Intermittent fasting and its impact on toxicities, symptoms and quality of life in patients on active cancer treatment

Intermittent fasting is a dietary intervention that is increasingly being tested for positive outcomes in patients receiving cancer treatment. In this review, we examine the impact of intermittent fasting on symptoms, toxicities, and quality of life in patients undergoing cancer therapy and highlight unmet investigative areas to prompt future research. While current evidence is preliminary and conclusions mixed, some promising clinical studies suggest that intermittent fasting interventions may improve fatigue and reduce gastrointestinal toxicities in certain patients with cancer. Emerging clinical evidence also demonstrates that intermittent fasting may reduce off-target DNA damage, and induce favorable cellular-level immune remodeling. Furthermore, intermittent fasting has the potential to lower hyperglycemia and the ratio of fat to lean body mass, which may benefit patients at risk of hyperglycemia and weight-related adverse effects of some common pharmacological cancer treatments. Larger controlled studies are necessary to evaluate intermittent fasting in relation to these endpoints and determine the effectiveness of intermittent fasting as an adjunct intervention during cancer care. Future cancer trials should evaluate intermittent fasting diets in the context of multimodal diet, exercise, and nutrition strategies, and also evaluate the impact of intermittent fasting on other important areas such as the circadian system and the gut microbiome.

Abstract 1997: Health-related quality of life at diagnosis in survivors of adolescent and young adult cancer

Purpose: Data are lacking on the distribution, factors associated with, and long-term impact of diminished health-related quality of life (HRQoL) at diagnosis in adolescent and young adult (AYA) cancer survivors (≥2 years post cancer diagnosis). Our goal was to fill this gap in knowledge.

Methods: A cohort of AYA (15y - 39y) cancer patients treated at MD Anderson between 2000-2016 who had survived at least 2 y was identified from our Institutional Tumor Registry. HRQoL was assessed at diagnosis with the SF12v1 questionnaire. Demographic and behavioral risk factors, tumor type, and vital status were ascertained. Physical composite summary (PCS) and mental composite summary (MCS) scores were generated from SF12 responses following mean-based normalization; PCS or MCS < 50 indicated “poor” HRQoL. Statistical tests included ANOVA, quantile regression, and multivariable Cox proportional hazards.

Results: 2,609 AYA cancer survivors (75% diagnosed between age of 26-39 y; 67% White, 18% Hispanic and 9% Black) were included. Breast cancer was the most frequent diagnosis (25%), followed by sarcoma (12%) and Hodgkin lymphoma (10%). Median follow-up for participants was 10.5 y. Overall mean PCS and MCS scores at diagnosis were 45.3 (SD: 11.4) and 47.0 (SD: 10.5), respectively. Female AYA cancer patients had significantly higher PCS, yet lower MCS compared to their male counterparts (both P<0.001). A positive association between age at diagnosis and PCS was observed (P<0.001), in contrast to the inverse association with MCS (P<0.001). Differences in PCS (P<0.001) and MCS (P=0.001) were also evident by tumor type. For example, women with breast cancer reported the most favorable PCS (51.5) at diagnosis, yet among the lowest MCS (46.1) of the nine tumor types analyzed. The Black AYA population had a larger burden of poor PCS at diagnosis with 61% of patients reporting scores <50 compared to 55% of Hispanic and 51% of non-Hispanic whites. Significant predictors of diminished PCS in AYA cancer survivors in the bottom 25% of PCS scores were younger age at diagnosis (P=0.003), male gender (P<0.001), diagnosis of a hematologic malignancy versus solid tumor (P<0.001), smoking (P=0.003) and not consuming any alcohol currently (P<0.001). Overall, low PCS (<50) at diagnosis (HR=1.57, P<0.001), and diagnosis of a solid tumor compared to a hematologic malignancy (HR=2.33, P<0.001) were associated with lower survival.

Conclusions: In this large, diverse AYA cancer survivor cohort, physical and mental HRQoL at diagnosis were impacted by AYA’s age at diagnosis, gender, tumor type, and smoking status. Low PCS at diagnosis was an independent predictor of diminished survival among AYA cancer survivors ≥2y post diagnosis. Our findings suggest that patient-reported poor physical well-being at diagnosis is a biomarker of poor prognosis for AYA cancers. Further studies are needed to identify interventions to improve outcomes for this population.

Citation Format: Goldy C. George, Clark R. Andersen, Xiaohui Tang, John A. Livingston, Michael E. Roth, Michelle A. Hildebrandt. Health-related quality of life at diagnosis in survivors of adolescent and young adult cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1997.

Patient-Reported Out-of-Pocket Costs and Financial Toxicity During Early-Phase Oncology Clinical Trials

BACKGROUND

Clinical trials are an important therapeutic option for patients with cancer. Although financial burden in cancer treatment is well documented, the financial burden associated with clinical trials is not well understood.

PATIENTS AND METHODS

We conducted a survey regarding economic burden and financial toxicity in patients with cancer enrolled in phase I clinical trials for >1 month. Financial toxicity score was assessed using the Comprehensive Score for Financial Toxicity survey. Patients also reported monthly out-of-pocket (OOP) costs.

RESULTS

Two hundred and thirteen patients completed the survey (72% non-Hispanic White; 45% with annual income ≤$60,000; 50% lived >300 miles from the clinic; 37% required air travel). Forty-eight percent of patients had monthly OOP costs of at least $1,000. Fifty-five percent and 64% of patients reported unanticipated medical and nonmedical expenses, respectively. Worse financial toxicity was associated with yearly household income <$60,000 (odds ratio [OR]: 2.7; p = .008), having unanticipated medical costs (OR: 3.2; p = .024), and living >100 miles away from the clinical trial hospital (OR: 2.3; p = .043). Non-White or Hispanic patients (OR: 2.5; p = .011) and patients who were unemployed or not working outside the home (OR: 2.5; p = .016) were more likely to report high unanticipated medical costs.

CONCLUSION

Among patients with cancer participating in clinical trials, economic burden is high, and most of patients' OOP costs were nonmedical costs. Financial toxicity is disproportionally higher in patients with lower income and those who travel farther, and unexpected medical costs were more common among non-White or Hispanic patients. OOP costs can be substantial and are often unexpected for patients.

IMPLICATIONS FOR PRACTICE

The financial burden of cancer treatment is well documented, but there are limited data regarding the financial burden associated with cancer clinical trials. This study surveyed 213 patients enrolled in early-phase clinical trials. Monthly out-of-pocket costs were at least $1000 for nearly half of patients. Worse financial toxicity was associated with income <$60,000 and living farther away from the hospital. Racial/ethnic minorities had higher rates of unanticipated medical costs. These data help to quantify the high financial burden for patients and may reveal a cause of disparities in clinical trial enrollment for underrepresented populations.

Abstract PO-208: Patient-reported out-of-pocket costs and financial toxicity during early- phase oncology clinical trials

Background Clinical trials are an important therapeutic option for cancer patients (pts). Although financial burden in cancer treatment is well-documented, the financial burden associated with clinical trials is not well understood, especially for pts with lower income. Methods We conducted a survey regarding economic burden and financial toxicity in cancer pts who had been on Phase I clinical trials for ≥1 month. Financial Toxicity Score (FTS) was assessed using the validated COmprehensive Score for Financial Toxicity (COST) survey (scale 0-44, lower scores indicate worse toxicity). Pts also reported monthly out-of-pocket (OOP) medical and non-medical expenses. We applied multivariable logistic regression to analyze risk of financial toxicity, and unanticipated expenses. Results Early-phase clinical trial pts (N=213, median age = 59y; 59% female; 74% White, 45% w/ annual income ≤$60K; 54% had employer sponsored insurance; 37% had Medicare; 50% lived &gt;300 miles from the clinic; 37% required air travel) had a median FTS of 20, with interquartile range of 12. Median monthly OOP costs for non-medical expenses was $1075, and for medical expenses was $475. Median total monthly OOP costs was $1750. 55% and 64% of pts reported that actual medical and non-medical expenses were higher than expected, respectively. Worse financial toxicity (≤ median FTS) in pts was associated with yearly household income &lt;$60K (OR: 2.7, P=0.008), having medical costs higher than expected (OR: 3.2, P=0.024), participation on ≥1 Phase I clinical trial prior to their current trial (OR: 2.2, P=0.028), and living &gt;100 miles away from the clinical trials hospital (OR: 2.3, P=0.043). 29% of pts received partial/full reimbursement of clinical trial-related travel costs from study sponsor/other/insurance. Racial/ethnic minority (OR: 2.6, P=0.008) and pts who were unemployed or not working outside the home (OR: 2.4, P=0.023) were more likely to report that actual medical costs were much higher than expected. 53% of pts used savings and 19% borrowed money from friends/family or had a personal fundraiser to pay for treatment. Conclusions Among cancer pts participating on clinical trials, economic burden is high, and most of pts’ OOP costs were on non- medical expenses. Financial toxicity is disproportionally higher in pts with lower income and those who travel farther, and unexpected medical costs were more common among minorities. OOP costs can be substantial and are often unexpected for pts. Future work should focus on methods to reduce disparities in clinical trial participation, including the role of reimbursement of trial-related expenses.

Citation Format: Ryan W. Huey, Goldy C. George, Penny Phillips, Revenda White, Filip Janku, Daniel D. Karp, Aung Naing, Sarina Piha-Paul, Vivek Subbiah, Apostolia M. Tsimberidou, Shubham Pant, Timothy A. Yap, Jordi Rodon, Funda Meric-Bernstam, Ya-Chen Tina Shih, David S. Hong. Patient-reported out-of-pocket costs and financial toxicity during early- phase oncology clinical trials [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-208.

Cancer-Related Internet Use and Online Social Networking Among Patients in an Early-Phase Clinical Trials Clinic at a Comprehensive Cancer Center

PURPOSE

We examined patterns, correlates, and the impact of cancer-related Internet use among patients with advanced cancer in a phase I clinical trials clinic for molecularly targeted oncologic agents.

METHODS

An anonymous questionnaire on Internet use for cancer-related purposes that incorporated input from phase I clinical trial oncologists and patients was self-administered by patients age ≥ 18 years in a phase I clinic. Multivariable modeling was used. Data were analyzed for the overall sample and by generation, which was defined by year of birth.

RESULTS

Of 291 patients (52% women, 82% non-Hispanic white, 50% age ≤ 60 years), 62% were cancer-related Internet users (CIUs). Cancer-related Internet use was associated with an income of ≥ $60,000 (odds ratio, 2.42; P = .004). CIUs used the Internet to learn about their cancer (85%), treatment adverse effects (65%), clinical trials (52%), new alternative treatments (42%), and symptom management (41%). CIUs most frequently used the hospital Web site (70%) to learn about clinical trials, followed by ClinicalTrials.gov (42%) and search engines (41%). The emotional impact of Internet-derived cancer information on CIUs varied-56% felt empowered, 34% anxious, 29% relieved, and 17% confused. Cancer-related Internet information made 51% of patients from the Millennial (born after 1990) and Generation X/Y (born 1965 to 1990) CIU populations anxious compared with < 29% of CIUs from older generations (born 1964 and before). Most CIUs desired more online information about new experimental drugs (91%) and US Food and Drug Administration-approved drugs for cancer (72%).

CONCLUSION

As most phase I patients use the Internet for cancer-related purposes, the Internet overall and hospital Web sites should provide more extensive, pertinent, and helpful information on clinical trials and cancer treatment to phase I patients.

Cancer-Related Internet Use and Its Association With Patient Decision Making and Trust in Physicians Among Patients in an Early Drug Development Clinic: A Questionnaire-Based Cross-Sectional Observational Study

Background

The role of cancer-related internet use on the patient-physician relationship has not been adequately explored among patients who are cancer-related internet users (CIUs) in early-phase clinical trial clinics.

Objective

We examined the association between cancer-related internet use and the patient-physician relationship and decision making among CIUs in an early drug development clinic.

Methods

Of 291 Phase I clinic patients who completed a questionnaire on internet use, 179 were CIUs. Generations were defined by the year of patient’s birth: “millennials” (after 1990) and “Generation X/Y” (1965-1990) grouped as “Millennials or Generation X/Y”; “Baby Boomers” (1946-1964); and “Greatest or Silent Generation” (1945 and earlier). Statistical analyses included the Wilcoxon matched-pairs signed-rank test and the Mann-Whitney U test.

Results

CIUs were 52% (94/179) female, 44% (78/179) were older than 60 years, and 60% (108/179) had household incomes exceeding US $60,000. The sources of information on cancer and clinical trials included physicians (171/179, 96%), the internet (159/179, 89%), and other clinical trial personnel (121/179, 68%). For the overall sample and each generation, the median values for trust in referring and Phase I clinical trial physicians among early drug development clinic CIUs were 5 on a 0-5 scale, with 5 indicating “complete trust.” CIUs’ trust in their referring (5) and phase 1 (5) physicians was higher than CIUs’ trust in Web-based cancer-related information (3; P<.001 for both). CIUs who reported visiting the National Cancer Institute (NCI) website, NCI.org, to learn about cancer reported higher levels of trust in Web-based cancer-related information than CIUs who did not use the NCI website (P=.02). Approximately half of CIUs discussed internet information with their doctor. Only 14% (23/165) of CIUs had asked their physician to recommend cancer-related websites, and 24% (35/144) of CIUs reported at least occasional conflict between their physician’s advice and Web-based information.

Conclusions

Despite the plethora of websites related to cancer and cancer clinical trials, patients in early-phase clinical trial settings trust their physicians more than Web-based information. Cancer-related organizations should provide regularly updated links to trustworthy websites with cancer and clinical trial information for patients and providers and educate providers on reliable cancer websites so that they can better direct their patients to appropriate internet content.

Insurance Clearance for Early-Phase Oncology Clinical Trials Following the Affordable Care Act

Purpose: The Affordable Care Act (ACA) required that private insurance plans allow clinical trial participation and cover standard-of-care costs, but the impact of this provision has not been well-characterized. We assessed rates of insurance clearance for trial participation within our large early-phase clinical trials program, before and after implementation of the requirement.Experimental Design: We analyzed the departmental database for the Clinical Center for Targeted Therapy (CCTT) at MD Anderson Cancer Center (Houston, TX). Among patients referred for sponsored trials, we described rates of insurance clearance and prolonged time to clearance (at least 14 days) from July 2012 to June 2013 (baseline), July 2013-December 2013 (following CCTT staffing changes in July 2103), and January 2014-June 2015 (following implementation of the ACA). We used multivariable logistic regression models to compare rates across these time periods.Results: We identified 2,404 referrals for insurance clearance. Among privately insured patients, insurance clearance rates were higher for those referred from January 2014 to June 2015 than for those referred from July 2012 to June 2013 (OR, 4.72; 95% CI, 2.96-7.51). There was no association between referral period and clearance rates for Medicare/Medicaid patients (P = 0.25). Referral from January 2014 to June 2015 was associated with lower rates of prolonged clearance among both privately insured (OR 0.57; 95% CI, 0.38-0.86) and Medicare/Medicaid patients (OR 0.39; 95% CI, 0.19-0.83).Conclusions: Within our large early-phase clinical trials program, insurance clearance rates among privately insured patients improved following implementation of the ACA's requirement for coverage of standard-of-care costs. Clin Cancer Res; 23(15); 4155-62. ©2017 AACR.

Phase 1b study of lenvatinib (E7080) in combination with temozolomide for treatment of advanced melanoma

OBJECTIVE AND METHODS

In this phase 1b study, patients with stage 4 or unresectable stage 3 melanoma were treated with escalating doses of lenvatinib (once daily) and temozolomide (TMZ) (days 1-5) in 28-day cycles, to determine the maximum tolerated dose (MTD) of the combination. Dose Level (DL)1: lenvatinib 20 mg, TMZ 100 mg/m2; DL2: lenvatinib 24 mg, TMZ 100 mg/m2; DL3: lenvatinib 24 mg, TMZ 150 mg/m2. Adverse events (AEs) were recorded and tumor response assessed per RECIST 1.0.

RESULTS

Dose-limiting toxicity occurred in 1 of 32 treated patients (DL1); MTD was not reached. The highest dose administered was lenvatinib 24 mg + TMZ 150 mg/m2. Most common treatment-related AEs included fatigue (56.3%), hypertension (53.1%), and proteinuria (46.9%). Overall objective response rate was 18.8% (6 patients), all partial response; (DL1, n = 1; DL3, n = 5). Stable disease (SD) ≥ 16 weeks was observed in 28.1% of patients (DL1 and DL2, n = 1 each; DL3, n = 7); 12.5% of patients had SD ≥ 23 weeks. Single and repeat-dose pharmacokinetics of lenvatinib were comparable across cycles and with concomitant TMZ administration.

CONCLUSIONS

Lenvatinib 24 mg/day + TMZ 150 mg/m2/day (days 1-5) demonstrated modest clinical activity, an acceptable safety profile, and was administered without worsening of either lenvatinib- or TMZ-related toxicities in this patient group.

Abstract 1530: Dissecting breast cancer dormant CTC phenotypes

Tumor relapse is a clinically relevant problem in breast cancer where patients are asymptomatic because disseminated cells appear to become dormant for periods longer than 20 years and are undetectable by current clinical tools. Uncovering phenotypes of circulating tumor cells (CTCs) - the “seeds” of intractable metastasis-offers the promise to dissect CTC heterogeneity in relation to metastatic competence, to predict biomarker assessment, and to significantly improve monitoring and treatment of cancer. However, little is known about CTC biology and how CTCs differ in their capacity to circulate while maintaining a metastatic potential. We hypothesized that EpCAM-negative breast cancer CTC subsets exist, and avoid organ arrest with extreme efficiency by the concomitant presence of quiescence and stem cell properties. We collected peripheral blood of clinically diagnosed breast cancer patients with or without brain metastasis, and performed multiparametric flow cytometry to isolate EpCAM-negative CTC subsets with stem-cell properties (CD44+/CD24-), along with combinatorial expression of two neoplastic markers: urokinase plasminogen activator receptor (uPAR) and integrin beta1 (int β1). EpCAM-negative CTCs were further interrogated at a single-cell level employing DEPArray platform. Second, we were able to culture FACS-sorted CTC subsets, selected for six cell-surface expression markers (CD45-/EpCAM-negative/CD44+/CD24-/uPAR+/-/int β1+/-), as long-term in-vitro 3D CTC tumorspheres. Third, CTC subsets were interrogated for biomarker profiling and biological characteristics. We identified adhesive, proliferative and invasive properties of 3D CTC tumorspheres which were distinct per uPAR/int β1 combinatorial expression. Lastly, we performed next-generation whole-genome sequencing and mutation analyses to discover unique genomic signatures of uPAR/int β1 CTC subsets and verified as putative CTCs originally disseminated from primary breast tumor. Additional investigations are being pursued assessing the molecular and genomic characterization of uPAR/int β1 CTC subsets comprehensively. Clinical relevance of this research includes that this may enhance abilities to prospectively identify patients who may be at high-risk of developing breast cancer brain metastasis.

Citation Format: Monika Vishnoi, Sirisha Peddibhotla, Wei Yin, Zhong Xue, Antonio T. Scamardo, Goldy C. George, David S. Hong, Dario Marchetti. Dissecting breast cancer dormant CTC phenotypes. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1530.

Abstract 3143: Deciphering mechanisms of circulating tumor cells in breast cancer dormancy

More than 67% of deaths in breast cancer patients occur after the initial 5-year survival period while residual disease can be dormant for periods longer than 20 years. Patients are asymptomatic because circulating tumor cells (CTCs) remain dormant and are undetectable by current clinical tools. Dormant CTCs may retain their long-term tumor-initiating (LTI) potential by adhering to their original genome, unlike rapidly cycling cancer cells that are known to have increased genomic instability. We hypothesized that hyperactive mechanisms of DNA repair preserve the genomic make-up of dormant CTCs allowing them to retain their LTI potential, ultimately causing disease relapse.

We isolated and characterized EpCAM-negative breast cancer CTCs by mutiparametric flow cytometry and DEPArrayTM. Individually isolated breast cancer CTCs had a large proportion (&gt;40%) of dormant (Ki67-/PCNA-) cells. Dormant CTCs had a lower incidence of double-strand DNA breaks (DSB) than proliferating cells as assessed by the phosphorylation status of Serine139 on gamma H2AX. This observation was further validated in a panel of eight genetically distinct breast cancer cell lines. Second, to understand whether dormant cells are inherently more resistant to DSB, we induced DSB in breast cancer cells by UV radiation and bleomycin treatment, and measured residual DSB at regular intervals. Results showed that besides being more resistant to DSB de novo, dormant breast cancer cells were also more efficient in repairing their DNA. There are two distinct phases of DSB repair - early [within 2 hours of DSB using Non-Homologous End Joining (NHEJ) methods] and late [evident after 24 hours using Homologous Recombination (HR)]. Unlike proliferating (S-G2M) cells, dormant (G0) cells lack the sister chromatid and repair their DNA exclusively by NHEJ methods. Therefore, and third, we investigated key players of the NHEJ pathway and examined their roles in maintaining genomic integrity. We found that the human telomere-associated protein RIF1, a mediator of alternative NHEJ, was significantly up-regulated in a dormant CTC subset. Dormant sub-populations of breast cancer cells confirmed RIF1 foci formation in areas of DNA damage. Fourth, mis-sense mutation of RIF1 in CAMA-1 cells (ΔRIF1 E1598K) attenuated resistance of the dormant subset to UV and bleomycin treatment.

Collectively, these findings suggest that RIF1 may play functional roles in maintaining the genomic integrity of dormant CTCs. Further investigations are being pursued to assess RIF1 contributions to retain CTC LTI potential leading to CTC-driven metastasis.

Citation Format: Debasish Boral, Haowen N. Liu, Wei Yin, Monika Vishnoi, Antonio Scamardo, Goldy C. George, David S. Hong, Dario Marchetti. Deciphering mechanisms of circulating tumor cells in breast cancer dormancy. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3143.

Sleep quality and its association with fatigue, symptom burden, and mood in patients with advanced cancer in a clinic for early-phase oncology clinical trials

BACKGROUND

Limited data exist about sleep quality for patients with advanced cancer in phase 1 clinical trials. Poor sleep quality is often not captured as an adverse event, and its association with fatigue, one of the most frequently reported adverse events, is not documented routinely. This article describes sleep quality and its relation with fatigue, symptom burden, and mood in patients recruited from an early-phase clinic for targeted therapy.

METHODS

Sleep, fatigue, symptom burden, and mood were assessed with the Pittsburgh Sleep Quality Index (PSQI), the Brief Fatigue Inventory, the MD Anderson Symptom Inventory (MDASI), and the Brief Profile of Mood States, respectively; the Eastern Cooperative Oncology Group (ECOG) performance status (PS) was determined from medical records.

RESULTS

The sample (n = 256) was 51.2% female, 90% had an ECOG PS of 0 or 1, and the mean age was 58 ± 0.8 years. Poor sleepers (global PSQI score > 5) constituted 64% of the sample. In separate multiple regression models, poor sleepers had higher levels of fatigue (P < .001), symptom burden (P < .001), and overall mood disturbance (P < .001) than good sleepers. Also, compared with good sleepers, poor sleepers had greater fatigue-related and symptom-related interference with daily activities (all P values < .001). The MDASI disturbed-sleep item correlated well with the global PSQI score (Pearson's r = 0.679, P < .001), and this suggests its usefulness as a patient-reported outcome screener of sleep quality in early-phase clinical trials clinics.

CONCLUSIONS

Poor sleep quality was a significant problem in the current study and was associated with greater fatigue, symptom burden, and mood disturbance. Sleep quality should be routinely assessed in patients with advanced cancer who are participating in early-phase clinical trials. Cancer 2016;122:3401-3409. © 2016 American Cancer Society.

The isolation and characterization of CTC subsets related to breast cancer dormancy

Uncovering CTCs phenotypes offer the promise to dissect their heterogeneity related to metastatic competence. CTC survival rates are highly variable and this can lead to many questions as yet unexplored properties of CTCs responsible for invasion and metastasis vs dormancy. We isolated CTC subsets from peripheral blood of patients diagnosed with or without breast cancer brain metastasis. CTC subsets were selected for EpCAM negativity but positivity for CD44(+)/CD24(-) stem cell signature; along with combinatorial expression of uPAR and int β1, two markers directly implicated in breast cancer dormancy mechanisms. CTC subsets were cultured in vitro generating 3D CTC tumorspheres which were interrogated for biomarker profiling and biological characteristics. We identified proliferative and invasive properties of 3D CTC tumorspheres distinctive upon uPAR/int β1 combinatorial expression. The molecular characterization of uPAR/int β1 CTC subsets may enhance abilities to prospectively identify patients who may be at high risk of developing BCBM.

Retreatment with anti-EGFR based therapies in metastatic colorectal cancer: impact of intervening time interval and prior anti-EGFR response

BACKGROUND

This retrospective study aims to investigate the activity of retreatment with anti-EGFR-based therapies in order to explore the concept of clonal evolution by evaluating the impact of prior activity and intervening time interval.

METHODS

Eighty-nine KRAS exon 2-wild-type metastatic colorectal patients were retreated on phase I/II clinical trials containing anti-EGFR therapies after progressing on prior cetuximab or panitumumab. Response on prior anti-EGFR therapy was defined retrospectively per physician-records as response or stable disease ≥6 months. Multivariable statistical methods included a multiple logistic regression model for response, and Cox proportional hazards model for progression-free survival.

RESULTS

Retreatment anti-EGFR agents were cetuximab (n = 76) or cetuximab plus erlotinib (n = 13). The median interval time between prior and retreatment regimens was 4.57 months (range: 0.46-58.7). Patients who responded to the prior cetuximab or panitumumab were more likely to obtain clinical benefit to the retreatment compared to the non-responders in both univariate (p = 0.007) and multivariate analyses (OR: 3.38, 95 % CI: 1.27, 9.31, p = 0.019). The clinical benefit rate on retreatment also showed a marginally significant association with interval time between the two anti-EGFR based therapies (p = 0.053). Median progression-free survival on retreatment was increased in prior responders (4.9 months, 95 % CI: 3.6, 6.2) compared to prior non-responders (2.5 months, 95 % CI, 1.58, 3.42) in univariate (p = 0.064) and multivariate analysis (HR: 0.70, 95 % CI: 0.43-1.15, p = 0.156).

CONCLUSION

Our data lends support to the concept of clonal evolution, though the clinical impact appears less robust than previously reported. Further work to determine which patients benefit from retreatment post progression is needed.

A phase 1 study of intermittently administered pazopanib in combination with continuous daily dosing of lapatinib in patients with solid tumors

PURPOSE

Preclinically, pazopanib/lapatinib combination acted synergistically to suppress the activity of multiple tyrosine kinases, including VEGFR-1, 2, 3, PDGFR and c-kit (pazopanib), HER1/EGFR and HER2 (lapatinib), and several other tyrosine kinases including c-Met through, plausibly, network inhibition effects. Clinically, continuous dosing of pazopanib/lapatinib combination was associated with a higher response rate than with lapatinib monotherapy, with poor tolerance. We explored multiple intermittent dose levels of pazopanib combined with continuous daily dosing of lapatinib in patients with solid tumors.

METHODS

The present study used a phase 1, modified 3 + 3, dose-escalation design to evaluate the safety and tolerability of the combination of orally received pazopanib once every other day with continuous daily dosing of lapatinib for 28 days. In the expansion phase, tumor response was evaluated in patients with specific genetic alterations (HER2 amplification, HER2 mutation, c-Met amplification, c-Met mutation, and EGFR mutation).

RESULTS

Twenty-four patients were treated. The most common drug-related adverse events were fatigue 7/24 (29%), skin rash 5/21 (21%), and diarrhea 3/24 (17%), with 4/24 (16%) patients experiencing grade ≥3 drug-related adverse events. Escalation to the FDA-approved dose (800 mg daily for pazopanib and 1500 mg every day for lapatinib) was not feasible due to toxicities. Pazopanib 200 mg every other day + lapatinib 500 mg daily was considered the maximum tolerated dose (MTD). No tumor response was observed, including in patients with the specific molecular genetic alterations tested.

CONCLUSION

Every other day dosing of pazopanib combined with daily lapatinib was tolerated at the established MTD, but no complete or partial tumor responses were observed at these dose levels.

Phase I Dose-Escalation Study of the Multikinase Inhibitor Lenvatinib in Patients with Advanced Solid Tumors and in an Expanded Cohort of Patients with Melanoma

PURPOSE

This "3+3" phase I study evaluated the safety, biologic, and clinical activity of lenvatinib, an oral multikinase inhibitor, in patients with solid tumors.

EXPERIMENTAL DESIGN

Ascending doses of lenvatinib were administered per os twice daily in 28-day cycles. Safety and response were assessed for all patients. Angiogenic and apoptotic factors were tested as possible biomarkers in an expanded melanoma cohort.

RESULTS

Seventy-seven patients were treated in 3 cohorts: 18 with intermittent twice-daily dosing (7 days on, 7 days off) of 0.1-3.2 mg; 33 with twice-daily dosing of 3.2-12 mg; and 26 with twice-daily dosing of 10 mg (expanded melanoma cohort). Maximum tolerated dose was established at 10 mg per os twice daily. Prominent drug-related toxicities included hypertension (43%), fatigue (42%), proteinuria (39%), and nausea (25%); dose-limiting toxicities included hypertension, fatigue, and proteinuria. Twelve patients (15.6%) achieved partial response (PR, n = 9) or unconfirmed PR (uPR, n = 3), and 19 (24.7%) achieved stable disease (SD) ≥23 weeks. Total PR/uPR/SD ≥23 weeks was 40.3% (n = 31). Responses (PR/uPR) by disease were as follows: melanoma, 5 of 29 patients (includes 1 patient with NRAS mutation); thyroid, 3 of 6 patients; pancreatic, 1 of 2 patients; lung, 1 of 1 patients; renal, 1 of 1 patients; endometrial, 1 of 4 patients; and ovarian, 1 of 5 patients. AUC(0-24) and C(max) increased dose proportionally. In multivariate Cox proportional hazard model analyses, increased baseline systolic blood pressure and decreased angiopoietin-1 ratio (2 hours:baseline) were associated with longer progression-free survival (PFS) in the expanded melanoma cohort (P = 0.041 and P = 0.03, respectively).

CONCLUSIONS

The toxicity profile, pharmacokinetics, and antitumor activity of lenvatinib are encouraging. Decreases in the angiopoietin-1 ratio correlated with longer PFS in melanoma patients.

Dual inhibition of the vascular endothelial growth factor pathway: a phase 1 trial evaluating bevacizumab and AZD2171 (cediranib) in patients with advanced solid tumors

BACKGROUND

The current study was conducted to evaluate the safety and biological activity of dual inhibition of the vascular endothelial growth factor (VEGF) pathway with combined bevacizumab and cediranib (a VEGF receptor tyrosine kinase inhibitor).

METHODS

This was a 3 + 3 dose escalation study in patients with advanced solid tumors. Cediranib was given orally daily for 21 days and bevacizumab intravenously every 2 weeks. Pharmacokinetics and correlates (nitric oxide synthase, nitrate oxide, and circulating tumor cells) were assessed.

RESULTS

Fifty-one patients were treated. Dose-limiting toxicities (DLTs) (grade 3-4; graded according to the National Cancer Institute Common Terminology Criteria of Adverse Events [version 3.0]) observed included 1 patient with chest pain, 1 patient with fatigue, 2 patients with thrombocytopenia, 3 patients with hypertension (1 with intracranial hemorrhage), and 1 patient with grade 5 hemoptysis. Moreover, 2 patients presented with grade 3 intracranial bleeding beyond the DLT window. Dose level 2 (cediranib at a dose of 20 mg/day and bevacizumab at a dose of 5 mg/kg every 2 weeks) was selected as the recommended phase 2 dose (RP2D); 17 patients were treated at dose level 2 with 1 DLT and no intracranial bleeding or severe hypertension reported. Pharmacokinetics of cediranib at dose level 3 demonstrated a 46% to 77% increase in area under the curve (0-24 hours) on cycle 1 day 1 compared with historical controls. Four patients attained partial remissions: inflammatory breast cancer (-54%), basal cell carcinoma (-33%), alveolar soft part sarcoma (-33%), and synovial sarcoma (-32%). Patients with a lower circulating tumor cell count (< 30) at the predose period had a longer time to tumor progression (P = .024, log-rank test).

CONCLUSIONS

Cediranib at a dose of 20 mg/day and bevacizumab at a dose of 5 mg/kg every 2 weeks was found to be the RP2D. Activity in several tumor types was noted. Central nervous system bleeding and severe hypertension were observed at doses above the RP2D.

Factors related to biopsy willingness in patients with advanced cancer in a phase 1 clinic for molecularly targeted therapy

PURPOSE

Tumor biopsies are critical for delineating pharmacodynamic effects of drugs and for optimal patient selection during oncology clinical trials of molecular targeted therapies. The purpose of this study was to identify factors related to patients' willingness to provide study-related tumor biopsies in phase 1 clinical trials of molecularly targeted therapy.

METHODS

An investigator-designed survey, that assessed biopsy willingness, demographic and clinical factors, was completed anonymously by patients with advanced cancer in a phase 1 clinic for targeted therapy. Data were analyzed using multivariate logistic regression models with odds ratios (OR) and 95 % confidence intervals (CI).

RESULTS

Three hundred and sixty-two patients with advanced cancer (50 % male, 56 % aged ≤ 60 years) participated. In univariate analyses, willingness to provide study-related biopsy was associated with male gender, white race, higher income, using the Internet for cancer-related information, and having had a biopsy previously (p < 0.05). In multivariate analyses, male gender (OR 2.41, 95 % CI 1.54, 3.78) and having had a biopsy (OR 3.71, 95 % CI 1.68, 8.15) were associated with willingness to have one biopsy; male gender (OR 1.97, 95 % CI 1.30, 3.00) and relying on the Internet as a source of information (OR 1.87, 95 % CI 1.21, 2.89) were associated with willingness to have more than one biopsy.

CONCLUSIONS

The results suggest that male gender is associated with greater stated willingness to undergo biopsy. Also, the Internet is an important source of information for patients with cancer and may strongly influence their decisions about whether to consent to biopsies in early clinical trials.

Melanoma patients in a phase I clinic: molecular aberrations, targeted therapy and outcomes

BACKGROUND

The purpose of the study was to assess the outcome of patients with advanced melanoma treated with matched molecularly targeted therapy.

PATIENTS AND METHODS

We reviewed 160 consecutive patients with metastatic melanoma treated in the phase I program (N = 35 protocols). Treatment was considered to be 'matched' (N = 84) if at least one drug in the regimen was known to inhibit the functional activity of at least one of the patient's mutations.

RESULTS

Of 160 patients, 134 (83.7%) had adequate tissue for molecular analysis; 69% (110 of 160) had ≥1 mutation: 61.2% (82 of 134), BRAF; 20.7% (23 of 111), NRAS; 2.6% (2 of 77), KIT; 2.3% (1 of 44), KRAS; 20% (1 of 5), GNAQ; 11.1% (1 of 9), P53 and 2.6% (1 of 39), coexisting mutations in BRAF and PIK3CA. Eighty-four patients (52.4%) were treated with matched-targeted agents, most of whom had BRAF mutations (N = 74). Twenty-six percent of patients (41 of 160) achieved a complete or partial remission (CR/PR) [40% (34 of 84)) on a matched phase I protocol versus 9.2% (7 of 76) for those on a non-matched study (P ≤ 0.0001)]. The median progression-free survival (PFS) (95% CI) was longer for patients treated on a matched phase I trial than on their prior first standard treatment [5.27 (4.10, 6.44) versus 3.10 (1.92, 4.28) months, P = 0.023], but not on non-matched phase I treatment. Multivariable analysis showed that matched therapy was an independent predictor of higher CR/PR rates, prolonged PFS and survival.

CONCLUSIONS

For melanoma patients, especially those with BRAF mutations, administering molecularly matched agents can be associated with better outcomes, including longer PFS compared with their first-line systemic therapy.

Targeting the molecular chaperone heat shock protein 90 (HSP90): lessons learned and future directions

Due to the critical role of heat shock protein 90 (HSP90) in regulating the stability, activity and intracellular sorting of its client proteins involved in multiple oncogenic processes, HSP90 inhibitors are promising therapeutic agents for cancer treatment. In cancer cells, HSP90 client proteins play a major role in oncogenic signal transduction (i.e., mutant epidermal growth factor receptor), angiogenesis (i.e., vascular endothelial growth factor), anti-apoptosis (i.e., AKT), and metastasis (i.e., matrix metalloproteinase 2 and CD91), processes central to maintaining the cancer phenotype. Thus, HSP90 has emerged as a viable target for antitumor drug development, and several HSP90 inhibitors have transitioned to clinical trials. HSP90 inhibitors include geldanamycin and its derivatives (i.e., tanespimycin, alvespimycin, IPI-504), synthetic and small molecule inhibitors (i.e., AUY922, AT13387, STA9090, MPC3100), other inhibitors of HSP90 and its isoforms (i.e., shepherdin and 5'-N-ethylcarboxamideadenosine). With more than 200 "client" proteins, many of them meta-stable and oncogenic, HSP90 inhibition can affect an array of tumors. Here we review the molecular structure of HSP90, structural features of HSP90 inhibition, pharmacodynamic effects and tumor responses in clinical trials of HSP90 inhibitors. We also discuss lessons learned from completed clinical trials of HSP90 inhibitors, and future directions for these promising therapeutic agents.

A multicenter phase I trial of PX-866, an oral irreversible phosphatidylinositol 3-kinase inhibitor, in patients with advanced solid tumors

PURPOSE

The objectives of the study were to evaluate the maximum tolerated dose (MTD), safety, pharmacodynamics, pharmacokinetics, and antitumor activity of PX-866 in patients with incurable cancers.

EXPERIMENTAL DESIGN

This was a phase I, open-label, dose-escalation study. Drug was administered orally once per day either on an intermittent (arm 1; days 1-5 and 8-12 of a 28-day cycle) or continuous (arm 2; days 1-28 of a 28-day cycle) schedule. Additional patients were treated at the arm 2 MTD in a food effects substudy.

RESULTS

Eighty-four patients were treated in the arm 1 (n = 51), arm 2 (n = 20), and food effects (n = 13) cohorts. The most frequent study drug-related adverse events were gastrointestinal disorders (69.0%), with diarrhea being the most common (48.8%). The MTD was 12 and 8 mg for arm 1 and 2, respectively. The dose-limiting toxicities (DLT) consisted of grade III diarrhea (n = 3) and grade III elevated aspartate aminotransferase (AST; n = 1). The pharmacokinetics profile was dose proportional, with no evidence of drug accumulation. PX-866-associated inhibition of platelet pAKTSER473 was observed at the arm 2 MTD. The best response per Response Evaluation Criteria in Solid Tumors (RECIST) was stable disease in 22% of evaluable patients in arm 1, 53% in arm 2, and 11% in the food effects cohort. Eight patients were on study for 4 or more months.

CONCLUSIONS

This first-in-human study shows that PX-866, an irreversible small-molecule inhibitor of phosphatidylinositol 3-kinase (PI3K), was well tolerated and was associated with prolonged stable disease, particularly when using a continuous dosing schedule.

Association between depressed mood and perceived weight in middle and high school age students: Texas 2004-2005

Research exploring the relationship between weight perception and depressed mood among adolescents is limited in the United States. The purpose of this study is to examine the association of perceived versus actual body weight and depressed mood in a representative sample of 8th and 11th grade public school students in Texas. Using data from the 2004-2005 School Physical Activity and Nutrition (SPAN) study, logistic regression analyses were conducted to assess the association of weight perception with depressed mood. Healthy weight students who perceived themselves to be a healthy weight were the reference group for all analyses. A high prevalence of misperception of body weight was observed. Overweight and obese 8th grade girls and boys who perceived themselves to be overweight had increased odds of depressed mood [Girls: OR 1.70 (95% CI: 1.07-2.69), Boys: OR 2.05 (95% CI: 1.16-3.62)]. Healthy weight 8th grade girls who perceived themselves to be overweight had 2.5 times greater odds of depressed mood (OR 2.63, 95% CI: 1.54-4.50). Healthy weight boys who perceived themselves to be underweight had more than twice the odds (OR 2.18, 95% CI: 1.23-3.89) of depressed mood. No weight category was significantly associated with depressed mood in boys or girls in 11th grade. The present study suggests that weight misperceptions are associated with depressed mood in young adolescents. Education about healthy body size is necessary to correct the common weight misperceptions observed. The high prevalence rates of depressed mood suggest a greater need for research into understanding factors that may contribute to depressed mood in adolescents.

Associations among dietary supplement use and dietary and activity behaviors by sex and race/ethnicity in a representative multiethnic sample of 11th-grade students in Texas

BACKGROUND AND OBJECTIVE

The purpose of this study was to examine associations among dietary supplement use and dietary/activity patterns in a representative sample of adolescents by sex and race/ethnicity, a research area where extant data is limited.

DESIGN/PARTICIPANTS

Cross-sectional, multistage, probability-based sample of 11th graders in Texas during 2004-2005 (n=6,422; 48.8% white/other, 37% Hispanic, and 14.2% African American; 50.6% boys; mean age 16.7 years).

SETTING

Classrooms. MAIN VARIABLES ASSESSED: Dietary supplement use, dietary/activity patterns, and anthropometrics.

STATISTICAL ANALYSES PERFORMED

Multiple logistic regression models (odds ratios [ORs] and 95% confidence intervals [CIs]).

RESULTS

Dietary supplement users reported healthy dietary and physical activity behaviors overall, yet sex- and race/ethnicity-specific differences were seen in associations among specific diet/activity behaviors and supplement use. In whites/others and Hispanics, but not African Americans, supplement use was associated with higher diet quality scores (OR 2.93, 95% CI 1.74 to 4.95 for whites/others; OR 3.93, 95% CI 2.26 to 6.83 for Hispanics), and regular consumption of breakfast (OR 2.27, 95% CI 1.40 to 3.66 for whites/others; OR 1.96, 95% CI 1.11 to 3.46 for Hispanics) and low-fat foods (OR 3.02, 95% CI 1.53 to 5.98 for whites/others; OR 3.59, 95% CI 1.11 to 11.6 for Hispanics). Supplement use was not associated with body mass index or with sedentary behaviors overall, but was associated with less television viewing only in whites/others (OR 0.53, 95% CI 0.33 to 0.84). For physical activity, boys and whites/others showed positive associations between supplement use and all indicators examined, but girls, Hispanics and African Americans showed mixed patterns of associations. Supplement use was associated with higher weight preference only in boys (OR 2.47, 95% CI 1.24 to 4.90), and vegetarian diets only in girls (OR 2.96, 95% CI 1.35 to 6.47).

CONCLUSIONS

Dietary and activity patterns associated with dietary supplement use may vary by sex- and racial/ethnic subpopulation, especially amongst African American youth. These findings together with further research on psychosocial and attitudinal characteristics associated with adolescent supplement use can enhance the development of targeted and tailored health communications about supplement use in adolescent subpopulations.

Diet- and body size-related attitudes and behaviors associated with vitamin supplement use in a representative sample of fourth-grade students in Texas

OBJECTIVE

To examine diet- and body size-related attitudes and behaviors associated with supplement use in a representative sample of fourth-grade students in Texas.

DESIGN

Cross-sectional data from the School Physical Activity and Nutrition study, a probability-based sample of schoolchildren. Children completed a questionnaire that assessed supplement use, food choices, diet-related attitudes, and physical activity; height and weight were measured.

SETTING

School classrooms.

PARTICIPANTS

Representative sample of fourth-grade students in Texas (n = 5967; mean age = 9.7 years standard error of the mean [SEM] = .03 years, 46% Hispanic, 11% African-American).

MAIN OUTCOME MEASURES

Previous day vitamin supplement consumption, diet- and body size-related attitudes, food choices, demographic factors, and physical activity.

ANALYSIS

Multivariable logistic regression models, P < .05.

RESULTS

The prevalence of supplement use was 29%. Supplement intake was associated with physical activity. Girls who used supplements were more likely to report positive body image and greater interest in trying new food. Relative to nonusers, supplement users were less likely to perceive that they always ate healthful food, although supplement use was associated with more healthful food choices in boys and girls (P < .001).

CONCLUSIONS AND IMPLICATIONS

The widespread use of supplements and clustering of supplement use with healthful diet and greater physical activity in fourth graders suggest that supplement use be closely investigated in studies of diet-disease precursor relations and lifestyle factors in children.

Food choices of low-income women during pregnancy and postpartum

OBJECTIVES

The purpose of this study was to examine dietary behavior during pregnancy and postpartum in a multiethnic sample of low-income women.

SUBJECTS

Participants were 149 Medicaid-qualified women (30% white, 24% African American, and 46% Hispanic; median age, 22 years).

DESIGN

Subjects were recruited into a longitudinal cohort design 0 to 1 days following delivery. Dietary choices during pregnancy and the first 6 months postpartum were assessed via validated food frequency questionnaires administered at 6 weeks and 6 months postpartum, respectively.

STATISTICAL ANALYSES PERFORMED

Frequencies and means were used for descriptive purposes. Paired and independent sample t tests were used for continuous variables; chi 2 and McNemar tests were used for categorical variables.

RESULTS

In all subjects, mean daily servings of grains (7.4 vs 6.2, P <.004), vegetables (2.5 vs 2.0, P <.002), and fruit (3.4 vs 1.7, P <.001) declined following childbirth, while the percentage of energy from fat (37.3% vs 38.4%, P <.023) and added sugar (14.4% vs 16.4%, P <.019) increased. Women who breastfed their infants at 6 months postpartum reported lower intakes of total fat (34.2% vs 37.9%, P <.005) during pregnancy and higher fruit (2.2 vs 1.6, P <.05) and vegetable (2.6 vs 1.8, P <.02) intakes in postpartum than those who bottle-fed. Also, a greater proportion of lactating than nonlactating women (66.7% vs 36.9%, P <.05) met recommendations for fruit intake during pregnancy.

CONCLUSIONS

The findings suggest that the transition from pregnancy to postpartum may be associated with a negative impact on dietary behavior that could compromise nutritional status in low-income women.

Compliance with dietary guidelines and relationship to psychosocial factors in low-income women in late postpartum

OBJECTIVES

The goals were to evaluate compliance with the Dietary Guidelines among low-income women during late postpartum and to examine the relationship between psychosocial variables and dietary compliance.

SUBJECTS/SETTING

Participants were 146 triethnic, low-income women who were recruited 0 to 1 days after childbirth and who visited a clinic site at 1 year postpartum.

DESIGN

At 1 year postpartum, multiple psychosocial characteristics were measured, and food choices and nutrient intakes were assessed via a validated food frequency questionnaire. Dietary guidelines index scores and measures of adherence to dietary recommendations were computed.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics, analysis of variance with post-hoc Scheffe tests, chi 2 with follow-up tests of independent proportions, and Pearson correlation coefficients were utilized.

RESULTS

For dietary compliance, 60% had adequate intakes of meat, but less than 30% met recommendations for grains, vegetables, fruits, dairy foods, total fat, and added sugar. Healthful weights (body mass index <25) were observed in 37% of women. Those in the highest tertile of dietary compliance had a more positive body image than those in the lowest tertile, and less neglect of self-care, weight-related distress, stress, depressive symptoms, and perceived barriers to weight loss ( P <.05). Dietary compliance and psychosocial scale scores did not vary by ethnicity.

CONCLUSIONS

Adherence to dietary guidelines was limited in the low-income, postpartum women. Psychosocial variables, such as neglect of self-care, weight-related distress, negative body image, stress, and depressive symptoms were associated with less healthful diets and lifestyle in late postpartum. Programs that target diet-related behavior change in low-income women might be improved by inclusion of psychosocial assessment and counseling components.

Compulsory treatment of 50 alcoholic drunken drivers. A follow-up study

Fifty alcoholic drunken drivers receiving treatment as part of a suspended sentence were studied to assess the efficacy of compulsory treatment. Twenty-six showed improvement in drinking behaviour, 12 did not co-operate and were referred back to court, 7 were re-arrested on further charges of drunken driving and 4 were committed to long-term rehabilitation centres (1 patient died too early to allow for adequate follow-up). The results compare favourably with improvement in alcoholics treated voluntarily. When regarded as their own controls, patients who had previously been arrested for drunken driving but had not been referred for treatment showed considerable improvement in their behaviour, as did patients who had had previous unsuccessful voluntary treatment. This programme appears to be worth while, at least for the duration of the suspended sentence. It also encourages early identification of alcoholics and their referral for treatment.

A case of tranylcypromine ('Parnate') addiction

A case of addiction to tranylcypromine is described where tolerance occurred and a severe withdrawal illness followed discontinuation of the drug. Previous reports in the literature of similar cases are reviewed and comparisons made, and the implications for management are discussed.

"Dieters" and "vomiters and purgers" in anorexia nervosa

Thirty-one females with primary anorexia nervosa were studied by means of a retrospective analysis of hospital notes. The patients were divided into 2 groups. The first group consisted of subjects who had become emaciated solely because of dieting, food refusal and excessive exercising ("dieters"); the second of those who had used additional means to bring about weight loss such, as habitual vomiting and the abuse of purgatives ("vomiters and purgers"). Most "dieters" were intense, introverted, socially withdrawan individuals whose anorexia behaviour had started in response to psychological stress. They had become completely preoccupied with thoughts of food, eating and losing weight. Several did well in treatment, and recovered fully from their anorexic symptoms. "Vomiters and purgers", on the other hand, were more outgoing in respect to personality. Most had previously been obese and, as they had been unable to keep themselves thin by simply abstaining from food, they had learnt to use other means to control their weight. These latter patients did less well in treatment. They continued to experience difficulty in controlling their weight, and the majority persisted with their abnormal behaviour.

Body weight and the pituitary response to hypothalamic releasing hormones in patients with anorexia nervosa

Fifteen women with anorexia nervosa were studied before and after weight gain. Basal plasma thyroid stimulating hormone (TSH) and prolactin (PRL), and the responses of both these hormones to thyrotropin releasing hormone (TRH), were normal. Basal plasma luteinizing hormone (LH) and follicle stimulating hormone (FSH) were low in patients who were emaciated, and their responses to gonadotropin releasing hormone (GnRH) were impaired. Both basal and stimulated levels of LH and FSH rose with weight gain, with a linear correlation between gonadotropin levels and body weight expressed as a percentage of standard. The FSH response became greater than normal in patients who had regained weight to more than 70% of standard, while the LH response to GnRH was exaggerated in those who had regained weight to more than 80%. Basal plasma estradiol (E2) levels were low at first, but returned to within the normal range in patients over 80% of standard. Menstruation resumed in some patients after they had regained weight. The relationship between body weight and gonadotropin levels appears to be an important feature of the menstrual disturbance in anorexia nervosa. The restoration of a normal body weight is a prerequisite for the resumption of menstruation in this condition, but other as yet unidentified factors may also be involved.

Some personality characteristics of patients with anorexia nervosa

Twenty-two female patients with anorexia nervosa were assessed by means of objective personality testing. The EPI, Leyton Obsessional Inventory, Cattell's 16 PF and Raven's Matrices were used for this purpose. The personality profile that emerged was of a highly neurotic and introverted person with moderately severe obsessional features and average intelligence.