Complementary and alternative medicine and musculoskeletal pain in the first year of adjuvant aromatase inhibitor treatment in early breast cancer patients

Background

Patients with breast cancer (BC) show strong interest in complementary and alternative medicine (CAM), particularly for adverse effects of adjuvant endocrine treatment — e.g., with letrozole. Letrozole often induces myalgia/limb pain and arthralgia, with potential noncompliance and treatment termination. This analysis investigated whether CAM before aromatase inhibitor (AI) therapy is associated with pain development and the intensity of AI-induced musculoskeletal syndrome (AIMSS) during the first year of treatment.

Patients and methods

The multicenter phase IV PreFace study evaluated letrozole therapy in postmenopausal, hormone receptor–positive patients with early BC. Patients were asked about CAM use before, 6 months after, and 12 months after treatment started. They recorded pain every month for 1 year in a diary including questions about pain and numeric pain rating scales. Data were analyzed for patients who provided pain information for all time points.

Results

Of 1396 patients included, 901 (64.5%) had used CAM before AI treatment. Throughout the observation period, patients with CAM before AI treatment had higher pain values, for both myalgia/limb pain and arthralgia, than non-users. Pain increased significantly in both groups over time, with the largest increase during the first 6 months. No significant difference of pain increase was noted regarding CAM use.

Conclusions

CAM use does not prevent or improve the development of AIMSS. Pain intensity was generally greater in the CAM group. Therefore, because of the risk of non-compliance and treatment discontinuation due to the development of higher pain levels, special attention must be paid to patient education and aftercare in these patients.

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Pain levels of myalgia/limb pain and arthralgia increase under letrozole intake.

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Within one year pain levels increase in both, CAM users as well as non-CAM users.

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In CAM users pain levels were higher at all time points than in non-CAM users.

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The greatest increase of pain levels was noted in the first six treatment months.

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CAM does not prevent or improve the development of myalgia/limb pain and arthralgia.

Influence of patient and tumor characteristics on early therapy persistence with letrozole in postmenopausal women with early breast cancer: results of the prospective Evaluate-TM study with 3941 patients

Background

Patients' compliance and persistence with endocrine treatment has a significant effect on the prognosis in early breast cancer (EBC). The purpose of this analysis was to identify possible reasons for non-persistence, defined as premature cessation of therapy, on the basis of patient and tumor characteristics in individuals receiving adjuvant treatment with letrozole.

Patients and methods

The EvAluate-TM study is a prospective, multicenter, noninterventional study in which treatment with the aromatase inhibitor letrozole was evaluated in postmenopausal women with hormone receptor-positive EBC in the early therapy phase. Treatment persistence was evaluated at two pre-specified study visits after 6 and 12 months. As a measure of early therapy persistence the time from the start to the end of treatment (TTEOT) was analyzed. Cox regression analyses were carried out to identify patient characteristics and tumor characteristics predicting TTEOT.

Results

Out of the total population of 3941 patients with EBC, 540 (13.7%) events involving treatment cessation unrelated to disease progression were observed. This was due to drug-related toxicity in the majority of cases (73.5%). Persistence rates were 92.2%, 86.9%, and 86.3% after 6, 12, and 15 months, respectively. The main factors influencing premature treatment discontinuation were older age [hazard ratio (HR) 1.02/year], comorbidities (HR 1.06 per comorbidity), low body mass index, and lower tumor grade (HR 0.85 per grade unit).

Conclusion

These results support the view that older, multimorbid patients with low tumor grade and low body mass index are at the greatest risk for treatment discontinuation and might benefit from compliance and support programs.

Comparison of Sacral-Alar-Iliac and Iliac-Only Methods of Pelvic Fixation in Early-Onset Scoliosis at 5.8 Years' Mean Follow-up

STUDY DESIGN

Retrospective.

OBJECTIVE

Compare clinical outcomes in early-onset scoliosis (EOS) patients treated with sacral-alar-iliac (SAI) versus iliac-only methods of pelvic fixation at two years' minimum follow-up.

SUMMARY OF BACKGROUND DATA

Pelvic fixation in EOS is challenged by poor bone, anchor migration, and displacement. The long-term outcomes of SAI fixation in EOS is unknown.

METHODS

We retrospectively reviewed EOS patients in a single center from 2000 to 2017. Inclusion criteria were posterior spinal instrumentation with pelvic fixation before age 10 and 2 years' minimum follow-up. Clinical and radiographic data were analyzed using chi-squared and Student t tests (significance defined as p <.05).

RESULTS

Seven subjects were included in the iliac-only fixation group (Galveston technique = 2, iliac screws = 5) and 17 in the SAI group. For the iliac-only group (mean follow-up = 6.8 years), pelvic obliquity improved from a mean of 18° at initial presentation to 11° at first instrumentation (p = .096), to 9° at end follow-up (p = .060), whereas the major curve improved correspondingly from a mean of 84° to 50° (p = .002) to 39° (p = .006). For the SAI group (mean follow-up = 5.5 years) at the same time points, pelvic obliquity improved from a mean of 25° to 6° (p <.001) to 5° (p <.001), whereas the major curve improved from a mean of 83° to 38° (p <.001) to 29° (p <.001). SAI fixation was associated with fewer complications (11 complications in 17 patients) compared to iliac-only fixation (10 complications in 7 patients) (p = .04). Neither method was associated with pelvic growth disturbances or neurologic deficits.

CONCLUSIONS

In EOS patients at 2 years' minimum (5.8 years' mean) follow-up, both SAI and iliac-only methods corrected major curve, only SAI fixation corrected pelvic obliquity, and neither was associated with pelvic growth disturbances. SAI fixation was also associated with fewer complications. These findings may be due to the length and direction of the SAI anchors and abutment on the iliac cortex.

LEVEL OF EVIDENCE

Level III.

Influence of side-effects on early therapy persistence with letrozole in post-menopausal patients with early breast cancer: Results of the prospective EvAluate-TM study

BACKGROUND

Endocrine treatment (ET) with an aromatase inhibitor (AI) is the treatment of choice in post-menopausal patients with hormone receptor-positive early breast cancer (EBC). However, adverse events (AEs) often lead to treatment discontinuation. This analysis aimed to identify side-effects that lead to patients failing to persist with letrozole treatment.

PATIENTS AND METHODS

Post-menopausal hormone receptor-positive EBC patients starting ET with letrozole were enroled in EvAluate-TM, a non-interventional study. Information regarding treatment compliance and persistence was gathered in months 6 and 12. Persistence was defined as the time from 30 d after the start to the end of treatment. The influence on persistence of musculoskeletal syndrome, menopausal disorder, sleep disorder and other AEs within the first 30 d was analysed using Cox regression analyses.

RESULTS

Among 3887 patients analysed, the persistence rate after 12 months was >85%. In all, 568 patients (14.6%) discontinued the treatment, 358 of whom (63.0%) did so only because of side-effects. The main AEs influencing persistence were musculoskeletal symptoms (hazard ratio [HR] 2.55; 95% confidence interval [CI], 1.90-3.42), sleep disorders (HR 1.95; 95% CI, 1.41-2.70) and other AEs (HR 2.03; 95% CI, 1.51-2.73). Menopausal disorder was not associated with non-persistence (HR 1.17; 95% CI, 0.74-1.84).

CONCLUSIONS

These results suggest that side-effects of AIs such as musculoskeletal syndrome and sleep disorder lead to ET discontinuation within the first treatment year in significant numbers of EBC patients. Compliance programmes adapted for subgroups that are at risk for early non-persistence might help to ensure the recommended therapy duration.

CLINICAL TRIALS NUMBER

CFEM345DDE19.

A Review of Integrative Medicine in Gynaecological Oncology

In recent years complementary and alternative medicine (CAM) has increasingly been the focus of international research. Numerous subsidised trials (7903) and systematic reviews (651) have been published, and the evidence is starting to be integrated into treatment guidelines. However, due to insufficient evidence and/or insufficient good quality evidence, this has mostly not translated to practice recommendations in reviews by the Cochrane collaboration gynaecology group. There is nevertheless a not insignificant number of CAM providers and users. The percentage of oncology patients who use CAM varies between 5 and 90 %. Doctors have been identified as the main providers of CAM. Half of gynaecologists offer CAM because of personal conviction or on suggestion from colleagues. This must be viewed in a critical light, since CAM is mostly practiced without appropriate training, often without sufficient evidence for a given method - and where evidence exists, practice guidelines are lacking - and lack of safety or efficacy testing. The combination of patient demand and lucrativeness for doctors/alternative medicine practitioners, both based on supposed effectiveness CAM, often leads to its indiscriminate use with uncertain outcomes and significant cost for patients. On the other hand there is published, positive level I evidence for a number of CAM treatment forms. The aim of this article is therefore to review the available evidence for CAM in gynaecological oncology practice. The continued need for research is highlighted, as is the need to integrate practices supported by good evidence into conventional gynaecological oncology.

Evaluation of Therapy Management and Patient Compliance in Postmenopausal Patients with Hormone Receptor-positive Breast Cancer Receiving Letrozole Treatment: The EvaluateTM Study

Introduction: The EvaluateTM study (Evaluation of therapy management and patient compliance in postmenopausal hormone receptor-positive breast cancer patients receiving letrozole treatment) is a prospective, non-interventional study for the assessment of therapy management and compliance in the routine care of postmenopausal women with invasive hormone receptor-positive breast cancer receiving letrozole. The parameters for inclusion in the study are presented and discussed here. Material and Methods: Between January 2008 and December 2009 a total of 5045 patients in 310 study centers were recruited to the EvaluateTM study. Inclusion criteria were hormone receptor-positive breast cancer and adjuvant treatment or metastasis. 373 patients were excluded from the analysis for various reasons. Results: A total of 4420 patients receiving adjuvant treatment and 252 patients with metastasis receiving palliative treatment were included in the study. For 4181 patients receiving adjuvant treatment, treatment with the aromatase inhibitor letrozole commenced immediately after surgery (upfront). Two hundred patients had initially received tamoxifen and started aromatase inhibitor treatment with letrozole at 1-5 years after diagnosis (switch), und 39 patients only commenced letrozole treatment 5-10 years after diagnosis (extended endocrine therapy). Patient and tumor characteristics were within expected ranges, as were comorbidities and concurrent medication. Conclusion: The data from the EvaluateTM study will offer a good overview of therapy management in the routine care of postmenopausal women with hormone receptor-positive breast cancer. Planned analyses will look at therapy compliance and patient satisfaction with how information is conveyed and the contents of the conveyed information.

Abstract P5-21-02: Hormone receptor status and endocrine therapy in a prospective observation study on trastuzumab (Herceptin®) in the adjuvant treatment of breast cancer

Background: Based on the findings from large randomized studies, Trastuzumab (T) was registered in 2006 for the treatment of early stage, HER2+ breast cancer (BC), after surgery, (neo)adjuvant chemotherapy (CT) and/or radiotherapy. However, limited systematic evidence is available on preceding, concomitant or sequential endocrine treatment (ET) based on the hormone receptor (HR) status. This large prospective observation study, reflecting the unrestricted routine practice of HER2 antibody treatment in Germany, allows to examine this topic.

Methods: At present, more than 4000 patients (pts) have been enrolled in this ongoing study; 3446 pts from more than 316 centres were already sufficiently documented to be analysed. Details on concomitant treatment was collected at baseline and for 12 months after start of T.

Results: With respect to an overall HR positivity (HR+), i.e. estrogen and/or progesterone receptor (ER, PR) being positive, of 2181/3446 (63%), these HER2+ pts do not differ from the general BC population. Both hormone receptor types are positive in 47%, while ER+ only or PR+ only was detected in 13% and 3%, respectively. Adjuvant ET of any type, starting before or during T treatment, was given in 87% of HR+ and in 3% of HR- pts. 6% of HR+ pts received T and ET without concomitant CT. Details on the adjuvant treatment options are provided in the table:

Cycle control, tolerability, efficacy and acceptability of the vaginal contraceptive ring, NuvaRing®: Results of clinical experience in Germany

OBJECTIVES

To investigate the real-life clinical experience of NuvaRing users in Germany.

METHODS

An open-label, prospective, uncontrolled, non-randomized, multicentre postmarketing surveillance study was conducted by 1204 gynaecologists amongst 5823 women requesting contraception. The women underwent routine examinations and contraceptive counselling, and were assessed after three and six cycles of NuvaRing use.

RESULTS

Good cycle control was observed and there was a reduction in cycle irregularity and inter-menstrual bleeding, bleeding duration and intensity, and dysmenorrhoea. NuvaRing was well tolerated, and had no significant effect on body weight or blood pressure. Nine women became pregnant unintentionally (two had conceived before they started to use NuvaRing, three due to non-compliance, one because of repeated ring expulsion/loss and three during treatment in spite of having applied this latter as instructed). Most women expressed their satisfaction with NuvaRing; 82% were 'very satisfied/ satisfied', 72% planned to continue using it and 82% would recommend it to others. More than 90% of women found NuvaRing 'without problems/easy' to insert and to remove, and more than 80% of the women and their partners were not disturbed by its presence during intercourse.

CONCLUSION

NuvaRing is a highly effective and acceptable method of once-monthly contraception that is safe and well tolerated.

Measurement of induced acrosome reactions in human sperm using physiologic stimuli - relevance for the prediction of fertilization outcome

Fertilization failure following standard in vitro fertilization in couples with normozoospermic men is an as yet unexplained phenomenon. A wide range of gametic disorders as well as environmental factors might contribute to this pathologic condition. One crucial condition appears to be the inability of the spermatozoa to undergo the acrosome reaction (AR). A discriminative test to distinguish fertile from non-fertile spermatozoa would be of utmost interest. In a prospective study, semen samples from men with normal semen parameters and fertilization failure were compared with semen samples from men with normal semen parameters and normal fertilization as to their capacity to undergo the AR. AR was induced using calcium ionophore as well as the physiologic stimuli progesterone and prostaglandin E(1). Discriminance analyses were undertaken to help identify patients with probable fertilization failure. Our data show that in patients with fertilization failure, the capacity of spermatozoa to undergo induced AR is greatly reduced using both unphysiologic and physiologic stimuli. However, physiologic stimuli are more suitable to identify patients with fertilization failure. Using physiologic stimuli, a formula was established to identify patients likely to fail at fertilization.

Cytogenetic analysis of giant oocytes and zygotes to assess their relevance for the development of digynic triploidy

BACKGROUND

In order to assess the role of binucleate giant oocytes for generating digynic triploidy, we studied their frequency, maturation patterns and chromosomal complements at metaphase II (MII) or after fertilization.

METHODS

Uncleaved, giant zygotes were incubated with podophyllotoxin and vinblastine, treated with hypotonic solution and fixed by a gradual fixation method. Giant MII oocytes were directly subjected to hypotonic treatment. The chromosomes were stained with Giemsa.

RESULTS

A total of 7065 oocytes were collected during the study period, of which 18 (0.26%) were classified as giant cells. When considering only those patients in whom giant cells were identified (among other normal sized cells) a giant cell frequency of 18/237 (7.6%) was found. Nine cells underwent a union of the nuclei during maturation to MII and four of them became fertilized showing two pronuclei. Seven oocytes maintained the binucleate state to MII and one of them was fertilized showing three pronuclei. Ten unfertilized cells were available for cytogenetic analysis and proved to be diploid. All five giant zygotes revealed triploidy.

CONCLUSIONS

The data suggest that giant oocytes may play an important, yet underestimated role in causing digynic triploidy. We recommend the exclusion of giant oocytes from IVF trials and that giant cells should be discarded, even if they carry the regular number of two pronuclei.

Sperm acrosome antigen-1. Specific tissue distribution of immunoreactivity in a teleost fish, the swordtail ( Xiphophorus helleri)

The acrosome reaction is a fundamental requirement for mammalian fertilization. Its exact molecular mechanisms and cellular elements are still poorly understood. We have detected an acrosomal sperm antigen, SAA-1, by monoclonal antibodies directed against SAA-1, that appears to be critically involved in the regulation of the acrosome reaction. SAA-1 is conserved within a broad range of mammalian species, emphasizing its important role in mammalian reproduction. Here we demonstrate that SAA-1 is immunohistochemically detectable in a nonmammalian vertebrate whose sperm do not possess an acrosome. In the swordtail, a live-bearing teleost with special reproductive tactics, we were able to demonstrate immunoreactivity of sperm heads of spermatids and mature sperm in the testis using monoclonal antibodies against SAA-1. Due to the cystic spermatogenesis with synchronous sperm maturation, immunoreactive maturational stages could be clearly identified. Stored immunoreactive sperm were also identified in spermathecal tissue of the female genital tract. Interestingly, immunoreactivity was furthermore detected in defined cells of the compounded endocrine organs pituitary and endocrine pancreas. All these different cell systems are involved in paracrine regulation and exhibit exocytotic properties. The possible nature of SAA-1 is discussed. Additionally, some new aspects of the morphologic composition of the swordtail pituitary are described.

Cytogenetic analysis of human zygotes displaying three pronuclei and one polar body after intracytoplasmic sperm injection

BACKGROUND

Digynic zygotes with three pronuclei and one polar body obtained after intracytoplasmic sperm injection (ICSI) were studied cytogenetically to elucidate the frequency and origin of chromosomal abnormalities at the earliest stage of conception.

METHODS

Uncleaved, single-cell zygotes were incubated with podophyllotoxin and vinblastine and fixed by a gradual fixation air drying method. The chromosomes were stained with Giemsa.

RESULTS

Twenty-two (50%) out of 44 informative zygotes revealed cytogenetic alterations, including aneuploidy (six cells, 13.6%), structural aberrations (10 cells, 22.7%) and combinations of numerical and structural abnormalities (two cells, 4.5%). In one case (2.3%), double aneuploidy or an effect of chromosomal translocation could not be distinguished and one zygote (2.3%) turned out tetraploid due to injection of a diploid spermatozoon. Two zygotes (4.5%) showed an irregular chromatid segregation between the two maternal complements. In completely analysable cells, the sex chromosome ratio XXX:XXY was 17:15.

CONCLUSIONS

Digynic ICSI zygotes carry a high rate of cytogenetic abnormalities that obviously have been transmitted by the participating oocytes and spermatozoa. We also confirmed the previously reported, possibly ICSI-induced irregular oocyte chromatid segregation. The results suggest that aneuploidy in the oocytes must have been caused by predivision instead of non-disjunction.

[Vaginal bleeding and premature contractions during pregnancy in uterus bicornis with expulsion of a decidual polyp]

Diagnosis and clinical course of a rare case are described, and the importance of prenatal ultrasound diagnostic is discussed.

Controlled trial with a monthly combination injectable contraceptive in Europe

In a controlled, multicenter trial conducted in Europe, the safety and efficacy of a monthly injectable combination hormone contraceptive were found to be comparable to those of an oral contraceptive. There were no contraceptive failures in either arm of the trial. The incidence and types of side-effects were similar. The rates of patient satisfaction in the monthly injectable and oral contraceptive arms of the study were also comparable; both exceeded 90%. The results from the European study are consistent with clinical trials conducted elsewhere and support the conclusion that the monthly combination injectable contraceptive represents a desirable new birth control method. Data from the 24-week interim analyses are presented.