Bothersome Hot Flashes Following Neoadjuvant Androgen Deprivation Therapy and Stereotactic Body Radiotherapy for Localized Prostate Cancer

PURPOSE/OBJECTIVE(S)

Androgen deprivation therapy (ADT) may improve cancer control in unfavorable localized prostate cancer treated with stereotactic body radiotherapy (SBRT). ADT is known to cause hormonally related symptoms that resolve with testosterone recovery. Hot flashes are particularly burdensome. This study sought to evaluate the timeline of hot flashes following short-course ADT and SBRT as well as its relationship with testosterone recovery.

MATERIALS/METHODS

Institutional IRB approval was obtained for this retrospective review of prospectively collected data (IRB#: 2009-510). ADT was initiated three months prior to the start of SBRT. Hot flashes were self-reported via question 13a a healthcare software prior to ADT initiation, the first day of robotic SBRT, and at each follow-up (1, 3, 6, 9, 12, 18, 24 and 36 months). The responses were grouped into three relevant categories (no problem, very small-small problem and moderate-big problem). Scores were transformed to a 0-100 scale with higher scores reflecting less bother. Testosterone levels were measured at each follow-up.

RESULTS

From 2007 to 2010, 122 localized prostate cancer patients (9 low-, 64 intermediate-, and 49 high-risk according to the D'Amico classification) at a median age of 72 years (range 54.5-88.3) were treated with short course ADT (3-6 months) and SBRT (35-36.25 Gy) at Georgetown University Hospital. Thirty-two percent were black and 27% were obese. 77% of patient received three months of ADT. At baseline, 2% of men experienced hot flashes that were a "moderate to big problem" and that proportion peaked at the start of SBRT (45%) before returning to baseline 9 months post-SBRT with a cumulative incidence of 52.4%. The median baseline healthcare software hot flash score of 94 declined to 50 at the start of SBRT but this returned to baseline by six months post SBRT. These changes were both statistically and clinically significant (MID = 9.5083). Testosterone recovery (> 230 ng/dL) occurred in approximately 70% of patients by 12 months post SBRT. Resolution of hot flashes correlated with testosterone recovery.

CONCLUSION

Bothersome hot flashes occur in greater than 50% of men treated with neoadjuvant ADT. Resolution of hot flashes occurs in the majority of patients within one year after treatment. Reassurance of the temporary nature of hot flashes may assist in reducing patient anxiety. Measuring testosterone levels at follow-up visits may allow for anticipatory counseling that may limit the associated bother.

Bothersome Gynecomastia Following Neoadjuvant GnRH Agonists and Stereotactic Body Radiotherapy for Localized Prostate Cancer

PURPOSE/OBJECTIVE(S)

Androgen deprivation therapy (ADT) is increasingly utilized in combination with stereotactic body radiotherapy (SBRT) for unfavorable prostate cancer. ADT such as gonadotropin releasing hormone (GnRH) agonists are known to cause hormonal-related side effects such as gynecomastia. The incidence of bothersome breast tenderness and/or enlargement following short course GnRH agonists and SBRT is unknown. This study sought to evaluate the timeline of gynecomastia as well as its relationship with testosterone recovery.

MATERIALS/METHODS

Gynecomastia was self-reported via question 13b of a healthcare software prior to ADT initiation, the first day of robotic SBRT, and at each follow-up (1, 3, 6, 9, 12, 18, 24 and 36 months). The responses were grouped into three relevant categories (no problem, very small-small problem, and moderate-big problem). Scores were transformed to a 0-100 scale with higher scores reflecting less bother. Testosterone levels were measured at each follow-up.

RESULTS

From 2007 to 2010, 122 localized prostate cancer patients (9 low-, 64 intermediate-, and 49 high-risk according to the D'Amico classification) at a median age of 72 years (range 54.5-88.3) were treated with short course ADT (3-6 months) and SBRT (35-36.25 Gy) at Georgetown University Hospital. Of the participants, 48% percent were non-white and 48% were overweight. 77% of patients received three months of ADT. At baseline, 2% of men experienced gynecomastia that was a "moderate to big problem" and that proportion peaked at 3 and 12 months post-SBRT (7%) before returning to less than baseline (0%) 24 months post-SBRT with a cumulative incidence of 14.75%. The median baseline healthcare software hot flash score of 98 declined to 90 at 3 months post-SBRT but this returned to baseline by 24 months post SBRT. These changes were both statistically and clinically significant (MID = 6.5). Testosterone recovery (> 230 ng/dL) occurred in approximately 70% of patients by 12 months post SBRT. The development and resolution of gynecomastia fluctuated at various timepoints and did not directly correlate with testosterone recovery.

CONCLUSION

Bothersome gynecomastia occurs in less than 15% of men treated with neoadjuvant ADT. Resolution of gynecomastia occurs in most patients within two years after treatment. Reassurance of the temporary nature of gynecomastia may assist in reducing patient anxiety. Institutional IRB (IRB#: 2009-510) approval was obtained for retrospective review of prospectively collected data.

An International Multicenter Review of the Malignancy Rate of Excised Papillomatous Breast Lesions

BACKGROUND

Papillary lesions of the breast are a relatively rare, but heterogeneous group ranging from benign to atypical and malignant. Debate exists regarding the optimal management of these lesions. In the absence of more accurate risk-stratification models, traditional management guidelines recommend surgical excision, despite the majority of lesions proving benign. This study sought to determine the rate of malignancy in excised breast papillomas and to elucidate whether there exists a population in which surgical excision may be unnecessary.

METHODS

A multicenter international retrospective review of core biopsy diagnosed breast papillomas and papillary lesions was performed between 2009 and 2013, following institutional ethical approval. Patient demographics, histopathological, and radiological findings were recorded. All data was tabulated, and statistical analysis performed using Stata.

RESULTS

A total of 238 patients were included in the final analysis. The age profile of those with benign pathology was significantly younger than those with malignant pathology (p < 0.001). Atypia on core needle biopsy was significantly associated with a final pathological diagnosis of malignancy (OR = 2.73). The upgrade rate from benign core needle biopsy to malignancy on the final pathological sample was 14.4 %; however, only 3.7 % had invasive cancer.

CONCLUSIONS

This international dataset is one of the largest in the published literature relating to breast papillomas. The overall risk of malignancy is significantly associated with older age and the presence of atypia on core needle biopsy. It may be possible to stratify higher-risk patients according to age and core needle biopsy findings, thereby avoiding surgery on low-risk patients.

Southwest Oncology Group S9921: Prolonged event-free survival in high-risk prostate cancer (PC) patients receiving adjuvant androgen deprivation

5009

Background: Patients with adverse pathologic risk factors after radical prostatectomy are at high risk for biochemical relapse and eventual death from disease. Adjuvant hormonal therapy with or without chemotherapy may prolong event free survival. Methods: SWOG 9921 randomized 859 eligible high risk PC patients to receive 2 years of adjuvant combined androgen blockade (CAB) (goserelin + bicalutamide) with (433) or without (426) chemotherapy (mitoxantrone + prednisone). The primary endpoint is survival. The DSMC has approved this analysis. PSA was to be assessed every 3 mo for 5 yrs and then every 6 mo for 10 more yrs. PSA relapse was defined as 3 consecutive measurements > 0.2 ng/ml. Death w/o relapse is censored. The CAB only eligible group is being reported (n=426). Risk groups based on eligibility criteria are as follows: Risk Group 1= positive margins or extraprostatic extension only with Gleason 7; elevated PSA (pre-op > 15 ng/ml), or had a pre-op PSA > 10 ng/ml and a biopsy Gleason 7(N=113); Risk Group 2 = seminal vesicle invasion or Gleason >/= 8, but no positive nodes (N=240), Risk Group 3 =positive nodes (N=69), 397 patients from both arms who completed 2 years of CAB were assessed for time to testosterone (T) recovery. T was assessed every 6 mo until it reached the institutional lower limit of normal. The median follow-up time from randomization is 3.8 years. Results: See Table . The estimated median time to T recovery (> 50ng/ml) is 11.7 mo from the end of CAB (95% CI 11.3, 11.9 months). The 6 and 18 mo recovery rates were 16% and 89%. Of 17 deaths (including ineligibles), 7 were from prostate cancer; 4 from other cancers, one cardiovascular disease, and 5 from miscellaneous causes. Conclusions: These data indicate a markedly low PSA relapse and death rates in high risk PC patients who received CAB. This likely is the result of stage migration, patient selection and/or the effects of CAB itself.

[Table: see text]

[Table: see text]

Weekly paclitaxel (P) with concurrent external beam radiation (EBRT) and androgen deprivation therapy (ADT) in high-risk prostate cancer (PC) patients with or without prior prostatectomy (RP)

5122

Background: EBRT with ADT (4 mos to 2–3 yrs) is standard treatment for high risk PC. In this trial, we evaluated weekly P given concurrently with EBRT and ADT in high risk PC. Methods: For pts undergoing RP, high risk was defined as: pT3 and/or pN+, M0, and/or rising PSA (> 0.5) post RP. For pts not undergoing RP (i.e. locally advanced PC [LAPC]) high risk included: cT2b-4N0, N+, M0; bGS 8–10; bGS ≥ 7 + PSA ≥ 10 but ≤ 150; and/or PSA ≥ 20 but ≤ 150. Treatment included ADT (4 or 24 mos, preplanned based on clinical presentation), P (40, 50, or 60 mg/m2/wk) x 7 with EBRT, and whole pelvis EBRT 45 Gy with 19.8 Gy boost (total 64.8 Gy) to prostate bed in RP pts and 25.2 Gy boost (total 70.2 Gy) to prostate in LAPC pts. Results: Between October 1999 and December 2006, 59 pts (29 W, 28 AA) were enrolled (n = 29 LAPC, n = 30 RP); median age 67 yrs, median PSA at trial entry 5.9 (27.5 LAPC, 1.6 RP), median GS 8. Pts were enrolled at different weekly doses of P: 40 mg/m2 n = 10 pts; 50 mg/m2 n = 31 pts; 60 mg/m2 n = 18 pts. ADT for 4 mos was given in 29 pts and for 24 mos in 30 pts. At 40 mg/m2 67/70 (96%), 50 mg/m2 202/217 (93%), and 60 mg/m2 98/126 (78%) planned doses of P were given. There were no acute grade 4 toxicities. Most common grade 3 toxicities were diarrhea 15%, urinary urgency or incontinence 10%, tenesmus 5%, and leukopenia 3%. Median duration of f/u was 75.3 mos, OS 78%, biochemical progression 24/59 (41%) pts, clinical progression 11/59 (19%) pts. Time to biochemical progression was similar between RP vs. LAPC (p = 0.17), between ADT 4 mos vs. 24 mos (p = 0.61), and between AA vs. W (p = 0.54). Conclusions: This trial establishes the feasibility of tri-modality therapy with ADT, EBRT and weekly paclitaxel in high risk PC, both in RP pts and in LAPC pts with intact prostate glands. The maximum tolerated dose of paclitaxel is 50 mg/m2 /wk when given weekly with concurrent radiation to the pelvis and hormone ablation.

No significant financial relationships to disclose.

Aquaporin gene expression and regulation in the ovine fetal lung

Fetal lung development is dependent upon secretion of liquid into the future airways which must be cleared at birth to establish air-breathing. Aquaporins (AQP) 1, 3, 4 and 5 are membranous water channel proteins that are present in the lung after birth in rodents, with little expression before birth. Our aim was to describe the changes in AQP1, 3, 4 and 5 expression and protein levels in the fetal lung of a long-gestation species (sheep) and in response to physiological factors known to alter fetal lung liquid dynamics. Both mRNA and high protein levels were detected for AQP1, 3, 4 and 5 by day 100 (term is ~150 days in ovine fetuses). A cortisol infusion (120-131 days) significantly (P < 0.05) increased AQP1 (0.9 +/- 0.2 (n = 4) vs.1.8 +/- 0.3 (n = 5)) and AQP5 (8.8 +/- 0.6 vs. 14.1 +/- 1.2) mRNA levels in fetal lung (measured by real-time PCR). Ten days of tracheal obstruction significantly (P < 0.05) decreased AQP5 mRNA levels (6.1 +/- 0.9 (n = 5) vs. 2.7 +/- 0.3 (n = 5)). Immunohistochemistry was used to show that protein levels changed in parallel with the mRNA changes. These findings suggest that AQPs could be involved in lung liquid production and reabsorption during fetal development in long-gestation species.

Relationship between cardiac protein tyrosine phosphorylation and myofibrillogenesis during axolotl heart development

The axolotl, Ambystoma mexicanum, is a useful system for studying embryogenesis and cardiogenesis. To understand the role of protein tyrosine phosphorylation during heart development in normal and cardiac mutant axolotl embryonic hearts, we have investigated the state of protein tyrosine residues (phosphotyrosine, P-Tyr) and the relationship between P-Tyr and the development of organized sarcomeric myofibrils by using confocal microscopy, two-dimensional isoelectric focusing (IEF)/SDS-polyacrylamide gel electrophoresis (PAGE) and immunoblotting analyses. Western blot analyses of normal embryonic hearts indicate that several proteins were significantly tyrosine phosphorylated after the initial heartbeat stage (stage 35). Mutant hearts at stages 40-41 showed less tyrosine phosphorylated staining as compared to the normal group. Two-dimensional gel electrophoresis revealed that most of the proteins from mutant hearts had a lower content of phosphorylated amino acids. Confocal microscopy of stage 35 normal hearts using phosphotyrosine monoclonal antibodies demonstrated that P-Tyr staining gradually increased being localized primarily at cell-cell boundaries and cell-extracellular matrix boundaries. In contrast, mutant embryonic hearts showed a marked decrease in the level of P-Tyr staining, especially at sites of cell-cell and cell-matrix junctions. We also delivered an anti-phosphotyrosine antibody (PY 20) into normal hearts by using a liposome-mediated delivery method, which resulted in a disruption of the existing cardiac myofibrils and reduced heartbeat rates. Our results suggest that protein tyrosine phosphorylation is critical during myofibrillogenesis and embryonic heart development in axolotls.

Docetaxel followed by hormone therapy after failure of definitive treatments for clinically localized/locally advanced prostate cancer: preliminary results

An increasingly important issue in the management of prostate cancer is the occurrence of biochemical failure (ie, increasing serum prostate-specific antigen [PSA] levels) in patients with clinically localized prostate cancer who initially underwent definitive treatments with curative intent (prostatectomy and/or radiation therapy). This pilot trial evaluated chemotherapy followed by hormone therapy for a defined period in patients with biochemical (and possibly clinical) recurrence after initial local therapies for localized/locally advanced prostate cancer. Patients who developed increasing PSA > 4 ng/mL after initial prostatectomy and/or radiation therapy received docetaxel, 70 mg/m(2) every 3 weeks for up to 6 courses, followed by 4 months of total androgen suppression (using a luteinizing hormone-releasing hormone agonist plus bicalutamide, 50 mg/d) and 8 months of peripheral androgen blockade (using finasteride, 5 mg/d, plus bicalutamide, 50 mg/d). Twenty-seven patients have enrolled to date, 23 of whom received four or six cycles of docetaxel before hormonal therapies. Seventeen (74%) of 23 patients who completed four to six cycles of chemotherapy had a > or =40% decrease in PSA, and 16 (89%) of 18 patients who completed 4 months of total androgen suppression achieved PSA values of < or =0.1. The most common hematologic toxicity was grade (3/4) neutropenia; grade 3 nonhematologic toxicities were rare, and no grade 4 nonhematologic toxicities were reported. Thus, the preliminary results suggest that docetaxel before hormonal therapy includes a PSA response in many prostate cancer patients with biochemical failure after definitive local therapies.

Effects of alcohol-related disease on hip fracture and mortality: a retrospective cohort study of hospitalized Medicare beneficiaries

OBJECTIVES

This study investigated the effect of alcohol-related disease on hip fracture and mortality.

METHODS

A retrospective cohort design was used. The study cohort consisted of hospitalized Medicare beneficiaries with alcohol-related disease (n = 150,119) and randomly matched controls without alcohol-related disease (n = 726,218) identified through the 1988-1989 inpatient claims file. Incidence rates of hip fracture and mortality were examined.

RESULTS

During the study period, 20,620 patients developed hip fracture, with 6973 cases among patients with alcohol-related disease and 13,647 cases among patients without alcohol-related disease. After adjustment for potential confounders, patients with alcohol-related disease had a 2.6-fold increased risk of hip fracture relative to patients without alcohol-related disease (95% confidence interval = 2.5, 2.6). Patients with alcohol-related disease had a higher risk of mortality at 1 year after hip fracture.

CONCLUSIONS

Alcohol-related disease increases the risk of hip fracture significantly and reduces long-term survival. The present results suggest that patients hospitalized for alcohol-related disease should be targeted for hip fracture prevention programs.

Creation of chimeric mutant axolotls: a model to study early embryonic heart development in Mexican axolotls

The Mexican axolotl (Ambystoma mexicanum) provides an excellent model for studying heart development since it carries a cardiac lethal mutation in gene c that results in failure of contraction of mutant embryonic myocardium. In cardiac mutant axolotls (c/c) the hearts do not beat, apparently because of an absence of organized myofibrils. To date, there has been no way to analyze the genotypes of embryos from heterozygous spawnings (+/c x +/c) until stage 35 when the normal (+/c or +/+) embryos first begin to have beating hearts; mutant (c/c) embryos fail to develop normal heartbeats. In the present study, we created chimeric axolotls by using microsurgical techniques. The general approach was to transect tailbud embryos and join the anterior and posterior halves of two different individuals. The chimeric axolotl is composed of a normal head and heart region (+/+), permitting survival and a mutant body containing mutant gonads (c/c) that permits the production of c/c mutant offspring: 100% c/c offspring were obtained by mating c/c chimeras (c/c x c/c). The mutant phenotypes were confirmed by the absence of beating hearts and death at stage 41 in 100% of the embryos. Examination of the mutant hearts with electron microscopy and comfocal microscopy after immunofluorescent staining for tropomyosin showed identical images to those described previously in naturally-occurring c/c mutant axolotls (i.e., lacking organized sarcomeric myofibrils). These "c/c chimeric" axolotls provide a useful and unique way to investigate early embryonic heart development in cardiac mutant Mexican axolotls.

Attenuation of endothelin-1 induced vasoconstriction by 17beta estradiol is not sustained during long-term therapy in postmenopausal women with coronary heart disease

OBJECTIVES

The goal of this study was to determine the long-term effects of estrogen replacement therapy on the response to endothelin-1 (ET-1) in postmenopausal women with coronary heart disease.

BACKGROUND

It is thought that the vasoconstrictor ET-1 is involved in the development and progression of atherosclerosis. Estrogen replacement may slow the development of atherosclerosis in postmenopausal women.

METHODS

Nineteen of 20 postmenopausal women randomized to either three months of 2 mg oral estradiol or placebo completed the double-blind placebo-controlled protocol. Change in forearm blood flow (FBF) in response to a 60 min brachial arterial infusion of ET-1 (5 pmol/min) was measured before randomization, after one month of randomized therapy and after three months of therapy using venous occlusion plethysmography.

RESULTS

Estrogen treatment had no effect on baseline FBF. Systolic and diastolic blood pressure and heart rate did not change in response to estrogen therapy or ET-1. Before randomization, in response to ET-1, FBF was reduced by -21.9% (mean response over 60 min) in the placebo group and -19.0% in the estradiol group (p = 0.67). After one month of therapy, the response was attenuated in the estrogen group, -10.0%, compared with the placebo group, -23.6 (difference in means 13.6%, 95% confidence interval [0.7%, 26.6%], p = 0.041). After three months of therapy, there was no difference in response between the placebo group, -27.0%, and estrogen group, -30.2% (p = 0.65).

CONCLUSIONS

In postmenopausal women with coronary heart disease, estrogen therapy inhibits the vasoconstrictor response to ET-1 after one month of therapy. This effect is lost after three months of therapy, suggesting that tachyphylaxis to one potentially beneficial action of estradiol develops during chronic treatment.

Management of advanced/metastatic prostate cancer: 2000 update

Over the past several years, the clinical presentation of prostate cancer has evolved so that more patients than ever before are presenting with clinically localized disease. However, a significant number of men continue to present with locally advanced or metastatic prostate cancer, or go on to develop metastasis after failing local therapies. Despite our better understanding of the biological principles and newer therapies, metastatic prostate cancer remains a lethal disease. Androgen ablation continues to be the first, most effective line of treatment for advanced/metastatic prostate cancer. Newer chemotherapy combinations with increasing activity are being identified in hormone-resistant prostate cancer. Based on novel targets, new treatment strategies are being developed and incorporated into clinical trials. Ultimately, the impact of these evolving treatments on advanced/hormone-resistant prostate cancer can best be assessed by well-designed phase III trials, many of which are now being launched or awaiting completion.

I.v. regional diamorphine for analgesia after foot surgery

Opioids administered to peripheral tissues can have significant analgesic effects in doses which would not be effective centrally. We have assessed the effects of regional diamorphine 2.5 mg i.v. in 14 patients undergoing surgical correction of bilateral arthritic foot deformities in a prospective, randomized, double-blind study. Patients acted as their own controls as only one foot received the active drug. Visual analogue scale (VAS) pain scores and wound tenderness were measured over 72 h. Diamorphine did not improve median VAS area under the curve pain scores during the first 6 h after surgery (33 (95% confidence intervals (CI) 25-46) vs 24 (17-35)). It also did not effect wound hypersensitivity when tested at 72 h after surgery (95 (47-125) vs 90 (50-125) g). There were no significant adverse effects.

Ontogeny of aquaporins 1 and 3 in ovine placenta and fetal membranes

A sensitive and highly reproducible method has been used to show that Aquaporin 3 (AQP(3)) mRNA is present in the ovine placenta and chorion from at least 60 days of gestation (term=145-150d) with levels increasing substantially (>16 fold) at 100 days, and remaining constant thereafter. By immuno- and hybridization histochemistry, the epithelial cells expressing AQP(3)were found to be the trophoblast cells. Some AQP(3)was expressed in fibroblasts of the amnion and allantois but none was expressed in the epithelia of these membranes. AQP(1)was expressed in endothelial cells of fetal and maternal blood vessels but not in any epithelial cell of the ovine placenta and fetal membranes. The level of AQP(3)expression is consistent with known ovine placental permeabilities to water, glycerol and urea.

Eligibility and response guidelines for phase II clinical trials in androgen-independent prostate cancer: recommendations from the Prostate-Specific Antigen Working Group

PURPOSE

Prostate-specific antigen (PSA) is a glycoprotein that is found almost exclusively in normal and neoplastic prostate cells. For patients with metastatic disease, changes in PSA will often antedate changes in bone scan. Furthermore, many but not all investigators have observed an association between a decline in PSA levels of 50% or greater and survival. Since the majority of phase II clinical trials for patients with androgen-independent prostate cancer (AIPC) have used PSA as a marker, we believed it was important for investigators to agree on definitions and values for a minimum set of parameters for eligibility and PSA declines and to develop a common approach to outcome analysis and reporting. We held a consensus conference with 26 leading investigators in the field of AIPC to define these parameters.

RESULT

We defined four patient groups: (1) progressive measurable disease, (2) progressive bone metastasis, (3) stable metastases and a rising PSA, and (4) rising PSA and no other evidence of metastatic disease. The purpose of determining the number of patients whose PSA level drops in a phase II trial of AIPC is to guide the selection of agents for further testing and phase III trials. We propose that investigators report at a minimum a PSA decline of at least 50% and this must be confirmed by a second PSA value 4 or more weeks later. Patients may not demonstrate clinical or radiographic evidence of disease progression during this time period. Some investigators may want to report additional measures of PSA changes (ie, 75% decline, 90% decline). Response duration and the time to PSA progression may also be important clinical end point.

CONCLUSION

Through this consensus conference, we believe we have developed practical guidelines for using PSA as a measurement of outcome. Furthermore, the use of common standards is important as we determine which agents should progress to randomized trials which will use survival as an end point.

Front-line police officers' practices, perceptions and attitudes about the enforcement of impaired driving laws in Canada

A survey of front line police officers' practices, perceptions and attitudes regarding detection of impaired driving, processing of driving while impaired (DWI) charges, criminal court proceedings and DWI sanctions was conducted across Canada. A sample of 1545 officers of all jurisdictions across the country, representative of different types of police services (i.e. national, provincial, municipal) and types of policing (i.e. traffic, general duty) were surveyed by mail. The results, based on a 71% response rate, indicate that: an average of 7.5 charges/year are laid by officers resulting mainly from erratic driving; videotaping and mobile breath testing could improve efficiency of DWI enforcement; it takes an average of 2 h 48 min to process each DWI charge; about 2/3 of officers say plea bargaining occurs at least sometimes; the average length of DWI trial is over 4 h; less than half of officers think Crown Attorneys are adequately prepared for DWI cases; about 3/4 of officers think the accused escapes conviction on a legal technicality at least sometimes; about 30% of officers say short-term licence suspensions and other forms of discretion are used at least sometimes; DWI places fifth in priority among 15 offences, up from eighth in a 1981 survey; DWI is a priority for most police management but human resources are not adequate; and there is greater support for administrative than for Criminal Code changes. Multiple regressions indicated that the number of DWI charges laid by officers depended mainly on the officers' personal priority regarding DWI enforcement. The results suggest that many officers want to enforce DWI laws but that the numerous procedural and legal barriers that they confront often force them to exercise discretion in the laying of DWI charges.

Phase II study of suramin plus aminoglutethimide in two cohorts of patients with androgen-independent prostate cancer: simultaneous antiandrogen withdrawal and prior antiandrogen withdrawal

Management of prostate cancer progression after failure of initial hormonal therapy is controversial. Recently, the activity of the simple discontinuation of antiandrogen therapy has been established by several groups, as well as the enhanced activity when combined with adrenal suppression (i.e., aminoglutethimide and hydrocortisone). Furthermore, suramin has generated considerable interest following reports of response rates ranging from 17 to 70%. More recently, suramin response rates of 18 and 22% have been reported when the potential confounding variables of flutamide withdrawal and hydrocortisone were prospectively controlled. On the basis of the activity of combining aminoglutethimide with flutamide withdrawal, we designed a protocol in which suramin was combined with aminoglutethimide in two cohorts of patients (those with simultaneous antiandrogen withdrawal compared to those who had previously discontinued antiandrogen therapy). Eighty-one evaluable patients were enrolled in this study between June 1992 and November 1994. Patients were a priori divided into two cohorts, those receiving prior antiandrogen withdrawal (n = 56) and those receiving simultaneous antiandrogen withdrawal (n = 25) at the time the patients were enrolled into the trial. For the group that discontinued antiandrogen prior to enrolling in therapy, the partial response rate (> 50% decline in PSA for > 4 weeks) was 14.2%, whereas the partial response was 44% for those patients who discontinued their antiandrogen at the time of starting suramin and aminoglutethimide. The median time to progression was 3.9 months in patients failing prior antiandrogen withdrawal and 5.5 months in those patients having concomitant antiandrogen withdrawal (P = 0.36 for the overall difference). The progression-free survival estimate at 1 year for patients having prior antiandrogen withdrawal was 19.8% [95% confidence interval (CI), 11-32.9%]. For those patients who experienced antiandrogen withdrawal simultaneous with the treatment, the progression-free survival estimates at 1 and 2 years were 27.1 (95% CI, 13.2-47.6%) and 4.5% (95% CI, 0.8-21.6%). The median survival time for those patients having prior antiandrogen withdrawal was 14.2 months, whereas the median survival was 21.9 months for those having concomitant antiandrogen withdrawal (P = 0.029 for the overall difference). In conclusion, the partial response rate of 44% for those who had concomitant flutamide withdrawal with adrenal suppression was consistent with that of other reports using a similar maneuver. Although this study was not randomized and thus we should not over-interpret the results, flutamide withdrawal plus adrenal suppression appears to have greater activity than flutamide withdrawal alone. Furthermore, these data suggest that suramin adds little to the response rate observed for other adrenal suppressive agents in the presence of antiandrogen withdrawal. This interpretation is in agreement with those studies controlling for adrenal suppression and flutamide withdrawal prior to suramin administration, which noted modest activity of short duration. Given that antiandrogen withdrawal is now accepted as an active maneuver for a subset of patients progressing after maximum androgen blockade, we propose that future trials attempting to maximize response rates incorporate this maneuver whenever possible into prospectively designed regimens.

Is economic hardship on the families of the seriously ill associated with patient and surrogate care preferences? SUPPORT Investigators

BACKGROUND

Serious illness often causes economic hardship for patients' families. However, it is not known whether this hardship is associated with a preference for the goal of care to focus on maximizing comfort instead of maximizing life expectancy or whether economic hardship might give rise to disagreement between patients and surrogates over the goal of care.

METHODS

We performed a cross-sectional study of 3158 seriously ill patients (median age, 63 years; 44% women) at 5 tertiary medical centers with 1 of 9 diagnoses associated with a high risk of mortality. Two months after their index hospitalization, patients and surrogates were surveyed about patients' preferences for the primary goal of care: either care focused on extending life or care focused on maximizing comfort. Patients and surrogates were also surveyed about the financial impact of the illness on the patient's family.

RESULTS

A report of economic hardship on the family as a result of the illness was associated with a preference for comfort care over life-extending care (odds ratio, 1.26; 95% confidence interval, 1.07-1.48) in an age-stratified bivariate analysis. Similarly, in a multivariable analysis controlling for patient demographics, illness severity, functional dependency, depression, anxiety, and pain, economic hardship on the family remained associated with a preference for comfort care over life-extending care (odds ratio, 1.31; 95% confidence interval, 1.10-1.57). Economic hardship on the family did not affect either the frequency or direction of patient-surrogate disagreements about the goal of care.

CONCLUSIONS

In patients with serious illness, economic hardship on the family is associated with preferences for comfort care over life-extending care. However, economic hardship on the family does not appear to be a factor in patient-surrogate disagreements about the goal of care.

How is androgen-dependent metastatic prostate cancer best treated?

The principles of management of newly diagnosed metastatic prostate cancer have changed little since the time of Huggins and his colleagues. Modern clinicians have many more weapons in their therapeutic armamentarium than those pioneers, but little progress has been made in improving the survival of men with this disease. The results of androgen deprivation are comparable using any one of a number of different monotherapy approaches. The use of combined androgen blockade may improve survival in men with minimal disease but at considerable economic cost and with significant impairment of quality of life. The benefit of this therapy for men with more extensive disease is uncertain. New modalities such as intermittent androgen blockade or combination therapies are exciting, but unproven.

Extramedullary myeloid cell tumors in myelodysplastic-syndromes: not a true indication of impending acute myeloid leukemia

The purpose of this report is to record a patient with myelodysplastic syndrome (MDS) associated acute myelogenous leukemia (AML) and leukemia cutis who had blast expression of the neural cell adhesion molecule (NCAM) and to review the world literature on prognostic implications of extramedullary myeloid cell tumors (granulocytic sarcoma, myeloblastoma, chloroma and leukemia cutis) in MDS and MDS associated AML. Case report and world literature from January 1965-January 1994 for all cases of MDS-associated extramedullary myeloid cell tumors (EMT) is reviewed, and the first patient with EMT, MDS associated AML and blast expression of NCAM is described. There have been 46 cases of MDS associated EMT previously reported. 32 cases occurred in the absence of AML. AML developed in 47% of these patients at a mean of 38 weeks from initial EMT. Of the patients not developing AML, median survival from initial EMT was 11 weeks. Nine patients received chemotherapy at the time of EMT and had a median survival of 36 weeks. The median survival for patients receiving conservative therapy for EMT was 48 weeks. Patients (n = 15) with EMT and MDS associated AML had a poor outcome regardless of therapy with a median survival of 11 weeks. Unlike other forms of isolated EMT, MDS associated EMT is not always a forerunner of AML. Premature induction therapy for MDS associated EMT does not appear to prolong survival. EMT in the setting of MDS associated AML is associated with a poor prognosis despite aggressive chemotherapy. Blast expression of NCAM may prove to be a risk factor for EMT in MDS associated AML.

Prevalence rates and correlates of psychiatric disorders among preschool children

OBJECTIVE

To determine the prevalence and correlates of psychiatric disorders among preschool children in a primary care pediatric sample.

METHOD

In a two-stage design, 3,860 preschool children were screened; 510 received fuller evaluations.

RESULTS

For quantitative assessment of disorder (> or = 90th percentile), prevalence of behavior problems was 8.3%. "Probable" occurrence of an Axis I DSM-III-R disorder was 21.4% (9.1%, severe). Logistic regression analyses indicated significant demographic correlates for quantitative outcomes (older age, minority status, male sex, low socio-economic status, father absence, small family size) but not for DSM-III-R diagnoses. Maternal and family characteristics were generally not significant. Child correlates included activity level, timidity, persistence, and IQ.

CONCLUSIONS

Overall prevalence of disorder was consistent with rates for older children; correlates varied by approach used for classification.

Lack of correlation between prostate-specific antigen and the presence of measurable soft tissue metastases in hormone-refractory prostate cancer

Appropriate staging procedures for patients with hormone-refractory prostate cancer are poorly defined. In particular, there are no studies correlating prostate-specific antigen (PSA) with more traditional methods of staging. We have evaluated the abdominal/pelvic CT scan, bone scan, and PSA results following initial diagnosis of hormone-refractory prostate cancer in 177 consecutive patients (median age = 63.1 years, range 45-80). Thirty-four patients (19.2%) had measurable lesions (> or = 2 cm) on CT scan compatible with metastatic disease. Of the patients with measurable lesions, 29/34 (85.3%) had retroperitoneal and/or pelvic adenopathy; 5 patients (14.7%) had measurable lesions in the liver. Other sites of metastatic disease were detected in less than 1% of the patients receiving scans. All patients had bone scan abnormalities compatible with metastatic disease. Results of these imaging studies were then compared to PSA serum concentration (Abbott IMx). The mean PSA concentration was not different in those patients with soft tissue disease as compared to those without soft tissue involvement and there was no correlation between PSA concentration and the presence or absence of measurable soft tissue disease. In contrast to previously published studies in hormone-naïve prostate cancer patients, these studies in hormone-refractory patients indicate that the detection of metastatic disease by standard radiological procedures cannot be predicted by measurement of serum PSA.

Prognostic value of dobutamine stress echocardiography in patients referred because of suspected coronary artery disease

To determine whether dobutamine stress echocardiography (DSE) provides prognostic information beyond that available from routine clinical data, we reviewed the outcome of 210 consecutive patients referred for DSE to evaluate chest pain, perioperative risk, and myocardial viability. Dobutamine was infused in increments of 10 micrograms/kg/min in 5-minute stages to a maximum of 40 micrograms/kg/min. The dobutamine stress echocardiogram was considered abnormal only if dobutamine induced a new wall motion abnormality as determined by review of the digitized echocardiographic images in a quad screen format and on videotape. Thirty percent of tests were abnormal. An abnormal test was more common (p < or = 0.02) in men and patients with angina pectoris, in patients taking nitrate therapy, or those with prior myocardial infarction or abnormal left ventricular wall motion at rest. Twenty-two deaths, 17 of which were cardiac, occurred over a median follow-up of 240 days (range 30 to 760). Sixteen cardiac deaths occurred in the 63 patients with versus 1 cardiac death among the 147 without a new wall motion abnormality (p < or = 0.0001). Other variables associated with cardiac death (p < or = 0.05) were age > 65 years, nitrate therapy, ventricular ectopy during DSE, suspected angina pectoris, and hospitalization at the time of DSE. When cardiac death, myocardial infarction, and revascularization procedures were all considered as adverse outcomes, a new wall motion abnormality continued to be the most powerful predictor of an adverse cardiac event.(ABSTRACT TRUNCATED AT 250 WORDS)

A phase I study of the somatostatin analogue somatuline in patients with metastatic hormone-refractory prostate cancer

BACKGROUND

Somatuline, a somatostatin analogue, has proven to be effective in several animal models of prostate cancer. Preliminary clinical studies also have suggested antitumor activity in patients with prostate cancer. The authors conducted a dose-escalation trial of 25 patients with metastatic hormone-refractory prostate cancer.

METHODS

Dosages of 4, 7, 10, 13, 18, and 24 mg/day were administered by continuous intravenous infusion for at least 28 days.

RESULTS

Plasma levels of insulin-like growth factor-I (IGF-I), but not those of IGF-II, declined modestly during therapy. Toxicities included grade I diarrhea, bloating, infection, nausea, and flatus. The gastrointestinal side effects were typically self-limiting and occurred during the initial portion of treatment cycles. In addition, three patients experienced grade II catheter-related infections. No clinical response was noted by either radiographic or tumor marker criteria. The maximally tolerated dose of somatuline was not determined.

CONCLUSION

A continuous intravenous infusion of 24 mg/day of somatuline is well tolerated and could be evaluated in other types of cancer or possibly in less advanced prostate cancer, but no clinical activity was noted at this dose in patients with advanced metastatic hormone-refractory prostate cancer.