Effects of a Geriatric Assessment Intervention on Patient-Reported Symptomatic Toxicity in Older Adults With Advanced Cancer

PURPOSE

Providing a geriatric assessment (GA) summary with management recommendations to oncologists reduces clinician-rated toxicity in older patients with advanced cancer receiving treatment. This secondary analysis of a national cluster randomized clinical trial (ClinicalTrials.gov identifier: NCT02054741) aims to assess the effects of a GA intervention on symptomatic toxicity measured by Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE).

METHODS

From 2014 to 2019, the study enrolled patients age ≥ 70 years, with advanced solid tumors or lymphoma and ≥ 1 GA domain impairment, who were initiating a regimen with high prevalence of toxicity. Patients completed PRO-CTCAEs, including the severity of 24 symptoms (11 classified as core symptoms) at enrollment, 4-6 weeks, 3 months, and 6 months. Symptoms were scored as grade ≥ 2 (at least moderate) and grade ≥ 3 (severe/very severe). Symptomatic toxicity was determined by an increase in severity during treatment. A generalized estimating equation model was used to assess the effects of the GA intervention on symptomatic toxicity.

RESULTS

Mean age was 77 years (range, 70-96 years), 43% were female, and 88% were White, 59% had GI or lung cancers, and 27% received prior chemotherapy. In 706 patients who provided PRO-CTCAEs at baseline, 86.1% reported at least one moderate symptom and 49.7% reported severe/very severe symptoms at regimen initiation. In 623 patients with follow-up PRO-CTCAE data, compared with usual care, fewer patients in the GA intervention arm reported grade ≥ 2 symptomatic toxicity (overall: 88.9% v 94.8%, P = .035; core symptoms: 83.4% v 91.7%, P = .001). The results for grade ≥ 3 toxicity were comparable but not significant (P > .05).

CONCLUSION

In the presence of a high baseline symptom burden, a GA intervention for older patients with advanced cancer reduces patient-reported symptomatic toxicity.

A Pragmatic Cluster-Randomized Trial of a Standing Order Entry Intervention for Colony-Stimulating Factor Use Among Patients at Intermediate Risk for Febrile Neutropenia

PURPOSE

Primary prophylactic colony-stimulating factors (PP-CSFs) are prescribed to reduce febrile neutropenia (FN) but their benefit for intermediate FN risk regimens is uncertain. Within a pragmatic, randomized trial of a standing order entry (SOE) PP-CSF intervention, we conducted a substudy to evaluate the effectiveness of SOE for patients receiving intermediate-risk regimens.

METHODS

TrACER was a cluster randomized trial where practices were randomized to usual care or a guideline-based SOE intervention. In the primary study, sites were randomized 3:1 to SOE of automated PP-CSF orders for high FN risk regimens and alerts against PP-CSF use for low-risk regimens versus usual care. A secondary 1:1 randomization assigned 24 intervention sites to either SOE to prescribe or an alert to not prescribe PP-CSF for intermediate-risk regimens. Clinicians were allowed to over-ride the SOE. Patients with breast, colorectal, or non-small-cell lung cancer were enrolled. Mixed-effect logistic regression models were used to test differences between randomized sites.

RESULTS

Between January 2016 and April 2020, 846 eligible patients receiving intermediate-risk regimens were registered to either SOE to prescribe (12 sites: n = 542) or an alert to not prescribe PP-CSF (12 sites: n = 304). Rates of PP-CSF use were higher among sites randomized to SOE (37.1% v 9.9%, odds ratio, 5.91; 95% CI, 1.77 to 19.70; P = .0038). Rates of FN were low and identical between arms (3.7% v 3.7%).

CONCLUSION

Although implementation of a SOE intervention for PP-CSF significantly increased PP-CSF use among patients receiving first-line intermediate-risk regimens, FN rates were low and did not differ between arms. Although this guideline-informed SOE influenced prescribing, the results suggest that neither SOE nor PP-CSF provides sufficient benefit to justify their use for all patients receiving first-line intermediate-risk regimens.

Effects of a Guideline-Informed Clinical Decision Support System Intervention to Improve Colony-Stimulating Factor Prescribing: A Cluster Randomized Clinical Trial

IMPORTANCE

Colony-stimulating factors are prescribed to patients undergoing chemotherapy to reduce the risk of febrile neutropenia. Research suggests that 55% to 95% of colony-stimulating factor prescribing is inconsistent with national guidelines.

OBJECTIVE

To examine whether a guideline-based standing order for primary prophylactic colony-stimulating factors improves use and reduces the incidence of febrile neutropenia.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial, the Trial Assessing CSF Prescribing Effectiveness and Risk (TrACER), involved 32 community oncology clinics in the US. Participants were adult patients with breast, colorectal, or non-small cell lung cancer initiating cancer therapy and enrolled between January 2016 and April 2020. Data analysis was performed from July to October 2021.

INTERVENTIONS

Sites were randomized 3:1 to implementation of a guideline-based primary prophylactic colony-stimulating factor standing order system or usual care. Automated orders were added for high-risk regimens, and an alert not to prescribe was included for low-risk regimens. Risk was based on National Comprehensive Cancer Network guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was to find an increase in colony-stimulating factor use among high-risk patients from 40% to 75%, a reduction in use among low-risk patients from 17% to 7%, and a 50% reduction in febrile neutropenia rates in the intervention group. Mixed model logistic regression adjusted for correlation of outcomes within a clinic.

RESULTS

A total of 2946 patients (median [IQR] age, 59.0 [50.0-67.0] years; 2233 women [77.0%]; 2292 White [79.1%]) were enrolled; 2287 were randomized to the intervention, and 659 were randomized to usual care. Colony-stimulating factor use for patients receiving high-risk regimens was high and not significantly different between groups (847 of 950 patients [89.2%] in the intervention group vs 296 of 309 patients [95.8%] in the usual care group). Among high-risk patients, febrile neutropenia rates for the intervention (58 of 947 patients [6.1%]) and usual care (13 of 308 patients [4.2%]) groups were not significantly different. The febrile neutropenia rate for patients receiving high-risk regimens not receiving colony-stimulating factors was 14.9% (17 of 114 patients). Among the 585 patients receiving low-risk regimens, colony-stimulating factor use was low and did not differ between groups (29 of 457 patients [6.3%] in the intervention group vs 7 of 128 patients [5.5%] in the usual care group). Febrile neutropenia rates did not differ between usual care (1 of 127 patients [0.8%]) and the intervention (7 of 452 patients [1.5%]) groups.

CONCLUSIONS AND RELEVANCE

In this cluster randomized clinical trial, implementation of a guideline-informed standing order did not affect colony-stimulating factor use or febrile neutropenia rates in high-risk and low-risk patients. Overall, use was generally appropriate for the level of risk. Standing order interventions do not appear to be necessary or effective in the setting of prophylactic colony-stimulating factor prescribing.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02728596.

Engaging older patients with cancer and their caregivers as partners in cancer research

Active patient partner engagement with SCOREboard – a diverse group of older patients with cancer, caregivers of older patients with cancer, survivors, and patient advocates – to conduct the largest randomized geriatric assessment clinical trial to date, has been shown to be feasible and resulted in tangible and invaluable benefits for both the research team and patient partners alike. Actively engaging patient partners should be an essential component in the development, conduct, and completion of all clinical research.

Soleus muscle stability in wild hibernating black bears

Based on studies of fast skeletal muscles, hibernating black and brown bears resist skeletal muscle atrophy during months of reduced physical activity and not feeding. The present study examined atrophy sparing in the slow soleus muscle, known to be highly prone to disuse atrophy in humans and other mammals. We demonstrated histochemically that the black bear soleus is rich in slow fibers, averaging 84.0 ± 6.6%. The percentages of slow fibers in fall (87.3 ± 4.9%) and during hibernation (87.1 ± 5.6%) did not differ ( P = 0.3152) from summer. The average fiber cross-sectional area to body mass ratio (48.6 ± 11.7 µm²/kg) in winter hibernating bears was not significantly different from that of summer (54.1 ± 11.8 µm²/kg, P = 0.4186) and fall (47.0 ± 9.7 µm²/kg, P = 0.9410) animals. The percentage of single hybrid fibers containing both slow and fast myosin heavy chains, detected biochemically, increased from 2.6 ± 3.8% in summer to 24.4 ± 24.4% ( P = 0.0244) during hibernation. The shortening velocities of individual hybrid fibers remained unchanged from that of pure slow and fast fibers, indicating low content of the minority myosins. Slow and fast fibers in winter bears exhibited elevated specific tension (kN/m²; 22%, P = 0.0161 and 11%, P = 0.0404, respectively) and maintained normalized power. The relative stability of fiber type percentage and size, fiber size-to-body mass ratio, myosin heavy chain isoform content, shortening velocity, power output, and elevated specific tension during hibernation validates the ability of the black bear to preserve the biochemical and performance characteristics of the soleus muscle during prolonged hibernation.

Estimation of anisotropy coefficient and total attenuation of swine liver at 850 nm based on a goniometric technique: influence of sample thickness

Estimation of optical properties of biologic tissue is crucial for theoretical modeling of laser treatments in medicine. Tissue highly absorbs and scatters the light between 650 nm and 1300 nm, where the laser provides therapeutic effects. Among other properties, the characteristic of biological tissues to scatter the light traveling trough, is described by the anisotropy coefficient (g). The relationship between g and the distribution of the scattered light at different angles is described by Henyey-Greenstein phase function. The measurement of angular distribution of scattered light is performed by the goniometric technique. This paper describes the estimation of g and attenuation coefficient, μt, of swine liver at 850 nm, performed by an ad hoc designed goniometric-based system, where a spectrometer measures intensities of scattered light at fixed angles (0°, 30°, 45°, 60, 120°, 135° and 150°). Both one-term and two-term Henyey-Greenstein phase function have been employed to estimate anisotropy coefficient for forward (gfs) and backward scattering (gbs). Measurements are performed on samples of two thicknesses (60 um and 30 urn) to investigate the influence of this factor on g, and repeated 6 times for each thickness. The estimated values of gfs were 0.947 and 0.951 for thickness of 60 μm and 30 μm, respectively; the estimations of gfs were -0.498 and -0.270 for thickness of 60 μm and 30 μm, respectively. Moreover, μt of liver has been estimated (i.e., 90±20 cm(1)), through Lambert-Beer equation. The comparison of our results with data reported in literature encourages the use of the ad hoc designed tool for performing experiments on other tissue, and at other wavelengths.

Selective oestrogen receptor modulators in prevention of breast cancer: an updated meta-analysis of individual participant data

BACKGROUND

Tamoxifen and raloxifene reduce the risk of breast cancer in women at elevated risk of disease, but the duration of the effect is unknown. We assessed the effectiveness of selective oestrogen receptor modulators (SERMs) on breast cancer incidence.

METHODS

We did a meta-analysis with individual participant data from nine prevention trials comparing four selective oestrogen receptor modulators (SERMs; tamoxifen, raloxifene, arzoxifene, and lasofoxifene) with placebo, or in one study with tamoxifen. Our primary endpoint was incidence of all breast cancer (including ductal carcinoma in situ) during a 10 year follow-up period. Analysis was by intention to treat.

RESULTS

We analysed data for 83,399 women with 306,617 women-years of follow-up. Median follow-up was 65 months (IQR 54-93). Overall, we noted a 38% reduction (hazard ratio [HR] 0·62, 95% CI 0·56-0·69) in breast cancer incidence, and 42 women would need to be treated to prevent one breast cancer event in the first 10 years of follow-up. The reduction was larger in the first 5 years of follow-up than in years 5-10 (42%, HR 0·58, 0·51-0·66; p<0·0001 vs 25%, 0·75, 0·61-0·93; p=0·007), but we noted no heterogeneity between time periods. Thromboembolic events were significantly increased with all SERMs (odds ratio 1·73, 95% CI 1·47-2·05; p<0·0001). We recorded a significant reduction of 34% in vertebral fractures (0·66, 0·59-0·73), but only a small effect for non-vertebral fractures (0·93, 0·87-0·99).

INTERPRETATION

For all SERMs, incidence of invasive oestrogen (ER)-positive breast cancer was reduced both during treatment and for at least 5 years after completion. Similar to other preventive interventions, careful consideration of risks and benefits is needed to identify women who are most likely to benefit from these drugs.

FUNDING

Cancer Research UK.

Abstract 65: Polymorphisms in chronic inflammation mediated pathway genes associated with risk of postmenopausal breast cancer (PMBC)

Background: PMBC most likely arises from combinations of less penetrant SNPs of common genes in combination with other environmental and lifestyle risk factors. Adiposity has the largest population attributable risk (PAR) for PMBC of all other factors at 21.3%. Of all the identified genes associated with human adiposity, the fat mass and obesity-associated gene (FTO) has been reported to have the strongest association and therefore a high PAR in the White population. Results from independent studies suggest that SNPs in the FTO gene are associated with PMBC. Furthermore, SNPs in several genes, i.e. estrogen receptor (ERS1), prostaglandin-endoperoxide synthase 2 (COX-2), ghrelin-obestatin ligand for growth hormone secretagouge receptor (GHRL), growth hormone secretagouge receptor (GHSR), interleukine 6 (IL6), mitogen-activated protein kinase (MAP3K1), are also associated with PMBC. To our knowledge the association between the complex of SNPs in these genes and PMBC has not been evaluated.

Methods: Cases with a confirmed diagnosis of primary invasive breast cancer were identified from the MyCode cohort. Controls, matched by date of blood donation and age, were identified from the same cohort. Three controls were matched to each case. Demographic, pathology and clinical data were retrieved and verified by reviewing electronic medical records. The SNP genotyping was performed on a Life Technologies TaqMan OpenArray Genotyping System (Applied BiosystemsLife Technologies, Foster City, CA) and analyzed using the Life Technologies TaqMan Genotyper Software. Logistic regression models were used to analyze the association between PMBC and SNPs. Each SNP was tested individually adjusting for common clinical risk factors (age, first degree breast cancer family history, smoking, alcohol, metabolic syndrome, hormone replacement therapy). Then Multiple-SNP nonepistatic analysis was performed to fit multiple SNPs simultaneously with adjustment for other common clinical factors.

Results: Cases (N=159) and controls (N=829) had a mean age of 65 years (± 9) and 64 years (± 9), respectively, at the time of entry into the cohort. A higher proportion of cases (26.5%) were diagnosed with metabolic syndrome, defined by the WHO criteria, compared with controls (4.0%) (p=0.0003). Self-reported family history of breast cancer was almost 4 fold higher among cases than controls (p=0.001). 41 SNPs were tested individually of the association of PMBC, among them 9 SNPs related to inflammatory pathways were tested in multiple SNPs model. One polymorphism in the MAP3K1gene (rs889312) showed increased risk of PMBC among homozygotes for the minor allele C (OR=1.98; 95% CI=1.08-3.63, p=0.03). Homozygotes for the A allele of rs689470 (PTGS2 gene) had a statistically significant increased risk of PMBC (OR= 3.38; 95% CI=1.09-10.51, p=0.03) while homozygotes for the G allele of rs2383529 had a lower risk for PMBC (OR= 0.32; 95% CI=0.11-0.92, p=0.03). In addition, we found a lower risk for PMBC for homozygotes for the C alleles of rs3020314 (ESR1 gene) (OR= 0.51; 95% CI=0.26-0.98; p=0.04). Similarly, the estimated risk of PMBC was lower (OR=0.13; 95% CI=0.03-0.55, p= 0.006) for homozygotes for the A allele of rs7801617 (IL6 gene).

Conclusion: Our preliminary findings concur with previous reports suggesting polymorphisms of 2 genes, MAP3K1 and PTGS2 increase the risk of PMBC independent of the well-established risk factors for PMBC. MAP3K1 gene acts in the MAPK-signaling pathway and is responsible for regulation of transcription of estrogen receptor; while, PTGS2 is an inflammatory mediator that is reported to up-regulate aromatase expression and subsequently local synthesis of estrogen in the breast. Further study is to evaluate independence of these SNPs with the known risk factors, as well as to test SNPs interactions effect.

Citation Format: Xiaowei(Sherry) Yan, Azadeh Stark, Xin Chu, Ryan Colonie, Jessica Webster, Ling Li, Jill Barnholtz-Sloan, Jeffrey Prichard, Victor Vogel, James F. Evans. Polymorphisms in chronic inflammation mediated pathway genes associated with risk of postmenopausal breast cancer (PMBC). [abstract]. In: Proceedings of the AACR Special Conference on Post-GWAS Horizons in Molecular Epidemiology: Digging Deeper into the Environment; 2012 Nov 11-14; Hollywood, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(11 Suppl):Abstract nr 65.

Second malignant neoplasms: assessment and strategies for risk reduction

Improvements in early detection, supportive care, and treatment have resulted in an increasing number of cancer survivors, with a current 5-year relative survival rate for all cancers combined of approximately 66.1%. For some patients, these survival advances have been offset by the long-term late effects of cancer and its treatment, with second malignant neoplasms (SMNs) comprising one of the most potentially life-threatening sequelae. The number of patients with SMNs is growing, with new SMNs now representing about one in six of all cancers reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program. SMNs reflect not only the late effects of therapy but also the influence of shared etiologic factors (in particular, tobacco and excessive alcohol intake), genetic susceptibility, environmental exposures, host effects, and combinations of factors, including gene-environment interactions. For selected SMNs, risk is also modified by age at exposure and attained age. SMNs can be categorized into three major groups according to the predominant etiologic factor(s): (1) treatment-related, (2) syndromic, and (3) those due to shared etiologic exposures, although the nonexclusivity of these groups should be underscored. Here we provide an overview of SMNs in survivors of adult-onset cancer, summarizing the current, albeit limited, clinical evidence with regard to screening and prevention, with a focus on the provision of guidance for health care providers. The growing number of patients with second (and higher-order) cancers mandates that we also further probe etiologic influences and genetic variants that heighten risk, and that we better define high-risk groups for targeted preventive and interventional clinical strategies.

Survival outcomes in pregnancy associated breast cancer: a retrospective case control study

Pregnancy-associated breast cancer (PABC) has been defined as breast cancer diagnosed during pregnancy or within one year of delivery. It is believed that after adjusting for age and stage, the 5-year survival rates are the same in both pregnant and nonpregnant women. We conducted a retrospective case-control study among patients treated at our institution between 1990 and 2005 to compare the 5-year survival outcomes for PABC with women treated for breast cancer who were not pregnant. Overall survival (OS) and disease-free survival (DFS) were estimated by the Kaplan-Meier method, and log rank tests were used to assess the associations between OS, DFS and pregnancy status, HER-2 status, ER/PR status, and family history. The median age was 33 years (range 24-42) for both groups. Twenty-two (55%) patients with PABC were ER/PR receptor positive compared with 20 (50%) for the controls. Ninety percent of patients with PABC received chemotherapy compared with 87.5% in the nonpregnant group. 91.5% of patients with PABC had breast-conserving surgery and 8.5% had mastectomies compared with 86% and 14%, respectively, for the control group. The median OS was 4.9 years in the PABC group compared with 6 years for the controls (p = 0.02). The median DFS was 2.7 years for the PABC group compared with 5.1 years for the controls (p = 0.01). The most common site of relapse was bone for the PABC group (27%) and local recurrence (33%) for the controls. Univariate analysis revealed that OS and DFS were associated with pregnancy status, family history, ER/PR status, and stage. After adjusting for age and stage, PABC patients had higher risk of both death (p = 0.01) and recurrence (p = 0.02) compared with nonpregnant controls. Women with PABC had significantly shorter OS and DFS compared with nonpregnant age and stage-matched controls.

The impact of an aromatase inhibitor on body composition and gonadal hormone levels in women with breast cancer

Aromatase inhibitors (AIs) have become the standard adjuvant therapy of postmenopausal breast cancer survivors. AIs induce a reduction of bioavailable estrogens by inhibiting aromatase, which would be expected to induce alterations in body composition, more extensive than induced by menopause. The objectives are to examine the impact of AIs on (1) DXA-scan derived body composition and (2) gonadal hormone levels. This is a sub-analysis of a 2-year double-blind, placebo-controlled, randomized trial of 82 women with nonmetastatic breast cancer, newly menopausal following chemotherapy, who were randomized to risedronate (35 mg once weekly) versus placebo, and stratified for their usage of AI versus no AI. Outcomes included DXA-scan derived body composition and gonadal hormone levels. As a group, total body mass increased in women over 24 months. Women on AIs gained a significant amount of lean body mass compared to baseline as well as to no-AI users (P < 0.05). Women not on an AI gained total body fat compared to baseline and AI users (P < 0.05). Free testosterone significantly increased and sex hormone binding globulin (SHBG) significantly decreased in women on AIs compared to no AIs at 24 months (P < 0.01) while total estradiol and testosterone levels remained stable. Independent of AI usage, chemotherapy-induced postmenopausal breast cancer patients demonstrated an increase of total body mass. AI users demonstrated maintenance of total body fat, an increase in lean body mass and free testosterone levels, and a decrease in SHBG levels compared to no-AI users. The mechanisms and implications of these changes need to be studied further.

Changes in body composition in women with breast cancer on aromatase inhibitors: A two-year trial

9528

Background: Aromatase inhibitors (AIs), the preferred adjuvant therapy of postmenopausal breast cancer patients, induce severe hypo-estrogenemia which differentiates them from the Estrogen-Receptor-Agonists-Antagonists (ERAAs). Little is known about the effect of AIs on body composition. We sought to examine the impact of AIs on body composition, and whether any changes correlate with gonadal hormone levels. Methods: We analyzed a two year double-blind trial (Risedronate's Effect on Bone loss in Breast CAncer, REBBeCA). 81 chemotherapy-induced newly postmenopausal nonmetastatic breast cancer patients had been randomized to risedronate 35 mg once weekly or placebo and followed, some of whom were on or started AI during the trial. Measures included body composition by whole body DXA-scan and serum sex hormone levels. Combining the two treatment arms, we estimated and compared body composition changes in those on (AI) and not on AIs (no-AI) using a linear mixed model, and examined correlations with serum hormone levels. Results: By 24 months, 41 women were on an AI. Over 2 years, lean mass increased by 1159g (p=0.0003) in women on an AI and did not change (85g; p=0.7684) in the no-AI group (adjusted difference, AD=1047g; p=0.0004). Percent fat did not change (0.0; p=0.9344) in those on an AI and increased (1.2; p=0.0097) in the no-AI group (AD=1.6; p=0.0433). The change in estradiol was associated with changes in lean mass (correlation r=0.42, p=0.0020) and percent fat (r=-0.48, p=0.0003). Conclusions: The use of AIs is associated with a decrease in fat mass and an increase in lean mass. The changes in estradiol are associated with alterations in body composition. The mechanisms and implications of these changes need to be studied further.

[Table: see text]

Prevention of breast cancer in postmenopausal women: approaches to estimating and reducing risk

BACKGROUND

It is uncertain whether evidence supports routinely estimating a postmenopausal woman's risk of breast cancer and intervening to reduce risk.

METHODS

We systematically reviewed prospective studies about models and sex hormone levels to assess breast cancer risk and used meta-analysis with random effects models to summarize the predictive accuracy of breast density. We also reviewed prospective studies of the effects of exercise, weight management, healthy diet, moderate alcohol consumption, and fruit and vegetable intake on breast cancer risk, and used random effects models for a meta-analyses of tamoxifen and raloxifene for primary prevention of breast cancer. All studies reviewed were published before June 2008, and all statistical tests were two-sided.

RESULTS

Risk models that are based on demographic characteristics and medical history had modest discriminatory accuracy for estimating breast cancer risk (c-statistics range = 0.58-0.63). Breast density was strongly associated with breast cancer (relative risk [RR] = 4.03, 95% confidence interval [CI] = 3.10 to 5.26, for Breast Imaging Reporting and Data System category IV vs category I; RR = 4.20, 95% CI = 3.61 to 4.89, for >75% vs <5% of dense area), and adding breast density to models improved discriminatory accuracy (c-statistics range = 0.63-0.66). Estradiol was also associated with breast cancer (RR range = 2.0-2.9, comparing the highest vs lowest quintile of estradiol, P < .01). Most studies found that exercise, weight reduction, low-fat diet, and reduced alcohol intake were associated with a decreased risk of breast cancer. Tamoxifen and raloxifene reduced the risk of estrogen receptor-positive invasive breast cancer and invasive breast cancer overall.

CONCLUSIONS

Evidence from this study supports screening for breast cancer risk in all postmenopausal women by use of risk factors and breast density and considering chemoprevention for those found to be at high risk. Several lifestyle changes with the potential to prevent breast cancer should be recommended regardless of risk.

Urinary estrogen metabolites in patients at high risk for breast cancer

Abstract #4080

Background:&#x2028; Variations in estrogen metabolism may be associated with increased breast cancer risk. Women who have preferential metabolism via 16α-hydroxylation are reported to have a higher risk of developing breast cancer compared to women who have preferential metabolism via 2α-hydroxylation. Profiling estrogen metabolites may identify women who are more likely to develop breast cancer within a population of women with known risk factors. Our aim was to evaluate estrogen metabolism in a group of high risk women.&#x2028; Methods:&#x2028; Women were recruited from the Magee-Women's Hospital High Risk Breast Cancer program. Risk factors included first degree family history, atypia, fibrocystic breast disease, BRCA1/2, Ashkenazi Jewish descent. Urine 2:16 OHE ratios were compared among the high risk group, an average risk control group, and a group of women with breast cancer. We also evaluated the relationship between urine 2:16 OHE ratios and epidemiological risk factors including BMI, alcohol use, smoking history and first degree family history.&#x2028; Results:&#x2028; There were 65 high risk patients, 30 breast cancer patients, and 41 controls. The Kruskaul-Wallis rank test and Wilcoxon rank-sum test were used for analysis. There was a significant difference in 2:16 OHE ratios among all three groups, p=0.0001. Urine 2:16 OHE ratios were lower in the high risk group (median 1.15) compared to the control group (2.22), p=0.00, and were lower in the breast cancer group (1.09) compared to the controls, p=0.00. There was a difference in BMI among all three groups, p=0.002. Overall, the 2:16 OHE ratio was positively associated with BMI, p=0.0006, and with alcohol use, p=0.02. Smoking history did not differ among all groups, and there was no association between smoking history and 2:16 OHE ratio. Within the high risk group, family history was not associated with 2:16 OHE ratio.&#x2028; Conclusions:&#x2028; Our research suggests that there is an association between lower urine 2:16 OHE ratios and high risk breast cancer. This association may be linked to specific risk factors such as BMI and alcohol use. This information may help to further elucidate the clinical relevance of using urinary 2:16 OHE ratios as clinical markers and prognostic indicators in this population.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4080.

Do we need to adjudicate major clinical events?

PURPOSE

The use of centralized systems to adjudicate clinical events is common in large clinical trials, in spite of relatively little published literature concerning the rationale and justification. The purpose of this manuscript is to review the reasons for central adjudication and to discuss whether trials could be simplified by limiting or streamlining the adjudication process.

METHODS

We reviewed the literature concerning central adjudication and documented the experience of adjudication in several clinical trials. Since definitions for nonfatal events are generally heterogeneous and subjective, one reason for a central process of adjudication is to assist in assuring systematic application of the definition used in the trial. In open-label trials, assuring that the adjudication is done blinded to treatment assignment may provide protection against differential misclassification. Regulatory authorities, including the FDA, derive confidence in the validity of results when central adjudication is performed. The clinical community has become accustomed to a certain amount of adjudication and may criticize trials that lack adjudication.

LIMITATIONS

It is difficult to document the value of adjudication in trials that have reported adjudicated and nonadjudicated event rates and related treatment effects. Making rationale decisions about when and how to adjudicate is hampered by the lack of published study of when and how central adjudication is helpful to improve the quality and validity of trials and at what cost.

CONCLUSIONS

Adjudication has not been shown to improve the ability to determine treatment effects. Thus, adjudication may be overly complex and overused in many large simple trials. The appropriate role of central adjudication - which trials, which outcomes, what methods - deserves scrutiny and further study.

Human serum albumin (HSA) nanoparticles: Reproducibility of preparation process and kinetics of enzymatic degradation

Nanoparticles prepared from human serum albumin (HSA) are versatile carrier systems for drug delivery and can be prepared by an established desolvation process. A reproducible process with a low batch-to-batch variability is required for transfer from the lab to an industrial production. In the present study the batch-to-batch variability of the starting material HSA on the preparation of nanoparticles was investigated. HSA can build dimers and higher aggregates because of a free thiol group present in the molecule. Therefore, the quality of different HSA batches was analysed by size exclusion chromatography (SEC) and analytical ultracentrifugation (AUC). The amount of dimerised HSA detected by SEC did not affect particle preparation. Higher aggregates of the protein detected in two batches by AUC disturbed nanoparticle formation at pH values below 8.0. At pH 8.0 and above monodisperse particles between 200 and 300 nm could be prepared with all batches, with higher pH values leading to smaller particles. Besides human derived albumin a particle preparation was also feasible based on recombinant human serum albumin (rHSA). Under comparable preparation conditions monodisperse nanoparticles could be achieved and the same effects of protein aggregates on particle formation were observed. For nanoparticulate drug delivery systems the enzymatic degradation is a crucial parameter for the release of an embedded drug. For this reason, besides the particle preparation process, particle degradation in the presence of different enzymes was studied. Under acidic conditions HSA as well as rHSA nanoparticles could be digested by pepsin and cathepsin B. At neutral pH trypsin, proteinase K, and protease were suitable for particle degradation. It could be shown that the kinetics of particle degradation was dependent on the degree of particle stabilisation. Therefore, the degree of particle stabilisation will influence drug release after cellular accumulation of HSA nanoparticles.

Monitoring the randomized trials of the Women's Health Initiative: the experience of the Data and Safety Monitoring Board

Data Safety Monitoring Committees (DSMB) for large, long-term randomized trials of agents in common use face challenging problems especially when the emerging data indicate unanticipated effects. The DSMB for the Women's Health Initiative Clinical Trials, on observing early indication of a surprising adverse cardiovascular effect of post-menopausal hormones, spent several years deliberating what recommendations it should make. This paper describes the dilemmas faced by the DSMB and the considerations it made over the course of its existence. The paper concludes with some recommendations for other DSMBs.

Mediterranean populations of the lesser white-toothed shrew (Crocidura suaveolens group): an unexpected puzzle of Pleistocene survivors and prehistoric introductions

An earlier study revealed the strong phylogeographical structure of the lesser white-toothed shrew (Crocidura suaveolens group) within the northern Palaearctic. Here, we aim to reconstruct the colonization history of Mediterranean islands and to clarify the biogeography and phylogeographical relationships of the poorly documented Middle East region with the northern Palaearctic. We performed analyses on 998-bp-long haplotypes of the mitochondrial cytochrome b gene of 143 samples collected around the Mediterranean basin, including islands and the Middle East. The analyses suggest that the Cypriot shrew belongs to the rare group of relict insular Pleistocene mammal taxa that have survived to the present day. In contrast, the Cretan, Corsican and Menorcan populations were independently introduced from the Middle East during the Holocene. The phylogeographical structure of this temperate Palaearctic species within the Middle East appears to be complex and rich in diversity, probably reflecting fragmentation of the area by numerous mountain chains. Four deeply divergent clades of the C. suaveolens group occur in the area, meaning that a hypothetical contact zone remains to be located in central western Iran.

The Study of Tamoxifen and Raloxifene (STAR): Change in patient-reported outcomes (PROs) after the end of treatment

1506

Background: STAR is a double-blind, placebo controlled, randomized phase III prevention trial to evaluate the efficacy of 5 years of raloxifene (R) compared to tamoxifen (T) in reducing the incidence of breast cancer in high-risk postmenopausal women. STAR was unblinded on 3/30/2006. Primary clinical outcomes, quality of life (QOL) and symptoms (SXs) were reported (JAMA, 6/2006). We now describe changes in QOL and SXs post-treatment. Methods: Endpoints for QOL were the MOS SF-36 physical (PCS) and mental (MCS) component scales and the CES-D. SXs were measured using a modified checklist from the NSABP BCPT. Questionnaires were administered before treatment, every 6 months until 60 months, and then at 66 or 72 months. Participants enrolled in QOL study at selected sites from 1/4/2000–5/31/2001. SX data were collected on all participants in the main trial. The change in PCS, MCS and SX scales after the end of treatment was analyzed with linear regression. Results: From 7/1/1999–11/4/2004, 19,747 participants enrolled in STAR and were eligible for the SX assessment; 4,338 completed both on- and post-treatment assessments. The QOL study enrolled 1983 participants; 400 completed both on- and post-treatment assessments. CES-D scores improved significantly from on- to off-treatment (p=.007), but less so for those stopping treatment early (p=.03). The MCS and CES-D returned to pre-treatment levels; the PCS remained below (p=0.02). These endpoints did not differ by treatment group. Forgetfulness (p=.01), musculoskeletal (p=.01), vasomotor (p<.0001), dyspareunia (p<.0001), bladder (p=.0002), weight gain (p<.0001), gynecological (p<.0001), and leg cramp (p<.0001) scales decreased in severity after treatment. Those who stopped treatment early had a greater decrease in vasomotor SXs (p=.01) but a lesser decrease in gynecological SXs (p=.02). Patients on T had a greater decrease in the vasomotor (p=.02) and bladder (p=.009) scales and a lesser decrease in weight gain (p=.04). Compared to pre-treatment levels, post-treatment vasomotor SXs decreased (p=0.009) and leg cramps increased (p<.0001). Conclusions: QOL and SXs changed significantly after treatment, largely returning to pre-treatment levels.

No significant financial relationships to disclose.

Oncologist-patient discussion of adjuvant hormonal therapy in breast cancer: results of a linguistic study focusing on adherence and persistence to therapy

Although studies have proven the benefit of 5+ years of adjuvant hormonal therapy (AHT) for breast cancer, data show adherence and persistence with therapy are suboptimal. This observational linguistic study analyzed communication between breast cancer patients and their oncologists to determine how adherence was addressed and to identify areas where communication could be improved. Community-based oncologists were recruited by letter to participate. Researchers visited oncologists (n = 14) to record patient-oncologist interactions and conduct separate post-visit interviews. Comprehensive linguistic analyses of visits between 28 postmenopausal, early-stage breast cancer patients on or initiating hormonal therapy and their oncologists were conducted to determine the nature of discussions of adherence and persistence to therapy. Oncologist-patient discussions about AHT were generally good but did not address potential difficulties of remaining adherent with long-term therapy. Discussions of persistence were usually monologues addressing the current state of "study data" and were not linked to the patient, the importance of persistence, or how the study data related to her situation. Because the patient's cancer was framed as being "in the past," discussions resembled those of chronic management in preventive medicine. This more ad-hoc approach to adherence and persistence is a potential stumbling block for motivating patients to stay on hormonal therapy. Additionally, the oncologists participating in this study recognized that adherence to therapy is a problem but did not feel "their patients" fell into this pattern. In this office-based evaluation, minimal nurse interactions were observed, which increases the importance of oncologist-patient communication. The authors recommend that oncologists leverage the existing good communication with their patients by increasing the amount and quality of discussions around the importance of adherence and persistence to AHT.

Benzyl isothiocyanate-induced apoptosis in human breast cancer cells is initiated by reactive oxygen species and regulated by Bax and Bak

Epidemiologic studies have revealed an inverse correlation between dietary intake of cruciferous vegetables and the risk of breast cancer. We now show that cruciferous vegetable constituent benzyl isothiocyanate (BITC) effectively suppresses growth of cultured human breast cancer cells (MDA-MB-231 and MCF-7) by causing G(2)-M phase cell cycle arrest and apoptosis induction. On the other hand, a normal mammary epithelial cell line (MCF-10A) is significantly more resistant to growth arrest and apoptosis by BITC compared with breast cancer cells. The BITC-mediated cell cycle arrest was associated with a decrease in levels of proteins involved in regulation of G(2)-M transition, including cyclin B1, cyclin-dependent kinase 1, and cell division cycle 25C. The BITC-induced apoptosis correlated with induction of proapoptotic proteins Bax (MCF-7) and Bak (MDA-MB-231 and MCF-7) and down-regulation of antiapoptotic proteins Bcl-2 and Bcl-xL (MDA-MB-231). The SV40-immortalized mouse embryonic fibroblasts derived from Bax and Bak double knockout mice were significantly more resistant to BITC-induced DNA fragmentation compared with wild-type mouse embryonic fibroblasts. The BITC treatment caused rapid disruption of the mitochondrial membrane potential, leading to cytosolic release of apoptogenic molecules, which was accompanied by formation of autophagosome-like structures as revealed by transmission electron microscopy. The BITC-mediated apoptosis was associated with generation of reactive oxygen species and cleavage of caspase-9, caspase-8, and caspase-3. Apoptosis induction by BITC was significantly attenuated in the presence of a combined superoxide dismutase and catalase mimetic EUK134 as well as caspase inhibitors. In conclusion, the present study reveals a complex signaling leading to growth arrest and apoptosis induction by BITC.

Studies on the current 137Cs body burden of children in Belarus--can the dose be further reduced?

After the Chernobyl reactor accident wide areas of Belarus were contaminated with radioactive fallout. The verification and documentation of the long-term development of radiation doses is still going on. A population group of special concern are the children living in contaminated regions. The annual dose limit of 1 mSv is still exceeded in some cases, essentially due to high body burdens of 137Cs as indicated by screening measurements with portable incorporation monitors. In this situation the evaluation of possible dose reduction measures in addition to the control of food contamination is being investigated. Special attention is given to the therapeutic application of a pectin preparation (Vitapect), for which a dose-lowering effect is presumed by Belarusian scientists. In a placebo-controlled double-blind study, several groups of contaminated children received a pectin compound named Vitapect for a two-week period during their stay in a sanatorium. For comparison the same number of control groups were given a placebo preparation. The 137Cs body burden of the children was measured at the beginning and the end. The mean relative reduction of the specific activity within the Vitapect groups was found to be approximately 33%, whereas the specific activity of the children who received a placebo decreased only by approximately 14%, due to clean food supply. It is known that pectins chemically bind cations like caesium in the gastrointestinal tract and thereby increase faecal excretion. Theoretical calculations based on this assumption and considering metabolism processes are qualitatively consistent with the experimentally found retention of radiocaesium in the human body after pectin treatment.

Case-control study of risk factors for breast cancer in Nigerian women

This study evaluated the potential risk factors for breast cancer in Nigerian women using a case-control design of 250 women with breast cancer and their age-matched female controls. Both cases and controls were recruited from 4 University Teaching Hospitals in Midwestern and Southeastern Nigeria. Data on the clinical and epidemiological characteristics were collected using interviewer-administered structured questionnaires. The mean age of the cases and controls were 46.1 and 47.1 years, respectively. Fifty-seven percent of the cases were premenopausal while 43% were postmenopausal. The association of risk factors with breast cancer was assessed using conditional logistic regression. Positive family history of breast cancer in first- and second-degree relatives (Odds ratio [OR] = 8.07, 95% confidence interval [CI], 1.003, 64.95, p = 0.04), education of high school level and above (OR = 1.35, 95% CI 1.04, 1.74, p = 0.0205), age at first fullterm pregnancy (FFTP) greater than 20 years (OR = 1.32 95% CI 1.01, 1.71, p = 0.0413) and waist/hip ratio (WHR) (OR = 1.98, 95% CI 1.27, 3.10, p = 0.0026) were associated with increased risk of breast cancer in the final multiple conditional logistic regression model. The findings from this study have shown that sociodemographic characteristics, reproductive variables and anthropometric measures are significant predictors of breast cancer risk in Nigerian women.

The study of tamoxifen and raloxifene (STAR): Initial findings from the NSABP P-2 breast cancer prevention study

LBA5

Background: The STAR trial was designed to compare raloxifene to tamoxifen in terms of relative effect on invasive breast cancer risk and on other beneficial and detrimental outcomes associated with the use of tamoxifen. Methods: The trial opened on 7-1-1999, and accrual was completed November 4, 2004, with 19,747 women enrolled. To be eligible, a woman had to be postmenopausal with a 5-year predicted breast cancer risk of 1.66% as determined by the modified Gail model. Women were randomized and treated in a double-blinded fashion to receive 5 yr of therapy with either 20 mg per day of tamoxifen or 60 mg per day of raloxifene. The protocol-defined monitoring plan called for a final analysis and release of findings when 327 invasive breast cancer cases had been diagnosed in the total population. The mean age of the population at the time of entry into this trial was 58 yr, and the mean 5-yr risk of breast cancer was 4.04%. 93.5% of the women were white; 51.5% had a hysterectomy before entry into the study; 9.2% had a history of LCIS; 71.1% had at least one first-degree relative with a history of breast cancer. The average time on the study is 47 months. Results: There was no difference between the treatment groups in terms of effect on invasive breast cancer: 163 cases in women assigned to tamoxifen and 167 in women assigned to raloxifene (RR = 1.02, 95% CI = 0.82–1.27). The risk of invasive uterine malignancies was 40% less in the raloxifene group (36 in women assigned tamoxifen and 23 in women assigned raloxifene [RR = 0.62, 95% CI = 0.35–1.08]). The risk of non invasive breast cancer was less in the tamoxifen group (57 cases in those assigned to tamoxifen and 81 in those assigned to raloxifene [RR = 1.41, 95% CI = 1.00–2.02]). There were no significant differences between the treatment groups for any of the other invasive cancer sites or for cardiac events, osteoporotic fractures, or deaths. There were fewer thromboembolic events in women taking raloxifene than in those taking tamoxifen. Conclusions: Raloxifene is an effective alternative to tamoxifen for reducing the incidence of invasive breast cancer in postmenopausal women at increased risk of developing the disease and is associated with fewer endometrial cancers, deep vein thromboses, and pulmonary emboli.

[Table: see text]

How conversations about adjuvant hormonal therapy differ from ‘typical‘ oncology discussions: Results of an observational linguistic study

6141

Background: Adjuvant hormonal therapy in breast cancer presents a conversational challenge for oncologists. Oral medications are a relatively new therapeutic paradigm, and many aspects of typical oncology communication, e.g., risk-benefit presentation, goal of therapy, and the role of patient in selecting/continuing therapy, require a different approach in this setting. An observational linguistic study was undertaken to capture how oncologists and patients discuss adjuvant therapy, and to develop recommendations to improve communication. Methods: Letters of invitation were mailed to 800+ community-based oncologists; of these, 14 met the screening criteria and agreed to participate in this study. 28 postmenopausal, early breast cancer patients on or initiating hormonal therapy were recorded during their regularly scheduled visits. Results: Adjuvant hormonal therapy discussions differ from infusional chemotherapy-focused oncology discussions in several ways: Selection of therapy is based on more than efficacy (e.g., cost, side effects); Chance of recurrence is discussed directly, without significant hedging; Disease name (“cancer”) is discussed openly–the word “cancer” is notably absent from other types of oncology discussions; Visits are routine–patients’ lives are no longer “on hold” (unlike other treatment discussions, where chemotherapy is assumed to be at the center of the patient’s life); Time between visits often moves from every three months to every six months after being on hormonal therapy for a year (unlike other therapies, where patients are seen frequently). Conclusions: Analysis of conversations shows that these patients are seen as, in some way, “cured” (goal of therapy is to prevent recurrence) and that patients are “given their lives back.” The conversational frame displays a lack of urgency and emotion, similar to that of discussions of dyslipidemia management and not like other chemotherapy discussions where the emotional content is very high. New models of therapy require new conversational approaches, e.g., where issues like adherence should be addressed directly, and longer-term therapeutic goals take on primary importance.

[Table: see text]

The study of tamoxifen and raloxifene (STAR): First report of patient-reported outcomes (PROs) from the NSABP P-2 Breast Cancer Prevention Study

LBA561

Background: STAR is a double-blind, randomized phase III prevention trial designed to evaluate the relative efficacy of raloxifene (R) compared to tamoxifen (T) in reducing the incidence of invasive breast cancer in high-risk postmenopausal women. In addition to standard safety monitoring, PROs were measured for quality of life (QOL) and symptoms (SXs). Methods: QOL was measured with the MOS SF-36, the CES-D, and the MOS Sexual Activity Questionnaire. SXs were measured using a modified checklist (SCL) from the NSABP P-1 BCPT. Primary endpoints were the SF-36 physical (PCS) and mental (MCS) component scales. A sample size of 1,670 provided statistical power of at least 0.8 (two-tailed test, alpha = .05). The QOL study was open to accrual at selected sites between 1/4/2000 and 5/31/2001, with questionnaires administered at baseline (pre-treatment), q 6 mos until 60 mos, and at 72 mos. SCL data were collected on all STAR participants. Longitudinal analyses used mixed effects modeling for the PCS, MCS, CES-D, and regression analyses were used to compare the average severity of SCL scores between T and R. Results: 19,747 participants enrolled in STAR and were eligible for the SCL assessment, with median follow-up time (mFU) 4.6 yrs. The QOL study enrolled 1,983 participants, 973 assigned to T and 1,010 assigned to R, mFU 5.4 yrs. QOL participants were comparable to women accrued concurrently at non-participating institutions. SCL and QOL forms compliance was high (with a low of 75% at 4.5 yrs for SCL and 74% for QOL). Mean PCS and MCS scores declined modestly over the 60 mos on study, with no significant difference between T and R. Mean CES-D scores worsened slightly on study, but with no significant difference between T and R. However, statistically significant differences (all p’s < .002) were noted between the T and R for severity of SXs, with R women reporting greater musculoskeletal problems, dyspareunia and weight gain and T women reporting greater vasomotor symptoms, leg cramps, bladder and gynecological problems. Conclusions: There were no significant differences between T and R in PROs for physical & mental health or depresson. While SX severity was generally low in this postmenopausal sample, the pattern of SXs differed between T and R.

[Table: see text]

Cytochrome P4501A1 genetic polymorphisms and breast cancer risk in Nigerian women

In this case-control study based on 250 women with breast cancer and 250 age-matched controls, we sought to evaluate the role of four polymorphic variants in the CYP1A1 gene in breast cancer susceptibility in Nigerian women. Heterozygosity for the CYP1A1 M1 genotype (CYP1A1 M1 [T/C]) was associated with a 21% reduced risk of breast cancer (OR = 0.79, 95% CI 0.46-1.40) while homozygosity for the genotype (CYP1A1 M1 [C/C]) conferred a non-significant 9% reduced risk of breast cancer. These risk profiles were not significantly altered in subgroup analysis by menopausal status. While heterozygosity for the CYP1A1 M3 genotype (T/C) conferred a non-significant 24% reduced risk of breast cancer (OR = 0.76, 95% CI 0.47-1.22), homozygosity for the variant was associated a non-significant 1.95-fold increased risk of breast cancer (OR = 1.95, 95% CI 0.24-6.01). Subgroup analysis showed a non-significant 11% reduced risk in premenopausal heterozygous carriers (OR = 0.89, 95% CI 0.45-1.44) and a non-significant 6% increased risk of postmenopausal breast cancer for carriers of the CYP1A1 M3 (T/C) genotype. The CYP1A1 M2 (isoleucine to valine) polymorphism in exon 7 and CYP1A1 M4 (threonine to asparagine) variant in codon 461 of the CYP1A1 gene were found to be very rare in our study subjects. This study has shown that while the CYP1A1 M1 polymorphism conferred reduced risk of breast cancer, homozygosity for the CYP1A1 M3 (C/C) was associated with increased risk of breast cancer although these risks did not attain statistical significance.

Physicochemical characterization of protamine-phosphorothioate nanoparticles

Protamine-oligonucleotide nanoparticles represent effective colloidal drug carriers for antisense phosphorothioate oligonucleotides (PTO). This study describes improvements in particle preparation and the physicochemical properties of the complexes prepared. The influence of component concentrations, length of the PTO chain and the PTO/protamine weight ratio on particle formation and size, shape and surface charge of the particles were studied in detail. Nanoparticles with diameters of 90-200nm were obtained, using protamine free base (PFB) and phosphorothioate in water. The chemical composition of the nanoparticles was analysed. More than 90% of the PTO could be assembled in the particle matrix using a > or = 1:2 ratio (w/w) of PTO and PFB. About 53-68% of the PFB was incorporated in the particle matrix. The complexes had a zetapotential of -19 up to +32 mV, depending on the PTO/PFB ratio. The kinetics of the assembly of this binary system were observed by dynamic light scattering (DLS) measurements and by sedimentation velocity analysis in the analytical ultracentrifuge (AUC). In addition, scanning electron microscopy (SEM) and atomic force microscopy (AFM) were applied to verify the results of DLS and the ultracentrifuge measurements. According to sedimentation velocity analysis, the particles were only moderately stable in water and unstable in salt solutions. However, the colloidal solution in water could be stabilized by polyethylenglycol 20000 (PEG), which also led to an increase of stability in cell medium.

Multilevel genetic analyses of two European supercolonies of the Argentine ant, Linepithema humile

Some ants have an extraordinary unicolonial social organization, whereby individuals mix freely among physically separated nests. Recently, it was shown that the European population of Linepithema humile consisted of two enormous unicolonial supercolonies. Workers of the same supercolony are never aggressive to each other. In contrast, aggressiveness is invariably high between workers from different supercolonies. Here we investigated whether gene flow occurs between two supercolonies. We identified a contact zone in which we sampled 46 nests. For each nest, aggression tests were conducted against workers from reference nests from both supercolonies. Workers were always very aggressive towards workers of one of the supercolonies but not to workers of the other. Thus, all nests could be clearly assigned to one of the two supercolonies. For 22 of the 46 nests, we genotyped 15-16 workers at five microsatellite loci. A four-level hierarchical analysis of variance revealed very strong genetic differentiation between the two supercolonies (F(SUPERCOLONY-TOTAL) = 0.541) and low differentiation between sectors (i.e. group of nests connected together with trails) within supercolonies (F(SECTOR-SUPERCOLONY) = 0.064). The very high differentiation between the two supercolonies indicates a lack of ongoing gene flow, a conclusion further bolstered by the finding that the two supercolonies share no common alleles at two of the five microsatellite loci. A Bayesian clustering method also revealed the occurrence of two distinct clusters. These clusters exactly match the grouping obtained by aggression tests. None of the 332 genotyped individuals were admixed despite the fact that some nests of the two supercolonies were separated by less than 30 m. These results demonstrate that the two supercolonies have completely separate gene pools.

Is there a difference between diabetic and non-diabetic ITAs? Histomorphological and immunohistochemical examinations of internal thoracic arteries

BACKGROUND

The relative resistance to arteriosclerosis of the internal thoracic artery is clinically valid. The aim of this study was to evaluate the graduation of intima and media fibrosis in ITA parts and to determine the extent of atherosclerosis using immunohistochemical methods related to patients' risk factors.

METHODS

227 distal ITA segments from 144 male and 83 female patients were examined. Mean age was 66.7 +/- 9.03 years. HE and Elastica van Gieson staining was performed to detect intima-/mediafibrosis.

POPULATION

insulin-dependent diabetes mellitus (idDM; n = 35), non-insulin-dependent diabetes mellitus (nidDM; n = 32), irradiation of the chest due to cancer (n = 27), control group with isolated hyperlipidemia, hypertension, peripheral vascular disease (n = 133). 12 ITA segments of each group were examined immunohistochemically using CD34, CD68, Tenascin, Collagen III, Collagen IV.

RESULTS

Histomorphological examinations using HE and Elastica van Gieson stainings showed for idDM-ITAs no fibrosis in 57 %, slight fibrosis in 34 %, medium in 6 %, no severe, for nidDM-ITAs no fibrosis in 63 %, slight 31 %, medium 3 %, severe 3 %, for ITAs after irradiation: no fibrosis in 37 %, slight in 62 %, no medium or severe fibrosis. Compared to the control group there was no statistically significant difference in diabetic ITAs. Immunohistochemical examinations, scored on a 0 - 3 basis with 0 being the lowest (no reaction), 3 the highest (severe reaction), showed mostly no or slight reaction to CD34, CD68, Tenascin, and Collagen III for intima and media, with comparable results for diabetic or "irradiated" ITAs to those of the control group. The most distinct reaction (medium= 2), was detected for Collagen IV, a marker which outlines basement membranes of endothelia and smooth muscle cells of the vessel wall, but without differences between the four groups. No severe reactions were observed.

CONCLUSIONS

The relative resistance of ITA to arteriosclerosis could be demonstrated in 227 ITA segments. Immunohistochemistry supports histomorphological findings. The influence of diabetes mellitus and irradiation remains irrelevant.

Achievement of ultralow emittance beam in the accelerator test facility damping ring

For high luminosity in electron-positron linear colliders, it is essential to generate low vertical emittance beams. We report on the smallest vertical emittance achieved in single-bunch-mode operation of the Accelerator Test Facility, which satisfies the requirement of the x-band linear collider. The emittances were measured with a laser-wire beam-profile monitor installed in the damping ring. The bunch length and the momentum spread of the beam were also recorded under the same conditions. The smallest vertical rms emittance measured at low intensity is 4 pm at a beam energy of 1.3 GeV, which corresponds to the normalized emittance of 1.0x1.0(-8) m. It increases by a factor of 1.5 for a bunch intensity of 10(10) electrons. The measured data agreed to the calculation of intrabeam scattering within much better than a factor of 2.

Optimization of the preparation process for human serum albumin (HSA) nanoparticles

Nanoparticles prepared by desolvation and subsequent crosslinking of human serum albumin (HSA) represent promising carriers for drug delivery. Particle size is a crucial parameter, in particular for the in vivo behaviour of nanoparticles after intravenous injection. The objective of the present study is the development of a desolvation procedure for the preparation of HSA-based nanoparticles under the aspect of a controllable particle size between 100 and 300 nm in combination with a narrow size distribution. A pump-controlled preparation method was established which enabled particle preparation under defined conditions. Several factors of the preparation process, such as the rate of addition of the desolvating agent, the pH value and the ionic composition of the HSA solution, the protein concentration, and the conditions of particle purification were evaluated. The pH value of the HSA solution prior to the desolvation procedure was identified as the major factor determining particle size. Varying this parameter, (mean) particle diameters could be adjusted between 150 and 280 nm, higher pH values leading to smaller nanoparticles. Washing the particles by differential centrifugation led to significantly narrower size distributions. The reproducibility of the particle size and particle size distribution under the proposed preparation conditions was demonstrated by sedimentation velocity analysis in the analytical ultracentrifuge and the cellular uptake of those nanoparticles was studied by confocal microscope imaging and FACS analysis. The stability of the resulting nanoparticles was evaluated by pH and buffer titration experiments. Only pH values distinctly outside the isoelectric pH range of HSA and low salt concentrations were able to prevent nanoparticle agglomeration.

Concurrent sequencing of full-dose CMF chemotherapy and radiation therapy in early breast cancer has no effect on treatment delivery

With the increasing use of breast-conserving therapy plus systemic chemotherapy for the treatment of early breast cancer, the optimal sequencing of radiation therapy and chemotherapy remains controversial. Sequencing of therapy may influence not only treatment delivery, but control rates, complications and cosmesis. The aim of this study was to evaluate whether concurrent sequencing of standard doses of CMF (cyclophosphamide, methotrexate and 5-fluorouracil) and adjuvant radiation therapy for early breast cancer impacted on optimum treatment delivery. As both an intravenous (i.v.) 3-week regimen and classic (standard) CMF were utilised in this study, both types of CMF were compared. The effect of sequencing on complications and treatment delays were also assessed. 116 patients treated with CMF chemotherapy and adjuvant tangent breast radiation were studied. 73 patients were treated prospectively with concurrent therapy and were retrospectively compared with a matched group of 40 patients treated with sequential or sandwich therapy. All patients had stage 1 or 2 cancers. There were no planned dose reductions introduced for either treatment modality. Concurrent sequencing had no impact on the ability to deliver optimum radiation or chemotherapy doses. There was no significant difference in acute Radiation Therapy Oncology Group (RTOG) skin reactions or complications between the two groups. Although small, there was a significant delay (1.32 days (0-15 versus 0.36 (0-7)) in the concurrent group (P=0.03) in the delivery of radiation therapy. Sequencing had no significant effect on haematological parameters. 'Standard' CMF had a more profound effect on treatment delivery than i.v. CMF (Radiation delay 2.2 days versus 0.26, P=0.002, % chemotherapy delivered 93% versus 99% P=0.000004). At a mean follow-up of 2.6 years, there was no difference in the cosmetic scores between the two groups. Both local and distant control rates were excellent. This study has shown that standard radiation therapy can be delivered safely concurrently with CMF chemotherapy. Whether this approach may lead to better control rates in the future needs further study.

Extremely low vertical-emittance beam in the accelerator test facility at KEK

Electron beams with the lowest, normalized transverse emittance recorded so far were produced and confirmed in single-bunch-mode operation of the Accelerator Test Facility at KEK. We established a tuning method of the damping ring which achieves a small vertical dispersion and small x-y orbit coupling. The vertical emittance was less than 1% of the horizontal emittance. At the zero-intensity limit, the vertical normalized emittance was less than 2.8 x 10(-8) rad m at beam energy 1.3 GeV. At high intensity, strong effects of intrabeam scattering were observed, which had been expected in view of the extremely high particle density due to the small transverse emittance.