Comparison of BEAM vs. LEAM regimen in autologous transplant for lymphoma at AIIMS

BEAM (BCNU, etoposide, cytrabine, melphalan) is the most widely used high dose chemotherapy regimen for autologous transplant in lymphoid malignancies. We report our early experience with an alternative regimen LEAM where BCNU was replaced with the oral analogue CCNU (lomustine) to tide over the non-availability of BCNU. Fifty one patients of relapsed or refractory lymphoma who received BEAM (n= 34) and LEAM (n= 17) from September 2001 to February 2012 were analyzed. From October 2009 onwards LEAM was used as the conditioning regimen instead of conventional BEAM. Patients in the LEAM group had more chemorefractory disease (35% vs 9%, p = 0.045) and high risk comorbidity score (24% vs 0%, p = 0.019). Grade 3 and 4 oral mucositis (67.6% vs. 64.7%, p = 0.834) and diarrhea (47% vs. 41.1%, p = 0.691) were similar. No difference was noted between the two groups in terms of engraftment, documented infections, antibiotic use, cumulative toxicity risk, length of hospital stay and 100 day transplant related mortality. The estimated 2 year overall survival (61.7% vs. 62.7%, p = 0.928) and event free survival (44.6% vs. 41.1%, p = 0.510) of the regimens BEAM and LEAM respectively were comparable. Thus LEAM appeared equivalent to BEAM in terms of toxicity and efficacy and can be used as an alternative to BEAM.

Serum galactomannan assay for diagnosis of probable invasive Aspergillosis in acute leukemia and hematopoietic stem cell transplantation

Background:

Invasive aspergillosis (IA) is a leading cause of mortality in acute leukemia and hematopoietic stem cell transplantation (HSCT).

Aims:

To determine the yield of galactomannan (GM) assay for the diagnosis of probable IA, its temporal relationship with the computed tomography (CT) scans and correlation with mortality in AL and HSCT.

Patients and Methods:

Consecutive neutropenic episodes (n=150) among inpatients aged ≥15 years with AL or recipients of HSCT were prospectively evaluated over 1½ years. All patients underwent weekly serum GM assay and optical density index >0.5 for ≥2 samples was defined as positive. IA was diagnosed according to EORTC 2008 guidelines.

Results:

Of the 150 episodes enrolled, 43 (28.7%) were diagnosed with IA: possible 25 (16.7%), probable 17 (11.3%) and proven 1 (0.7%). The yield of GM assay in diagnosing probable IA was 17/42 (40.5%). In 88.2% of probable IA episodes, GM was positive before high-resolution CT at a median of 10 days (range 1-16). In the episodes with ≥2 samples tested, fatality was higher in those ≥2 values positive for GM, compared to the rest (31% vs. 13.2%, odd ratio 2.96, 95% CI 1.09-8.00; P=0.04).

Conclusions:

In AL and HSCT, GM assay could identify patients with probable IA earlier than CT chest and also predicted a higher risk of death.

A multicenter phase II randomized study of Cremophor-free polymeric nanoparticle formulation of paclitaxel in women with locally advanced and/or metastatic breast cancer after failure of anthracycline

AIMS

Paclitaxel is extensively used in the treatment of advanced carcinomas of the breast, ovary and non-small cell lung cancer. In clinical use it is formulated in the non-ionic surfactant polyethoxylated castor oil (Cremophor) and dehydrated alcohol to enhance drug solubility. Cremophor adds to toxic effects of paclitaxel by producing or contributing to the well-described hypersensitivity reactions that commonly occur during its infusion, affecting a large number of patients. This randomized trial was conducted to evaluate efficacy and safety of novel nanoparticle-based paclitaxel in the treatment of patients with advanced breast cancer.

METHOD

Patients were randomized to receive either nanoparticle paclitaxel (NP) 300 mg/m(2) , (NP300) or NP220 mg/m(2) or Cremophor paclitaxel 175 mg/m(2) (CP 175). NP was administered as a 1-h infusion without premedication and CP as a 3-h infusion with premedication every 3 weeks.

RESULTS

In total, 194 patients who had been administered at least one dose were included for safety analysis and 170 patients who completed at least two cycles of therapy were analyzed for efficacy. NP showed an overall response rate (complete response + partial response) of 40% in the NP220 and NP300 arms as compared to 31% in the CP arm. The incidence of neutropenia (all grades) was lowest in the NP220 arm (39.4%) compared to the NP300 (55%) and CP arm (50%).

CONCLUSION

NP is well tolerated and can be safely administered without any premedication in comparison to conventional paclitaxel, which requires the use of premedication before administration. NP demonstrates promising efficacy with a favorable safety profile.

Lack of efficacy of adjuvant lapatinib in HER2-negative breast cancer (HER2–ve BC): Analysis of patients in the TEACH trial

628

Background: Benefit from trastuzumab (T) in patients (pts) with HER2–ve tumors by central laboratory FISH testing was shown in an exploratory analysis of the NSABP B-31trial and confirmed by levels of expression of HER2 mRNA. DNA sequencing studies demonstrate that undetected HER2 mutations may drive tumor growth. It is hypothesized that pts with BC deemed as HER2–ve based on amplification may still benefit from anti-HER2 therapy. We undertook an exploratory analysis of disease free survival (DFS) in pts in TEACH whose tumors were HER2–ve or borderline by central FISH testing. Methods: TEACH, a randomized, double-blind, placebo (P)-controlled trial in 33 countries, evaluated lapatinib (L) in reducing relapse risk in T-naive pts pretreated with chemotherapy for HER2+ BC. L showed a hazard ratio (HR) for DFS compared with P of 0.83 (95% confidence interval [CI] 0.70-1.00); P=.053 in the ITT population (n=3147) and in pts with HER2+ BC by central FISH [HR: 0.82 (0.67-1.00); P=.04]. We conducted an exploratory analysis of DFS in pts with borderline or HER2–ve tumors by central FISH. Estimated DFS times were calculated using a stratified log-rank test. HR was estimated by a stratified Cox regression model. Results: 657 pts (21%) did not have centrally confirmed HER2+ BC (L: 341 and P: 316) in the ITT population: 425 had negative (HER2:CEP-17 ratio <1.8) or borderline (≥1.8–<2.0) FISH testing (L: 218 and P: 207), 216 were unevaluable due to insufficient tissue or sample failed to hybridize (L: 114 and P: 102) and 16 were not centrally tested. In the 425 pts with centrally confirmed HER2–ve or borderline FISH results with 27 events in L and 34 in P, the HR for DFS in L compared with P was 0.94 (0.56-1.57). The percentage of pts with DFS at 4 yrs was 85.0% (79.5%-90.4%) in L and 81% (75.1%-87.1%) in P. Conclusions: Although L showed efficacy in pts with centrally confirmed HER2+ BC in the TEACH trial, our analysis did not show benefit in pts whose tumors were HER2–ve or borderline by central FISH. The TEACH trial shows once again that quality control of HER2 testing is crucial and central laboratory testing should be considered for non-specialized centers worldwide. Clinical trial information: NCT00374322.

Clinical features and outcome of follicular lymphoma: 17 years experience from All-India Institute of Medical Sciences (AIIMS), New Delhi, India

e19524

Background: Follicular lymphoma (FL) is second most common lymphoma in adult, constituted 20% of all lymphoma cases in the west. There is limited information is available on FL from India. Methods: The clinic-pathological profile, treatment outcome and prognostic factors for survival were assessed in 181 patients of FL seen at AIIMS, New Delhi, a large tertiary referral centre, over a period of 17 years (1996-2012). Results: There were 120 males and 61 females. The median age was 51 years (24-80 years). The common presenting features were lymphadenopathy 71%, fatigue 23% and fever 20%. Ann Arbor Rai stage distribution was: stage I - 9%, stage II - 11%, stage III -22 % and stage IV - 58%. Thirty six patients (20%) had ECOG performance status III/IV. Extra nodal involvement and bulky disease were present in 40 (22%) and 31 (19%) patients respectively. Follicular Lymphoma International Prognostic Index (FLIPI) 1 score : Low -25%, Intermediate-45% and high risk in 30% of cases. FL grade 1, 2 and 3 were seen in 63 ( 35%), 63 (35%) and 55 (30%) patients respectively. One forty five patients (80%) received treatment at presentation. Chemotherapeutic regimen used were: CHOP-45 , CVP-51, chlorambuil and prednisolone -7 , BR ( bendamustine and rituximab)-12, RCHOP- 14 and RCVP in 7 cases. The overall response (ORR) and complete remission (CR) rates were 70% and 35% respectively. Relapse occurred in 54 patients, 50 patients died and progression was observed in 63(35%) patients. Median overall survival (OS) and event free survival (EFS) was 5.5 years and 3.5 years respectively, with median follow up period of 3 years. Grade 3 histology, failure to attain CR, low serum albumin, PS III/IV, bulky disease and high risk FLIPI were significantly associated with lower event free survival. High risk FLIPI (HR 1.46, 95% CI 1.03-2.10, p=0.003) and failure to attain CR (HR 2.64, CI 1.10-4.30, p=0.001) were predictors of poor OS. Conclusions: FL represents 9 % of all lymphoma in adult. This is the largest data from single institute from India. Eighty percentage of patients presented in stage III/IV disease. High risk FLIPI and failure to attain CR were important prognostic variables for OS.

Nimotuzumab plus chemotherapy versus chemotherapy alone in advanced non-small cell lung cancer: A phase II, open-label, multicenter, randomized study

8053

Background: To evaluate the safety and efficacy of nimotuzumab in combination with chemotherapy (docetaxel and carboplatin) versus chemotherapy alone in stage IIIB/IV non-small cell lung cancer (NSCLC) patients. Methods: This multicenter, open-label, phase II study, randomized 110 patients to receive nimotuzumab plus chemotherapy (nimotuzumab group) or chemotherapy alone (control group), and comprised concomitant, maintenance, and follow-up phases. Nimotuzumab (200 mg) was administered once weekly for 13 weeks during the first 2 phases with 4 cycles of chemotherapy; docetaxel (75 mg/m2) and carboplatin (area under the curve [AUC] = 5 mg/ml*min), every 3 weeks for a maximum of 4 cycles during the concomitant phase. The primary endpoint was objective response rate (ORR; sum of complete response [CR] and partial response [PR]). Secondary endpoints, overall survival (OS), and progression-free survival (PFS) were estimated using Kaplan-Meier method. Efficacy was evaluated on the intent-to-treat (ITT) and efficacy-evaluable (EE) sets. Safety was assessed from adverse events (AEs) and serious adverse events (SAEs) data. Results: ORR was significantly higher in the nimotuzumab group than in the control group in the ITT (54% vs. 34.5%; P=0.04) population. CR and PR were achieved in 3.6% and 50% patients, respectively, in the nimotuzumab group, and in 4% and 30.9% patients, respectively, in the control group. No significant differences in median PFS and OS were observed. Safety profiles were comparable between the 2 groups. Conclusions: Nimotuzumab plus chemotherapy significantly improved ORR as compared to chemotherapy alone; the combination was safe and well tolerated in stage IIIB/IV NSCLC patients.

Breast cancer in the young (≤35 years): A single center study from the All India Institute of Medical Sciences

e12539

Background: Breast cancer in young women (</= 35 years) is uncommon and accounts for 1-2 % of all breast cancer in the West. There is limited data on breast cancer in the young from India. The aim of our study was to assess clinical, pathological parameters and outcome in young breast cancer patients. Methods: We carried out an analysis of 271 patients of young breast cancer patients (</=35 years) registered between 2000 to 2012 at I.R.C.H, AIIMS, New Delhi, India. Results: The median age was 31 years (range 18-35). The median duration of symptoms was 10 months (range 0.25-60). Breast lump was the commonest (93%) presenting symptom (left >right side). Ninety percent of patients were married and median age at first child birth was 23 years. Positive family history was elicited in only 15 patients. The TNM stage distribution was: stage I was 3 %, stage II- 20%, stage III- 55%, and stage IV- 22%. The median clinical tumour size was 5.1 cm. Modified radical mastectomy was the commonest surgical procedure and this was done in 80 % of cases. The histopathological analysis showed 93% had infiltrating ductal carcinoma. Thirty percent of tumours were high grade and 55% had pathological node positive disease. ER/PR and her-2neu positivity was 33% and 30% respectively. Triple negative breast cancer (TNBC) constituted 33%. Fifty five patients presented with metastasis. A combination of anthracycline and taxanes were used in the majority of patients and Trastuzumab could be used only in 6 cases out of 72 patients who were Her-2 neu positive. With a median follow up of 30 months (non metastatic group), three years disease free survival (DFS) and overall survival (OS) was 50% and 60%. Higher nodal stage, tumour size (>5 cm), negative hormonal status (triple negative) and visceral metastasis at baseline predicted poor outcome. Conclusions: Young women constituted 8 % of breast cancer cases, this proportion is much higher than the published Western figures of 1-2 % and reflects younger age of our population. Even in this young group ER/ PR positivity was 33% and almost a third were her-2 neu positive. Higher nodal stage, tumour size (>5 cm), triple negativity and visceral metastasis at baseline predicted poor outcome.

A randomized controlled trial comparing modified gemcitabine plus oxaliplatin (mGEMOX) to gemcitabine plus cisplatin in the management of unresectable gall bladder cancer

TPS4162

Background: In a recently conducted study we have shown that combination of gemcitabine and oxaliplatin is superior to 5 fluorouracil and leucoverine or best supportive care. (Sharma A, Dwary AD, Mohanti BK,et al. Best supportive care compared with chemotherapy for unresectable gall bladder cancer:A randomized controlled study. J Clin Oncol. 2010; 28: 4581-4586.) In another recent publication from UK, gemcitabine and cisplatin combination was found superior to gemcitabine alone in biliary tract cancers (J W Valle, HS Wasan, DD Palmer, et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Eng J Med. 2010;362:1273-1281.).The current study is being planned to see whether the combination of gemcitabine and oxaliplatin is equivalent (equivalence study) to gemcitabine and cisplatin in these patients. Methods: Primary end point of the study is overall survival in subjects receiving mGEMOX or GemCis regimen. Secondary end points are: a) Comparison of progression free survival in 2 groups; b) Response rates in two groups; c) Identification of genes predictive of responses in a subset of patients; d) To evaluate role of PET CT in GBC patients predicting disease activity. Sample size was calculated taking median survival of 9.5 months in our previous study with mGEMOX and 11.7 months with GemCis. For this total of 216 patients are required (108 in each arm); to make for major protocol violation and lost to follow up additional 22 patients in each arm will be enrolled. Thus in total 260 patients (130) in each arm will be recruited. This will have alpha and beta values of 0.05 and 0.20 respectively. So far 103 patients have been enrolled and interim analysis is being planned. Treatment protocol: Cycles will be repeated every 3 weeks. Arm A- mGEMOX. Inj Oxaliplatin 80 mg/m22 hours infusion in Dextrose 5% Day 1 and 8. Inj Gemcitabine 900 mg/m2IV 30 minutes infusion day 1 and 8 maximum of 6 cycles. Arm B- GEMCIS. Inj Cisplatin 25 mg/m2PO Days 1 and 8. Inj Gemcitabine 1000 mg/m2IV 30 minutes infusion day1and 8 maximum of 8 cycles. Clinical trial information: CTRI/2010/091/001406.

Prothrombotic profile in multiple myeloma: Response to treatment and associated thrombotic complications: A prospective observational study

e19531

Background: Venous thromboembolism (VTE) is a major complication of Multiple myeloma. The exact cause of thrombosis, role of anti myeloma drugs especially immunomodulators and steroids and the relation of thrombosis with alteration of thrombotic profile is not clear. While some available data is suggestive of low incidence of VTE in Asian population, true incidence and risk factors of VTE in Indian population is not known.So the present study was undertaken to have an evaluation of prothrombotic factors in Indian population. Methods: A prospective observational study was conducted from July 2008 to November 2009 at All India Institute of Medical Sciences (AIIMS), New Delhi, India. Thirty patients of newly diagnosed myeloma were recruited and were treated with thalidomide and dexamethasone for 4 months. Prothrombotic profile including protein Cand S, activated protein C resistance, plasma fibrinogen, factor VII and von Willebrand factor level was measured and Doppler study was done at baseline and after 4 months. Statistical analysis was done using SPSS 15 software. Frequency distribution, mean, median, range, standard deviation, Inter Quartile Range were calculated. To find out difference between pre and post treatment, Macnemar chi-square test (for proportion) and paired t test (mean) were done. Results: At the base line 4 patients (13%) had low protein C, 3 (10 %) had low protein S and 2 patients (6%) had high factor VIII. Post induction therapy 7 patients showed low protein C, 1 had low protein S and 1 had high factor VIII value. Rest of the factors was within normal limit both at baseline and post treatment in other patients. During the study period 2 subjects developed DVT. While one had low protein S, other patient had low protein C and low anti thrombin III which was done to find out the cause of DVT. Conclusions: Incidence of DVT in our patients seems to be less than western published data. Although thrombotic factors abnormalities are present in myeloma patients but the relation of coagulation factor abnormalities and development of DVT require further study. A larger prospective trial may be required to get a clear picture.

Clinical features and outcome of T-cell acute lymphoblastic leukemia in patients older than 9 years: A single center experience of 110 patients from AIIMS, New Delhi, India

7081

Background: It is known that T cell acute lymphoblastic leukemias (ALL) have poorer outcomes than their B cell counterparts. Data on T-ALL in the age group of >9 years from India is minimal. Methods: This is a single institutional analysis of patients of above 9 years who were treated from January 2000 to December 2010. All patients who completed at least 4 weeks of induction therapy were analysed for various outcomes. Results: T-ALL formed 30% of all ALL in this age group. Of the 110 newly registered patients of T-ALL, the median age was 17 years (Range 10-50 years) with an M:F ratio of 5.9:1. Of this 62%, 30% and 18% patients belonged to 10-18, 19-30 and > 31 years age group respectively. Eighteen (19%) and 2 (2%) and 33 (30%) had CSF, testicular and other extramedullary sites involvement respectively. Twenty eight per cent had a total leucocyte count (TLC) of above 100x109/L. Patients available for survival analysis were 104(94.5%). Complete remission (CR)rate was 68.2% and induction mortality was 14.4%. At a median follow up of 56.4 months 5 year leukemia free survival was 52.3% (median not attained). Twenty seven (38%) patients relapsed (median relapse time of 15.2 months, range 0.7 to 47.3 months), 55% during maintenance phase. The 5 year overall survival (OS) was 46.9% (median OS of 35.4 months). The 5 year OS of 10-18, 19-30 and > 31 years age groups were 42.8%, 71% and 16.6% respectively (p value not significant). Not attaining CR in 1st induction, spontaneous tumor lysis syndrome and peripheral blood blast count of > 80% were significant poor prognostic factors for survival. Conclusions: This is one of the largest study of T-ALL outcomes in patients above 9 years from a single center from India. Attainment of CR in 1st induction was the most important risk factor for survival. 5 year OS was 47%.

Clinical features and outcome of B-cell acute lymphoblastic leukemia in patients older than 9 years: A single center experience of 241 cases from AIIMS, New Delhi, India

7082

Background: Data on B cell Acute Lymphoblastic leukemia (ALL) in the poor prognostic age group of > 9 years from India is minimal. Methods: This is an analysis of patients of above 9 years that were diagnosed and treated from January 2000 to December 2010 at a single institute . All patients who completed at least 4 weeks of induction therapy were analysed for various outcomes. Results: Of the 241 newly registered patients, the median age was 19 years (Range 10-78 years) with an M:F ratio of 1.9:1. Out of this 47%, 25% & 28% patients belonged to 10-18, 19-30 & > 31 years age group respectively. Twenty seven (11.6%) and 5(2%) had CSF and testicular involvement respectively. Thirty nine per cent had a total leucocyte count (TLC) of above 30x109/L. Philadelphia chromosome (Ph) positivity was seen in 27% and was equally distributed among the different age groups. Patients available for outcome analysis were 213(88.4%). Complete remission rate (CRR) was 66.6% and induction mortality was 26.3%.At a median follow up of 65.8 months 5 year leukemia free survival was 30.5%. Seventy eight (55%) patients relapsed (median relapse time of 13.5 months, range 1.7 to 53.4 months) , 55% during maintenance phase. The 5 year overall survival (OS) was 30.3% with a median OS of 15.8 months. The OS was similar in 10-18 and 19-30 age groups (5 year OS 35% vs. 27.5%, p=0.641) but it was significantly lower in >31 years (5year OS 21%, p=0.008). Apart from this, extramedullary disease, not attaining a CR in 1st induction, albumin at presentation below 3.5gm% and TLC of >100x109/L were significant poor prognostic markers for survival. Conclusions: This is a large study of B-ALL outcomes in patients above 9 years from a single center in India. Patients above 30 years had a worse prognosis while the prognosis of 10-18 and 19-30 years age group were similar. Induction mortality was higher mainly because of advanced disease and poor performance status at presentation.

Sputum collection and disposal among pulmonary tuberculosis patients in coastal South India

BACKGROUND

Safe sputum disposal practices minimise the spread of pulmonary tuberculosis (PTB).

OBJECTIVES

To study the perceptions and practices of sputum disposal among PTB patients.

METHODOLOGY

This study was conducted among 206 diagnosed sputum-positive TB patients registered in selected DOTS centres in Mangalore.

RESULTS

Safe sputum disposal practice was followed by 50% of the subjects: it was higher among females (62%), patients of middle socio-economic status (75.5%) and those with a family history of TB (70%). Furthermore, 75% patients believed that TB was caused by several factors.

CONCLUSIONS

High proportions of subjects were unaware about the causes of TB and did not practise safe disposal of sputum.

Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial

BACKGROUND

For women with oestrogen receptor (ER)-positive early breast cancer, treatment with tamoxifen for 5 years substantially reduces the breast cancer mortality rate throughout the first 15 years after diagnosis. We aimed to assess the further effects of continuing tamoxifen to 10 years instead of stopping at 5 years.

METHODS

In the worldwide Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) trial, 12,894 women with early breast cancer who had completed 5 years of treatment with tamoxifen were randomly allocated to continue tamoxifen to 10 years or stop at 5 years (open control). Allocation (1:1) was by central computer, using minimisation. After entry (between 1996 and 2005), yearly follow-up forms recorded any recurrence, second cancer, hospital admission, or death. We report effects on breast cancer outcomes among the 6846 women with ER-positive disease, and side-effects among all women (with positive, negative, or unknown ER status). Long-term follow-up still continues. This study is registered, number ISRCTN19652633.

FINDINGS

Among women with ER-positive disease, allocation to continue tamoxifen reduced the risk of breast cancer recurrence (617 recurrences in 3428 women allocated to continue vs 711 in 3418 controls, p=0·002), reduced breast cancer mortality (331 deaths vs 397 deaths, p=0·01), and reduced overall mortality (639 deaths vs 722 deaths, p=0·01). The reductions in adverse breast cancer outcomes appeared to be less extreme before than after year 10 (recurrence rate ratio [RR] 0·90 [95% CI 0·79–1·02] during years 5–9 and 0·75 [0·62–0·90] in later years; breast cancer mortality RR 0·97 [0·79–1·18] during years 5–9 and 0·71 [0·58–0·88] in later years). The cumulative risk of recurrence during years 5–14 was 21·4% for women allocated to continue versus 25·1% for controls; breast cancer mortality during years 5–14 was 12·2% for women allocated to continue versus 15·0% for controls (absolute mortality reduction 2·8%). Treatment allocation seemed to have no effect on breast cancer outcome among 1248 women with ER-negative disease, and an intermediate effect among 4800 women with unknown ER status. Among all 12,894 women, mortality without recurrence from causes other than breast cancer was little affected (691 deaths without recurrence in 6454 women allocated to continue versus 679 deaths in 6440 controls; RR 0·99 [0·89–1·10]; p=0·84). For the incidence (hospitalisation or death) rates of specific diseases, RRs were as follows: pulmonary embolus 1·87 (95% CI 1·13–3·07, p=0·01 [including 0·2% mortality in both treatment groups]), stroke 1·06 (0·83–1·36), ischaemic heart disease 0·76 (0·60–0·95, p=0·02), and endometrial cancer 1·74 (1·30–2·34, p=0·0002). The cumulative risk of endometrial cancer during years 5–14 was 3·1% (mortality 0·4%) for women allocated to continue versus 1·6% (mortality 0·2%) for controls (absolute mortality increase 0·2%).

INTERPRETATION

For women with ER-positive disease, continuing tamoxifen to 10 years rather than stopping at 5 years produces a further reduction in recurrence and mortality, particularly after year 10. These results, taken together with results from previous trials of 5 years of tamoxifen treatment versus none, suggest that 10 years of tamoxifen treatment can approximately halve breast cancer mortality during the second decade after diagnosis.

FUNDING

Cancer Research UK, UK Medical Research Council, AstraZeneca UK, US Army, EU-Biomed.

Prevalence and aetiology of anaemia in lymphoid malignancies

BACKGROUND

We prospectively studied the prevalence, type and causes of anaemia in newly diagnosed patients with lymphoid malignancies.

METHODS

Between January 2007 and June 2008, a total of 316 newly diagnosed, consecutive patients (aged 15 years or above) of Hodgkin lymphoma, non-Hodgkin lymphoma and chronic lymphocytic leukaemia with anaemia (haemoglobin <11 g/dl), were analysed to determine the prevalence and a subgroup of 46 patients was analysed for the cause of anaemia.

RESULTS

Hodgkin lymphoma, non-Hodgkin lymphoma and chronic lymphocytic leukaemia were the diagnoses in 81 (25.8%), 203 (64.7%) and 30 (9.6%) patients, respectively. Anaemia was present in 134 patients (42.4%). Anaemia of chronic disease was present in 33/46 (71.7%) and iron deficiency in 18/46 (39.1%) patients. Vitamin B12 and/or folate deficiency was detected in 10/46 (21.7%) patients (B12 deficiency alone in 7, folate deficiency alone in 1 and combined B12 and folate deficiency in 2). Autoimmune haemolytic anaemia was detected in 5/46 (10.9%) although direct Coombs test was positive in 17/46 (37%) patients. Among patients with Hodgkin lymphoma and non-Hodgkin lymphoma, anaemia due to bone marrow involvement was present in 16/40 (40%). In most patients with bone marrow involvement, anaemia was due to other causes. In only 3 patients, anaemia was attributable to bone marrow involvement alone. Anaemia was multifactorial in 18/46 (39.1%) patients. Nutritional deficiency alone or in combination was present in 22/46 (47.8%) patients.

CONCLUSION

Anaemia is common in lymphoid malignancies at initial presentation. Besides managing anaemia of chronic disease and bone marrow involvement, nutritional and autoimmune causes should be ruled out.