Platinum chemotherapy for BRCA1-related breast cancer: do we need more evidence?

A recent prospective clinical trial provides further evidence that breast cancers arising in germline BRCA1 mutation carriers are highly sensitive to cisplatin chemotherapy. The potential significance of these data for the management of patients with BRCA1-related and BRCA2-related breast cancer is discussed.In a previous issue of Breast Cancer Research Tomasz Byrski and colleagues present the results of a prospective phase II study of cisplatin in BRCA1-related metastatic breast cancer - that is, breast cancer arising in women with a germline mutation in BRCA1 [1]. They report evidence of substantial efficacy with an overall response rate of 80%, including 45% with complete response, and a time to progression of 12 months. The majority of patients in the study had triple receptor-negative breast cancer, and this time to progression compares favorably with median progression-free survival for triple receptor-negative breast cancer in contemporary series [2]. This study follows on from a retrospective study by the same group that reported a pathological complete response rate of 83% with neoadjuvant cisplatin chemotherapy, compared with a rate of 15% with nonrandomized comparator neoadjuvant chemotherapy [3].The molecular basis for these high response rates is well understood. Both BRCA1 and BRCA2 are required for DNA double-strand break repair by homologous recombination (HR-based DNA repair) [4,5]. Mutations in BRCA1 and BRCA2 inactivate protein function, and in cancer the wild-type allele is almost invariably lost, leading to a defect in HR-based DNA repair in the cancer. Platinum chemotherapy generates interstrand cross-links that can only be adequately repaired by HR-based DNA repair, and consequently BRCA1-deficient and BRCA2-deficient cells are highly sensitive to platinum chemotherapy both in vitro and in vivo. With high response rates in a prospective clinical trial, and a strong biological rationale, it is time to ask whether we are moving towards a new chemotherapy standard for BRCA1-related, and potentially by inference BRCA2-related, breast cancer or whether we need more evidence.The main strength of the current study is that it has been carried out at all. BRCA1 mutations account for a small proportion of patients with advanced breast cancer, even in countries with founder mutations, and this presents a substantial barrier to running studies testing standard chemotherapy. Use of the chemotherapy regimen outside the trial, and the wide availability of novel therapy trials competing for the same patients, add to the challenges of recruiting such trials. Nevertheless, the study by Byrski and colleagues is an open-label single-arm study of only 20 patients, with no central radiological confirmation of response rates, and both this study design and this size make a meaningful interpretation of progression-free survival very difficult. The study was in addition not prospectively registered in a clinical trial registry, removing one of the safeguards against publication bias.The study is dominated by women with three specific mutations in BRCA1 that represent the three founder mutations found in the Polish population [1], with over one-half being the single mutation 5382insC. One of these mutations, C61G, is predicted not to sensitize to cisplatin on the basis of preclinical data [6] yet cancers with this mutation appear to be just as sensitive to cisplatin in the study [1], a discrepancy for which it is important to understand the basis. Prior studies reported by this group have also been drawn from the Polish founder mutations, and we have limited data on the response of cancers with other BRCA1 mutations, and very limited data for BRCA2 mutations.Although the data for BRCA1/2-related breast are therefore relatively limited, there are substantial data on the sensitivity of BRCA1-related and BRCA2-related ovarian cancers to platinum-based chemotherapy [7,8]. BRCA1/2-related serous ovarian cancers are highly sensitive to platinum chemotherapy, and remain sensitive to repeat challenges with platinum chemotherapy, which likely explains the improved survival of BRCA1/2-related serous ovarian cancer compared with BRCA1/2 wild-type serous ovarian cancer [8].Should the accumulation of data, which includes this study by Byrski and colleagues, alter our approach to the treatment of BRCA1-related and BRCA2-related breast cancer? For patients with metastatic BRCA1-related breast cancer, although the data are limited, it seems clear that these patients should be offered the option of platinum-containing chemotherapy at some point during their treatment course. Whether platinum chemotherapy should be used as the first line in preference to other chemotherapy agents is unclear, and this is the subject of the BRCA trial ({"type":"clinical-trial","attrs":{"text":"NCT00321633","term_id":"NCT00321633"}}NCT00321633, {"type":"clinical-trial","attrs":{"text":"NCT00532727","term_id":"NCT00532727"}}NCT00532727) that randomizes first-line patients between carboplatin and docetaxel. For those with BRCA1 mutation-associated triple receptor-negative breast cancer and anthracycline-resistant and taxane-resistant disease, where there are few available active therapies, and the option of platinum-agent chemotherapy seems well founded.Whether the platinum agent should be cisplatin or whether carboplatin would have a similar response rate is unknown. Any difference in efficacy between the two drugs is likely to be small and may be outweighed by logistical and toxicity advantages for the patient. Whether patients with evidence of disease response and a long platinum-free interval (>6 months off chemotherapy) should be retreated with platinum-based chemotherapy on progression or whether they should be treated with alternative chemotherapy regimens remains unclear, and we await data to guide such decisions. Although there are few direct data on BRCA2-related breast cancer, the strength of the biological rational, the comparative data between BRCA1 and BRCA2 in ovarian cancer, and the evidence of poly(ADP ribose) polymerase (PARP) inhibitor efficacy in BRCA2-related breast cancer [9] all suggest that similar advice should apply to BRCA2-related breast cancer.What about the curative setting and patients receiving adjuvant or neoadjuvant chemotherapy? Here the data are less robust. Standard adjuvant anthracycline/taxane chemotherapy cures a substantial proportion of women with breast cancer, with evidence of better outcomes and therapy responses in the BRCA1/2 carrier population [10,11], so changes to this standard should only be made on the basis of strong evidence. At present the data to support platinum agents in this context are limited to retrospective analysis [3] or to prospective data for a very small number of patients [12]. Prospective studies are still required before routine practice changes in the curative setting. The one current exception to this is in the treatment of HER2-positive breast cancer in BRCA1/2 carriers. Relative equipoise has already been shown in the general breast cancer population for the TCH (docetaxel, carboplatin, trastuzumab) regimen compared with standard anthracycline-taxane-trastuzumab-based chemotherapy [13], and the TCH (docetaxel, carboplatin, trastuzumab) regimen presents an attractive option for BRCA1/2 carriers with HER2-positive breast cancer.PARP inhibitors target the same HR-based DNA repair defect as cisplatin chemotherapy, and there is evidence of efficacy for the PARP inhibitor olaparib in BRCA1-related and BRCA2-related breast cancer with substantial prior chemotherapy exposure [9]. PARP inhibitors target the DNA repair defect in a more specific fashion and are well tolerated without typical chemotherapy side effects [9]. The challenge in BRCA1/2-related advanced breast cancer is to develop and support a collaborative mechanism where patients can be identified and entered into randomized trials that test novel therapies such as PARP inhibitors, or mechanistically based chemotherapy, to robustly assess the efficacy relative to standard care, and therefore allow these patients to benefit from these BRCA1/2-focused treatments.     

Use of the Complete Rockall Score and the Forrest Classification to Assess Outcome in Patients with Non-variceal Upper Gastrointestinal Bleeding Subject to After-hours Endoscopy: A Retrospective Cohort Study

Objectives:

To evaluate the usefulness of the Forrest classification and the complete Rockall score with customary cut-off values for assessing the risk of adverse events in patients with upper gastrointestinal bleeding (UGI-B) subject to after-hours emergency oesophago-gastro-duodenoscopy (E-EGD) within six hours after admission.

Methods:

The medical records of patients with non-variceal UGI-B proven by after-hours endoscopy were analysed. For ''high risk'' situations (Forrest stage Ia–IIb/complete Rockall score > 2), univariate analysis was conducted to evaluate odds ratio for reaching the study endpoints (30-day and one-year mortality, re-bleeding, hospital stay ≥ 3 days).

Results:

During the study period (75 months), 86 cases (85 patients) met the inclusion criteria. Patients ''age was 66.36 ± 14.38 years; 60.5% were male. Mean duration of hospital stay was 15.21 ± 19.24 days. Mortality rate was 16.7% (30 days) and 32.9% (one year); 14% of patients re-bled. Univariate analysis of post-endoscopic Rockall score ≥ 2 showed an odds ratio of 6.09 for death within 30 days (p = 0.04). No other significant correlations were found.

Conclusion:

In patients with UGI-B subject to after-hours endoscopy, a ''high-risk'' Rockall score permits an estimation of the risk of death within 30 days but not of re-bleeding. A ''high-risk '' Forrest score is not significantly associated with the study endpoints.     

Initial evaluation of a continuous speech recognition program for radiology

The aims of this work were to measure the accuracy of one continuous speech recognition product and dependence on the speaker's gender and status as a native or nonnative English speaker, and evaluate the product's potential for routine use in transcribing radiology reports. IBM MedSpeak/Radiology software, version 1.1 was evaluated by 6 speakers. Two were nonnative English speakers, and 3 were men. Each speaker dictated a set of 12 reports. The reports included neurologic and body imaging examinations performed with 6 different modalities. The dictated and original report texts were compared, and error rates for overall, significant, and subtle significant errors were computed. Error rate dependence on modality, native English speaker status, and gender were evaluated by performing ttests. The overall error rate was 10.3 +/- 3.3%. No difference in accuracy between men and women was found; however, significant differences were seen for overall and significant errors when comparing native and nonnative English speakers (P = .009 and P = .008, respectively). The speech recognition software is approximately 90% accurate, and while practical implementation issues (rather than accuracy) currently limit routine use of this product throughout a radiology practice, application in niche areas such as the emergency room currently is being pursued. This methodology provides a convenient way to compare the initial accuracy of different speech recognition products, and changes in accuracy over time, in a detailed and sensitive manner.     

Acanthamoeba keratitis: a comprehensive photographic reference of common and uncommon signs

There has been a significant increase in the number of reported cases of Acanthamoeba keratitis reported internationally over the last 24 months. Diagnosing Acanthamoeba keratitis is often difficult and part of the difficulty is attributed to the variability of presentation. This article provides a comprehensive photographic reference of common and uncommon clinical signs of Acanthamoeba keratitis.     

Neurodevelopmental outcome in high-risk preterm infants treated with inhaled nitric oxide

Inhaled nitric oxide (iNO) is used to treat preterm infants with hypoxaemic respiratory failure. In this study we describe the long-term survival and neurodevelopmental status of high-risk preterm infants enrolled into a randomized controlled trial of iNO therapy. Information regarding long-term outcome was available for all 25 children enrolled in the original trial who survived until discharge from hospital. Formal, blinded, developmental assessment and neurological examinations were performed in 21 out of 22 children still alive at 30 mo of age, corrected for prematurity. No significant differences were found in long-term mortality (12/20 vs 8/22, RR 1.65, 95% CI 0.87-3.3), neurodevelopmental delay (4/7 vs 9/14, RR 0.89, 95% CI 0.37-1.75), severe neurodisability (0/7 vs 5/14, p = 0.12) or cerebral palsy (0/7 vs 2/14, p = 0.53) between iNO-treated and control infants. CONCLUSION: In this study there was no evidence of a significant effect on either survival or long-term neurodevelopmental status in infants treated with iNO.     

Surviving the 'heartsink' experience

The authors describe a pilot workshop designed to help doctorsachieve a greater understanding of and ability to cope withtheir ‘heartsink’ patients. Participants were askedto list their personal objectives in attending and a numberof cases were discussed in the group. A ‘heartsink survivalkit’ was provided which consisted of skills and strategieswhich are useful in difficult consultations and an approachto reassessing the goals of the relationship which might promotea more realistic understanding. The workshop was videotapedand two scenarios are presented. The implications for furthertraining are discussed.