OT1-01-01: Prospective Clinical Trial Evaluating Efficacy of Zoledronic Acid (ZA) Prophylaxis for Prevention of Aromatase Inhibitor Associated Musculoskeletal Symptoms: ZAP-AIMSS Trial

Brief background: Aromatase inhibitor associated musculoskeletal symptoms (AIMSS) occur in approximately 50% of patients receiving AIs (Henry 08). However, interventions to prevent or treat AIMSS have not been established. In a retrospective study (Muslimani 09), patients receiving bisphosphonates along with AIs were less likely to report AIMSS compared to those not taking bisphosphonates (35% vs. 60%). However, the efficacy of bisphosphonates in reducing incidence of AIMSS has not been studied prospectively, so it cannot be recommended for routine clinical practice.

Trial design: We are conducting a single arm, phase II clinical trial of 4 mg intravenous zoledronic acid (ZA) given at baseline and at 6 months, in combination with letrozole 2.5 mg daily for one year. Development of AIMSS will be assessed using the standardized Health Assessment Questionnaire (HAQ-DI) and pain Visual Analog Scale (VAS) at baseline,1, 3, 6, and 12 months. Secondary endpoints include mammographic breast density (when intact contralateral breast), bone mineral density, bone turnover metabolites, circulating inflammatory markers, and patient reported quality of life measures. Prevalence of AIMSS will be compared to historical controls from a recently completed multi-institutional study designated Exemestane and Letrozole Pharmacogenetics (ELPh trial, ClinicalTrials.gov #NCT00228956). The current study has the same eligibility criteria, method and intervals of outcome assessment, and AI medication, as the ELPh trial, ensuring that the two cohorts are comparable.

Eligibility criteria: Postmenopausal women who have completed local therapy and chemotherapy for hormone receptor positive DCIS or stage I-III breast cancer and who are scheduled to receive adjuvant AI. Prior tamoxifen therapy is permitted.

Specific aims:

1. Percentage of women experiencing AIMSS at 1, 3, 6, and 12 months after initiation of ZA and letrozole, as compared to historical controls.

2. Change in bone mineral density and breast density between baseline and 12 months for those receiving ZA and letrozole, as compared to historical controls.

3. Change in bone turnover markers and inflammatory markers between baseline and 1, 3, 6 and 12 months for those receiving ZA and letrozole, as compared to historical controls.

Statistical methods: Allowing for a 20% dropout rate, a total sample size of 59 patients yields 80% power to detect reduction in AIMSS incidence from 50% to 30% with a two sided type I error rate of 5%. The rates of AIMSS and other endpoints at each time point and across all time points between controls and patients will be compared with a logistic regression model that adjusts for potential confounding variables and include random effects as appropriate to account for correlation between outcomes in the same patient.

Present accrual and target accrual: The Johns Hopkins Institutional Review Board approved the study and it opened to accrual in January 2011. Since that time, 12 participants have signed consent and started therapy, and 2 have completed the 3 month evaluation.

Funding: Trial supported by BCRF. ZA and letrozole kindly supplied by Novartis.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-01-01.

A retrospective study of the value of indirect CT venography: a British perspective

OBJECTIVE

The aim of this study was to establish the value of indirect CT venography (CTV) in clinical practice within the UK.

METHODS

804 combined CT pulmonary angiogram and CTV studies were retrospectively reviewed. CTV was performed 180 s after the injection of contrast using an incremental technique with a 5-mm collimation and a 5-cm interspace between images extending from the iliac crests to the tibial plateaus.

RESULTS

12.9% of studies had isolated pulmonary emboli (PE), 3.0% had both a PE and deep vein thrombosis (DVT) and 1.1% had an isolated DVT. The proportion of positive cases diagnosed by CTV alone was 6.6%.

CONCLUSION

In a UK-based practice, the incidence and the proportion of isolated DVT diagnosed by CTV are lower than expected from published data. An analysis of possible causes for this is made within the paper.

The utility of assessing the gross appearances of FNA specimens

OBJECTIVE

Ideally, fine needle aspiration (FNA) cytology should be performed with near-patient assessment of the adequacy of the specimen by a cytopathologist. However, this is often not feasible. A cruder alternative is for the FNA practitioner to examine the gross appearances of the specimen and to try to predict the its quality. This study set out to determine the value of this approach.

METHODS

The study was conducted in tertiary public hospitals in New Zealand and the UK. FNA gross material grading was performed by a variety of pathologists on FNA samples taken using manual guidance and image guidance. The FNA gross material grade was compared with the findings on microscopic examination.

RESULTS

Nine out of 123 FNA samples were assessed as Grade 1 (unlikely to contain diagnostic material). All were subsequently reported as having insufficient diagnostic tissue on microscopic examination. Forty-two of the FNA samples were assessed as Grade 2 (possibly contains diagnostic material) and 46 as Grade 3 (probably contains diagnostic material). None from either of these grades was reported as showing insufficient diagnostic material on microscopic examination. Twenty-six cases were reported as Grade 4 (material suggesting a specific diagnosis). None of these was reported as showing insufficient diagnostic material on microscopic examination. The most common Grade 4 provisional diagnosis was that of a colloid cyst or colloid nodule of the thyroid (seven cases). Only two cases had misleading Grade 4 provisional diagnoses. Both were thought to be pus on gross examination but showed necrotic carcinoma on microscopic examination.

CONCLUSIONS

The gross appearances of FNA samples can usually predict the adequacy of the samples and sometimes predict the final microscopic diagnosis. However, near-patient microscopic assessment of FNA specimens is preferable if available.

Hospital discharge correspondence — how effective is it?

Continuity of patient care after discharge from hospital relies on effective discharge communication between the hospital doctors and the patient's general practitioner. The aim of this study was to investigate the effectiveness of discharge communication, in terms of its content and timing. The study involved analysing all discharge correspondence received by two city-based group practice medical centres over a period of one month. Three hundred and one pieces of discharge correspondence were scrutinised. These comprised 164 initial discharge summaries and 137 follow-up discharge letters. In general, information was more thoroughly and more accurately recorded in the follow-up letters than in the discharge summaries; however, there were significant delays in the receipt of the letters by the GPs. Results showed that there are many aspects of the correspondence between secondary and primary care which need improving. These include: improvement in the design of discharge correspondence forms; improvement in completing the forms; and improvement to the administrative systems for dispatching discharge correspondence. Although not specifically looked at in this study, we also believe that it would be useful for a mechanism to be set up for hospital pharmacists to establish links with their community colleagues in advance of a patient's discharge in order that the patient's pharmaceutical needs may be readily met in the community.

Effects of Gender and Age on Paediatric Headache

The aim of this study was to evaluate the impact of gender and age on headache characteristics and disability. Headache characteristics were assessed at an initial visit to a paediatric specialty care centre and five follow-up visits. A total number of 4121 patients were evaluated. Fifty-eight per cent of the sample was female. Boys were younger at their first headache and initial visit. They more frequently described headache pain as squeezing and location as top of the head. Girls reported more frequent and longer headaches. Girls more often described headache pain as sharp and location as back of the head. Age accounted for more variance than gender in headache severity, duration, frequency and disability. Gender differences exist in headache characteristics. Age is also an important factor in the variability in characteristics and disability. Longitudinal studies are needed to describe further the natural history of headaches in childhood and compare outcome between genders.

A pilot study evaluating surrogates of response to short-term vorinostat in women with newly diagnosed breast cancer

e14508

Background: Epigenetic modifications contribute to breast cancer initiation and progression and may be reversible, thus representing an attractive area for new drug investigation. In preclinical breast cancer models, the histone deacetylase (HDAC) inhibitor suberoylanilide hydroxamic acid (SAHA, vorinostat) induces cell cycle arrest, apoptosis and differentiation. Methods: We evaluated the safety and tolerability of short term vorinostat in women with a primary clinical stage I-III histologically confirmed carcinoma of the breast on a core needle biopsy. Participants received vorinostat 300 mg PO bid for a total of 6 doses, the last dose 2 hours prior to surgery or biopsy. Peripheral blood mononuclear cells were collected at baseline and following the last vorinostat dose to determine histone acetylation. Baseline and post-treatment tumor specimens were collected for analysis of histone acetylation, candidate gene methylation and expression. Tissues were also collected from untreated controls. Paired t-tests and Fisher's exact tests were used to evaluate changes from baseline for continuous and categorical data, respectively. Results: From March 2006 to October 2008, 25 women signed an informed consent and initiated study drug. Median age was 55 and 80% had hormone receptor positive tumors. Twenty-two women took all 6 prescribed doses. One participant took 4 and one 5 doses due to insurance clearance delay; one received a single dose due to fatigue and abdominal pain. Study-related surgical delays did not occur. Grade 1 toxicities included diarrhea (28%), low white blood cell count (24%), and fatigue, taste alterations and nausea (16% each). Tissue and blood samples were successfully collected. Tissue was also collected from 25 untreated controls. No significant change was observed in the proliferation marker Ki67 following 3 days of agent administration. Modulation of apoptosis, histone acetylation and gene methylation will be presented. Conclusions: Short-term administration of vorinostat is feasible, safe, and allows for studies of biomarker modulation. The results will be used to design future studies in which vorinostat will be administered in combination with other targeted therapies or with other epigenetic modifiers.

[Table: see text]

Prospective surveillance of women with a family history of breast cancer: auditing the risk threshold

To evaluate current guidelines criteria for inclusion of women in special ‘breast cancer family history’ surveillance programmes, records were reviewed of women referred to Scottish breast cancer family clinics between January 1994 and December 2003 but discharged as at ‘less than ‘moderate’ familial risk’. The Scottish Cancer Registry was then interrogated to determine subsequent age-specific incidence of breast cancer in this cohort and corresponding Scottish population figures. Among 2074 women, with an average follow-up of 4.0 years, 28 invasive breast cancers were recorded up to December 2003, where 14.4 were expected, a relative risk (RR) of 1.94. Eleven further breast cancers were recorded between January 2004 and February 2006 (ascertainment incomplete for this period). The overall RR for women in the study cohort exceeded the accepted ‘cutoff’ level (RR=1.7) for provision of special counselling and surveillance. The highest RR was found for the age group 45–59 years and this group also generated the majority of breast cancers. The National Institute for Clinical Excellence (‘NICE’) guidelines appear to be more accurate than those of the Scottish Intercollegiate Guidelines Network (‘SIGN’) in defining ‘moderate’ familial risk, and longer follow-up of this cohort could generate an evidence base for further modification of familial breast cancer services.

Germline mutation prevalence in the base excision repair gene, MYH, in patients with endometrial cancer

Germline mutations in the base excision repair gene, MutY human homolog (MYH), have recently been associated with a recessively inherited multiple adenoma polyposis syndrome and colorectal cancer. The spectrum of extracolonic lesions is still being characterized, although preliminary reports suggest that bi-allelic mutation carriers may share some of the clinical features of other hereditary colon cancer syndromes. Of 225 endometrial cancer patients, we identified one individual as a compound heterozygote, carrying mutations Y165C and G382D of MYH, and five individuals with heterozygous defects (three G382D and two Y165C). The patient with the bi-allelic Y165C/G382D mutation also had a sebaceous carcinoma, a feature of Muir-Torre syndrome. Although several intronic polymorphisms were detected in the heterozygous carriers, no other pathogenic variants were identified. While not conclusive, this novel and interesting finding provides evidence that bi-allelic germline mutations in MYH may increase susceptibility to endometrial cancer.

Bacterial contaminants and antibiotic prophylaxis in total hip arthroplasty

We have investigated the contaminating bacteria in primary hip arthroplasty and their sensitivity to the prophylactic antibiotics currently in use. Impressions (627) of the gloved hands of the surgical team in 50 total hip arthroplasties were obtained on blood agar. The gloves were changed after draping, at intervals of 20 minutes thereafter, and before using cement. Changes were also undertaken whenever a visible puncture was detected. The culture plates were incubated at 37°C for 48 hours. Isolates were identified and tested for sensitivity to flucloxacillin, which is a recognised indicator of sensitivity to cefuroxime. They were also tested against other agents depending upon their appearance on Gram staining.

We found contamination in 57 (9%) impressions and 106 bacterial isolates. Coagulase-negative staphylococci were seen most frequently (68.9%), but we also isolated Micrococcus (12.3%), diphtheroids (9.4%), Staphylococcus aureus (6.6%) and Escherichia coli (0.9%). Of the coagulase-negative staphylococci, only 52.1% were sensitive to flucloxacillin and therefore to cefuroxime. We believe that it is now appropriate to review the relevance of prophylaxis with cefuroxime and to consider the use of other agents.

Complementary role of adjunctive breast magnetic resonance imaging and scintimammography in patients of all ages undergoing breast cancer surgery

The aims of this study were to assess breast MRI and scintimammography (SMM) for the detection of breast cancer, and to determine any complementary role of these tests to each other and conventional imaging. Seventy-two patients (age 35-81 years) with a suspicious breast mass were investigated by mammography, breast ultrasound, breast MRI and SMM before undergoing surgical excision of the breast mass. Sensitivity, specificity and area under receiver operator characteristic curves were calculated for each test. Of the 72 patients, there were 66 proven malignant tumours, including two patients with bilateral breast cancer. When comparing the diagnostic sensitivity of breast MRI and SMM for lesion size, both tests showed higher sensitivities for lesions >25 mm in size, particularly for SMM. When these tests were compared for patient age, patients less than 51 years showed higher sensitivities for both tests. This was statistically significant for breast MRI. The overall respective diagnostic sensitivities for mammography, mammography with breast ultrasound, breast MRI and SMM were 56, 67, 86 and 85%. The differences were significant between mammography, mammography/ultrasound and both breast MRI and SMM. Breast MRI and SMM offer incremental diagnostic advantage in the diagnosis of breast cancer. Although improved diagnostic accuracy is seen in patients of all ages, those patients less than 51 years of age receive the greatest diagnostic benefit.

Barriers to following dietary recommendations in Type 2 diabetes

AIMS

To evaluate barriers to following dietary recommendations in patients with Type 2 diabetes.

METHODS

We conducted focus groups and surveys in urban and suburban VA and academic medical centres. For the written survey, a self-administered questionnaire was mailed to a random sample of 446 patients with diabetes. For the focus groups, six groups of patients with diabetes (three urban, three suburban) were conducted, with 6-12 participants in each group. The focus groups explored barriers across various types of diabetes self-management; we extracted all comments relevant to barriers that limited patients' ability to follow a recommended diet.

RESULTS

The written survey measured the burden of diabetes therapies (on a seven-point rating scale). Moderate diet was seen as a greater burden than oral agents (median 1 vs. 0, P = 0.001), but less of a burden than insulin (median 1 vs. 4, P < 0.001). A strict diet aimed at weight loss was rated as being similarly burdensome to insulin (median 4 vs. 4, P = NS). Despite this, self-reported adherence was much higher for both pills and insulin than it was for a moderate diet. In the focus groups, the most commonly identified barrier was the cost (14/14 reviews), followed by small portion sizes (13/14 reviews), support and family issues (13/14 reviews), and quality of life and lifestyle issues (12/14 reviews). Patients in the urban site, who were predominantly African-American, noted greater difficulties communicating with their provider about diet and social circumstances, and also that the rigid schedule of a diabetes diet was problematic.

CONCLUSIONS

Barriers to adherence to dietary therapies are numerous, but some, such as cost, and in the urban setting, communication with providers, are potentially remediable. Interventions aimed at improving patients' ability to modify their diet need to specifically address these areas. Furthermore, treatment guidelines need to consider patients' preferences and barriers when setting goals for treatment.