Dixie Mills

Technical Enhancements to Breast Ductal Lavage

BackgroundDuctal lavage is a technique that samples the contents of breast ducts for research into the biology of breast cancer. Enthusiasm for this method has declined because of technical challenges associated with the procedure. These include: difficulty in duct cannulation, high levels of subject discomfort, and an inability to confirm perforation.MethodsAs part of a larger institutional review board (IRB)-approved study, consenting healthy women underwent ductal lavage of 3–4 ducts in one breast. Intranipple lidocaine was administered before duct cannulation. Ductoscopy was performed prior to catheterization and high-definition ultrasound was used for imaging during the lavage procedure. Pain scores were recorded at 24 hours and 2 weeks. Subjects were asked to return in 6 months for a repeat of the procedure.ResultsDuctoscopy was performed prior to lavage under real-time ultrasound 308 times in 107 subjects. There were 280 confirmed ducts (90.9%) and 21 perforations (6.8%), while seven (2.3%) were indeterminate. Subjects reported minimal discomfort, and 91% reported a 0 (0–10 range) pain score 2 weeks after the procedure. The retention rate was 90% at 6 months.ConclusionThe injection of lidocaine directly into the nipple greatly increases the feasibility of duct cannulation and improves subject comfort. Confirmation of duct cannulation and lavage can be documented with ductoscopy and ultrasound imaging. These procedures can be added to ductal lavage to facilitate its use as a research tool.

Examination of Duct Physiology in the Human Mammary Gland

Background The human breast comprise several ductal systems, or lobes, which contain a small amount of fluid containing cells, hormones, proteins and metabolites. The complex physiology of these ducts is likely a contributing factor to the development of breast cancer, especially given that the vast majority of breast cancers begin in a single lobular unit. Methods We examined the levels of total protein, progesterone, estradiol, estrone sulfate, dehydroepiandrosterone sulfate, and macrophages in ductal fluid samples obtained from 3 ducts each in 78 women, sampled twice over a 6 month period. Samples were processed for both cytological and molecular analysis. Intraclass correlation coefficients and mixed models were utilized to identify significant data. Results We found that the levels of these ductal fluid components were generally uncorrelated among ducts within a single breast and over time, suggesting that each lobe within the breast has a distinct physiology. However, we also found that estradiol was more correlated in women who were nulliparous or produced nipple aspirate fluid. Conclusions Our results provide evidence that the microenvironment of any given lobular unit is unique to that individual unit, findings that may provide clues about the initiation and development of ductal carcinomas.

Preliminary exploration into the physiology of the resting breast.

Background Epidemiological and animal data are clear that early first pregnancy decreases subsequent breast cancer risk. The mechanism for this decrease however is less clear and several hypotheses abound. One possibility that has not received any attention is the physiology of fluid secretion in the breast. The ductal systems have secretions which can be accessed either through nipple aspiration or ductal lavage. It is not clear whether the mechanisms identified for absorption, secretion, concentration and local synthesis that have been described in the lactating breast are consistently available to the non lactating breast or whether there is a difference in nulliparous and parous women. It is not clear whether the known changes to the ductal-alveolar system with the first pregnancy remain permanent or have long lasting ramifications. The hypothesis tested was that the first pregnancy permanently changes the physiology of the ductal epithelial membrane transport. Two known drug transport mechanisms in lactating women were tested using caffeine and cimetidine.

The Role of Ductal Lavage: A Cautionary Tale

Nearly one hundred years ago, the English surgeon and author, Sir Geoffrey Keynes, wrote “the breast is a gland which throughout life is exhibiting some secretory activity, the difference between a lactating and a non-lactating breast being one partly of degree and partly of the chemical constitution of the secretion” (Keynes 1923). While knowledge about the histopathology of breast cancer has progressed significantly in the subsequent years, the intraluminal cells and secretions of the ductal system in the non-lactating or resting breast have received little attention. Most pathologists have considered these cells and secretions to be sloughed off degenerating epithelium and proteinaceous material and of little biological interest (Petrakis 1986). However, there has been isolated interest in looking more carefully at this fluid and determining its physiology and its clinical significance.

Abstract 2894: A new resource to accelerate research into the cause and prevention of breast cancer: The Love/Avon Army of Women

Background: It is well established that there is a need for more research into the cause and prevention of breast cancer. While many studies are done in cell lines and laboratory animals, translation of findings to women often falters due to perceived difficulty in recruiting women for research. The DSLRF partnered with The Avon Foundation for Women to form the Love/Avon Army of Women (AOW); an on-line recruitment resource designed to partner women with scientists in an effort to accelerate breast cancer research. Methods: The AOW was launched in October 2008 with the goal of recruiting one million women interested in participating in breast cancer research, and of encouraging researchers to submit studies for recruitment. Researchers interested in having the AOW recruit for their studies, submit a proposal that will be reviewed by the AOW Scientific Advisory Committee, comprised of nominees from AACR and NBCC. If a study is accepted, a mass e-mail describing the study procedures and inclusion/exclusion criteria is sent to the entire AOW database. Women sign up on-line at www.armyofwomen.org to become an AOW member. Women aren9t committing to participating in a particular study, but agree to receive AOW e-mails about breast cancer research studies. If the individual is interested and qualifies for a study, she undergoes a secondary on-line screening and then her contact information is passed on to the principal investigator to begin the enrollment process. Results: As of November 2009, over 320,000 women have become AOW members. Membership includes survivors, those who have not been diagnosed with breast cancer, as well as those with and without a family history of breast cancer, ranging from ages 18 to 100, representing all 50 US states and 47 countries. To date, the AOW has recruited for 16 studies, both regional and national, that vary from biomarker and circadian rhythm research to psycho-social and quality of life studies. With over 13,000 AOW members having participated in the research process, this method of recruitment has been found to be effective and efficient. The diversity of the AOW members has proved beneficial for many studies such as those needing to enroll African American women, women of varying sexual orientations, or young survivors. Many studies were closed to enrollment within the first 24 hours after accruing all subjects while others were very quickly over-enrolled by 5-10%. This overwhelming response has led many researchers to seek additional funding to increase their statistical significance and accommodate all eligible subjects. Conclusions: The Love/Avon Army of Women is a novel resource for scientists to accelerate accrual, expand the number and diversity of their subject population and to obtain exactly the type of specimens they need when they need it. This new partnership between women and scientists can revolutionize research and accelerate efforts to eradicate breast cancer. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2894.

The Love/Avon Army of Women – Accelerating Research into the Etiology and Prevention of Breast Cancer.

Background: There is a need to facilitate research aimed at finding the cause and prevention of breast cancer. A deterrent has been the difficulty basic scientists have in involving normal women in clinical research. However, the Dr Susan Love Research Foundation has had success in recruiting healthy community women for studies. In 2006 we partnered with a Texas Tech University scientist who had planned to do his research in an animal model because he felt it would be impossible to obtain blood and core needle biopsies from the women fitting his strict criteria. However by accessing our registry of potential volunteers we were able to collect all the specimens. A grant from the Avon Foundation for Women allowed us expand and to develop the Love/Avon Army of Women (AOW). Methods: The AOW was launched in October 2008 by Dr. Love on national media- to recruit one million women who are willing to participate in clinical research into the cause and prevention of breast cancer. Researchers contact the AOW and apply for access to the AOW. Projects are reviewed by the AOW Scientific Advisory Committee which includes members nominated by the AACR and the NBCC. If a researcher cannot obtain his or her own specimens, there are regional AOW Centers where the appropriate data and samples can be collected according to the specifications of the scientist. The criteria and procedures of approved AOW studies are e-mailed to the entire AOW database allowing viral distribution beyond the registry. Women self-select and sign up for studies on-line after a secondary screen. Researchers are responsible for explaining the study and will report back to the participating women the overall findings of the study via webcast once completed ensuring a partnership between the women and the researchers while educating women in the way research is conducted. Results: As of June 2009, over 286,000 women have become Army of Women members by signing up at www.armyofwomen.org. Members of all races/ethnicities ranging in ages from 18 to 100 are represented. There are members in all 50 states as well as many countries throughout the world. Twenty per cent of members are breast cancer survivors while the rest are unaffected. Since October 2008, the AOW has recruited for ten studies. All have had a rapid and substantial response, continually far exceeding the researcher9s expectations. Five were closed within a week. Over 11,000 women have participated in AOW supported clinical research studies. Efforts are underway to launch a large online cohort study enabling collection of cross-sectional and longitudinal data that can be accessed to address specific questions in survivors and unaffected women. Conclusions: The Love/Avon Army of Women is an available resource for epidemiologists and basic scientists who have projects that need human breast tissue, ductal fluid, urine, saliva or blood as well as data. This novel resource allows breast cancer scientists to obtain exactly the type of specimens and information they need when they need it and promises to revolutionize research and accelerate efforts to eradicate breast cancer. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3075.

State of the Science and the Intraductal Approach for Breast Cancer: Proceedings Summary of The Sixth International Symposium on the Intraductal Approach To Breast Cancer Santa Monica, California, 19–21 February 2009

Researchers are using the intraductal approach to advance breast cancer risk assessment, prevention, diagnosis, and treatment. Procedures and technologies that can access and interrogate the ductal-alveolar systems include nipple aspiration, ductal lavage and ductoscopy. Ductoscopic papillectomy, ductoscopic margin evaluation, and intraductal therapy are considered promising investigational and innovative treatments. These techniques are used to explore the biology of the normal breast; collect and analyze breast fluid and cells to identify biomarkers that can be used in breast cancer detection and risk assessment; and to identify new ways to find and administer therapeutic and/or preventive agents to the breast tissue. This report summarizes the latest research findings in these areas, presented at The 6th International Symposium on the Intraductal Approach to Breast Cancer in 2009.

Abstract B65: Atypia in ductal lavage: A reproducible marker of risk?

B65 Background The majority of breast cancers originate in the ductal epithelium of the breast. Ductal lavage provides a minimally invasive tool for assessing epithelial cells and their microenvironment. Previous studies of pathological atypical hyperplasia on biopsy, and cytological aypia in nipple aspirate fluid (NAF) and random fine needle aspiration (FNA) have suggested that these cells are precancerous because of the subsequent increased risk of cancer. It has therefore been hypothesized that serial ductal lavage could be used to identify atypia and monitor the effects of chemoprevention over time. This report is part of a larger study examining the differences in hormone levels and cytology between ducts and their reproducibility. This report presents a cohort of women unselected for risk who voluntarily underwent ductal lavage of the same ducts on two occasions six months apart. Samples were analyzed for epithelial cells and macrophages. Methods A total of 107 women were recruited in this IRB-approved prospective study to undergo ductal lavage of three fluid or non-fluid-yielding ducts within a breast. Women were unselected for risk: the average Gail score was 1.67 and ten women had a history of contralateral breast cancer. The average age was 51 years. Fifty-four women were premenopausal, 4 were perimenopausal and 49 were postmenopausal. Samples were submitted in a blinded fashion to a central laboratory and were analyzed by duct for both macrophage and epithelial cell number on Papanicolaou-stained slides. If adequate epithelial cells were present (>10), a diagnosis of each duct (benign, mild atypia, or marked aytpia) was made by an experienced cytopathologist. Results Of the 107 women, 317 (99%) ducts were successfully cannulated without regard to nipple aspirate fluid (NAF) production. Thirty ducts in 23 women were diagnosed with mild or marked atypia on either of the two visits. Of these ducts, 16 were diagnosed at the initial visit and 13 at the second visit. Only one duct was diagnosed with mild atypia on both visits, in a woman with a Gail score of 1.4. Cellular atypia in ductal lavage was not reproducible at a six month interval (p=0.45). This absence of reproducibility was seen in women at all risk levels. Macrophage and epithelial cell numbers also showed a lack of reproducibility at the six month interval (p=0.31 and p=0.22, respectively). Conclusion Atypia on cytology in ductal lavage in women unselected for risk was not reproducible at a six month interval, suggesting that a single diagnosis of atypia on lavage should not be used as a marker for the identification of women at risk. Further studies are necessary to indicate whether persistent atypia over an extended interval could represent an elevated risk for breast cancer. In addition, ongoing studies are being performed to identify better cellular markers of premalignancy and subsequent risk. Citation Information: Cancer Prev Res 2008;1(7 Suppl):B65.

Abstract B23: Love/Avon army of women: Revolutionizing research

Abstracts: Frontiers in Cancer Prevention Research 2008 B23 Introduction Ten years ago the NCI published an Executive Summary stating that it is “clear that a more complete understanding of the normal mammary gland...will be a critical underpinning of continued advances in detecting, preventing and treating breast cancer.” A deterrent to obtaining this understanding has been the difficulty basic scientists have in involving normal women in their research. The Love/Avon Army of Women, is a “just in time” tissue and data resource launched to give researchers access to the samples/data they need in an attempt to accelerate research into the cause and prevention of breast cancer. Background The Dr Susan Love Research Foundation piloted the concept of a “just in time” database in Southern California recruiting over 700 women who were willing to consider participating in clinical research. As new studies arise the women are informed and if appropriate decide whether to participate. In 2006, we expanded our pilot when we agreed to partner with Texas Tech University in a study titled “Analysis of Parity-Induced Protection in Human Breast and Serum.” Initially the PI planned to do research in an animal model because he felt it would be impossible to obtain blood and breast core needle biopsies from 44 women each year, 11 who had their first child before 25, 11 women who had their first child after 35 and 22 age-matched nulliparous controls. By accessing our registry of healthy women and reaching out to other less-traditional communities, such as nuns and lesbians, we have been able to collect all the specimens to date for the study. The Avon Foundation has also been able to recruit volunteers at their Walks for other Avon grants. These experiences led us to launch this joint venture, the Love/Avon Army of Women, to extend this experience to any scientist who needs it. Methods Starting Oct 1, 2008 one million women will be recruited from around the country who are willing to participate in clinical research. They will sign up on a website with minimal information. Scientists who need access to human breast tissue, ductal fluid, urine, saliva or blood as well as those collecting data for epidemiology studies will contact the AOW through the website. Once a grant has been awarded by an outside funder, the research will be reviewed for appropriateness for the AOW. Then an eblast will go out to all members of the AOW describing the study, the criteria for participation as well as what will be involved. Women will self select and RSVP to the AOW. After undergoing a secondary screen they will either be referred to the researcher directly or to an Army center where the appropriate data and specimens will be collected according to the specifications of the scientist. All scientists will be required to participate in a webcast with all the women who have responded to explain the research question and how this study will move us forward in finding the cause and prevention of breast cancer. Again, after the study has been completed the researcher will report back to the participating women the overall findings of the study via webcast. This will ensure a partnership between the women and the researchers in moving towards the goal of eradicating breast cancer. Conclusions The Love/Avon Army of Women is a novel resource for breast cancer scientists to obtain exactly the type of specimens they need when they need it. This new partnership between women and scientists can revolutionize research and accelerate efforts to eradicate breast cancer. Citation Information: Cancer Prev Res 2008;1(7 Suppl):B23.