[Cancer immune therapy for the treatment of haematological malignancies]

Cancer immune therapy is now used routinely for the treatment of several solid malignancies, albeit just recently having entered the clinic for treatment of haematological malignancies. Several studies demonstrate that cancer immune therapy is a promising treatment modality for the latter. Especially treatment with chimeric antigen receptor T cells for acute lymphoblastic leukaemia and lymphoma is promising. Other promising treatment modalities are immune check point inhibitors for both lymphoid and myeloid malignancies, as well as therapeutic cancer vaccination targeting tumour antigens.

Abstract B129: Human endogenous retroviruses as a potential reservoir for T-cell mediated cancer immunotherapy

Epigenetic modulation using DNA methyltransferase inhibitors (DNMTis), such as 5-azacytidine (5-aza-CR), have been shown to affect the cellular immunogenicity in vitro through upregulations of human endogenous retroviruses (HERV) leading to activation of the INFγ response pathway. HERVs comprise up to 8% of the human genome, and may hold a large reservoir of potential tumor antigens.We examined the in vivo efficacy of 5-aza-CR in terms of upregulations of HERV expression during standard treatment regimen, as well as the ability of such HERV transcripts to form T-cell antigens leading to measurable T-cell recognition upon treatment. We have studied 66 HERV genes that have been shown to be transcribed in human tissues. To identify HERV derived immune recognition, we generated a library of 1169 HERV derived potential antigenic peptides restricted to most abundant MHC class I molecules in the Caucasian population. Peripheral blood mononuclear cells (PBMCs) from a cohort of 19 patients and bone marrow samples from a cohort of 11 patients, treated with DNMTis for different hematological malignancies (MDS, AML, and CMML) were used to detect CD8+ T-cells reactive to ERV-derived peptides. We detected CD8+ T-cells specific to several HERV-derived peptides both in healthy and diseased individuals. Further, in an additional cohort of patients we examined expression level of these HERVs by RNA seq analysis and compared with healthy individuals demonstrating a disease associated upregulation of HERVs in hematological malignancies. Presence of T-cells reactive to HERV antigens and enhanced expression of HERVs in these malignancies suggest that HERVs may indeed provide a pool of shared tumor associated antigens. These antigens could potentially be enhanced through DNMTi treatment and may provide a target for T-cell mediated immunotherapy.

Citation Format: Sunil Kumar Saini, Anne-Mette Bjerregaard, Andreas D. Ørskov, Ashwin Unnikrishnan, Staffan Holmberg, Govardhan Anande, Amalie Kai Bentzen, Zoltan Szallasi, Aron C. Eklund, Kirsten Grønbæk, Sine Reker Hadrup. Human endogenous retroviruses as a potential reservoir for T-cell mediated cancer immunotherapy [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr B129.

Novel Strategies for Peptide-Based Vaccines in Hematological Malignancies

Peptides vaccination is an interesting approach to activate T-cells toward desired antigens in hematological malignancies. In addition to classical tumor associated antigens, such as cancer testis antigens, new potential targets for peptide vaccination comprise neo-antigens including JAK2 and CALR mutations, and antigens from immune regulatory proteins in the tumor microenvironment such as programmed death 1 ligands (PD-L1 and PD-L2). Immunosuppressive defenses of tumors are an important challenge to overcome and the T cell suppressive ligands PD-L1 and PD-L2 are often present in tumor microenvironments. Thus, PD-L1 and PD-L2 are interesting targets for peptide vaccines in diseases where the tumor microenvironment is known to play an essential role such as multiple myeloma and follicular lymphoma. In myelodysplastic syndromes the drug azacitidine re-exposes tumor associated antigens, why vaccination with related peptides would be an interesting addition. In myeloproliferative neoplasms the JAK2 and CALR mutations has proven to be immunogenic neo-antigens and thus possible targets for peptide vaccination. In this mini review we summarize the basis for these novel approaches, which has led to the initiation of clinical trials with various peptide vaccines in myelodysplastic syndromes, myeloproliferative neoplasms, multiple myeloma, and follicular lymphoma.

Treatment strategies, outcomes and prognostic factors in 291 patients with secondary CNS involvement by diffuse large B-cell lymphoma

PURPOSE

Secondary CNS involvement (SCNS) is a profoundly adverse complication of diffuse large B-cell lymphoma. Evidence from older series indicated a median overall survival (OS) < 6 months; however, data from the immunochemotherapy era are limited.

METHODS

Patients diagnosed with SCNS during or after first-line immunochemotherapy were identified from databases and/or regional/national registries from three continents. Clinical information was retrospectively collected from medical records.

RESULTS

In total, 291 patients with SCNS were included. SCNS occurred as part of first relapse in 254 (87%) patients and 113 (39%) had concurrent systemic relapse. With a median post-SCNS follow-up of 48 months, the median post-SCNS OS was 3.9 months and 2-year OS rate was 20% (95% CI: 15-25). In multivariable analysis of 173 patients treated with curative/intensive therapy (such as high-dose methotrexate [HDMTX] or platinum-containing regimens), age ≤60 years, performance status 0-1, absence of combined leptomeningeal and parenchymal involvement, and SCNS occurring after completion of first-line therapy were associated with superior outcomes. Patients ≤60 years with performance status 0-1 and treated with HDMTX-based regimens for isolated parenchymal SCNS had a 2-year OS of 62% (95% CI: 36-80). In patients with isolated SCNS, the addition of rituximab to HDMTX-based regimens was associated with improved OS. Amongst patients with isolated SCNS in CR following intensive treatment, high-dose chemotherapy and autologous stem cell transplantation did not improve OS (P = 0.9).

CONCLUSIONS

In this large international cohort of patients treated with first-line immunochemotherapy, outcomes following SCNS remain poor. However, a moderate proportion of patients with isolated SCNS who received intensive therapies achieved durable remissions.

The number of extranodal sites assessed by PET/CT scan is a powerful predictor of CNS relapse for patients with diffuse large B-cell lymphoma: An international multicenter study of 1532 patients treated with chemoimmunotherapy

PURPOSE

Development of secondary central nervous system involvement (SCNS) in patients with diffuse large B-cell lymphoma is associated with poor outcomes. The CNS International Prognostic Index (CNS-IPI) has been proposed for identifying patients at greatest risk, but the optimal model is unknown.

METHODS

We retrospectively analysed patients with diffuse large B-cell lymphoma diagnosed between 2001 and 2013, staged with PET/CT and treated with R-CHOP(-like) regimens. Baseline clinicopathologic characteristics, treatments, and outcome data were collected from clinical databases and medical files. We evaluated the association between candidate prognostic factors and modelled different risk models for predicting SCNS.

RESULTS

Of 1532 patients, 62 (4%) subsequently developed SCNS. By multivariate analysis, disease stage III/IV, elevated serum LDH, kidney/adrenal and uterine/testicular involvement were independently associated with SCNS. There was a strong correlation between absolute number of extranodal sites and risk of SCNS; the 144 patients (9%) with >2 extranodal sites had a 3-year cumulative incidence of SCNS of 15.2% (95% confidence interval [CI] 9.2-21.2%) compared with 2.6% (95% CI 1.7-3.5) among those with ≤2 sites (P < 0.001). The 3-year cumulative risks of SCNS for CNS-IPI defined risk groups were 11.2%, 3.1% and 0.4% for high-, intermediate- and low-risk patients, respectively. All risk models analysed had high negative predictive values, but only modest positive predictive values.

CONCLUSIONS

Patients with >2 extranodal sites or high-risk disease according to the CNS-IPI should be considered for baseline CNS staging. Clinical risk prediction models suffer from limited positive predictive ability, highlighting the need for more sensitive biomarkers to identify patients at highest risk of this devastating complication.

Uterine, but not ovarian, female reproductive organ involvement at presentation by diffuse large B-cell lymphoma is associated with poor outcomes and a high frequency of secondary CNS involvement

Involvement of the internal female reproductive organs by diffuse large B-cell lymphoma (DLBCL) is uncommon, and there are sparse data describing the outcomes of such cases. In total, 678 female patients with DLBCL staged with positron emission tomography/computed tomography and treated with rituximab-containing chemotherapy were identified from databases in Denmark, Great Britain, Australia, and Canada. Overall, 27/678 (4%) had internal reproductive organ involvement: uterus (n = 14), ovaries (n = 10) or both (n = 3). In multivariate analysis, women with uterine DLBCL experienced inferior progression-free survival and overall survival compared to those without reproductive organ involvement, whereas ovarian DLBCL was not predictive of outcome. Secondary central nervous system (CNS) involvement (SCNS) occurred in 7/17 (41%) women with uterine DLBCL (two patients with concomitant ovarian DLBCL) and 0/10 women with ovarian DLBCL without concomitant uterine involvement. In multivariate analysis adjusted for other risk factors for SCNS, uterine involvement by DLBCL remained strongly associated with SCNS (Hazard ratio 14·13, 95% confidence interval 5·09-39·25, P < 0·001). Because involvement of the uterus by DLBCL appears to be associated with a high risk of SCNS, those patients should be considered for CNS staging and prophylaxis. However, more studies are needed to determine whether the increased risk of secondary CNS involvement also applies to women with localized reproductive organ DLBCL.

Education in cardiopulmonary resuscitation in Sweden and its clinical consequences

AIM

To describe the use of cardiopulmonary resuscitation (CPR) training programmes in Sweden for 25 years and relate those to changes in the percentage of patients with out of hospital cardiac arrest (OHCA) who receive bystander CPR.

METHODS

Information was gathered from (a) the Swedish CPR training registry established in 1983 and includes most Swedish education programmes in CPR and (b) the Swedish Cardiac Arrest Register (SCAR) established in 1990 and currently covers about 70% of ambulance districts in Sweden.

RESULTS

CPR education in Sweden functions according to a cascade principle (instructor-trainers who train instructors who then train rescuers in CPR). Since 1989, 5000 instructor-trainers have taught more than 50,000 instructors who have taught nearly 2 million of Sweden's 9 million inhabitants adult CPR. This is equivalent to one new rescuer per 100 inhabitants every year in Sweden. In addition, since 1989, there are 51,000 new rescuers in Advanced Life Support (ALS), since 1996, 41,000 new Basic Life Support (BLS) rescuers with Automated External Defibrillation (AED) training, and since 1998, there are 93,000 new rescuers in child CPR. As a result of this CPR training the number of bystander CPR attempts for OHCA in Sweden increased from 31% in 1992 to 55% in 2007.

CONCLUSION

By using a cascade principle for CPR education nearly 2 million rescuers were educated in Sweden (9 million inhabitants) between 1989 and 2007. This resulted in a marked increase in bystander CPR attempts.

Knee osteoarthritis and body mass index: a population‐based case–control study

OBJECTIVE

It is well established that overweight is related to osteoarthritis of the knees. The aim of this study was to investigate the risk of knee osteoarthritis for men and women in relation to body mass index (BMI) within the normal weight range and to assess the effect of former versus current weight.

METHODS

A population-based case-control study was carried out in the southern part of Sweden, including 825 cases with X-ray verified femorotibial osteoarthritis and 825 age-, sex-, and county-matched population controls. Mailed questionnaire data on weight, height, and confounding factors (heredity, smoking, knee injuries, and physical activity) were collected and analysed using logistic regression models. The response frequency was 89%.

RESULTS

Mean age of the participants was 63 years, and 57% were women. The adjusted risk of knee osteoarthritis was increased fourfold in men with a current BMI 23 to < 25 kg/m2 as compared to men with BMI < 23 kg/m2 (OR 4.0, 95% CI 1.7-9.5). The commensurate risk for women was 1.6 (95% CI 0.9-3.1). BMI at 30 years of age was similarly related to knee osteoarthritis.

CONCLUSION

A moderate increase in BMI, within the normal weight range, was significantly related to knee osteoarthritis among men. Overweight at any time was related to knee osteoarthritis.

Evaluation of Adjuvant! Online to predict the effect of optimal endocrine therapy (ovarian function suppression plus tamoxifen) for premenopausal breast cancer patients with estrogen-receptor-positive breast cancer

585

Background: Adjuvant! Online (AOL) is a user-friendly, web-based tool that provides estimates of adjuvant therapy outcomes for individual patients. While reliable evidence underpins estimates for most patient cohorts, there is a paucity of data on the effect of adding chemotherapy to complete estrogen blockade for premenopausal women with estrogen-receptor positive breast cancer. Methods: International Breast Cancer Study Group (IBCSG) Trial 11–93 enrolled 174 premenopausal women with estrogen-receptor positive, node-positive breast cancer from 1993 to 1998. Fifty percent of patients had 1 positive axillary lymph node and 97% had between 1 and 3 positive nodes. Patients were randomized to receive ovarian function suppression plus five years of tamoxifen with or without chemotherapy. The estimated hazard rates and corresponding 10-year relapse-free survival percents obtained from Trial 11–93 data (Breast Cancer Res Treat. 2009;113:137–144) were compared with those predicted using AOL. Results: The 10-year relapse-free survival percents predicted from AOL were 64.4% (95% CI, 61.9% to 67.2%) for endocrine therapy alone and 74.9% (95% CI, 73.1% to 76.8%) for chemoendocrine therapy. By contrast, these estimates in Trial 11–93 were 76.4% (95% CI, 65.8% to 84.0%) for endocrine therapy alone and 74.9% (95% CI, 64.5% to 82.7%) for chemoendocrine therapy. The AOL estimate for the endocrine alone control group is lower than that observed in Trial 11–93 (p = 0.03), while the estimates for the two chemoendocrine therapy groups are similar. Conclusions: AOL appears to underestimate the effectiveness of adjuvant endocrine therapy alone for premenopausal women with endocrine responsive breast cancer, thus overestimating the added benefit - if any - from chemotherapy for this patient population. Prospective clinical trials addressing the question are warranted.

No significant financial relationships to disclose.

Tolerability to treatment with metoprolol in acute myocardial infarction in relation to age

A double-blind trial with the beta 1-selective blocker metoprolol in suspected acute myocardial infarction and during 3 months' follow-up included 1395 patients, aged 40-74 years, 698 on metoprolol and 697 on placebo. In order to further evaluate the tolerability to beta-blockade in the elderly, the total series was divided into 2 groups according to median age (61 years) and into quartiles, the lowest quartile (40-57 years) being compared with the highest (67-74 years). The decrease in heart rate and systolic blood pressure after intravenous metoprolol in the acute phase was similar in the elderly and the younger patients. Hypotension was observed more often in the metoprolol-treated than in the placebo-treated younger patients, while no difference was observed in the elderly. Bradycardia was observed more often in the metoprolol group in both age groups, while there was no difference regarding the incidence of congestive heart failure in either the younger or in the elderly patients. The effect on mortality, serious ventricular arrhythmias and chest pain seemed to be similar in different age groups. From the present series we conclude that hemodynamic reactions and tolerability to beta-blockade can be expected to be similar in elderly and younger patients.

Hemodynamic effects of the cardioselective beta-blocking agent metoprolol in acute myocardial infarction. A 24-hour catheterization study

Hemodynamic changes were studied in ten patients with uncomplicated transmural myocardial infection during 24 hours on beta-blockade. The cardioselective beta-adrenergic blocking drug metoprolol was injected (15 mg i.v.) within the first 24 hours after onset of chest pain and was followed by oral therapy (25-50 mg at 6-hour intervals). There was a decrease in heart rate, systolic BP, and cardiac output, which was most marked after the injection. The stroke volume and diastolic BP for the whole group of patients remained unchanged. The pulmonary artery end diastolic pressure did not change significantly after the injection but a continuous fall was obtained in three out of four patients with initially elevated values. The preejection period, measured from the ECG and carotid pressure curve, as initially short and was prolonged in all patients after administration of the beta-blocking drug. It is concluded that the cardioselective beta-blocking drug metoprolol may be used in selected patients in the acute phase of myocardial infarction without danger of hemodynamic deterioration during the first 24 hours of therapy. The selection of patients can be based on clinical criteria. In this study signs of left heart failure, hypotension, poor peripheral circulation, bradycardia, and AV block were regarded as contraindications.

Transradial coronary intervention without pre-screening for a dual palmar blood supply

It is usual practice to determine the presence of collateral blood supply to the hand prior to radial artery cannulation. We propose that pre-screening for a dual palmar vascular supply is not necessary and the presence of a palpable radial pulse is sufficient to allow successful radial artery cannulation. We retrospectively analysed our interventional PTCA registry, including only patients who had a transradial procedure without being pre-screened with an Allen's test or plethysmography. We report our data including complications the day after the procedure and at 30 days, and provide an up to date discussion on the need to assess patients for a dual palmar blood supply prior to transradial intervention.

Characteristics and outcome amongst young adults suffering from out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation is attempted

OBJECTIVES

Amongst patients suffering from out-of-hospital cardiac arrest, young adults represent a minority. However, these victims suffer from the catastrophe when they are in a very active phase of life and have a long life expectancy. This survey aims to describe young adults in Sweden who suffer from out-of-hospital cardiac arrest and in whom cardiopulmonary resuscitation (CPR) is attempted in terms of characteristics and outcome.

DESIGN

Prospective and descriptive design.

SUBJECTS AND METHODS

Young adults (18-35 years) who suffered from out-of-hospital cardiac arrest in whom CPR was attempted and who were included in the Swedish Cardiac Arrest Registry between 1990 and 2004.

MAIN OUTCOME MEASURES

Survival to 1 month.

RESULTS

In all, 1105 young adults (3.1% of all the patients in the registry) were included, of which 29% were females, 51% were nonwitnessed and 15% had a cardiac aetiology. Only 17% were found in ventricular fibrillation, 53% received bystander CPR. The overall survival to 1 month was 6.3%. High survival was found amongst patients found in ventricular fibrillation (20.8%) and those with a cardiac aetiology (14.8%). Ventricular fibrillation at the arrival of the rescue team remained an independent predictor of an increased chance of survival (odds ratio: 7.43; 95% confidence interval: 3.44-16.65).

CONCLUSION

Amongst young adults suffering from out-of-hospital cardiac arrest and in whom CPR was attempted, a minority survived to 1 month. Subgroups with a higher survival could be defined (patients found in ventricular fibrillation and patients in whom there was a cardiac aetiology). However, only one independent predictor of an increased chance of survival could be demonstrated, i.e. ventricular fibrillation at the arrival of the rescue team.

Association between interval between call for ambulance and return of spontaneous circulation and survival in out-of-hospital cardiac arrest

AIM

To describe the association between the interval between the call for ambulance and return of spontaneous circulation (ROSC) and survival in out-of-hospital cardiac arrest.

PATIENTS

All patients suffering an out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was started, included in the Swedish Cardiac Arrest Registry (SCAR) for whom information about the time of calling for an ambulance and the time of ROSC was available.

RESULTS

Among 26,192 patients who were included in SCAR and were not witnessed by the ambulance crew, information about the time of call for an ambulance and the time of ROSC was available in 4847 patients (19%). There was a very strong relationship between the interval between call for an ambulance and ROSC and survival to one month. If the interval was less than or equal to 5 min, 47% survived to one month. If the interval exceeded 30 min, only 5% (n = 35) survived to one month. The vast majority of the latter survivors had a shockable rhythm either on admission of the rescue team or at some time during resuscitation.

CONCLUSION

Among patients who have ROSC after an out-of-hospital cardiac arrest, there is a very strong association between the interval between the call for ambulance and ROSC and survival to one month. However, even if this delay is very long (> 30 min after calling for an ambulance), a small percentage will ultimately survive; they are mainly patients who at some time during resuscitation have a shockable rhythm. The overall percentage of patients for whom CPR continued for more than 30 min who are alive one month later can be assumed to be extremely low.

Knee injuries account for the sports-related increased risk of knee osteoarthritis

Increased risk of osteoarthritis has been found among athletes active in different kinds of sports. Knee injury is an established risk factor for knee osteoarthritis. In this population-based case-control study we investigated the risk of knee osteoarthritis with respect to sports activity and previous knee injuries. A total of 825 cases with x-ray-verified femorotibial osteoarthritis were identified at six hospitals in southern Sweden. The cases were matched (age, sex and residential area) with 825 controls from the general population. Mailed questionnaire data on sports activity for more than 1 year after the age of 16, knee injuries and confounding variables (weight, height, heredity, smoking and occupation) were collected and analyzed using logistic regression models. The response frequency was 89%. Among men knee osteoarthritis was related to soccer (odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1-2.2), ice hockey (OR 1.9, 95% CI 1.2-3.0) and tennis (OR 2.0, 95% CI 1.1-3.8) but not to track and field sports, cross-country skiing, and orienteering. After adjustment for confounding variables soccer and ice hockey remained significantly related to knee osteoarthritis, but after adjustment for knee injuries no significant relation remained. The sports-related increased risk for knee osteoarthritis was explained by knee injuries.

Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest

AIM

To explore the rate of survival to hospital discharge among patients who were brought to hospital alive after an out-of-hospital cardiac arrest in different hospitals in Sweden.

PATIENTS AND METHODS

All patients who had suffered an out-of-hospital cardiac arrest which was not witnessed by the ambulance crew, in whom cardiopulmonary resuscitation (CPR) was started and who had a palpable pulse on admission to hospital were evaluated for inclusion. Each participating ambulance organisation and its corresponding hospital(s) required at least 50 patients fulfilling these criteria.

RESULTS

Three thousand eight hundred and fifty three patients who were brought to hospital by 21 different ambulance organisations fulfilled the inclusion criteria. The number of patients rescued by each ambulance organisation varied between 55 and 900. The survival rate, defined as alive 1 month after cardiac arrest, varied from 14% to 42%. When correcting for dissimilarities in characteristics and factors of the resuscitation, the adjusted odds ratio for survival to 1 month among patients brought to hospital alive in the three ambulance organisations with the highest survival versus the three with the lowest survival was 2.63 (95% CI: 1.77-3.88).

CONCLUSION

There is a marked variability between hospitals in the rate of 1-month survival among patients who were alive on hospital admission after an out-of-hospital cardiac arrest. One possible contributory factor is the standard of post-resuscitation care.

Timing of CMF chemotherapy in combination with tamoxifen in postmenopausal women with breast cancer: role of endocrine responsiveness of the tumor

BACKGROUND

Controversy persists about whether chemotherapy benefits all breast cancer patients.

PATIENTS AND METHODS

In the International Breast Cancer Study Group (IBCSG) trial VII, 1212 postmenopausal patients with node-positive disease were randomized to receive tamoxifen for 5 years or tamoxifen plus three concurrent courses of cyclophosphamide, methotrexate and 5-fluorouracil ('classical' CMF) chemotherapy, either early, delayed or both. In IBCSG trial IX, 1669 postmenopausal patients with node-negative disease were randomized to receive either tamoxifen alone or three courses of adjuvant classical CMF prior to tamoxifen. Results were assessed according to estrogen receptor (ER) content of the primary tumor.

RESULTS

For patients with node-positive, ER-positive disease, adding CMF either early, delayed or both reduced the risk of relapse by 21% (P=0.06), 26% (P=0.02) and 25% (P=0.02), respectively, compared with tamoxifen alone. There was no difference in disease-free survival when CMF was given prior to tamoxifen in patients with node-negative, ER-positive tumors.

CONCLUSIONS

CMF given concurrently (early, delayed or both) with tamoxifen was more effective than tamoxifen alone for patients with node-positive, endocrine-responsive breast cancer, supporting late administration of chemotherapy even after commencement of tamoxifen. In contrast, sequential CMF and tamoxifen for patients with node-negative, endocrine-responsive disease was ineffective.

Characteristics and outcome among children suffering from out of hospital cardiac arrest in Sweden

AIM

To evaluate the characteristics, outcome and prognostic factors among children suffering from out of hospital cardiac arrest in Sweden.

METHODS

Patients aged below 18 years suffering from out of hospital cardiac arrest which were not crew witnessed and included in the Swedish cardiac arrest registry were included in the survey. This survey included the period 1990-2001 and 60 ambulance organisations covering 85% of the Swedish population (8 million inhabitants).

RESULTS

In all 457 children participated in the survey of which 32% were bystander witnessed and 68% received bystander CPR. Ventricular fibrillation was found in 6% of the cases. The overall survival to 1 month was 4%. The aetiology was sudden infant death syndrome in 34% and cardiac in 11%. When in a multivariate analysis considering age, sex, witnessed status, bystander CPR, initial rhythm, aetiology and the interval between call for, and arrival of, the ambulance and place of arrest only one appeared as an independent predictor of an increased chance of surviving cardiac arrest occurring outside home (adjusted odds ratio 8.7; 95% CL 2.2-58.1).

CONCLUSION

Among children suffering from out of hospital cardiac arrest in Sweden that were not crew witnessed, the overall survival is low (4%). The chance of survival appears to be markedly increased if the arrest occurs outside the patients home compared with at home. No other strong predictors for an increased chance of survival could be demonstrated.

Can we define patients with no chance of survival after out-of-hospital cardiac arrest?

OBJECTIVE

To evaluate whether subgroups of patients with no chance of survival can be defined among patients with out-of-hospital cardiac arrest.

PATIENTS

Patients in the Swedish cardiac arrest registry who fulfilled the following criteria were surveyed: cardiopulmonary resuscitation (CPR) was attempted; the arrest was not crew witnessed; and patients were found in a non-shockable rhythm.

SETTING

Various ambulance organisations in Sweden.

DESIGN

Prospective observational study.

RESULTS

Among the 16,712 patients who fulfilled the inclusion criteria, the following factors were independently associated with a lower chance of survival one month after cardiac arrest: no bystander CPR; non-witnessed cardiac arrest; cardiac arrest occurring at home; increasing interval between call for and arrival of the ambulance; and increasing age. When these factors were considered simultaneously two groups with no survivors were defined. In both groups patients were found in a non-shockable rhythm, no bystander CPR was attempted, the arrest was non-witnessed, the arrest took place at home. In one group the interval between call for and arrival of ambulance exceeded 12 minutes. In the other group patients were older than 80 years and the interval between call for and arrival of the ambulance exceeded eight minutes.

CONCLUSION

Among patients who had an out-of-hospital cardiac arrest and were found in a non-shockable rhythm the following factors were associated with a low chance of survival: no bystander CPR, non-witnessed cardiac arrest, the arrest took place at home, increasing interval between call for and arrival of ambulance, and increasing age. When these factors were considered simultaneously, groups with no survivors could be defined. In such groups the ambulance crew may refrain from starting CPR.

Air flow and particle control with different ventilation systems in a classroom

Most ventilation and air conditioning systems are designed without much concern about how settling particles behave in ventilation air flows. For displacement ventilation systems, designers normally assume that all pollutants follow the buoyant air flow into an upper zone, where they are evacuated. This is, however, not always true. Previous studies show that high concentrations of settling respirable particles can be found in the breathing zone, and that the exposure rates can be a health hazard to occupants. The emphasis here is on how ventilation systems should be designed to minimize respirable airborne particles in the breathing zone. The supply and exhaust conditions of the ventilation air flow are shown to play an important role in the control of air quality. Computer simulation programs of computational fluid dynamics (CFD) type are used. Particle concentrations, thermal conditions and modified ventilation system solutions are reported.

Characteristics and outcome among patients having out of hospital cardiac arrest at home compared with elsewhere

OBJECTIVE

To describe the characteristics and outcome of patients who have a cardiac arrest at home compared with elsewhere out of hospital.

PATIENTS

Subjects were patients included in the Swedish cardiac arrest registry between 1990 and 1999. The registry covers about 60% of all ambulance organisations in Sweden.

METHODS

The study sample comprised patients reached by the ambulance crew and in whom resuscitation was attempted out of hospital. There was no age limit. Crew witnessed cases were excluded. The patients were divided into two groups: cardiac arrest at home and cardiac arrest elsewhere.

RESULTS

Among a study population of 24 630 patients the event took place at home in 16 150 (65.5%). Those in whom the arrest took place at home differed from the remainder in that they were older, were more often women, less often had a witnessed cardiac arrest, were less often exposed to bystander cardiopulmonary resuscitation (CPR), were less often found in ventricular fibrillation, and had a longer interval between collapse and call for ambulance, arrival of ambulance, start of CPR, and first defibrillation. Of patients in whom the arrest took place at home, 11.3% were admitted to hospital alive, v 19.4% in the elsewhere group (p < 0.0001); corresponding figures for survival after one month were 1.7% v 6.2% (p < 0.0001). The adjusted odds ratio for survival after one month (at home v not at home; considering age, sex, initial arrhythmia, bystander CPR, aetiology, and whether the arrest was witnessed) was 0.40 (95% confidence interval 0.33 to 0.49; p < 0.0001).

CONCLUSIONS

Sixty five per cent of out of hospital cardiac arrests in Sweden occur at home. The patients differed greatly from those with out of hospital cardiac arrests elsewhere, and fewer than 2% were alive after one month. Having an arrest at home was a strong independent predictor of adverse outcome. Further research is needed to identify the reasons for this.

Development of an instrument to measure patient perception of the quality of nursing care

Although patient satisfaction has been given considerable attention in health care, analysis of the conceptual and measurement limitations of existing measures indicates that a more elemental approach to obtaining patients' perspectives is warranted. In this investigation we developed and evaluated the psychometric properties of an instrument designed to measure patients' perceptions of the degree to which their needs were met while hospitalized. This 15-item instrument, Patient Perception of Hospital Experience with Nursing (PPHEN), based on Swanson-Kauffman's framework of caring, is internally consistent and represents a single construct best described as feeling cared for. The relationship of PPHEN to other measures demonstrates concurrent validity; moreover, the scale is responsive to differences in care provided, as shown by differences in means for different hospitals. PPHEN offers a brief, theoretically oriented, internally consistent, and valid patient self-report measure of nursing care. It does not require patients to compare their expectations of care with the care received but only to evaluate whether their needs were met. It promises to be useful to clinical and health services researchers.

Analysis of Schizosaccharomyces pombe mediator reveals a set of essential subunits conserved between yeast and metazoan cells

With the identification of eight new polypeptides, we here complete the subunit characterization of the Schizosaccharomyces pombe RNA polymerase II holoenzyme. The complex contains homologs to all 10 essential gene products present in the Saccharomyces cerevisiae Mediator, but lacks clear homologs to any of the 10 S. cerevisiae components encoded by nonessential genes. S. pombe Mediator instead contains three unique components (Pmc2, -3, and -6), which lack homologs in other cell types. Presently, pmc2(+) and pmc3(+) have been shown to be nonessential genes. The data suggest that S. pombe and S. cerevisiae share an essential protein module, which associates with nonessential speciesspecific subunits. In support of this view, sequence analysis of the conserved yeast Mediator components Med4 and Med8 reveals sequence homology to the metazoan Mediator components Trap36 and Arc32. Therefore, 8 of 10 essential genes conserved between S. pombe and S. cerevisiae also have a metazoan homolog, indicating that an evolutionary conserved Mediator core is present in all eukaryotic cells. Our data suggest a closer functional relationship between yeast and metazoan Mediator than previously anticipated.

Measurement of skills in cardiopulmonary resuscitation--do professionals follow given guidelines?

Since it is suggested that only effective cardiopulmonary resuscitation (CPR) improves survival rates, quality control of training outcomes is important and comparisons between different training methods are desirable. The aim of this study was to test a model of quality assurance, consisting of a computer program combined with the Brennan et al. checklist, for evaluation of CPR performance. A small group of trained medical professionals (cardiac care unit nurses) (n = 10) was used in this pilot study. The result points out several points of concern: half of the participants did not open the airway prior to breathing control. Over 90% of all inflations were 'too fast' and 71% were 'too much'. Only 6.5% of the inflations were correct. On average, the participants made 5.4 inflations per minute. Concerning chest compressions, 40% were 'too deep' while only 4% were 'too shallow'. In spite of the fact that the participants had an average rate at 95 compressions per minute the number of compressions varied between 32 and 51 during 1 minute. When new guidelines are discussed, it would be beneficial if they were tested by a number of people to investigate if following the guidelines is at all possible.

Blood lipid levels in a rural male population

OBJECTIVES

Farmers have a low risk for cardiovascular disease, which may be related to a favourable blood lipid profile. In order to study the blood lipid levels and evaluate the effect of other cardiovascular risk factors on the blood lipid profile, this cross-sectional study was made.

MATERIAL AND METHODS

A total of 1013 farmers and 769 non-farming rural men in nine different Swedish counties were examined, interviewed, and replied to questionnaires. The inter-relationships between different risk factors were analysed using a multivariate linear regression model.

RESULTS

The farmers had a significantly more favourable blood lipid profile than the non-farmers although the total cholesterol levels were almost the same for the two groups. In the total study population there were significant positive relationships between total cholesterol level and body mass index (BMI), diastolic blood pressure and smoking. The high-density lipoprotein (HDL) level was positively related to physical workload and alcohol consumption, and negatively related to BMI, waist/hip ratio and smoking. Triglyceride levels showed a positive relationship to BMI, waist/hip ratio and blood pressure. Differences between farmers and other rural males were seen, especially with respect to the effect of physical activity and psychosocial factors. Among the farmers, a negative correlation between the Karasek-Theorell authority over work index and total cholesterol, the low-density lipoprotein (LDL)/HDL ratio and triglyceride levels was observed.

CONCLUSIONS

This study indicated that diet is of minor significance for the blood lipid profile, whereas factors such as physical activity, body weight and the waist/hip ratio, smoking, alcohol consumption, and perhaps psychosocial working conditions are major independent factors affecting the blood lipid profile most prominently among farmers, but also among non-farming rural men.

Factors modifying the effect of bystander cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in Sweden

AIM

To describe possible factors modifying the effect of bystander cardiopulmonary resuscitation on survival among patients suffering an out-of-hospital cardiac arrest.

PATIENTS

A national survey in Sweden among patients suffering out-of-hospital cardiac arrest and in whom resuscitative efforts were attempted. Sixty per cent of ambulance organizations were included.

DESIGN

Prospective evaluation. Survival was defined as survival 1 month after cardiac arrest.

RESULTS

In all, 14065 reports were included in the evaluation. Of these, resuscitation efforts were attempted in 10966 cases, of which 1089 were witnessed by ambulance crews. The report deals with the remaining 9877 patients, of whom bystander cardiopulmonary resuscitation was attempted in 36%. Survival to 1 month was 8.2% among patients who received bystander cardiopulmonary resuscitation vs 2.5% among patients who did not receive it (odds ratio 3.5, 95% confidence interval 2.9-4.3). The effect of bystander cardiopulmonary resuscitation on survival was related to: (1) the interval between collapse and the start of bystander cardiopulmonary resuscitation (effect more marked in patients who experienced a short delay); (2) the quality of bystander cardiopulmonary resuscitation (effect more marked if both chest compressions and ventilation were performed than if either of them was performed alone); (3) the category of bystander (effect more marked if bystander cardiopulmonary resuscitation was performed by a non-layperson); (4) interval between collapse and arrival of the ambulance (effect more marked if this interval was prolonged); (5) age (effect more marked in bystander cardiopulmonary resuscitation among the elderly); and (6) the location of the arrest (effect more marked if the arrest took place outside the home).

CONCLUSION

The effect of bystander cardiopulmonary resuscitation on survival after an out-of-hospital cardiac arrest can be modified by various factors. Factors that were associated with the effect of bystander cardiopulmonary resuscitation were the interval between the collapse and the start of bystander cardiopulmonary resuscitation, the quality of bystander cardiopulmonary resuscitation, whether or not the bystander was a layperson, the interval between collapse and the arrival of the ambulance, age and the place of arrest.

Characteristics and outcome among patients suffering in-hospital cardiac arrest in monitored and non-monitored areas

AIM

To describe the characteristics and outcome among patients suffering in-hospital cardiac arrest in relation to whether the arrest took place in a ward with monitoring facilities.

METHODS

All patients who suffered an in-hospital cardiac arrest during a 4-year period in Sahlgrenska Hospital, Göteborg, Sweden and in whom resuscitative efforts were attempted, were prospectively recorded and described in terms of characteristics and outcome.

RESULTS

Among 557 patients, 292 (53%) had a cardiac arrest in wards with monitoring facilities. Those in a monitored location more frequently had a confirmed or possible acute myocardial infarction (AMI) as judged to be the cause of arrest (P < 0.0001), and the arrest was witnessed more frequently (96 vs. 79%; P < 0.0001). Ventricular fibrillation/tachycardia was observed more often as initial arrhythmia in monitored wards (56 vs. 44%; P = 0.006). The median interval between collapse and first defibrillation was 1 min in monitored wards and 5 min in non-monitored wards (P < 0.0001). Among patients with arrest in monitored wards 43.2% were discharged alive compared with 31.1% of patients in non-monitored wards (P = 0.004). Cerebral performance category (CPC-score) at discharge was somewhat better among survivors in monitored wards.

CONCLUSION

In a Swedish University Hospital 47% of in-hospital cardiac arrests in which resuscitation was attempted took place in wards without monitoring facilities. These patients differed markedly from those having arrest in wards with monitoring facilities in terms of characteristics, interval to defibrillation and outcome. A shortening of the interval between collapse and defibrillation in these patients might increase survival even further.

A prospective study of morbidity and mortality rates among farmers and rural and urban nonfarmers

Farmers are known to have lower morbidity and mortality rates than the mean for other occupational groups in the general population. Whether this is due to the urban-rural health gradient or to occupational factors related to farming is not clear. To explore this issue, we conducted a prospective study of farmers and matched rural and urban referents. Official hospital admission and mortality data for the years 1989-1996 were obtained. The relative risk of being admitted to hospital were 10% higher among rural and urban referents than among the farmers. The biggest differences were seen for mental and cardiovascular disorders. The odds of dying during follow-up did not differ between the two rural groups but were doubled among urban referents. In conclusion, the lower morbidity and mortality rates among farmers are partly due to the urban-rural health gradient but in addition salutogenic factors linked to farming seem to be active.

Chromatin-mediated transcriptional regulation by the yeast architectural factors NHP6A and NHP6B

The Saccharomyces cerevisiae NHP6A and NHP6B proteins are chromatin architectural factors, functionally and structurally related to the mammalian high mobility group (HMG)-1 and -2 proteins, a family of non-sequence-specific DNA binding proteins. nhp6a nhp6b mutants have various morphological defects and are defective in the induced expression of several RNA polymerase II-transcribed genes. We found that NHP6A/B proteins are also required for full induction of the yeast CHA1 gene. Importantly, CHA1 basal level expression is increased 10-fold in an nhp6a nhp6b double deletion mutant. Micrococcal nuclease and DNase I analysis of the CHA1 gene in this strain showed an open promoter structure, characteristic of the activated state of this promoter, even under non-inducing conditions. To address the possible function of the NHP6A/B proteins in chromatin-mediated gene regulation, we performed whole-genome transcriptional profiling of a Deltanhp6a Deltanhp6b yeast strain. Our results suggest that NHP6A/B proteins play an important regulatory role, repressing as well as potentiating expression of genes involved in several cellular processes, and that NHP6A/B control is exerted at the level of the individual gene.

Effect of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients in Sweden

BACKGROUND

Information from the Swedish Cardiac Arrest Registry was used to investigate: (a) The proportion of patients suffering an out-of-hospital cardiac arrest who were given bystander cardiopulmonary resuscitation (B-CPR). (b) Where and by whom B-CPR was given. (c) The effect of B-CPR on survival.

METHOD

a prospective, observational study of cardiac arrests reported to the Swedish Cardiac Arrest Registry. Analyses were based on standardised reports of out-of-hospital cardiac arrests from ambulance organisations in Sweden, serving 60% of the Swedish population. From 1983 to 1995 approximately 15-20% of the population had been trained in CPR.

RESULTS

Of 9877 patients, collected between January 1990 and May 1995, B-CPR was attempted in 36%. In 56% of these cases, the bystanders were lay persons and in 25% they were medical personnel. Most of the arrests took place at home (69%) and only 23% of these patients were given B-CPR in contrast to cardiac arrest in other places where 53% were given CPR. Survival to 1 month was significantly higher in all cases that received B-CPR (8.2 vs. 2.5%). The odds ratio for survival to 1 month with B-CPR was in a logistic regression analysis 2.5 (95% CI 1.9-3.1).

CONCLUSIONS

In Sweden, the willingness and ability to perform B-CPR appears to be relatively widespread. More than half of B-CPR was performed by laypersons. B-CPR resulted in a two to threefold increase in survival.

[Improved survival after in-hospital cardiac arrest]

Internationally, survival among patients suffering in-hospital cardiac arrest is relatively low and unchanged at about 15%. Our experience at Sahlgrenska Hospital in Göteborg indicates a higher rate. We found survival to be related to the type of arrhythmia initially encountered, the highest rate having been observed among patients in ventricular fibrillation. We also found survival among patients suffering cardiac arrest to be higher in monitored as opposed to non-monitored wards. Whether the improved survival rate observed at Sahlgrenska as compared with international observations among patients suffering cardiac arrest is due to improvements in the organization or to patient selection is not clear. In order to achieve a higher survival rate after in-hospital cardiac arrest an efficient organization in which health care providers are given regular training and feed back is most likely of the utmost importance.

A comparison between patients suffering in-hospital and out-of-hospital cardiac arrest in terms of treatment and outcome

AIM

To compare treatment and outcome amongst patients suffering in-hospital and out-of-hospital cardiac arrest in the same community.

PATIENTS

All patients suffering in-hospital cardiac arrest in Sahlgrenska University Hospital covering half the catchment area of the community of Göteborg (500 000 inhabitants) and all patients suffering out-of-hospital cardiac arrest in the community of Göteborg. Criteria for inclusion were that resuscitation efforts should have been attempted. TIME OF SURVEY: From 1 November 1994 to 1 November 1997.

METHODS

Data were recorded both prospectively and retrospectively.

RESULTS

In total, 422 patients suffered in-hospital cardiac arrest and 778 patients suffered out-of-hospital cardiac arrest. Patients with in-hospital cardiac arrest included more women and were more frequently found in ventricular fibrillation. The median interval between collapse and defibrillation was 2 min in in-hospital cardiac arrest compared with 7 min in out-of-hospital cardiac arrest (< 0.001). The proportion of patients being discharged from hospital was 37.5% after in-hospital cardiac arrest, compared with 8.7% after out-of-hospital cardiac arrest (P < 0.001). Corresponding figures for patients found in ventricular fibrillation were 56.9 vs. 19.7% (P < 0.001) and for patients found in asystole 25.2 vs. 1.8% (P < 0.001).

CONCLUSION

In a survey evaluating patients with in-hospital and out-of-hospital cardiac arrest in whom resuscitation efforts were attempted, we found that the former group had a survival rate more than four times higher than the latter. Possible strong contributing factors to this observation are: (i) shorter time interval to start of treatment, and (ii) a prepared selection for resuscitation efforts.

Psychosocial conditions and access to an occupational health service among farmers

To determine whether membership in an occupational health service program varies with correlation with psychosocial risk factors, this study was carried out among farmers in connection with a larger investigation of salutogenic factors. The study was based on information collected via questionnaires (answered on location) and standardized interviews. The material consists of 364 farmers or persons engaged in agriculture who had occupational health care and 548 without it. There were clear differences in psychosocial patterns between the groups. Those with occupational health care were less often single and had more education and more social contacts than did those without such care. Eating times were more regular and meals were better in those with occupational health care. Karasek-Theorell's indices for psychological demands and decision latitude at work were also higher in this group. Better-educated farmers and those with larger farms were more often members of an occupational health care program. In addition, this group had fewer psychosocial risk factors.

Epidemiology of human immunodeficiency virus-associated opportunistic infections in the United States in the era of highly active antiretroviral therapy

The incidence of nearly all AIDS-defining opportunistic infections (OIs) decreased significantly in the United States during 1992-1998; decreases in the most common OIs (Pneumocystis carinii pneumonia ¿PCP, esophageal candidiasis, and disseminated Mycobacterium avium complex ¿MAC disease) were more pronounced in 1996-1998, during which time highly active antiretroviral therapy (HAART) was introduced into medical care. Those OIs that continue to occur do so at low CD4+ T lymphocyte counts, and persons whose CD4+ counts have increased in response to HAART are at low risk for OIs, a circumstance that suggests a high degree of immune reconstitution associated with HAART. PCP, the most common serious OI, continues to occur primarily in persons not previously receiving medical care. The most profound effect on survival of patients with AIDS is conferred by HAART, but specific OI prevention measures (prophylaxis against PCP and MAC and vaccination against Streptococcus pneumoniae) are associated with a survival benefit, even when they coincide with the administration of HAART. Continued monitoring of incidence trends and detection of new syndromes associated with HAART are important priorities in the HAART era.

Possibilities of implementing dispatcher-assisted cardiopulmonary resuscitation in the community. An evaluation of 99 consecutive out-of-hospital cardiac arrests

AIM

By evaluating tape recordings of true cardiac arrest calls, to judge the dispatchers ability to (a) identify cases as suspected cardiac arrest (CA), (b) give the case the right priority, (c) identify CA cases suitable for dispatcher-assisted, telephone-guided cardiopulmonary resuscitation (T-CPR) and (d) accomplish T-CPR.

METHODS

Evaluation of 99 tape recordings of consecutive cases that had been admitted to the two city hospitals in Göteborg after out-of-hospital CA.

RESULTS

In 70% of the interviews, the dispatcher demonstrated impeccable behaviour with short, distinct questions, quickly resulting in a decision on how to handle the case. In 30%, serious criticism could be voiced as the dispatcher displayed very stressful behaviour, or omitted to ask important questions such as whether the patient was conscious and breathing. In 21%, the interviews indicated a clear opportunity to perform T-CPR. In another 10%, there was a possibility of performing T-CPR. Only in 8% was T-CPR actually accomplished.

CONCLUSIONS

(1) In the majority of the interviews, the quality was very high, while in one-third, serious criticism could be voiced. (2) In our study, only one-third (95% confidence interval, 22-41) of CA cases were suitable for T-CPR, and T-CPR was performed in only 8% of the 99 cases. (3) To optimise the dispatcher ability to identify suspected CA and initiate T-CPR, both medical knowledge and practical training are needed, preferably with protocols for pre-arrival instructions.

Incidence, duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in sweden

The chance of survival from ventricular fibrillation (VF) is up to ten times higher than those with other cardiac arrest rhythms. To calculate the effect of out-of-hospital resuscitation organisations on survival, it is necessary to know the percentage of cardiac arrest patients initially in VF and the relationship between delay time to defibrillation and survival.

AIM

To study the incidence of VF at the time of cardiac arrest and on first ECG, the duration of VF and the relation between time to defibrillation and survival.

METHOD

The Swedish Cardiac Arrest Registry has collected standardised reports on out-of-hospital cardiac arrests from ambulance organisations in Sweden, serving 60% of the Swedish population.

RESULTS

In 14065 cases of out-of-hospital cardiac arrest collected between 1990 and 1995, resuscitation was attempted in 10966 cases.

INCIDENCE

The first ECG showed VF in 43% of all patients. The incidence of VF at the time of cardiac arrest was estimated to be 60-70% in all patients and 80-85% in the cases with probable heart disease.

DURATION

The estimated disappearance rate of VF was slow. Thirty minutes after collapse approximately 40% of the patients were in VF.

SURVIVAL

Overall survival to 1 month was only 1.6% for patients with non-shockable rhythms and 9.5% for patients found in VF. With increasing time to defibrillation, the survival rate fell rapidly from approximately 50% with a minimal delay to 5% at 15 min.

CONCLUSIONS

This study suggests a high initial incidence of VF among out-of-hospital cardiac arrest patients and a slow rate of transformation into a non-shockable rhythm. The survival rate with very short delay times to defibrillation was approximately 50%, but decreased rapidly as the delay increased.

Attitudes of trained Swedish lay rescuers toward CPR performance in an emergency. A survey of 1012 recently trained CPR rescuers

59 years old. Only 1% had attended the course because of their own or a relative's cardiac disease. Ninety-four per cent believed there was a minor to major risk of serious disease transmission while performing CPR. When predicting their willingness to perform CPR in six scenarios, 17% would not start CPR on a young drug addict, 7% would not perform CPR on an unkempt man, while 97% were sure about starting CPR on a relative and 91% on a known person. In four of six scenarios, respondents from rural areas were significantly more positive than respondents from metropolitan areas about starting CPR. In conclusion, readiness to perform CPR on a known person is high among trained CPR rescuers, while hesitation about performing CPR on a stranger is evident. Respondents from rural areas are more frequently positive about starting CPR than those from metropolitan areas.

Early start of adjuvant chemotherapy may improve treatment outcome for premenopausal breast cancer patients with tumors not expressing estrogen receptors. The International Breast Cancer Study Group

PURPOSE

The proper time to commence adjuvant chemotherapy after primary surgery for breast cancer is unknown. An analysis of the International (Ludwig) Breast Cancer Study Group (IBCSG) Trial V at a median follow-up of 11 years suggested that early initiation of adjuvant chemotherapy might improve outcome for premenopausal, node-positive patients whose tumors did not express any estrogen receptor (ER).

PATIENTS AND METHODS

We investigated the relationship between early initiation of adjuvant chemotherapy, ER status, and prognosis in 1,788 premenopausal, node-positive patients treated on IBCSG trials I, II, and VI. The disease-free survival for 599 patients (84 with ER-absent tumors) who commenced adjuvant chemotherapy within 20 days (early initiation) was compared with the disease-free survival for 1,189 patients (142 with ER-absent tumors) who started chemotherapy 21 to 86 days after surgery (conventional initiation). The median follow-up was 7.7 years.

RESULTS

Among patients with ER-absent tumors, the 10-year disease-free survival was 60% for the early initiation group compared with 34% for the conventional initiation group (226 patients; hazard ratio [HR], 0. 49; 95% confidence interval [CI], 0.33 to 0.72; P =.0003). This difference remained statistically significant in a Cox multiple regression analysis controlling for study group, number of positive nodes, tumor size, age, vessel invasion, and institution (HR, 0.60; 95% CI, 0.39 to 0.92; P =.019). Conversely, early initiation of chemotherapy did not significantly improve disease-free survival for patients with tumors expressing ER (1,562 patients; multiple regression HR, 0.93; 95% CI, 0.79 to 1.10; P =.40).

CONCLUSION

In premenopausal patients with ER-absent tumors, early initiation of systemic chemotherapy after primary surgery might improve outcome. Further confirmatory studies are required before any widespread modification of current clinical practice. In premenopausal patients with tumors expressing some ER, gains from early initiation are unlikely to be clinically significant.