Breast Cancer Risk Biomarkers in Premenopausal Women

The central hypothesis is that 6 months of administration of high dose omega-3 fatty acid esters \[eicosapentaenoic acid (EPA) 1860 mg, and docosahexaenoic acid (DHA) 1500 mg\] daily in the form of a standard prescription strength dose of Lovaza™ (two 1 gram capsules twice daily) will have a favorable side effect profile and potential efficacy as demonstrated by favorable modulation of one or more blood and breast tissue risk biomarkers for breast cancer in premenopausal women.

• Lovaza™ (Drug), also known as esters of EPA and DHA: 4 capsules daily for 6 months

Primary outcomes

• The Proportion of Subjects That Complete an Intervention of Lovaza™ 4 Grams Per Day [6 month visit]: The proportion of subjects that complete an intervention of Lovaza™ 4 grams per day (\~ 1800 mg EPA and 1500 mg DHA) administered for 6 months to premenopausal women under age 55.

Secondary outcomes

• Modulation of the Risk Biomarker Masood Score [6 month value compared to baseline value]: Change in the semiquantitative cytology index score (Masood score) from baseline to end of study. Masood Score range 6 - 24; increasing values denote increasing cytologic abnormality. Thus, negative values for change reflect an improvement, i.e., less cytologic abnormality after intervention.
• Modulation of Ki-67 Expression [6 month value compared to baseline value]: Change (baseline to end of study) in percent of benign breast epithelial cells exhibiting immunostaining for Ki-67
• Change in (DHA+EPA):AA Ratio for Phospholipids in Plasma. [baseline to end of intervention (~6 months)]: Change (from baseline to end of study) for the ratio derived from levels of DHA, EPA, and Arachadonic Acid (AA); measured as percent of total fatty acid content in the phospholipid compartment of plasma.
• Change in Quality of Life. [duration of intervention, baseline to ~ 6 months]: Change in score on Breast Cancer Prevention Trial (BCPT) Symptom Checklist. 43 symptoms, each scored as 0 to 4, are summed to provide a global score (range 0 to 172). Increasing score represents increasing problems with side effects. For change in score over period of intervention, a negative score indicates an improvement in quality of life while a positive score indicates increasing interference with daily activities due to worsening symptoms. Theoretically, the range of change could be -172 to +172.

Sex: Female, ages: 25 Years to 54 Years, accepts healthy volunteers

Inclusion Criteria

* Subjects must be premenopausal and between the ages of 25 and 54 and must have had a menstrual period within the past 12 months. Women who are not menstruating regularly due to use of certain types of contraceptives may be entered with restrictions. Their estrogen progesterone, and follicle stimulating hormone (FSH) levels must be documented at baseline random periareolar fine needle aspiration (RPFNA) and their off study RPFNA must take place at a similar portion of their cycle (high or low progesterone levels). In order to do this a serum progesterone will have to be obtained \~ 4 weeks before planned RPFNA and again 2 weeks later such that the RPFNA can be performed in the same phase of the "cycle" as baseline.
* Subjects must be at increased risk for breast cancer on the basis of at least one of the following criteria:
* A five-year Gail risk of ≥ 1.67% or three times the average risk for a woman of the same age using either the Surveillance Epidemiology and End Results (SEER, http://seer.cancer.gov) database or the NCI Breast Cancer Risk Assessment Tool (www.cancer.gov/bcrisktool)., or 10 yr Tyrer-Cuzick risk twice that of the population risk as listed in model, or RPFNA atypia
* BMI <40 Kg/m3
* A first degree relative with breast cancer under the age of 60 or multiple second degree relatives with breast cancer.
* Multiple prior biopsies or at least one prior biopsy exhibiting atypical hyperplasia (AH), lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS).
* RPFNA evidence of hyperplasia with atypia within the last three years;
* Chest or neck radiation before age 30;
* Mammographic breast density by visual estimate equals or exceeds 50%.
* Subjects must be willing to continue the same hormonal milieu present at baseline throughout trial. If not using an oral, vaginal, or topical contraceptive, must be willing to actively use barrier methods of contraception to prevent pregnancy.
* Six months or more must have elapsed from completion of a prevention intervention trial (with exception of a weight reduction trial), ingestion of a selective estrogen receptor modulator (SERM) or aromatase inhibitor (AI) prior to baseline biomarker assessment.
* Subjects must be willing to undergo measurement of height, weight, and BMI and undergo body composite analysis (DEXA) at initiation and conclusion of intervention.
* Subjects with a history of AH, LCIS, or ER-positive DCIS by diagnostic biopsy, must have been counseled about appropriate standard prevention therapies such as tamoxifen and are either not eligible or are not interested in standard prevention therapies. Women with DCIS must have had appropriate local therapy (lumpectomy plus radiation or mastectomy). If subject has had a DCIS, at least two months must have elapsed from surgery and/or radiation therapy to the involved breast. Only the contralateral (uninvolved breast) will be studied by RPFNA. The subject may not have had any radiation therapy to the contralateral breast to be studied
* Subjects > 40 must have had a screening mammogram within 6 months of entering the interventional portion of the study and read as not suspicious for breast cancer or if suspicious must have completed all suggested tests including biopsy and found to have no evidence of cancer. Subjects of sufficient age and/or risk for a baseline mammogram must be willing to have an off-study mammogram performed 6 months after study entry.
* Subjects must have had an RPFNA of the breast within six months prior to entering the intervention portion of the study and be willing to have another RPFNA at \~6.5 months after starting Lovaza™.
* Tissue Eligibility: Subjects must have cytomorphologic evidence of hyperplasia with atypia or borderline atypia (Masood score 14 or higher). There must be ≥500 epithelial cells on the slide for cytomorphology and evidence of proliferation by Ki-67 staining. There must be sufficient reserved methanol- formalin-fixed material for real time quantitative polymerase chain reaction (RT-qPCR). Frozen tissue must also have been obtained for fatty acid analysis, reverse phase proteomics, adipokines and cytokines, and RT-qPCR.
* Subjects must be willing to undergo phlebotomy at baseline, and 6 months and 6.5 months approximately 3 tablespoons of blood will be obtained at baseline, and 6 months and 6.5 months or 6 tablespoons if the subject decides to participate in the optional monocyte cytokine release assay .
* Subjects must produce a spot urine sample at baseline, 6 months and at study conclusion. Baseline urine sample will in part be used to document that subject is not pregnant.
* Subjects must be willing to complete questionnaires regarding diet and supplement use, quality of life, relevant family history, personal health and reproductive history and medications at initiation and conclusion of the intervention.
* Subjects must be willing to sign an informed consent for the entire study and separate consent for repeat RPFNA

Exclusion Criteria

* Women that have had a metastatic malignancy of any kind.
* Women that have had prior invasive breast cancer, diagnosed or treated within the past five years.
* Women who are currently taking anticoagulants.
* Women who have breast implants.
* Women who have undergone change in their hormonal milieu in the past 6 months this includes pregnancy, lactation, or stopping or starting hormonal contraceptives..
* Women who have taken omega 3 fatty acid supplements within 3 weeks prior to their baseline RPFNA.
* Women who regularly take NSAIDS (>7 tablets weekly).

Inclusion of Women and Minorities

-This study utilizes women at increased risk for breast cancer. Subjects recruited from an established cohort of women followed in the Breast Cancer Prevention Center. From previous trials we can expect 6% minority accrual which is similar to our hospital demographics. Males are not included due to the low absolute risk of breast cancer, and the difficulty of performing RPFNA on the male breast.

Participant flow

Outcome results

• The Proportion of Subjects That Complete an Intervention of Lovaza™ 4 Grams Per Day (Primary), Number, proportion of enrolled participants: Lovaza™ 0.94
• Modulation of the Risk Biomarker Masood Score (Secondary), Median, change in units on a scale: Lovaza™ -1 (-3 to 0) (p <0.001)
• Modulation of Ki-67 Expression (Secondary), Median, Change in percent Ki-67 expression: Lovaza™ -1.45 (-2.55 to 0) (p 0.021)
• Change in (DHA+EPA):AA Ratio for Phospholipids in Plasma. (Secondary), Median, ratio: Lovaza™ 0.61 (0.34 to 0.81) (p <0.001)
• Change in Quality of Life. (Secondary), Median, units on a scale: Lovaza™ 1.0 (-2.25 to 3.0) (p 0.48)

Adverse events

Time frame: duration of intervention, planned at 6 months

Other adverse events by term

• Carol Fabian, MD, Principal investigator, University of Kansas Medical Center