Breast cancer in elderly women: a Cancer Research Campaign trial comparing treatment with tamoxifen and optimal surgery with tamoxifen alone. The Elderly Breast Cancer Working Party

Three hundred and eighty-one women with operable breast cancer aged over 70 years were randomly allocated to 40 mg tamoxifen daily and optimal surgery or to tamoxifen alone. At a median follow-up of 34 months there was no demonstrable difference in survival rate or in quality of life between the two treatment groups. More patients treated with tamoxifen alone had a subsequent change of management and this was usually an operation for local treatment failure. This progression to surgery has not been shown to be disadvantageous and the study will continue. Informed consent for randomization was difficult to obtain, leading to the exclusion of eligible patients, and it is therefore proposed to include non-randomized patients in a total cohort study.

Inhibition of enzymes of estrogen and androgen biosynthesis by esters of 4-pyridylacetic acid

A variety of esters of 4-pyridylacetic acid have been prepared by base mediated exchange from the methyl ester. Several of the esters of alcohols that contained a cyclohexyl ring were potent inhibitors of human placental aromatase and of the rat testicular 17 alpha-hydroxylase/C17-20lyase complex. The most potent agents found against both enzyme complexes were the borneyl, isopinocampheyl, and 1-adamantyl esters. These were over 100 times more potent than aminoglutethimide against aromatase and of greater potency than ketoconazole against hydroxylase/lyase. Potency against either enzyme complex was reduced if the ester function was borne on the cyclohexyl ring in an axial rather than an equatorial position. Some differential selectivity could be introduced since whereas methyl substitution adjacent to the carbonyl group reduced the inhibition of aromatase, it increased that against hydroxylase/lyase.

Hydroxyperfluoroazobenzenes: novel inhibitors of enzymes of androgen biosynthesis

In a search for inhibitors of 17 alpha-hydroxylase-C17,20-lyase and testosterone-5 alpha-reductase, target enzymes in the development of drugs to treat hormone-dependent prostatic cancer, we have identified certain compounds chemically derived by the hydrolysis of decafluoroazobenzene (4) as novel inhibitors for these two enzymes. Hydrolysis of 4 gave the known 4-hydroxynonafluoroazobenzene (1) and the novel 2-hydroxynonafluoroazobenzene (2). By AlI3 demethylation of 4,4'-dimethoxyoctafluoroazobenzene (5) or by hydrolysis of 4 under phase-transfer conditions 4,4'-dihydroxyoctafluoroazobenzene (3) was obtained. Compounds 1 and 2 were inhibitors of the hydroxylase (IC50 values, respectively, 30 and 63 microM) and of the lyase (IC50 values 33 and 16 microM) steps on the pathway of androgen biosynthesis. The 2-hydroxy compound 2 underwent spontaneous conversion into octafluorodibenz[b,f][1,4,5]oxadiazepine (6) which had IC50 values, respectively, of 50 and 15 microM for the hydroxylase and lyase steps and which contributed to the observed activity of 2. Effective inhibitors of the 5 alpha-reductase were 1 (Ki 10 microM) and 3 (Ki4 microM): the activities of 1 and 3 were markedly pH dependent, with respective IC50 values of 14 and 5 microM at pH 7.4 and of 2 and 0.8 microM at pH 6.6.

Ethics of clinical research: lessons for the future

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Postoperative radiotherapy and late mortality: evidence from the Cancer Research Campaign trial for early breast cancer

OBJECTIVE

To identify any excess mortality caused by adjuvant radiotherapy for early breast cancer.

DESIGN

Prospective randomised clinical trial. Two thousand subjects needed for study to have a 90% chance of detecting a difference in survival rate of 7% with 95% significance. Patients were followed up until June 1988, giving follow up of 158-216 months.

SETTING

A multicentre trial mainly drawing patients from centres in the United Kingdom.

PATIENTS

2800 Women presenting with clinical stage I or II carcinoma of the breast from June 1970 to April 1975.

INTERVENTIONS

One group of women (n = 1376) had simple mastectomy followed by immediate postoperative radiotherapy (1320 to 1510 rets). The remaining women (n = 1424) had simple mastectomy with subsequent careful observation of the axilla, radiotherapy being delayed until there was obvious progression or recurrence of disease locally.

END POINT

Increased mortality in patients treated with radiotherapy from causes other than breast cancer.

MEASUREMENTS AND MAIN RESULTS

Survival was measured from time of first treatment to death or last follow up. Deaths from any cause and from specified causes were counted as events. Comparison over the whole follow up showed a slight excess mortality in the group treated with radiotherapy (relative risk 1.04; 95% confidence interval 0.94 to 1.15). The relative risk of death from breast cancer was 0.97 (0.87 to 1.08) but that of death from other causes was 1.37 (1.09 to 1.72), the increase mainly being in women who had had tumours of the left breast (1.61 (1.17 to 2.24)) and had been treated with orthovoltage (1.85 (1.27 to 2.71)). Analysis of causes of death after five years showed a relative risk of 2.11 (1.25 to 3.59) for new malignancies and of 1.65 (1.05 to 2.58) for cardiac disease, the increase in cardiac mortality being most pronounced in patients who had had tumours of the left breast and whose treatment had included orthovoltage radiation (relative risk 2.67 (1.28 to 5.55)).

CONCLUSIONS

Adjuvant radiotherapy after simple mastectomy for early breast cancer produces a small excess late mortality from other cancers and cardiac disease. The risk has to be balanced against the higher risk of local recurrence when immediate postoperative radiotherapy is not given. The balance has to be assessed for each patient, and for many patients radiotherapy will still be desirable in the initial treatment of their early breast cancer.

The Cancer Research Campaign trials of adjuvant therapy for early breast cancer

It is now assumed that for many women there has already been dissemination of tumour at the time of diagnosis of their early breast cancer. Systemic treatment is required if a cure is sought. The use of perioperative cyclophosphamide and long-term tamoxifen, either as single agents or in combination, has been investigated in the Cancer Research Campaign Breast Adjuvant Trial. A total of 2,230 women were recruited to the study. A benefit has been seen for both agents. The implications of these results for the current treatment of women with early breast cancer and for the design of future trials are discussed.

Cancer Research Campaign Adjuvant Breast Trial for patients under 50

The objectives of the Cancer Research Campaign Adjuvant Breast Trial are to determine whether the administration of a course of adjuvant tamoxifen, or ablation of ovarian function, results in a prolongation of time to recurrence or death, for women aged under 50 years and treated for operable breast cancer. The basis and aims of the trial are discussed.

Adjuvant radiotherapy in breast cancer. Consideration of cost-benefits in relation to the CRC (Cancer Research Campaign) (King's/Cambridge) trial

The Cancer Research Campaign (CRC) Trial demonstrates a decreased incidence of local recurrence for patients randomized to prophylactic radiotherapy following mastectomy. Irradiated patients alive after 5 years, however, have a small increased risk of dying from causes other than breast cancer. How to estimate the cost-benefit of such therapy is discussed.

Is there a role for perioperative adjuvant therapy in the treatment of early breast cancer?

Despite having been investigated for many years, the role of adjuvant perioperative chemotherapy in the treatment of early breast cancer has still to be fully defined. This paper reviews the early trials of perioperative cytotoxic therapy and overviews the two largest trials; the Scandinavian Adjuvant Chemotherapy Study Group (SACSG) Trial, which began in 1965 and recruited 1026 patients, and the Cancer Research Campaign (CRC) Adjuvant Trial with 2230 patients entered between 1981 and 1985. Overview analysis of these two trials clearly shows a small but highly significant increase in time to first event (P less than 0.001). Increased survival, although significant in the SACSG trial, has not yet been demonstrated in the CRC study, but at this stage of follow-up (median 2.5 years) this is not surprising.

1-Alkyl analogues of aminoglutethimide. Comparative inhibition of cholesterol side chain cleavage and aromatase and metabolism of the 1-propyl derivative, a highly selective inhibitor of aromatase

A homologous series of 1-n-alkyl-derivatives of aminoglutethimide (AG) has been synthesised and tested for inhibitory activity towards the cholesterol side chain cleavage enzyme (desmolase) from bovine adrenals and human placental aromatase in an attempt to find a selective aromatase inhibitor. Activity against desmolase declined from an IC50 value of 30 microM for the parent drug to 220 microM for the n-propyl derivative but increased again thereafter. Against aromatase, activity was least for the methyl and ethyl derivatives and highest (IC50 = 1.6 microM) for the hexyl and octyl analogues. The optimal ratio IC50 (desmolase):IC50 aromatase of 44 was found for the n-propyl derivative, which was therefore selected for preliminary metabolism studies using rat and mouse liver microsomes and hepatocytes and in these species in vivo. There were parallels with AG, most notably in the analogous formation from the n-propyl derivative of an arylhydroxylamine in the mouse.

Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice

Patients with biliary obstruction due to malignant disease, and judged unfit for open operation, were randomised to have a biliary stent inserted either endoscopically via the papilla of Vater or percutaneously. Analysis after 75 patients had been entered showed that the endoscopic method had a significantly higher success rate for relief of jaundice (81% versus 61%, p = 0.017) and a significantly lower 30-day mortality (15% versus 33%, p = 0.016). The higher mortality after percutaneous stents was due to complications associated with liver puncture (haemorrhage and bile leaks). When stenting is indicated in elderly and frail patients the endoscopic method should be tried first.

The Cancer Research Campaign (King's/Cambridge) trial for early breast cancer: an analysis of the radiotherapy data

A detailed study has been made of the patients receiving routine post-operative radiotherapy in the Cancer Research Campaign trial for early breast cancer. Particular attention has been paid to the routine dose delivered and the incidence of recurrence in different areas. Little difference was apparent in the incidence of local recurrence in groups of patients receiving different levels of dosage, although there was a threefold reduction in five-year local recurrence-free rates compared with that for patients who received no irradiation. Moderate or severe telangiectasis occurred more frequently as the dose increased. When analysed in terms of survival, there was a tendency for the patients receiving more than 1510 ret to do a little better, but this was not statistically significant and could be due to some unexplained patient selection or higher dosage. There was no suggestion that irradiation might cause reduced survival.

The cancer research campaign (King's/Cambridge trial for early breast cancer: clinico-pathological aspects

Analysis of pathological data in the 10th year of follow-up of a multicentre trial of the management of operable breast cancer has confirmed the correlation of prognosis with tumour grade, tumour size and lymph-node status. For each factor examined there was no difference in survival between the 2 treatment groups ("watch policy" and radiotherapy) but patients in the WP group whose tumours were of Grade II or III or greater than 2 cm, or with lymph-node metastases, had a greater chance of local recurrence. Cellular reaction had no relationship with prognosis, except in patients with Grade III tumours. The clinical relevance and application of these results are discussed.

Cancer growth, response to treatment and survival time in mice: beneficial effect of the prostaglandin synthesis inhibitor flurbiprofen

Adult mice were injected subcutaneously with cells from a syngeneic metastasizing mammary cancer. Daily treatment with flurbiprofen starting before injection of the cancer cells reduced tumour growth and lengthened the survival of mice whose tumours were excised at 3 weeks. When low doses of radiotherapy and chemotherapy were given, additional treatment with flurbiprofen starting 25 days after injecting the cancer cells substantially inhibited tumour growth.

Comparison of propranolol and Ro 3-3528 in hyperthyroid tachycardia and dysrhythmias

Ro 3-3528, a non-selective β-adrenoceptor blocking drug which lacks intrinsic activity, produces a dose-response effect in hyperthyroid tachycardia, and shows no dysrhythmic properties. In hyperthyroid patients, β-blocking drugs of this nature are preferable to those possessing intrinsic sympathomimetic activity, which may have dysrhythmic properties in this condition.