Abstract P4-16-01: Evaluation of miracle mouthwash (MMW) plus hydrocortisone or prednisolone mouth rinses as prophylaxis for everolimus-associated stomatitis: Results of a randomized phase II study

Background: Oral stomatitis is a frequent adverse event (AE) associated with mTOR-inhibitor therapy, and can impact adherence. In BOLERO-2, patients (pts) with hormone receptor-positive (HR+) metastatic breast cancer (MBC) treated with exemestane plus everolimus (EVE), the incidence of all-grade (G) stomatitis or related AEs was 67%, with 24%/8% of pts developing G2/G3 stomatitis or related AEs, respectively (Perez et al ASCO 2013 Abs 7029). In BOLERO-2, 24% of pts required EVE dose reduction for stomatitis (Rugo et al Ann Oncol 2014;25:808). This study evaluated 2 steroid-based mouth rinses for the prevention or amelioration of oral stomatitis in pts with MBC treated with EVE. Methods: This prospective randomized phase II study enrolled postmenopausal pts (planned accrual=100) with HR+ MBC within the US Oncology Network who were initiating therapy with an aromatase inhibitor plus EVE (10 mg/day)(AIE). Pts were randomized 1:1 to prophylactic therapy with 1 of 2 oral rinses (ARM 1: MMW 480 ml recipe: 320 mL oral Benadryl, 2 g Tetracycline, 80 mg Hydrocortisone, 40 mL Nystatin suspension, water; or ARM 2: Prednisolone (P) 15mg/5mL oral solution, 1.8% alcohol). Pts were instructed to swish/expectorate 10 ml of the assigned rinse 4x daily starting with D1 of EVE treatment, for a total of 12 wks. The primary objective was to determine the incidence of G≥2 stomatitis or related oral AEs during the first 12 wks of treatment. Based on a historical estimate that ≥37% of pts receiving AIE develop G≥2 stomatitis, 50 pts for each arm were required to detect a reduction of the incidence of G≥2 stomatitis from 37% to <20%, with alpha = 0.05, 80% power, and a 1-sided test. Secondary objectives included assessment of AEs (all grades), determination of the percentage of pts requiring dose interruption/reduction of EVE or discontinuation of therapy due to toxicity, and evaluation of the impact of the oral rinses on the duration and severity of stomatitis. Results: As of 5/30/2016, a total of 104 pts have been randomized and 100 pts have received treatment (49 MMW; 51 P). Median age was 61 yrs (range 31-82 yrs). The incidence of stomatitis and related oral AEs (any grade) during the first 12 wks was 29% (n=14/49) and 27.5% (14/51) in the MMW and P arms respectively. The incidence of G2 oral AEs was 12% (6/49) and 8% (4/51) with MMW and P respectively. There was only 1 G3 oral AE (MMW arm), and no G4 events. There was 1 EVE dose reduction (MMW) and 4 EVE dose delays (3 MMW, 1 P) during the first 12 wks of treatment. No pts stopped the steroid mouth rinse therapy due to mouth rinse-related toxicity. Conclusion: These prospective data provide evidence of a reduced incidence of mTOR-associated oral AEs with prophylactic use of a steroid mouth rinse. The 29%/27.5% incidence of all-grade and 12%/8% incidence of G2 oral AEs, with only 1 G3 event, compare favorably with the 67% and 24%/8% incidence of all-grade and G2/3 stomatitis, respectively, in BOLERO-2. These data also show the safety and tolerability of these 2 steroid mouth rinses. Prophylactic use of steroid mouth rinses substantially decreases the incidence of G2/3 stomatitis and the need for EVE dose modifications.

Citation Format: Jones VE, McIntyre KJ, Paul D, Wilks ST, Ondreyco SM, Sedlacek SM, Melnyk Jr. AM, Oommen SP, Wang Y, O'Shaughnessy JA. Evaluation of miracle mouthwash (MMW) plus hydrocortisone or prednisolone mouth rinses as prophylaxis for everolimus-associated stomatitis: Results of a randomized phase II study [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 P4-16-01.

Impact of Weight Loss on Plasma Leptin and Adiponectin in Overweight-to-Obese Post Menopausal Breast Cancer Survivors

Women who are obese at the time of breast cancer diagnosis have higher overall mortality than normal weight women and some evidence implicates adiponectin and leptin as contributing to prognostic disadvantage. While intentional weight loss is thought to improve prognosis, its impact on these adipokines is unclear. This study compared the pattern of change in plasma leptin and adiponectin in overweight-to-obese post-menopausal breast cancer survivors during weight loss. Given the controversies about what dietary pattern is most appropriate for breast cancer control and regulation of adipokine metabolism, the effect of a low fat versus a low carbohydrate pattern was evaluated using a non-randomized, controlled study design. Anthropometric data and fasted plasma were obtained monthly during the six-month weight loss intervention. While leptin was associated with fat mass, adiponectin was not, and the lack of correlation between leptin and adiponectin concentrations throughout weight loss implies independent mechanisms of regulation. The temporal pattern of change in leptin but not adiponectin was affected by magnitude of weight loss. Dietary pattern was without effect on either adipokine. Mechanisms not directly related to dietary pattern, weight loss, or fat mass appear to play dominant roles in the regulation of circulating levels of these adipokines.

Weight loss interventions for breast cancer survivors: impact of dietary pattern

Body weight management is not emphasized in clinical practice guidelines for breast cancer survivors, reflecting the lack of evidence that weight loss improves prognosis. Even if this situation changes, the optimal design for weight loss interventions is unclear. We conducted a 6-month non-randomized, controlled weight loss intervention in 249 post-menopausal breast cancer survivors. This paper reports effects on two secondary endpoints, change in body weight and composition. Participants were predominantly non-Hispanic whites (89%) with a mean age of 54.9 ± 9.2 years, a mean BMI of 29.0 ± 2.6 kg/m: ² and an average of 43 ± 5% body fat. Two dietary interventions, low fat or low carbohydrate, were investigated and consisted of a 42 day cycle of menus and recipes. Weight loss counseling and anthropometric assessment were provided at monthly clinic visits. One hundred ninety-two women completed the trial (77% retention). In comparison to the nonintervention control, both intervention arms achieved significant decreases in body weight (12.5%), body fat (27.5%), waist circumference (9.5%), and hip circumference (7.8%) (all p < 0.001) with minimal effects on lean mass (1.3% decrease). Median time to 5 and 10% weight loss was 2 (95% confidence interval = 1 to 3) and 4 (95% confidence interval = 3 to 5) months, respectively, and 23% of participants experienced ≥ 15% weight loss. Loss of body weight and fat mass was rapid and substantial irrespective of dietary approach when a structured program was provided with monthly anthropometric assessment and weight loss counseling.

ER as a predictor of early breast cancer (EBC) outcomes in patients

590

Background: Some ER-negative (ER-) breast cancers express low levels of estrogen receptors and approximately 12% express androgen receptors (Traina, T, et al. ASCO, 2012). Whether young premenopausal women (age <40) with ER- breast cancer (BC) who are more likely to retain ovarian function after adjuvant chemotherapy have a worse outcome than older women with ER- disease has not been widely investigated. Methods: We analyzed 2 adjuvant US Oncology BC studies: 99-016, 1830 BC patients randomized to doxorubicin/cyclophosphamide (AC)→Paclitaxel (P) (AC/P) vs AP→weekly P (no cyclophosphamide [C]) (AP/wP); and 01-062, 2611 patients randomized to AC→docetaxel (T) vs AC→T plus capecitabine (XT). ER+ patients received standard endocrine therapy following chemotherapy. Five-year DFS results did not show significant differences between the treatment arms on either study. The outcomes were analyzed for 5-year DFS by age ≤40yrs and >40yrs and by ER status. Results: In the two studies combined, ER- patients ≤40 had a superior DFS (84%) than ER- patients >40 (80%), while ER+ patients ≤40 had a worse 5-yr DFS (83%) than ER+ patients >40 (89%), although these findings were of borderline significance (see Table below). In 99-016, omitting C did not adversely affect outcomes in either age group, regardless of ER status. Conclusions: We did not observe worse outcomes in ER- patients ≤40 years compared to those >40 years in 2 US Oncology adjuvant chemotherapy trials, suggesting no adverse impact of assumed greater ovarian function following adjuvant chemotherapy in patients ≤40yrs. ER+ patients ≤40 had a worse DFS than ER+ patients >40. Omitting C in ER- patients ≤40 or >40 did not adversely affect outcome. [Table: see text]

Adjuvant capecitabine for invasive lobular/mixed early breast cancer (EBC): USON 01062 exploratory analyses

547

Background: Randomized phase III USON 01062 trial determining if patients with EBC would benefit from addition of capecitabine to docetaxel after AC (AC-T vs AC-XT). AC-T: docetaxel 100mg/M2 IV; AC-XT: docetaxel 75mg/M2 IV with capecitabine 825mg/M2 PO BID 14/7 days every 21days for 4 cycles. The primary endpoint, improvement in disease-free survival (DFS) at 5 years, was not met (HR=0.84, p=0.12) likely due to lower-than-expected event rate. The secondary endpoint, overall survival (OS), was improved with capecitabine (HR 0.68, p=0.01) (O’Shaughnessy, J. ASCO, 2011). Methods: Molecular analyses demonstrate that pleomorphic lobular (mixed lobular/ductal) carcinomas evolve from the same precursor and/or through the same genetic pathway as classical lobular cancers (Reis-Filho, J., J Path, 2005). We conducted exploratory analyses to evaluate the addition of adjuvant capecitabine in ductal vs lobular or lobular/ductal (mixed) EBC within USON 01062. Histology was classified according to local pathology assessment on patients’ primary cancers. Results: In ductal patients (n=2195), there was no difference in DFS (HR=0.92, p=0.48) and OS (HR=0.75, p=0.07) with AC-T vs AC-XT. In lobular/mixed patients (n=355), adding capecitabine improved DFS (HR=0.55, p=0.055) and OS (HR=0.38, p=0.04). There was no difference in DFS (HR=1.004, p=0.98) in the ER+ ductal patients (n=1258) with the addition of capecitabine. Conclusions: Ductal and lobular cancers have distinct histologic and molecular characteristics; lobular cancers are generally less sensitive to chemotherapy (Cristofanilli, M. JCO, 2005). This exploratory analysis suggests that patients with lobular/mixed EBC may benefit from adjuvant capecitabine. This hypothesis requires evaluation in other adjuvant capecitabine trials. [Table: see text]

Effect of dietary patterns differing in carbohydrate and fat content on blood lipid and glucose profiles based on weight-loss success of breast-cancer survivors

INTRODUCTION

Healthy body weight is an important factor for prevention of breast cancer recurrence. Yet, weight loss and weight gain are not currently included in clinical-practice guidelines for posttreatment of breast cancer. The work reported addresses one of the questions that must be considered in recommending weight loss to patients: does it matter what diet plan is used, a question of particular importance because breast cancer treatment can increase risk for cardiovascular disease.

METHODS

Women who completed treatment for breast cancer were enrolled in a nonrandomized, controlled study investigating effects of weight loss achieved by using two dietary patterns at the extremes of macronutrient composition, although both diet arms were equivalent in protein: high fat, low carbohydrate versus low fat, high carbohydrate. A nonintervention group served as the control arm; women were assigned to intervention arms based on dietary preferences. During the 6-month weight-loss program, which was menu and recipe defined, participants had monthly clinical visits at which anthropometric data were collected and fasting blood was obtained for safety monitoring for plasma lipid profiles and fasting glucose. Results from 142 participants are reported.

RESULTS

Adverse effects on fasting blood lipids or glucose were not observed in either dietary arm. A decrease in fasting glucose was observed with progressive weight loss and was greater in participants who lost more weight, but the effect was not statistically significant, even though it was observed across both diet groups (P = 0.21). Beneficial effects of weight loss on cholesterol (4.7%; P = 0.001), triglycerides (21.8%; P = 0.01), and low-density lipoprotein (LDL) cholesterol (5.8%; P = 0.06) were observed in both groups. For cholesterol (P = 0.07) and LDL cholesterol (P = 0.13), greater reduction trends were seen on the low-fat diet pattern; whereas, for triglycerides (P = 0.01) and high-density lipoprotein (HDL) cholesterol (P = 0.08), a decrease or increase, respectively, was greater on the low-carbohydrate diet pattern.

CONCLUSIONS

Because an individual's dietary preferences can affect dietary adherence and weight-loss success, the lack of evidence of a negative effect of dietary pattern on biomarkers associated with cardiovascular risk is an important consideration in the development of breast cancer practice guidelines for physicians who recommend that their patients lose weight. Whether dietary pattern affects biomarkers that predict long-term survival is a primary question in this ongoing clinical trial.

Impact of a commercial reference laboratory test recurrence score on decision making in early-stage breast cancer

PURPOSE

To investigate whether recurrence score (RS) as determined using a commercial reference laboratory test influences clinicians' treatment recommendations and eventual treatment in patients with early-stage breast cancer.

METHODS

A retrospective analysis was performed on 74 patients from a community-based oncology practice with estrogen receptor (ER) -positive, lymph node (LN) -negative stage I or II breast cancer for which RS was obtained. Demographic and pathology information was extracted from medical records. Ten-year relapse-free survival was calculated using Adjuvant! Online. Treatment recommendations before the RS knowledge were compared with treatment recommendations after RS knowledge and to the treatment eventually administered.

RESULTS AND CONCLUSION

A weak correlation was found between RS and both patient age and tumor size, modest correlation between RS and tumor grade, and modest correlation between RS and 10-year recurrence as determined by Adjuvant! Online. For 21% and 25% of patients, knowledge of the RS changed the clinicians' treatment recommendations and eventual treatment, respectively. The decision to change from hormone therapy to chemotherapy (with or without hormone therapy) was generally associated with high RS (high distant recurrence risk as determined by the commercial reference laboratory test), whereas the decision to change from chemotherapy to hormone therapy was generally associated with low RS (low distant recurrence risk as determined by the commercial reference laboratory test). Knowledge of the RS changed treatment recommendations and eventual treatment in patients with ER-positive/LN-negative early-stage breast cancer. Use of genomic-based prognosis may result in more accurate estimates of true recurrence risk than currently possible with commonly used prognostic factors (such as patient age, tumor size, and tumor grade) alone and thus lead to an increase in appropriate adjuvant therapy decision making.

Effect of a low fat versus a low carbohydrate weight loss dietary intervention on biomarkers of long term survival in breast cancer patients ('CHOICE'): study protocol

Background

Weight loss in overweight or obese breast cancer patients is associated with an improved prognosis for long term survival. However, it is not clear whether the macronutrient composition of the chosen weight loss dietary plan imparts further prognostic benefit. A study protocol is presented for a dietary intervention to investigate the effects of weight loss dietary patterns that vary markedly in fat and carbohydrate contents on biomarkers of exposure to metabolic processes that may promote tumorigenesis and that are predictive of long term survival. The study will also determine how much weight must be lost for biomarkers to change in a favorable direction.

Methods/Design

Approximately 370 overweight or obese postmenopausal breast cancer survivors (body mass index: 25.0 to 34.9 kg/m²) will be accrued and assigned to one of two weight loss intervention programs or a non-intervention control group. The dietary intervention is implemented in a free living population to test the two extremes of popular weight loss dietary patterns: a high carbohydrate, low fat diet versus a low carbohydrate, high fat diet. The effects of these dietary patterns on biomarkers for glucose homeostasis, chronic inflammation, cellular oxidation, and steroid sex hormone metabolism will be measured. Participants will attend 3 screening and dietary education visits, and 7 monthly one-on-one dietary counseling and clinical data measurement visits in addition to 5 group visits in the intervention arms. Participants in the control arm will attend two clinical data measurement visits at baseline and 6 months. The primary outcome is high sensitivity C-reactive protein. Secondary outcomes include interleukin-6, tumor necrosis factor-α, insulin-like growth factor-1 (IGF), IGF binding protein-3, 8-isoprostane-F2-alpha, estrone, estradiol, progesterone, sex hormone binding globulin, adiponectin, and leptin.

Discussion

While clinical data indicate that excess weight for height is associated with poor prognosis for long term survival, little attention is paid to weight control in the clinical management of breast cancer. This study will provide information that can be used to answer important patient questions about the effects of dietary pattern and magnitude of weight loss on long term survival following breast cancer treatment.

Clinical Trial Registration

CA125243

In vivo investigation of changes in biomarkers of oxidative stress induced by plant food rich diets

It is well established that vegetables and fruit (VF) contain antioxidant phytochemicals. Consequently, it is expected that individuals who consume diets with a high content of VF should be better protected against oxidative cellular damage than individuals who do not, but not all data support this assumption. The objective of this study was to identify possible explanations for this conundrum. The effects of two diets that differed in VF content on markers of oxidative damage were studied. Sixty-four women participated in a 14-day dietary intervention. Subjects consumed on average either 3.6 or 12.1 servings of VF per day. The primary end points assessed were 8-hydroxy-2-deoxyguanosine (8-oxo-dG) in peripheral lymphocyte DNA and 8-isoprostaglandin F-2alpha (8-iso-PGF2alpha) excreted in urine. Subjects consuming the high versus low VF diet had lower concentrations of 8-oxo-dG (p < 0.01) and of 8-iso-PGF2alpha (p < 0.01). However, the reduction in oxidative end points by high VF was not uniform. Rather, an antioxidant effect was observed primarily in individuals whose oxidative end points at baseline were above the median for the study population. Using change in plasma carotenoids (end point minus baseline measurements) as an index of phytochemical intake, the reduction in oxidative markers was inversely proportional to change in plasma carotenoids; this effect was stronger for lipid peroxidation (p < 0.01) than DNA oxidation (p < 0.05). These findings imply that increasing exogenous antioxidant exposure may primarily benefit individuals with elevated levels of oxidative stress. Null findings do not necessarily indicate that an antioxidant compound lacks in vivo activity.

Paclitaxel after doxorubicin plus cyclophosphamide as adjuvant chemotherapy for node-positive breast cancer: results from NSABP B-28

PURPOSE

The primary aim of National Surgical Adjuvant Breast and Bowel Project (NSABP) B-28 was to determine whether four cycles of adjuvant paclitaxel (PTX) after four cycles of adjuvant doxorubicin/cyclophosphamide (AC) will prolong disease-free survival (DFS) and overall survival (OS) compared with four cycles of AC alone in patients with resected operable breast cancer and histologically positive axillary nodes.

PATIENTS AND METHODS

Between August 1995 and May 1998, 3,060 patients were randomly assigned (AC, 1,529; AC followed by PTX [AC --> PTX], 1,531). Patients > or = 50 years and those younger than 50 years with estrogen receptor (ER) or progesterone receptor (PR) -positive tumors also received tamoxifen for 5 years, starting with the first dose of AC. Postlumpectomy radiotherapy was mandated. Postmastectomy or regional radiotherapy was prohibited. Median follow-up is 64.6 months.

RESULTS

The addition of PTX to AC significantly reduced the hazard for DFS event by 17% (relative risk [RR], 0.83; 95% CI, 0.72 to 0.95; P = .006). Five-year DFS was 76% +/- 2% for patients randomly assigned to AC --> PTX compared with 72% +/- 2% for those randomly assigned to AC. Improvement in OS was small and not statistically significant (RR, 0.93; 95% CI, 0.78 to 1.12; P = .46). Five-year OS was 85% +/- 2% for both groups. Subset analysis of the effect of paclitaxel according to hormone receptors or tamoxifen administration did not reveal statistically significant interaction (for DFS, P = .30 and P = .44, respectively). Toxicity with the AC --> PTX regimen was acceptable for the adjuvant setting.

CONCLUSION

The addition of PTX to AC resulted in significant improvement in DFS but no significant improvement in OS with acceptable toxicity. No significant interaction between treatment effect and receptor status or tamoxifen administration was observed.

Effect of increased vegetable and fruit consumption on markers of oxidative cellular damage

The goal of this study was to test the hypothesis that increased consumption of vegetables and fruit would reduce markers of oxidative cellular damage that can be assessed in blood or urine. Twenty-eight women participated in a 14 day dietary intervention. The primary end-points assessed were: 8-hydroxydeoxyguanosine (8-OHdG) in DNA isolated from peripheral lymphocytes, determined by HPLC with electrochemical detection; 8-OHdG excreted in urine, measured by ELISA; malondialdehyde (MDA) in urine, measured by fluorimetric detection following derivatization with thiobarituric acid and separation via HPLC; urinary 8-isoprostane F-2alpha (8-EPG) detected by ELISA. Pre- and post-intervention plasma levels of selected carotenoids were determined by HPLC. Subjects were free living and consumed a completely defined recipe-based diet that increased their average daily consumption of vegetables and fruit from 5.8 servings at baseline to 12.0 servings throughout the intervention. Overall, the level of 8-OHdG in DNA isolated from lymphocytes and in urine and the level of 8-EPG in urine were reduced by the intervention, whereas urine concentrations of MDA were minimally affected. The reduction in lymphocyte 8-OHdG was greater in magnitude (32 versus 5%) in individuals with lower average pre-intervention levels of plasma alpha-carotene (56 ng/ml) than in individuals with higher average pre-intervention plasma levels of alpha-carotene (148 ng/ml). The results of this study indicate that consumption of a diet that significantly increased vegetable and fruit intake from a diverse number of botanical families resulted in significant reductions in markers of oxidative cellular damage to DNA and lipids.

Promoting cancer screening among the first-degree relatives of breast and colorectal cancer patients: the design of two randomized trials

BACKGROUND

In this paper two large nationwide trials are described, both of which will test a comparable telephone-based counseling intervention to promote cancer screening among the first-degree relatives (FDRs) of breast and colorectal cancer patients. The unit of randomization will be the family unit of eligible FDRs. Access to FDRs will be obtained from their relatives with cancer. Selected intervention and design issues are reviewed, including how both projects will respond to FDRs who exhibit significant levels of cancer-specific anxiety or distress and how potential high-risk cancer families will be accommodated.

METHODS

Pursuant to the development of both studies, two feasibility surveys were conducted to determine whether patients would grant access to their FDRs and whether the FDRS identified by these patients would be receptive to the telephone intervention.

RESULTS

Approximately 80% (106 of 132) of breast cancer patients agreed to provide access to their eligible FDRs when contacted on-site at participating hospitals and clinics. Of those subsequently selected for telephone follow-up (n = 95 or 90%), 80% (n = 76) were successfully contacted by telephone, and of these 97% (n = 74) provided the names and telephone numbers of their FDRs. Among colorectal cancer patients contacted on-site (n = 46), 96% (n = 44) agreed to provide access to their FDRs, and of those contacted by telephone (n = 33 or 75%), 91% (n = 30) provided the requested information about their FDRs. Once contacted, 95% of breast cancer FDRs (55 of 58) and 91% of colorectal cancer patients (51 of 56) endorsed the intervention strategy.

CONCLUSIONS

It is argued that this intervention, if proven effective, could provide an exportable strategy for reaching large numbers of high-risk individuals to promote cancer screening.

Clinical observations of axillary involvement for tubular, lobular, and ductal carcinomas of the breast

BACKGROUND AND OBJECTIVES

Recently, there has been much interest in identifying primary breast cancer characteristics which have predictive value for axillary metastases. We studied breast cancer patients to determine variables associated with the incidence/extent of axillary involvement and to construct a modeled analysis.

METHODS

Patients with invasive ductal, lobular, and tubular breast cancer (group 1, n = 15,719) were analyzed by tumor size and histology for the probability/extent of axillary metastases. A subgroup of patients was analyzed separately for any association of axillary involvement and other variables (group 2).

RESULTS

In group 1, the incidence and extent (number of positive lymph nodes) of axillary metastases correlated significantly with histology and increasing tumor size of ductal and lobular histologies. Significant associations for < or = 10% axillary involvement in group 2 were age and S phase for tubular histology and differentiation for ductal histology. In a multivariate analysis, increasing tumor size was the only statistically significant correlate for axillary involvement (group 2) and for increasing number of positive nodes (group 1).

CONCLUSIONS

A multivariate model of tumor size and age combined with staging techniques can successfully confirm or assess extent of axillary metastases in breast carcinoma.

Delay in diagnosis and treatment of breast cancer: implications for education

Breast cancer is an important health concern for women in the United States. Delay in establishing diagnosis and initiating treatment may result in more advanced disease at the time of diagnosis and worse outcomes. This study evaluates 225 women from a public hospital, a university hospital cancer center, and a private practice. Times to evaluation, diagnosis, and initiation of treatment were examined. The elapsed times for the diagnosis, treatment, and combined intervals were all significantly longer for women seen in the public hospital when compared with private practice (25 and 14 days, p = 0.008, for the diagnosis interval; 15 and 10 days, p = 0.007 for the treatment interval, and 43 and 24 days, p = 0.001 for the intervals combined). Delays of three to six months or more than six months were due primarily to provider misdiagnosis and patient noncompliance in the nonprivate sites. Information learned from this study can be used to educate health care providers, patients, and systems of care to facilitate earlier diagnosis and treatment, thus reducing potentially significant delays and improving patient outcomes.

First-line and salvage therapy of metastatic breast cancer with mitomycin/vinblastine

The combination chemotherapy regimen of mitomycin/vinblastine has been used in the treatment of metastatic breast cancer since the early 1980s. We report results of use of mitomycin/vinblastine in 35 women with metastatic breast cancer who had failed prior treatment with one to four chemotherapeutic regimens. Despite heavy prior treatment and significant tumor burdens, 34% of patients achieved a partial remission and another 14% had disease stabilization with a very acceptable toxicity profile. This regimen was also used for the first time as first-line chemotherapy in 11 women with metastatic breast cancer. Response was observed in 9 of 11 patients (82%). Hemolytic-uremic syndrome occurred in 6 of the 46 women (13%) treated in the two protocols and is the most serious potential complication. Mitomycin/vinblastine is an effective salvage regimen and an excellent first-line chemotherapeutic treatment for women with metastatic breast cancer.

Salvage therapy for metastatic disease

Available evidence supports the use of the combination of mitomycin plus vinblastine as salvage therapy for metastatic breast cancer. In our experience with 39 patients, this combination is as at least as effective as doxorubicin salvage therapy. In addition, those who respond usually do so within the first 4 weeks of treatment. Trial results show that its safety and toxicity profile was more favorable than doxorubicin-based regimens. In addition, the hematologic toxicities associated with mitomycin can be managed by decreasing the dose and/or prolonging the dosing interval. Most of the patients in this study received full doses of chemotherapy for the duration of the trial. We concluded that mitomycin plus vinblastine is effective and well tolerated in the treatment of metastatic breast disease.

An overview of megestrol acetate for the treatment of advanced breast cancer

Megestrol acetate was one of the first progestational agents to be evaluated for use in the hormonal therapy of advanced breast cancer. Since that time, megestrol acetate has become a standard for progestin antitumor research because of its progestational potency and excellent safety profile. As single-agent therapy, the average overall response rate to megestrol acetate therapy is 30%. This response rate is equivalent to that reported for tamoxifen, another hormonal agent widely used in treatment of breast cancer. Furthermore, although the side-effect profiles of these two agents are similar, the weight gain associated with megestrol acetate use may be beneficial in breast cancer patients who also have cancer cachexia. Because megestrol acetate and tamoxifen have been shown to be somewhat non-cross-resistant, megestrol acetate may prove useful as first-line treatment for disease that progresses during adjuvant tamoxifen therapy. Other focuses of research, including treatment of estrogen- and progestogen-receptor negative disease and moderation of weight loss for cancer cachexia, may offer hope to many cancer patients, even those with a currently unfavorable prognosis.

Pelvic and sacropelvic exenteration for locally advanced or recurrent anorectal cancer

Postirradiation "fixed" anorectal tumors are often considered incurable. Since 1980, we have carried out 12 pelvic and seven sacropelvic exenterations for this problem (adenocarcinoma, 18; squamous cancer, one). Nine tumors were primary; ten were recurrent (five after an anterior resection and five after an abdominoperineal resection). Prior irradiation ranged from 3000 to 12,000 rad (30 to 120 Gy). Four patients had synchronous distant metastases; three died of disease (one with local recurrence), and the fourth patient has been living with disease (distant metastasis). Fifteen patients (four with B2 tumors and 11 with Astler-Coller C2 disease) had no extrapelvic disease. One patient died of postoperative complications; two others died free of disease. Three of the 15 patients died of disease (all with local recurrence), and one has been living with disease (local recurrence). Eight (53%) of 15 patients have been living free of disease 12+ to 53+ months. The results suggest that many patients with fixed postirradiation anorectal tumors may be salvaged by aggressive surgery.

Essential thrombocythemia and leukemic transformation

Alkylating agents and 32P have been widely employed in the treatment of patients with essential thrombocythemia (ET). During a four-month period, we observed 3 cases of ET that had transformed into leukemia. Two patients had been treated with uracil mustard: One developed acute myelogenous leukemia 79 months after institution of therapy, and the other patient developed chronic myelomonocytic leukemia 24 months after the start of therapy. The third patient had been treated with busulfan, and ET evolved into myelofibrosis and eventually into acute undifferentiated leukemia with myelofibrosis. The patient who developed acute myelogenous leukemia was asymptomatic at the time of diagnosis of ET but was treated because his platelet count was greater than 1,000,000/mm3. He died 1 month after leukemic transformation, during induction chemotherapy. The other 2 patients presented with symptoms referable to their thrombocythemia. Review of the English literature revealed 12 other definite or probable cases of ET with leukemic transformation, all but 1 having been treated with alkylating agents and/or 32P. We propose that the natural history of ET may be similar to that of polycythemia vera, with evolution into leukemia being an unusual occurrence except in the setting of previous chemotherapy. Therefore, the current practice of treating asymptomatic patients with ET may not be justified, since administration of alkylating agents or 32P may increase the risk of subsequent development of leukemia.

Amoxapine-associated agranulocytosis with thrombocytosis occurring early during recovery

Agranulocytosis developed in a 35-year-old woman after she received 18 g of amoxapine, a tricyclic antidepressant, over 57 days. On the fifth day after cessation of amoxapine treatment, her platelet count rose from normal to a peak value of 999,000/mm3 on the 13th day. No cause for this thrombocytosis was apparent. Granulocytes appeared in the peripheral blood on the 15th day, and the thrombocytosis abated with the platelet count returning to a normal level by day 22. This confirms a previous report that amoxapine may be associated with agranulocytosis and suggests that thrombocytosis may occur as an early sign of recovery of the bone marrow in drug-associated toxic agranulocytosis.

Hyperkalemia complicating digoxin toxicity in a patient with renal failure

We describe the occurrence of hyperkalemia in a stable hemodialysis patient who developed digoxin toxicity. The patient had been receiving digoxin for 2 years. His maintenance digoxin dose was increased from 0.125 to 0.25 mg three times a week, which resulted in a toxic serum level of 4.9 ng/mL (therapeutic range is 0.8 to 2.0 ng/mL). As a consequence of the digoxin toxicity, he became hyperkalemic (7.8 mEq/L), and this value returned to normal only after the digoxin level was lowered by a combination of oral charcoal and dialysis. This study shows how readily hyperkalemia can occur in an anephric patient manifesting digoxin toxicity. Thus, potentially lethal hyperkalemia can occur in hemodialysis patients who ingest therapeutic quantities of digoxin. Digoxin toxicity should be added to the differential diagnosis of hyperkalemia in patients with renal failure. This can occur despite the absence of a history of massive ingestion of a cardiac glycoside.