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Breast cancer is the most common malignancy in women, with the majority classified as hormone receptor–positive (HR+) and HER2 receptor–negative (HER2−). After the approval of the CDK4/6 inhibitors, palbociclib, ribociclib and abemaciclib for advanced HR+/HER2− breast cancer, combinations of endocrine therapy (ET) and CDK4/6 inhibitors are becoming routine practice. However, drug resistance remains an important issue. To overcome this, multiple targeted therapies are in development, and several approaches are in clinical trial in combination with ET, including drugs that inhibit CDK7, FGFR, AURKA, HDAC and the PI3K–AKT–mTOR pathway. Triple combinations of investigational drugs with ET and CDK4/6 inhibitors are also being trialled.

Background: The effect of the COVID-19 on breast cancer treatment is unknown. The pandemic’s impact on treatment delivery was assessed in patients undergoing chemotherapy treatment at a major London oncology centre. Methods: Treatment and medical records for all patients attending the chemotherapy unit and on outpatient treatment for breast cancer over an 8 week period (during first lockdown; 23rd March-17th May 2020) were compared to a similar time period in 2019. Results: Breast cancer diagnosis referrals fell by 38% mainly due to screening services halting which had a knock-on effect on patient numbers starting their first treatment (reduced by 34%). Neoadjuvant, adjuvant, and palliative patients were all affected, mostly at the start of lockdown. On-site chemotherapy and supportive treatments fell by 39% compared to 2019, mainly due to fewer number of bone-modifying agents. Towards the end of 8 week period, treatment numbers had nearly returned to normal. The system adapted by modifying treatment regimens, using telemedicine, increased use of supportive medications and less frequent blood tests. Conclusion: COVID-19’s global impact has significantly reduced breast cancer treatments given during the first lockdown. Whilst recovery is now evident, cancer services, patients, and clinical cancer research must be prioritised in future waves.

The peri‐operative use of angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers is thought to be associated with an increased risk of postoperative acute kidney injury. To reduce this risk, these agents are commonly withheld during the peri‐operative period. This study aimed to investigate if withholding angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers peri‐operatively reduces the risk of acute kidney injury following major non‐cardiac surgery. Patients undergoing elective major surgery on the gastrointestinal tract and/or the liver were eligible for inclusion in this prospective study. The primary outcome was the development of acute kidney injury within seven days of operation. Adjusted multi‐level models were used to account for centre‐level effects and propensity score matching was used to reduce the effects of selection bias between treatment groups. A total of 949 patients were included from 160 centres across the UK and Republic of Ireland. From this population, 573 (60.4%) patients had their angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers withheld during the peri‐operative period. One hundred and seventy‐five (18.4%) patients developed acute kidney injury; there was no difference in the incidence of acute kidney injury between patients who had their angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers continued or withheld (107 (18.7%) vs. 68 (18.1%), respectively; p = 0.914). Following propensity matching, withholding angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers did not demonstrate a protective effect against the development of postoperative acute kidney injury (OR (95%CI) 0.89 (0.58–1.34); p = 0.567).

The role of estrogen receptor (ER) α as a target in treatment of breast cancer is clear, but those of ERβ1 and ERβ2 in the breast remain unclear. We have examined expression of all three receptors in surgically excised breast samples from two archives: (i): 187 invasive ductal breast cancer from a Japanese study; and (ii) 20 lobular and 24 ductal cancers from the Imperial College. Samples contained normal areas, areas of hyperplasia, and in situ and invasive cancer. In the normal areas, ERα was expressed in not more than 10% of epithelium, whereas approximately 80% of epithelial cells expressed ERβ. We found that whereas ductal cancer is a highly proliferative, ERα-positive, ERβ-negative disease, lobular cancer expresses both ERα and ERβ but with very few Ki67-positive cells. ERβ2 was expressed in 32% of the ductal cancers, of which 83% were postmenopausal. In all ERβ2-positive cancers the interductal space was filled with dense collagen, and cell nuclei expressed hypoxia-inducible factor 1α. ERβ2 expression was not confined to malignant cells but was strong in stromal, immune, and endothelial cells. In most of the high-grade invasive ductal cancers neither ERα nor ERβ was expressed, but in the high-grade lobular cancer ERβ was lost and ERα and Ki67 expression were abundant. The data show a clear difference in ER expression between lobular and ductal breast cancer and suggest (i) that tamoxifen may be more effective in late than in early lobular cancer and (ii) a potential role for ERβ agonists in preventing in situ ductal cancers from becoming invasive.

Background There have been many randomised trials of adjuvant tamoxifen among women with early breast cancer, and an updated overview of their results is presented. Methods In 1995, information was sought on each woman in any randomised trial that began before 1990 of adjuvant tamoxifen versus no tamoxifen before recurrence. Information was obtained and analysed centrally on each of 37 000 women in 55 such trials, comprising about 87% of the worldwide evidence. Compared with the previous such overview, this approximately doubles the amount of evidence from trials of about 5 years of tamoxifen and, taking all trials together, on events occurring more than 5 years after randomisation. Findings Nearly 8000 of the women had a low, or zero, level of the oestrogen-receptor protein (ER) measured in their primary tumour. Among them, the overall effects of tamoxifen appeared to be small, and subsequent analyses of recurrence and total mortality are restricted to the remaining women (18 000 with ER-positive tumours, plus nearly 12 000 more with untested tumours, of which an estimated 8000 would have been ER-positive). For trials of 1 year, 2 years, and about 5 years of adjuvant tamoxifen, the proportional recurrence reductions produced among these 30 000 women during about 10 years of follow-up were 21% (SD 3), 29% (SD 2), and 47% (SD 3), respectively, with a highly significant trend towards greater effect with longer treatment (χ21=52·0, 2p Interpretation For women with tumours that have been reliably shown to be ER-negative, adjuvant tamoxifen remains a matter for research. However, some years of adjuvant tamoxifen treatment substantially improves the 10-year survival of women with ER-positive tumours and of women whose tumours are of unknown ER status, with the proportional reductions in breast cancer recurrence and in mortality appearing to be largely unaffected by other patient characteristics or treatments.

Circulating tumor cells (CTCs) have been studied in breast cancer with the CellSearch(R) system. Given the low CTC counts in non-metastatic breast cancer, it is important to evaluate the inter-reader agreement., JOURNAL ARTICLE, SCOPUS: ar.j, info:eu-repo/semantics/published

Estrogens have long been recognized as being important for stimulating the growth of a large proportion of breast cancers. Now it is recognized that estrogen action is mediated by two receptors, and the presence of estrogen receptor alpha (ER alpha) correlates with better prognosis and the likelihood of response to hormonal therapy. Over half of all breast cancers overexpress ER alpha and around 70% of these respond to anti-estrogen (for example tamoxifen) therapy. In addition, the presence of elevated levels of ER alpha in benign breast epithelium appears to indicate an increased risk of breast cancer, suggesting a role for ER alpha in breast cancer initiation, as well as progression. However, a proportion of ER alpha-positive tumors does not respond to endocrine therapy and the majority of those that do respond eventually become resistant. Most resistant tumors remain ER alpha-positive and frequently respond to alternative endocrine treatment, indicative of a continued role for ER alpha in breast cancer cell proliferation. The problem of resistance has resulted in the search for and the development of diverse hormonal therapies designed to inhibit ER alpha action, while research on the mechanisms which underlie resistance has shed light on the cellular mechanisms, other than ligand binding, which control ER alpha function.

Background: [18F]ICMT-11 is an isatin analogue which has been developed by our group as a novel PET radiotracer for studies of apoptosis in vivo. Preclinical studies have demonstrated subnanomolar affinity to caspase 3, and validated the potential for imaging apoptosis in xenograft models. A first-in-man study showed that the agent was well tolerated with acceptable dosimetry. This is the first study of this agent to measure the effect of chemotherapy on radiotracer uptake in patients. As apoptosis is a dynamic process, one of the main objectives of the study was to determine the optimal time-point for imaging post-chemotherapy and compare the results with immunohistochemistry assessments at the same time-points. The study was approved by a regional ethics committee and ARSAC. Methods: 7 patients with breast tumour lesions measuring 15mm or more, due to undergo neoadjuvant chemotherapy with FEC (5FU, Epirubicin, Cyclophosphamide) had dynamic PET scans for 66mins 30seconds following intravenous injection of [18F]ICMT-11 with a mean activity of 340.82 Mbq±20.76 and Specific Activity range of 447.014-5128.34 Gbq/µmol prior to chemotherapy and 24h-2 weeks post-chemotherapy. A breast biopsy was also obtained within a few hours of the 2nd PET scan to correlate apoptosis in the breast tissue utilising TUNEL and Caspase 3 staining by immunohistochemistry. Volumes of interest were drawn manually and analyzed using Analyze software®. Results: The scans were well tolerated in all patients. Uptake of [18F]ICMT-11 was demonstrated in all tumor lesions. The tumours studied included ER positive and PR positive, HER2 positive and triple negative patients. The first cohort patients were imaged pre-chemotherapy and 24-48h post chemotherapy. Tumour to Breast ratio (TBR) showed an increase from 1.42±0.21(pre) to 1.71±0.33 (post). Tumour to muscle ratio (TMR) was not increased, 1.52±0.30(pre) and 1.22±0.09 (post). In addition, an increase the SUV was noted in the lymph nodes of patients, at both 24 and 48h. (SUVav 0.39±0.02 (pre), 0.45±0.03 (post), and SUVmax 0.87± 0.02(pre) ,1.22±0.12 (post). The lymph nodes were however not sampled for immunohistochemistry. A further cohort of patients had the follow-up scan 2 weeks post chemotherapy, TBR and TMR were both increased in this cohort 1.50±0.22 (pre), 2.52±0.48 (post),and 1.82±0.10 (pre), 2.08±0.0.04 (post), respectively. Caspase and TUNEL labelling with immunohistochemistry also showed increased in apoptosis in the breast biopsies at 2 weeks compared to baseline in keeping with the PET data. Conclusion: These preliminary data suggest that [18F]ICMT-11 is a promising marker for chemotherapy induced apoptosis in vivo, and correlates with findings in tumor biospsies using TUNEL and immunostaining for caspase 3. Further work is underway to study a larger cohort of patients, and identify the optimal PET pharmacokinetic parameter to describe [18F]ICMT-11 uptake and retention. Citation Format: Shairoz Merchant, Eric O Aboagye, Adrian Lim, Kasia Kozlowski, Naina Patel, Jennifer Steel, Susan Cleator, Sami Shousha, Vidhya Varghese, Raoul C Coombes, Laura Kenny. Evaluation of apoptosis in breast cancer using the novel PET probe [18F]ICMT-11 in patients treated with neoadjuvant FEC chemotherapy: Initial assessment of optimum imaging time and relation to caspase-3 immunostaining [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-01-02.

The objective of this study was to evaluate the clinical response of locally advanced breast cancer (LABC) to neoadjuvant (NA) chemotherapy with 5-fluorouracil, epirubicin and cyclophosphamide (FEC) and to study the role of docetaxel in patients who fail to respond to first-line chemotherapy. Patients were enrolled who had primary tumours without distant metastasis that were too extensive for conservative surgery. All underwent NA chemotherapy for breast cancer and thereafter surgery and/or radical radiotherapy. NA chemotherapy with FEC was administered to 88 patients between February 1998 and June 2005. A median of 6 cycles of FEC (range 1-8) was given, followed in 21 cases by a median of 4 cycles (range 2-6) of docetaxel. Where clinically established, with FEC the clinical complete response (cCR) was 22/81 (27%), clinical partial response (cPR) 41/81 (51%), clinical stable disease (cSD) 18/81 (22%). In patients where the response to FEC was regarded as insufficient, docetaxel was given. Response rates were cCR 3/21 (14%); cPR 10/21 (48%), cSD 8/21 (38%). There were 11 cases of pathological complete response (pCR), 9 in the FEC-only group and 2 in the docetaxel group. Following chemotherapy 49 (56%) patients underwent mastectomy, 32 (36%) breast conserving surgery and 5 (6%) radical radiotherapy, giving a breast conservation rate of 42%. Two patients died before receiving surgery or radical radiotherapy. The results show that neoadjuvant FEC is a reasonable NA therapy in breast cancer and that docetaxel is effective in FEC refractory cases. Only 8 of 81 (10%) assessable patients did not respond to any chemotherapy, giving an overall clinical response rate of 90%, which is comparable to studies in which taxanes were given irrespective of response to preceding therapy with antracycline including regimes.

Background Brain metastases are common in human epidermal growth factor receptor (Her)-2-positive breast cancer. Drug access to brain metastases and normal brain is key to management of cranial disease. In this study, positron emission tomography (PET) scanning after administration of radiolabelled lapatinib was used to obtain direct evidence of cranial drug access. Methods Patients with Her-2+ metastatic breast cancer either with at least one 1-cm diameter brain metastasis or without brain metastases underwent dynamic carbon-11 radiolabelled lapatinib ([11C]lapatinib)-PET. Less than 20 μg of [11C]lapatinib was administered before and after 8 days of oral lapatinib (1,500 mg once daily). Radial arterial blood sampling was performed throughout the 90-min scan. The contribution of blood volume activity to the tissue signal was excluded to calculate lapatinib uptake in normal brain and metastases. Partitioning of radioactivity between plasma and tissue (V T) was calculated and the tissue concentration of lapatinib derived. Plasma lapatinib levels were measured and adverse events noted. Results Six patients (three with brain metastases) were recruited. About 80% plasma radioactivity corresponded to intact [11C]lapatinib after 60 min. PET signal in the brain corresponded to circulating radioactivity levels, with no [11C]lapatinib uptake observed in normal brain tissue. In contrast, radioactivity uptake in cranial metastases was significantly higher (p = 0.002) than that could be accounted by circulating radioactivity levels, consistent with [11C]lapatinib uptake in brain metastases. There was no difference in lapatinib uptake between the baseline and day 8 scans, suggesting no effect of increased drug access by inhibition of the drug efflux proteins by therapeutic doses of lapatinib. Conclusions Increased lapatinib uptake was observed in brain metastases but not in normal brain. Trial registration ClinicalTrials.gov: NCT01290354