Cabozantinib Plus Durvalumab in Patients With Advanced Urothelial Carcinoma After Platinum Chemotherapy: Safety and Preliminary Activity of the Open-Label, Single-Arm, Phase 2 ARCADIA Trial

BACKGROUND

Durvalumab and cabozantinib have shown single-agent activity in patients with metastatic urothelial carcinoma (UC). ARCADIA is a phase 2 study evaluating their combination in patients with platinum-treated, advanced UC (NCT03824691). Herein, we report the results of the planned interim safety analysis and the preliminary activity.

PATIENTS AND METHODS

Patients with Eastern Cooperative Oncology Group Performance Status (ECOG PS) 0 or 1, UC and non-UC histology, and failure of a maximum of two regimens received cabozantinib 40 mg daily, orally, in combination with durvalumab 1500 mg, intravenously, every 28 days. Response was evaluated by Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 every two cycles and by fluorodeoxyglucose positron emission tomography (FDG-PET) scans.

RESULTS

As of August 20, 2020, 16 patients were enrolled with a median follow-up of 6.7 months (range, 2-11). Four patients (25%) had ECOG PS 1 and had received two prior regimens. No grades 3 or 4 treatment-related adverse events (TRAEs) occurred within the first two cycles. The most common grades 1 and 2 TRAEs were fatigue (7, 43.8%), diarrhea (5, 31.3%), and dysphonia (5, 31.3%). Objective responses were seen in six patients (37.5%; 95% confidence interval, 15.2-64.6), including two complete responses (12.5%). One additional patient with bone-only disease obtained a decrease in FDG uptake and in circulating tumor DNA consistent with response. Angiogenesis-related gene alterations were found in 57% responders versus 0% nonresponders.

CONCLUSION

The durvalumab and cabozantinib combination was safe and endowed with preliminary clinical activity in patients with advanced UC. Mature results will clarify the role of cabozantinib and that of tumor biomarkers in this tumor type.

Pembrolizumab and nab-paclitaxel as salvage therapy for platinum-treated, locally advanced or metastatic urothelial carcinoma: interim results of the open-label, single-arm, phase II PEANUT study

BACKGROUND

Pembrolizumab is a new standard of care for patients with platinum-treated, metastatic urothelial carcinoma (UC). Nab-paclitaxel is active in advanced UC. In the PEANUT study (NCT03464734) we investigated their combination in advanced UC.

PATIENTS AND METHODS

PEANUT was an open-label, single-arm, phase II trial that included patients who had failed one or two chemotherapy regimens, including platinum chemotherapy. Biomarker analyses focused on programmed cell-death ligand-1 combined positive score (CPS) and comprehensive genomic profiling on tumor samples and circulating tumor DNA. Patients received 200 mg pembrolizumab on day 1 (D1), and 125 mg/m² nab-paclitaxel on D1 and D8, every 3 weeks, until disease progression or unacceptable toxicity. The primary end point was progression-free survival (PFS) according to RECIST (v1.1). The assumption was to detect an improvement in the median PFS from ≤3.0 months (H0) to ≥5.0 months (H1).

RESULTS

Between January 2019 and January 2020, the PEANUT study enrolled 70 patients: 24% had failed two prior systemic therapies; 31% had an Eastern Cooperative Oncology Group (ECOG) performance status of 1; and 28.6% had liver metastases. After a median follow-up of 9.8 months, 40 patients have relapsed (57.1%). The median PFS was 5.9 months [95% confidence interval (CI) 3.1-11.5]. The confirmed objective response rate (ORR) was 38.6% (95% CI 27-51) with 17 partial responses and 10 complete responses (14.3%). The median duration of response was not reached. Five patients (7.1%) had ongoing responses lasting >12 months. The most common any-grade treatment-related adverse events included alopecia (71.4%), neutropenia (32.9%), and peripheral neuropathy (34.3%). Neither tumor mutational burden nor CPS was significantly associated with PFS at univariable analyses. The single-arm design of the trial was the major limitation.

CONCLUSIONS

Pembrolizumab combined with nab-paclitaxel, as second- and third-line chemoimmunotherapy for metastatic UC, showed a favorable safety profile, durable PFS, and a clinically meaningful ORR in these preliminary analyses. This combination warrants additional randomized studies in earlier disease stages. CLINICALTRIALS.

GOV NUMBER

ClinicalTrials.govNCT03464734; https://clinicaltrials.gov/ct2/show/NCT03464734.

Abstract P2-12-01: Comprehensive genomic profiling of 34 cases of breast angiosarcoma

Background: Angiosarcoma of the breast (BAS) is a rare but lethal neoplasia, either arising de novo or secondary to radiation therapy, with incidence of the latter disease increasing. We queried a database of more than 70,000 advanced cancer patients assayed with comprehensive genomic profiling (CGP) in the course of clinical care to uncover the frequency, type and associated genomic alterations (GA) in BAS and to highlight possible routes to benefit from targeted therapy.

Methods: CGP was performed for 34 BAS cases using a hybrid-capture, adaptor ligation based next generation sequencing assay of up to 315 genes to a mean coverage depth of >500X. The results were analyzed for base substitutions, short insertions and deletions, selected rearrangements, and copy number changes. RNA sequencing for 265 genes was also performed for 24 cases. Limited clinical histories from submitted pathology reports were reviewed under IRB permission.

Results: Clinical specimens from 34 BAS patients, all females, were assayed. The cases harbored 87 total GA for a mean of 2.59 per case, 25% of which were copy number amplifications. The most commonly altered genes were MYC (41%, 14/34), PIK3CA (26%, 9/34), and KDR (26%, 9/34). All MYC alterations were amplifications with a mean copy number of 39, and alterations in other MYC family members (MYCN and MYCL1) were not observed. KDR was recurrently altered as T771R (7/9) and T771K (1/9) and amplified in one case (1/9).

MYC and KDR alterations were mutually exclusive (p<0.0001). 6/14 MYC amplified cases had prior histories of breast carcinoma, with 3/6 noted as being treated with radiation therapy. For the remainder of MYC amplified cases (8/14), no relevant clinical history was available.

Two cases harboring gene fusions were identified including CIC-MEGF8 and NTRK1-PEAR1. Two rearrangements of potential functional significance including CIC-DEDD2 and HT-ALK (exon1 HT - exon5-29 ALK including kinase domain) were also observed. The case harboring HT-ALK also had MYC amplification and known prior radiation therapy. Two other MYC amplified cases also harbored targetable kinase alterations, including FLT4 amplification (described as targetable in Ravi et al JNCCN 2016) and FGFR3 S249C, a known activating mutation.

Conclusions: MYC amplification defines over 40% (14/34) of advanced BAS cases. Of MYC amplified cases, 28% (4/14) harbored targetable alterations of tyrosine kinases including a potential novel ALK fusion. FLT4 amplification only co-occurred with MYC amplification, but this result was not statistically significant in this small series. KDR and MYC alteration were mutually exclusive, and 45% of non-MYC altered cases (9/20) harbored KDR alterations, which were predominantly mutations of T771. Further clinico-pathologic correlation, particularly history of radiation therapy, will be explored in this series, as well defining BAS that harbor neither MYC nor KDR alterations.

Citation Format: Ravi V, Madison R, Schrock AB, Cote G, Millis S, Alvarez R, Choy E, Katz D, Chung J, Gay L, Miller VA, Ross JS, Ali SM, Schnitt S. Comprehensive genomic profiling of 34 cases of breast angiosarcoma [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 P2-12-01.

The process of care in preventive in-home comprehensive geriatric assessment

OBJECTIVES

To describe the process of care of a program of in-home comprehensive geriatric assessment (CGA) and to determine: (1) if there are major findings in all domains of CGA (medical, functional, mental health, and social/ environmental), (2) if there is a continued clinical yield when CGA is repeated annually, and (3) factors that affect patient adherence with recommendations from CGA.

DESIGN

Descriptive prospective study of subjects allocated to the intervention group of a 3-year randomized trial of preventive in-home CGA.

SETTING

Homes of participants living in an urban setting.

PARTICIPANTS

Persons aged 75 years or older and living at home who received the intervention (N = 202 subjects, mean age 80.8 years, 70% female, 95% white, 64% living alone).

INTERVENTION

Annual in-home CGA and quarterly home visits by gerontologic nurse practitioners for 3 years.

MEASUREMENTS

Detailed data were collected prospectively on clinical problems detected by CGA, and specific recommendations were made for these problems using an instrument developed explicitly for this project to study the CGA process. Subject adherence with these recommendations was also recorded.

RESULTS

Major problems were identified in all domains of CGA; the most common problems were medical. In the first year, 76.7% of subjects had at least one major problem identified that was either previously unknown or suboptimally treated. One-third of subjects had additional major problems identified during the second and third years. A constant number of therapeutic and preventive recommendations was made each year (11.5 per subject annually). Subject adherence varied by type of recommendation (ANOVA, F = 108.4, P < .001); adherence was better for referrals to a physician than for referrals to a non-physician professional or community service or for recommendations involving self-care activities (Scheffe's test, P < .001).

CONCLUSION

In these community-dwelling older people, there was a continued yield of problems identified and recommendations made when CGA was repeated annually for 3 years, supporting the practice of repeat CGA in older people in the community. Subject adherence with recommendations from CGA varied by type of recommendation, but further work is needed to determine additional factors that affect this adherence and to determine the association between the yield of CGA (i.e., problems identified, recommendations given and adherence with these recommendations) and important clinical outcomes.

Immunologic abnormalities in humans exposed to chlorpyrifos: preliminary observations

Twelve individuals who were exposed to chlorpyrifos were studied 1-4.5 y following exposure to determine changes in the peripheral immune system. The subjects were found to have a high rate of atopy and antibiotic sensitivities, elevated CD26 cells (p < .01), and a higher rate of autoimmunity, compared with two control groups. Autoantibodies were directed toward smooth muscle, parietal cell, brush border, thyroid gland, myelin, and ANA. Chlorpyrifos exposure was implicated in the immunologic abnormalities reported. The immunologic changes were similar to those reported for other pesticides.

Latex nanosphere delivery system (LNDS): novel nanometer-sized carriers of fluorescent dyes and active agents selectively target neuronal subpopulations via uptake and retrograde transport

A wide range of latex particles are described which are capable of carrying high concentrations of fluorescent dyes, drugs, and photoactive agents selectively to subpopulations of neurons in vitro and in vivo. Particle size, charge, and concentration were all found to influence uptake into cultured neurons or retrograde transport in vivo. Chromophore loadings of greater than 14% (w/w) were obtained. Incorporation of a photoactivated dye (chlorin e6) into the polymer did not compromise the ability of the dye to produce singlet oxygen following light exposure. We refer to this unique family of latex particles as the latex nanosphere delivery system (LNDS). The LNDS will be usefull for studies of neuroanatomy and nervous system development, as well as more general areas of biomedical research where it is desirable to selectively label subpopulations of cells. The LNDS also offers a means of providing targeted delivery of drugs or photoactive agents to selected subpopulations of cells; this will allow experimentation not currently possible using any existent methodology.

Immune activation and autoantibodies in humans with long-term inhalation exposure to formaldehyde

Four groups of patients with long-term inhalation exposure to formaldehyde (HCHO) were compared with controls who had short-term periodic exposure to HCHO. The following were determined for all groups: total white cell, lymphocyte, and T cell counts; T helper/suppressor ratios; total Ta1+, IL2+, and B cell counts; antibodies to formaldehyde-human serum albumin (HCHO-HSA) conjugate and autoantibodies. When compared with the controls, the patients had significantly higher antibody titers to HCHO-HSA. In addition, significant increases in Ta1+, IL2+, and B cells and autoantibodies were observed. Immune activation, autoantibodies, and anti-HCHO-HSA antibodies are associated with long-term formaldehyde inhalation.

Acidic fibroblast growth factor enhances peripheral nerve regeneration in vivo

When added to a collagen-filled nerve guide, purified acidic fibroblast growth factor (aFGF) increased the number of myelinated axons that regenerated across a 5-mm nerve gap distance. In addition, a greater number of primary sensory and motor neurons extended axons through the nerve guide in animals treated with aFGF. Thus the effect of aFGF on peripheral nerve regeneration is not simply an increase in axonal branching within the nerve guide tube. This is the first highly purified growth factor since nerve growth factor that has been shown to promote nerve regeneration in vivo. This experimental model provides a convenient and quantitative means to assess the effects of putative neuronotropic factors on peripheral nerve regeneration in vivo.

Building-related illness and antibodies to albumin conjugates of formaldehyde, toluene diisocyanate, and trimellitic anhydride

A case of building-related health complaints was investigated with respect to the relationship among frequency of symptoms, antibodies to albumin conjugates of formaldehyde (HCHO), toluene diisocyanate (TDI), and tirmellitic anhydride (TMA), and volatile organic chemicals (VOCs). The indoor air concentrations of VOCs, HCHO, TDI, and TMA did not exceed Fed-OSHA and ACGIH permissible standards. However, HCHO concentrations ranged between 0.05 and 0.08 ppm. The reported symptoms were multiple, involving the eyes, nose, sinuses, throat, lungs, skeletomuscular system, and central nervous system. Anti-HCHO, -TDI, and -TMA isotypes were found in 12 of 14 full-time employees and were nondetectable in one part-time employee. There was a positive, but not statistically significant, correlation (r values ranged between .24 and .55) between symptoms and the geometric mean titers to conjugates. The data suggest that a synergistic immunological response to airborne chemicals may be occurring in these subjects. In conclusion, immunological monitoring of affected individuals where chemicals are suspected may prove to be useful in future investigations of building-related illness.

Rabbit retinal ganglion cells survive optic nerve transection and entubulation repair with type I collagen nerve guide tubes

The major objective of the experiments reported in this paper was to qualitatively test the hypothesis that rabbit retinal ganglion cells survive optic nerve transection and entubulation repair of the proximal optic nerve stump. The optic nerve of rabbits was transected immediately behind the globe, and a 1-cm length of a Type I collagen nerve guide tube was sutured onto the short proximal stump. The nerve guide was either left empty or was filled with a Type I collagen gel (Vitrogen, Collagen Corp.). Following 8-12 weeks survival time, the animals were sacrificed and the retinae were prepared as whole mounts and processed for immunocytochemistry using an antibody which selectively labels the retinal ganglion cells. Although no formal cell counts were carried out, the animals which received Vitrogen within the nerve guide showed a qualitative enhancement of retinal ganglion cell survival compared to the group with the nerve guide alone. The results suggest that specific manipulations of the central nervous system microenvironment may enhance neuronal survival following axonal transection.

Colloidal gold fluorescent microspheres: a new retrograde marker visualized by light and electron microscopy

A new retrograde tracer, rhodamine latex microspheres, permits labeled neurons to be visualized with fluorescence light microscopy. However, their use has been limited to the light microscope. We now have developed colloidal gold fluorescent microspheres which identify retrogradely labeled neurons first by fluorescence microscopy and then by electron microscopy. This new fluorescent/EM tracer will find widespread use in the field of neuroscience to elucidate the ultrastructural integrity of neuronal networks.

Is antioxidant deficiency related to chronic obstructive pulmonary disease?

This report describes an assay with the capability of detecting antioxidant activity of plasma and of purified proteins. The method is based on the enzymatic oxidation of plasma elastase inhibitory capacity of enzyme(s) in extracts of human lysosomes in the presence of hydrogen peroxide, chloride, and magnesium ions. Using this method we measured the antioxidant activity of the plasma of 59 subjects. We detected a strong relationship between a deficiency in the antioxidant activity of plasma and the presence of a family history of lung disease (p less than 0.005), and an abnormal mean FEV1/FVC ratio (p less than 0.005).

Pursed lips breathing training using ear oximetry

Pursed lips breathing (PLB) training is often used in the management of patients with chronic obstructive lung disease (COLD). Previous clinical studies have demonstrated that PLB improves arterial oxygen saturation (SaO2) and CO2 removal as well as relieving dyspnea. Twelve hypoxemic subjects with stable COLD were randomly assigned to either the pursed lips (P) or control group consisting of general relaxation (R). The SaO2 was monitored via ear oximetry, and respiratory rate and tidal volume were monitored using a strain gage transducer and the minute volume was calculated. The PLB was taught by an experienced instructor using the ear oximeter as a monitoring display with a goal toward increasing SaO2. The subject was taught general relaxation (Rlx) with the aid of pleasant music. We compared PLB and Rlx treatments using an A-B-A crossover study design. In both groups, PLB significantly improved SaO2 over baseline (p less than 0.001) whereas Rlx did not. We conclude that patients can learn to increase their SaO2 by PLB using ear oximetry adjunctively.

Unfocused laser illumination kills dye-targeted mouse neurons by selective photothermolysis

Selective photothermolysis (SP) is a novel technique by which brief, unfocused laser pulses are selectively absorbed by, and cause selective thermal damage to, endogenously pigmented structures. The present experiments demonstrate the feasibility of using an exogenous non-fluorescent chromophore (procion blue) to effect cellular damage by SP. Dorsal root ganglia neurons in vitro were selectively labeled with procion blue and subsequently damaged by unfocused laser illumination. Progressive cellular damage was assessed by propidium iodide (PI), a fluorescent dye that leaks through damaged membranes and binds to nucleic acids. Graded scores of intracellular PI fluorescence demonstrated a highly significant difference in amount of damage between groups of experimental and control cells. Selective photothermolysis is discussed as an experimental tool for neurobiologists in particular and for general use within the biomedical field.

An in vivo model to quantify motor and sensory peripheral nerve regeneration using bioresorbable nerve guide tubes

An in vivo preparation is presented to study the rate and time course of motor and sensory axonal regeneration. The cut ends of a transected sciatic nerve were inserted into each end of a 5-6 mm non-toxic and bioresorbable nerve guide tube to create a 4 mm nerve gap in adult mice. Subsequently, cell bodies in the ventral spinal cord and L3-L5 dorsal root ganglia that had regenerated axons across the gap were retrogradely labeled with horseradish peroxidase (HRP). The HRP was applied 3 mm distal to the nerve guide and was accessible only to axons that had regenerated through the nerve guide. Labeled cells were counted in 40 micron serial sections at 2, 4 and 6 weeks after initial nerve transection. The results indicate a significant increase in the number of labeled motor and sensory cell bodies over time. By 6 weeks after transection, approximately two thirds as many ventral horn motor cells and one third as many dorsal root ganglion sensory cells were labeled as in control non-transected animals. These data serve as a baseline to compare differential effects of additives to the nerve guide lumen in terms of sensory and motor neuron response.

Increased rate of peripheral nerve regeneration using bioresorbable nerve guides and a laminin-containing gel

The sciatic nerve of adult mice was transected and proximal and distal nerve stumps were sutured into a nontoxic bioresorbable nerve guide. Nerve guide lumens were either empty or filled with a gel containing 80% laminin and additional extracellular matrix components. Two weeks later cells in the L3 through L5 dorsal root ganglia and the ventral horn of the spinal cord were retrogradely filled with horseradish peroxidase. All animals with the laminin-containing gel but none with empty nerve guides displayed labeled cells. This suggests that the laminin-containing gel significantly hastened axonal regeneration in vivo.

Nontoxic nerve guide tubes support neovascular growth in transected rat optic nerve

Nontoxic, bioresorbable "nerve guide" tubes were used to bridge the transected optic nerves of adult rats. Nerve guides were fabricated as polymers of synthetic poly D,L-lactates with 2% triethyl citrate added as a plasticizer. The local environment was manipulated further by the addition of the proteins collagen, fibrinogen, and anti-Thy-1 antibody to the nerve guide lumens at the time of operation. Neovascular growth through the nerve guide lumens was quantified with the aid of a computer-controlled microscope. Neovascular growth was greater in the nerve guides to which proteins had been added, compared with initially empty nerve guides. These experiments demonstrated the effectiveness of these nerve guide tubes in supporting and directing neovascular growth in the mammalian central nervous system, and suggested that specific alterations of the local environment within the nerve guide lumen can affect the extent of neovascular growth.

Retinal ganglion cells and axons survive optic nerve transection

The effects of optic nerve transection on optic axon and retinal cell survival was studied in C57BL/6J mice. The optic nerve was transected either intracranially or intraorbitally . Data are presented which show that an intracranial transection of the optic nerve may be achieved while maintaining the blood supply to the retina. Intraorbital optic nerve transection, however, necessitates destruction of the retinal blood supply. Cell survival in the retinal ganglion cell layer is compared for both transection methods. In addition, electron microscopic evidence is presented which indicates axonal survival in the optic nerve up to at least 90 days following intracranial transection.

Respiratory impairment in coke oven workers: relationship to work exposure and bronchial inflammation detected by sputum cytology

Coke oven workers are at excess risk of developing lung cancer and may be at risk for chronic obstructive lung disease (COLD). We have studied 3799 male workers to assess the relationship between the two diseases. Repeated lung function and sputum cytology tests were obtained over a 3-year period. Sputum samples were assessed using standardized methods; in addition to metaplastic and neoplastic changes, we reproducibly assessed the presence and extent of acute and chronic inflammatory changes. Spirometric flow rates (FEV1) were significantly reduced in workers most exposed to coke oven emissions, particularly in those with excessive inflammatory cells and regular metaplasia in sputum. The presence of reactive bronchial epithelial cells and metaplasia were potent predictors of an abnormal FEV1/FVC. Studies like these may offer a means to investigate the relationship between COLD and lung cancer. Such changes in sputum may identify individuals at risk of developing both diseases.

Regulation of hippocampal sympathetic ingrowth: role of afferent input

Peripheral noradrenergic fibers from the superior cervical ganglion (SCG) appear in the hippocampal formation of the adult rat central nervous system following damage to the medial septal nucleus or its afferent fibers. The appearance of these fibers coincides with a significant and substantial increase in the concentration of norepinephrine in the dentate gyrus and in the ability of synaptosomes made from the dentate to take up [3H]norepinephrine (NE) in vitro. Up to 7 weeks following a medial septal lesion, dentate norepinephrine levels are significantly lower if the sympathetic preganglionic trunk has been sectioned at the time septal lesions are made. By contrast, the uptake of [3H]NE into dentate synaptosomes is not affected by the preganglionic section. Furthermore, if the sectioned preganglionic trunk is allowed to reinnervate the SCG, the dentate NE concentration rapidly returns to levels equivalent to dentates with intact sympathetic preganglionic trunks. In addition to the ingrowth of the sympathetic fibers, central noradrenergic fibers display a sprouting or 'pruning' response to medial septal lesions. These data show that afferent input regulates the neurotransmitter concentration during sympathetic ingrowth while retrograde influences from the target appear to regulate the density or extent of the growing fibers. The experimental findings are discussed in light of the hypothesis that the hippocampal formation is capable of producing a sympathetic growth factor following septal denervation.

Sprouting of noradrenergic fibers in hippocampus after medial septal lesions: contributions of the central and peripheral nervous systems

The neuronal sprouting of noradrenergic fibers was studied in the hippocampal formation. The extent and time course of lesion-induced plasticity of both central and peripheral noradrenergic neurons was determined by assaying norepinephrine (NE) concentrations and high-affinity [3H]NE uptake in the dentate gyrus at 2 to 16 weeks after medial septal lesions. Two weeks after a medial septal lesion there was a dramatic decrease in dentate NE. During the subsequent weeks normal concentrations of dentate NE were reestablished. The recovery or increase of NE with time reflected a contribution from both central and peripheral noradrenergic systems. Although both central and peripheral noradrenergic systems contributed to this recovery, they did so in very different ways. The time course of the central noradrenergic response was slower than that of the peripheral system and the final NE concentrations were quite different for the two systems. The central adrenergic system's sprouting response apparently stabilized when normal NE concentrations were attained, whereas the ingrowth of peripheral sympathetic fibers continued to concentrations that were well above normal unoperated levels. The findings have implications in relationship to the different possible controlling mechanisms governing neuronal plasticity of the central and peripheral noradrenergic systems.

Definition and comparability of nosocomial infection rates

Nosocomial infection rates are frequently calculated by dividing the number of infections acquired during a month by the number of patients discharged during that month. This method does not allow for prediction of future events or comparability between locations for statistical analysis. A more appropriate rate is the number of infections divided by patient-days spent in the hospital. This rate avoids the problems associated with the commonly used method. On the basis of the rate of infections per patient-day, it is possible to test for interhospital and intrahospital differences as well as for differences over time.

Risk factors for obstructive lung disease

To assess the role of various risk factors in the pathogenesis of chronic obstructive lung disease (COLD), 163 men and women were followed for approximately 6 yr. Subjects were either community volunteers or relatives of patients with antitrypsin deficiency (PiZ or MZ phenotype). At the onset of the study no subject was receiving medical care for COLD. Covariance analysis revealed that expiratory airflow rates declined excessively in male subjects who had the PiMZ phenotype and reported a family history of lung disease. In subjects with the combination of characteristics, loss of lung function approximated that reported in subjects who have established COLD. In several such subjects, abnormalities have progressed so that they now require treatment. Changes in lung function were less striking in the presence of only 1 or 2 of the 3 risk factors studied. These findings demonstrated that the characteristics of the population being studied can influence the outcome of an investigation. This effect may help account fo the conflicting results of previous investigations designed to assess the role of the PiMZ phenotype in the pathogenesis of COLD.