Waiting Time for Breast Conserving Surgery Patients in a Public and a Private University Affiliated Hospital in Atlanta

Background: The time it takes for a patient to undergo the entire breast cancer pathway treatment varies for diverse patient populations in different health care settings. In this study we analyzed delay in breast cancer treatment (DBCT) for a defined population of breast cancer patients. All of the patients had identical cancer care trajectories of breast-conserving therapy (BCT) for infiltrating ductal carcinoma (IDC) or ductal carcinoma in situ (DCIS), followed by neo-adjuvant therapy in two different hospital settings; including a University-based inner-city hospital and a University-affiliated private practice hospital.Materials and Methods: A retrospective chart review of 214 patients treated from 2004 to 2008 was conducted. Five consecutive diagnostic and treatment events in a total of four time intervals (see Figure 1 below) were defined and correlated with demographic factors such as age, race, marital status, distance traveled to visit, insurance status type, and hospital type. Non-parametric Wilcoxon Rank-Sum test was used for statistical analysis.Results: The mean ages of the patients in both hospitals were similar (59.2 yrs public hospital vs. 61.9 yrs private hospital). Patients treated in the public hospital experienced greater DBCT compared to patients who were treated in the private institution (125 vs. 88 days, p < 0.001). Overall, the largest delay was the time period from diagnostic core biopsy to surgery (50 days). The only time interval that showed greater delay for African-American (AA) women compared to Caucasian women was time from final pathology diagnosis to medical oncology evaluations (26 vs. 33 days, p=0.036). Patients who were married or insured experienced less DBCT compared to patients who were not (80 vs. 117 days and 83.3 vs.167 days respectively, p < 0.001). Medicaid patients had shorter wait times in the public compared to in the private hospital (136 vs. 153 days, ns). Patients who experienced less than 90 days of delay to undergo the entire treatment traveled an average 27.3 miles (sd=76.6) for their hospital visit, while patients who experienced greater than 90 days of delay to undergo the same treatment traveled an average 14.2 miles (sd=19.9) for their hospital visit.Discussion: Differences in DBCT are multi-factorial and arise from system-based issues that vary among hospital settings along with demographic factors such as marital status and race that are independent of the hospital setting. More effective scheduling for surgical treatment and follow up appointments may reduce the wait time. In order to significantly shorten DBCT further, prospective studies are needed to evaluate the intricate connection of psychosocial and system barriers to breast cancer treatment.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3070.

[Vaginal pelvic repair. Always with mesh or not?]

Several surgical methods are possible when aiming at reconstruction of pelvic organ prolapse in women, and the experienced surgeon implements the knowledge gained from open, laparoscopic, and vaginal techniques. These feature different rates of success and relapse as well as different complication risks. Because of the accumulating morbidity of aging patients, there is a search for a safe minimally invasive technique. With the advent of synthetic meshes, surgeons have used them frequently and often uncritically for reconstruction of the female pelvic floor. In these cases the vaginal approach is preferred as opposed to alternative techniques, as it is less invasive and allows for better convalescence. Furthermore, this approach leads to low complication and relapse rates even when synthetic meshes are omitted.

Supraclavicular lymph node metastases of unknown origin: HPV-typing identifies the primary tumour

Cancers of unknown primary origin (CUP) account for 0.5-10% of all malignancies. CUP patients with metastases have a median survival of approximately 6 months, despite therapy. Identification of the primary tumour site may offer the opportunity of a specific and more efficient treatment. The case of a 45-year-old woman with supraclavicular lymph node metastases of a squamous cell CUP is reported. A staging laparoscopy with multiple biopsies and a loop diathermy excision of the cervix were performed. Human papillomavirus (HPV)-testing in the tissues revealed the tumour cells as metastases of an occult cervical cancer. Primary platin-based chemotherapy combined with paclitaxel leads to a complete apparative remission. Twelve months later, staging positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose in combination with computed tomography identified an isolated left renal lymph node metastasis. The patient received targeted radiation therapy, combined with cisplatin. To date, 19 months after diagnosis, she is doing well without any evidence of disease. The presented case report addresses the difficulties involving the identification of CUP. HPV-DNA is found in over 95% of cervical cancers. As the presented case illustrates, testing for this virus DNA in human tissues can be a useful diagnostic tool in patients with CUP where cervical cancer is the possible primary tumour.

The effect of zoledronic acid on bone metastasis in patients suffering from renal cell cancer (RCC): A German prospective single-arm clinical trial

5107

Background: The incidence of RCC increased over the last decades and about 30% of patients will develop bone metastasis. These pts. face considerable skeletal morbidity e.g. bone pain, pathologic fractures, spinal cord compression or tumor induced hypercalcemia (TIH). A prospective trial was initiated in RCC metastatic to bone evaluating the SRE (skeletal related event) rate under therapy with zoledronic acid (ZA). Primary objective was the proportion of pts. with at least one SRE after 12 months. Methods: Patients with RCC must have had ≥1 bone metastasis and ≤2 prior applications of a bisphosphonate. Bone lesions were diagnosed by bone scan and ≥1 lesion was confirmed using X-ray, CT or MRI. Pts. passed a 12 months treatment period receiving 4 mg ZA every 3 weeks. Pts. were followed every 3 weeks for 54 weeks for development of SREs (radiation or surgery to bone, spinal cord compression, pathologic bone fractures) and TIH. A bone scan was done, if AP or LDH were >2xULN or symptoms occurred. Suspected SRE was confirmed by X-ray, CT or MRI. After end of treatment patients entered a survival follow-up. Results: 51 pts. participated in the study. Median age was 63 years and 2/3 were male. Proportions of MSKCC risk groups good/intermediate/poor for pretreated pts. were 8%, 56%, and 18%, respectively. 78% of pts. suffered from ≤6 bone metastases. 18% had already experienced at least one SRE before study entry. 26% obtained prior medications, mainly interferons (20%), interleukins (16%) and chemotherapy (16%). 25 pts. completed the 12 months treatment period. Based on a preliminary analysis 13 pts. (26%) experienced at least one SRE with an absolute number of 23 events. No TIH was observed. Bone lesions response was observed in 3 pts. (2 CR, 1 PR) out of 33 pts. currently available. Final efficacy and safety results of the 12 months treatment phase will be shown at presentation. Conclusions: Pts. with mRCC and bone metastases are at high risk for experiencing an SRE with a reported incidence of up to 74%. This is the first study prospectively evaluating SRE rate in patients with mRCC and bone lesions receiving ZA. A preliminary analysis indicates an SRE-rate of 26% and no TIH was observed. Final results of this trial could further support the use of ZA in mRCC.

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Quantitative assessment of HER2 status and correlation with efficacy for patients (pts) with metastatic breast cancer (MBC) in a phase II study of trastuzumab-DM1 (T-DM1)

1003

Background: The antibody-drug conjugate T-DM1 combines the biological activity of trastuzumab with targeted delivery of an anti-microtubule agent (DM1) to HER-2-expressing cancer cells. This analysis examines correlation of response to T-DM1 with HER-2 status, as assessed by fluorescent in situ hybridization (FISH), immunohistochemistry (IHC), mRNA quantitative real-time polymerase chain reaction (qRT-PCR), and enzyme-linked immunosorbent assay (ELISA) (HER-2 extracellular domain [ECD]), for pts enrolled in TDM4258g, a phase II study of T-DM1 in pts with MBC. Methods: TDM4258g is an open-label, single-arm study of T-DM1 administered at 3.6 mg/kg IV q3w. Pts had progressed on HER-2-directed therapy and received chemotherapy in the metastatic setting and were HER-2 + based on local testing. Archival tissue (paraffin block or >7 unstained tumor slides) was collected for retrospective central laboratory testing. HER-2 DNA amplification was determined by FISH, and protein levels by IHC. qRT-PCR for HER-2 was performed on extracted RNA; baseline HER-2 ECD ELISA was performed on pt sera. HER-2 data for each pt were compared with pt's best response. Results: As of August 29, 2008, 112 pts had enrolled; 107 were efficacy-evaluable pts with median 4.4 mos follow-up. There were 42/107 (39.3%) partial responses (PR) (investigator assessment). Of 86 pts centrally tested, 64 (74.4%) were confirmed HER-2+ (FISH+ and/or IHC 3+), with 32/64 (50%) PR. Of 76 pts tested by both FISH and IHC, 15/76 (19.7%) were confirmed HER-2- (FISH- and IHC 2+/1/0), with 2/15 (13.3%) PR. In HER-2+ pts, response rates did not correlate with high versus low FISH+ counts, nor with HER-2 ECD levels. Among 39 HER-2+ (FISH+ and/or IHC3+) efficacy-evaluable pts with qRT-PCR data, there were 13/19 (68.4%) PR for pts with qRT-PCR above median levels, and 7/20 (35.0%) PR for pts with qRT-PCR below median. Conclusions: HER-2+ pts (by central retesting) had better responses to T-DM1 than HER-2- pts, although a small number of PR were observed in HER-2- pts. Assessment of HER-2 expression by qRT-PCR may identify pts more likely to respond to T-DM1 therapy. Updated data, including additional diagnostic markers, will be presented at the meeting.

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First Report of Leaf Rust of Blueberry Caused by Pucciniastrum vaccinii in Hawaii

Blueberries (Vaccinium corymbosum L.) are a potential high-value, niche market crop for Hawaii. In May of 2007, rust-like symptoms were observed on multiple blueberry plants in a private nursery in Waimea, HI. In September of 2007, a similar leaf rust was observed on one bush of V. corymbosum cv. Sharpblue in the corner of a 36.6 × 9.1-m experimental plot at Mealani Research Station in Waimea. Within a month, rust was observed throughout the plot on 'Biloxi', 'Emerald', 'Jewel', 'Misty', 'Sapphire', and 'Sharpblue'. Preliminary field observations suggest that 'Sharpblue' and 'Sapphire' are highly susceptible to the rust and 'Biloxi' shows some tolerance. Leaf lesions began as approximately 1-mm² chlorotic flecks that expanded and developed into reddish brown, necrotic spots with a chlorotic halo. New lesions and uredinia kept appearing over the course of 4 months. Defoliation occurred on plants where infection was severe. Yellowish orange pustules containing urediniospores first appeared on the abaxial side of older leaves and later appeared on new leaves. Urediniospores were elliptical to obovate (19.4 to 24.8 × 15.2 to 19.8 μm) with a thick, slightly roughened wall and a well-developed pore. Urediniospore morphology and dimensions were consistent with the description of Pucciniastrum vaccinii (G. Wint.) (1). A pathogenicity test was conducted with two 18-month-old 'Sharpblue' plants. Fully expanded leaves were sprayed with freshly collected urediniospores (3.8 × 10⁵ spores per ml) suspended in a 0.05% solution of Tween 20 in water. The control plant was sprayed with sterile distilled water (SDW). Plants were covered with plastic bags for 48 h and held in a growth chamber at 20 to 22°C under continuous fluorescent lighting. The plastic bags were then removed and the plants were maintained in the growth chamber. Yellowish orange pustules that were identical to the original symptoms developed on 100% of inoculated leaves after 10 days. The plant inoculated with SDW remained symptomless. While leaf rust caused by P. vaccinii has been reported on Ohelo berry (V. reticulatum) (2), it has not been reported on V. corymbosum in Hawaii. To our knowledge, this is the first report of P. vaccinii on blueberry plants in Hawaii. This rust disease may pose a threat to the potential blueberry industry in Hawaii. References: (1) P. R. Bristow and A. W. Stretch. Page 20 in: Compendium of Blueberry and Cranberry Diseases. F. L. Caruso and D. C. Ramsdell, eds. The American Phytopathological Society, St. Paul, MN, 1995. (2) D. F. Farr et al. Fungal Databases. Systematic Botany and Mycology Laboratory. Online publication. ARS, USDA, 2008.

Standardized remission criteria in schizophrenia: descriptive validity and comparability with previously used outcome measures

INTRODUCTION

Standardized consensus criteria for remission in schizophrenia were recently proposed. As yet, the validity of these criteria and their comparability with previously used outcome measures are unclear.

METHODS

The symptom-severity component of the proposed remission criteria was applied to 288 inpatients who fulfilled the ICD-10 criteria for schizophrenia. Global functioning and psychopathological symptoms were assessed using GAF, PANSS, SANS, HAM-D and CDSS.

RESULTS

When patients with symptom remission at discharge from hospitalization (n=158, 54.9%) were compared to those without symptom remission, significant differences were found with respect to the global functioning (GAF) and all observed psychopathological symptom dimensions. The percentage agreement with previously used outcome measures ranged between 52.6 and 80.0%, the kappa values between 0.120 and 0.594. A moderate accordance (kappa value: 0.495) was found with a Clinical Global Impression (CGI) severity score of three or less.

DISCUSSION

The results indicate a high descriptive validity of the symptom-severity component of the proposed remission definition. However, the new criteria differ partially from previously used outcome measures. This aspect should be considered in the interpretation of clinical trials.

Use of the continuous glucose monitoring system in Goettingen Minipigs, with a special focus on the evaluation of insulin-dependent diabetes

OBJECTIVES

Adult pig islet isolation has greatly improved in the past few years. Islet grafts may now be tested in large animals. Continuous Glucose Monitoring System (CGMS) was applied to diabetic Goettingen Minipigs (GMP) to improve the management of hyperglycemia and hypoglycemia and their welfare before transplantation.

METHODS

GMP (25-35 kg) received a minipig diet once daily. Diabetes was induced by streptozotocin (STZ; 150 mg/kg intravenous [IV]; n = 5) or by surgical pancreatectomy (PGMP; n = 3). Interstitial glucose concentration (IGC) was monitored continuously with an implanted sensor; CGMS was calibrated using conventional blood glucose tests 3-4 times per day; CGMS data were fed into the monitor memory and analyzed using CGMS software.

RESULTS

Glucose sensors were handled accurately. Diabetes occurred 2-3 days after STZ or immediately after pancreatectomy with basal C-peptide secretion of <0.4 ng/mL (measured using intravenous glucose tolerance test) and prompt loss of body weight. Insulin substitution was necessary to keep the GMP in good condition for up to 5-6 months, with stable body weight and normal behavior. Some GMP became hypoglycemic, which was only documented by CGMS, but not by conventional glucose assays. Tight glucose control and substitution of exocrine enzymes (Creon 25,000 E/d) reduced morbidity of the PGMP, which was then comparable with that of STZ-GMP.

CONCLUSIONS

The CGMS, developed for humans, is equally suitable for the 2 GMP diabetes models. Close-meshed glucose monitoring and insulin treatment improved the general condition of the diabetic GMP, ie, the islet graft recipients, and will thus greatly add to posttransplantation success.

Factors associated with definitive peritoneal drainage for spontaneous intestinal perforation in extremely low birth weight neonates

PURPOSE

Peritoneal drainage (PD) constitutes a definitive therapy for a subset of extremely low birth weight (ELBW) infants with spontaneous intestinal perforation (SIP). We investigated the factors which may differentiate these patients from those who require a laparotomy (LAP) after initial PD.

METHODS

A retrospective chart review of all ELBW infants (<1000 grams) who underwent PD at two tertiary neonatal intensive care units over a 42-month period was performed. Demographic, clinical, laboratory, and radiological data of the entire patient cohort were collected. Patients who underwent definitive PD were compared to those who required LAP following PD. Statistical comparisons were performed using independent samples T-tests for continuous variables, and Fisher's exact test for categorical variables.

RESULTS

Sixteen ELBW infants with SIP underwent PD. Five patients (31%) had definitive PD and 11 (69%) subsequently required LAP. Patients who had definitive PD had a lower percent band count at diagnosis (3.2+/-1.5 vs. 18.0+/-4.8; p=0.01), and were less likely to require vasopressor therapy at diagnosis and drain placement (40% vs. 91%, p=0.06), 24 hours later (40% vs. 100%, p=0.02), and 48 hours later (20% vs. 91%, p=0.01). There were no other statistically significant differences in any of the measured variables. Survival to discharge was 80% for PD and 82% for LAP (p=1.0).

CONCLUSION

Peritoneal drainage for spontaneous intestinal perforation in ELBW neonates is more likely to be definitive in the absence of bandemia and vasopressor requirement. These may be important factors in deciding whether to proceed to laparotomy.