Tough Choices: Exploring Medication Decision-Making During Pregnancy and Lactation Among Women With Inflammatory Arthritis

Objective

This study explored how women’s beliefs about drug safety and interactions with their health care providers influenced their decisions to continue arthritis medications during pregnancy and lactation.

Methods

We collaborated with ArthritisPower, a patient‐powered research network, and CreakyJoints, its partner online community, to develop and disseminate a survey among members with inflammatory arthritis who had at least one pregnancy after diagnosis. Participants’ free‐text responses were evaluated by using thematic analysis.

Results

Women in the sample were 40 years old on average (N = 66). Nineteen of their pregnancies had ended in fetal loss. Fifteen percent of all pregnancies were exposed to methotrexate. Among women who used safe arthritis medications, up to 80% discontinued treatment either in preparation for pregnancy or during pregnancy or lactation. Women’s decisions to continue medications during pregnancy were influenced by their perceptions of safety and advisement from health care providers, although they often described that advice about medication safety was inconsistent between providers.

Conclusion

Women often chose to endure active inflammatory arthritis rather than to use disease‐modifying antirheumatic drugs because of concerns about medication safety during pregnancy and lactation. Conflicting medical advice from health care providers undermined patients’ trust in their providers and in the safety of their medications. The high rate of peripartum exposure to methotrexate, a fetotoxic drug, underscores the need for better family planning care for women with childbearing potential.

Pregnancy, Periods, and "The Pill": Exploring the Reproductive Experiences of Women with Inflammatory Arthritis

Objective

Women with inflammatory arthritis appear to have fewer children as compared with healthy women, but few studies have assessed how patients' attitudes and decision making influence their family sizes. Little is also known about how patients experience other aspects of their reproductive lives, such as menstruation and contraception.

Methods

We partnered with ArthritisPower, a patient‐powered research network, and its associated online patient community, CreakyJoints, to create and disseminate a survey among female members aged 18‐50 years with inflammatory arthritis.

Results

Women in the final sample (n = 267) were 40 years old on average; most had rheumatoid arthritis (79%) and were predominantly white and college educated. Many women chose to limit childbearing because of their arthritis (58%); they feared that their arthritis was heritable, their diseases and medications could directly harm a fetus, they would be incapable of physically caring for a child, and arthritis could cause premature death, preventing them from raising their children. Infertility affected 40% of the sample. Half of women experienced subjective arthritis flares around the time of menstruation. Oral contraceptive pills (OCPs) did not worsen disease activity for most women and even prevented menstrual‐associated arthritis flares for a subset of women.

Conclusion

Our findings suggest that infertility, but also potentially outsized fear and anxiety related to their diagnoses, may affect the family sizes of women with inflammatory arthritis. The observation that menstruation worsens disease activity for some women requires additional study, and OCP use should be explored as a possible treatment for menstrual‐associated arthritis. Clinicians may wish to consider how they communicate patients' individual pregnancy‐associated risks, reassure patients when appropriate, and help to guide and support patients to make well‐informed reproductive decisions.

Combining online and in-person methods to evaluate the content validity of PROMIS fatigue short forms in rheumatoid arthritis

PURPOSE

Fatigue is frequent and often severe and disabling in RA, and there is no consensus on how to measure it. We used online surveys and in-person interviews to evaluate PROMIS Fatigue 7a and 8a short forms (SFs) in people with RA.

METHODS

We recruited people with RA from an online patient community (n = 200) and three academic medical centers (n = 84) in the US. Participants completed both SFs then rated the comprehensiveness and comprehensibility of the items to their fatigue experience. Cognitive debriefing of items was conducted in a subset of 32 clinic patients. Descriptive statistics were calculated, and associations were evaluated using Pearson and Spearman correlation coefficients.

RESULTS

Mean SF scores were similar (p ≥ .61) among clinic patients reflecting mild fatigue (i.e., 54.5-55.9), but were significantly higher (p < .001) in online participants. SF Fatigue scores correlated highly (r ≥ 0.82; p < .000) and moderately with patient assessments of disease activity (r ≥ 0.62; p = .000). Most (70-92%) reported that the items "completely" or "mostly" reflected their experience. Almost all (≥ 94%) could distinguish general fatigue from RA fatigue. Most (≥ 85%) rated individual items questions as "somewhat" or "very relevant" to their fatigue experience, averaged their fatigue over the past 7 days (58%), and rated fatigue impact versus severity (72 vs. 19%). 99% rated fatigue as an important symptom they considered when deciding how well their current treatment was controlling their RA.

CONCLUSIONS

Results suggest that items in the single-score PROMIS Fatigue SFs demonstrate content validity and can adequately capture the wide range of fatigue experiences of people with RA.

Abstract P5-17-03: Breast cancer in young women in Canada: A needs assessment

Objective: A Needs Assessment was conducted by Rethink Breast Cancer to assess age-related differences in experiences for breast cancer patients. This was the first national survey to identify the needs and current gaps in care for younger breast cancer patients. The report, published in March 2013, provided critical evidence-based information and benchmarks to stakeholders on the associated challenges. The following data supplements the main findings presented at the 2013 SABCS by providing a descriptive overview of the differences in breast cancer experiences between younger (≤45 years of age) and older (&gt;45 years of age) women.

Methods: From June to October 2011, an online bilingual (English and French) quantitative survey was open to Canadian women who had a diagnosis of breast cancer (initial or recurrence) in the prior 6 years. The survey focused on their pre-diagnosis, diagnosis, treatment, and post-treatment experiences. 574 women responded to the survey: 372 (65%) aged ≤45 years and 202 aged &gt;45 years. The differences in responses between the younger and older respondents was analyzed using the Pearson's Chi-Square test (α = 0.05).

Results: Finding a lump (64.3 vs 39.6%; p &lt;.01) and experiencing pain or discomfort in the breast (24.5 vs 14.4%; p &lt;.01) were significantly more likely to cause concerns in younger women. Older women were significantly more likely to be concerned by results from a screening test/mammogram (45.0 vs 8.1%; p &lt;.01). It is plausible that younger women do not receive mammograms as often as their older counterparts. Of the 319 women that found a lump, self-examination (38.6%) was the most frequent method of discovery. However, this was significantly more likely among older rather than younger women (51.3 vs 34.3%; p = 0.02). Follow-up appointments for future reassessment were significantly more likely to be scheduled with younger rather than older women (15.1 vs 5.0%; p = 0.02). With respect to treatment, younger women were significantly more likely than older women to be recommended chemotherapy (81.7 vs 67.3%; p &lt;.01), targeted therapy (21.0 vs 10.9%; p &lt;.01), bilateral mastectomy (17.2 vs 8.9%; p &lt;.01), breast reconstruction (30.9 vs 14.4%; p &lt;.01), node dissection (37.9 vs 23.3%; p &lt;.01), oophorectomy (10.8 vs 5.0%; p = 0.02), and hysterectomy (7.8 vs 2.0%; p &lt;.01). Transitioning from regular to occasional monitoring by a healthcare team was reported to be very or somewhat difficult (59.1 vs 41.8%; p &lt;.01) for younger instead of older women, while older women were significantly more likely to report little to no difficulty with this transition (58.2 vs 40.9%; p &lt;.01).

Conclusions: The Needs Assessment demonstrated significant age-related differences in almost all aspects of breast cancer care, including during pre-diagnosis, treatment, and post-treatment. Differences such as greater recommendations for more aggressive treatments and difficulty in care transitions may lead to challenges being faced by younger women relative to their older counterparts. Tools such as checklists and guidelines may assist healthcare teams in meeting the needs of younger women. Future studies are warranted to assess the impact of such tools in helping improve patient education, advocacy, and support programs for this population.

Citation Format: DeCoteau MJ, Mercado MG, Ginsberg S, Dhir V, Brezden-Masley C. Breast cancer in young women in Canada: A needs assessment [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-17-03.

Patient's experience with subcutaneous and oral methotrexate for the treatment of rheumatoid arthritis

Background

Despite the prominent position of methotrexate (MTX) in Rheumatoid Arthiris (RA) therapeutics, its real-world effectiveness may be influenced by a relative lack of tolerability or other side effects that physicians may not be aware of but that are bothersome to patients.

The aim of this study is to identify suboptimal patient experience with MTX and to raise awareness for clinicians to identify opportunities to mitigate bothersome symptoms and side effects and optimize response to MTX.

Methods

We conducted a prospective, cross-sectional, online survey among RA patients who were members of Creakyjoints, a large arthritis patient community. Eligible participants must have recently initiated a new biologic, subcutaneous (SQ) MTX, or oral MTX in the last 12 months and were uniquely assigned to one of these 3 groups. Descriptive statistics were used to compare patient-reported side effects and tolerability related to MTX use in the 3 medication groups (SQ MTX, oral MTX, and biologic).

Results

A total of 382 (85 %) of 448 eligible patients completed the survey and were grouped as: biologic (n = 218), SQ MTX (n = 49), and oral MTX (n = 115). Demographics were mean standard deviation (SD) age 48 (10) years, 92 % white, 91 % women. Symptoms significantly more prevalent in the SQ and oral MTX groups included diarrhea, fatigue, malaise, and hair loss. Injection related pain was lower with SQ MTX compared to SQ biologics. Out of a total of 8 potential symptoms and side effects examined, higher dose MTX (> = 20 mg/week) was associated with a 2.26 (1.25–4.09) greater likelihood of more side effects referent to < =10 mg/week.

Conclusion

Results from this real-world RA patient cohort suggest that MTX is accompanied by many patient-reported side effects and tolerability problems that may be under-recognized by physicians. These may impact both treatment satisfaction and medication adherence.

Openness to and preference for attributes of biologic therapy prior to initiation among patients with rheumatoid arthritis: patient and rheumatologist perspectives and implications for decision making

PURPOSE

Despite American College of Rheumatology recommendations, appropriate and timely initiation of biologic therapies does not always occur. This study examined openness to and preference for attributes of biologic therapies among patients with rheumatoid arthritis (RA), differences in patients' and rheumatologists' perceptions, and discussions around biologic therapy initiation.

PATIENTS AND METHODS

A self-administered online survey was completed by 243 adult patients with RA in the US who were taking disease-modifying antirheumatic drugs (DMARDs) and had never taken, but had discussed biologic therapy with a rheumatologist. Patients were recruited from a consumer panel (n=142) and patient advocacy organization (n=101). A separate survey was completed by 103 rheumatologists who treated at least 25 patients with RA per month with biologic therapy. Descriptive and bivariate analyses were conducted separately for patients and rheumatologists. Attributes of biologic therapy included route of administration (intravenous infusion or subcutaneous injection), frequency of injections/infusions, and duration of infusion.

RESULTS

Over half of patients (53.1%) were open to both intravenous infusion and subcutaneous injection, whereas rheumatologists reported 40.7% of patients would be open to both. Only 26.3% of patients strongly preferred subcutaneous injection, whereas rheumatologists reported 35.2%. Discrepancies were even more pronounced among specific patient types (eg, older vs younger patients and Medicare recipients). Among patients, 23% reported initiating discussion about biologics and 54% reported their rheumatologist initiated the discussion. A majority of rheumatologists reported discussing in detail several key aspects of biologics, whereas a minority of patients reported the same.

CONCLUSION

Preferences differed among patients with RA from rheumatologists' perceptions of these preferences for biologic therapy, including greater openness to intravenous infusion among patients than assumed by rheumatologists and relative lack of discussion about key aspects of biologic therapy perceived by patients. There is a need for more open communication about treatment options, which may encourage more appropriate, timely transition to biologic therapy.

2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

OBJECTIVE

To develop a new evidence-based, pharmacologic treatment guideline for rheumatoid arthritis (RA).

METHODS

We conducted systematic reviews to synthesize the evidence for the benefits and harms of various treatment options. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence. We employed a group consensus process to grade the strength of recommendations (either strong or conditional). A strong recommendation indicates that clinicians are certain that the benefits of an intervention far outweigh the harms (or vice versa). A conditional recommendation denotes uncertainty over the balance of benefits and harms and/or more significant variability in patient values and preferences.

RESULTS

The guideline covers the use of traditional disease-modifying antirheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids in early (<6 months) and established (≥6 months) RA. In addition, it provides recommendations on using a treat-to-target approach, tapering and discontinuing medications, and the use of biologic agents and DMARDs in patients with hepatitis, congestive heart failure, malignancy, and serious infections. The guideline addresses the use of vaccines in patients starting/receiving DMARDs or biologic agents, screening for tuberculosis in patients starting/receiving biologic agents or tofacitinib, and laboratory monitoring for traditional DMARDs. The guideline includes 74 recommendations: 23% are strong and 77% are conditional.

CONCLUSION

This RA guideline should serve as a tool for clinicians and patients (our two target audiences) for pharmacologic treatment decisions in commonly encountered clinical situations. These recommendations are not prescriptive, and the treatment decisions should be made by physicians and patients through a shared decision-making process taking into account patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

Use of oral and subcutaneous methotrexate in rheumatoid arthritis patients in the United States

OBJECTIVE

To examine the patterns of methotrexate (MTX) use among rheumatoid arthritis (RA) patients.

METHODS

Using data from RA patients enrolled in a US commercial health plan and the US Medicare program, we identified RA patients initiating oral MTX. Persistence with MTX (oral or subcutaneous [SC]) was defined as no gap for ≥90 days.

RESULTS

New oral MTX users in Medicare (n = 20,431) were 76.9% women, had a mean ± SD age of 69.7 ± 11.7 years, and contributed a median followup of 2.6 years (interquartile range 1.7-3.5 years). Only 38% received dosages ≥20 mg/week at any time. Approximately 50% of patients discontinued MTX at 1 year, although more than one-third of patients subsequently restarted. New commercially insured oral MTX users (n = 4,048) were similar to Medicare patients, except for age. Among Medicare patients, 19% starting oral MTX subsequently initiated a biologic agent, mostly anti-tumor necrosis factor (85%). Of these, only 50% received MTX at a dosage of ≥20 mg/week, and only 21% of individuals switched to SC MTX (4%) or received hydroxychloroquine (8%), sulfasalazine (5%), or leflunomide (8%) prior to biologic agents. In commercially insured patients, 35% initiated a biologic agent, mostly anti-tumor necrosis factor therapies (90%). Of these, 43% never received MTX ≥20 mg/week.

CONCLUSION

Titration to a higher-dose oral MTX and use of SC MTX among RA patients were infrequent and may have been underutilized. Further work to optimize MTX dosing before patients are switched to a biologic agent may be warranted.

Obese adults with primary growth hormone resistance (Laron Syndrome) have normal endothelial function

OBJECTIVE

Classic Laron Syndrome (LS) is a recessive disease of insulin-like growth factor I (IGF-I) deficiency and primary growth hormone insensitivity, clinically characterized by dwarfism and marked obesity. The aim of the current study was to investigate the impact of long-term IGF-I deficiency on flow-mediated dilation (FMD) in 11 non-IGF-I-treated LS adults with long-term IGF-I deficiency who on stress echocardiography were found to have reduced cardiac dimensions and output, but normal left ventricular (LV) ejection fraction at rest and LV contractile reserve following stress.

DESIGN

Following an overnight fast we assessed percent improvement in endothelium-dependent FMD (%FMD) and endothelium-independent nitroglycerin (%NTG)-mediated vasodilation non-invasively in the brachial artery, using high resolution ultrasound in 11 non-treated adult patients with LS without known coronary artery disease, and compared them to 11 age- and sex-matched healthy controls. All subjects underwent symptom-limited exercise testing (Bruce protocol).

RESULTS

LS patients had a significantly higher body mass index (29+/-6 vs. 25+/-2 kg/m(2), p=0.04), lower low-density lipoprotein cholesterol (142+/-28 vs. 176+/-12 mg/dl, p=0.03) and a smaller mean brachial artery diameter (4.63+/-0.72 vs. 5.70+/-1.06 mm, p=0.01) compared to controls. However, brachial artery %FMD and %NTG were not significantly different between the LS patients and controls (13.1+/-6.2% vs. 15.4+/-5.2%, p=0.28 and 22.3+/-6.0% vs. 18.9+/-6.2%, p=0.30; respectively). Cardiac performance, assessed by exercise duration time and metabolic equivalents (METs), was significantly greater in control subjects than in LS patients (10.3+/-2.0 vs. 6.0+/-1.4 min, p<0.01 and 10.2+/-2.0 vs. 7.2+/-1.4 METs, p<0.01; respectively).

CONCLUSIONS

FMD was found to be within normal limits in non-IGF-I-treated adult patients with LS, despite congenital absence of IGF-I and obesity.

A prospective comparison of three heat preservation methods for patients undergoing hypothermic cardiopulmonary bypass

OBJECTIVE

To prospectively compare 3 methods of body heat preservation in patients undergoing surgery requiring the use of hypothermic cardiopulmonary bypass (CPB).

DESIGN

Prospective, randomized, and nonblinded.

SETTING

University teaching hospital.

PARTICIPANTS

Adult cardiac surgery patients (n = 101).

INTERVENTIONS

Subjects were randomly assigned to 1 of 3 treatment groups: Group 1 (n = 33) used a fluid-filled warming blanket, group 2 (n = 31) used a heated and humidified breathing circuit, and group 3 (n = 37) used intravenous fluid warmers for the administration of all fluids. Treatments started on separation from CPB and concluded at the end of the intraoperative experience. Anesthetic technique, minute ventilation, conduct of CPB, and room temperature in the operating room were standardized.

MEASUREMENTS AND MAIN RESULTS

Blood temperature was measured at its nadir on CPB, on separation from CPB, and just before departure from the operating room. No differences were found among groups for CPB duration, coldest venous temperature on CPB, rewarming time, rate of rewarming, room temperature, or blood temperature on separation from CPB. There were no significant differences found in post-CPB temperature afterdrop among groups.

CONCLUSIONS

This study suggests that there is no statistically significant disparity in the effectiveness of these 3 intraoperative heat preservation methods. Ease of use and cost-effectiveness should guide the choice of warming method post-CPB.

A comparison of inhaled nitric oxide and milrinone for the treatment of pulmonary hypertension in adult cardiac surgery patients

OBJECTIVE

To investigate the relative effects of milrinone and nitric oxide on pulmonary and systemic hemodynamic responses in cardiac surgery patients with a history of pulmonary hypertension.

DESIGN

Prospective and randomized.

SETTING

University hospital.

PARTICIPANTS

Forty-five adult cardiac surgery patients.

INTERVENTIONS

Cardiac surgery patients with pulmonary hypertension were randomly assigned to one of three study groups: Group 1 patients (n = 15) were treated with intravenous milrinone on separation from cardiopulmonary bypass, group 2 patients (n = 15) with 20 ppm of inhaled nitric oxide, and group 3 patients (n = 15) with 40 ppm of inhaled nitric oxide. Heart rate, right ventricular ejection fraction, and pulmonary vascular resistance were measured throughout the perioperative period at specific data points.

MEASUREMENTS AND MAIN RESULTS

There were no significant differences in demographics, anesthesia, surgery, or baseline hemodynamics among the groups. The group receiving 40 ppm nitric oxide had a significantly higher (p<0.05) right ventricular ejection fraction on arrival in the intensive care unit (40% v. 30% for the milrinone group and 33% for the nitric oxide 20 ppm group). The milrinone group required significantly more phenylephrine in the intensive care unit (p<0.05).

CONCLUSIONS

Treatment of pulmonary hypertension in adult cardiac surgery patients with inhaled nitric oxide compared with milrinone is associated with lower heart rates, higher right ventricular ejection fraction, and a lower requirement for treatment with vasopressor agents.

Presence and phosphorylation of transcription factors in developing dendrites

In screening amplified poly(A) mRNA from hippocampal dendrites and growth cones in culture to determine candidates for local translation, we found that select transcription factor mRNAs were present. We hypothesized that synthesis of transcription factor proteins within dendrites would provide a direct signaling pathway between the distal dendrite and the nucleus resulting in modulation of gene expression important for neuronal differentiation. To evaluate this possibility, radiolabeled amplified antisense RNA was used to probe slot blots of transcription factor cDNAs as well as arrayed blots of zinc finger transcription factors. The mRNAs encoding the cAMP response element binding protein (CREB), zif 268, and one putative transcription factor were detected. We expanded upon these results showing that CREB protein is present in dendrites, that translation of CREB mRNA in isolated dendrites is feasible and that CREB protein found in dendrites can interact with the cis-acting cyclic AMP reponse element DNA sequence by using an in situ Southwestern assay. Further, CREB protein in dendrites is not transported to this site from the cell body because fluorescently tagged CREB microperfused into the soma did not diffuse into the dendrites. In addition, CREB protein microperfused into dendrites was rapidly transported to the nucleus, its likely site of bioactivity. Lastly, by using the isolated dendrite system we show that phosphorylation of Ser-133 on CREB protein can occur in isolated dendrites independent of the nucleus. These data provide a regulatory pathway in which transcription factors synthesized and posttranslationally modified in dendrites directly alter gene expression bypassing the integration of signal transduction pathways that converge on the nucleus.

The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration

This study retrospectively investigated the value of both endoscopically visible oropharyngeal secretions in the hypopharynx and swallowing frequency in the prediction of aspiration of food and liquid. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed on a total of 69 individuals that included hospitalized elderly, nonhospitalized elderly, and young normal subjects. A four-level rating scale for determining the severity of accumulated oropharyngeal secretions was developed and employed to rate subjects prior to the presentation of food or liquid during the FEES. Spontaneous dry swallows were also counted during the observation period of the FEES. It was found that the accumulation of endoscopically visible oropharyngeal secretions located within the laryngeal vestibule was highly predictive of aspiration of food or liquid. There were significantly fewer spontaneous swallows in hospitalized subjects when compared with nonhospitalized subjects. There was also a significant decrease in the frequency of spontaneous swallows in aspirating hospitalized subjects when compared with nonaspirating hospitalized subjects. Results are discussed in terms of integrating this information with clinical bedside examination techniques.

Managed care's paradoxical effect

This paper addresses the efforts made by the managed care industry to cut costs in the spending of the health-care dollar. It focuses on what appears to be disproportionate attention being paid to the dollar at the expense of appropriate patient care. It examines the effects of cuts in the mental health-care dollar as this relates to shorter lengths of stay in more expensive settings and not effectively utilizing a continuum of care. It also shows how managed care has impacted medical liability and the legal implications thereof.

A phase II trial of iproplatin (CHIP) in previously treated advanced breast cancer

Iproplatin (CHIP) was administered to 35 previously treated women with metastatic adenocarcinoma of the breast. The drug was given at a dose of 45 mg/m2 intravenously for 5 consecutive days and was repeated every 28 days. In this trial, there was one partial response and two patients with stable disease out of 29 evaluable patients. The median duration of response in patients with either a partial response or stable disease was 4.8 months. Myelosuppression was the major toxicity, 11 patients had severe thrombocytopenia and 3 severe neutropenia. Mild renal insufficiency, anemia, and nausea and vomiting were also noted. Iproplatin has limited activity in heavily pretreated women with advanced breast carcinoma; further studies in patients less heavily treated may show an improved response rate.

Developmental and hormonal factors in the sexually dimorphic, asymmetrical response to focal cortical lesions

The developmental and hormonal determinants of the lateralized response to focal cortical suction lesions were examined in a series of experiments. In an initial study, Sprague-Dawley male rats 25, 30, 55 or 90 days of age, received right unilateral focal frontocortical suction lesions. Only 90-day-old rats developed hyperactivity, suggesting a specific role for maturational factors in the production of this response. Prepubertally castrated adult male rats receiving right frontocortical suction lesions at 90 days also failed to develop hyperactivity, suggesting that sexual maturational factors and/or the presence of testosterone are necessary for the expression of this response. Testosterone implants, producing physiological relevant levels of circulating testosterone reinstated the hyperactivity response to adult cortical lesions in prepubertally castrated male rats. Similar lesions in the left hemisphere, however, did not produce hyperactivity in castrated male rats with testosterone replacement. Finally, in ovariectomized adult female rats, testosterone did not allow the expression of a hyperactivity response to right frontocortical suction lesions. Together, these results demonstrate both an organizational and permissive role for sex steroids in the sexually dimorphic asymmetrical response to cortical injury.

Phase I--preliminary phase II trial of iproplatin, a cisplatin analogue

Iproplatin was administered intravenously over 30 min daily for 5 consecutive days every 3 weeks to 80 evaluable patients with a variety of refractory solid tumor malignancies. Thrombocytopenia was the dose-limiting toxicity. Reversible drug-induced renal dysfunction was observed in 3 patients. One patient sustained mild ototoxicity but neurotoxicity was not encountered. Transient neutropenia, anemia, nausea, vomiting, diarrhea, elevations of liver enzymes, alopecia, and skin rash also occurred. The spectrum and severity of toxicity of iproplatin were found to differ from those of cisplatin. The maximally tolerated dose (MTD) was 45 mg/m2/day in patients who received prior chemotherapy and 65 mg/m2/day in those who did not. No complete responses occurred. Partial responses were obtained in 2/15 patients with colon cancer, 3/18 with breast cancer, 2/4 with carcinoma of unknown primary site and 1/2 with pancreatic cancer. Thirteen patients with lung (5), breast (4), colon (2), head and neck (1) and cervical (1) cancers had stable disease. Based on the different toxicity profiles between iproplatin and cisplatin and the possible antitumor efficacy of the former, phase II investigation of iproplatin has been initiated.

Responses to chemotherapy or chemohormonal therapy in advanced breast cancer patients treated previously with adjuvant chemotherapy. A subset analysis of CALGB Study 8081

The Cancer and Leukemia Group B (CALGB) evaluated the response to subsequent chemotherapy or chemohormonal therapy in 46 patients with advanced breast cancer treated previously with adjuvant chemotherapy that had been completed 6 months or more before protocol entry. The results were compared with 379 patients in the same study who had not received prior adjuvant chemotherapy. The patients were treated with cyclophosphamide, Adriamycin (Adria Laboratories, Columbus, OH), and 5-fluorouracil (CAF), with or without tamoxifen. There was no difference in response rate, response duration, time to treatment failure, or survival between patients who had received prior adjuvant chemotherapy and those who had not. The addition of tamoxifen to CAF failed to enhance response rates or response durations in all subgroups. Women who relapsed 6 months or more after completion of adjuvant chemotherapy did not have inherently drug-resistant tumors. They responded to standard CAF chemotherapy with the same response rate and survival as patients untreated previously with chemotherapy.

Carboplatin or iproplatin in advanced non-small cell lung cancer: a Cancer and Leukemia Group B Study

The effect of the cisplatin analogs carboplatin (CBDCA) or iproplatin (CHIP) was evaluated in patients with extensive non-small cell lung cancer. The randomized phase II design was used to achieve balance between patient groups and comparison of response rates was not a primary objective of the study. CBDCA (400 mg/m2 iv) or CHIP (270 mg/m2 iv) was administered every 4 weeks until relapse of disease. Overall, 11 of 70 patients (16%; 95% confidence interval: 7%-25%) responded to CBDCA and five of 71 patients (7%; 95% confidence interval: 1%-13%) responded to CHIP. There were two complete responses to CHIP and none to CBDCA. The most frequent severe or life-threatening toxic effects were thrombocytopenia and leukopenia. Median survival for patients receiving CBDCA was 6.5 months; for those on CHIP it was 5.0 months (P = 0.59). CBDCA is probably active in patients with non-small cell lung cancer whereas CHIP has limited activity. Further evaluation of CBDCA as part of combination chemotherapy for non-small cell lung cancer is warranted.

Chemotherapy versus chemoimmunotherapy (CAF v CAFVP v CMF each +/- MER) for metastatic carcinoma of the breast: a CALGB study. Cancer and Leukemia Group B

Three combination chemotherapy regimens each with or without the methanol-extracted residue of bacillus Calmette-Guérin (BCG) (MER) were compared for efficacy. After stratification for disease-free interval and dominant sites of disease, patients were randomized to either CMF (cyclophosphamide [CYC], 100 mg/m2 orally, days 1 through 14; methotrexate [MTX], 40 mg intravenously [IV], days 1 and 8; 5-fluorouracil [5-FU], 500 mg/m2 IV, days 1 and 8), or CAF (CYC, 100 mg/m2 orally, days 1 through 14; doxorubicin [DOX], 25 mg/m2 IV, days 1 and 8; 5-FU, 500 mg/m2 IV, days 1 and 8), or CAFVP (CAF as above plus vincristine [VCR], 1.0 mg/m2 IV, days 1 and 8; and prednisone [PRED], 40 mg/m2 orally, days 1 through 14). Nonspecific immunotherapy with MER was administered in five sites at 100 micrograms or at the lowest tenfold dilution that produced a 1-cm indurated lesion. A total of 432 patients were entered, but 37 were disqualified, leaving 395 evaluable for treatment results and toxicities. One hundred thirty-five evaluable patients were randomized to chemoimmunotherapy until October 28, 1978. One hundred twenty-six evaluable patients were randomized to chemotherapy alone in the same time period. For the entire study, a total of 260 evaluable patients were randomized to chemotherapy. Chemoimmunotherapy patients were compared with the initial 126 chemotherapy patients. Chemotherapy regimens were compared among all 260 patients. Patient characteristics were similar between regimens and between chemotherapy and chemoimmunotherapy treatment groups. For patients on chemotherapy plus MER, there was no significant differences between the regimens for response frequencies: 43%, 41%, and 32%, respectively for CMF, CAF, and CAFVP. The comparable chemotherapy alone group had 36%, 58%, and 63% response, respectively. The response rates, adjusted for chemotherapy regimen, were 52% and 38% (P = .02) for chemotherapy and chemoimmunotherapy, respectively. MER was associated with painful ulcers and fevers. Thus, MER produced toxicity without response or survival benefit and further randomization after October 28, 1978 was to chemotherapy alone. For 260 evaluable patients on chemotherapy alone, the complete (CR) and partial responses (PR) were 37%, 55%, and 58%, respectively for CMF, CAF, and CAFVP. These response rates for CAF and CAFVP were significantly better than CMF (P = .01 and P less than .01, respectively). These comparisons were consistent within subgroupings such as dominant sites of disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent day hospital: a cost-effective treatment alternative

AYC (Arizona Youth for Change) is the result of a joint venture between two of the leading adolescent service providers in inpatient and residential (long-term) care in the Southwest. Youth Health Resources, Inc., the corporate identity, focuses in the area of alternative treatment for adolescents. Components of the AYC programs are discussed, as well as some statistical data regarding the outcome of treatment. Also addressed are trends in the mental-health community, as well as the use of a "continuum-of-care" model.

Chemoendocrine therapy vs chemotherapy alone for advanced breast cancer in postmenopausal women: preliminary report of a randomized study

From January 1980 to August 1982 the Cancer and Leukemia Group B conducted a prospective randomized trial comparing chemoendocrine therapy with T-CAF (cyclophosphamide, adriamycin, and 5-fluorouracil plus tamoxifen) to CAF alone in postmenopausal women with advanced breast cancer. The patients were stratified by estrogen receptor (ER) status into three groups: ER-negative, ER-positive, ER-unknown. They were also stratified by dominant site of metastatic disease: visceral and other (osseous and/or soft tissue). A total of 246 eligible patients were enrolled in the study; 232 were evaluable and constitute the basis for this report. The study revealed that there was no difference in overall response frequency or response duration between T-CAF and CAF; there was no difference in response between T-CAF and CAF in ER-positive or in ER-negative patients; and there was no difference in response between T-CAF and CAF by dominant site of metastatic disease. The expected advantage of T-CAF over CAF, especially for ER-positive patients, was not observed.

Measurement of myelin basic protein and of anti-basic protein antibodies by ELISA utilizing biotinylated antibodies

Immunoglobulins were conjugated to peroxidase by the biotin-avidin method and used in ELISA systems for measuring myelin basic protein (MBP) and anti-MBP antibodies. To measure concentration of MBP, microplate wells were coated with affinity purified rabbit anti-MBP antibodies and incubated with varying concentrations of MBP. Bound antigen was measured by incubating with biotinylated anti-MBP antibodies and avidin-peroxidase. As little as 0.2 ng/ml of MBP could be measured by this assay. To measure anti-MBP antibodies, microplate wells were coated with human MBP and incubated with varying concentrations of affinity purified rabbit anti-human MBP antibodies. Binding was measured by incubating with either peroxidase-conjugated anti-rabbit antibodies or biotinylated anti-rabbit antibodies and avidin peroxidase. The two methods were equally sensitive. The avidin-biotin method for enzyme conjugation promises to be a useful and versatile tool for ELISA systems.

Phase I trial of chlorozotocin: attempted amelioration of myelotoxicity by glucose administration

Chlorozotocin is a new anticancer agent with the chloroethylnitrosourea cytotoxic moiety attached to the carbon-2 position of glucose. Like other chloroethylnitrosoureas, this agent produces delayed myelotoxicity which is dose-limiting. A phase I trial of chlorozotocin with administration of glucose was done in an attempt to modify the myelotoxicity. The patients received the first course of chlorozotocin (200 mg/m2) in the fasting state and then the second course of chlorozotocin with boluses of a 50% glucose solution. With the second course of chlorozotocin administration, the glucose concentration remained threefold greater than after the first course for at least 1 hour. The plasma half-life and apparent volume of distribution of chlorozotocin were similar following either course. The wbc, neutrophil, and platelet count nadirs after the first course of this agent were not significantly different than the nadirs after the second course. We were unable to modify the myelotoxicity of chlorozotocin with boluses of a 50% glucose solution.

Systemic chemotherapy for a primary germ cell tumor of the brain: a pharmacokinetic study

Systemic administration of most chemotherapeutic agents has been assumed to be ineffective in the treatment of primary and metastatic brain tumors because these agents fail to cross the intact blood-brain barrier. However, agents which fail to penetrate the intact blood-brain barrier may penetrate it under conditions which include the presence of tumor in the central nervous system (CNS) and prior CNS irradiation. This paper reports the results of pharmacokinetic studies of bleomycin, cisplatin, and vinblastine in the CNS of a patient with a primary germ cell tumor of the brain who had received prior radiotherapy. Significant concentrations of bleomycin and cisplatin, but not of vinblastine, were reached in the cerebrospinal fluid (CSF) of the patient following iv administration. The area under the bleomycin CSF concentration times time curve was 25% of the area under the bleomycin plasma concentration times time curve. The areas under two cisplatin CSF curves were 50% and 155% of the areas under the corresponding free cisplatin plasma curves. Moreover, an objective response of the tumor to the chemotherapy was documented. This study provides evidence that, under certain circumstances, significant concentrations of cisplatin and bleomycin may be obtained in human CSF following systemic administration and that it may be possible to treat primary or metastatic CNS tumors with agents effective against systemic tumor of the same histologic type.

Combination chemotherapy and radiotherapy in small-cell carcinoma of the lung

A combination of chemotherapy (Cytoxan, vincristine, and CCNU) and radiation therapy was used to treat 37 patients with small-cell carcinoma of the lung. There was 49% complete remission and an overall 76% objective response with an overall median survival of 12.5 months and 17 months for those showing a complete response. No serious morbidity was observed.

Test of an orienting-reaction-recovery account of short-interval autonomic conditioning

The electrodermal and plethysmographic components of the orienting reaction in 24 subjects were examined in a conditioning-analog arrangement (tones and lights patterned analogously to CS and UCS presentations in classical conditioning) in order to test the orienting-reaction-recovery (ORR) account according to which apparent short-interval autonomic conditioning (SIAC) can be completely accounted for by an ORR effect. The form of the test was to see whether ORR following change from a repeatedly presented forward ('CS-UCS') analog would exceed that to change from a backward ('UCS-CS') analog, as is the case in SIAC with CS-alone test trials following repeated CS-UCS versus UCS-CS pairings. The results did not support the ORR account, although they were shown to be consistent with the relevant experimental literature, when critically examined, and to provide internal evidence for the adequacy of the present test of this particular formulation of the ORR account of SIAC.

Motivation, anxiety and stress in a difficult verbal task

A complex verbal learning task was administered under stress or nonstress conditions to Ss shown by pre-tests to have either high or low scores on anxiety and need for achievement. Subsidiary findings from the pre-tests were that debilitating anxiety scores had a significant negative correlation with facilitating anxiety scores, and also with achievement scores. The verbal learning showed a significant interaction with “drive” variables: Ss high in need for achievement performed better if anxiety and stress were high but Ss low in need for achievement performed better if anxiety and stress were low. Ss high on only one or two drive variables showed significantly poorer learning than the pool of Ss high on all three or low on all three drive variables.