Surgical Oncology

NEW ORLEANS – Renal mass biopsy has traditionally played a restricted diagnostic role, but with its improved diagnostic accuracy, it is becoming a viable clinical tool in the modern era, according to Dr. Matthew Maurice.

“We were seeking to understand the current role of biopsy in the management of renal masses, said Dr. Maurice, a urology resident at University Hospitals Case Medical Center in Cleveland. “We used the National Cancer Database and looked at data from 2003 to 2011; what we saw was a rise in renal mass biopsy in the final 3 years of the study. It’s a very small increase, but a statistically significant increase, with people in 2011 having 1.3 times higher odds of being biopsied than they would have had in 2003.”

Dr. Maurice and his colleagues at Case Medical conducted a study examining renal mass biopsy use in the modern era, and presented their findings in a poster at the annual meeting of the American Urological Association.

Using the National Cancer Database (NCDB), Dr. Maurice and his colleagues identified all patients diagnosed with renal cell carcinoma (RCC) between 2003 and 2011. Patients within the RCC cohort were then classified as having undergone renal biopsy or not. Renal biopsy utilization rates were plotted over time, and patient, disease, provider, and treatment variables were evaluated via univariate and multivariate logistic regression models to determine the predictors of renal biopsy.

Out of 304,583 patients with kidney cancer, 35,942 patients (11.8%) underwent renal mass biopsy. From 2009 to 2011, Dr. Maurice and his coinvestigators observed a significant increase in biopsy use; patients diagnosed with a renal mass in 2011 had 1.3 times higher odds of being biopsied compared with those diagnosed in 2003 (odds radio, 1.3, confidence interval, 1.3-1.4, P < .01).

Eventual treatment was the strongest predictor of biopsy utilization. “Patients receiving observation or thermal ablative therapy (either cryoablation or radiofrequency ablation) were much more likely to receive biopsy than were those who received surgical therapy such as radical or partial nephrectomy,” Dr. Maurice explained. “So it seems like those treatments are driving the use of renal biopsy utilization in contemporary patients.”

Compared to patients treated with partial nephrectomy, patients managed with observation, cryoablation, or radiofrequency ablation had 4.2, 8.0, and 19.1 times the odds of being biopsied, respectively (OR, 4.2, CI, 4.0-4.5, P < .01; OR, 8.0, CI, 8.0-8.1, P < .01; OR, 19.1, CI, 18.4-19.7, P < .01). Patients with other known cancers, bulky lymph node involvement, or small masses ranging from 2 to 4 cm in size were also more likely to be biopsied (P < .01).

“Nonacademic hospitals were more likely to biopsy,” he added. “It could be that these hospitals are using observation and thermal ablative therapies more frequently.” Conversely, wealthier patients, patients treated at academic hospitals, and patients treated in the Northeast were significantly less likely to be biopsied. (P < .01).

On the basis of the data analyzed in this study, Dr. Maurice and his colleagues concluded that there is a trend in use of renal mass biopsy in nonacademic centers in recent years, particularly among patients with small renal masses and in those who eventually undergo observation or focal ablative therapies. Lesser indications predicting the usage of renal mass biopsy include the existence of other primary cancers and bulky lymph nodes.

Dr. Maurice reported no relevant financial relationships.

NEW ORLEANS – Renal mass biopsy has traditionally played a restricted diagnostic role, but with its improved diagnostic accuracy, it is becoming a viable clinical tool in the modern era, according to Dr. Matthew Maurice.

“We were seeking to understand the current role of biopsy in the management of renal masses, said Dr. Maurice, a urology resident at University Hospitals Case Medical Center in Cleveland. “We used the National Cancer Database and looked at data from 2003 to 2011; what we saw was a rise in renal mass biopsy in the final 3 years of the study. It’s a very small increase, but a statistically significant increase, with people in 2011 having 1.3 times higher odds of being biopsied than they would have had in 2003.”

Dr. Maurice and his colleagues at Case Medical conducted a study examining renal mass biopsy use in the modern era, and presented their findings in a poster at the annual meeting of the American Urological Association.

Using the National Cancer Database (NCDB), Dr. Maurice and his colleagues identified all patients diagnosed with renal cell carcinoma (RCC) between 2003 and 2011. Patients within the RCC cohort were then classified as having undergone renal biopsy or not. Renal biopsy utilization rates were plotted over time, and patient, disease, provider, and treatment variables were evaluated via univariate and multivariate logistic regression models to determine the predictors of renal biopsy.

Out of 304,583 patients with kidney cancer, 35,942 patients (11.8%) underwent renal mass biopsy. From 2009 to 2011, Dr. Maurice and his coinvestigators observed a significant increase in biopsy use; patients diagnosed with a renal mass in 2011 had 1.3 times higher odds of being biopsied compared with those diagnosed in 2003 (odds radio, 1.3, confidence interval, 1.3-1.4, P < .01).

Eventual treatment was the strongest predictor of biopsy utilization. “Patients receiving observation or thermal ablative therapy (either cryoablation or radiofrequency ablation) were much more likely to receive biopsy than were those who received surgical therapy such as radical or partial nephrectomy,” Dr. Maurice explained. “So it seems like those treatments are driving the use of renal biopsy utilization in contemporary patients.”

Compared to patients treated with partial nephrectomy, patients managed with observation, cryoablation, or radiofrequency ablation had 4.2, 8.0, and 19.1 times the odds of being biopsied, respectively (OR, 4.2, CI, 4.0-4.5, P < .01; OR, 8.0, CI, 8.0-8.1, P < .01; OR, 19.1, CI, 18.4-19.7, P < .01). Patients with other known cancers, bulky lymph node involvement, or small masses ranging from 2 to 4 cm in size were also more likely to be biopsied (P < .01).

“Nonacademic hospitals were more likely to biopsy,” he added. “It could be that these hospitals are using observation and thermal ablative therapies more frequently.” Conversely, wealthier patients, patients treated at academic hospitals, and patients treated in the Northeast were significantly less likely to be biopsied. (P < .01).

On the basis of the data analyzed in this study, Dr. Maurice and his colleagues concluded that there is a trend in use of renal mass biopsy in nonacademic centers in recent years, particularly among patients with small renal masses and in those who eventually undergo observation or focal ablative therapies. Lesser indications predicting the usage of renal mass biopsy include the existence of other primary cancers and bulky lymph nodes.

Dr. Maurice reported no relevant financial relationships.

NEW ORLEANS – Renal mass biopsy has traditionally played a restricted diagnostic role, but with its improved diagnostic accuracy, it is becoming a viable clinical tool in the modern era, according to Dr. Matthew Maurice.

“We were seeking to understand the current role of biopsy in the management of renal masses, said Dr. Maurice, a urology resident at University Hospitals Case Medical Center in Cleveland. “We used the National Cancer Database and looked at data from 2003 to 2011; what we saw was a rise in renal mass biopsy in the final 3 years of the study. It’s a very small increase, but a statistically significant increase, with people in 2011 having 1.3 times higher odds of being biopsied than they would have had in 2003.”

Dr. Maurice and his colleagues at Case Medical conducted a study examining renal mass biopsy use in the modern era, and presented their findings in a poster at the annual meeting of the American Urological Association.

Using the National Cancer Database (NCDB), Dr. Maurice and his colleagues identified all patients diagnosed with renal cell carcinoma (RCC) between 2003 and 2011. Patients within the RCC cohort were then classified as having undergone renal biopsy or not. Renal biopsy utilization rates were plotted over time, and patient, disease, provider, and treatment variables were evaluated via univariate and multivariate logistic regression models to determine the predictors of renal biopsy.

Out of 304,583 patients with kidney cancer, 35,942 patients (11.8%) underwent renal mass biopsy. From 2009 to 2011, Dr. Maurice and his coinvestigators observed a significant increase in biopsy use; patients diagnosed with a renal mass in 2011 had 1.3 times higher odds of being biopsied compared with those diagnosed in 2003 (odds radio, 1.3, confidence interval, 1.3-1.4, P < .01).

Eventual treatment was the strongest predictor of biopsy utilization. “Patients receiving observation or thermal ablative therapy (either cryoablation or radiofrequency ablation) were much more likely to receive biopsy than were those who received surgical therapy such as radical or partial nephrectomy,” Dr. Maurice explained. “So it seems like those treatments are driving the use of renal biopsy utilization in contemporary patients.”

Compared to patients treated with partial nephrectomy, patients managed with observation, cryoablation, or radiofrequency ablation had 4.2, 8.0, and 19.1 times the odds of being biopsied, respectively (OR, 4.2, CI, 4.0-4.5, P < .01; OR, 8.0, CI, 8.0-8.1, P < .01; OR, 19.1, CI, 18.4-19.7, P < .01). Patients with other known cancers, bulky lymph node involvement, or small masses ranging from 2 to 4 cm in size were also more likely to be biopsied (P < .01).

“Nonacademic hospitals were more likely to biopsy,” he added. “It could be that these hospitals are using observation and thermal ablative therapies more frequently.” Conversely, wealthier patients, patients treated at academic hospitals, and patients treated in the Northeast were significantly less likely to be biopsied. (P < .01).

On the basis of the data analyzed in this study, Dr. Maurice and his colleagues concluded that there is a trend in use of renal mass biopsy in nonacademic centers in recent years, particularly among patients with small renal masses and in those who eventually undergo observation or focal ablative therapies. Lesser indications predicting the usage of renal mass biopsy include the existence of other primary cancers and bulky lymph nodes.

Dr. Maurice reported no relevant financial relationships.

BOSTON – Many cancer patients do not pursue or at least do not achieve complete freedom from pain when permitted control over their opioid dose, according to a comprehensive analysis of published studies that evaluated patient-controlled analgesia.

“We do not know why. Patients were encouraged in these studies to titrate opioids until they were pain free or until they had side effects. Although this could be an issue of side effects, another interpretation is that complete pain control is not the goal for many individuals,” reported Dr. Brian H. Wetherington of the University of Kentucky, Lexington.

The data from this analysis were presented at the International Conference on Opioids from a comprehensive literature search that included 905 potentially relevant articles. Of these, 62 met inclusion criteria, particularly an assessment of patient-controlled opioids in patients with cancer pain. The studies also had to assess pain control with a visual analog scale (VAS) or the Neuropathy Pain Scale (NPS) using a 10-point system with 10 being the greatest level of pain imaginable.

“We were interested in evaluating whether patients, when given complete control over their opioids, would take sufficient doses to provide complete pain relief, which is often stated as the goal in pain management,” explained Dr. Wetherington, who was coauthor of a study led by his colleague at University of Kentucky, Dr. Michael Harned.

The answer was no. When the data from the 62 studies, which included 5,251 patients with cancer pain were collated, the average pain score at baseline was 5.4. At the time of assessment of pain control, the mean pain score was 2.7.

“The mean pain score for patients managing their own cancer pain on opioids was reduced from study entry but remained at the moderate to severe pain level or higher than what many health care providers would recommend,” Dr. Wetherington reported.

This review of published studies does not explain why lower pain scores are not reached, but the Dr. Wetherington and his coauthors hypothesized that patients are demonstrating their own benefit-to-risk ratio assessment.

This is thought to be the first systematic review to find that patients do not seek complete control of pain when given access to unrestricted analgesia, but several individual studies have made the same point. In one study cited by the authors, patients on a fentanyl patch only reduced their pain scores to 3.0 on average when given unlimited access to oral morphine for breakthroughs (J. Pain Symptom Manage. 1998;16:102-11).

“We think this deserves further study, because there may be lessons regarding how we think of optimal pain control. While the therapeutic target is often described as complete pain relief, these data suggest that this may not be the goal for patients when they are left to select their own level of pain control,” Dr. Wetherington explained.

The same observation regarding the failure of patients to eliminate all pain on patient-controlled analgesia has been made anecdotally by Dr. William G. Brose of Stanford (Calif.) University. However, he suggested in an interview that patients might be reluctant to rate themselves completely pain free on a subjective scale. He also believes that level of analgesia may not be the most relevant endpoint.

“We are increasingly evaluating change in patient function, which may be a more useful tool for evaluating the efficacy of pain control,” Dr. Brose said.

BOSTON – Many cancer patients do not pursue or at least do not achieve complete freedom from pain when permitted control over their opioid dose, according to a comprehensive analysis of published studies that evaluated patient-controlled analgesia.

“We do not know why. Patients were encouraged in these studies to titrate opioids until they were pain free or until they had side effects. Although this could be an issue of side effects, another interpretation is that complete pain control is not the goal for many individuals,” reported Dr. Brian H. Wetherington of the University of Kentucky, Lexington.

The data from this analysis were presented at the International Conference on Opioids from a comprehensive literature search that included 905 potentially relevant articles. Of these, 62 met inclusion criteria, particularly an assessment of patient-controlled opioids in patients with cancer pain. The studies also had to assess pain control with a visual analog scale (VAS) or the Neuropathy Pain Scale (NPS) using a 10-point system with 10 being the greatest level of pain imaginable.

“We were interested in evaluating whether patients, when given complete control over their opioids, would take sufficient doses to provide complete pain relief, which is often stated as the goal in pain management,” explained Dr. Wetherington, who was coauthor of a study led by his colleague at University of Kentucky, Dr. Michael Harned.

The answer was no. When the data from the 62 studies, which included 5,251 patients with cancer pain were collated, the average pain score at baseline was 5.4. At the time of assessment of pain control, the mean pain score was 2.7.

“The mean pain score for patients managing their own cancer pain on opioids was reduced from study entry but remained at the moderate to severe pain level or higher than what many health care providers would recommend,” Dr. Wetherington reported.

This review of published studies does not explain why lower pain scores are not reached, but the Dr. Wetherington and his coauthors hypothesized that patients are demonstrating their own benefit-to-risk ratio assessment.

This is thought to be the first systematic review to find that patients do not seek complete control of pain when given access to unrestricted analgesia, but several individual studies have made the same point. In one study cited by the authors, patients on a fentanyl patch only reduced their pain scores to 3.0 on average when given unlimited access to oral morphine for breakthroughs (J. Pain Symptom Manage. 1998;16:102-11).

“We think this deserves further study, because there may be lessons regarding how we think of optimal pain control. While the therapeutic target is often described as complete pain relief, these data suggest that this may not be the goal for patients when they are left to select their own level of pain control,” Dr. Wetherington explained.

The same observation regarding the failure of patients to eliminate all pain on patient-controlled analgesia has been made anecdotally by Dr. William G. Brose of Stanford (Calif.) University. However, he suggested in an interview that patients might be reluctant to rate themselves completely pain free on a subjective scale. He also believes that level of analgesia may not be the most relevant endpoint.

“We are increasingly evaluating change in patient function, which may be a more useful tool for evaluating the efficacy of pain control,” Dr. Brose said.

BOSTON – Many cancer patients do not pursue or at least do not achieve complete freedom from pain when permitted control over their opioid dose, according to a comprehensive analysis of published studies that evaluated patient-controlled analgesia.

“We do not know why. Patients were encouraged in these studies to titrate opioids until they were pain free or until they had side effects. Although this could be an issue of side effects, another interpretation is that complete pain control is not the goal for many individuals,” reported Dr. Brian H. Wetherington of the University of Kentucky, Lexington.

The data from this analysis were presented at the International Conference on Opioids from a comprehensive literature search that included 905 potentially relevant articles. Of these, 62 met inclusion criteria, particularly an assessment of patient-controlled opioids in patients with cancer pain. The studies also had to assess pain control with a visual analog scale (VAS) or the Neuropathy Pain Scale (NPS) using a 10-point system with 10 being the greatest level of pain imaginable.

“We were interested in evaluating whether patients, when given complete control over their opioids, would take sufficient doses to provide complete pain relief, which is often stated as the goal in pain management,” explained Dr. Wetherington, who was coauthor of a study led by his colleague at University of Kentucky, Dr. Michael Harned.

The answer was no. When the data from the 62 studies, which included 5,251 patients with cancer pain were collated, the average pain score at baseline was 5.4. At the time of assessment of pain control, the mean pain score was 2.7.

“The mean pain score for patients managing their own cancer pain on opioids was reduced from study entry but remained at the moderate to severe pain level or higher than what many health care providers would recommend,” Dr. Wetherington reported.

This review of published studies does not explain why lower pain scores are not reached, but the Dr. Wetherington and his coauthors hypothesized that patients are demonstrating their own benefit-to-risk ratio assessment.

This is thought to be the first systematic review to find that patients do not seek complete control of pain when given access to unrestricted analgesia, but several individual studies have made the same point. In one study cited by the authors, patients on a fentanyl patch only reduced their pain scores to 3.0 on average when given unlimited access to oral morphine for breakthroughs (J. Pain Symptom Manage. 1998;16:102-11).

“We think this deserves further study, because there may be lessons regarding how we think of optimal pain control. While the therapeutic target is often described as complete pain relief, these data suggest that this may not be the goal for patients when they are left to select their own level of pain control,” Dr. Wetherington explained.

The same observation regarding the failure of patients to eliminate all pain on patient-controlled analgesia has been made anecdotally by Dr. William G. Brose of Stanford (Calif.) University. However, he suggested in an interview that patients might be reluctant to rate themselves completely pain free on a subjective scale. He also believes that level of analgesia may not be the most relevant endpoint.

“We are increasingly evaluating change in patient function, which may be a more useful tool for evaluating the efficacy of pain control,” Dr. Brose said.

CHICAGO – Women with breast cancer treated with neoadjuvant chemotherapy and surgery are more likely to have a recurrence in the breast, chest wall, or axilla or to die if they don’t receive adjuvant radiation therapy, even if they had a pathologic complete response to the chemotherapy, new data show.

In a meta-analysis of three Gepar trials conducted by the German Breast Group, radiation therapy was associated with a 38% lower multivariate risk of locoregional recurrence or death, investigators reported at the annual meeting of the American Society of Clinical Oncology. Significant benefit was seen regardless of pathologic complete response, although findings across other subgroups were not consistent, possibly due to selection bias or underlying confounders.

“Radiotherapy is an independent prognostic factor for locoregional recurrence–free survival after neoadjuvant chemotherapy in breast cancer. However, the optimal selection criteria remain unclear,” commented first author Dr. David Krug of University Hospital Heidelberg (Germany).

“We are eagerly awaiting the results of prospective studies that are currently recruiting patients,” he added, referring to the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-51 trial and the Radiotherapy After Primary Chemotherapy for Breast Cancer (RAPCHEM) trial.

Findings of this meta-analysis are not practice changing, according to invited discussant Dr. Monica Morrow, chief of the breast service, department of surgery, and the Anne Burnett Windfohr Chair of Clinical Oncology at the Memorial Sloan Kettering Cancer Center in New York. “The Gepar data is not consistent enough across subsets to draw any different conclusions other than we need more data,” she said.

Focusing on the women who underwent mastectomy, she noted that only a small number who had a pathologic complete response did not receive radiation therapy, “so this study unfortunately lacks the power to tell us anything about the ability to eliminate radiation in this group.”

“What we’d really like to know about local control after neoadjuvant therapy is what’s the relative contribution of pretreatment stage and posttreatment stage to the risk of locoregional recurrence, especially in patients who achieve pathologic complete response? And if we try to address that question with this study, the results were a little murky,” Dr. Morrow further noted. For example, patients with higher–T stage primary tumors benefited from postmastectomy radiation, but patients who were clinically node positive did not.

“I think right now, what we have to say is we need to continue to do what we have been doing up until the present time, namely, patients whose presenting stage clearly indicates the need for radiotherapy should receive it, and patients who have lower-stage disease perhaps not,” she concluded, agreeing that the NSABP B-51 trial should help put this issue to rest.

Dr. Krug and his colleagues performed a pooled meta-analysis of data from the GeparTrio, GeparQuattro, and GeparQuinto trials of neoadjuvant chemotherapy, in which guidelines specified when adjuvant radiation therapy should be used. Those guidelines called for whole-breast radiation therapy with a boost after breast-conserving surgery (with omission of the boost in low-risk patients); radiation therapy after mastectomy for patients having more extensive disease before neoadjuvant chemotherapy; and radiation therapy for those with greater involvement of the regional lymphatics.

The meta-analysis was based on a total of 3,370 women. Overall, 94% received radiation therapy (99% of those who had undergone breast-conserving surgery and 85% of those who had undergone mastectomy).

With a median follow-up of 4.2 years, the 5-year rate of locoregional recurrence–free survival was 89.2% in the entire study population, according to Dr. Krug.

Women who did not receive radiation therapy had a significantly elevated risk of such recurrence or death compared with peers who received it. In subgroups analyses, benefit was significant whether women had had a pathologic complete response to neoadjuvant chemotherapy or not. Greatest absolute benefit was seen in those with a pathologic complete response, clinically positive nodes, or pathologically negative nodes.

The 5-year rate of disease-free survival was 74.0% in the entire study population. Here, there was only a trend toward a higher risk of events for women who did not receive radiation therapy.

In multivariate analyses, radiation therapy independently predicted better locoregional recurrence–free survival (hazard ratio, 0.62; P = .038) but not disease-free survival.

When analyses were restricted to women who had undergone mastectomy, radiation therapy was associated with significantly better locoregional recurrence–free survival among those with clinical stage T3/4 disease, pathologically negative nodes, a conversion from clinically positive to pathologically negative nodes, or hormone receptor–negative, HER2-positive disease.

It was associated with poorer disease-free survival for patients who did not achieve a pathologic complete response, had clinical stage T1/2 disease, or were clinically node negative.

Multivariate analysis here again showed that radiation therapy independently predicted better locoregional recurrence–free survival (HR, 0.56; P = .029) but not disease-free survival.

CHICAGO – Women with breast cancer treated with neoadjuvant chemotherapy and surgery are more likely to have a recurrence in the breast, chest wall, or axilla or to die if they don’t receive adjuvant radiation therapy, even if they had a pathologic complete response to the chemotherapy, new data show.

In a meta-analysis of three Gepar trials conducted by the German Breast Group, radiation therapy was associated with a 38% lower multivariate risk of locoregional recurrence or death, investigators reported at the annual meeting of the American Society of Clinical Oncology. Significant benefit was seen regardless of pathologic complete response, although findings across other subgroups were not consistent, possibly due to selection bias or underlying confounders.

“Radiotherapy is an independent prognostic factor for locoregional recurrence–free survival after neoadjuvant chemotherapy in breast cancer. However, the optimal selection criteria remain unclear,” commented first author Dr. David Krug of University Hospital Heidelberg (Germany).

“We are eagerly awaiting the results of prospective studies that are currently recruiting patients,” he added, referring to the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-51 trial and the Radiotherapy After Primary Chemotherapy for Breast Cancer (RAPCHEM) trial.

Findings of this meta-analysis are not practice changing, according to invited discussant Dr. Monica Morrow, chief of the breast service, department of surgery, and the Anne Burnett Windfohr Chair of Clinical Oncology at the Memorial Sloan Kettering Cancer Center in New York. “The Gepar data is not consistent enough across subsets to draw any different conclusions other than we need more data,” she said.

Focusing on the women who underwent mastectomy, she noted that only a small number who had a pathologic complete response did not receive radiation therapy, “so this study unfortunately lacks the power to tell us anything about the ability to eliminate radiation in this group.”

“What we’d really like to know about local control after neoadjuvant therapy is what’s the relative contribution of pretreatment stage and posttreatment stage to the risk of locoregional recurrence, especially in patients who achieve pathologic complete response? And if we try to address that question with this study, the results were a little murky,” Dr. Morrow further noted. For example, patients with higher–T stage primary tumors benefited from postmastectomy radiation, but patients who were clinically node positive did not.

“I think right now, what we have to say is we need to continue to do what we have been doing up until the present time, namely, patients whose presenting stage clearly indicates the need for radiotherapy should receive it, and patients who have lower-stage disease perhaps not,” she concluded, agreeing that the NSABP B-51 trial should help put this issue to rest.

Dr. Krug and his colleagues performed a pooled meta-analysis of data from the GeparTrio, GeparQuattro, and GeparQuinto trials of neoadjuvant chemotherapy, in which guidelines specified when adjuvant radiation therapy should be used. Those guidelines called for whole-breast radiation therapy with a boost after breast-conserving surgery (with omission of the boost in low-risk patients); radiation therapy after mastectomy for patients having more extensive disease before neoadjuvant chemotherapy; and radiation therapy for those with greater involvement of the regional lymphatics.

The meta-analysis was based on a total of 3,370 women. Overall, 94% received radiation therapy (99% of those who had undergone breast-conserving surgery and 85% of those who had undergone mastectomy).

With a median follow-up of 4.2 years, the 5-year rate of locoregional recurrence–free survival was 89.2% in the entire study population, according to Dr. Krug.

Women who did not receive radiation therapy had a significantly elevated risk of such recurrence or death compared with peers who received it. In subgroups analyses, benefit was significant whether women had had a pathologic complete response to neoadjuvant chemotherapy or not. Greatest absolute benefit was seen in those with a pathologic complete response, clinically positive nodes, or pathologically negative nodes.

The 5-year rate of disease-free survival was 74.0% in the entire study population. Here, there was only a trend toward a higher risk of events for women who did not receive radiation therapy.

In multivariate analyses, radiation therapy independently predicted better locoregional recurrence–free survival (hazard ratio, 0.62; P = .038) but not disease-free survival.

When analyses were restricted to women who had undergone mastectomy, radiation therapy was associated with significantly better locoregional recurrence–free survival among those with clinical stage T3/4 disease, pathologically negative nodes, a conversion from clinically positive to pathologically negative nodes, or hormone receptor–negative, HER2-positive disease.

It was associated with poorer disease-free survival for patients who did not achieve a pathologic complete response, had clinical stage T1/2 disease, or were clinically node negative.

Multivariate analysis here again showed that radiation therapy independently predicted better locoregional recurrence–free survival (HR, 0.56; P = .029) but not disease-free survival.

CHICAGO – Women with breast cancer treated with neoadjuvant chemotherapy and surgery are more likely to have a recurrence in the breast, chest wall, or axilla or to die if they don’t receive adjuvant radiation therapy, even if they had a pathologic complete response to the chemotherapy, new data show.

In a meta-analysis of three Gepar trials conducted by the German Breast Group, radiation therapy was associated with a 38% lower multivariate risk of locoregional recurrence or death, investigators reported at the annual meeting of the American Society of Clinical Oncology. Significant benefit was seen regardless of pathologic complete response, although findings across other subgroups were not consistent, possibly due to selection bias or underlying confounders.

“Radiotherapy is an independent prognostic factor for locoregional recurrence–free survival after neoadjuvant chemotherapy in breast cancer. However, the optimal selection criteria remain unclear,” commented first author Dr. David Krug of University Hospital Heidelberg (Germany).

“We are eagerly awaiting the results of prospective studies that are currently recruiting patients,” he added, referring to the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-51 trial and the Radiotherapy After Primary Chemotherapy for Breast Cancer (RAPCHEM) trial.

Findings of this meta-analysis are not practice changing, according to invited discussant Dr. Monica Morrow, chief of the breast service, department of surgery, and the Anne Burnett Windfohr Chair of Clinical Oncology at the Memorial Sloan Kettering Cancer Center in New York. “The Gepar data is not consistent enough across subsets to draw any different conclusions other than we need more data,” she said.

Focusing on the women who underwent mastectomy, she noted that only a small number who had a pathologic complete response did not receive radiation therapy, “so this study unfortunately lacks the power to tell us anything about the ability to eliminate radiation in this group.”

“What we’d really like to know about local control after neoadjuvant therapy is what’s the relative contribution of pretreatment stage and posttreatment stage to the risk of locoregional recurrence, especially in patients who achieve pathologic complete response? And if we try to address that question with this study, the results were a little murky,” Dr. Morrow further noted. For example, patients with higher–T stage primary tumors benefited from postmastectomy radiation, but patients who were clinically node positive did not.

“I think right now, what we have to say is we need to continue to do what we have been doing up until the present time, namely, patients whose presenting stage clearly indicates the need for radiotherapy should receive it, and patients who have lower-stage disease perhaps not,” she concluded, agreeing that the NSABP B-51 trial should help put this issue to rest.

Dr. Krug and his colleagues performed a pooled meta-analysis of data from the GeparTrio, GeparQuattro, and GeparQuinto trials of neoadjuvant chemotherapy, in which guidelines specified when adjuvant radiation therapy should be used. Those guidelines called for whole-breast radiation therapy with a boost after breast-conserving surgery (with omission of the boost in low-risk patients); radiation therapy after mastectomy for patients having more extensive disease before neoadjuvant chemotherapy; and radiation therapy for those with greater involvement of the regional lymphatics.

The meta-analysis was based on a total of 3,370 women. Overall, 94% received radiation therapy (99% of those who had undergone breast-conserving surgery and 85% of those who had undergone mastectomy).

With a median follow-up of 4.2 years, the 5-year rate of locoregional recurrence–free survival was 89.2% in the entire study population, according to Dr. Krug.

Women who did not receive radiation therapy had a significantly elevated risk of such recurrence or death compared with peers who received it. In subgroups analyses, benefit was significant whether women had had a pathologic complete response to neoadjuvant chemotherapy or not. Greatest absolute benefit was seen in those with a pathologic complete response, clinically positive nodes, or pathologically negative nodes.

The 5-year rate of disease-free survival was 74.0% in the entire study population. Here, there was only a trend toward a higher risk of events for women who did not receive radiation therapy.

In multivariate analyses, radiation therapy independently predicted better locoregional recurrence–free survival (hazard ratio, 0.62; P = .038) but not disease-free survival.

When analyses were restricted to women who had undergone mastectomy, radiation therapy was associated with significantly better locoregional recurrence–free survival among those with clinical stage T3/4 disease, pathologically negative nodes, a conversion from clinically positive to pathologically negative nodes, or hormone receptor–negative, HER2-positive disease.

It was associated with poorer disease-free survival for patients who did not achieve a pathologic complete response, had clinical stage T1/2 disease, or were clinically node negative.

Multivariate analysis here again showed that radiation therapy independently predicted better locoregional recurrence–free survival (HR, 0.56; P = .029) but not disease-free survival.

Subsequent to the 2012 U.S. Preventative Services Task Force recommendation discouraging prostate-specific antigen (PSA)-based screening, prostate cancer screening significantly declined among men age 50 years and older in the United States, according to a study published online in the Journal of Clinical Oncology.

Based on National Health Interview Surveys in 2005, 2010, and 2013, self-reported PSA-testing levels decreased most among men aged 50-59 years, from 33.2% in 2010 to 24.8% in 2013 (odds ratio, 0.66; P < .01). Declines from 2010 to 2013 were also observed among men aged 60-74 years (51.2%-43.6%; OR, 0.74; P < .01); and aged 75 and older (43.9%-37.1%, OR, 0.75; P = .03). Among men aged 40-49 years, the decline from 12.5% to 11.2% was not significant (Journ. Clin. Onc. 2015 June 8 [doi:10.1200/JCO.2015.61.6532]).

©alexdans/Thinkstock

The declines may reflect increased adherence by physicians to USPSTF guidelines; nevertheless, in 2013 approximately one-third of men aged 65 or older who had high risk for 9-year mortality (about 1.4 million individuals) were screened.

“Persistently elevated screening rates among men with limited remaining life expectancies are troubling and merit further interventions,” wrote Dr. Michael Drazer of the University of Chicago Medical Center and colleagues. “These may include increasing awareness of initiatives such as Choosing Wisely recommendations from the American Society of Clinical Oncology and recommendations from the American Geriatrics Society,” they wrote.

If these efforts prove unsuccessful, reducing or eliminating reimbursements for screening and interventions may be considered, the authors suggest.

A multivariate model identified factors that predict which men over age 65 are likely to be screened, and these are men who went to college, were married, consumed alcohol, and received a colonoscopy in the last 10 years. They found no significant predictors in the patient population for declines in screening from 2010 to 2013.

Several studies support the use of extended screening intervals (every 2-3 years) for patients at low risk for prostate cancer. Annual screening of men aged 55-67 years has been estimated to result in a 50% overdiagnosis rate.

Drs. Drazer and Huo reported having no financial disclosures. Dr. Eggener reported having consulting or advisory roles with Myriad Genetics, Medivation, Janssen Pharmaceuticals, Genomic Health, OPKO Diagnostics, and MDxHealth.

Subsequent to the 2012 U.S. Preventative Services Task Force recommendation discouraging prostate-specific antigen (PSA)-based screening, prostate cancer screening significantly declined among men age 50 years and older in the United States, according to a study published online in the Journal of Clinical Oncology.

Based on National Health Interview Surveys in 2005, 2010, and 2013, self-reported PSA-testing levels decreased most among men aged 50-59 years, from 33.2% in 2010 to 24.8% in 2013 (odds ratio, 0.66; P < .01). Declines from 2010 to 2013 were also observed among men aged 60-74 years (51.2%-43.6%; OR, 0.74; P < .01); and aged 75 and older (43.9%-37.1%, OR, 0.75; P = .03). Among men aged 40-49 years, the decline from 12.5% to 11.2% was not significant (Journ. Clin. Onc. 2015 June 8 [doi:10.1200/JCO.2015.61.6532]).

©alexdans/Thinkstock

The declines may reflect increased adherence by physicians to USPSTF guidelines; nevertheless, in 2013 approximately one-third of men aged 65 or older who had high risk for 9-year mortality (about 1.4 million individuals) were screened.

“Persistently elevated screening rates among men with limited remaining life expectancies are troubling and merit further interventions,” wrote Dr. Michael Drazer of the University of Chicago Medical Center and colleagues. “These may include increasing awareness of initiatives such as Choosing Wisely recommendations from the American Society of Clinical Oncology and recommendations from the American Geriatrics Society,” they wrote.

If these efforts prove unsuccessful, reducing or eliminating reimbursements for screening and interventions may be considered, the authors suggest.

A multivariate model identified factors that predict which men over age 65 are likely to be screened, and these are men who went to college, were married, consumed alcohol, and received a colonoscopy in the last 10 years. They found no significant predictors in the patient population for declines in screening from 2010 to 2013.

Several studies support the use of extended screening intervals (every 2-3 years) for patients at low risk for prostate cancer. Annual screening of men aged 55-67 years has been estimated to result in a 50% overdiagnosis rate.

Drs. Drazer and Huo reported having no financial disclosures. Dr. Eggener reported having consulting or advisory roles with Myriad Genetics, Medivation, Janssen Pharmaceuticals, Genomic Health, OPKO Diagnostics, and MDxHealth.

Subsequent to the 2012 U.S. Preventative Services Task Force recommendation discouraging prostate-specific antigen (PSA)-based screening, prostate cancer screening significantly declined among men age 50 years and older in the United States, according to a study published online in the Journal of Clinical Oncology.

Based on National Health Interview Surveys in 2005, 2010, and 2013, self-reported PSA-testing levels decreased most among men aged 50-59 years, from 33.2% in 2010 to 24.8% in 2013 (odds ratio, 0.66; P < .01). Declines from 2010 to 2013 were also observed among men aged 60-74 years (51.2%-43.6%; OR, 0.74; P < .01); and aged 75 and older (43.9%-37.1%, OR, 0.75; P = .03). Among men aged 40-49 years, the decline from 12.5% to 11.2% was not significant (Journ. Clin. Onc. 2015 June 8 [doi:10.1200/JCO.2015.61.6532]).

©alexdans/Thinkstock

The declines may reflect increased adherence by physicians to USPSTF guidelines; nevertheless, in 2013 approximately one-third of men aged 65 or older who had high risk for 9-year mortality (about 1.4 million individuals) were screened.

“Persistently elevated screening rates among men with limited remaining life expectancies are troubling and merit further interventions,” wrote Dr. Michael Drazer of the University of Chicago Medical Center and colleagues. “These may include increasing awareness of initiatives such as Choosing Wisely recommendations from the American Society of Clinical Oncology and recommendations from the American Geriatrics Society,” they wrote.

If these efforts prove unsuccessful, reducing or eliminating reimbursements for screening and interventions may be considered, the authors suggest.

A multivariate model identified factors that predict which men over age 65 are likely to be screened, and these are men who went to college, were married, consumed alcohol, and received a colonoscopy in the last 10 years. They found no significant predictors in the patient population for declines in screening from 2010 to 2013.

Several studies support the use of extended screening intervals (every 2-3 years) for patients at low risk for prostate cancer. Annual screening of men aged 55-67 years has been estimated to result in a 50% overdiagnosis rate.

Drs. Drazer and Huo reported having no financial disclosures. Dr. Eggener reported having consulting or advisory roles with Myriad Genetics, Medivation, Janssen Pharmaceuticals, Genomic Health, OPKO Diagnostics, and MDxHealth.

CHICAGO – Researchers have identified a new histologic subset of metastatic castration-resistant prostate cancer called intermediate atypical carcinoma.

“Despite being cytologically bland, this is an aggressive cancer with shortened survival similar to that seen with small-cell neuroendocrine cancer,” study author Dr. Eric J. Small said at the annual meeting of the American Society of Clinical Oncology.

Patrice Wendling/Frontline Medical News

Therapies targeting the androgen receptor (AR) like abiraterone and enzalutamide have revolutionized the treatment of metastatic castration-resistant prostate cancer (mCRPC), but resistance to these agents is near-universal and leads to progressive disease and death. At the same time, clinicians are seeing an increasing number of patients with small cell neuroendocrine prostate cancer (SCNC), Dr. Small, professor of medicine at the University of California, San Francisco, said.

As part of a larger project designed to understand the mechanisms of resistance to abiraterone (Zytiga) and enzalutamide (Xtandi) undertaken by the West Coast Prostate Cancer Dream Team, biopsies were performed of a metastatic site in about 160 eligible men with mCRPC.Most (58%) had a Gleason score of 8 or more at diagnosis; 40% had been treated with abiraterone, 10% with enzalutamide, and 17% with both.

Formalin-fixed paraffin-embedded tissue was collected for histologic evaluation by three independent pathologists. Fresh frozen tissue, which underwent laser capture microdissection, was used for genomic analysis.

As of May 1, 173 of 300 planned biopsies have been conducted. In the 160 samples evaluated to date, there was adequate tissue for analysis in 124, for a 78% biopsy success rate, he said.

Among the 124 evaluable biopsies, 35% were classified as pure adenocarcinoma and 13% as pure SCNC.

A novel subtype was identified in another 26% that “consisted of a pure population of cells that was distinct from adenocarcinoma and distinct from small cell neuroendocrine cancer. We have termed this group intermediate atypical carcinoma (IAC),” Dr. Small said.

The remaining quarter of biopsies was composed of mixed populations.

In addition to the independent review, a consensus meeting with two additional pathologists confirmed that this was a new, highly reproducible pathologic subclass, he said.

The researchers next sought to determine whether IAC is phenotypically distinct. A survival analysis was performed based on biopsy pathology and revealed that men who develop IAC have poor survival.

Indeed, survival with IAC (median 11.9 months) tracks with that of SCNC (median 6.6 months) and is distinct from adenocarcinoma, with a log-rank P value of .041, Dr. Small said. Further, when IAC and SCNC were grouped together, there was a dramatically different survival curve (median 8.9 months) than that seen with adenocarcinoma (P = .006).

An analysis using microresected samples indicated that IAC is also genomically distinct, he said. Small cell nuclear clusters showed enrichment of neuronal and cell cycle elements and downregulation of androgen-receptor elements and the immune system.

Based on these findings, machine learning was used to develop a 50-gene signature, with 88.3% accuracy to distinguish small cell from non–small cell histology and 78.5% accuracy to distinguish small cell or IAC histology from adenocarcinoma. The test is not clinically available at this time, but is being used to identify new therapeutic targets.

“We are actively identifying the unique features of this subtype that can be targeted with therapy,” Dr. Small said in an interview. “There is a huge unmet need, since no one knows how to treat these patients, who comprise a significant portion of patients.”

Indeed, in the analysis, IAC represented a fourth of all metastatic castration-resistant biopsies and when combined with small cell neuroendocrine cancer accounted for 40% of all samples.

“This comprises the single largest group of abiraterone- and enzalutamide-refractory patients,” he concluded. “The increasing use of highly potent AR-targeted therapy may contribute to the increasing frequency of this entity, although that is conjecture at this point and certainly ascertainment bias may play a role.”

Discussant Dr. Scott Tomlins, a pathologist from the University of Michigan in Ann Arbor, said one of the study’s major findings is that collecting tissue for comprehensive molecular analysis is feasible in the context of a well-funded, team-based infrastructure, adding that this will likely have to be the way going forward. Despite limited sample numbers, there also appears to be a “strong signal” that gene expression signatures can discriminate various subtypes.

The study was funded by StandUpToCancer, the Prostate Cancer Foundation, and American Association for Cancer Research. Dr. Small reported having no disclosures.

[email protected]

On Twitter @pwendl

CHICAGO – Researchers have identified a new histologic subset of metastatic castration-resistant prostate cancer called intermediate atypical carcinoma.

“Despite being cytologically bland, this is an aggressive cancer with shortened survival similar to that seen with small-cell neuroendocrine cancer,” study author Dr. Eric J. Small said at the annual meeting of the American Society of Clinical Oncology.

Patrice Wendling/Frontline Medical News

Therapies targeting the androgen receptor (AR) like abiraterone and enzalutamide have revolutionized the treatment of metastatic castration-resistant prostate cancer (mCRPC), but resistance to these agents is near-universal and leads to progressive disease and death. At the same time, clinicians are seeing an increasing number of patients with small cell neuroendocrine prostate cancer (SCNC), Dr. Small, professor of medicine at the University of California, San Francisco, said.

As part of a larger project designed to understand the mechanisms of resistance to abiraterone (Zytiga) and enzalutamide (Xtandi) undertaken by the West Coast Prostate Cancer Dream Team, biopsies were performed of a metastatic site in about 160 eligible men with mCRPC.Most (58%) had a Gleason score of 8 or more at diagnosis; 40% had been treated with abiraterone, 10% with enzalutamide, and 17% with both.

Formalin-fixed paraffin-embedded tissue was collected for histologic evaluation by three independent pathologists. Fresh frozen tissue, which underwent laser capture microdissection, was used for genomic analysis.

As of May 1, 173 of 300 planned biopsies have been conducted. In the 160 samples evaluated to date, there was adequate tissue for analysis in 124, for a 78% biopsy success rate, he said.

Among the 124 evaluable biopsies, 35% were classified as pure adenocarcinoma and 13% as pure SCNC.

A novel subtype was identified in another 26% that “consisted of a pure population of cells that was distinct from adenocarcinoma and distinct from small cell neuroendocrine cancer. We have termed this group intermediate atypical carcinoma (IAC),” Dr. Small said.

The remaining quarter of biopsies was composed of mixed populations.

In addition to the independent review, a consensus meeting with two additional pathologists confirmed that this was a new, highly reproducible pathologic subclass, he said.

The researchers next sought to determine whether IAC is phenotypically distinct. A survival analysis was performed based on biopsy pathology and revealed that men who develop IAC have poor survival.

Indeed, survival with IAC (median 11.9 months) tracks with that of SCNC (median 6.6 months) and is distinct from adenocarcinoma, with a log-rank P value of .041, Dr. Small said. Further, when IAC and SCNC were grouped together, there was a dramatically different survival curve (median 8.9 months) than that seen with adenocarcinoma (P = .006).

An analysis using microresected samples indicated that IAC is also genomically distinct, he said. Small cell nuclear clusters showed enrichment of neuronal and cell cycle elements and downregulation of androgen-receptor elements and the immune system.

Based on these findings, machine learning was used to develop a 50-gene signature, with 88.3% accuracy to distinguish small cell from non–small cell histology and 78.5% accuracy to distinguish small cell or IAC histology from adenocarcinoma. The test is not clinically available at this time, but is being used to identify new therapeutic targets.

“We are actively identifying the unique features of this subtype that can be targeted with therapy,” Dr. Small said in an interview. “There is a huge unmet need, since no one knows how to treat these patients, who comprise a significant portion of patients.”

Indeed, in the analysis, IAC represented a fourth of all metastatic castration-resistant biopsies and when combined with small cell neuroendocrine cancer accounted for 40% of all samples.

“This comprises the single largest group of abiraterone- and enzalutamide-refractory patients,” he concluded. “The increasing use of highly potent AR-targeted therapy may contribute to the increasing frequency of this entity, although that is conjecture at this point and certainly ascertainment bias may play a role.”

Discussant Dr. Scott Tomlins, a pathologist from the University of Michigan in Ann Arbor, said one of the study’s major findings is that collecting tissue for comprehensive molecular analysis is feasible in the context of a well-funded, team-based infrastructure, adding that this will likely have to be the way going forward. Despite limited sample numbers, there also appears to be a “strong signal” that gene expression signatures can discriminate various subtypes.

The study was funded by StandUpToCancer, the Prostate Cancer Foundation, and American Association for Cancer Research. Dr. Small reported having no disclosures.

[email protected]

On Twitter @pwendl

CHICAGO – Researchers have identified a new histologic subset of metastatic castration-resistant prostate cancer called intermediate atypical carcinoma.

“Despite being cytologically bland, this is an aggressive cancer with shortened survival similar to that seen with small-cell neuroendocrine cancer,” study author Dr. Eric J. Small said at the annual meeting of the American Society of Clinical Oncology.

Patrice Wendling/Frontline Medical News

Therapies targeting the androgen receptor (AR) like abiraterone and enzalutamide have revolutionized the treatment of metastatic castration-resistant prostate cancer (mCRPC), but resistance to these agents is near-universal and leads to progressive disease and death. At the same time, clinicians are seeing an increasing number of patients with small cell neuroendocrine prostate cancer (SCNC), Dr. Small, professor of medicine at the University of California, San Francisco, said.

As part of a larger project designed to understand the mechanisms of resistance to abiraterone (Zytiga) and enzalutamide (Xtandi) undertaken by the West Coast Prostate Cancer Dream Team, biopsies were performed of a metastatic site in about 160 eligible men with mCRPC.Most (58%) had a Gleason score of 8 or more at diagnosis; 40% had been treated with abiraterone, 10% with enzalutamide, and 17% with both.

Formalin-fixed paraffin-embedded tissue was collected for histologic evaluation by three independent pathologists. Fresh frozen tissue, which underwent laser capture microdissection, was used for genomic analysis.

As of May 1, 173 of 300 planned biopsies have been conducted. In the 160 samples evaluated to date, there was adequate tissue for analysis in 124, for a 78% biopsy success rate, he said.

Among the 124 evaluable biopsies, 35% were classified as pure adenocarcinoma and 13% as pure SCNC.

A novel subtype was identified in another 26% that “consisted of a pure population of cells that was distinct from adenocarcinoma and distinct from small cell neuroendocrine cancer. We have termed this group intermediate atypical carcinoma (IAC),” Dr. Small said.

The remaining quarter of biopsies was composed of mixed populations.

In addition to the independent review, a consensus meeting with two additional pathologists confirmed that this was a new, highly reproducible pathologic subclass, he said.

The researchers next sought to determine whether IAC is phenotypically distinct. A survival analysis was performed based on biopsy pathology and revealed that men who develop IAC have poor survival.

Indeed, survival with IAC (median 11.9 months) tracks with that of SCNC (median 6.6 months) and is distinct from adenocarcinoma, with a log-rank P value of .041, Dr. Small said. Further, when IAC and SCNC were grouped together, there was a dramatically different survival curve (median 8.9 months) than that seen with adenocarcinoma (P = .006).

An analysis using microresected samples indicated that IAC is also genomically distinct, he said. Small cell nuclear clusters showed enrichment of neuronal and cell cycle elements and downregulation of androgen-receptor elements and the immune system.

Based on these findings, machine learning was used to develop a 50-gene signature, with 88.3% accuracy to distinguish small cell from non–small cell histology and 78.5% accuracy to distinguish small cell or IAC histology from adenocarcinoma. The test is not clinically available at this time, but is being used to identify new therapeutic targets.

“We are actively identifying the unique features of this subtype that can be targeted with therapy,” Dr. Small said in an interview. “There is a huge unmet need, since no one knows how to treat these patients, who comprise a significant portion of patients.”

Indeed, in the analysis, IAC represented a fourth of all metastatic castration-resistant biopsies and when combined with small cell neuroendocrine cancer accounted for 40% of all samples.

“This comprises the single largest group of abiraterone- and enzalutamide-refractory patients,” he concluded. “The increasing use of highly potent AR-targeted therapy may contribute to the increasing frequency of this entity, although that is conjecture at this point and certainly ascertainment bias may play a role.”

Discussant Dr. Scott Tomlins, a pathologist from the University of Michigan in Ann Arbor, said one of the study’s major findings is that collecting tissue for comprehensive molecular analysis is feasible in the context of a well-funded, team-based infrastructure, adding that this will likely have to be the way going forward. Despite limited sample numbers, there also appears to be a “strong signal” that gene expression signatures can discriminate various subtypes.

The study was funded by StandUpToCancer, the Prostate Cancer Foundation, and American Association for Cancer Research. Dr. Small reported having no disclosures.

[email protected]

On Twitter @pwendl

CHICAGO – Dr. Walter M. Stadler provides his take on ASCO 2015 presentations and discussions around genitourinary research, including practice-changing results on the use of chemotherapy for treating prostate cancer and the timing of androgen suppression. He also addresses the disappointing results for using precision medicine to treat bladder cancer versus the encouraging results from immunotherapy for both bladder and renal cell cancer. Dr. Stadler is the Fred C. Buffett Professor of Medicine and Surgery; associate dean for clinical research; chief, section of hematology/oncology; and director, genitourinary program, University of Chicago. He had no financial disclosures.

[email protected]

On Twitter @nikolaideslaura

CHICAGO – Dr. Walter M. Stadler provides his take on ASCO 2015 presentations and discussions around genitourinary research, including practice-changing results on the use of chemotherapy for treating prostate cancer and the timing of androgen suppression. He also addresses the disappointing results for using precision medicine to treat bladder cancer versus the encouraging results from immunotherapy for both bladder and renal cell cancer. Dr. Stadler is the Fred C. Buffett Professor of Medicine and Surgery; associate dean for clinical research; chief, section of hematology/oncology; and director, genitourinary program, University of Chicago. He had no financial disclosures.

[email protected]

On Twitter @nikolaideslaura

CHICAGO – Dr. Walter M. Stadler provides his take on ASCO 2015 presentations and discussions around genitourinary research, including practice-changing results on the use of chemotherapy for treating prostate cancer and the timing of androgen suppression. He also addresses the disappointing results for using precision medicine to treat bladder cancer versus the encouraging results from immunotherapy for both bladder and renal cell cancer. Dr. Stadler is the Fred C. Buffett Professor of Medicine and Surgery; associate dean for clinical research; chief, section of hematology/oncology; and director, genitourinary program, University of Chicago. He had no financial disclosures.

[email protected]

On Twitter @nikolaideslaura

SAN DIEGO – Routine preoperative use of genetic testing to detect mutations implicated in thyroid carcinogenesis can help guide perioperative decision making, though risks associated with mutations are not always clear-cut.

For individuals with thyroid cancer (TC), the presence of certain mutations was associated with higher risk of early recurrence of cancer as well as distant metastases, according to a recent study presented by Dr. Linwah Yip at the annual meeting of the American Surgical Association. She and her colleagues at the University of Pittsburgh built on their previous work to characterize how thyroid cancer genotype relates both to cancer histology and to disease-related outcomes.

Using data from the electronic medical record of a single institution, Dr. Yip and her colleagues examined data from consecutive patients who had initial surgery for histologically confirmed TC. Of the 1,510 patients in the study cohort, 77% were women, and patients had a mean age of 49 years. All of the cancers in the study were tested for mutations in seven genes known to be associated with thyroid carcinogenesis. Mutation testing was a routine part of preoperative care for thyroid cancer patients, often performed on preoperative fine needle aspiration (FNA) biopsy.

Outcomes tracked in the study, Dr. Yip said, included the type and stage of thyroid cancer identified and whether the cancer recurred.

Mutations were found in 1,039 patients (69%), and no more than one mutation was found in any one tumor. No tumor genotype was specifically associated with tumor size or whether the tumor was multifocal.

Overall, BRAF V600E was the most common mutation associated with TC, and patients with this mutation were the ones most likely to have a recurrence (P = .001). However, Dr. Yip noted that there is phenotypic heterogeneity in how the recurrences present. More distant metastatic disease and lateral lymph node metastases were most likely with RET/PTC1 and three mutations (P = .02).

By contrast, about 25% of thyroid cancers in the study showed mutations in RAS, PAX8/PPARG, or BRAF K601E. These mutations were associated with a more indolent disease course, with more encapsulated tumors and an overall disease-free survival of nearly 100% at 5 years after diagnosis. Dr. Yip said, “However, RAS variations can be associated with any histologic type of thyroid cancer, including anaplastic.”

Dr. Yip said that clinicians should consider conducting perioperative neck ultrasound with lymph node mapping if BRAF V600E or RET/PTC mutations are found. Her recommendation for these patients was a total thyroidectomy, with consideration of a central compartment neck dissection performed prophylactically, in light of the > 50% chance for lymph node involvement. Additionally, surveillance for distant metastases in the form of a chest CT should be considered when tumors are REC/PTC positive.

Study limitations include its retrospective nature and the fact that the treating physicians were not blinded to mutation testing results. Additionally, Dr. Yip noted, in patients with multifocal disease, only the most aggressive tumor was included.

Dr. Chris McHenry of Case Western Reserve University, Cleveland, noted in discussion that disease-specific survival was not related to mutation testing in this study. For patients with advanced thyroid cancer who have limited treatment options, however, mutation testing may help direct specific adjuvant therapies based on risk.

Dr. Nikiforov is a consultant for Quest Diagnostics. The others reported no disclosures.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

SAN DIEGO – Routine preoperative use of genetic testing to detect mutations implicated in thyroid carcinogenesis can help guide perioperative decision making, though risks associated with mutations are not always clear-cut.

For individuals with thyroid cancer (TC), the presence of certain mutations was associated with higher risk of early recurrence of cancer as well as distant metastases, according to a recent study presented by Dr. Linwah Yip at the annual meeting of the American Surgical Association. She and her colleagues at the University of Pittsburgh built on their previous work to characterize how thyroid cancer genotype relates both to cancer histology and to disease-related outcomes.

Using data from the electronic medical record of a single institution, Dr. Yip and her colleagues examined data from consecutive patients who had initial surgery for histologically confirmed TC. Of the 1,510 patients in the study cohort, 77% were women, and patients had a mean age of 49 years. All of the cancers in the study were tested for mutations in seven genes known to be associated with thyroid carcinogenesis. Mutation testing was a routine part of preoperative care for thyroid cancer patients, often performed on preoperative fine needle aspiration (FNA) biopsy.

Outcomes tracked in the study, Dr. Yip said, included the type and stage of thyroid cancer identified and whether the cancer recurred.

Mutations were found in 1,039 patients (69%), and no more than one mutation was found in any one tumor. No tumor genotype was specifically associated with tumor size or whether the tumor was multifocal.

Overall, BRAF V600E was the most common mutation associated with TC, and patients with this mutation were the ones most likely to have a recurrence (P = .001). However, Dr. Yip noted that there is phenotypic heterogeneity in how the recurrences present. More distant metastatic disease and lateral lymph node metastases were most likely with RET/PTC1 and three mutations (P = .02).

By contrast, about 25% of thyroid cancers in the study showed mutations in RAS, PAX8/PPARG, or BRAF K601E. These mutations were associated with a more indolent disease course, with more encapsulated tumors and an overall disease-free survival of nearly 100% at 5 years after diagnosis. Dr. Yip said, “However, RAS variations can be associated with any histologic type of thyroid cancer, including anaplastic.”

Dr. Yip said that clinicians should consider conducting perioperative neck ultrasound with lymph node mapping if BRAF V600E or RET/PTC mutations are found. Her recommendation for these patients was a total thyroidectomy, with consideration of a central compartment neck dissection performed prophylactically, in light of the > 50% chance for lymph node involvement. Additionally, surveillance for distant metastases in the form of a chest CT should be considered when tumors are REC/PTC positive.

Study limitations include its retrospective nature and the fact that the treating physicians were not blinded to mutation testing results. Additionally, Dr. Yip noted, in patients with multifocal disease, only the most aggressive tumor was included.

Dr. Chris McHenry of Case Western Reserve University, Cleveland, noted in discussion that disease-specific survival was not related to mutation testing in this study. For patients with advanced thyroid cancer who have limited treatment options, however, mutation testing may help direct specific adjuvant therapies based on risk.

Dr. Nikiforov is a consultant for Quest Diagnostics. The others reported no disclosures.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

SAN DIEGO – Routine preoperative use of genetic testing to detect mutations implicated in thyroid carcinogenesis can help guide perioperative decision making, though risks associated with mutations are not always clear-cut.

For individuals with thyroid cancer (TC), the presence of certain mutations was associated with higher risk of early recurrence of cancer as well as distant metastases, according to a recent study presented by Dr. Linwah Yip at the annual meeting of the American Surgical Association. She and her colleagues at the University of Pittsburgh built on their previous work to characterize how thyroid cancer genotype relates both to cancer histology and to disease-related outcomes.

Using data from the electronic medical record of a single institution, Dr. Yip and her colleagues examined data from consecutive patients who had initial surgery for histologically confirmed TC. Of the 1,510 patients in the study cohort, 77% were women, and patients had a mean age of 49 years. All of the cancers in the study were tested for mutations in seven genes known to be associated with thyroid carcinogenesis. Mutation testing was a routine part of preoperative care for thyroid cancer patients, often performed on preoperative fine needle aspiration (FNA) biopsy.

Outcomes tracked in the study, Dr. Yip said, included the type and stage of thyroid cancer identified and whether the cancer recurred.

Mutations were found in 1,039 patients (69%), and no more than one mutation was found in any one tumor. No tumor genotype was specifically associated with tumor size or whether the tumor was multifocal.

Overall, BRAF V600E was the most common mutation associated with TC, and patients with this mutation were the ones most likely to have a recurrence (P = .001). However, Dr. Yip noted that there is phenotypic heterogeneity in how the recurrences present. More distant metastatic disease and lateral lymph node metastases were most likely with RET/PTC1 and three mutations (P = .02).

By contrast, about 25% of thyroid cancers in the study showed mutations in RAS, PAX8/PPARG, or BRAF K601E. These mutations were associated with a more indolent disease course, with more encapsulated tumors and an overall disease-free survival of nearly 100% at 5 years after diagnosis. Dr. Yip said, “However, RAS variations can be associated with any histologic type of thyroid cancer, including anaplastic.”

Dr. Yip said that clinicians should consider conducting perioperative neck ultrasound with lymph node mapping if BRAF V600E or RET/PTC mutations are found. Her recommendation for these patients was a total thyroidectomy, with consideration of a central compartment neck dissection performed prophylactically, in light of the > 50% chance for lymph node involvement. Additionally, surveillance for distant metastases in the form of a chest CT should be considered when tumors are REC/PTC positive.

Study limitations include its retrospective nature and the fact that the treating physicians were not blinded to mutation testing results. Additionally, Dr. Yip noted, in patients with multifocal disease, only the most aggressive tumor was included.

Dr. Chris McHenry of Case Western Reserve University, Cleveland, noted in discussion that disease-specific survival was not related to mutation testing in this study. For patients with advanced thyroid cancer who have limited treatment options, however, mutation testing may help direct specific adjuvant therapies based on risk.

Dr. Nikiforov is a consultant for Quest Diagnostics. The others reported no disclosures.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

CHICAGO – Patients who had elective neck dissection at the time of primary surgery for oral cancers had a 12.5% better overall survival rate than did patients who had therapeutic neck dissections at the time of recurrence.

The risk of death was reduced by 36% among patients randomized in a phase III trial to neck lymph node dissection at the time of primary surgery, and the risk of recurrences was reduced by 55%, reported Dr. Anil D’Cruz of the head and neck service of Tata Memorial Centre, Mumbai, India.

“Elective neck dissection should be the standard of care for early oral, node-negative squamous cell cancers, based on the findings of our study,” he said at the annual meeting of the American Society of Clinical Oncology.

CHICAGO – Patients who had elective neck dissection at the time of primary surgery for oral cancers had a 12.5% better overall survival rate than did patients who had therapeutic neck dissections at the time of recurrence.

The risk of death was reduced by 36% among patients randomized in a phase III trial to neck lymph node dissection at the time of primary surgery, and the risk of recurrences was reduced by 55%, reported Dr. Anil D’Cruz of the head and neck service of Tata Memorial Centre, Mumbai, India.

“Elective neck dissection should be the standard of care for early oral, node-negative squamous cell cancers, based on the findings of our study,” he said at the annual meeting of the American Society of Clinical Oncology.

CHICAGO – Patients who had elective neck dissection at the time of primary surgery for oral cancers had a 12.5% better overall survival rate than did patients who had therapeutic neck dissections at the time of recurrence.

The risk of death was reduced by 36% among patients randomized in a phase III trial to neck lymph node dissection at the time of primary surgery, and the risk of recurrences was reduced by 55%, reported Dr. Anil D’Cruz of the head and neck service of Tata Memorial Centre, Mumbai, India.

“Elective neck dissection should be the standard of care for early oral, node-negative squamous cell cancers, based on the findings of our study,” he said at the annual meeting of the American Society of Clinical Oncology.