-randomized Phase II arms utilized a Gehan design (95% probability of detecting a 24wk clinical benefit rate (CBR, partial response [PR] + stable disease) of > 20%; 14 patients [pts] in the first stage; 11 in the second stage for each arm). Prior therapy with ≥ 2 lines of endocrine therapy (for ERα+ arm); ≥ 1 line of chemo (for AR + ERα- arm); and prior trastuzumab if HER2-positive was required. ERα and AR positivity was defined as immunoreactivity in ≥ 1% cells. Results In the phase I study, daily dosing of AA was well tolerated with variable PK at all dose levels. PD studies of CYP17 blockade demonstrated suppression of circulating estradiol and androgen levels below the limit of assay detection with 1000mg and 250-2000mg AA respectively; 1000mg was selected for Phase II evaluation. In the ERα+ arm, 6 pts (Phase I) and 25pts (Phase II) received 1000mg AA, of whom 4 were HER2-positive. The median age (range) was 60 (46-80), prior lines of hormonal and chemotherapy were 3 (2-4) and 2 (0-5) respectively. There was 1 partial response (PR) lasting 14m in a pt who had received 4 and 5 lines of hormonal and chemotherapy respectively. Median progression-free survival was 11wk. CBR at 24wk was 21%. In the AR + ERα- arm, recruitment is ongoing. Hypokalaemia easily managed by hydrocortisone administration, was the commonest drug related adverse event (AE). Conclusion AA was well tolerated and merits further evaluation in MBC. Cancer Research UK (Drug Development Office) Sponsored and funded the trial. Johnson & Johnson provided AA. Disclosure M. Dowsett: The Institute of Cancer Research has a commercial interest in Abiraterone. Mitch Dowsett is an employee of the Institute of Cancer Research, which has a ‘Rewards to Inventors’ scheme and is a recipient of the scheme. J.S. de Bono: The Institute of Cancer Research has a commercial interest in Abiraterone. Prof de Bono is an employee of the Institute of Cancer Research, and recipient of a ‘Rewards to Inventors’ scheme. He is also a consultant for Johnson and Johnson. All other authors have declared no conflicts of interest.

Background SECRAB, a randomised trial comparing sequential (Seq) to synchronous (Syn) chemo-radiation using a CMF or Anthracycline-CMF regimen, demonstrates reduces local recurrence rates after Syn treatment for early breast cancer (EBC) (Fernando 2011 EJC:47 S2). Cosmesis study results are presented. Methods 2296 women were randomised and cosmesis was assessed in 382. Cosmesis and telangiectasia were assessed as excellent, good, moderate and poor for patients having wide local excision (WLE) while telangiectasia alone was assessed for those having mastectomy. Photographs were taken for 301 patients for blinded independent review using a consensus method (Haviland 2008 Clin Oncol 20:497). Patient perception was assessed using EORTC BR23 quality of life questionnaire (Q 39-42). Assessments were made at baseline, 1, 2 and 5 years post surgery. Results The results of clinician assessed cosmesis and telangiectasia are shown below. There was no statistically significant difference between the arms Table: 253PD Category Odds Ratio (OR) Excellent Good Moderate/Poor (95% CI) Seq Syn Seq Syn Seq Syn Excellent/good vs moderate/poor Cosmesis, n (%) 14 (23) 15 (21) 37 (60) 37 (51) 11 (18) 21 (29) 1.87, (0.82,4.27) p = 0.1 Telangiectasia, n (%) 79 (68) 99 (62) 33 (28) 54 (34) 4 (4) 7 (4) 1.28, (0.37,4.48) p = 0.7 Data on independent assessment of change in breast appearance after WLE was available for 145 (98%) patients. Minimal, mild and marked changes were observed in 70, 29 and 1% of patients respectively for the Syn arm and 72, 28 and 0% for the Seq arm. There was no difference between treatment arms (OR, mild/marked vs minimal, 1.10, 95% CI 0.54-2.26, p = 0.8). There was no change in patient's perception of their breast appearance (baseline vs. final assessment questionnaire). Conclusions There was no significant difference in cosmesis or telangiectasia between the two arms as assessed by the clinician or by independent photographic review. There was no difference in patient perception of breast appearance. Contrary to the result of the main study, which showed a borderline significant worsening of telangiectasia in the Syn arm, no such difference was seen in the cosmesis study. Syn chemo-radiation reduces local recurrence in EBC without affecting cosmesis. Disclosure All authors have declared no conflicts of interest.

Background Doxorubicin (DOX) produces a well-known cardiomyopathy through multiple mechanisms, which include, among many, Ca2+ overload due to reduced SERCA2a activity and inappropriate opening of the RyR2, and impaired myocardial energetics. DOX generates Reactive Oxygen and Nitrogen Species (ROS and RNS), posing the heart at increased demand for oxygen, setting the stage for metabolic ischemia that also activates late INa, target of ranolazine (RAN). Here, we aim at assessing whether RAN, diminishing intracellular Ca2+ through inhibition of late INa, and enhancing myocardial glucose utilization (and/or reverting impairment of glucose utilization caused by chemotherapy) prevents DOX cardiotoxicity. Methods We measured left ventricular (LV) function with fractional shortening (FS) by echocardiography in C57BL6 mice, 2-4 mo old, pretreated with RAN (370mg/kg/day, a dose comparable to the one used in humans) per os for 3 days. RAN was then administered for additional 7 days, alone and together with DOX (2.17mg/kg/day ip), according to our well established protocol. Hearts were then excised, mRNA expression was analyzed by qRT- PCR, interstitial fibrosis with picrosirius red staining. By Western blotting, we measured the activation of the apoptotic pathway. Results After 7 days with DOX, FS decreased to 50 ± 2%, p = .002 vs 60 ± 1% (sham). RAN alone did not change FS (59 ± 2%). Interestingly, in mice treated with RAN + DOX, the reduction in FS was milder: 57 ± 1%, p = 0.01 vs DOX alone. DOX-cardiotoxicity was accompanied by significant elevations in ANP (1000 folds), BNP (500 folds), CTGF (26 folds) and MMP2 (81 folds) mRNAs, while co-treatment with RAN significantly lowered these same genes compared to DOX. The alterations in extracellular matrix remodeling were confirmed by an increase of interstitial collagen with DOX (3.66%), p = .004 vs 2.19% (sham), which was normal in hearts co-treated with RAN (2.02%, p = .0002 vs DOX). Finally, the levels of PARP and pro-Caspase 3 were significantly decreased in DOX (indicating activation of apoptosis) but not in RAN + DOX. Conclusions In mice, RAN prevents DOX cardiotoxic effects. We plan to test RAN as a cardioprotective agent with other antineoplastic cardiotoxic drugs in mice, and to better characterize the cardioprotective mechanisms of RAN in these settings. Disclosure All authors have declared no conflicts of interest.

A. Valachis, A. Nearchou, N.P. Polyzos, D. Mauri, P.A. Lind. General Hospital of Eskilstuna, Department of Oncology, Eskilstuna, Sweden; Panhellenic Association for Continual Medical Research (PACMeR), Section of Obstetrics & Gynecology, Athens, Greece; Panhellenic Association for Continual Medical Research (PACMeR), Section of Oncology, Lamia, Greece; Karolinska Institute, Oncology, Stockholm, Sweden

e11040 Background: Anti-ErbB2 therapies are associated with increased risk of left ventricular (LV) dysfunction. Trastuzumab increases the frequency of asymptomatic decrease in LV ejection fraction (LVEF) by 3-18%, and the risk of heart failure (HF) by 2-4%. The newer ErbB2 antibody rhuMAb 2C4 (pertuzumab) seems to affect ligand induced ErbB signaling in a more direct fashion, affecting EGFR/ErbB2 dimerization; yet, its cardiac side effects are only beginning to emerge. Here, we test whether the murine 2C4 induces cardiac dysfunction in normal mice. Methods: In vivo cardiac function was measured with LV fractional shortening (FS) by M-mode echocardiography in sedated C57BL/6 mice (2-4 mo. old) at day 0, and after 2 and 6 days of daily i.p. administration of 2C4 (2.25 μg/g/day) or doxorubicin (Doxo, 2.17 μg/g/day) as a positive control, and in sham animals. With Speckle Tracking echocardiography (ST) we also evaluated radial myocardial strain (%), a very sensitive parameter which can predict LV dysfunction...

e13612 Background: The mTOR inhibitor temsirolimus is being evaluated for anticancer efficacy in hundreds of clinical trials and is approved for treatment of advanced renal cell carcinoma. The PI3K...

Background: The TEAM (Tamoxifen Exemestane Adjuvant Multinational) trial is a contemporary multinational study of the effects of 5 years of adjuvant hormonal therapy, either exemestane (E) or tamoxifen switching to E (TàE). Five-year results were presented at SABCS 2009 showing no difference in outcome between E vs TàE (Rea D, SABCS Abstract 11), thus giving us the opportunity to analyze the causes of mortality in the entire population of 9766 women. Methods: Postmenopausal women with hormone receptor positive (HR+) early breast cancer (BC) were randomized to E or TàE for 5 years after completion of surgery, adjuvant chemotherapy (when indicated), and radiation therapy based on local guidelines. All data were collected and analyzed at the Central Data Center in Leiden. The primary outcome of DFS as well as safety and other secondary outcomes were analyzed in 2009 after 1285 events had occurred to trigger the analysis. Results: Between 2001 and January 2006, 9766 women were randomized; 100% were HR+, 50% had node negative disease, 68% received adjuvant radiotherapy, and 36% received adjuvant chemotherapy. The median follow-up was 5.1 years with over 60% of women having been followed for 5 or more years. Among 961 deaths, 568 (59%) were caused by BC and 393 (41%) by causes other than BC. The cumulative incidence of death from BC vs. other causes at 5-years for all women and by nodal status is as follows (see table): There was a general relationship with non-breast cancer deaths and increasing age at diagnosis (≥70 years), as expected. Non-breast cancer causes of mortality included second malignancy (105); cardiac (71), cerebral (33), or pulmonary (28) events; miscellaneous other causes (105); and unknown (51). Conclusions: Among 9766 postmenopausal women with HR+ BC treated with contemporary hormonal strategies following standard primary treatment, the probability of death from causes other than BC was nearly as high as the probability of dying from BC. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD08-03.

1052 Background: Aromatase inhibitors (AI) block estrogen synthesis and are effective for the treatment of estrogen receptor (ER) positive breast cancer in postmenopausal women. Despite initial benefit, resistance to AIs and disease progression occur, at which point cytotoxic chemotherapy is often the remaining treatment option. Entinostat, an oral class 1 isoform-selective HDACi, has been shown in preclinical studies to restore sensitivity to acquired AI resistance. The goal of this study was to determine whether the addition of entinostat to AI therapy in patients currently progressing on AI therapy could restore AI sensitivity and prolong the clinical benefit. Methods: Postmenopausal women with ER+ breast cancer progressing on an AI after 3 months were enrolled. Additional entry criteria included measurable disease by RECIST and ≤1 chemotherapy for metastatic disease. Patients with rapidly-progressive breast cancer were excluded. Patients continued with the AI on which they progressed plus entinostat 5...

ABSTRACT WITHDRAWN: This abstract was withdrawn by the authors prior to the start of the Symposium. Background: Current evidence for HER2/TOP2A as predictive biomarkers of anthracycline response is conflicting. An interim meta-analysis (Di Leo et al Cancer Res;69:99S SABCS2009) suggested a weak, statistically significant, association between TOP2A and anthracycline benefit. We previously showed duplication of chromosome 17 alpha satellite (CEP17) predicted sensitivity to anthracyclines independently in three trials (BR9601, NEAT and MA.5, Bartlett et al Cancer Res 69:74S/364S). We performed a retrospective meta-analysis, incorporating data from 4 trials (including the Belgium study), to test the hypothesis that CEP17 is a predictive biomarker for anthracycline benefit in order to provide a unifying hypothesis in trials for which previous biomarker data is conflicting.Methods: FISH was performed in 2 labs (Bartlett lab for BR9601/NEAT & Belgian studies & O'Malley lab for MA5). ER/PgR (IHC) etc were collected from trial Case Report Forms. BR9601/NEAT and Belgian study tumors were scored counting all cells with a minimum of one CEP17 signal/cell: in MA.5 a minimum of 2 CEP17 signals were required for cells to be scored. These methodological differences did not affect HER2/CEP17 ratios but necessitated different definitions for CEP17 duplication defined as >1.86 observed copies/cell for BR9601, NEAT and JB (Watters BCRT 2003 77:109-14) and >2.25 for MA.5 (Goetz 2004).Results: FISH was successful in 85% (2531/2975) of cases. CEP17 duplication was detected in 27.5% of tumors (BR9601=37.6%, NEAT=20.0%, MA5=40.2% & JB=28.5%) and was associated with poorer RFS & OS (HR 0.80 95%CI 0.7-0.92 p=0.011 & HR 0.79, 95%CI 0.68-9.92, p=0.018, respectively).A significant treatment*marker interaction was observed in a meta-analysis of all data (2531 cases) as univariate(p

Background: The Tamoxifen and Exemestane Adjuvant Multinational (TEAM) trial included prospectively planned biomarker studies to identify prognostic and predictive biomarkers for patients receiving endocrine therapy. Quantitative IHC data for ER/PgR (Can Res 69:83S, SABCS2008), HER2, HER3 and Ki67 was available for the current analysis relative to outcome of estrogen receptor–positive (ER+) early postmenopausal breast cancer (BC) patients treated with exemestane versus tamoxifen.Patients & Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative analysis of hormone receptors (HER2/3) by conventional IHC, and image analysis derived continuous scores for Ki67/ER/PgR were analyzed relative to disease-free survival and treatment on an intent to treat basis using survival data for the first 2.75 years of the TEAM trial. Data on HER2FISH and EGF Receptor IHC will be presented.Results: Of 4595 eligible cases samples received, 16 were excluded, 271 had incomplete biomarker data, leaving 4308 patients for the final biomarker analysis. 1275 (30%) cases were HER2/3 positive.A significant treatment by marker effect was observed for exemestane versus tamoxifen with HER2/3 negative cases deriving benefit from aromatase inhibitor treatment (HER2/3-ve HR=0.69 95%CI, 0.53-0.88; HER2/3 pos HR, 1.13; 95%CI, 0.82–1.55; p=0.016 for interaction in multivariate analysis). By conventional and STEPP analysis no predictive effect of Ki67 was observed. In multivariate regression analysis increased HER2 expression (P=0.0001) decreased PgR expression (P Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 75.

Background: Exemestane (E) is a steroidal aromatase inhibitor (AI) with an established role in early breast cancer after 2–3 years of tamoxifen (T). Additionally, AIs have shown superiority to T as initial adjuvant therapy. The Tamoxifen Exemestane Adjuvant Multinational (TEAM) study has been prospectively designed to compare the role of E as initial adjuvant therapy with a sequential approach of T followed by E (T→E).Methods: Postmenopausal patients with hormone receptor–positive early breast cancer were randomized to open-label E 25 mg/d or T 20 mg/d. All patients completed surgery and chemotherapy, if indicated. Data were collected and analyzed by the Central Data Center in Leiden, The Netherlands. The trial was initiated in 2001 with the primary objective being a comparison of disease-free survival (DFS) with T vs E. In 2004, TEAM was modified in response to new data; all those initially receiving T were switched to E after 2.5–3 years. An additional 2500 patients were recruited and randomized at diagnosis to E or T→E for 5 years. The modified study design includes 2 coprimary endpoints: (1) DFS of T vs E that was previously reported at 2.75 years median follow-up (Jones S et al, abstract #15 presented at SABCS 2008); and (2) DFS at 5 years of E vs T→E that will be the focus of results presented here.Results: Between 2001 and January 2006, 9775 women were randomized to TEAM. In total, 99% of patients were ER+ and/or PgR+, 50% were node-negative, 44% underwent mastectomy, 68% received radiotherapy, and 36% received chemotherapy. In September 2009, median follow-up will be 5.5 years and the protocol-specified 1285 overall DFS events (locoregional or distant recurrence, second breast cancers, or death without recurrence) will have occurred, allowing for analysis of the second coprimary endpoint. We will present a detailed analysis of the 5-year results from theTEAM trial, the only prospectively powered randomized trial to compare 5 years of an initial AI vs T→AI, 2 commonly received adjuvant therapies for women with hormone receptor–positive early breast cancer. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 11.