Adherence Rate to Alliance for Clinical Trials in Oncology Z0011 Trial Based on Breast Cancer Subtype

BACKGROUND

The American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011 or Z11) trial demonstrated no survival advantage with completion axillary lymph node dissection (ALND) for patients with T1-2 breast cancer, 1 to 2 positive SLNs who received adjuvant chemoradiation therapy. More than 70% of the cohort had estrogen receptor (ER)+ tumors. There is paucity of data on the adherence rate to Z11, as well as a dearth of data on the applicability of Z11 for the different subtypes. We conducted a large hospital-based study to evaluate the adherence rate to Z11 based on subtypes.

STUDY DESIGN

The National Cancer Database was queried to evaluate 33,859 patients diagnosed with T1-2, N1, and M0 breast cancer treated with lumpectomy with negative margins, and adjuvant chemoradiation therapy between 2012 and 2018. Patients were classified into 3 groups: (1) ER+/HER2-, (2) ER-/HER2-, and (3) HER2+ regardless of ER status. The revised Scope of the Regional Lymph Node Surgery 2012 was used to classify patients into those who underwent an SLN or ALND. Differences in use of ALND by subtypes were compared. The Kaplan-Meier method and log-rank test were used to compare overall survival (OS). A p value of <0.05 was considered statistically significant.

RESULTS

For ER+/human epidermal growth factor receptor 2 (HER2)-, ER-/HER2-, and HER2+ tumors, the rate of ALND was 43.6%, 50.2%, and 47.8%, respectively. The 5-year OS for SLN and ALND for the entire cohort was 94.0% and 93.1% (p = 0.0004); for ER+/HER2-, it was 95.4% and 94.7% (p = 0.04); for ER-/HER2-, it was 84.1% and 84.3% (p = 0.41); for HER2+, it was 94.2% and 93.2% (p = 0.20). Multivariable cox proportional hazard regression analysis demonstrated no significant survival differences between SLN and ALND (p = 0.776).

CONCLUSIONS

Z11 is applicable for women with early N1 disease, regardless of subtypes. ALND did not confer a survival advantage over SLN. Despite this, up to 50% of patients who fit Z11 criteria continue to undergo ALND.

Health related quality of life in adults after late repair of tetralogy of fallot: experience from a low-middle income country

PURPOSE

Without neonatal screening in low middle-income countries like Pakistan, Tetralogy of Fallot (TOF) is a congenital heart disease which frequently remains untreated beyond infancy. The purpose of this study is to determine and assess outcomes and health related quality of life (HRQOL) in patients who undergo complete repair of TOF as adults.

METHODS

56 patients who underwent complete TOF repair after 16 years of age were included. Patient data was collected via retrospective chart review, and a semi structured interview along with Short-Form 36 (SF-36) questionnaire were used to assess HRQOL.

RESULTS

66.1% of patients were male with the mean age at surgery of 22.3 ± 6.00. All patients had a post-operative NYHA Classification of I or II, 94.6% had an ejection fraction of ≥ 50% and 28.6% showed small residual lesions in follow-up echocardiograms. 32.1% of patients suffered post-operative morbidity. For the quantitative assessment using SF-36 scores, patients showed good scores of median 95 (65-100). A major cause of delay to treatment was lack of consensus between treatments offered by doctors in different parts of Pakistan. There was a pattern of 'inability to fit in' among patients who had had late TOF repair, despite self- reported improved HRQOL.

CONCLUSION

Our results indicate that even with a delayed diagnosis, surgical repair of TOF produces good functional results. However, these patients face significant psychosocial issues. While early diagnosis remains the ultimate goal, patients undergoing late repair should be managed in more holistic manner with attention to psychological impact of the disease as well.

Plasmodium in the bone marrow: case series from a hospital in Pakistan, 2007-2015

Background

Malaria is a life-threatening, multisystem disease caused by the plasmodial parasite with a global incidence of approximately 229 million annually. The parasites are known to have unique and crucial interactions with various body tissues during its life cycle, notably the liver, spleen, and recent work has shown the bone marrow to be a reservoir of infection.

Methods

This study is a case series of patients in whom examination of bone marrow revealed malarial parasites. A retrospective record review of 35 parasite-positive bone marrow specimens examined at Aga Khan University Hospital (AKUH), Karachi, Pakistan, over the years 2007 to 2015 was conducted. Bone marrow aspirates were collected as per International Council for Standardization in Haematology (ICSH) guidelines.

Results

The median age of patients was 22 years (range 1–75), and 60 % (n = 21) were male. 22 patients had evidence of Plasmodium falciparum, 12 had evidence of Plasmodium vivax and 1 patient had a mixed infection. Gametocytes and trophozoites were the most common stages identified on both peripheral blood and bone marrow examinations. Indications for bone marrow examination included fever of unknown origin and the workup of cytopenias and malignancies.

Conclusions

The incidental finding of Plasmodium in samples of bone marrow suggests the reticuloendothelial system may be regularly harbour these parasites, be the infection acute or chronic in character.

Molecular-like hierarchical self-assembly of monolayers of mixtures of particles

We present a technique that uses an externally applied electric field to self-assemble monolayers of mixtures of particles into molecular-like hierarchical arrangements on fluid-liquid interfaces. The arrangements consist of composite particles (analogous to molecules) which are arranged in a pattern. The structure of a composite particle depends on factors such as the relative sizes of the particles and their polarizabilities, and the electric field intensity. If the particles sizes differ by a factor of two or more, the composite particle has a larger particle at its core and several smaller particles form a ring around it. The number of particles in the ring and the spacing between the composite particles depend on their polarizabilities and the electric field intensity. Approximately same sized particles form chains (analogous to polymeric molecules) in which positively and negatively polarized particles alternate.

Electrohydrodynamic removal of particles from drop surfaces

A uniform electric field is used for cleaning drops of the particles they often carry on their surface. In a first step, particles migrate to either the drop's poles or equator. This is due to the presence of an electrostatic force for which an analytical expression is derived. In a second step, particles concentrated near the poles are released into the ambient liquid via tip streaming, and those near the equator are removed by stretching the drop and breaking it into several droplets. In the latter case, particles are all concentrated in a small middle daughter droplet.

Expectations of cancer patients about clinical trials in multidisciplinary clinics

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Background: Progress in cancer treatment is very much dependent on the effective interaction of several specialties. To facilitate the process, more and more multidisciplinary clinics have been created over the last decade, especially in academic settings. This approach has been more established in the academic setting to help facilitate better patient accrual to clinical trials. Although there are studies confirming the effectiveness of this approach in fulfilling practice guidelines, there is however no study of patients’ expectations at a multidisciplinary clinic, especially in regard to the patients’ attitude towards clinical trials. This study examines patients’ preferences for services offered in an academic Methods: Surveys were handed to patients at the time of the first clinic visit and at time of progressive disease. The surveys were designed as a self directed questionnaire with the following questions that were rated on an ordinate scale from not at all important (score 1) to extremely important value (score 7): to see all doctors the same day; to be treated at a university-based cancer center; to have everything completely explained; to have the first appointment within 10 days; to know your cases will be discussed at conference; to have help with transportation and medical costs; and to participate in clinical trials. Results: 94 patients were surveyed at the GI and Thoracic Multimodality Clinic. Among patients the highest preference was “to have every thing explained,” score 6.7 (6.5–7.0, CI), immediately followed by the discussion at the multidisciplinary conference, score 6.6 (6.5–6.8, CI). Clinical trials ranked lowest, score 4.8 (4.4–5.2,CI). The difference was statistically significant, p = 0.012. There was no difference between GI and Thoracic Multimodality Clinic patients. Patients with progressive cancers showed a slightly higher interest in clinical trials, but still ranking trials below most other services. Conclusions: Patients value complete explanations of the disease and management plan far more than they value clinical trials. Considering that nationwide less than 5% of cancer patients are enrolled in clinical studies, it is important for physicians to explain the merit of clinical trials to patients and public.

No significant financial relationships to disclose.