Long-term survival of women with breast cancer in biomarker context – Vu Hong Thang

34 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH Corresponding author: Vu Hong Thang, Medical Oncology Department, National Cancer Hospital, Hanoi, Vietnam Email: vuhongthang@hmu.edu.vn Received: 6/11/2017 Accepted: 18/9/2018 LONG-TERM SURVIVAL OF WOMEN WITH BREAST CANCER IN BIOMARKER CONTEXT Vu Hong Thang 1,2 , Tran Van Thuan 1,2 , Ta Thanh Van 2 , Lambert Skoog 3 ¹National Cancer Hospital, Vietnam ²Hanoi Medical University, Vietnam 3Karolinska University Hospital, Solna, Stockholm, Sweden Little is known about breast cancer in Vietnamese women. The aim of this study was to examine the correlation of prognostic factors with relative survival of Vietnamese women afflicted by breast cancer treated at the National Cancer Hospital in Hanoi, Vietnam. We recruited 248 women with operable breast cancer treated with surgery and adjuvant therapy. Tumor tissue samples were stained by a range of immunohisto- chemically approaches and analyzed for the hormone receptors, HER2 gene amplification status. The Cox model was used to determine the relationship between survival and prognostic treatment factors. The disease-free survival rate, overall survival rate and cancer-specific survival rate were 75.8%, 80.6%, and 86.4%, respectively, at 5 years and 62.3%, 68.1%, 78.9%, respectively, at 9 years. Women with poor prog- nostic factors (e.g., advanced clinical stage, high tumor grade, progesterone receptor (PgR) negativity, HER2 amplification) had significantly lower survival rates. Postmenopausal women had significantly lower survival rates as compared to premenopausal women when analyzed by univariate analysis (HR = 0.6, 95% CI: 0.38 - 0.95, p = 0.029). However, these comparisons were not statistically significant when subjected to a multivariable analysis (HR = 0.67, 95%CI: 0.41 - 1.08, p = 0.1). Premenopausal women had a higher survival rate than postmenopausal patients in groups treated by endocrine therapy or chemotherapy. Postmeno- pausal women had lower levels of survival than premenopausal women. This might be attributable to more poor prognostic factors in postmenopausal women. The cancer-specific survival in the present study was comparable to that for patients from other Asian and Western countries. Keywords: breast cancer; biomarkers; survival I. INTRODUCTION Breast cancer is the most common cancer in women and a major cause of cancer-related deaths in many countries [1]. There are, how- ever, differences in incidence, prognostic markers and survival among ethnic groups. In the USA, the breast cancer incidence among Vietnamese women was 55.5/100.000, which was found to be lower than those in other eth- nic groups such as Chinese, Filipino, Japa- nese and non-Hispanic white women [2]. In Hanoi (Vietnam), the breast cancer incidence (per 100,000 people) was low, at 17.5 cases, which is considerably lower than that reported for Vietnamese women, 36.6 per 100.000, living in the US and Caucasian Americans, 98.7 per 100.000 [3]. In Vietnam, findings from cancer registries in three regions showed that breast cancer is the most common form of cancer in women [4], but due to historical reasons, there are no nationwide data available on its incidence and prevalence. Breast cancer death amounts to 5.69% of all cancer deaths in Vietnamese women [5]. Recent reports from the United JMR 116 E3 (7) - 2018 35 JOURNAL OF MEDICAL RESEARCH States showed that the mortality rates of USA- born, Vietnamese patients were the lowest among Asian populations and much lower than that of non - Hispanic white women [2; 6]. Similarly, it was also found that African- American women had lower survival rates than white women, even after adjustment for prognostic characteristics [7]. Breast cancer mortality has been declining in Europe over time with marked decreases observed in Northern countries attributable to early detec- tion and treatment [8]. Very few data have been reported on breast cancer survival among women living in Vietnam. Two studies showed that premeno- pausal Vietnamese women benefited from oophorectomy plus tamoxifen [9; 10]. In our previous studies, we have found that Vietnamese women had breast cancer tumors with a high frequency of the human epidermal growth factor receptor-2 (HER2) gene amplifi- cation, hormone receptor negativity and had more advanced stages of tumor compared to Swedish women [11; 12]. The aim of this study was to examine the correlation of survival with prognostic factors and treatment of Vietnamese breast cancer women registered as patients at the National Cancer Hospital, Hanoi, Vietnam. II. METHODS 1. Study population and treatment Two hundred and forty-eight patients with primary breast cancer in clinical stage I-IIIb, operated on between June 2002 and October 2003, were recruited randomly from the National Cancer Hospital, Hanoi, Vietnam. Patients were treated with modified radical mastectomy or conservative surgery and axil- lary node sampling with a median of 10 lymph nodes excised (range 6-35). Classification of histological type was defined according WHO criteria. Tumor grade was assessed by the Scarff-Bloom-Richardson (SBR) as well as the Elston-Ellis grading method [13]. Informed consent was obtained from all patients before treatment. Patients who received modified radical mastectomy were treated with adjuvant radiotherapy for tumors ≥ 3 cm at a dose of 50 Gy to the chest wall and 50 Gy to the axillary area if node positive. Patients who received partial mastectomy were given 50 Gy to the entire breast and a boost to 60 - 65 Gy to the tumor bed. Patients with lymph node metasta- sis received adjuvant chemotherapy with anthracycline or taxane regimens range over 4 - 6 cycles. Of 123 premenopausal patients with hormone receptor-positive tumors, 104 (84.5%) received endocrine therapy including 74 patients with castration by radiotherapy at a dose of 15 Gy and 11 of those became meno- pausal after chemotherapy and 19 peri- menopausal women were treated with ta- moxifen alone. Postmenopausal women with hormone receptor - positive tumors were treated with tamoxifen at a dose of 20 mg daily for at least two but often for 5 years. In the first years, all patients were followed-up with physi- cal examination, chest x-rays, abdominal ultra- sound and a blood test for CA15-3 level. Pa- tients with symptoms suggesting metastasis were examined by CT/ MRI scans or bone scan. The majority of the patients were con- tinuously followed up by examination at Na- tional Cancer Hospital but some patients living outside of Hanoi could only be reached by telephone. If a patient could not be contacted, the relatives were interviewed to clarify the reason for this failure. The last day of follow- 36 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH up was July 31, 2011, with a 99-month median follow-up (range 4 - 108 months). Patients who were alive after the last day of follow-up were censored. 2. Tissue assessment All tumors were analysed for hormone receptor content by immunohistochemistry in the Department of Pathology at the National Cancer Hospital, Hanoi, Vietnam. Receptor positivity was defined as > 1% of stained nuclei and patients with positive tumor(s) received endocrine treatment in the National Cancer Hospital. These tumors were also analysed at Karolinska Hospital (Sweden) for hormone receptor content, HER2 expression using an automated immunostaining platform and SISH procedure. SISH scoring was carried out independently following the recom- mendation of the manufacturer. The adequacy of staining assessed by examining each slide for HER2 and chromosome 17 signals, identi- fied as black and pink dots, respectively in the nuclei of normal cells, which can include fibro- blasts, endothelial cells or normal epithelial cells. The entire stained section was scanned and an area of the invasive tumor with the most easily identifiable signal deposits was chosen for counting. Twenty cancer cells were counted for dots representing both HER2 and chromosome 17. A single dot was counted as one, a small cluster as six and a large cluster as twelve. We did not count overlapping nu- clei, or cells in which black dots were found in the cytoplasm. Finally, the ratio of HER2 gene⁄ chromosome 17 was calculated by dividing the total score for HER2 by the total score for chromosome 17. A ratio of < 1.8 indicated that the HER2 gene was not amplified, whereas a ratio of > 2.2 showed amplification of the gene. In tumors with a ratio between 1.8 and 2.2, a final decision was made after counting an additional 20 nuclei. The results have also been presented previously and those indica- tors were correlated to disease outcome in this study [11; 12]. 3. Statistical analysis The data was stored using SPSS software, version 19.0 for Window (SPSS, Chicago, IL). Analyses were performed using SPSS and STATA version 10.1, StataCorp Texas, USA. Differences in clinicopathological characteris- tics, including tumor grade, tumor size, lymph node status and breast cancer subtypes between premenopausal and postmenopausal patients, were examined using aχ 2 test and odds ratio (OR) using 95% confident intervals (95% CIs). Disease-free survival (DFS) was defined as the interval from the date of opera- tion to the date of first detection of metastasis or contralateral breast cancer. Breast cancer- specific survival (CSS) was calculated from the date of operation to the date of death of a patient caused directly by cancer. Overall survival (OS) was defined as the date of operation to date of death of any cause or the last day of follow up. The survival rates were estimated by using the Kaplan-Meier method. Log-rank test was used to compare DFS and OS between groups. Univariate and multivariate Cox re- gression models were used to determine the relationship between breast cancer deaths and the prognostic and treatment factors. After the modeling process, the proportionality as- sumption was checked using Schoenfeld re- sidual plots and no violation was found. All tests were two-sided and a p ≤ 0.05 value was used as the significance level. JMR 116 E3 (7) - 2018 37 JOURNAL OF MEDICAL RESEARCH 4. Research ethics This work was approved by the ethical committee of the Hanoi Medical University, No 38/HMUIRB, 95/HMUIRB-extension (Vietnam). III. RESULTS Characteristics of the patients treated in 2002 - 2003 The median age of study participants was 46 years (range 26 - 72 years). From Table 1, it can be seen that 159 patients (64.1%) were premenopausal, 85 (34.3%) postmenopausal and 4 (1.6%) had unknown menopausal status at diagnosis. Of all patients, 10.5%, 70.6% and 18.9% were in clinical stages I, II and IIIa/ b, respectively. 227 patients (91.5%) had invasive ductal carcinoma, while 21 patients (8.5%) had other subtypes. The tumors were classified according to SBR criteria as grades I, II and III in 9.2%, 71.3% and 10.8% of women, respectively. At the time of surgery, 109 patients (44%) had metastatic axillary node(s) and 76 of them (70%) were given chemotherapy. Hormone receptor-positive tumors (ER + and/or PgR+) were found in 164 patients and 112 (68%) of these were given tamoxifen. No patient was treated with Herceptin. Survival and clinicopathologic factors During the median observation time of 99 months, 48 patients died from breast cancer and 28 patients died of unknown causes. No autopsies were performed. Of the 171 (68.9%) living patients, 13 had evidence of recurrence/ metastasis. One patient dropped out after con- firmed metastasis. In addition, during follow up, one patient developed leukaemia, another had Vaquez disease (Primary polycythemia) but both are still alive as of (insert date that this report was written). The DFS, OS and CSS rates were 75.8%, 80.6% and 86.4% at 5 years, respectively; and 62.3%, 68.1%, 78.9% at 9 years, respectively. These trends of survival are shown in Fig. 1. A comparison of prognostic factors between pre- and postmenopausal women can be seen in Table 1. Postmenopausal women more often had poor prognostic factors such as hormone receptor-negative disease and HER2 amplification. In the univariate model, premenopausal women seemed to have a better survival (HR = 0.61, 95%CI: 0.38 - 0.95, p = 0.03), however, this relation was diminished when analysis was carried out using the multivariate model (HR = 0.67, 95% CI: 0.41 -1.08, p = 0.10). The improved survival rate for premenopausal patients is also seen in Fig. 2. We also confirmed, not surprisingly, that participants with PgR- negative tumors also had lower survival than women with PgR-positive tumors (HR = 1.77, 95%CI: 1.01 - 3.11, p = 0.045) (Table 1). ER- positive, PgR-positive, HER2-negative tumors had improved survival rate (Fig. 3a-c). It can be seen from these Figures that premenopausal women had better survival than postmenopausal patients. 38 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH Histological subtype Ductal carcinoma* 148 (93) 76 (89) 0.63 (0.319) Others 11 (7) 9 (11) Tumor grade (SBR) I,II 135 (86) 65 (78) 1.59 (0.242) III Unknown 17 (11) 5 (3) 13 (15) 6 (7) Lymph node (-) 89 (56) 47 (55) 1.03 (0.919) (+) 70 (44) 38 (45) ER status (-) 45 (29) 46 (54) 2.93 (0.0001) (+) 112 (71) 39 (46) PgR status (-) 65 (41) 62 (73) 3.81 (< 0.0001) (+) 92 (59) 23 (27) HER2 gene Negative 105 (66) 39 (46) 2.34 (0.002) Amplification 53 (34) 46 (54) Chemotherapy No 97 (61) 58 (68) 1.37 (0.264) Yes 62 (39) 27 (32) Hormone therapy** No 19 (16) 11 (27) 0.5 (0.103) Yes 104 (84) 30 (73) *ductal and ductal carcinoma component ** compared for hormone positive patients Table 1. Comparison of clinicopathological parameters according to menopause status Variable Pre n (%) Post n (%) OR (P-value) Clinical stage I, II 134 (85) 64 (75) 1.83 (0.069) III 24 (15) 21 (25) JMR 116 E3 (7) - 2018 39 JOURNAL OF MEDICAL RESEARCH Figure 1. Disease-free survival, overall survival and cancer specific survival of operable breast cancers Univariate analysis Multivariate analysis (after adjusted stage, hormone receptors, HER2 status) Figure 2. Overall survival of operable breast cancers by menopause status Post 5 years 9 years Pre 5 years 9 years ER(-) 69.6% 59.7% ER(-) 75% 72.7% ER(+) 75.8% 58.3% ER(+) 88.1% 73.3% Figure 3a. Comparison of overall survival by ER and menopausal status 40 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH Post 5 years 9 years Pre 5 years 9 years PgR(-) 65.5% 50.3% PgR(-) 82.6% 71.3% PgR(+) 90.9% 81.8% PgR(+) 85.6% 74.5% Figure 3b. Comparison of overall survival by PgR and menopausal status Post 5 years 9 years Pre 5 years 9 years HER2(-) 73.8% 62.2% HER2(-) 86.1% 74.9% HER2(+) 71% 56.0% HER2(+) 80.8% 69.2% Figure 3c. Comparison of overall survival by HER2 and menopausal status IV. DISCUSSION It is estimated that more than 16.000 women in Vietnam are diagnosed with breast cancer every year. Vietnamese patients are younger than Western patients at the time of diagnosis and it seems that there are differ- ences in tumor prognostic markers between Vietnamese and Swedish women with breast cancer [11; 12]. The 5-year OS in the current study was 80.6% for all patients which was similar to sur- vival rates reported in France [14], but was lower than survival of foreign-born Vietnamese women living in the country which was re- ported to be 86% [6]. The 5-year survival rate of Vietnamese women less than 50 years treated in the National Cancer Hospital in Hanoi is similar to that reported in the Eastern JMR 116 E3 (7) - 2018 41 JOURNAL OF MEDICAL RESEARCH region of England (85.6% vs. 85.0%) and slightly lower after 9 years of treatment [15]. This might partly be explained by the fact that all patients in these studies were most likely treated in advanced hospitals with reliable guidelines and techniques. However, the 5- year DFS in our study population was lower as compared to Chinese women in Hong Kong with similar stages, 75.8% vs. 81.2% [16]. To our knowledge, this is the first study with active, long-term follow-up of pre- and postmenopausal women with breast cancers from Vietnam. We usually recommend that breast cancer patients have their check-up after treatment at the Cancer Hospital in Ha- noi. This was, however, difficult for patients living at a distance from Hanoi. Therefore, 10 patients (4%) were lost to follow-up during the course of the study. One further difficulty is that some patients decided to go to their local hospital or to seek traditional medicine treat- ment. In fact, it appears that some patients did not seek medical attention, although they had various symptoms. We therefore believe that our data overestimates the DFS rate, and to some extent also overestimates CSS, while the OS data are likely to be more robust. Viet- nam introduced national mortality statistics in 1992 which was based on commune-level re- ports. However, the assessment of cause of death is in many patients is not always thor- ough[5]. In the present study, 48 of 76 patients that died (63%) had evidence of metastasis by investigation at hospitals and cancer was de- termined as the primary cause of death. More advanced treatment and early diag- nosis has improved breast cancer survival over the recent years [2; 7]. In our study, vari- ables including menopausal status, clinical stage, tumor grade and various biomarkers were associated with survival. The lowest sur- vival was seen in women with advanced stages, high-grade tumors, high cell prolifera- tion, or triple negative tumors. Stage of dis- ease was the strongest prognosticator regard- less of other factors. A report on breast cancer survival among Asian patients living in Malay- sia and Singapore indicated a 5-year survival level was lower than that found in our study [17]. The survival rate was associated with both tumor characteristics and hospital setting [15]. Although ER and HER2 status in our study was found to not be statistically related to survival, it seems that patients with ER (-) and/or HER2 amplified tumors have poor sur- vival. These findings are consistent with previ- ous reports based on random samples of either Asian or Western women [15, 18 - 21]. It should, however, be pointed out that the sur- vival of patients suffering from breast cancer is not only dependent on clinicopathological fea- tures but also on hospital settings [15]. A re- cent report from Sweden found that CSS at ten years was lower in low socioeconomic status women than in their high socioeco- nomic status counterparts (78% vs. 82%, re- spectively) [22]. We were not able to compare the socioeconomic status of our Vietnamese patients, but it can be assumed that such pa- rameters are highly likely to have influenced patient survival. Therefore, further studies on Vietnamese patients should investigate the relationship between survival and socioeco- nomic factors, combined with the quality of breast cancer treatment available. As reported previously, we found different clinicopathological and tumor cell characteris- tics of breast cancers from Vietnamese and Swedish patients. The difference was seen particularly with respect to patient age [11]. 42 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH Dabakuyo et. al. stated that the survival rate was lower in patients whose age was 60 years or older and in postmenopausal women more broadly [14]. It has also been reported that the cancer mortality rate has also increased with rising age in Northern Vietnam [23]. One limi- tation in our study is that we were not able to assess the exact cause of death in some pa- tients; therefore, it is difficult to precisely deter- mine breast cancer-specific survival. More- over, one important reason for the lack of the precision is that for legal and cultural reasons, autopsies are not performed in Vietnam. The modest sample size is also contributed to limit in this study. However, 48 (63%) of the dead patients had been confirmed as having metas- tatic disease and cancer death seems plausi- ble among these patients. We found that post- menopausal women had a significantly lower OS rate than premenopausal women. But postmenopausal women more often had tu- mors with poor prognostic factors as com- pared to premenopausal women in this study. When adjusted for disease stage, hormone receptors and HER2 gene status, we found that postmenopausal women still tended to have a decreased survival rate although it was not statistically significant. The National Cancer Hospital is the largest cancer centre in Northern Vietnam with more than 10,000 patients treated annually. During the past fifteen years, research on treatment of breast cancer in cooperation with University of Wisconsin showed that premenopausal Vietnamese women benefited from oophorec- tomy and tamoxifen regardless hormone re- ceptor status [9]. One limitation is that our find- ings are based on breast cancer patients treated in a single institution with access to adequate therapies and thus do not reflect treatment in all hospitals in Vietnam. Further studies are needed on similar groups of pa- tients in the other major cancer centres throughout Vietnam. To improve survival rate, it is additionally important for patients to be diagnosed at early stages as well. V. CONCLUSION Although many patients had tumors with unfavourable prognostic characteristics, their long-term survival prospects were favourable. In contrast to similar reports from western populations, postmenopausal women had shorter survival and poor prognostic factors as compared to premenopausal women. Im- proved reports on disease recurrence and cause of death in combination with knowledge about socioeconomic status are needed to obtain a more precise picture of breast cancer survival Vietnamese patients. 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