Bio

Academic Appointments


Administrative Appointments


  • Chair, Scientific Review Committee, Stanford Cancer Institute (2009 - 2012)
  • Unit-based Medical Director, F-Ground, Stanford Hospital and Clinics (2009 - 2012)

Research & Scholarship

Current Research and Scholarly Interests


Clinical investigations in breast cancer include institutional and NSABP studies of chemoprevention, adjuvant therapy, psychosocial interventions, treatment of metastatic disease, methods of decreasing anthracycline cardiotoxicity, and modulation of multidrug resistance. Research in meta-analysis includes the performance of meta-analysis in a wide variety of settings in cancer treatment by the international Meta-Analysis Group in Cancer.

Computer science research efforts focus on computer-based systems for patient care. These include: the development of expert systems to assist in the care of patients with cancer (ONCOCIN) or AIDS (T-Helper); the development of computer-based systems using speech and pen-based input for medical records to access sources of medical knowledge; the design of three-dimensional methods of performing and representing literature searches; and the development of standards for implementing of medical computer-based systems; the development of smart agents and medical ontologies.

Clinical Trials


  • Intellectual Impairment in Women With Breast Cancer Recruiting

    RATIONALE: Breast cancer and its treatment may cause changes in a patient's ability to think, learn, and remember. Gathering information about a woman's genes, brain function, and personal history may help doctors learn more about the disease and plan the best treatment. PURPOSE: 1. To determine changes in brain function that occur following breast cancer chemotherapy. 2. To gain further understanding of the individual differences in brain function changes and recovery based on demographic, medical and treatment variables.

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  • A Phase 2 Study of Standard Chemotherapy Plus BSI-201 (a PARP Inhibitor) in the Neoadjuvant Treatment of Triple Negative Breast Cancer Not Recruiting

    This study will investigate whether the neoadjuvant combination of gemcitabine, carboplatin, and BSI-201 will cause a high percentage of triple negative breast cancer patients to achieve a pathologic complete response prior to surgery. Based on data generated by BiPar/Sanofi, it is concluded that iniparib does not possess characteristics typical of the PARP inhibitor class. The exact mechanism has not yet been fully elucidated, however based on experiments on tumor cells performed in the laboratory, iniparib is a novel investigational anti-cancer agent that induces gamma-H2AX (a marker of DNA damage) in tumor cell lines, induces cell cycle arrest in the G2/M phase in tumor cell lines, and potentiates the cell cycle effects of DNA damaging modalities in tumor cell lines. Investigations into potential targets of iniparib and its metabolites are ongoing.

    Stanford is currently not accepting patients for this trial. For more information, please contact Pei-Jen Chang, (650) 725 - 0866.

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  • Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer Not Recruiting

    RATIONALE: Drugs used in chemotherapy, such as fluorouracil, epirubicin, cyclophosphamide, and doxorubicin, work in different ways to stop tumor cells from dividing so they stop growing or die. It is not yet known which combination chemotherapy regimen is more effective in treating breast cancer. PURPOSE: This randomized phase III trial is studying two combination chemotherapy regimens to compare how well they work in treating women who have undergone surgery for breast cancer that has not spread to the lymph nodes.

    Stanford is currently not accepting patients for this trial. For more information, please contact Marilyn Florero, (650) 724 - 1953.

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  • A Study of AC Followed by a Combination of Paclitaxel Plus Trastuzumab or Lapatinib or Both Given Before Surgery to Patients With Operable HER2 Positive Invasive Breast Cancer Not Recruiting

    The primary purpose of this study is to determine whether breast cancer tumors respond (as measured by pathologic complete response: the absence of microscopic evidence of invasive tumor cells in the breast) to combined chemotherapy of AC(doxorubicin and cyclophosphamide) followed by paclitaxel plus trastuzumab or lapatinib or both given before surgery to patients with HER2-positive breast cancer. Trastuzumab will also be given to all patients after surgery. The study will also evaluate the toxic effects of the chemotherapy combination, including effects on the heart, and will determine survival and progression-free survival 5 years after treatment. Also, the study will look at whether there are gene expression profiles in the tumor tissue that can predict pathologic complete response.

    Stanford is currently not accepting patients for this trial. For more information, please contact Marilyn Florero, (650) 724 - 1953.

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  • S0307 Zoledronate, Clodronate, or Ibandronate in Treating Women Who Have Undergone Surgery for Stage I, Stage II, or Stage III Breast Cancer Not Recruiting

    RATIONALE: Zoledronate, clodronate, or ibandronate may delay or prevent bone metastases in patients with nonmetastatic breast cancer. It is not yet known whether zoledronate is more effective than clodronate or ibandronate in treating breast cancer. PURPOSE: This randomized phase III trial is studying zoledronate to see how well it works compared to clodronate or ibandronate in treating women who have undergone surgery for stage I, stage II, or stage III breast cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Mary Chen, (650) 723 - 8686.

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  • A Clinical Trial Comparing the Combination of TC Plus Bevacizumab to TC Alone and to TAC for Women With Node-Positive or High-Risk Node-Negative, HER2-Negative Breast Cancer Not Recruiting

    The main purpose of this study is to learn if adding bevacizumab to standard treatment with chemotherapy (docetaxel, doxorubicin, and cyclophosphamide) for early stage HER2-negative breast cancer will prevent breast cancer from returning. A second purpose of this study is to learn if adding bevacizumab to treatment with chemotherapy will help women with HER2-negative breast cancer live longer. The researchers also want to learn about the side effects of the combination of drugs used in this study.

    Stanford is currently not accepting patients for this trial. For more information, please contact Marilyn Florero, (650) 724 - 1953.

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  • Phase II Neoadjuvant Doxorubicin and Cyclophosphamide -> Docetaxel With Lapatinib in Stage II/III Her2Neu+ Breast Cancer Not Recruiting

    This trial combines dose dense chemotherapy with Doxorubicin and Cyclophosphamide (AC) followed by standard every 3 week docetaxel and GW572016 for neoadjuvant treatment of her2neu positive stage II/III breast cancer. GW572016 or Lapatinib, the investigational agent, acts as a duel inhibitor of both epidermal growth factor receptor (EGFR) and ErbB-2 (Her2/neu) tyrosine kinase activity. EGFR and ErbB2 receptors are frequently over-expressed or altered in human cancers including breast cancer. This study plans to determine the antitumor activity of this regimen and its effectiveness of preventing tumor growth and spread.

    Stanford is currently not accepting patients for this trial. For more information, please contact Mary Chen, (650) 723 - 8686.

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  • S0500 Treatment Decision Making Based on Blood Levels of Tumor Cells in Women With Metastatic Breast Cancer Receiving Chemotherapy Not Recruiting

    RATIONALE: Drugs used in chemotherapy work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Measuring blood levels of tumor cells may help in learning how well chemotherapy works to kill metastatic breast cancer cells and allow doctors to plan better treatment. When blood levels of tumor cells are high while receiving chemotherapy, it is not yet known whether it is more effective to change chemotherapy regimens at that time or wait until disease progression. PURPOSE: This randomized phase III trial is studying treatment decision making based on blood levels of tumor cells in women with metastatic breast cancer receiving chemotherapy.

    Stanford is currently not accepting patients for this trial. For more information, please contact Pei-Jen Chang, (650) 725 - 0866.

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  • A Safety and Immunology Study of a Modified Vaccinia Vaccine for HER-2(+) Breast Cancer After Adjuvant Therapy Not Recruiting

    The current trial, BNIT-BR-003, will evaluate the safety and biological activity of a fixed dose of MVA-BN®-HER2 following adjuvant chemotherapy in patients with HER-2-positive breast cancer. The intent of vaccination is to induce a combined antibody and T-cell anti-HER-2 immune response, which is intended to target HER-2-expressing tumor cells, and may induce tumor regression or slow progression of disease.

    Stanford is currently not accepting patients for this trial. For more information, please contact Mary Chen, (650) 723 - 8686.

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  • Anastrozole & ZD1839 Compared With Fulvestrant & ZD1839 in Postmenopausal Women w/ Metastatic Breast Cancer Not Recruiting

    This randomized phase II trial is studying how well giving gefitinib together with anastrozole works compared to giving gefitinib together with fulvestrant in treating postmenopausal women with recurrent or metastatic breast cancer. Estrogen can stimulate the growth of breast cancer cells. Hormone therapy using anastrozole and fulvestrant may fight breast cancer by blocking the use of estrogen. Gefitinib (ZD1839) may stop the growth of cancer cells by blocking the enzymes necessary for their growth. It is not yet known whether gefitinib is more effective when combined with anastrozole or fulvestrant in treating breast cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Nancy Mori, (650) 724 - 0201.

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  • Suppression of Ovarian Function Plus Either Tamoxifen or Exemestane Compared With Tamoxifen Alone in Treating Premenopausal Women With Hormone-Responsive Breast Cancer Not Recruiting

    RATIONALE: Estrogen can stimulate the growth of breast tumor cells. Ovarian function suppression combined with hormone therapy using tamoxifen or exemestane may fight breast cancer by reducing the production of estrogen. It is not yet known whether suppression of ovarian function plus either tamoxifen or exemestane is more effective than tamoxifen alone in preventing the recurrence of hormone-responsive breast cancer. PURPOSE: This randomized phase III trial is studying ovarian suppression with either tamoxifen or exemestane to see how well they work compared to tamoxifen alone in treating premenopausal women who have undergone surgery for hormone-responsive breast cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Marilyn Florero, (650) 724 - 1953.

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  • Docetaxel and Cyclophosphamide Compared to Anthracycline-Based Chemotherapy in Treating Women With HER2-Negative Breast Cancer Not Recruiting

    RATIONALE: Drugs used in chemotherapy work in different ways to stop the growth of breast cancer cells, either by killing the cells or by stopping them from dividing. Giving the drugs in different combinations may kill more breast cancer cells. Giving combination chemotherapy after surgery may kill any tumor cells that remain after surgery. PURPOSE: This randomized phase III trial is studying different combination chemotherapy regimens and their side effects and comparing how well they work in treating women with non-metastatic breast cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Donna Adelman, 650-724-1953.

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  • Chemotherapy With or Without Trastuzumab After Surgery in Treating Women With Invasive Breast Cancer Recruiting

    This randomized phase III clinical trial studies chemotherapy with or without trastuzumab after surgery to see how well they work in treating women with invasive breast cancer. Drugs used in chemotherapy work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Giving more than one drug (combination chemotherapy) and giving chemotherapy after surgery may kill more tumor cells. Monoclonal antibodies, such as trastuzumab, can block cancer growth in different ways. Some block the ability of cancer cells to grow and spread. Others find cancer cells and help kill them or carry cancer-killing substances to them. It is not yet known whether combination chemotherapy is more effective with trastuzumab in treating breast cancer.

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  • Adjuvant Chemotherapy in Treating Women Who Have Undergone Resection for Relapsed Breast Cancer; Chemotherapy as Adjuvant for LOcally Recurrent Breast Cancer Not Recruiting

    RATIONALE: Drugs used in chemotherapy use different ways to stop tumor cells from dividing so they stop growing or die. It is not yet known whether chemotherapy is effective in treating women who have undergone surgery and radiation therapy for relapsed breast cancer. PURPOSE: Randomized phase III trial to determine the effectiveness of adjuvant chemotherapy in treating women who have undergone resection for local and/or regional relapsed breast cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Marilyn Florero, (650) 724 - 1953.

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  • Radiation Therapy (WBI Versus PBI) in Treating Women Who Have Undergone Surgery For Ductal Carcinoma In Situ or Stage I or Stage II Breast Cancer Not Recruiting

    RATIONALE: Radiation therapy uses high-energy x-rays to kill tumor cells. Giving radiation therapy in different ways may kill any tumor cells that remain after surgery. It is not yet known whether whole breast radiation therapy is more effective than partial breast radiation therapy in treating breast cancer. PURPOSE: This randomized phase III trial is studying whole breast radiation therapy to see how well it works compared to partial breast radiation therapy in treating women who have undergone surgery for ductal carcinoma in situ or stage I or stage II breast cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Marilyn Florero, (650) 724 - 1953.

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  • Vitamin D and Breast Cancer: Does Weight Make a Difference? Recruiting

    This protocol is a randomized, controlled and blinded clinical trial in obese and non-obese subjects diagnosed with breast cancer in whom we will test the effects of vitamin D supplementation in the neoadjuvant setting and evaluate changes in biomarker expression in blood and tissue comparing core breast biopsy to definitive surgical samples. Our goal is to determine whether dietary vitamin D can reverse the negative effects of obesity and insulin resistance as reflected by favorable changes in the gene expression patterns in the pathologic specimens as well as in serum biomarkers of insulin resistance and adipokine secretion. We expect that vitamin D administration will improve the breast cancer gene expression pattern from a high-risk configuration to a low-risk profile in the obese patients and will also cause improvement in the non-obese.

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  • Pilot Study to Determine Radioiodide Accumulation and Dosimetry in Breast Cancers Using 124I PET/CT Not Recruiting

    This is a pilot imaging study for women whose tumors express NIS [Na+I- symporter, sodium iodide symporter]. Eligibility is limited to the presence of strong (3+) and/or plasma membrane staining in > 20% of cells as determined by immunohistochemical methods. A total of 10 patients will be imaged with 124I PET/CT (serial scans over 24 hour period) to determine radioiodide uptake and distribution in tumor tissue. Thyroid iodide uptake and retention will be blocked beginning one week prior to 124I PET/CT scan with thyroid hormone (T3) and methimazole (impedes organification). Tumor, organ and whole body dosimetry will be calculated in each patient.

    Stanford is currently not accepting patients for this trial. For more information, please contact Marilyn Florero, (650) 724 - 1953.

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  • A Safety and Immunology Study of a Modified Vaccinia Vaccine for HER-2(+) Metastatic Breast Cancer Not Recruiting

    The current trial, BNIT-BR-002, will evaluate the safety and biological activity of a fixed dose of MVA-BN®-HER2, with and without Herceptin, following 1st- or 2nd-line chemotherapy in patients with Her-2-positive metastatic breast cancer. The intent of vaccination is to induce anti-Her-2 immune responses, both antibody and T cell, that will then attack the Her-2 expressing tumors, and may induce tumor regression or slow progression of disease.

    Stanford is currently not accepting patients for this trial. For more information, please contact Mary Chen, (650) 723 - 8686.

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  • A Safety and Immunology Study of a Modified Vaccinia Vaccine for HER-2(+) Breast Cancer After Adjuvant Therapy Not Recruiting

    The current trial, BNIT-BR-003, will evaluate the safety and biological activity of a fixed dose of MVA-BN®-HER2 following adjuvant chemotherapy in patients with HER-2-positive breast cancer. The intent of vaccination is to induce a combined antibody and T-cell anti-HER-2 immune response, which is intended to target HER-2-expressing tumor cells, and may induce tumor regression or slow progression of disease.

    Stanford is currently not accepting patients for this trial. For more information, please contact Mary Chen, (650) 723 - 8686.

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  • Sleep, Circadian Hormonal Dysregulation, and Breast Cancer Survival Not Recruiting

    Recent research provides evidence that disrupted circadian rhythms, including hormonal patterns and sleep, are associated with increased risk of breast cancer incidence and faster progression to mortality. We have observed that a loss of normal diurnal cortisol rhythm associated with more awakenings during the night predicts early mortality with metastatic breast cancer. Other recent studies have shown that nighttime shift work is associated with higher breast cancer incidence, and in a murine model disrupting circadian cortisol cycles produced a doubling of implanted tumor growth. There is also recent evidence that abnormal clock genes are associated with cancer. However, it is not clear whether sleep disruption per se affects breast cancer progression, or whether such an effect is mediated by hormonal and immune dysregulation of this prevalent and hormone-mediated cancer. We propose to study sleep disruption as a prognostic factor in the progression of metastatic breast cancer. We will also examine sleep patterns in association with disrupted circadian rhythms of cortisol, ACTH, and melatonin as well as measures of immune function known to be salient to breast cancer progression. These are natural killer cell cytoxicity and specific cytokine, IL-6. We plan to recruit 105 women 45 years through 75 years with metastatic or recurrent breast cancer and 20 age and SES-matched controls for a two-week at home sleep study with Actiwatch and two nights of in-home EEG monitoring, followed by 28 hours of continuous blood sampling and one night of EEG sleep monitoring in our lab at Stanford. This will provide a full examination of circadian hormones associated with sleep patterns. We will relate these assessments to the subsequent course of breast cancer progression. Results of this study will provide specific evidence regarding how improved sleep management may affect the course of breast cancer. Aim 1: To study 24-hr diurnal rhythms of HPA axis hormones and melatonin in women with metastatic or recurrent breast cancer. Hypothesis 1: Women with metastatic or recurrent breast cancer will have reduced amplitude and disrupted phase of 24-hr diurnal rhythms of cortisol, ACTH, and melatonin. Aim 2: To describe sleep disruption in women with metastatic breast cancer and examine psychosocial, endocrine, and immune factors that may be associated with sleep disruption. Hypothesis 2: Women with metastatic or recurrent breast cancer will have a higher incidence of both at home and laboratory-examined sleep disruption than control women without breast cancer. Hypothesis 3: Poorer sleep quality will be associated with more pain, more emotional suppression in response to stressors, less emotional support, greater depression and anxiety, and greater perceived and traumatic stress. Hypothesis 4: Poorer sleep quality and quantity of sleep and daytime sleepiness and fatigue will be associated with abnormal circadian neuroendocrine (i.e., cortisol, ACTH, and melatonin) and immune patterns (i.e., suppressed day and night time NK activity and loss of NK rhythms; increased day time IL-6 levels and /or loss of IL-6 rhythm). Aim 3: To study the relationship between sleep disruption and survival time among metastatic and recurrent breast cancer patients. Hypothesis 5: Poorer sleep quality and quantity of sleep will predict shorter survival. Hypothesis 6: Reduced diurnal amplitude and an abnormal phase of cortisol will predict shorter survival. Explanatory Aim 4: To investigate whether sleep disruption mediates the relation of psychosocial factors to health outcomes.

    Stanford is currently not accepting patients for this trial. For more information, please contact Bita Nouriani, (650) 723 - 8479.

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  • A Pharmacokinetic and Randomized Trial of Neoadjuvant Treatment With Anastrozole Plus AZDO530 in Postmenopausal Patients With Hormone Receptor Positive Breast Cancer Recruiting

    The investigators propose to conduct a Phase I/randomized Phase II study design in order to test the tolerability and efficacy or AZD0530 when used together with anastrozole in therapy of ER+ and/or PR+ postmenopausal breast cancer. The Phase I pharmacokinetic (PK) cohort of the study (cohort A) will be conducted in postmenopausal women with metastatic disease and will ascertain safety and toxicity. Patients in the randomized Phase II cohort of the study (cohort B) will consist of postmenopausal women with locally advanced ER+ breast cancer who are randomized to either neoadjuvant treatment with anastrozole plus placebo, or anastrozole in combination with AZD0530. The Phase II cohort will permit extended assays of tolerability, initial estimates of efficacy, and the investigation of molecular (protein and RNA expression profiles) and cellular assays (measures of TICs) as predictors of drug efficacy.

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  • Phase II Anastrozole and ZD6474 in Neoadjuvant Treatment of Postmenopausal Hormone Receptor-Positive Breast Cancer Not Recruiting

    In this study we plan to study the combination of ZD6474, a dual inhibitor of EGFR and VEGFR-2 with anastrozole in the neoadjuvant setting for patients with Stage I-III breast cancer. The aim is to overcome mechanisms of resistance and simultaneously block multiple critical signaling pathways known to stimulate breast cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Marcy Chen, (650) 723 - 8686.

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  • Ph I/II of Vitamin D on Bone Mineral Density & Markers of Bone Resorption Not Recruiting

    Aromatase inhibitors are potent suppressors of breast cancer growth, but side effects include bone loss, fractures, arthralgias and myalgias. We hypothesize vitamin D administration might be beneficial in treating these symptoms and to protect bone.

    Stanford is currently not accepting patients for this trial. For more information, please contact Charlene Kranz, (650) 498 - 7977.

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  • Phase 2 Study of Gemzar, Taxol & Avastin Combination as 1st Line Treatment for Metastatic Breast Cancer Not Recruiting

    Given the lack of other viable treatment options for metastatic neuroendocrine tumors, contrasted with our positive anecdotal experience, and the relative tolerability of the treatment regimen for colorectal cancer patients, we propose a single-institution phase II trial investigating the efficacy of capecitabine, oxaliplatin and bevacizumab for patients with metastatic neuroendocrine tumors.

    Stanford is currently not accepting patients for this trial. For more information, please contact Mary Chen, (650) 723 - 8686.

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  • Everolimus in Combination With Exemestane in the Treatment of Postmenopausal Women With Estrogen Receptor Positive Locally Advanced or Metastatic Breast Cancer Who Are Refractory to Letrozole or Anastrozole Not Recruiting

    There are no treatments specifically approved after recurrence or progression on a NSAI. In light of the need for new treatment options for postmenopausal women after failure of prior non steroidal aromatase inhibitors (NSAI) therapy, the purpose of this Phase III study is to compare efficacy and safety of a treatment with exemestane + everolimus to exemestane + placebo in postmenopausal women with estrogen receptor positive locally advanced or metastatic breast cancer refractory to NSAI.

    Stanford is currently not accepting patients for this trial. For more information, please contact Mary Chen, (650) 723 - 8686.

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  • A Phase 3, Multi-Center Study of Gemcitabine/Carboplatin, With or Without BSI-201, in Patients With ER-, PR-, and Her2-Negative Metastatic Breast Cancer Not Recruiting

    The goal of this study was to determine the effect on overall survival and progression free survival by adding iniparib (BSI-201/SAR240550) to the combination of gemcitabine/carboplatin in adult patients with triple negative breast cancer (estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, and human epidermal growth factor receptor 2 (HER2)-negative). Based on data generated by BiPar/Sanofi, it is concluded that iniparib does not possess characteristics typical of the poly (ADP-ribose) polymerase (PARP) inhibitor class. The exact mechanism has not yet been fully elucidated, however based on experiments on tumor cells performed in the laboratory, iniparib is a novel investigational anti-cancer agent that induces gamma-H2AX (a marker of DNA damage) in tumor cell lines, induces cell cycle arrest in the G2/M phase in tumor cell lines, and potentiates the cell cycle effects of DNA damaging modalities in tumor cell lines. Investigations into potential targets of iniparib and its metabolites are ongoing.

    Stanford is currently not accepting patients for this trial. For more information, please contact Charlene Kranz, (650) 498 - 7977.

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Teaching

2013-14 Courses


Publications

Journal Articles


  • mTOR Inhibitors in the Treatment of Breast Cancer ONCOLOGY-NEW YORK Vinayak, S., Carlson, R. W. 2013; 27 (1): 38-?

    Abstract

    The phosphatidylinositol 3-kinase/mammalian target of rapamycin (PI3K/mTOR) pathway is commonly dysregulated in breast cancer. In preclinical studies, hyperactivation of the PI3K pathway has been linked to resistance to both endocrine therapy and trastuzumab (Herceptin). Rapalogs, agents that primarily inhibit mTOR-raptor complex 1, have been studied in combination with endocrine therapy to overcome endocrine resistance.Trials of combination endocrine therapy and rapalogs in metastatic hormone receptor-positive breast cancer have demonstrated variable results. However, two independent trials have recently shown that combination everolimus (Afinitor) and tamoxifen or combination everolimus and exemestane (Aromasin) is more effective than either endocrine agent alone. These trials selected patients with cancer refractory to endocrine therapy, which may be important in sensitizing tumors to inhibition of this pathway. In human epidermal growth factor receptor 2 (HER2)-positive breast cancer, the early clinical data with combinations of PI3K/mTOR inhibitors and anti-HER2 therapies are encouraging. Efforts to identify clinical biomarkers of response or resistance to mTOR inhibitors are ongoing. This review will summarize results of preclinical and clinical studies aswell as ongoing clinical trials with mTOR or dual PI3K/mTOR inhibitors.

    View details for Web of Science ID 000314141000003

    View details for PubMedID 23461041

  • Single Cell Profiling of Circulating Tumor Cells: Transcriptional Heterogeneity and Diversity from Breast Cancer Cell Lines PLOS ONE Powell, A. A., Talasaz, A. H., Zhang, H., Coram, M. A., Reddy, A., Deng, G., Telli, M. L., Advani, R. H., Carlson, R. W., Mollick, J. A., Sheth, S., Kurian, A. W., Ford, J. M., Stockdale, F. E., Quake, S. R., Pease, R. F., Mindrinos, M. N., Bhanot, G., Dairkee, S. H., Davis, R. W., Jeffrey, S. S. 2012; 7 (5)

    Abstract

    To improve cancer therapy, it is critical to target metastasizing cells. Circulating tumor cells (CTCs) are rare cells found in the blood of patients with solid tumors and may play a key role in cancer dissemination. Uncovering CTC phenotypes offers a potential avenue to inform treatment. However, CTC transcriptional profiling is limited by leukocyte contamination; an approach to surmount this problem is single cell analysis. Here we demonstrate feasibility of performing high dimensional single CTC profiling, providing early insight into CTC heterogeneity and allowing comparisons to breast cancer cell lines widely used for drug discovery.We purified CTCs using the MagSweeper, an immunomagnetic enrichment device that isolates live tumor cells from unfractionated blood. CTCs that met stringent criteria for further analysis were obtained from 70% (14/20) of primary and 70% (21/30) of metastatic breast cancer patients; none were captured from patients with non-epithelial cancer (n = 20) or healthy subjects (n = 25). Microfluidic-based single cell transcriptional profiling of 87 cancer-associated and reference genes showed heterogeneity among individual CTCs, separating them into two major subgroups, based on 31 highly expressed genes. In contrast, single cells from seven breast cancer cell lines were tightly clustered together by sample ID and ER status. CTC profiles were distinct from those of cancer cell lines, questioning the suitability of such lines for drug discovery efforts for late stage cancer therapy.For the first time, we directly measured high dimensional gene expression in individual CTCs without the common practice of pooling such cells. Elevated transcript levels of genes associated with metastasis NPTN, S100A4, S100A9, and with epithelial mesenchymal transition: VIM, TGFß1, ZEB2, FOXC1, CXCR4, were striking compared to cell lines. Our findings demonstrate that profiling CTCs on a cell-by-cell basis is possible and may facilitate the application of 'liquid biopsies' to better model drug discovery.

    View details for DOI 10.1371/journal.pone.0033788

    View details for Web of Science ID 000305335000005

    View details for PubMedID 22586443

  • Invasive Breast Cancer JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Carlson, R. W., Allred, C., Anderson, B. O., Burstein, H. J., Carter, W. B., Edge, S. B., Erban, J. K., Farrar, W. B., Forero, A., Giordano, S. H., Goldstein, L. J., Gradishar, W. J., Hayes, D. F., Hudis, C. A., Ljung, B., Mankoff, D. A., Marcom, P. K., Mayer, I. A., McCormick, B., Pierce, L. J., Reed, E. C., Sachdev, J., Smith, M. L., Somlo, G., Ward, J. H., Wolff, A. C., Zellars, R. 2011; 9 (2): 136-222

    View details for Web of Science ID 000287942900002

    View details for PubMedID 21310842

  • Left Ventricular Dysfunction in Patients Receiving Cardiotoxic Cancer Therapies Are Clinicians Responding Optimally? JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Yoon, G. J., Telli, M. L., Kao, D. P., Matsuda, K. Y., Carlson, R. W., Witteles, R. M. 2010; 56 (20): 1644-1650

    Abstract

    The purpose of this study was to examine treatment practices for cancer therapy-associated decreased left ventricular ejection fraction (LVEF) detected on echocardiography and whether management was consistent with American College of Cardiology/American Heart Association guidelines.Patients treated with anthracyclines or trastuzumab are at risk of cardiotoxicity. Decreased LVEF represents a Class I indication for drug intervention according to American College of Cardiology/American Heart Association guidelines.Patients receiving anthracycline or trastuzumab at Stanford University from October 2005 to October 2007 and who had undergone echocardiography before and after receiving an anthracycline or trastuzumab were identified. Chart review examined chemotherapy regimens, cardiac risk factors, imaging results, concomitant medications, and cardiology consultations.Eighty-eight patients received therapy with an anthracycline or trastuzumab and had a pre-treatment and follow-up echocardiogram. Ninety-two percent were treated with anthracyclines, 17% with trastuzumab after an anthracycline, and 8% with trastuzumab without previous treatment with anthracycline. Mean baseline LVEF was 60%, with 14% having a baseline <55%. Forty percent had decreased LVEF (<55%) after anthracycline and/or trastuzumab treatment. Of these patients, 40% received angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, 51% beta-blocker therapy, and 54% cardiology consultation. Of patients with asymptomatic decreased LVEF, 31% received angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, 35% beta-blocker therapy, and 42% cardiology consultation. Of those with symptomatic decreased LVEF, 67% received angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, 100% beta-blocker therapy, and 89% cardiology consultation.Many cancer survivors are not receiving treatment consistent with heart failure guidelines. There is substantial opportunity for collaboration between oncologists and cardiologists to improve the care of oncology patients receiving cardiotoxic therapy.

    View details for DOI 10.1016/j.jacc.2010.07.023

    View details for Web of Science ID 000283737600007

    View details for PubMedID 21050974

  • Phase II Trial of Anastrozole Plus Goserelin in the Treatment of Hormone Receptor-Positive, Metastatic Carcinoma of the Breast in Premenopausal Women JOURNAL OF CLINICAL ONCOLOGY Carlson, R. W., Theriault, R., Schurman, C. M., Rivera, E., Chung, C. T., Phan, S., Arun, B., Dice, K., Chiv, V. Y., Green, M., Valero, V. 2010; 28 (25): 3917-3921

    Abstract

    To explore the antitumor activity of the aromatase inhibitor, anastrozole, in the treatment of premenopausal women with hormone receptor-positive, metastatic breast cancer who have been rendered functionally postmenopausal with the use of the luteinizing hormone-releasing hormone agonist, goserelin.Premenopausal women with estrogen and/or progesterone receptor-positive, metastatic or recurrent breast cancer were enrolled in this prospective, single-arm, multicenter phase II trial. Patients were treated with goserelin 3.6 mg subcutaneous monthly and began anastrozole 1-mg daily 21 days after the first injection of goserelin. Patients continued on treatment until disease progression or unacceptable toxicity.Thirty-five patients were enrolled of which 32 were evaluable for response and toxicity. Estradiol suppression was assessed, with mean estradiol levels of 18.7 pg/mL at 3 months and 14.8 pg/mL at 6 months. One participant (3.1%) experienced a complete response, 11 (34.4%) experienced partial response, and 11 (34.4%) experienced stable disease for 6 months or longer for a clinical benefit rate of 71.9%. Median time to progression was 8.3 months (range, 2.1 to 63+) and median survival was not been reached (range, 11.1 to 63+). The most common adverse events were fatigue (50%), arthralgias (53%), and hot flashes (59%). There were no grade 4 to 5 toxicities.The combination of goserelin plus anastrozole has substantial antitumor activity in the treatment of premenopausal women with hormone receptor-positive metastatic breast cancer.

    View details for DOI 10.1200/JCO.2009.24.9565

    View details for Web of Science ID 000281502500006

    View details for PubMedID 20679610

  • Impaired interferon signaling is a common immune defect in human cancer PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Critchley-Thorne, R. J., Simons, D. L., Yan, N., Miyahira, A. K., Dirbas, F. M., Johnson, D. L., Swetter, S. M., Carlson, R. W., Fisher, G. A., Koong, A., Holmes, S., Lee, P. P. 2009; 106 (22): 9010-9015

    Abstract

    Immune dysfunction develops in patients with many cancer types and may contribute to tumor progression and failure of immunotherapy. Mechanisms underlying cancer-associated immune dysfunction are not fully understood. Efficient IFN signaling is critical to lymphocyte function; animals rendered deficient in IFN signaling develop cancer at higher rates. We hypothesized that altered IFN signaling may be a key mechanism of immune dysfunction common to cancer. To address this, we assessed the functional responses to IFN in peripheral blood lymphocytes from patients with 3 major cancers: breast cancer, melanoma, and gastrointestinal cancer. Type-I IFN (IFN-alpha)-induced signaling was reduced in T cells and B cells from all 3 cancer-patient groups compared to healthy controls. Type-II IFN (IFN-gamma)-induced signaling was reduced in B cells from all 3 cancer patient groups, but not in T cells or natural killer cells. Impaired-IFN signaling was equally evident in stage II, III, and IV breast cancer patients, and downstream functional defects in T cell activation were identified. Taken together, these findings indicate that defects in lymphocyte IFN signaling arise in patients with breast cancer, melanoma, and gastrointestinal cancer, and these defects may represent a common cancer-associated mechanism of immune dysfunction.

    View details for DOI 10.1073/pnas.0901329106

    View details for Web of Science ID 000266580500043

    View details for PubMedID 19451644

  • First-Line Chemotherapy for Metastatic Breast Cancer CLINICAL BREAST CANCER Telli, M. L., Carlson, R. W. 2009; 9: S66-S72

    Abstract

    The selection of first-line chemotherapy for metastatic breast cancer (MBC) is complex because of the myriad of treatment options available and the inherent biologic heterogeneity of the disease. The potential treatment options are greatly influenced by estrogen and progesterone receptor and HER2 status of the tumor, and biopsy with reassessment of these markers at the time of disease recurrence is strongly recommended. Metastatic breast cancer is generally an incurable disease, with survival that could range from months to several years. Important but modest improvements in overall survival (OS) have been observed for women with MBC over the past few decades, in part because of improvements in systemic therapy. For women with endocrine-responsive disease, hormonal therapy is the appropriate initial treatment choice at the time of disease recurrence with rare exception. Initiation of systemic chemotherapy is appropriate for women with disease that is either hormone receptor negative, endocrine therapy refractory, or rapidly progressive with visceral involvement. The addition of trastuzumab to chemotherapy for women with HER2-positive breast cancer represents a clear standard of care. For HER2-negative MBC, sequential single-agent chemotherapy is preferred over combination therapy as a result of the more favorable toxicity profile and absence of a clinically significant improvement in survival with combination treatment. Many single-agent chemotherapeutic agents have activity in MBC, with most data supporting an anthracycline- or taxane-based approach. Bevacizumab in combination with chemotherapy prolongs progression-free survival in women with MBC, though its position in the first-line treatment of MBC relative to standard chemotherapy remains unclear at this time because of lack of OS benefit.

    View details for DOI 10.3816/CBC.2009.s.007

    View details for Web of Science ID 000267527100003

    View details for PubMedID 19596645

  • Predictors and Temporal Trends of Adjuvant Aromatase Inhibitor Use in Breast Cancer JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Svahn, T. H., Niland, J. C., Carlson, R. W., Hughes, M. E., Ottesen, R. A., Theriault, R. L., Edge, S. B., Schott, A. F., Bookman, M. A., Weeks, J. C. 2009; 7 (2): 115-121

    Abstract

    After the first report of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial, adjuvant aromatase inhibitor use increased rapidly among National Comprehensive Cancer Network member institutions. Increased aromatase inhibitor use was associated with older age, vascular disease, overexpression of human epidermal growth factor receptor 2 (HER2), or more advanced stage, and substantial variation was seen among institutions. This article examines adjuvant endocrine therapy in postmenopausal women after the first report of the trial, identifies temporal relationships in aromatase inhibitor use, and examines characteristics associated with choice of endocrine therapy among 4044 postmenopausal patients with hormone receptor-positive nonmetastatic breast cancer presenting from July 1997 to December 2004. Multivariable logistic regression analysis examined temporal associations and characteristics associated with aromatase inhibitor use. Time-trend analysis showed increased aromatase inhibitor and decreased tamoxifen use after release of ATAC results (P < .0001). In multivariable regression analysis, institution (P <. 0001), vascular disease (P <. 0001), age (P = .0002), stage (P = .0002), and HER2 status (P = .0009) independently predicted aromatase inhibitor use. Institutional rates of use ranged from 15% to 66%. Adjuvant aromatase inhibitor use increased after the first report of ATAC, with this increase associated with older age, vascular disease, overexpression of HER2, or more advanced stage. Substantial variation was seen among institutions.

    View details for Web of Science ID 000270264400004

    View details for PubMedID 19200415

  • The Decline in Breast Cancer Incidence: Real or Imaginary? CURRENT ONCOLOGY REPORTS Kurian, A. W., Clarke, C. A., Carlson, R. W. 2009; 11 (1): 21-28

    Abstract

    Breast cancer is a major global problem, with nearly 1 million cases occurring each year. Over the past several decades, the disease's incidence has risen worldwide, increasing in developing and developed countries. This rise in breast cancer incidence has been attributed to changes in lifestyle and reproductive factors and to the dissemination of population-wide mammographic screening, which facilitates diagnosis. Recently, a decline in breast cancer incidence was reported in the United States and several other developed countries, and a substantial reduction in menopausal hormone therapy use was proposed as a possible cause. However, significant controversy remains as to the timing, causes, generalizability, and longevity of this reported decline in incidence.

    View details for Web of Science ID 000207843700006

    View details for PubMedID 19080738

  • Selecting high priority quality measures for breast cancer quality improvement MEDICAL CARE Hassett, M. J., Hughes, M. E., Niland, J. C., Ottesen, R., Edge, S. B., Bookman, M. A., Carlson, R. W., Theriault, R. L., Weeks, J. C. 2008; 46 (8): 762-770

    Abstract

    Although many quality measures have been created, there is no consensus regarding which are the most important. We sought to develop a simple, explicit strategy for prioritizing breast cancer quality measures based on their potential to highlight areas where quality improvement efforts could most impact a population.Using performance data for 9019 breast cancer patients treated at 10 National Comprehensive Cancer Network institutions, we assessed concordance relative to 30 reliable, valid breast cancer process-based treatment measures. We identified 4 attributes that indicated there was room for improvement and characterized the extent of burden imposed by failing to follow each measure: number of nonconcordant patients, concordance across all institutions, highest concordance at any 1 institution, and magnitude of benefit associated with concordant care. For each measure, we used data from the concordance analyses to derive the first 3 attributes and surveyed expert breast cancer physicians to estimate the fourth. A simple algorithm incorporated these attributes and produced a final score for each measure; these scores were used to rank the measures.We successfully prioritized quality measures using explicit, objective methods and actual performance data. The number of nonconcordant patients had the greatest influence on the rankings. The highest-ranking measures recommended chemotherapy and hormone therapy for hormone-receptor positive tumors and radiation therapy after breast-conserving surgery.This simple, explicit approach is a significant departure from methods used previously, and effectively identifies breast cancer quality measures that have broad clinical relevance. Systematically prioritizing quality measures could increase the efficiency and efficacy of quality improvement efforts and substantially improve outcomes.

    View details for Web of Science ID 000258014400002

    View details for PubMedID 18665055

  • New models and online calculator for predicting non-sentinel lymph node status in sentinel lymph node positive breast cancer patients BMC CANCER Kohrt, H. E., Olshen, R. A., Bermas, H. R., Goodson, W. H., Wood, D. J., Henry, S., Rouse, R. V., Bailey, L., Philben, V. J., Dirbas, F. M., Dunn, J. J., Johnson, D. L., Wapnir, I. L., Carlson, R. W., Stockdale, F. E., Hansen, N. M., Jeffrey, S. S. 2008; 8

    Abstract

    Current practice is to perform a completion axillary lymph node dissection (ALND) for breast cancer patients with tumor-involved sentinel lymph nodes (SLNs), although fewer than half will have non-sentinel node (NSLN) metastasis. Our goal was to develop new models to quantify the risk of NSLN metastasis in SLN-positive patients and to compare predictive capabilities to another widely used model.We constructed three models to predict NSLN status: recursive partitioning with receiver operating characteristic curves (RP-ROC), boosted Classification and Regression Trees (CART), and multivariate logistic regression (MLR) informed by CART. Data were compiled from a multicenter Northern California and Oregon database of 784 patients who prospectively underwent SLN biopsy and completion ALND. We compared the predictive abilities of our best model and the Memorial Sloan-Kettering Breast Cancer Nomogram (Nomogram) in our dataset and an independent dataset from Northwestern University.285 patients had positive SLNs, of which 213 had known angiolymphatic invasion status and 171 had complete pathologic data including hormone receptor status. 264 (93%) patients had limited SLN disease (micrometastasis, 70%, or isolated tumor cells, 23%). 101 (35%) of all SLN-positive patients had tumor-involved NSLNs. Three variables (tumor size, angiolymphatic invasion, and SLN metastasis size) predicted risk in all our models. RP-ROC and boosted CART stratified patients into four risk levels. MLR informed by CART was most accurate. Using two composite predictors calculated from three variables, MLR informed by CART was more accurate than the Nomogram computed using eight predictors. In our dataset, area under ROC curve (AUC) was 0.83/0.85 for MLR (n = 213/n = 171) and 0.77 for Nomogram (n = 171). When applied to an independent dataset (n = 77), AUC was 0.74 for our model and 0.62 for Nomogram. The composite predictors in our model were the product of angiolymphatic invasion and size of SLN metastasis, and the product of tumor size and square of SLN metastasis size.We present a new model developed from a community-based SLN database that uses only three rather than eight variables to achieve higher accuracy than the Nomogram for predicting NSLN status in two different datasets.

    View details for DOI 10.1186/1471-2407-8-66

    View details for Web of Science ID 000255935500001

    View details for PubMedID 18315887

  • Effects of supportive-expressive group therapy on survival of patients with metastatic breast cancer - A randomized prospective trial CANCER Spiegel, D., Butler, L. D., Giese-Davis, J., Koopman, C., Miller, E., DiMiceli, S., Classen, C. C., Fobair, P., Carlson, R. W., Kraemer, H. C. 2007; 110 (5): 1130-1138

    Abstract

    This study was designed to replicate our earlier finding that intensive group therapy extended survival time of women with metastatic breast cancer. Subsequent findings concerning the question of whether such psychosocial support affects survival have been mixed.One hundred twenty-five women with confirmed metastatic (n = 122) or locally recurrent (n = 3) breast cancer were randomly assigned either to the supportive-expressive group therapy condition (n = 64), where they received educational materials plus weekly supportive-expressive group therapy, or to the control condition (n = 61), where they received only educational materials for a minimum of 1 year. The treatment, 90 minutes once a week, was designed to build new bonds of social support, encourage expression of emotion, deal with fears of dying and death, help restructure life priorities, improve communication with family members and healthcare professionals, and enhance control of pain and anxiety.Overall mortality after 14 years was 86%; median survival time was 32.8 months. No overall statistically significant effect of treatment on survival was found for treatment (median, 30.7 months) compared with control (median, 33.3 months) patients, but there was a statistically significant intervention site-by-condition interaction. Exploratory moderator analysis to explain that interaction revealed a significant overall interaction between estrogen-receptor (ER) status and treatment condition (P = .002) such that among the 25 ER-negative participants, those randomized to treatment survived longer (median, 29.8 months) than ER-negative controls (median, 9.3 months), whereas the ER-positive participants showed no treatment effect.The earlier finding that longer survival was associated with supportive-expressive group therapy was not replicated. Although it is possible that psychosocial effects on survival are relevant to a small subsample of women who are more refractory to current hormonal treatments, further research is required to investigate subgroup differences.

    View details for DOI 10.1002/cncr.22890

    View details for Web of Science ID 000249191100025

    View details for PubMedID 17647221

  • Trastuzumab-related cardiotoxicity: Calling into question the concept of reversibility JOURNAL OF CLINICAL ONCOLOGY Telli, M. L., Hunt, S. A., Carlson, R. W., Guardino, A. E. 2007; 25 (23): 3525-3533

    Abstract

    To assess the spectrum and reversibility of the cardiotoxicity observed in the adjuvant trastuzumab trials.The design and efficacy of the major adjuvant trastuzumab trials was assessed, including the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-31, North Central Cancer Treatment Group N9831, Herceptin Adjuvant, Breast Cancer International Research Group 006, and Finland Herceptin trials. The cardiotoxicity data were evaluated with a focus on the follow-up cardiac evaluations of women who were diagnosed with cardiotoxicity. Proposed mechanisms of trastuzumab-related cardiotoxicity were considered. The natural history of congestive heart failure (CHF) was reviewed with the goal of placing the trastuzumab experience in context.Up to 4% of patients enrolled onto the adjuvant trastuzumab trials experienced severe CHF during treatment. In these trials, early stopping rules that identified an unacceptable level of cardiotoxicity were never reached. Despite this, a large number of patients on these trials experienced some form of cardiotoxicity that ultimately required discontinuation of trastuzumab. Approximately 14% of patients in the NSABP B-31 trial discontinued trastuzumab because of asymptomatic decreases in left ventricular ejection fraction (LVEF). Results of follow-up cardiac evaluations of patients diagnosed with any degree of cardiotoxicity in the NSABP B-31 trial document that a clinically significant proportion of patients have sustained decrements in their LVEF to less than 50%.Adjuvant trastuzumab provides substantial benefits to patients with human epidermal growth factor receptor 2-positive breast cancer, however, competing immediate and long-term cardiovascular risks are a great concern. Continued cardiac follow-up of these women is of critical importance.

    View details for DOI 10.1200/JCO.2007.11.0106

    View details for Web of Science ID 000248744300023

    View details for PubMedID 17687157

  • Phyllodes tumors of the breast: natural history, diagnosis, and treatment. Journal of the National Comprehensive Cancer Network Telli, M. L., Horst, K. C., Guardino, A. E., Dirbas, F. M., Carlson, R. W. 2007; 5 (3): 324-330

    Abstract

    Phyllodes tumors of the breast are unusual fibroepithelial tumors that exhibit a wide range of clinical behavior. These tumors are categorized as benign, borderline, or malignant based on a combination of histologic features. The prognosis of phyllodes tumors is favorable, with local recurrence occurring in approximately 15% of patients overall and distant recurrence in approximately 5% to 10% overall. Wide excision with a greater than 1 cm margin is definitive primary therapy. Adjuvant systemic therapy is of no proven value. Patients with locally recurrent disease should undergo wide excision of the recurrence with or without subsequent radiotherapy.

    View details for PubMedID 17439760

  • Adjuvant endocrine therapy in hormone receptor-positive postmenopausal breast cancer: evolution of NCCN, ASCO, and St Gallen recommendations. Journal of the National Comprehensive Cancer Network Carlson, R. W., Hudis, C. A., Pritchard, K. I. 2006; 4 (10): 971-979

    Abstract

    Endocrine therapy has a firm role in adjuvant treatment of women with hormone receptor-positive invasive breast cancer. Until recently, tamoxifen was the most commonly used adjuvant endocrine therapy in premenopausal and postmenopausal women. Several randomized clinical trials have studied the third-generation selective aromatase inhibitors (AIs) (anastrozole, letrozole, and exemestane) as adjuvant endocrine therapy in postmenopausal women. These studies compared therapy with an AI alone versus tamoxifen alone; 2 to 3 years of tamoxifen followed by switching to an AI versus continuation of tamoxifen; or extended therapy with an AI after approximately 5 years of tamoxifen therapy. No statistically significant differences in overall survival were observed. A single trial using extended treatment with an adjuvant AI suggests a small, statistically significant survival advantage in women with axillary lymph node-positive disease while showing no statistically significant decrease in survival with the use of an AI. The toxicities of the AIs are generally acceptable, with fewer endometrial cancers, gynecologic complaints, and thromboembolic events, but more bone fractures and arthralgias compared with tamoxifen alone. Three widely disseminated treatment guidelines, the National Comprehensive Cancer Network Breast Cancer Clinical Practice Guidelines in Oncology, the American Society of Clinical Oncology Technology Assessment on the Use of Aromatase Inhibitors, and the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer, now incorporate AIs in the adjuvant therapy of postmenopausal women with estrogen receptor-positive breast cancer.

    View details for PubMedID 17112447

  • A pilot phase II trial of valspodar modulation of multidrug resistance to paclitaxel in the treatment of metastatic carcinoma of the breast (E1195): A trial of the eastern cooperative oncology group CANCER INVESTIGATION Carlson, R. W., O'Neill, A. M., Goldstein, L. J., Sikic, B. I., Abramson, N., Stewart, J. A., Davidson, N. E., Wood, W. C. 2006; 24 (7): 677-681

    Abstract

    To assess the activity and toxicity of valspodar (PSC-833) in combination with paclitaxel in women with anthracycline refractory, metastatic breast cancer.Limited, multi-institutional, Phase II trial of valspodar at 5 mg/kg/dose orally every 6 hours for 12 doses in combination with paclitaxel 70 mg/m2 administered intravenously as a 3-hour infusion beginning 4 hours after the fifth dose of valspodar, every 3 weeks. Eligible patients had bi-dimensionally measurable metastatic carcinoma of the breast, prior anthracycline therapy or a medical contraindication to anthracycline therapy, no more than one prior chemotherapy for recurrent or metastatic breast cancer, and adequate organ function. Treatment was continued until disease progression or unacceptable toxicity.Thirty-four patients are evaluable for response and 37 for toxicity. Two (6 percent) patients achieved a complete response and 5 (15 percent) a partial response for an objective response rate of 21 percent (95 percent confidence interval of 9 to 38 percent). Median duration of response was 9.7 months (95 percent confidence interval 8.0-17.2 months), median time to progression was 3.3 months (95 percent confidence interval 2.0-4.2 months), and median survival was 12 months (95 percent confidence interval 8.1-17.3 months). The toxicity experienced was acceptable.Combination valspodar plus paclitaxel is an active regimen and has acceptable toxicity. The combination is not clearly more active than single agent paclitaxel.

    View details for DOI 10.1080/07357900600981349

    View details for Web of Science ID 000242207700003

    View details for PubMedID 17118777

  • Breast cancer followed by corpus cancer: Is there a higher risk for aggressive histologic subtypes? GYNECOLOGIC ONCOLOGY Chan, J. K., Manuel, M. R., Cheung, M. K., Osann, K., Husain, A., Teng, N. N., Rao, A., Carlson, R. W., Whittemore, A. S. 2006; 102 (3): 508-512

    Abstract

    To analyze corpus cancer patients with a breast cancer history for risk of developing aggressive uterine histologic types.Corpus cancer patients with a history of breast cancer were identified from the Surveillance Epidemiology and End Results database from 1988 to 2001. Demographics, clinico-pathologic, and survival data were analyzed using Kaplan-Meier and logistic regression analyses.Of 52,109 women diagnosed with corpus cancer, 1922 had a history of breast cancer. Women with a history of breast cancer had a significantly higher proportion of uterine papillary serous carcinomas (UPSC) and sarcomas compared to those without a breast cancer history (9.4% vs. 6.3% for UPSC and 10.3% vs. 8.4% for sarcoma; P < 0.001). Patients with endometrioid or sarcoma of the uterus after breast cancer had significantly worse 5-year survivals than patients without a breast cancer history (84.4% vs. 90.5%; P < 0.001 and 49.0% vs. 63.6%, P < 0.001, respectively). Older age, advanced stage, lack of surgery and radiation treatment, poor histologic types, and history of breast cancer were independent prognostic factors for poorer survival.In this study, the proportional incidence of UPSC and sarcoma was significantly higher in women with a breast cancer history. These findings highlight the association of breast cancer and high-risk corpus cancer subtypes.

    View details for DOI 10.1016/j.ygyno.2006.01.014

    View details for Web of Science ID 000240871000017

    View details for PubMedID 16483640

  • HER2 testing in breast cancer: NCCN Task Force report and recommendations. Journal of the National Comprehensive Cancer Network Carlson, R. W., Moench, S. J., Hammond, M. E., Perez, E. A., Burstein, H. J., Allred, D. C., Vogel, C. L., Goldstein, L. J., Somlo, G., Gradishar, W. J., Hudis, C. A., Jahanzeb, M., Stark, A., Wolff, A. C., Press, M. F., Winer, E. P., Paik, S., Ljung, B. 2006; 4: S1-22

    Abstract

    The NCCN HER2 Testing in Breast Cancer Task Force was convened to critically evaluate the ability of the level of HER2 expression or gene amplification in breast cancer tumors to serve as a prognostic and a predictive factor in the metastatic and adjuvant settings, to assess the reliability of the methods of measuring HER2 expression or gene amplification in the laboratory, and to make recommendations regarding the interpretation of test results. The Task Force is a multidisciplinary panel of 24 experts in breast cancer representing the disciplines of medical oncology, pathology, radiation oncology, surgical oncology, epidemiology, and patient advocacy. Invited members included members of the NCCN Breast Cancer Panel and other needed experts selected solely by the NCCN. During a 2-day meeting, individual task force members provided didactic presentations critically evaluating important aspects of HER2 biology and epidemiology: HER2 as a prognostic and predictive factor; results from clinical trials in which trastuzumab was used as a targeted therapy against HER2 in the adjuvant and metastatic settings; the available testing methodologies for HER2, including sensitivity, specificity, and ability to provide prognostic and predictive information; and the principles on which HER2 testing should be based. Each task force member was charged with identifying evidence relevant to their specific expertise and presentation. Following the presentations, an evidence-based consensus approach was used to formulate recommendations relating to the pathologic and clinical application of the evidence to breast cancer patient evaluation and care. In areas of controversy, this process extended beyond the meeting to achieve consensus. The Task Force concluded that accurate assignment of the HER2 status of invasive breast cancer is essential to clinical decision making in the treatment of breast cancer in both adjuvant and metastatic settings. Formal validation and concordance testing should be performed and reported by laboratories performing HER2 testing for clinical purposes. If appropriate quality control/assurance procedures are in place, either immunohistochemistry (IHC) or fluorescence in situ hybridization (FISH) methods may be used. A tumor with an IHC score of 0 or 1+, an average HER2 gene/chromosome 17 ratio of less than 1.8, or an average number of HER2 gene copies/cell of 4 or less as determined by FISH is considered to be HER2 negative. A tumor with an IHC score of 3+, an average HER2 gene/chromosome 17 ratio of greater than 2.2 by FISH, or an average number of HER2 gene copies/cell of 6 or greater is considered HER2 positive. A tumor with an IHC score of 2+ should be further tested using FISH, with HER2 status determined by the FISH result. Tumor samples with an average HER2 gene/chromosome ratio of 1.8 to 2.2 or average number of HER2 gene copies/cell in the range of greater than 4 to less than 6 are considered to be borderline, and strategies to assign the HER2 status of such samples are proposed.

    View details for PubMedID 16813731

  • NCCN Task Force Report: Adjuvant Therapy for Breast Cancer. Journal of the National Comprehensive Cancer Network Carlson, R. W., Brown, E., Burstein, H. J., Gradishar, W. J., Hudis, C. A., Loprinzi, C., Mamounas, E. P., Perez, E. A., Pritchard, K., Ravdin, P., Recht, A., Somlo, G., Theriault, R. L., Winer, E. P., Wolff, A. C. 2006; 4: S1-26

    Abstract

    The National Comprehensive Cancer Network (NCCN) first published the NCCN Breast Cancer Treatment Guidelines in 1996. The Guidelines address the treatment of all stages of breast cancer across the spectrum of patient care and have been updated yearly. Adjuvant therapy for breast cancer has undergone an especially rapid evolution over the past few years. Therefore, the NCCN Breast Cancer Guidelines Panel was supplemented by additional experts to form the Adjuvant Therapy Task Force to provide a forum for an extended discussion and expanded input to the adjuvant therapy recommendations for the Breast Cancer Treatment Guidelines. Issues discussed included methods of risk-stratification for recurrence; how biologic markers such as HER2 status, quantitative estrogen receptor, or genetic markers can be incorporated as prognostic or predictive factors; and how age, menopausal status, and estrogen receptor levels impact benefits from chemotherapy and endocrine therapy. Additionally, the task force discussed the strategies for use of aromatase inhibitors in postmenopausal women and the potential incorporation of trastuzumab into adjuvant therapy of women with HER2/neu positive breast cancer. This supplement summarizes the background data and ensuing discussion from the Adjuvant Task Force meeting.

    View details for PubMedID 16507275

  • Update: NCCN breast cancer Clinical Practice Guidelines. Journal of the National Comprehensive Cancer Network Carlson, R. W., McCormick, B. 2005; 3: S7-11

    View details for PubMedID 16280118

  • Breast cancer. Journal of the National Comprehensive Cancer Network Carlson, R. W., Anderson, B. O., Burstein, H. J., Cox, C. E., Edge, S. B., Farrar, W. B., Goldstein, L. J., Gradishar, W. J., Hayes, D. F., Hudis, C., Jahanzeb, M., Ljung, B., Marks, L. B., McCormick, B., Nabell, L. M., Pierce, L. J., Reed, E. C., Silver, S. M., Smith, M. L., Somlo, G., Theriault, R. L., Ward, J. H., Winer, E. P., Wolff, A. C. 2005; 3 (3): 238-289

    View details for PubMedID 16002000

  • The history and mechanism of action of fulvestrant. Clinical breast cancer Carlson, R. W. 2005; 6: S5-8

    Abstract

    Fulvestrant is a pure antiestrogen that emerged from a systematic medicinal chemistry strategy of modification of long-chain alkyl substitutes in the 7a-position of estradiol. Fulvestrant has no uterotrophic effects on the immature or ovariectomized rat and blocks the agonistic effects of estradiol and tamoxifen in a dose-dependent manner. In in vivo and in vitro breast cancer models, fulvestrant has anticancer activity at least as good as tamoxifen and is superior to tamoxifen in some models. Fulvestrant requires intramuscular administration in a proprietary formulation of castor oil and alcohols. When fulvestrant binds to estrogen receptor monomers it inhibits receptor dimerization, activating function 1 (AF1) and AF2 are rendered inactive, translocation of receptor to the nucleus is reduced, and degradation of the estrogen receptor is accelerated. This results in pure antiestrogenic effects. There is substantial preclinical evidence that the nonsteroidal hormone-dependent mechanisms of estrogen receptor activation and regulation via growth factor receptors and their signal transduction pathways are important in the development of breast cancer hormonal resistance. Methods of exploiting the interactions between these nonsteroidal hormone-dependent mechanisms of resistance and hormonal agents such as fulvestrant are an active area for drug development and clinical investigation.

    View details for PubMedID 15865849

  • Predictors of local recurrence after breast-conservation therapy. Clinical breast cancer Horst, K. C., Smitt, M. C., Goffinet, D. R., Carlson, R. W. 2005; 5 (6): 425-438

    Abstract

    Breast-conserving therapy (BCT) is a proven local treatment option for select patients with early-stage breast cancer. This paper reviews pathologic, clinical, and treatment-related features that have been identified as known or potential predictors for ipsilateral breast tumor recurrence in patients treated with BCT. Pathologic risk factors such as the final pathologic margin status of the excised specimen after BCT, the extent of margin involvement, the interaction of margin status with other adverse features, the role of biomarkers, and the presence of an extensive intraductal component or lobular carcinoma in situ all impact the likelihood of ipsilateral breast tumor recurrence. Predictors of positive repeat excision findings after conservative surgery include young age, presence of an extensive intraductal component, and close or positive margins in prior excision. Finally, treatment-related factors predicting ipsilateral breast tumor recurrence include extent of breast radiation therapy, use of a boost to the lumpectomy cavity, use of tamoxifen or chemotherapeutic agents, and timing of systemic therapy with irradiation. The ability to predict for an increased risk of ipsilateral breast tumor recurrence enhances the ability to select optimal local treatment strategies for women considering BCT.

    View details for PubMedID 15748463

  • Adjuvant aromatase inhibitors following tamoxifen for early-stage breast cancer in postmenopausal women: what do we really know? Clinical breast cancer Chung, C. T., Carlson, R. W. 2004; 5: S18-23

    Abstract

    Adjuvant hormonal therapy in the treatment of women with early-stage, hormone receptor (HR)-positive breast cancer is now considered the standard of care. Adjuvant tamoxifen decreases the risk of breast cancer recurrence and death in women with early-stage breast cancer when taken for 5 years. The benefits of tamoxifen are counterbalanced by toxicities including an increased risk of endometrial cancer and thromboembolic events. The selective aromatase inhibitors (AIs)--including anastrozole, letrozole, and exemestane--are challenging the role of tamoxifen as the adjuvant hormonal therapy of choice in postmenopausal women. Results of the Arimidex and Tamoxifen Alone or in Combination trial favor the use of anastrozole over tamoxifen as initial adjuvant hormonal therapy, with improvement in disease-free survival (DFS) and a favorable toxicity profile. The results of 2 large adjuvant trials using AIs sequentially with tamoxifen in postmenopausal women with early-stage, HR-positive breast cancer have been reported. The MA-17 study randomized women to placebo or letrozole for 5 years after completion of 4.5-6 years of initial tamoxifen. The Intergroup Exemestane Study (IES) randomized women following 2-3 years of adjuvant tamoxifen to continue to receive tamoxifen or switch to exemestane for a total of 5 years of adjuvant hormonal therapy. The MA-17 and IES trials demonstrated superior DFS with the AI and corroborated the smaller GROCTA-4B and Italian Tamoxifen Arimidex trials, which studied sequential therapy with aminoglutethamide or anastrozole. There is now substantial medical evidence supporting the use of AIs in postmenopausal women with early-stage, HR-positive breast cancer.

    View details for PubMedID 15347435

  • High-dose chemotherapy and stem cell transplantation does not improve relapse-free or overall survival in women with high-risk breast cancer. Cancer treatment reviews Carlson, R. W., Wheatley, K. 2004; 30 (1): 131-137

    View details for PubMedID 14766131

  • Rational surveillance programs for early stage breast cancer patients after primary treatment. Breast disease Mollick, J. A., Carlson, R. W. 2004; 21: 47-54

    Abstract

    The majority of women with early stage breast cancers are successfully treated with surgery, radiation therapy and adjuvant systemic therapy. However, 30% of all Stage I and Stage II patients can be expected to experience a relapse. The belief that early detection of recurrences can lead to an increase in survival has been used to justify intensive follow-up regimens following primary treatment of patients with early stage disease. However, the vast majority of data support a program of scheduled surveillance visits and demonstrate that a comprehensive history and physical examination is as efficacious as programs utilizing intensive testing and imaging procedures in the asymptomatic patient. Screening mammography to detect ipsilateral in-breast recurrence or a new primary cancer in the contralateral breast is the only imaging study that is recommended for routine surveillance. Knowledge of the natural history of breast cancer, risk factors for relapse, and the symptoms and physical findings commonly associated with recurrence are central to efficiently and effectively monitoring this cohort of women in clinical practice.

    View details for PubMedID 15687722

  • Predictors of reexcision findings and recurrence after breast conservation INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS Smitt, M. C., Nowels, K., Carlson, R. W., Jeffrey, S. S. 2003; 57 (4): 979-985

    Abstract

    To identify predictors of reexcision findings and local recurrence in the setting of breast-conserving therapy with radiation.The records of 535 patients who underwent breast-conserving surgery followed by radiation for Stage I or II cancer between 1972 and 1996 were reviewed. The mean follow-up period for surviving patients without evidence of recurrence is 6 years. Various clinical and pathologic prognostic factors were examined for significance with regard to reexcision findings and recurrence rates. Pathologic margin status was classified as negative, close (

    View details for DOI 10.1016/S0360-3016(03)00740-5

    View details for Web of Science ID 000186293800010

    View details for PubMedID 14575828

  • Phase I trial of uracil-ftorafur, leucovorin, and etoposide: an active all-oral regimen for metastatic breast cancer BREAST CANCER RESEARCH AND TREATMENT Hartman, A. R., Grekowicz, A., Lum, B. L., Carlson, R. W., Schurman, C., Sikic, B. I., Shapiro, R., Stockdale, F. E. 2003; 82 (1): 61-69

    Abstract

    To determine the maximum tolerated doses, toxicities, and therapeutic effect of an oral chemotherapy regimen consisting of uracil-ftorafur, etoposide, and leucovorin for metastatic breast cancer.The regimen consists of 28-day cycles of uracil-ftorafur, etoposide, and leucovorin administered orally on days 1-14. The dose of etoposide was fixed at 50 mg/m2/day, and uracil-ftorafur was escalated in 50 mg/m2/day increments from 200 to 350 mg/m2. Leucovorin, was used at a dose of 90 mg/day. Eligibility criteria required prior treatment with a taxane or anthracycline.A total of 23 patients were enrolled. Twenty patients are assessable for toxicity and 16 patients are assessable for response. All non-hematologic toxicities were grade 1 or 2. Three hematologic dose-limiting toxicities (DLTs) were observed. Partial responses were seen in 6 of 16 (37.5%, 95% confidence interval 15%, 85%) of assessable patients with durations ranging from 4 to 20 months. Stable disease was observed in 4 of 16 (25%) of patients with durations from 4 to 12 months. Median time to progression was 10.5 months. An intent to treat analysis revealed a response of 26%.The recommended dose and schedule of this combination is uracil-ftorafur 350 mg/m2, leucovorin 90 mg/day, and etoposide 50 mg/m2 for two consecutive weeks in a 4-week cycle. This all-oral regimen is well tolerated and demonstrates encouraging efficacy in a cohort of heavily pretreated patient with metastatic breast cancer.

    View details for Web of Science ID 000186609000008

    View details for PubMedID 14672404

  • Treatment of breast cancer in countries with limited resources. breast journal Carlson, R. W., Anderson, B. O., Chopra, R., Eniu, A. E., Jakesz, R., Love, R. R., Masetti, R., Schwartsmann, G. 2003; 9: S67-74

    Abstract

    Early and accurate diagnosis of breast cancer is important for optimizing treatment. Local treatment of early stage breast cancer involves either mastectomy or breast-conserving surgery followed by whole-breast irradiation. The pathologic and biologic properties of a woman's breast cancer may be used to estimate her probability for recurrence of and death from breast cancer, as well as the magnitude of benefit she is likely to receive from adjuvant endocrine therapy or cytotoxic chemotherapy. Ovarian ablation or suppression with or without tamoxifen is an effective endocrine therapy in the adjuvant treatment of breast cancer in premenopausal women with estrogen receptor (ER)-positive or ER-unknown breast cancer. In postmenopausal women with ER- and/or progesterone receptor (PR)-positive or PR-unknown breast cancer, the use of tamoxifen or anastrozole is effective adjuvant endocrine therapy. The benefit of tamoxifen is additive to that of chemotherapy. Cytotoxic chemotherapy also improves recurrence rates and survival, with the magnitude of benefit decreasing with increasing age. Substantial support systems are required to optimally and safely use breast-conserving approaches to local therapy or cytotoxic chemotherapy as systemic therapy. Locally advanced breast cancer (LABC) accounts for at least half of all breast cancers in countries with limited resources and has a poor prognosis. Initial treatment of LABC with anthracycline-based chemotherapy is standard and effective. Addition of a sequential, neoadjuvant taxane thereafter increases the rate of pathologic complete responses. Neoadjuvant endocrine therapy may benefit postmenopausal women with hormone receptor-positive LABC. After an initial response to neoadjuvant chemotherapy, the use of local-regional surgery is appropriate. Most women will require a radical or modified radical mastectomy. In those women in whom mastectomy is not possible after neoadjuvant chemotherapy, the use of whole-breast and regional lymph node irradiation alone is appropriate. In those women who cannot receive neoadjuvant chemotherapy because of resource constraints, mastectomy with node dissection, when feasible, may still be considered in an attempt to achieve local-regional control. After local-regional therapy, most women should receive additional systemic chemotherapy. Women with LABC that has a positive or unknown hormone receptor status benefit from endocrine therapy with tamoxifen. The treatment of LABC requires multiple disciplines and is resource intensive. Efforts to reduce the number of breast cancers diagnosed at an advanced stage thus have the potential to improve rates of survival while decreasing the use of limited resources.

    View details for PubMedID 12713499

  • The role of aromatase inhibitors in early breast cancer. Current treatment options in oncology Chung, C. T., Carlson, R. W. 2003; 4 (2): 133-140

    Abstract

    The role of hormonal therapy for the treatment of patients with early stage breast cancer has been evaluated in many studies. The results of these studies establish tamoxifen as the gold standard of hormonal therapy for the adjuvant treatment of hormone receptor-positive invasive breast cancer in pre- and postmenopausal women. Studies show tamoxifen reduces the risk of invasive breast cancer in women at increased risk for the disease, including women with ductal carcinoma in situ. Tamoxifen has adverse effects such as hot flashes, increased risk of uterine cancer in postmenopausal women, and rare occurrence of thromboembolic disease. Despite the multiple therapeutic roles of tamoxifen, alternatives are needed. Aromatase inhibitors (AI) are drugs with antiestrogenic activity. AIs function by inhibiting the peripheral conversion of adrenally synthesized androstenedione to estradiol through inhibition of the aromatase enzyme. AIs do not suppress estradiol synthesis by the ovary adequately. Therefore, AIs are effective in reducing circulating estradiol levels in postmenopausal women, but not premenopausal women. Selective nonsteroidal AIs, including anastrozole (Arimidex; AstraZeneca, Wilmington, DE) and letrozole (Femara; Novartis, East Hanover, NJ), and the steroidal AI exemestane (Aromasin; Pharmacia, Peapack, NJ) have been associated with increased specificity and improved therapeutic index compared to nonselective AIs such as aminoglutethamide. Nonsteroidal and steroidal AIs have demonstrated to be superior to megestrol acetate in second-line therapy of postmenopausal women with metastatic breast cancer, and selective nonsteroidal AIs have shown to be superior to tamoxifen in first-line therapy of postmenopausal women with metastatic breast cancer. The ATAC (Arimidex, tamoxifen, alone, or in combination) trial is the only published randomized trial comparing the efficacy of an AI to tamoxifen for the adjuvant treatment of women with early breast cancer. This large study showed that at a median follow-up time of 33 months, anastrozole alone results in significant improvement in disease-free survival rates, reduction in contralateral breast cancers, and increased tolerability, compared to tamoxifen in postmenopausal women. Although the long-term effects of AIs are not known, the early positive results of the ATAC trial led to the approval of anastrozole by the US Food and Drug Administration for use as adjuvant hormonal therapy for postmenopausal women with hormone receptor-positive invasive breast cancer. Thus, there is an alternative to tamoxifen for postmenopausal women with relative/absolute contraindications to tamoxifen use or patients who choose not to take tamoxifen because of its side-effect profile. New AIs may challenge the position of tamoxifen as the gold standard for the treatment of early stage breast cancer in postmenopausal women.

    View details for PubMedID 12594939

  • NCCN breast cancer clinical practice guidelines in oncology: an update. Journal of the National Comprehensive Cancer Network Carlson, R. W. 2003; 1: S61-3

    Abstract

    The 2002 NCCN Breast Cancer Clinical Practice Guidelines in Oncology represent the 7th annual update produced by a multidisciplinary panel of breast cancer experts from the NCCN member institutions. The Breast Cancer Panel uses an objective, evidence-based method when high-level evidence from clinical trials exists. In clinical situations in which high-level evidence is lacking, recommendations are generated through a multidisciplinary consensus development process. The NCCN institutions also review the complete guideline on an annual basis. In this update, several of the modifications in the 2002 Breast Cancer Guidelines are highlighted, including the use of aromatase inhibitors and leuteinizing hormone-releasing hormone agonists plus tamoxifen in the first-line therapy of metastatic breast cancer and the use of anastrozole in the adjuvant setting. The new guidelines for axillary lymph node staging are reported on in a companion article in this issue.

    View details for PubMedID 19795577

  • Goals and objectives in the management of metastatic breast cancer ONCOLOGIST Chung, C. T., Carlson, R. W. 2003; 8 (6): 514-520

    Abstract

    Patients with metastatic breast cancer consist of a heterogeneous group of patients whose prognoses and clinical courses can vary depending on host factors, such as comorbidity and age, and on tumor factors, such as hormone-receptor status, grade, and anatomical site of disease. Although the median survival time for patients with metastatic breast cancer is 2-4 years, subsets of patients with either indolent or limited metastatic disease may have prolonged survival times. Further, expectations of treatment, both in terms of efficacy and of toxicity, vary greatly based upon the specific treatment, patient characteristics, and tumor characteristics. Thus, the goals of treatment for patients with metastatic breast cancer are influenced by estimates of prognoses as well as a balance between physician and patient preferences regarding efficacy and toxicity considerations. Traditionally, objective measures of response and survival have been the targeted end points in clinical trial design and in physician selection of therapy for metastatic breast cancer. More recently, issues of quality of life have surfaced as important end points, especially from the perspective of the patient. The decision-making process in selecting the optimal treatment for patients with metastatic breast cancer is, therefore, a multidimensional process involving subjective as well as objective goals of treatment. Ultimately, the benefits of treatment must justify the risks and toxicities of the treatment, and the impact of treatment should be measured in relation to specified goals. Both physician and patient perspectives are important in establishing the objectives of treatment, and this process is optimally an interactive and ongoing process throughout the course of disease.

    View details for Web of Science ID 000186862900005

    View details for PubMedID 14657529

  • Sequential hormonal therapy for metastatic breast cancer after adjuvant tamoxifen or anastrozole BREAST CANCER RESEARCH AND TREATMENT Carlson, R. W., Henderson, I. C. 2003; 80: S19-S26

    Abstract

    The use of adjuvant endocrine therapy in the treatment of hormone receptor-positive, early breast cancer has become important in both pre- and postmenopausal women. Tamoxifen has been the principal adjuvant hormonal therapy in pre- and postmenopausal women with hormone receptor-positive breast cancer for nearly 20 years. Recent data in premenopausal women suggest benefit from ovarian ablation with or without tamoxifen. Early results from the 'Arimidex', Tamoxifen, Alone or in Combination (ATAC) trial have demonstrated that the third-generation, selective aromatase inhibitor (AI) anastrozole ('Arimidex') is a suitable alternative adjuvant therapy for postmenopausal women with hormone receptor-positive disease. After recurrence or relapse on adjuvant endocrine therapy, responses to the sequential use of additional endocrine agents are common. The increase in the number of options now available for adjuvant therapy will have important implications for the selection of the optimal sequence of endocrine agents in the treatment of recurrent breast cancer. Menopausal status is an important factor in determining the endocrine therapy that a patient receives. For premenopausal women, tamoxifen and/or a luteinizing hormone-releasing hormone agonist such as goserelin ('Zoladex') are both options for adjuvant endocrine treatment. After progression on adjuvant and first-line tamoxifen, ovarian ablation is an appropriate second-line therapy. For premenopausal women who have undergone ovarian ablation, the use of third-line therapy with an AI becomes possible. For postmenopausal women, a wide choice of endocrine treatment options is available and an optimal sequence has yet to be determined. Options for first-line therapy of metastatic disease include an AI for women who have received adjuvant tamoxifen or tamoxifen for patients who have received adjuvant anastrozole. In addition, data suggest that fulvestrant ('Faslodex'), a novel estrogen receptor (ER) antagonist that downregulates the ER protein and has no known agonist effects, is a promising therapeutic option that has shown efficacy in the treatment of postmenopausal women with advanced breast cancer. Other agents that may be used in the sequence include the steroidal AI exemestane and the progestin megestrol acetate. The widening range of adjuvant endocrine options therefore represents an opportunity to prolong patient benefits in the treatment of hormone receptor-positive breast cancer, and will require the further refinement of the optimal sequence of endocrine agents for the treatment of recurrent breast cancer.

    View details for Web of Science ID 000184961200004

    View details for PubMedID 14535531

  • Sequencing of endocrine therapies in breast cancer - integration of recent data BREAST CANCER RESEARCH AND TREATMENT Carlson, R. W. 2002; 75 (1): S27-S32

    Abstract

    A wide range of endocrine therapies has demonstrated activity in the treatment of hormone receptor-positive metastatic breast cancer and sequential tumor responses to sequential hormonal therapies are common. However, the optimal sequence of the hormonal therapies has not yet been determined. The selection of endocrine therapies in women with hormone receptor-positive breast cancer is strongly influenced by the menopausal status of the patient. For premenopausal women, tamoxifen alone or combined with ovarian suppression using a luteinizing hormone-releasing hormone (LHRH) agonist - such as goserelin or leuprolide - is an appropriate first-line hormonal therapy. Ovarian ablation or megestrol acetate is an appropriate second-line hormonal therapy for premenopausal women treated with tamoxifen as first-line therapy, or ovarian ablation plus an aromatase inhibitor (AI) or megestrol acetate for women treated with first-line tamoxifen plus an LHRH agonist. For postmenopausal women, the non-steroidal AIs anastrozole and letrozole now represent the preferred first-line hormonal treatment for metastatic breast cancer, based upon both efficacy and toxicity considerations. For second-line therapy in postmenopausal women, a number of options now exist, including tamoxifen, the steroidal AI exemestane, and the new agent fulvestrant. Fulvestrant, a novel estrogen receptor (ER) antagonist that downregulates the ER and has no known agonist effects, has been demonstrated to be at least as effective as anastrozole in postmenopausal women whose tumors progress on tamoxifen. The establishment of the optimal sequence of the endocrine therapies should offer significant benefits to women with hormone-sensitive metastatic breast cancer.

    View details for Web of Science ID 000177727200006

    View details for PubMedID 12353821

  • Locally advanced breast cancer: is surgery necessary? breast journal Favret, A. M., Carlson, R. W., Goffinet, D. R., Jeffrey, S. S., Dirbas, F. M., Stockdale, F. E. 2001; 7 (2): 131-137

    Abstract

    A retrospective analysis of the treatment of locally advanced breast cancer (LABC) was undertaken at Stanford Medical Center to assess the outcome of patients who did not undergo surgical removal of their tumors. Between 1981 and 1998, 64 patients with locally advanced breast cancer were treated with induction chemotherapy, radiation with or without breast surgery, and additional chemotherapy. Sixty-two (97%) patients received cyclophosphamide, doxorubicin, and 5-fluorouracil (CAF) induction chemotherapy. Induction chemotherapy was followed by local radiotherapy in 59 (92%) patients. Based on the clinical response to chemotherapy and patient preference, 44 (69%) patients received no local breast surgery. Radiotherapy was followed by an additional, non-doxorubicin-containing chemotherapy in all patients. The mean age of patients was 49 years. Of the 65 locally advanced breast cancers in 64 patients, 26 (41%) were stage IIIA, 35 (55%) were stage IIIB, and 4 (6%) were stage IV (supraclavicular lymph nodes only). Response to induction chemotherapy was seen in 59 patients (92%), with 29 (45%) achieving a complete clinical response and 30 (47%) a partial clinical response. With a mean follow-up of 51 months (range 7-187 months), 43 patients (67.2%) have no evidence of recurrent disease. Eight (12.5%) have recurred locally, and 21 (32.8%) have recurred with distant metastasis. Actuarial 5-year survival is 75%, disease-free survival is 58%, and local control rate is 87.5%. These data indicate that the routine inclusion of breast surgery in a combined modality treatment program for LABC does not appear necessary for the majority of patients who experience a response to induction chemotherapy.

    View details for PubMedID 11328324

  • NCCN Practice Guidelines for breast cancer ONCOLOGY-NEW YORK Carlson, R. W., Anderson, B. O., Bensinger, W., Cox, C. E., Davidson, N. E., Edge, S. B., Farrar, W. B., Goldstein, L. J., Gradishar, W. J., Lichter, A. S., McCormick, B., Nabell, L. M., Reed, E. C., Silver, S. M., Smith, M. L., Somlo, G., Theriault, R., Ward, J. H., Winer, E. P., Wolff, A. 2000; 14 (11A): 33-49

    Abstract

    The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. In many situations, the patient and physician have the responsibility to jointly explore and ultimately select the most appropriate option from among the available alternatives. With rare exception, the evaluation, treatment, and follow-up recommendations contained within these guidelines were based largely on the results of past and present clinical trials. However, there is not a single clinical situation in which the treatment of breast cancer has been optimized with respect to either maximizing cure or minimizing toxicity and disfigurement. Therefore, patient and physician participation in prospective clinical trials allows patients not only to receive state-of-the-art cancer treatment but also to contribute to the improvement of treatment of future patients.

    View details for Web of Science ID 000166713700003

    View details for PubMedID 11195418

  • New bilateral microcalcifications at mammography in a postlactational woman: Case report RADIOLOGY Stucker, D. T., Ikeda, D. M., Hartman, A. R., George, T. I., Nowels, K. W., Birdwell, S. L., Goffinet, D., Carlson, R. W. 2000; 217 (1): 247-250

    Abstract

    A 33-year-old woman with a strong family history of breast cancer who was referred for mammography 5 weeks after completing lactation was found to have new diffuse bilateral microcalcifications in the breast ducts. Contrast material-enhanced magnetic resonance imaging of the breast showed bilateral patchy areas of abnormal enhancement. Large-core needle biopsy showed diffuse calcifications within expanded benign ducts in a background of lactational change, without evidence of malignancy. To the authors' knowledge, these calcifications have not been previously reported and are possibly related to milk stasis or apoptosis associated with lactation.

    View details for Web of Science ID 000089452500038

    View details for PubMedID 11012452

  • Multidisciplinary Management of Locally Advanced Breast Cancer. The breast journal Carlson, R. W., Favret, A. M. 1999; 5 (5): 303-307

    Abstract

    The treatment of locally advanced breast cancer is aimed at achieving long-term local control with local surgery and/or radiation therapy and at improving disease-free and overall survival through the application of systemic cytotoxic chemotherapy and hormonal therapy. Studies of local therapy alone with surgery or radiotherapy have demonstrated high rates of local recurrence and low rates of long-term survival. The application of anthracycline-based neoadjuvant chemotherapy has resulted in rates of response ranging from 72% to 97%, clinical complete responses of 12-52%, and pathologic complete responses of 4-33%. Multidisciplinary treatment with neoadjuvant therapy, followed by local surgery and/or radiation therapy, followed by additional chemotherapy, has resulted in rates of local control that exceed 80%, and 5-year survival rates exceeding 50% are not unusual. The use of anthracycline-based neoadjuvant chemotherapy in the treatment of locally advanced breast cancer is thus now firmly established. Research in the treatment of locally advanced breast cancer is needed to further define the optimal method of local therapy and the role of new agents such as the taxanes.

    View details for PubMedID 11348306

  • Quality of life issues in the treatment of metastatic breast cancer ONCOLOGY-NEW YORK Carlson, R. W. 1998; 12 (3): 27-31

    Abstract

    The treatment of metastatic breast cancer involves the sequential selection and delivery of hormonal therapies and cytotoxic chemotherapies. The available therapies for metastatic breast cancer are rarely curative, although high rates of response and modest prolongation of survival may be achieved in association with varying degrees of treatment-related toxicity. Therefore, the selection of appropriate therapy requires a reasoned consideration of the likelihood of benefit from therapy balanced with the impact of therapy on the patient's quality of life. Several instruments have been developed to measure quality of life in cancer patients, but none has been universally accepted, and they require time and resources to administer. Few randomized clinical trials have incorporated quality of life assessments. Thus, the clinician must balance antitumor activity, performance status, and the usual toxicity measures, (e.g., nausea, myelosuppression, asthenia) as surrogates for quality of life associated with each specific therapy. Studies have confirmed the clinical impression that antitumor activity of treatment generally correlates with quality of life outcome. The hormonal therapies have the quality of life advantages of limited and non-threatening acute toxicity, rare chronic toxicity, need for infrequent visits to health care providers, oral administration, and, in appropriately selected patients, response and duration of response rates equivalent to those of the cytotoxic agents. A number of cytotoxic agents have activity in the treatment of metastatic breast cancer. Although the active single agents differ substantially in their toxicity profiles, the dose-limiting toxicity is usually myelosuppression. Recently, several agents with substantial activity against breast cancer have become available, including the taxanes (paclitaxel and docetaxel), vinorelbine, and gemcitabine. Oral formulations of vinorelbine are being studied that may provide the additional advantages of not requiring intravenous access, requiring fewer visits to the health care professional, and providing patients with a greater sense of control of their treatment.

    View details for Web of Science ID 000073005300005

    View details for PubMedID 9556780

  • Effects of medical and psychotherapeutic treatment on the survival of women with metastatic breast carcinoma CANCER KOGON, M. M., Biswas, A., Pearl, D., Carlson, R. W., Spiegel, D. 1997; 80 (2): 225-230

    Abstract

    The authors previously reported a statistically significant effect of psychosocial intervention on survival time of women with metastatic breast carcinoma. In this study, the authors investigated whether this effect could be explained by differences in the medical treatment patients received subsequent to their group participation or differences in causes of death.Of the original 86 study participants, medical treatment charts for 61 and death certificates for 83 were available for further analysis. The authors reviewed the course of the medical treatment they received subsequent to their entry into the randomized psychotherapy trial.Although there were no statistically significant differences with regard to chemotherapy and hormone therapy between the control and treatment groups, women in the control group tended to have received more adrenalectomies, although this procedure did not account for the difference in survival time between the control group and the treatment group. Furthermore, women in the control group developed more bone and lung metastases than the women in the treatment group.Differences in disease course between the control and treatment groups appeared to be independent of any differences in medical treatment received.

    View details for Web of Science ID A1997XJ01600009

    View details for PubMedID 9217034

  • Scientific review of tamoxifen. Overview from a medical oncologist. Seminars in oncology Carlson, R. W. 1997; 24 (1): S1-151 S1 7

    Abstract

    Tamoxifen is a widely used, effective, and well-tolerated agent in the treatment of primary and recurrent breast cancer. In the adjuvant setting, tamoxifen decreases the annual odds of recurrence and death by 25% and 16%, respectively. The toxicities of tamoxifen are of minor concern in the poor-prognosis group of women with metastatic breast cancer. In the more favorable group of women with early breast cancer, the benefits of tamoxifen appear to substantially outweigh the known toxicities. In retrospective analysis, tamoxifen has been consistently demonstrated to decrease the occurrence of contralateral second breast cancer and to be associated with an increased frequency of diagnosis of endometrial carcinoma. It is not known whether tamoxifen is promoting the growth of pre-existing, clinically occult endometrial carcinomas or is truly etiologic for the development of new cancers. The endometrial carcinomas that are associated with tamoxifen appear to have a biology and natural history similar to non-tamoxifen-associated endometrial carcinomas. There is no evidence supporting an association between hepatocellular carcinomas and tamoxifen in humans. Retrospective analysis of the association of colorectal carcinoma and gastric carcinoma provides little convincing evidence of a causal relationship, although further study is warranted.

    View details for PubMedID 9045312

  • NCCN Breast Cancer Practice Guidelines. The National Comprehensive Cancer Network. Oncology (Williston Park, N.Y.) Carlson, R. W., Goldstein, L. J., Gradishar, W. J., Lichter, A. S., McCormick, B., Moe, R. E., Theriault, R. L. 1996; 10 (11): 47-75

    View details for PubMedID 8953596

  • Trade-offs between survival and breast preservation for three initial treatments of ductal carcinoma-in-situ of the breast JOURNAL OF CLINICAL ONCOLOGY Hillner, B. E., Desch, C. E., Carlson, R. W., Smith, T. J., Esserman, L., Bear, H. D. 1996; 14 (1): 70-77

    Abstract

    To assess the trade-offs between survival and breast preservation of currently accepted approaches for ductal carcinoma-in-situ (DCIS) of the breast.Decision analysis was performed using the Markov model of hypothetical cohorts of 55-year-old white women with nonpalpable mammographic abnormalities found to be DCIS. Strategies were breast-conserving surgery (BCS), BCS with 50-Gy radiation (RT) or initial mastectomy. Recurrence rates were derived from the published literature. Main outcomes were overall, breast cancer-free, and event-free survival plus years of both breasts preserved.Using the conditions defined in this model, the actuarial survival rates at 10 and 20 years were 91.7% and 74.1% for the initial mastectomy strategy, 91.0% and 72.1% for BCS plus RT, and 89.6% and 68.2% for BCS alone. At 20 years, the initial mastectomy strategy also had a greater breast cancer-free survival rate of 74.5%, compared with 63.3% for BCS plus RT, or 46.8% for BCS alone. However, BCS alone had the highest survival rate with both breasts preserved (64.2%) compared with BCS plus RT (56.0%) or initial mastectomy (0%). Of the breast-conserving strategies at 20 years, the breast event-free survival rate (no invasive cancer or DCIS) was greater for BCS plus RT (47.2%) compared with BCS alone (28.4%). Using just survival as the primary end point, mastectomy is the optimal strategy by a small margin. However, if quality-adjusted survival is at issue, mastectomy is the choice only if the yearly reduction in quality of life due to mastectomy is less than 1%.BCS with or without radiation compared with mastectomy as initial management of DCIS of the breast trades a slight decrease in survival rates for the value of breast preservation. This model should aid clinicians in matching treatments to their patients' preferences.

    View details for Web of Science ID A1996TP68700011

    View details for PubMedID 8558224

  • Reappraisal of hepatic arterial infusion in the treatment of nonresectable liver metastases from colorectal cancer Journal of the National Cancer Institute Piedbois P, Buyse M, Kemeny N, Rougier P, Carlson R, Allen-Mersh T, O'Connel M, Change A, Sondak V, Kemeny M, Levy 1996; 88: 252-258
  • THE IMPORTANCE OF THE LUMPECTOMY SURGICAL MARGIN STATUS IN LONG-TERM RESULTS OF BREAST-CONSERVATION CANCER Smitt, M. C., Nowels, K. W., ZDEBLICK, M. J., JEFFREY, S., Carlson, R. W., Stockdale, F. E., Goffinet, D. R. 1995; 76 (2): 259-267

    Abstract

    The impact of the surgical margin status on long-term local control rates for breast cancer in women treated with lumpectomy and radiation therapy is unclear.The records of 289 women with 303 invasive breast cancers who were treated with lumpectomy and radiation therapy from 1972 to 1992 were reviewed. The surgical margin was classified as positive (transecting the inked margin), close (less than or equal to 2 mm from the margin), negative, or indeterminate, based on the initial biopsy findings and reexcision specimens, as appropriate. Various clinical and pathologic factors were analyzed as potential prognostic factors for local recurrence in addition to the margin status, including T classification, N classification, age, histologic features, and use of adjuvant therapy. The mean follow-up was 6.25 years.The actuarial probability of freedom from local recurrence for the entire group of patients at 5 and 10 years was 94% and 87%, respectively. The actuarial probability of local control at 10 years was 98% for those patients with negative surgical margins versus 82% for all others (P = 0.007). The local control rate at 10 years was 97% for patients who underwent reexcision and 84% for those who did not. Reexcision appears to convey a local control benefit for those patients with close, indeterminate, or positive initial margins, when negative final margins are attained (P = 0.0001). Final margin status was the most significant determinant of local recurrence rates in univariate analysis. By multivariate analysis, the final margin status and use of adjuvant chemotherapy were significant prognostic factors.The attainment of negative surgical margins, initially or at the time of reexcision, is the most significant predictor of local control after breast-conserving treatment with lumpectomy and radiation therapy.

    View details for Web of Science ID A1995RH15100015

    View details for PubMedID 8625101

  • Computer-based screening of patients with HIV/AIDS for clinical-trial eligibility. The Online journal of current clinical trials Carlson, R. W., Tu, S. W., Lane, N. M., Lai, T. L., Kemper, C. A., Musen, M. A., Shortliffe, E. H. 1995; Doc No 179: [3347 words, 32 paragraphs]

    Abstract

    To assess the potential effect of a computer-based system on accrual to clinical trials, we have developed methodology to identify retrospectively and prospectively patients who are eligible or potentially eligible for protocols.Retrospective chart abstraction with computer screening of data for potential protocol eligibility.A county-operated clinic serving human immunodeficiency virus (HIV) positive patients with or without acquired immune deficiency syndrome (AIDS).A randomly selected group of 60 patients who were HIV-infected, 30 of whom had an AIDS-defining diagnosis.Using a computer-based eligibility screening system, for each clinic visit and hospitalization, patients were categorized as eligible, potentially eligible, or ineligible for each of the 17 protocols active during the 7-month study period. Reasons for ineligibility were categorized.None of the patients was enrolled on a clinical trial during the 7-month period. Thirteen patients were identified as eligible for protocol; three patients were eligible for two different protocols; and one patient was eligible for the same protocol during two different time intervals. Fifty-four patients were identified as potentially eligible for a total of 165 accrual opportunities, but important information, such as the result of a required laboratory test, was missing, so that eligibility could not be determined unequivocally. Ineligibility for protocol was determined in 414 (35%) potential opportunities based only on conditions that were amenable to modification, such as the use of concurrent medications; 194 (17%) failed only laboratory tests or subjective determinations not routinely performed; and 346 (29%) failed only routine laboratory tests.There are substantial numbers of eligible and potentially eligible patients who are not enrolled or evaluated for enrollment in prospective clinical trials. Computer-based eligibility screening when coupled with a computer-based medical record offers the potential to identify patients eligible or potentially eligible for clinical trial, to assist in the selection of protocol eligibility criteria, and to make accrual estimates.

    View details for PubMedID 7719564

  • Toward a patient-centered knowledge-server standard for CPRs. Proceedings of the 1994 Annual Healthcare Information and Management Systems Society Conference Tuttle MS, Sheretz DD, Fagan LM, Carlson RW, Cole WG, Schipma PB, Nelson SJ. 1994; 88: 114-128
  • IMPACT OF OMEPRAZOLE ON THE PLASMA-CLEARANCE OF METHOTREXATE CANCER CHEMOTHERAPY AND PHARMACOLOGY Reid, T., Yuen, A., CATOLICO, M., Carlson, R. W. 1993; 33 (1): 82-84

    Abstract

    Omeprazole inhibits the gastric hydrogen pump and is an effective treatment for peptic ulcers. Methotrexate is a chemotherapeutic agent that inhibits dihydrofolate reductase and is eliminated by a hydrogen-ion-dependent mechanism in the kidney. We present evidence that omeprazole inhibits methotrexate clearance and may result in potentially toxic methotrexate levels.

    View details for Web of Science ID A1993MC70700014

    View details for PubMedID 8269594

  • A METHODOLOGY FOR DETERMINING PATIENTS ELIGIBILITY FOR CLINICAL-TRIALS METHODS OF INFORMATION IN MEDICINE Tu, S. W., Kemper, C. A., Lane, N. M., Carlson, R. W., Musen, M. A. 1993; 32 (4): 317-325

    Abstract

    The task of determining patients' eligibility for clinical trials is knowledge and data intensive. In this paper, we present a model for the task of eligibility determination, and describe how a computer system can assist clinical researchers in performing that task. Qualitative and probabilistic approaches to computing and summarizing the eligibility status of potentially eligible patients are described. The two approaches are compared, and a synthesis that draws on the strengths of each approach is proposed. The result of applying these techniques to a database of HIV-positive patient cases suggests that computer programs such as the one described can increase the accrual rate of eligible patients into clinical trials. These methods may also be applied to the task of determining from electronic patient records whether practice guidelines apply in particular clinical situations.

    View details for Web of Science ID A1993LQ71400012

    View details for PubMedID 8412828

  • Reducing the cardiotoxicity of the anthracyclines. Oncology (Williston Park, N.Y.) Carlson, R. W. 1992; 6 (6): 95-?

    Abstract

    Most patients are not at risk for anthracycline-associated cardiotoxicity, since the cancer usually develops resistance before a dangerously high cumulative dose can be given. However, select patients may benefit from continued therapy. The physician's goal is to continue to treat these patients without risking drug-related cardiomyopathy. A simple maneuver is to switch from bolus administration to a weekly low-dose or continuous-infusion schedule. Pretreatment with ICRF-187, a new cardioprotective agent currently under investigation, may prove highly useful in the near future. Perhaps most important, the physician must be able to spot the early signs of drug-related cardiac injury. This can be accomplished with radionuclide ventriculography to determine both resting and exercise ejection fractions. Patients shown to be at high risk can then be withdrawn from the drug or further monitored with endomyocardial biopsy and right heart catheterization.

    View details for PubMedID 1535212

  • T-HELPER: automated support for community-based clinical research. Proceedings / the ... Annual Symposium on Computer Application [sic] in Medical Care. Symposium on Computer Applications in Medical Care Musen, M. A., Carlson, R. W., Fagan, L. M., Deresinski, S. C., Shortliffe, E. H. 1992: 719-723

    Abstract

    There are increasing expectations that community-based physicians who care for people with HIV infection will offer their patients opportunities to enroll in clinical trials. The information-management requirements of clinical investigation, however, make it unrealistic for most providers who do not practice in academic centers to participate in clinical research. Our T-HELPER computer system offers community-based physicians the possibility of enrolling patients in clinical trials as a component of primary care. T-HELPER facilitates data management for patients with HIV disease, and can offer patient-specific and situation-specific advice concerning new protocols for which patients may be eligible and the treatment required by those protocols in which patients currently are enrolled. We are installing T-HELPER at three county-operated AIDS clinics in the San Francisco Bay Area, and plan a comprehensive evaluation of the system and its influence on clinical research.

    View details for PubMedID 1482965

  • LATE CONSOLIDATIVE RADIATION-THERAPY IN THE TREATMENT OF LIMITED-STAGE SMALL-CELL LUNG-CANCER CANCER Carlson, R. W., Sikic, B. I., Gandara, D. R., HENDRICKSON, C. G., WITTLINGER, P. S., Shields, J. A., Wong, P. P., WHITE, J. E., MEAKIN, C. J., MCWHIRTER, K. M., Lamborn, K. R., Phillips, T. L. 1991; 68 (5): 948-958

    Abstract

    Two hundred twenty-three patients were enrolled on this randomized Phase III trial testing the value of late consolidative involved-field radiation therapy in the treatment of limited-stage small cell lung cancer (SCLC). Patients were treated with induction chemotherapy consisting of alternating cycles of procarbazine, vincristine, lomustine, and cyclophosphamide (POCC) and etoposide, doxorubicin, and methotrexate (VAM) for 6 to 9 months. Responding patients were then randomized at 6 or 9 months to chemotherapy alone or to involved-field radiation therapy. All partial and complete responders received prophylactic cranial irradiation. Of the 180 eligible and evaluable patients, 80 (44%) achieved a complete response and 39 (22%) achieved a partial response (overall rate of response, 66%). Actuarial median survival time was 11.6 months, with 16% of patients surviving 2 years and 11% surviving 5 years. Forty-eight patients were randomized to chemotherapy alone (24 patients) versus chemotherapy plus involved-field radiation therapy (24 patients). There were no significant differences in time to progression or survival between those patients receiving or not receiving involved-field radiation therapy. The thorax was the site of first relapse in 58% of patients randomized to chemotherapy alone versus 29% in patients randomized to chemotherapy plus involved-field radiation therapy (P equals 0.042). The major acute toxicity was reversible myelosuppression, and the major late toxicity was chronic central nervous system dysfunction. The authors conclude that the addition of late consolidative radiation therapy to induction chemotherapy in the treatment of limited-stage SCLC is well tolerated and improves local control, but does not improve time to progression or rates of survival.

    View details for Web of Science ID A1991GD02500006

    View details for PubMedID 1655219

  • SUCCESSFUL TREATMENT OF METASTATIC THYMIC CARCINOMA WITH CISPLATIN, VINBLASTINE, BLEOMYCIN, AND ETOPOSIDE CHEMOTHERAPY CANCER Carlson, R. W., Dorfman, R. F., Sikic, B. I. 1990; 66 (10): 2092-2094

    Abstract

    Thymic carcinomas are rare malignant neoplasms of the thymic epithelium that are distinguished from the malignant thymomas by the presence of cytologic atypia. Thymic carcinomas may metastasize outside of the thorax and are associated with a very poor prognosis. Complete responses of thymic carcinoma to chemotherapy alone have not been reported. A 21-year-old man with metastatic undifferentiated carcinoma of probable thymic origin is presented who achieved a pathologic complete response with cisplatin, vinblastine, and bleomycin chemotherapy. Additional consolidative chemotherapy with cisplatin and etoposide was administered. The patient remains disease-free 5 years after diagnosis. Cisplatin, vinblastine, and bleomycin chemotherapy appears to have significant activity against thymic carcinoma.

    View details for Web of Science ID A1990EH74500007

    View details for PubMedID 1699650

  • TRIMETREXATE IN LOCALLY ADVANCED OR METASTATIC ADENOCARCINOMA OF THE PANCREAS - A PHASE-II STUDY OF THE NORTHERN CALIFORNIA ONCOLOGY GROUP INVESTIGATIONAL NEW DRUGS Carlson, R. W., Doroshow, J. H., ODUJINRIN, O. O., Flam, M. S., Malec, M., Lamborn, K. R. 1990; 8 (4): 387-389

    View details for Web of Science ID A1990EJ35100009

    View details for PubMedID 2150672

  • A PHASE-II TRIAL OF CARBETIMER FOR THE TREATMENT OF COLORECTAL-CANCER - A TRIAL OF THE NORTHERN-CALIFORNIA-ONCOLOGY-GROUP AMERICAN JOURNAL OF CLINICAL ONCOLOGY-CANCER CLINICAL TRIALS AUDEH, M. W., Jacobs, C. D., Davis, T. E., Carlson, R. W. 1990; 13 (4): 324-326

    Abstract

    Carbetimer (carboxyimamidate) was administered at a dose of 6,500 mg/m2/day intravenously for 5 consecutive days to 14 patients with measurable metastatic or recurrent colorectal cancer in a single institution phase II study of the Northern California Oncology Group. A total of 38 cycles of therapy were administered; nine patients completed at least three cycles of treatment. No partial or complete responses were observed. One patient did have a greater than 50% response in the liver while developing new retroperitoneal lymphadenopathy and is considered a nonresponder. Carbetimer was well tolerated with elevations of calcium from 10.2 to 12.5 mg/dl in nine patients, prolongation of prothrombin time and partial thromboplastin time in 14 patients, proteinuria in 10 patients, dizziness in six patients, nausea in two patients, and venous pain during infusion in three patients. Myelosuppression was not observed. Carbetimer at this dose and schedule is inactive in the treatment of colorectal cancer.

    View details for Web of Science ID A1990DT05600012

    View details for PubMedID 2198795

  • A MULTIINSTITUTIONAL EVALUATION OF THE ANALGESIC EFFICACY AND SAFETY OF KETOROLAC TROMETHAMINE, ACETAMINOPHEN PLUS CODEINE, AND PLACEBO IN CANCER PAIN PHARMACOTHERAPY Carlson, R. W., BORRISON, R. A., SHER, H. B., Eisenberg, P. D., MOWRY, P. A., WOLIN, E. M. 1990; 10 (3): 211-216

    Abstract

    Seventy-five patients with moderate to severe cancer pain were randomly assigned in a double-blind fashion to receive first-dose ketorolac tromethamine 10 mg orally, acetaminophen 600 mg plus codeine 60 mg orally, or placebo, followed by subsequent doses of ketorolac or acetaminophen plus codeine four times daily for 7 days. Patient characteristics were similar among the treatment groups. The first-dose observation documented that both ketorolac and acetaminophen plus codeine produced an equivalent reduction in cancer pain and were superior to placebo as measured by pain intensity differences and pain relief. Multidose comparison documented a small but statistically significant advantage in mean daily pain relief favoring acetaminophen plus codeine, although there were no differences in mean daily ratings of overall effects for either study medication. Adverse symptoms were acceptable with both ketorolac and acetaminophen plus codeine. We conclude that ketorolac has significant analgesic activity in patients with cancer pain, although its precise role in the treatment regimen of these patients remains undefined.

    View details for Web of Science ID A1990DM69100006

    View details for PubMedID 2196536

  • ENHANCEMENT OF THE CLINICAL ACTIVITY OF MELPHALAN BY THE HYPOXIC CELL SENSITIZER MISONIDAZOLE CANCER RESEARCH Coleman, C. N., Carlson, R. W., Halsey, J., Kohler, M., Gribble, M., Sikic, B. I., Jacobs, C. 1988; 48 (12): 3528-3532

    Abstract

    One hundred patients with non-small cell lung cancer were entered by members of the Northern California Oncology Group into a randomized Phase II trial of i.v. melphalan versus i.v. melphalan with concomitant oral misonidazole. The patients had not received prior chemotherapy. Eighty-five patients were evaluable for assessment of response and 89 were evaluable for toxicity analysis. The melphalan/misonidazole group had a superior response rate (two complete and four partial responses among 42 patients or 14%) compared to the melphalan group in which there were no responses among 43 patients (p = 0.024, two-sided Fisher exact test). Since hematological toxicity was equivalent in the two groups, there was an improvement in therapeutic index. Data from 12 patients undergoing pharmacological studies demonstrated that the plasma concentration of melphalan was 25% higher in the misonidazole group, a difference that is not statistically significant. Although the mechanism of interaction has not been fully established, this randomized trial demonstrates that a chemosensitizer can enhance the clinical antitumor activity of an alkylating agent and suggests that chemosensitizers in combination with alkylating agents should be investigated in further clinical trials.

    View details for Web of Science ID A1988N713400041

    View details for PubMedID 2836059

  • THE CLINICAL BIOLOGY OF BREAST-CANCER ANNUAL REVIEW OF MEDICINE Carlson, R. W., Stockdale, F. E. 1988; 39: 453-464

    Abstract

    Breast cancers present as a spectrum of neoplasms. The natural histories of the neoplasms are tied to the biological properties of the neoplastic cells that compose them. We review the histological, cytological, kinetic, and other parameters that best characterize the clinical biology of breast cancer.

    View details for Web of Science ID A1988M825500037

    View details for PubMedID 2835930

  • PHASE-II EVALUATION OF ORAL MEDROXYPROGESTERONE ACETATE IN ADVANCED BREAST-CANCER - A NORTHERN CALIFORNIA ONCOLOGY GROUP-STUDY CANCER TREATMENT REPORTS Tan, Y. O., Hendrickson, C., MCWHIRTER, K., Kohler, M., Hannigan, J. F., Carlson, R. W. 1987; 71 (10): 969-970

    View details for Web of Science ID A1987K718800015

    View details for PubMedID 2958131

  • COMBINED MODALITY THERAPY OF LOCALLY ADVANCED BREAST-CANCER - ONE INSTITUTIONS EXPERIENCE AND A REVIEW OF THE LITERATURE ANTICANCER RESEARCH Hu, E., Stockdale, F. E., Turner, B., Carlson, R. W., Levine, J., KUSHLAN, P. 1987; 7 (4): 733-736

    Abstract

    Fourteen patients with locally advanced breast cancer were treated at Stanford University Medical Center with a combined modality approach. Treatment consisted of an initial 5 day course of cyclophosphamide followed by three cycles of combination chemotherapy (CAF or CMF). Patients subsequently received radiation therapy to the involved breast and regional nodal areas, followed by mastectomy if resistant disease was present following irradiation. Additional chemotherapy (CMF) was administered for 6 cycles. With a median follow up of 42 months, all fourteen patients are free of local disease. Five out of the fourteen patients have experienced distant relapses and two patients died. We conclude that an aggressive combined modality approach to treatment of locally advanced breast cancer can result in excellent local control and survival even in poor prognosis patients. A review of pertinent studies on multimodality treatment for locally advanced breast cancer confirms our findings.

    View details for Web of Science ID A1987K599800011

Conference Proceedings


  • New models and online calculator for predicting non-sentinel lymph node status in sentinel lymph node positive breast cancer patients Kohrt, H., Olshen, R., Bermas, H., GOODSON, W., Henry, S., Rouse, R., Bailey, L., Philben, V., Dirbas, F., Dunn, J., Johnson, D., Wapnir, I., Carlson, R., STOCKDALE, F., Hansen, N., JEFFREY, S. SPRINGER. 2008: 588-588
  • MagSweeper: an automated system for high efficiency and specificity capture of live circulating tumor cells Powell, A. A., Talasaz, A. A., Mindrinos, M., Carlson, R., Pease, F. W., Davis, R. W., Jeffrey, S. S. SPRINGER. 2007: S24-S24
  • Supportive-expressive group therapy and survival in patients with metastatic breast cancer: A randomized clinical intervention trial Spiegel, D., Butler, L. D., Giese-Davis, J., Koopman, C., Miller, E., DiMiceli, S., Classen, C., Fobair, P., Carlson, R. W., Kraemer, H. C. NATURE PUBLISHING GROUP. 2006: S134-S134
  • Predicting non-sentinel lymph node involvement in breast cancer patients. Kohrt, H. E., Olshen, R. A., Goodson, W. H., Rouse, R. V., Bailey, L., Philben, V., Dirbas, F. M., Stockdale, F. E., Carlson, R. W., Jeffrey, S. S. AMER SOC CLINICAL ONCOLOGY. 2006: 10S-10S
  • Development of a new device for high throughput isolation of live circulating tumor cells. Talasaz, A. A., Powell, A. A., Mindrinos, M., Carlson, R. W., Pease, F. W., Davis, R. W., Jeffrey, S. S. SPRINGER. 2006: S213-S213
  • Supportive-expressive group therapy and survival in patients with metastatic breast cancer: A randomized clinical intervention trial. Spiegel, D., Butler, L. D., Giese-Davis, J., Koopman, C., Miller, E., DiMiceli, S., Classen, C. C., Fobair, P., Carlson, R. W., Kraemer, H. C. SPRINGER. 2006: S240-S240
  • NCCN: Breast cancer. Carlson, R. W., Edge, S. B., Theriault, R. L. 2001: 54-61

    Abstract

    The 2001 NCCN Breast Cancer Guidelines reflect the results of 5 generations of NCCN Breast Cancer Guidelines. Evidence-based guidelines, such as the NNCN Breast Cancer Guidelines, are possible only because of the availability of high-level evidence at multiple decision points in treatment. The continued performance of high quality clinical trials is central to our ability to further improve the treatment of breast cancer. The panel believes that participation in high quality clinical trials is the preferred treatment at all points in breast cancer therapy.

    View details for PubMedID 11760559

  • Supportive-expressive group therapy and distress in patients with metastatic breast cancer - A randomized clinical intervention trial Classen, C., Butler, L. D., Koopman, C., Miller, E., DiMiceli, S., Giese-Davis, J., Fobair, P., Carlson, R. W., Kraemer, H. C., Spiegel, D. AMER MEDICAL ASSOC. 2001: 494-501

    Abstract

    Metastatic breast cancer carries with it considerable psychosocial morbidity. Studies have shown that some patients with metastatic breast cancer experience clinically significant anxiety and depression and traumatic stress symptoms. Supportive-expressive group psychotherapy was developed to help patients with cancer face and adjust to their existential concerns, express and manage disease-related emotions, increase social support, enhance relationships with family and physicians, and improve symptom control.Of 125 women with metastatic breast cancer recruited into the study, 64 were randomized to the intervention and 61 to the control condition. Intervention women were offered 1 year of weekly supportive-expressive group therapy and educational materials. Control women received educational materials only. Participants were assessed at baseline and every 4 months during the first year. Data at baseline and from at least 1 assessment were collected from 102 participants during this 12-month period, and these participants compose the study population.Primary analyses based on all available data indicated that participants in the treatment condition showed a significantly greater decline in traumatic stress symptoms on the Impact of Event Scale (effect size, 0.25) compared with the control condition, but there was no difference in Profile of Mood States total mood disturbance. However, when the final assessment occurring within a year of death was removed, a secondary analysis showed a significantly greater decline in total mood disturbance (effect size, 0.25) and traumatic stress symptoms (effect size, 0.33) for the treatment condition compared with the control condition.Supportive-expressive therapy, with its emphasis on providing support and helping patients face and deal with their disease-related stress, can help reduce distress in patients with metastatic breast cancer.

    View details for Web of Science ID 000168479100010

    View details for PubMedID 11343530

  • Management of breast cancer after Hodgkin's disease Wolden, S. L., Hancock, S. L., Carlson, R. W., Goffinet, D. R., Jeffrey, S. S., Hoppe, R. T. AMER SOC CLINICAL ONCOLOGY. 2000: 765-772

    Abstract

    To evaluate the incidence, detection, pathology, management, and prognosis of breast cancer occurring after Hodgkin's disease.Seventy-one cases of breast cancer in 65 survivors of Hodgkin's disease were analyzed.The median age at diagnosis was 24.6 years for Hodgkin's disease and 42.6 years for breast cancer. The relative risk for invasive breast cancer after Hodgkin's disease was 4.7 (95% confidence interval, 3.4 to 6. 0) compared with an age-matched cohort. Cancers were detected by self-examination (63%), mammography (30%), and physician exam (7%). The histologic distribution paralleled that reported in the general population (85% ductal histology) as did other features (27% positive axillary lymph nodes, 63% positive estrogen receptors, and 25% family history). Although 87% of tumors were less than 4 cm, 95% were managed with mastectomy because of prior radiation. Two women underwent lumpectomy with breast irradiation. One of these patients developed tissue necrosis in the region of overlap with the prior mantle field. The incidence of bilateral breast cancer was 10%. Adjuvant systemic therapy was well tolerated; doxorubicin was used infrequently. Ten-year disease-specific survival was as follows: in-situ disease, 100%; stage I, 88%; stage II, 55%; stage III, 60%; and stage IV, zero.The risk of breast cancer is increased after Hodgkin's disease. Screening has been successful in detecting early-stage cancers. Pathologic features and prognosis are similar to that reported in the general population. Repeat irradiation of the breast can lead to tissue necrosis, and thus, mastectomy remains the standard of care in most cases.

    View details for Web of Science ID 000085401800008

    View details for PubMedID 10673517

  • INTEGRATION OF PEN-BASED COMPUTER-TECHNOLOGY IN CLINICAL SETTINGS ACUFF, R. D., Fagan, L. M., Rindfleisch, T. C., Carlson, R. W., Tuttle, M. S., Sherertz, D. D. BMJ PUBLISHING GROUP. 1994: 1042-1042

    View details for Web of Science ID A1994QF21600245

    View details for PubMedID 7949880

  • T-HELPER - AUTOMATED SUPPORT FOR COMMUNITY-BASED CLINICAL RESEARCH Musen, M. A., Carlson, R. W., Fagan, L. M., Deresinski, S. C., Shortliffe, E. H. MCGRAW-HILL BOOK CO. 1993: 719-723

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