Increasing the dose intensity of chemotherapy by more frequent administration or sequential scheduling: a patient-level meta-analysis of 37 298 women with early breast cancer in 26 randomised trials

Background Increasing the dose intensity of cytotoxic therapy by shortening the intervals between cycles, or by giving individual drugs sequentially at full dose rather than in lower-dose concurrent treatment schedules, might enhance efficacy. Methods To clarify the relative benefits and risks of dose-intense and standard-schedule chemotherapy in early breast cancer, we did an individual patient-level meta-analysis of trials comparing 2-weekly versus standard 3-weekly schedules, and of trials comparing sequential versus concurrent administration of anthracycline and taxane chemotherapy. The primary outcomes were recurrence and breast cancer mortality. Standard intention-to-treat log-rank analyses, stratified by age, nodal status, and trial, yielded dose-intense versus standard-schedule first-event rate ratios (RRs). Findings Individual patient data were provided for 26 of 33 relevant trials identified, comprising 37 298 (93%) of 40 070 women randomised. Most women were aged younger than 70 years and had node-positive disease. Total cytotoxic drug usage was broadly comparable in the two treatment arms; colony-stimulating factor was generally used in the more dose-intense arm. Combining data from all 26 trials, fewer breast cancer recurrences were seen with dose-intense than with standard-schedule chemotherapy (10-year recurrence risk 28·0% vs 31·4%; RR 0·86, 95% CI 0·82–0·89; p<0·0001). 10-year breast cancer mortality was similarly reduced (18·9% vs 21·3%; RR 0·87, 95% CI 0·83–0·92; p<0·0001), as was all-cause mortality (22·1% vs 24·8%; RR 0·87, 95% CI 0·83–0·91; p<0·0001). Death without recurrence was, if anything, lower with dose-intense than with standard-schedule chemotherapy (10-year risk 4·1% vs 4·6%; RR 0·88, 95% CI 0·78–0·99; p=0·034). Recurrence reductions were similar in the seven trials (n=10 004) that compared 2-weekly chemotherapy with the same chemotherapy given 3-weekly (10-year risk 24·0% vs 28·3%; RR 0·83, 95% CI 0·76–0·91; p<0·0001), in the six trials (n=11 028) of sequential versus concurrent anthracycline plus taxane chemotherapy (28·1% vs 31·3%; RR 0·87, 95% CI 0·80–0·94; p=0·0006), and in the six trials (n=6532) testing both shorter intervals and sequential administration (30·4% vs 35·0%; RR 0·82, 95% CI 0·74–0·90; p<0·0001). The proportional reductions in recurrence with dose-intense chemotherapy were similar and highly significant (p<0·0001) in oestrogen receptor (ER)-positive and ER-negative disease and did not differ significantly by other patient or tumour characteristics. Interpretation Increasing the dose intensity of adjuvant chemotherapy by shortening the interval between treatment cycles, or by giving individual drugs sequentially rather than giving the same drugs concurrently, moderately reduces the 10-year risk of recurrence and death from breast cancer without increasing mortality from other causes. Funding Cancer Research UK, Medical Research Council

20-Year Risks of Breast-Cancer Recurrence after Stopping Endocrine Therapy at 5 Years

The administration of endocrine therapy for 5 years substantially reduces recurrence rates during and after treatment in women with early-stage, estrogen-receptor (ER)-positive breast cancer. Extending such therapy beyond 5 years offers further protection but has additional side effects. Obtaining data on the absolute risk of subsequent distant recurrence if therapy stops at 5 years could help determine whether to extend treatment

Long-term outcomes for neoadjuvant versus adjuvant chemotherapy in early breast cancer: meta-analysis of individual patient data from ten randomised trials

Background Neoadjuvant chemotherapy (NACT) for early breast cancer can make breast-conserving surgery more feasible and might be more likely to eradicate micrometastatic disease than might the same chemotherapy given after surgery. We investigated the long-term benefits and risks of NACT and the influence of tumour characteristics on outcome with a collaborative meta-analysis of individual patient data from relevant randomised trials. Methods We obtained information about prerandomisation tumour characteristics, clinical tumour response, surgery, recurrence, and mortality for 4756 women in ten randomised trials in early breast cancer that began before 2005 and compared NACT with the same chemotherapy given postoperatively. Primary outcomes were tumour response, extent of local therapy, local and distant recurrence, breast cancer death, and overall mortality. Analyses by intention-to-treat used standard regression (for response and frequency of breast-conserving therapy) and log-rank methods (for recurrence and mortality). Findings Patients entered the trials from 1983 to 2002 and median follow-up was 9 years (IQR 5–14), with the last follow-up in 2013. Most chemotherapy was anthracycline based (3838 [81%] of 4756 women). More than two thirds (1349 [69%] of 1947) of women allocated NACT had a complete or partial clinical response. Patients allocated NACT had an increased frequency of breast-conserving therapy (1504 [65%] of 2320 treated with NACT vs 1135 [49%] of 2318 treated with adjuvant chemotherapy). NACT was associated with more frequent local recurrence than was adjuvant chemotherapy: the 15 year local recurrence was 21·4% for NACT versus 15·9% for adjuvant chemotherapy (5·5% increase [95% CI 2·4–8·6]; rate ratio 1·37 [95% CI 1·17–1·61]; p=0·0001). No significant difference between NACT and adjuvant chemotherapy was noted for distant recurrence (15 year risk 38·2% for NACT vs 38·0% for adjuvant chemotherapy; rate ratio 1·02 [95% CI 0·92–1·14]; p=0·66), breast cancer mortality (34·4% vs 33·7%; 1·06 [0·95–1·18]; p=0·31), or death from any cause (40·9% vs 41·2%; 1·04 [0·94–1·15]; p=0·45). Interpretation Tumours downsized by NACT might have higher local recurrence after breast-conserving therapy than might tumours of the same dimensions in women who have not received NACT. Strategies to mitigate the increased local recurrence after breast-conserving therapy in tumours downsized by NACT should be considered—eg, careful tumour localisation, detailed pathological assessment, and appropriate radiotherapy

Context-sensitive analysis of obfuscated x86 executables

A method for context-sensitive analysis of binaries that may have obfuscated procedure call and return operations is presented. Such binaries may use operators to directly manipulate stack instead of using native call and ret instructions to achieve equivalent behavior. Since definition of context-sensitivity and algorithms for contextsensitive analysis have thus far been based on the specific semantics associated to procedure call and return operations, classic interprocedural analyses cannot be used reliably for analyzing programs in which these operations cannot be discerned. A new notion of context-sensitivity is introduced that is based on the state of the stack at any instruction. While changes in ‘calling’-context are associated with transfer of control, and hence can be reasoned in terms of paths in an interprocedural control flow graph (ICFG), the same is not true of changes in ‘stack’-context. An abstract interpretation based framework is developed to reason about stackcontexts and to derive analogues of call-strings based methods for the context-sensitive analysis using stack-context. The method presented is used to create a context-sensitive version of Venable et al.’s algorithm for detecting obfuscated calls. Experimental results show that the context-sensitive version of the algorithm generates more precise results and is also computationally more efficient than its context-insensitive counterpart

Context-sensitive analysis without calling-context

Since Sharir and Pnueli, algorithms for context-sensitivity have been defined in terms of 'valid' paths in an interprocedural flow graph. The definition of valid paths requires atomic call and ret statements, and encapsulated procedures. Thus, the resulting algorithms are not directly applicable when behavior similar to call and ret instructions may be realized using non-atomic statements, or when procedures do not have rigid boundaries, such as with programs in low level languages like assembly or RTL. We present a framework for context-sensitive analysis that requires neither atomic call and ret instructions, nor encapsulated procedures. The framework presented decouples the transfer of control semantics and the context manipulation semantics of statements. A new definition of context-sensitivity, called stack contexts, is developed. A stack context, which is defined using trace semantics, is more general than Sharir and Pnueli's interprocedural path based calling-context. An abstract interpretation based framework is developed to reason about stack-contexts and to derive analogues of calling-context based algorithms using stack-context. The framework presented is suitable for deriving algorithms for analyzing binary programs, such as malware, that employ obfuscations with the deliberate intent of defeating automated analysis. The framework is used to create a context-sensitive version of Venable et al.'s algorithm for analyzing x86 binaries without requiring that a binary conforms to a standard compilation model for maintaining procedures, calls, and returns. Experimental results show that a context-sensitive analysis using stack-context performs just as well for programs where the use of Sharir and Pnueli's calling-context produces correct approximations. However, if those programs are transformed to use call obfuscations, a contextsensitive analysis using stack-context still provides the same, correct results and without any additional overhead. © Springer Science+Business Media, LLC 2011

A tight bound for exhaustive key search attacks against Message Authentication Codes

A Message Authentication Code (MAC) is a function that takes a message and a key as parameters and outputs an authentication of the message. MAC are used to guarantee the legitimacy of messages exchanged through a network, since generating a correct authentication requires the knowledge of the key defined secretly by trusted parties. However, an attacker with access to a sufficiently large number of message/authentication pairs may use a brute force algorithm to infer the secret key: from a set containing initially all possible key candidates, subsequently remove those that yield an incorrect authentication, proceeding this way for each intercepted message/authentication pair until a single key remains. In this paper, we determine an exact formula for the expected number of message/authentication pairs that must be used before such form of attack is successful, along with an asymptotical bound that is both simple and tight. We conclude by illustrating a modern application where this bound comes in handy, namely the estimation of security levels in reflection-based verification of software integrity