From Anti-doping-I to Anti-doping-II: Toward a paradigm shift for doping prevention in sport

Doping remains an intractable issue in sport and occurs in a complex and dynamic environment comprising interactions between individual, situational, and environmental factors. Anti-doping efforts have previously predominantly focused on athlete behaviours and sophisticated detection methods, however, doping issues remain. As such, there is merit in exploring an alternative approach. The aim of this study was to apply a systems thinking approach to model the current anti-doping system for four football codes in Australia, using the Systems Theoretic Accident Model and Processes (STAMP). The STAMP control structure was developed and validated by eighteen subject matter experts across a five-phase validation process. Within the developed model, education was identified as a prominent approach anti-doping authorities use to combat doping. Further, the model suggests that a majority of existing controls are reactive, and hence that there is potential to employ leading indicators to proactively prevent doping and that new incident reporting systems could be developed to capture such information. It is our contention that anti-doping research and practice should consider a shift away from the current reactive and reductionist approach of detection and enforcement to a proactive and systemic approach focused on leading indicators. This will provide anti-doping agencies a new lens to look at doping in sport.

Quality Improvement Within a Mental Health Setting: Alcohol Detoxification

Aims We describe a clinical audit on alcohol detoxification, using NICE guidelines as a comparable standard. NICE guidelines recommend completing a thorough alcohol history, documentation of a physical examination including screening for Wernicke's encephalopathy, monitoring of vital signs and liver investigations. Breath alcohol level and standardised assessment of withdrawal should be completed in addition to documentation of chlordiazepoxide and thiamine prescriptions. The reported mental health service completed the first cycle of the audit as part of a large-scale, international audit on alcohol detoxification by the Prescribing Observatory for Mental Health, UK (POMH-UK). Two additional audit cycles were completed within the service to ensure continuous quality improvement and clinical effectiveness. Methods Retrospective chart reviews were performed for admissions within pre-defined 6-month periods. Inclusion criteria: ICD-10 F10 diagnosis; prescription of alcohol detoxification schedule. Results This mental health service demonstrated greater compliance with the NICE standards in comparison to other services in the POMH-UK audit. The second-cycle audit showed increased compliance in most areas compared to the initial results. The third-cycle audit focused on two specific areas that required improvement to optimise quality improvement - Breath Alcohol Level and Clinical Institute of Withdrawal Assessment, documentation of which improved from 79% to 85% and 39% to 91% respectively in the final audit cycle. Conclusion The results of this audit indicate that adherence to defined clinical standards within this mental health service exceeds that of the benchmark POMH-UK data. The effectiveness of electronic patient records in improving adherence to set clinical standards, specifically in relation to documentation of clinical parameters is evident. The report also confirms continued improved results with each audit cycle within the service.

Abstract OT1-01-05: Endocrine treatment alone as primary treatment for elderly patients with estrogen receptor positive good prognosis operable breast cancer: A single arm phase II, single institution study

Background: It is estimated that approximately 46,000 women age >75 are diagnosed annually with breast cancer. Due to competing co-morbidities, there is wide variation in treatment recommendations which can lead to over- or under-treatment. Though surgery for breast cancer is considered low-morbidity, many elderly women given a choice, choose not to have surgery. Previous randomized trials comparing surgery with tamoxifen versus endocrine therapy alone in women age >70 unselected for ER status demonstrated similar overall survival with poorer local control in the latter group. A new standard of care needs to be defined for elderly women with good prognosis ER+ tumors, since these women may benefit from endocrine therapy alone to treat their cancer without compromising local and distant control.

Hypothesis: We hypothesize that endocrine therapy alone provides adequate local and systemic control of breast cancer in a subpopulation of women age 70 or older with ER+ breast cancer and good prognostic characteristics.

Primary Objective

To correlate response to neoadjuvant endocrine treatment at 6 months with Oncotype DX Recurrence Score (RS) in women with early-stage ER+ breast cancer who are age >70.

Secondary Objective

1. To determine the breast cancer-specific survival of women with early-stage ER+ breast cancer, age >70, treated with endocrine therapy alone.

2. To determine the rate of overall survival of women with early-stage ER+ breast cancer, age >70 treated with endocrine therapy alone.

Study Design: This is a prospective single arm phase II study. Patients with clinical stage I/II ER+ breast cancer, grade 1-2, Ki67<30 or RS <18 (performed on the diagnostic core biopsy) continue to be enrolled and followed for time to progression. A Kaplan-Meier model will be used to estimate the 5-year local progression rate. If the true 5-year progression rate is 10%, then 50 patients will provide power = .90 at a one-sided .05 significance level to demonstrate that the rate is less than 25.5%. Exploratory objectives include: evaluation of the molecular characteristics of breast cancers of responders versus non-responders, determine compliance with medications, evaluate cost-effectiveness, and quality of life.

Results: Between February 2017 and April 2018, 11 patients were enrolled into the study. Two patients could not tolerate endocrine therapy and received standard of care treatment. For the 9 patients on study, average tumor size was 1.7cm, average Ki67 was 15%, average RS was 14. All of the patients received an aromatase inhibitor. At 6 months, 71% of the patients had a partial response, 28% had stable disease. None of the patients developed progressive disease.

Conclusion: A new standard of care needs to be defined for women age >70 with good prognosis ER+ tumors, since these women may benefit from endocrine therapy alone to treat their cancer without compromising local and distant control. We continue to enroll patients to determine the optimal tumor markers for identifying women who can be treated with PET only to control their cancer.

Citation Format: Aft R, Cherian M, Frith A, Suresh R, Glover-Collins K, Naughton M, Moon C, Conant L, Ma C. Endocrine treatment alone as primary treatment for elderly patients with estrogen receptor positive good prognosis operable breast cancer: A single arm phase II, single institution study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-01-05.

Kynurenine pathway metabolism and the neurobiology of treatment-resistant depression: Comparison of multiple ketamine infusions and electroconvulsive therapy

Current first-line antidepressants can take weeks or months to decrease depressive symptoms. Low dose ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, shows potential for a more rapid antidepressant effect, with efficacy also evident in previously treatment-resistant populations. However, a greater understanding of the physiological mechanisms underlying such effects is required. We assessed the potential impact of ketamine infusion on neurobiological drivers of kynurenine pathway metabolism in major depression (HPA axis hyperactivity, inflammation) in patients with treatment-resistant depression compared to gender-matched healthy controls. Furthermore, we assessed these biomarkers before and after electroconvulsive therapy (ECT), which is currently the gold standard for management of treatment-resistant depression. As previously demonstrated, treatment with ketamine and ECT was associated with improved depressive symptoms in patients. At baseline, waking cortisol output was greater in the ECT cohort, kynurenine was greater in the ketamine cohort, and kynurenic acid was lower in patients compared to healthy controls, although inflammatory markers (IL-6, IL-8, IL-10 or IFN-γ) were similar in patients and controls. Furthermore, in patients who responded to ECT, the cortisol awakening response was decreased following treatment. Despite a trend towards reduced kynurenine concentrations in those who responded to ketamine, ketamine was not associated with significant alterations in any of the biomarkers assessed.

Syphilis Among U.S.-Bound Refugees, 2009-2013

U.S. immigration regulations require clinical and serologic screening for syphilis for all U.S.-bound refugees 15 years of age and older. We reviewed syphilis screening results for all U.S.-bound refugees from January 1, 2009 through December 31, 2013. We calculated age-adjusted prevalence by region and nationality and assessed factors associated with syphilis seropositivity using multivariable log binomial regression models. Among 233,446 refugees, we identified 874 syphilis cases (373 cases per 100,000 refugees). The highest overall age-adjusted prevalence rates of syphilis seropositivity were observed among refugees from Africa (1340 cases per 100,000), followed by East Asia and the Pacific (397 cases per 100,000). In most regions, male sex, increasing age, and living in non-refugee camp settings were associated with syphilis seropositivity. Future analysis of test results, stage of infection, and treatment delivery overseas is warranted in order to determine the extent of transmission risk and benefits of the screening program.

Abstract P6-12-02: Racial/ethnic differences in sleep quality and duration among breast cancer survivors: Results from the women's health initiative (WHI)

BACKGROUND: Sleep is a crucial factor for optimal health, but breast cancer survivors often report poor sleep quality. It is estimated 20-70% of survivors have at least one sleep problem, which contribute to quality of life and health differences among survivors. Minority groups tend to have poorer sleep quality and shorter sleep duration than Non-Hispanic Whites (NHW). African-Americans (AA) with breast cancer have a poorer prognosis than NHW for each stage-specific diagnosis and are twice as likely as NHW to report short sleep duration, yet survivor studies are still lacking in AA participants. The purpose of this study was to examine sleep quality and duration patterns before and after cancer diagnosis by race/ethnicity among WHI breast cancer survivors.

METHODS: There were 12,098 postmenopausal women diagnosed with invasive breast cancer after WHI enrollment who were eligible for this secondary analysis. Baseline demographic and clinical characteristics were described. The WHI Insomnia Rating Scale (WHIIRS) was measured at multiple time points pre- and post-diagnosis. A higher WHIIRS scores (0-20 points) indicates greater sleep disturbance and ≥9 points identifies clinical insomnia. A linear mixed model was fit to the WHIIRS sleep quality data to examine if the trend in sleep quality with time changed following a cancer diagnosis. For short (<6hrs) and long (≥9hrs) sleep duration, we fit a logistic regression model with multilevel mixed effects.

RESULTS: The majority of participants were NHW (87.4%), mean age at diagnosis was 70.3 years, and 75% had localized breast cancer at diagnosis. At baseline, 30% of women had insomnia. The lowest average WHIIRS score was 5.6 among Asians, and the highest was 6.6 among American-Indians and NHWs (p=0.02). AAs had the most women sleeping ≤5 hrs/night and NHW had the least (19.6% vs 5.7%, p<0.01). At diagnosis, the average WHIIRS score was 7.2. After diagnosis, sleep quality improved in the overall study population (p=0.03). Short sleep duration ranged from 6% before diagnosis, 9% at diagnosis and 11% after diagnosis (p=0.29). Long sleep duration ranged from 3% before diagnosis, 6% at diagnosis and 15% after diagnosis (p=0.43). There was no difference in sleep quality across race after diagnosis (p=0.53). The probability of short sleep and long sleep after diagnosis did not differ significantly across race (p=0.12, p=0.90), however racial minorities tended to have higher probabilities of short sleep at diagnosis compared to NHWs.

DISCUSSION: Sleep is an appealing area to target for improvement due to the multiple ways it can be treated. With increasing survival rates, there is an emphasis on improving quality of life in survivors. Our results span 20 years pre-diagnosis to 15 years post-diagnosis and are similar to shorter follow-up studies which found most women's sleep problems resolve within a few years of treatment completion. The lack of difference by race was an unexpected finding in another similar longitudinal study, which suggested most differences are seen in cross-sectional sleep studies. This study adds to the literature on longitudinal sleep data, especially to the little data on sleep trajectories in minority breast cancer survivors.

Citation Format: Beverly CM, Naughton M, Foraker R, Pennell M, Young G, Hale L, Crane T, Pan K, Danhauer S, Feliciano E, Paskett E. Racial/ethnic differences in sleep quality and duration among breast cancer survivors: Results from the women's health initiative (WHI) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-02.

Abstract P5-21-30: Retrospective review of palbociclib (Pal) efficacy and benefit from subsequent treatments following Pal progression in patients (pts) with hormone receptor positive (HR+) and HER2 negative (HER2-) metastatic breast cancer (MBC)

Background

The cyclin-dependent kinase (CDK) 4/6 inhibitor Pal is approved for HR+ HER2- MBC. However, the optimal therapy following Pal progression is unknown. Therefore we conducted this retrospective study to review Pal efficacy and summarize the practice pattern and responses to subsequent treatments post Pal progression.

Methods

We performed a chart review of pts with HR+ HER2- MBC who began Pal treatment at Washington University Siteman Cancer Center between Feb 16, 2015 and July 13, 2016 and collected information on pts demographics, diagnosis, and treatment history. Duration of therapy was used to calculate the progression free survival (PFS) for each regimen. Treatment was considered first-line if administered without any prior systemic therapy or at least 1 year from completion of adjuvant hormonal therapy (HT). Treatments received after progression on 1st line therapy or upon relapse during or within 1 year from the completion of adjuvant HT were considered second-line regimens.

Statistical analyses were performed on SAS software, version 9.4. The Kaplan-Meier method was used to generate time-to-event curves, from which median PFS was calculated. A stratified log-rank test was used for all comparisons, and the P value derived from the comparison was reported.

Results

We completed a chart review for 81 pts (78 female and 3 male; 63 Caucasian, 14 African American, and 4 other races) with HR+ HER2- MBC (68 were ER+PR+, 13 were ER+PR-) who received Pal plus letrozole (n=65) or fulvestrant (n=15) or anastrozole (n=1), with a median age of 62.0 years (range 28.1 - 85.6) at the start of Pal.

The median follow up was 20.0 months (mos) (range 10.8 – 27.9). 25 pts were still on Pal treatment. The median PFS on Pal was 19.9 mos in the first-line setting (n=20), compared to 12.1 mos and 4.4 mos in the second-line (n=14) and subsequent lines (n=47), respectively (p=0.0287). Among the 54 pts who progressed on Pal, 38 moved on to the next treatment. 20 pts received chemotherapy and 16 pts received HT or a HT combination. 2 pts received fulvestrant plus Pal upon progression on letrozole plus Pal, and treatment was still ongoing at 4 mos and 7 mos of follow up, respectively. The most common treatments post Pal were single-agent capecitabine (Cape) (n=9) and the combination of exemestane (Exe) and everolimus (Eve) (n=8). The median PFS was 4.7 mos with Cape compared to 8.4 mos with Exe and Eve (p=0.60). The median PFS was 4.7 mos for the 20 pts who received chemo, whereas the median PFS was 4.9 mos with subsequent HT (n=16) (p=0.75).

Conclusion

Pal plus letrozole or fulvestrant is effective for the treatment of HR+ HER2- MBC, with activity observed beyond the 1st and 2nd line treatment settings. The PFS of Pal observed in this single center retrospective study is consistent with that of published data. Single-agent cape or the Exe and Eve combination were common treatment choices following progression on Pal. Although the study is limited by its small sample size, the median PFS of 8.4 mos with Exe and Eve indicates its potential efficacy in the setting of Pal progression. Additional pts and followup data will be presented.

Citation Format: Xi J, Oza A, Thomas S, Naughton M, Ademuyiwa F, Weilbaecher KN, Suresh R, Bose R, Cherian MA, Hernandez-Aya L, Frith A, Peterson LL, Krishnamurthy J, Ma CX. Retrospective review of palbociclib (Pal) efficacy and benefit from subsequent treatments following Pal progression in patients (pts) with hormone receptor positive (HR+) and HER2 negative (HER2-) metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-30.

Abstract OT1-02-10: A phase 2 study of poziotinib in patients with HER2-positive metastatic breast cancer (MBC) who have received prior HER2 regimens for MBC

Background: Poziotinib is a novel, oral, quinazoline-based pan-HER inhibitor that irreversibly blocks signaling through the epidermal growth factor receptor (EGFR) family of tyrosine-kinase receptors, including EGFR (HER1/ErbB1/EGFR), HER2 (ErbB2), and HER4 (ErbB4), as well as HER receptor mutations. This, in turn, leads to inhibition of the proliferation of tumor cells that overexpress these receptors. It is well established that breast cancers are associated with a mutation in, or overexpression of, members of the EGFR receptor family. The primary objective of this Phase 2 study is to evaluate the Objective Response Rate (ORR) of poziotinib in patients with human epidermal growth factor receptor 2 (HER2)-positive MBC. The secondary efficacy variables are Progression-Free Survival (PFS), Disease Control Rate (DCR), Overall Survival (OS), and Time to Progression (TTP).

Trial Design: This is a Phase 2, open-label, multicenter study to evaluate the efficacy, safety and tolerability of poziotinib in patients with HER2-positive MBC who have received at least 2 prior HER2- directed treatment regimens. Each treatment cycle is 21 days in duration. During each cycle, eligible patients receive 24 mg of poziotinib orally (as three 8-mg tablets) once daily for 14 days, followed by a 7 day treatment-free period.

Eligibility Criteria: Eligible patients are at least 18 years of age, have confirmed HER2 overexpression, adequate hematologic, renal and hepatic function, and have received at least 2 prior HER2-directed therapy regimens, including trastuzumab and trastuzumab emtansine (TDM-1). Patients are excluded if they have prior exposure to poziotinib, a history of congestive heart failure, left ventricular ejection fraction <50%, unable to take oral medications, or have conditions that cause malabsorption. A 30 day wash out period from previous chemotherapeutic or radiation therapies is required.

Statistical Methods: The purpose of this study is to evaluate the efficacy of poziotinib compared to the efficacy of other standard HER2-positive breast cancer treatments as reported in the literature. The ORR will be analyzed descriptively along with the 95% CI. The secondary efficacy variables will be analyzed descriptively.

Target Accrual: Approximately 70 patients. Enrollment began February 2016.

Contact Information: For more information or to refer a patient,

email: spi-poz-201@sppirx.com or fax: 1-949-398-9711.

Citation Format: Lathrop K, Lucas J, Vacirca JL, Bhat G, Choi MR, Naughton M. A phase 2 study of poziotinib in patients with HER2-positive metastatic breast cancer (MBC) who have received prior HER2 regimens for MBC [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-02-10.

Abstract S6-05: A phase II trial of neoadjuvant palbociclib, a cyclin-dependent kinase (CDK) 4/6 inhibitor, in combination with anastrozole for clinical stage 2 or 3 estrogen receptor positive HER2 negative (ER+HER2-) breast cancer (BC)

Background

ER+ BC is associated with activated CDK4/6. The CDK4/6 inhibitor palbociclib (P) markedly improves time to progression in advanced ER+HER2- BC. We conducted a neoadjuvant phase II trial to determine the activity of P in primary breast cancer as a prelude to adjuvant studies.

Methods

To assess molecular changes induced by anastrozole (A) or P+A, patients (pts) were treated initially with A alone (1mg PO daily) for 28 days in cycle 0 (C0) before the addition of P (125mg PO daily on D1-21 each cycle) on C1D1. P+A was administered for 4 28-day cycles followed by C5 with A alone for 2-4 weeks (wks) before surgery. P was added in C5 for 10-12 days immediately prior to surgery in the last 20 pts enrolled to assess molecular changes induced by A, either alone or in combination with P immediately prior to surgery, in resected tumor. Goserelin was added in premenopausal pts.

Research tumor biopsies were obtained at baseline, C1D1, and C1D15. Central Ki67 analysis was performed at all timepoints, those with Ki67 >10% at C1D15 went off study treatment.

The primary endpoint was complete cell cycle arrest (CCA), defined as Ki67 <2.7%, at C1D15. Patient stratification was based on PIK3CA mutation status with an initial focus on PIK3CA wild type (WT) disease. Pts with PIK3CA mutant (Mut) tumors enrolled to a separate cohort. A sample size of 33 pts in the PIK3CA WT cohort was chosen based on the Fleming's single-stage phase II design to test the hypothesis that P+A leads to > 50% improvement over A in CCA rate on C1D15 biopsy (44% with A alone based on historical data, vs 66% with P+A, power = 0.8, alpha=0.05). The primary endpoint is met if >20 pts achieved CCA in this cohort.

Correlative endpoints included assessment of markers of proliferation, apoptosis, senescence, Rb, gene expression microarray, intrinsic subtype, and next generation sequencing of 83-gene panels, which will be reported at the meeting.

Results

Between 4/23/2013 and 4/24/2015, 50 pts (33 PIK3CA WT, 11 PIK3CA Mut, 2 pending, 4 tissue quantity or quality not sufficient for sequencing (QNS)) were enrolled to the study. Median age was 57.5 (range: 34.1–79.6) years. Four pts, all with WT PIK3CA, went off study due to Ki67 >10% on C1D15 biopsy, 26 pts completed treatment and surgery, 1 refused surgery, 3 withdrew study treatment in C1, and 16 continued to receive study drug (2 in C0, 3 in C1, 4 in C2, 5 in C3, 1 in C4, and 1 in C5). Among the 40 pts currently evaluable for the primary endpoint (C1D15 Ki67), CCA occurred in 34 (85%) pts, including 9 of 9 (100%) PIK3CA Mut, 22 of 28 (78.5%) WT, and 3 of 3 QNS pts. Preliminary analysis of available data indicated a significantly lower Ki67 value after 2 wks of P+A (C1D15) compared to that on A alone (C1D1) (p=0.034, n=18).

Conclusion

This study met the primary endpoint demonstrating that P+A is a highly effective anti-proliferative combination. The sequential biopsy design clearly demonstrated that P+A increased cell cycle control over A alone. P+A was effective regardless of PIK3CA mutation status and these results support the evaluation of this combination in the adjuvant setting for ER+HER2- BC.

Citation Format: Ma CX, Gao F, Northfelt D, Goetz M, Forero A, Naughton M, Ademuyiwa F, Suresh R, Anderson KS, Margenthaler J, Aft R, Hobday T, Moynihan T, Gillanders W, Cyr A, Eberlein TJ, Hieken T, Krontiras H, Hoog J, Han J, Guo Z, Vij K, Mardis E, Al-Kateb H, Sanati S, Ellis MJ. A phase II trial of neoadjuvant palbociclib, a cyclin-dependent kinase (CDK) 4/6 inhibitor, in combination with anastrozole for clinical stage 2 or 3 estrogen receptor positive HER2 negative (ER+HER2-) breast cancer (BC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S6-05.

Abstract P5-13-04: A phase II neoadjuvant trial of MK-2206, an AKT inhibitor, in combination with anastrozole for clinical stage 2 or 3 PIK3CA mutant estrogen receptor positive HER2 negative (ER+HER2-) breast cancer (BC)

Background

Activating mutations in PIK3CA occur in approximately 40% ER+BC. MK-2206 (M), a pan-AKT inhibitor, induced apoptosis of ER+ BC under estrogen deprivation in preclinical studies. We conducted this neoadjuvant trial to determine the pathologic complete response (pCR) rate of M plus anastrozole (A) for PIK3CA mutant (Mut) ER+ BC.

Methods

This single arm open label study of M+A used a 2-stage Simon phase II design (stage 1, n=16; stage 2, n=13, alpha=0.10, power=0.90) to test whether pCR rate <1% (based on historical data with A alone), against the alternative that pCR rate ≥15% in PIK3CA Mut ER+ BC. At least 1 pCR in stage 1 was required to proceed to stage 2.

Eligible patients (pts) with clinical stage II or III ER+HER2- BC were pre-registered and proceeded to a research tumor biopsy for PIK3CA sequencing, followed by treatment with daily A monotherapy for 28 days (cycle 0). Pts with PIK3CA Mut BC were subsequently registered, underwent a second biopsy, and started M (150mg PO weekly) with daily A on cycle 1 day 1 (C1D1) for a maximum of four 28-day cycles followed by surgery. Goserelin was added for premenopausal pts. A tumor biopsy on C1D17, 17 days post the start of M, was performed. Those with C1D17 Ki67 >10% discontinued study treatment. pCR was defined as no invasive cancer in the breast and the lymph nodes. Tumor specimens collected at all timepoints are being analyzed for markers of proliferation, apoptosis, and PI3K pathway activity, gene expression microarray, intrinsic subtypes, and next generation sequencing of 83 genes.

Results

Of the 51 pts pre-registered, 35 pts did not register due to no PIK3CA mutation (n=22), inadequate specimen for testing (n=6), physician/pt decision (n=7). The remaining 16 pts (median age: 58, range: 40-77 years) received combination therapy. Three pts did not complete 4 cycles due to C1D17 Ki67 >10% (n=2) and intolerability (grade (Gr) 4 transaminase elevation in C1, n=1). Other severe toxicities possibly related to M included Gr 3 rash (25%) and pruritus (12.5%). Of the 13 pts completed study therapy and underwent surgery, all had residual disease in the breast and 7 also had positive nodes. Table 1 summarized changes in Ki67 during treatment.

ComparisonsnAbsolute changes in Ki67 median (range)Wilcoxon signed rank p-valueC1D1 relative to pre-registration11-17.0% (-49.8 to 4.1%)0.0020C1D17 relative to pre-registration14-16.4% (-51.4 to 4.1%)0.0004C1D17 relative to C1D112-1.5% (-18.6 to 15.8%)0.9697C1D1, biopsy post 28 days of A alone; C1D17 biopsy post 17 days on combination therapy

Although Ki67 levels post A monotherapy (C1D1) or M+A (C1D17) were significantly lower than that of pre-registration samples, Ki67 did not differ between C1D17 and C1D1 samples. Other correlative studies are ongoing and results will be presented.

Conclusion

Despite the small sample size, biomarker analysis on serial biopsy specimens demonstrated that M+A is unlikely to be more effective than A alone in PIK3CA Mut ER+ BC. This trial demonstrated the feasibility of genomic sequencing for pt selection and the value of a small, well-designed proof-of-principle neoadjuvant trial for the evaluation of targeted agents.

Citation Format: Ma CX, Suman VJ, Goetz M, Northfelt D, Burkard M, Ademuyiwa F, Naughton M, Margenthaler J, Aft R, Gray R, Tavaarwerk A, Wilke L, Haddad T, Moynihan T, Loprinzi C, Hieken T, Hoog J, Guo Z, Han J, Vij K, Mardis E, Sanati S, Al-Kateb H, Doyle L, Erlichman C, Ellis MJ. A phase II neoadjuvant trial of MK-2206, an AKT inhibitor, in combination with anastrozole for clinical stage 2 or 3 PIK3CA mutant estrogen receptor positive HER2 negative (ER+HER2-) breast cancer (BC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-13-04.

Serum BDNF as a peripheral biomarker of treatment-resistant depression and the rapid antidepressant response: A comparison of ketamine and ECT

BACKGROUND

Ketamine is associated with rapid antidepressant efficacy but the biological mechanisms underpinning this effect are unclear. Serum brain-derived neurotrophic factor (sBDNF) is a potential circulating biomarker of treatment-resistant depression (TRD) and ketamine response but it is unclear if this is a common target of both ketamine and electroconvulsive therapy (ECT), the current gold standard for TRD. Moreover, the impact of multiple ketamine infusions on sBDNF has not yet been established.

METHODS

Thirty five TRD patients with a current DSM-IV diagnosis of recurrent depressive disorder received up to 12 ECT sessions (N=17) or up to three intravenous infusions of low-dose (0.5mg/kg) ketamine (N=18). Blood samples were taken over the course of the study for assessment of sBDNF. Symptom severity and response were monitored using the 17-item Hamilton Depression Rating Scale (HDRS). sBDNF was assessed in 20 healthy controls to allow comparison with TRD patients.

RESULTS

As expected, sBDNF was lower in TRD patients at baseline compared to healthy controls. Ketamine and ECT treatment were both associated with significant reductions in depressive symptoms. However, sBDNF was significantly elevated only at one week following the first ketamine infusion in those classified as responders one week later. sBDNF was not elevated following subsequent infusions. ECT reduced depressive symptoms, as expected, but was not associated with an enhancement in BDNF.

LIMITATIONS

Patients continued with their psychotropic medications throughout this trial.

CONCLUSIONS

SBDNF normalisation does not appear to be a prerequisite for symptomatic improvement in TRD following ketamine or ECT treatment.

Abstract PD1-4: A phase I study of BKM120 and fulvestrant in postmenopausal women with estrogen receptor positive metastatic breast cancer

Background

BKM120, a pan-Phosphatidylinositol-3-kinase (PI3K) inhibitor, in combination with fulvestrant (F) induced synergistic apoptotic effect in preclinical studies of estrogen receptor positive (ER+) breast cancer. We therefore conducted a phase I trial of BKM120 and F in postmenopausal women with ER+ metastatic breast cancer (MBC) to determine the maximum tolerated dose (MTD) and the tolerability of this combination.

Methods

A standard 3+3 phase I design was chosen for phase IA to determine the MTD. Upon completion of phase 1A, an expansion cohort phase IB was initiated to further assess the tolerability and efficacy. Patients (pts) with ER+ MBC with measurable disease were eligible. No more than 3 lines of systemic therapy in the metastatic setting were allowed in phase 1B. Cycle (C) length was 28 days. Adverse events (AEs) were assessed using CTCAE 4.0. Tumor measurement occurred every 3 cycles.

Results

Since November 2011, 18 pts (median age: 60 (range 48-71) years) were treated at 3 dose levels (DL) of BKM120 [Table 1]. Since none of the 3 pts enrolled at the starting dose of BKM120 (DL1: 80mg daily) experienced any DLT during C1, 3 pts were then enrolled at DL2 (BKM120 100 mg daily). No DLT was observed in C1, however 2 experienced grade (G) 3 ALT elevation during C2. Therefore, 3 pts were treated with BKM120 100mg 5 days on and 2 days off schedule (DL2b), without any significant AEs. Subsequently Phase IB enrolled 9 pts at this dose level.

Across different DLs, most AEs were G1. MTD was not reached based on C1 toxicity. However, asymptomatic ALT elevations occurred frequently during C2, resulting in dose interruption and dose reductions of BKM120 [Table 1]. Other AEs led to dose interruption and reductions include G2 confusion, G2 hyperglycemia and G3 rash. However, only 2 pts discontinued treatment due to AEs.

Table 1 Dose Level and Adverse EventsPhase IANBKM120No. pts dose reduced (AE, Cycle)No. pts discontinued (AE, Cycle)DL1380mg daily1 (G3 ALT, C2)1 (G2 confusion, C2)DL23100mg daily1 (G3 ALT, C2), 1 (G3 ALT, C2; G3 Rash, C7)0DL2b3*100mg daily, 5/700Phase IB (DL2b)9100mg daily, 5/71 (G3 ALT, C2; G3 Rash, C4), 1 (G2 ALT, G3 hyperglycemia, C2)1 (G4 ALT, C2)* 1 pt started DL2 in C1, then switched to DL2b following an amendment

Eleven pts with a median of 2 prior endocrine therapy (range 1-9) and 0-1 chemotherapy regimens in the metastatic setting were evaluable for response [Table 2]. Among these pts, 6 had prior disease progression on F. Clinical benefit was observed in 6 (54.5%) pts, including 1 partial response (PR) and 5 prolonged SD lasting for at least 6 cycles. Eight pts continue to receive treatment to date. Data will be updated at the time of presentation.

Table 2 ResponsePhaseDLEval. pts (N)Best responseDuration on study (mon)IA11PD3  1SD19+ 21PD1  2SD9, 7 2b1PR12IB2b5SD4+, 6, 6, 10+, 11++ treatment ongoing

Conclusion

BKM120 100mg, administered daily or intermittently, plus F was tolerable without DLT during C1. Grade 2/3 ALT elevation was common in C2, especially with daily dosing, but most pts continued treatment with reduced dose of BKM120. Promising activity was observed in this Phase I trial. Phase III studies of this combination have been started in ER+ MBC.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD1-4.

GDNF gene delivery via a 2-(dimethylamino)ethyl methacrylate based cyclized knot polymer for neuronal cell applications

Nonviral genetic therapeutic intervention strategies for neurological disorders hold great promise, but a lack of vector efficacy, coupled with vector toxicity, continue to hinder progress. Here we report the application of a newly developed class of polymer, distinctly different from conventional branched polymers, as a transfection agent for the delivery of glial cell line derived neurotrophic factor (GDNF) encoding gene. This new 2-(dimethylamino)ethyl methacrylate (DMAEMA) based cyclized knot polymer was studied for neuronal cell transfection applications, in comparison to branched polyethyleneimine (PEI). While showing a similar transfection profile over multiple cell types, the cyclized knot polymer showed far lower toxicity. In addition, transfection of Neu7 astrocytes with the GDNF encoding gene was able to cause neurite outgrowth when cocultured with dorsal root ganglia (DRGs). The cyclized knot polymer assessed here (PD-E 8%PEG), synthesized via a simple one-pot reaction, was shown to have great potential for neuronal gene therapy applications.

Effect of (Neo)adjuvant zoledronic acid on disease-free and overall survival in clinical stage II/III breast cancer

BACKGROUND

Despite neoadjuvant/adjuvant chemotherapy, women with resectable stage II/III breast cancer (BC) have high risk of recurrent disease. Recent data suggest that zoledronic acid (ZOL) therapy concurrent with adjuvant treatments may improve cancer-related outcomes in patients with BC.

METHODS

Disease-free survival (DFS; secondary end point) and overall survival (OS; tertiary end point) were evaluated in 119 women with stage II/III BC randomised to intravenous ZOL 4 mg every 3 weeks for 1 year or no ZOL (control) starting with the first chemotherapy cycle.

RESULTS

At 61.9 months' median follow-up, there was no significant difference in recurrence or survival between study arms. However, time to recurrence or death (DFS) was significantly different between subgroups defined by oestrogen receptor (ER) status (interaction P=0.010 for DFS and 0.025 for OS). Hazard ratios (HRs) for disease recurrence and death were significantly less among patients with ER-negative (ER(-)) tumours who received ZOL vs no ZOL (DFS: HR=0.361, 95% confidence interval (CI) 0.148, 0.880; OS: HR=0.375, 95% CI 0.143, 0.985).

CONCLUSION

ZOL administered with chemotherapy may improve DFS and OS in a subset of BC patients with ER(-) tumours. This study was not powered to compare subgroups of patients; thus, these findings should be considered hypothesis generating.

An examination of Australian general practitioners' knowledge, attitudes and practices in relation to sleep disorders

BACKGROUND

Sleep disorders represent an under-recognised public health problem and are reported to be under-diagnosed in general practices.

AIMS

To examine general practitioners' (GPs) attitude, knowledge and practice behaviour and identify barriers to detection, diagnosis and treatment of sleep disorders encountered in the Australian primary care setting.

METHOD

Using mixed methods, quantitative data from the Dartmouth Sleep Knowledge Questionnaire (DSKQ) were analysed using MS Excel 2007. Qualitative data were obtained from one focus group and eight interviews. Data were thematically analysed.

RESULTS

15 GPs participated; seven in a focus group and eight in interviews. Scores from DSKQ suggest gaps in GPs' knowledge. Qualitative analysis revealed that patients frequently presented with sleep disorders underpinned by mental health disorders. GPs agreed that prescribing pharmacological interventions was undesirable and behavioural interventions were preferred. Barriers included limited training for GPs, lack of resources, patient expectations and willingness to engage in lifestyle changes, and consultation time constraints.

DISCUSSION

Greater flexibility to investigate sleep related problems within the standard consultation and improved access to educational activities could assist GPs. Patient factors, such as adherence to management strategies, are paramount to successful management of sleep disorders; however, these obstacles to clinical practice may be difficult to overcome.

CONCLUSION

Providing education for GPs about sleep disorders, greater flexibility within consultations may improve patient care and patient engagement in management strategies may assist, yet a critical success factor in disease management includes patient engagement in management strategies.

Abstract P3-02-12: Effect of Platelet Function Inhibition on Circulating Tumor Cells in Patients with Metastatic Breast Cancer: A Randomized Phase II Trial

Background: Tumor-recruited platelets have been implicated in tumor cell survival in the circulation, and in tumor cell arrest and adhesion at distant metastatic sites. Tumor cells activate platelets through a variety of mechanisms including the generation of thrombin and ADP. Blockade of platelet activation and aggregation can inhibit metastasis in animal models. Clopidogrel (Plavix) inhibits ADP mediated platelet activation through blockade of the P2Y12 receptor. Aspirin blocks thromboxane production and can partially disrupt thrombin and ADP mediated activation of platelets. We hypothesized that disruption of platelet function and aggregation will result in a decrease in circulating tumor cells (CTC) number. We evaluated the impact of platelet inhibitors clopidogrel and aspirin on CTC in women with metastatic breast cancer.

Methods: Eligible patients had a diagnosis of metastatic breast cancer, had no contraindications to receive aspirin or clopidogrel, and were on a planned anti-neoplastic treatment break or were on stable endocrine therapy for at least 2 months. Maintenance zoledronic acid and/or trastuzumab was allowed. Patients were randomized to receive either aspirin and clopidogrel or no treatment. CTC was measured at baseline, 2 weeks, 1 month, and monthly thereafter. CTC determinations were made via the CellSearch® assay from Veridex®. Platelet aggregation in whole blood using VerifyNow® P2Y12 and aspirin cartridges was performed on all samples to monitor drug compliance. The primary endpoint was proportion of patients with detectable CTC at 1 month.

Results: 48 patients were enrolled, 22 and 19 remained on study at 1 month for the no treatment and treatment arms. Patient characteristics: the median age was 56, 58% of patients were ER positive, 35% were Her2 positive, the median number of organs involved with metastasis was 2, and the median time since diagnosis of metastasis was approximately 22 months. Baseline CTC was ≥1 in 65% of patients and was ≥5 in 13% of patients. Proportion of patients with CTC ≥1 at time of study completion was compared between groups using Fisher's Exact Test and showed no difference between groups. Mean CTC was compared using non-parametric testing and was not different at any time point; however, the no treatment group's mean CTC increased more rapidly over time compared to the treatment group. Medication compliance as monitored by platelet function testing was outstanding. Clopidogrel and aspirin were well tolerated with no patients developing an SAE related to bleeding. Discussion: There was no statistically significant difference between patients who received anti-platelet therapy and those who did not with respect to the primary endpoint, proportion of detectable CTC at one month. In this population of patients with treated metastatic breast cancer, the CTC numbers were lower than expected, which likely decreased our ability to detect a difference in CTC number with anti-platelet therapy. Aspirin and clopidogrel were well tolerated in patients with metastatic breast cancer. Future studies addressing the utility of CTC in clinical settings as well as the potential role for anti-platelet therapy in breast cancer are needed.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-02-12.

Abstract P6-14-04: Effect of Zoledronic Acid on Disease-Free Survival and Overall Survival in Women with Clinic Stage II/III Undergoing Neoadjuvant Chemotherapy for Breast Cancer

Background: We conducted a randomized Phase II study examining the effect zoledronic acid (ZA) on disseminated tumor cells (DTC) in women undergoing neoadjuvant chemotherapy (Lancet Oncology11:421). We now report on the effect of ZA administered concurrently with neoadjuvant/adjuvant chemotherapy on disease-free survival and overall survival in this patient population.

Methods: Between March 2003-2006, 120 women with newly diagnosed clinical stage II/III breast cancer were randomized to either ZA 4 mg IV every 3 weeks for 1 year starting with the first cycle of chemotherapy or no bisphosphonate. 4 cycles of epirubicin (75 mg/m2)/docetaxel (75 mg/m2) were given prior to surgery and 2 cycles in the adjuvant setting. Eligible patients received adjuvant endocrine therapy and trastuzumab. Disease-free survival was defined as the time from trial registration to first detectable recurrence. Overall survival was defined as the time from trial registration to date of breast-cancer related death. Data was analyzed using Kaplan-Meier and Cox proportional hazard models.

Results: Of 120 patients randomized 119 patients were evaluable. Treatment arms were balanced for grade, menopausal status, and tumor biomarkers. Tumors of 55 (46.2%) women were estrogen-receptor (ER) positive/Her2-negative, 40 (33.6%) were ER-negative/Her2-negative and 24 (20.2%) were Her2-positive.With a median follow up of 61.9 (4.93-85.43) months, there was no significant difference in recurrence or survival between the ZA and no ZA groups (p=0.88, p=.92 respectively). Subgroup analysis demonstrated that time to recurrence and death was significantly different between patient groups based on ER-status and ZA treatment (p=.013 for recurrence, p=.013 for survival).

Months

Time to recurrence and hazard of death was similar in three of the subgroups, ER-positive/Her2-negative/control, ER-positive/Her2-negative/ZA, and ER-negative/Her2-negative/ZA (p>.05 for recurrence and p>.05 for survival. ER-negative/Her2- negative patients in the no ZA treatment arm experienced a significantly decreased time to recurrence and survival compared to ER-positive patients (p=.0039, p=.0074, respectively). The hazard ratio of death for ER-negative/Her2-negative patients was reduced from 8.36 to 3.15 with ZA treatment. The estimated 5yr survival for ER-positive/Her2-negative/control, ER-positive/Her2-negative/ZA, ER-negative/Her2-negative/control, ER-negative/Her2-negative/ZA were 96.6%, 80.0%, 63.2% and 81.0% respectively.

Discussion: ZA administered with chemotherapy conferred a disease-free survival and overall survival benefit to a subset of breast cancer patients with ER-negative/Her2-negative tumors. Longer follow-up may be required to determine if there is a benefit in other tumor subgroups. Larger studies are warranted to examine the effects of ZA in patients at high risk of developing metastatic disease.

PIK3CA mutation analysis in recurrent breast cancer

11041

Background: Mutations in PIK3CA (encoding p110α catalytic subunit of phosphatidylinositol-3-kinase) are among the most common genetic events identified in breast cancer but the role of these mutations in determining the clinical course of the disease is uncertain. Furthermore the frequency of PIK3CA mutation in metastatic breast cancer samples has not been adequately studied but is an important concern in the design of studies with novel agents designed to inhibit mutant PIK3CA. Methods: We have established a tumor banking protocol for patients (pts) with metastatic breast cancer. In this study, we performed a mutational analysis of exons 9 (HD) and 20 (KD) of the PIK3CA using tumor DNA obtained from pts with recurrent disease and correlated mutational status with clinicopathological features and prognosis. Results: Biopsies were obtained from sites of recurrence in 51 pts with stage 4 disease. The median F/U was 44 (range: 0.9–239) months and death has occurred in 66%. Mutations in PIK3CA were identified in 24.5% (11.3% in HD and 13.2% in KD). PIK3CA mutation was significantly correlated with lower tumor grade (47% in grade 1/2 vs 8% in grade 3, p=0.004), positive ER (35% in ER+ vs 5% in ER-, p=0.017), and PR (37% in PR+ vs 5% in PR-, p=0.011). Overall survival (OS) was 139.5 and 53.7 months for mutation- and non-mutation- carriers respectively (p=0.014). Conclusions: About one quarter of pts with recurrent/advanced breast cancer carry PIK3CA mutations in samples of recurrent disease, which correlated with positive ER/PR status and a more indolent clinical course. These patients are good candidates for experimental protocols that combine endocrine agents with PI3 kinase inhibitors but the slower kinetics of disease progression in PIK3CA mutation carriers may have to be taken into account for statistical designs and power size calculations.

No significant financial relationships to disclose.

Clinical trial participants’ strategies for coping with prescription drug costs: A companion study to CALGB 80405

9503

Background: The strategies used by clinical trial participants to cope with the high costs of prescription drugs are poorly characterized. Methods: We identified a cohort of newly metastatic CRC patients participating in CALGB 80405, a phase III trial comparing first-line systemic chemotherapy with Bevacizumab, Cetuximab or both agents. We surveyed trial participants about their prescription drug insurance status and strategies they used to cope with out-of-pocket prescription drug costs. We surveyed patients before trial initiation and again 3 months later to assess the extent to which embarking on chemotherapy imposes additional financial burden requiring use of coping strategies. Results: Out of 1422 trial participants, 806 (57%) completed the baseline survey. The 515 enrolled before 09/01/2007 were asked to repeat the survey by phone at 3 months; 409/505 alive at 3 months (81%) did so. The 409 patients in the analytic cohort had similar clinical and demographic features to those not surveyed. 60/409 (15%) lacked prescription drug coverage and only 48/409 (12%) discussed prescription drug costs with their physicians. Conclusions: In the context of a trial in which costs of chemotherapy are covered and most participants had prescription drug insurance, patients rarely discuss prescription drug costs with their physicians. Although a considerable minority report having used coping strategies to lessen the cost burden, only a very small minority newly adopt such strategies after starting chemotherapy on trial.

[Table: see text]

[Table: see text]

Questionnaires to Assess Urinary and Anal Incontinence: Review and Recommendations

PURPOSE

We reviewed and provide recommendations about the most scientifically robust and appropriate questionnaires for evaluating symptoms and the quality of life impact of urinary and/or anal incontinence, and vaginal and pelvic floor problems. We also investigated the use of these questionnaires in randomized, controlled trials of treatment strategies.

MATERIALS AND METHODS

The Symptom and Quality of Life Committee of the International Consultation on Incontinence performed a systematic review of questionnaires related to urinary and anal incontinence, and vaginal and pelvic floor problems, searching MEDLINE, The Cochrane Library and other electronic databases between 2001 and 2004.

RESULTS

A total of 23 robust and relevant questionnaires could be recommended in clinical practice and research. The development of questionnaires to assess anal incontinence, and pelvic floor and vaginal problems has been limited with some promising measures but with none achieving the highest level of rigor. From 2001 to 2004 there were 150 published randomized trials of treatments for incontinence. Increasingly trials of incontinence are using recommended measures (38% of those for urinary incontinence and 22% of those for anal incontinence used the highest quality questionnaires in 2001 to 2004) but none of vaginal and pelvic floor problems used recommended questionnaires.

CONCLUSIONS

With increasing acknowledgment of the value of patient based assessment much attention has been given to the development of questionnaires to assess symptoms and quality of life. Sufficient measures are now available for urinary incontinence, and researchers and clinicians are encouraged to use the 18 achieving the highest level of rigor and their validated translations. In contrast, the development of questionnaires for anal incontinence and pelvic/vaginal problems is in its infancy and further study in this area is needed. Randomized trials of treatments for incontinence should use only questionnaires achieving the highest level of scientific rigor.

Reversal of adverse effects of neoadjuvant chemotherapy on bone turnover in pre- and post-menopausal women with zoledronic acid

556

Background: Ovarian failure secondary to adjuvant chemotherapy is known to have an adverse effect on bone mineral density and to increase bone turnover markers. The effects of chemotherapy with growth factor support in the absence of hormonal changes have not been described. The impact of zoledronic acid on these changes was also explored. Methods: We evaluated bone turnover markers in 82 women undergoing neoadjuvant chemotherapy for localized stage II/III breast cancer at initial diagnosis prior to treatment and after 4 cycles of epirubicin (75mg/m2)-docetaxel (75mg/m2) with pegylated G-CSF support with or without zoledronic acid. 47% of patients were post-menopausal and all groups were balanced for other variables. Women were randomized to receive zoledronic acid 4 mg IV every 3 weeks concurrently with chemotherapy (n=41) versus no bisphosphonate treatment (n=41). Bone turnover markers included: urinary N-telopeptide (NTx), serum bone specific alkaline phosphatase (BAP)and osteocalcin (OSTEO). Results: Women, regardless of menopausal status, who received no bisphosphonate had statistically significant increases in NTx, from baseline after 3 months of neoadjuvant chemotherapy using multivariable mixed repeated measures (p=0.0213). Women who received zoledronic acid concurrently with neoadjuvant chemotherapy had statistically significant decreases in NTx (p<0.0001), BAP (p<0.0001) and OSTEO (p=0.0295) from baseline. This is the first demonstration that anthracycline-taxane chemotherapy with growth factor support increased bone turnover markers in both post-menopausal and pre-menopausal women independent of hormone therapy, radiation therapy and surgery. Conclusions: Neoadjuvant chemotherapy with anthracycline- taxane and growth factor support increased bone resorption markers in both post-menopausal and pre-menopausal women. Zoledronic acid given concurrently with each cycle of chemotherapy reversed this increase in bone turnover markers.

No significant financial relationships to disclose.

Symptom clusters in newly-diagnosed brain tumor patients

8587

Background: A symptom cluster is 2 or more co-occurring symptoms. Patients with brain tumors experience disease and treatment-related symptoms that impact their health-related quality of life (QOL). Identifying symptom clusters will facilitate treatment and improve QOL outcomes. Methods: 66 patients were enrolled in a phase III, placebo-controlled, double-blind, prospective randomized clinical trial assessing the effect of prophylactic d-methylphenidate (d-MPH) on QOL in newly diagnosed brain tumor patients receiving brain radiation therapy (RT). Inclusion criteria were: age ≥ 13 years, primary or metastatic brain tumor, partial or whole brain RT with a total dose of ≥ 2,500 cGy in ≥ 10 fractions, KPS ≥ 70, and life expectancy ≥ 3 months. Patients received d-MPH 5–15 mg BID (or placebo) starting week 1 of RT and continuing for 8 weeks post-RT. QOL data were collected at baseline, the end of RT, and 4, 8, and 12 weeks following RT using the Functional Assessment of Cancer Therapy-Brain (FACT-Br) and the Center for Epidemiologic Studies Depression Scale (CES-D). Symptom data were analyzed using exploratory factor analysis, multi-dimensional scaling (MDS), and cluster analysis. Results: The study failed to show a treatment effect for d-MPH (Butler J et al, Int J Radiat Oncol Biol Physics 63 [Supp1]:80, 2005).Thus, both d-MPH and placebo patients were analyzed together. 58 and 48 patients were analyzed at baseline and the end of RT, respectively. Two symptom clusters were identified using exploratory factor analysis and supported by MDS and cluster analysis: an expressive language cluster including difficulty reading, writing, and finding the right words, and a mood cluster including feeling sad, anxious, and having depressed mood. Conclusions: Two symptom clusters were identified in patients undergoing brain RT: an expressive language cluster and a mood cluster. This suggests that interventions that target both cognitive function and mood should be utilized. Further research on symptom clusters in cancer patients is needed. This study was supported by NCI grant 1 U10 CA81851.

No significant financial relationships to disclose.

Blood lead levels of primary school children in Dhaka, Bangladesh

Dhaka, Bangladesh, has one of the highest air lead levels in the world. In February 2000, we evaluated children at five primary schools in Dhaka to determine blood lead (BPb) levels, sources of environmental exposure, and potential risk factors for lead poisoning. Selected schools represented a range of geographic and socioeconomic strata. A total of 779 students 4-12 years of age participated. The mean BPb level was 15.0 microg/dL (range 4.2-63.1 microg/dL). Most students (87.4%) had BPb levels above the Centers for Disease Control and Prevention's level of concern (10 microg/dL). Elevated BPb levels correlated with soil eating [odds ratio (OR) = 3.31; 95% confidence interval (CI), 1.30-8.39], low parental education (OR = 2.72; 95% CI, 1.97-3.75), living close to major roads (OR = 2.30; 95% CI, 1.23-4.29), and increasing age (OR = 1.11; 95% CI, 1.06-1.16). BPb levels measured were similar to those in other countries that use leaded gasoline. No other potential sources of lead exposure were consistently identified. Combustion of leaded gasoline is the main source of lead exposure in Dhaka, resulting in ubiquitous contamination of the environment. The increase in BPb levels with age, a finding contrary to observations in the United States and Australia, may be related to increased outdoor activities. The Bangladeshi government recently announced a plan to eliminate leaded gasoline. Baseline BPb surveys are critical to develop and evaluate intervention policies. Strategies to reduce BPb levels need to address variations in socioeconomic status, construction type and location of housing, and levels of hygiene.

Scatter factor-hepatocyte growth factor elevation in the serum of patients with prostate cancer

PURPOSE

Scatter factor (SF), also known as hepatocyte growth factor (HGF), has been shown to induce proliferation, scattering and invasiveness in human prostate cancer cell lines. In this study we determined the serum level of SF-HGF in men with metastatic prostate cancer compared to those with localized prostate cancer and without prostate cancer.

MATERIALS AND METHODS

Serum samples were obtained from men with biopsy proved adenocarcinoma of the prostate and radiographic evidence of metastatic disease, those with biopsy proved adenocarcinoma of the prostate and clinically localized disease, and those with negative sextant prostate biopsies. Serum SF-HGF was determined using a commercially available enzyme-linked immunosorbent assay kit.

RESULTS

Of the 108 men enrolled in our study 52 had negative sextant biopsies, 36 had clinically localized cancer and 20 had metastatic disease. The serum level in men with metastatic disease was significantly elevated (mean 2,117 pg./ml., range 820 to 6,403) compared to that in men with localized cancer and without prostate cancer (mean 974 pg./ml., range 437 to 2,132 and 700, range 272 to 1,875, respectively, p = 9.5 x 10(-15)). Logistic regression analysis demonstrated that the association of ln (SF-HGF) with prostate cancer persisted after controlling for patient age and ln (prostate specific antigen) (p = 3.1 x 10(-4)).

CONCLUSIONS

Serum SF-HGF is increased in men with metastatic prostate cancer. SF-HGF levels are associated with metastatic prostate cancer independent of the prostate specific antigen level and patient age. These data imply that SF-HGF may be an important serum marker for prostate cancer.

Characterization of D-fenfluramine-induced hypothermia: evidence for multiple sites of action

The effects of D-fenfluramine on core body temperature has been largely investigated under conditions of either high or low ambient temperature, whereas little research has focused on this response under normal environmental conditions. Moreover, there has been neglect in research on the mechanisms underlying changes in body temperature. In this study, we demonstrate that D-fenfluramine (5 and 10 mg/kg) induces a sustained decrease in body temperature in the rat under normal ambient temperatures. Pre-treatment with the selective serotonin reuptake inhibitor sertraline (5 mg/kg), the full 5-HT(1A) receptor antagonist 4-fluoro-N-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-2-pyridinyl benzamide], WAY 100635 (0.15 mg/kg) and the 5-HT(2C) receptor antagonist benzofuran-2-carboxamidine, RO 43-0440 (2.5 mg/kg) blocked D-fenfluramine-induced hypothermia. Depletion of 5-hydroxytryptamine (5-HT) stores following treatment with the serotonergic neurotoxin parachlorophenylalanine reversed the initial hypothermic effects of D-fenfluramine but not the later effects, as D120 min post-challenge) in animals pre-treated with parachlorophenylalanine. Such findings are consistent with a requirement for D-fenfluramine uptake into 5-HT neurons followed by release of 5-HT from intracellular stores and stimulation of post-synaptic 5-HT receptors to reduce body temperature. The hypothermic response to D-fenfluramine was potentiated by ketanserin pre-treatment 30 min post-challenge but then antagonized at later time intervals. Pre-treatment with the dopamine, D(2) antagonist, haloperidol (1 mg/kg) and sulpiride (30 mg/kg) had a similar effect in blocking the hypothermia as WAY 100635, suggesting a role for dopamine D(2) receptors in the response. Pre-treatment with the alpha(2)-adrenoceptor antagonist yohimbine failed to block the hypothermic response. These results suggest multiple sites of action mediating D-fenfluramine-induced hypothermia and may be the result of a combined effect of D-fenfluramine and its active metabolite norfenfluramine affecting not only the release of 5-HT but also stimulation of post-synaptic receptors.

Tularemia--an unusual cause of a solitary pulmonary nodule in the post-transplant setting

We report a case of tularemia presenting as a solitary pulmonary nodule following syngeneic PBSC transplant. Seven months after undergoing a syngeneic PBSC transplant for AML, our patient presented with fever without localizing signs. Chest X-ray revealed a solitary pulmonary nodule. Culture of a CT guided needle aspiration revealed Francisella tularensis. The patient was successfully treated with ciprofloxacin. His fever resolved and clearance of the nodule was documented on a CT scan 2 months after diagnosis and initiation of treatment. To our knowledge, this is the only reported case of tularemia occurring in the post-transplant setting. The possible relationship between transplant-induced immune dysfunction and the occurrence of this rare infection is discussed.

Trust amalgamation. A partnership challenge

Structure and role clarity should be an early priority A rigorous and fair appointments process is required Short term performance will be affected Communicate all the time The 'must be dones' still have to be done The trust has not reached its first birthday