Phase III randomized trial of droloxifene and tamoxifen as first-line endocrine treatment of ER/PgR-positive advanced breast cancer

PURPOSE

This trial was designed to demonstrate equivalence between droloxifene 40 mg/d and tamoxifen 20 mg/d as first-line treatment in pre- and post-menopausal women with ER+ and/or PgR+ advanced breast cancer based on time to disease progression and tumor response.

MATERIALS AND METHODS

One thousand three hundred fifty four women with measurable disease, previously untreated by hormonal or chemotherapy for advanced or recurrent breast cancer, were enrolled by 179 institutions in 35 countries. Patients were stratified at baseline for menopausal status. Patients receiving adjuvant hormonal therapy within I year were excluded. All patients gave written informed consent, were randomized to 40mg droloxifene or 20 mg tamoxifen daily as single-agent therapy and underwent tumor assessment every 3 months. A central committee reviewed digitized images for all cases of tumor progression or objective response.

RESULTS

The hazard ratio (droloxifene/tamoxifen) for the primary endpoint, time to disease progression, was 1.287 favoring tamoxifen (95% C.I.: 1.114-1.487; p <.001). The objective response rate (CR+PR) was 22.4% for droloxifene and 28.6% for tamoxifen (p = .02). Tamoxifen was superior to droloxifene overall, among both pre- and postmenopausal patients and among patients < or =65 years; there was no difference among women >65 years. The hazard ratio for all-cause mortality was 0.871 (95% C.I.: 0.672-1.129; p = .29), favoring droloxifene but not statistically significant.

CONCLUSIONS

Droloxifene was significantly less effective than tamoxifen overall and particularly among women under 65 years. Tamoxifen and droloxifene were both less effective in pre-menopausal women with receptor-positive disease compared to post-menopausal women. Further clinical development of droloxifene was stopped.

A monounsaturated fatty acid-rich pecan-enriched diet favorably alters the serum lipid profile of healthy men and women

Frequent consumption of nuts is associated with decreased risk of cardiovascular disease. We investigated the effect of pecans rich in monounsaturated fat as an alternative to the Step 1 diet in modifying serum lipids and lipoproteins in men and women with normal to moderately high serum cholesterol. In a single-blind, randomized, controlled, crossover feeding study, we assigned 23 subjects (mean age: 38 y; 9 women, 14 men) to follow two diets, each for 4 wk: a Step I diet and a pecan-enriched diet (accomplished by proportionately reducing all food items in a Step I diet by one fifth for a 20% isoenergetic replacement with pecans). The percentage of energy from fat in the two diets was 28.3 and 39.6%, respectively. Both diets improved the lipid profile; however, the pecan-enriched diet decreased both serum total and LDL cholesterol by 0.32 mmol/L (6.7 and 10.4%, respectively) and triglyceride by 0.14 mmol/L (11.1%) beyond the Step I diet, while increasing HDL cholesterol by 0.06 mmol/L (2.5 mg/dL). Serum apolipoprotein B and lipoprotein(a) decreased by 11.6 and 11.1%, respectively, and apolipoprotein A1 increased by 2.2% when subjects consumed the pecan compared with the Step I diet. These differences were all significant (P < 0.05). A 20% isoenergetic replacement of a Step I diet with pecans favorably altered the serum lipid profile beyond the Step I diet, without increasing body weight. Nuts such as pecans that are rich in monounsaturated fat may therefore be recommended as part of prescribed cholesterol-lowering diet of patients or habitual diet of healthy individuals.

The role of the infection control nurse as a clinical nurse specialist or advanced nurse practitioner

The specialty of infection control is examined regarding the role of the infection control nurse and the educational requirements for practitioners in this field in relation to post titles of clinical nurse specialist and advanced nurse practitioner. Whilst not fulfilling all the role constituents of a clinical nurse specialist, the infection control nurse is seen as more akin to a clinical nurse specialist than an advanced nurse practitioner.

Nurses' perceptions of the reliability of an automated medication dispensing system

Automated medication dispensing systems (AMDS) technology is increasingly being implemented in health care facilities to reduce the risk of medication errors. However, the case study evidence of their effectiveness has so far been mixed. It has been suggested that the attitudes of nursing staff toward AMDS can be an important factor in influencing whether or not the technology will be successfully implemented. Nurses' attitudes toward AMDS were examined at Riverview Health Centre, a long-term care facility where the Meditrol automated dispensing system had been installed the previous year. It was found that nurses were generally distrustful of AMDS and skeptical that it had reduced medication errors. A number of technological, organizational, and social factors has been put forward to explain this distrust. In addition, the efforts of hospital administrators to raise nurses' confidence in the system's reliability were also delineated.