A phase II randomised, placebo-controlled trial of low dose (metronomic) cyclophosphamide and nintedanib (BIBF1120) in advanced ovarian, fallopian tube or primary peritoneal cancer

BACKGROUND

We investigated the safety and efficacy of a combination of the oral tyrosine kinase inhibitor, nintedanib (BIBF 1120) with oral cyclophosphamide in patients with relapsed ovarian cancer.

PATIENTS AND METHODS

Patients with relapsed ovarian, fallopian tube or primary peritoneal cancer received oral cyclophosphamide (100 mg o.d.) and were randomised (1,1) to also have either oral nintedanib or placebo. The primary endpoint was overall survival (OS). Secondary endpoints included progression free survival (PFS), response rate, toxicity, and quality of life.

RESULTS

117 patients were randomised, 3 did not start trial treatment, median age 64 years. Forty-five (39%) had received ≥5 lines chemotherapy. 30% had received prior bevacizumab. The median OS was 6.8 (nintedanib) versus 6.4 (placebo) months (hazard ratio 1.08; 95% confidence interval 0.72-1.62; P = 0.72). The 6-month PFS rate was 29.6% versus 22.8% (P = 0.57). Grade 3/4 adverse events occurred in 64% (nintedanib) versus 54% (placebo) of patients (P = 0.28); the most frequent G3/4 toxicities were lymphopenia (18.6% nintedanib versus 16.4% placebo), diarrhoea (13.6% versus 0%), neutropenia (11.9% versus 0%), fatigue (10.2% versus 9.1%), and vomiting (10.2% versus 7.3%). Patients who had received prior bevacizumab treatment had 52 days less time on treatment (P < 0.01). 26 patients (23%) took oral cyclophosphamide for ≥6 months. There were no differences in quality of life between treatment arms.

CONCLUSIONS

This is the largest reported cohort of patients with relapsed ovarian cancer treated with oral cyclophosphamide. Nintedanib did not improve outcomes when added to oral cyclophosphamide. Although not significant, more patients than expected remained on treatment for ≥6 months. This may reflect a higher proportion of patients with more indolent disease or the higher dose of cyclophosphamide used.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.govNCT01610869.

Pre-Hospital Fast Positive Cases Identified by DFB Ambulance Paramedics: Final Clinical Diagnosis

Ischaemic stroke clinical outcomes are improved by earlier treatment with intravenous thrombolysis. An existing pathway at the Mater University Hospital for assessment of suspected acute stroke in the Emergency Department was updated, aiming to shorten door-to-needle time. This study examines the final clinical diagnosis of Dublin Fire Brigade Ambulance Paramedic identified Face-Arm-Speech-Test (FAST) positive patients presenting to the Emergency Department over a 7 month period. A retrospective analysis was carried out of 177 consecutive FAST positive patients presenting between March and November 2014. The final clinical diagnosis was acute stroke in 57.1% (n=101) of patients. Of these, 76 were ischaemic strokes of whom 56.5% (n=43) were thrombolysed. In the pre-hospital setting Ambulance Paramedics can identify, with reasonable accuracy, acute stroke using the FAST test. Over half of the ischaemic stroke patients presenting via this pathway can be treated with intravenous thrombolysis.

A randomised, placebo-controlled trial of weekly paclitaxel and saracatinib (AZD0530) in platinum-resistant ovarian, fallopian tube or primary peritoneal cancer†

BACKGROUND

We investigated whether the Src inhibitor saracatinib (AZD0530) improved efficacy of weekly paclitaxel in platinum-resistant ovarian cancer.

PATIENTS AND METHODS

Patients with platinum-resistant ovarian, fallopian tube or primary peritoneal cancer were randomised 2 : 1 to receive 8-week cycles of weekly paclitaxel (wPxl; 80 mg/m(2)/week ×6 with 2-week break) plus saracatinib (S; 175 mg o.d.) or placebo (P) continuously, starting 1 week before wPxl, until disease progression. Patients were stratified by taxane-free interval (<6 versus ≥6 months/no prior taxane). The primary end point was progression-free survival (PFS) rate at 6 months. Secondary end points included overall survival (OS) and response rate (RR).

RESULTS

A total of 107 patients, median age 63 years, were randomised. Forty-three (40%) had received >2 lines of prior chemotherapy. The 6-month PFS rate was 29% (wPxl + S) versus 34% (wPxl + P) (P = 0.582). Median PFS was 4.7 versus 5.3 months (hazard ratio 1.00, 95% confidence interval 0.65-1.54; P = 0.99). RR (complete + partial) was 29% (wPxl + S) versus 43% (wPxl + P), P value = 0.158. Grade 3/4 adverse events were 36% versus 31% (P = 0.624); the most frequent G3/4 toxicities were vomiting (5.8% saracatinib versus 8.6% placebo), abdominal pain (5.8% versus 0%) and diarrhoea (4.3% versus 5.7%). Febrile neutropenia was more common in the saracatinib arm (4.3%) than placebo (0%). Response, PFS and OS were all significantly (P < 0.05) better in patients with taxane interval ≥6 months/no prior taxane (n = 85) than those <6 months (n = 22), regardless of randomisation.

CONCLUSIONS

Saracatinib does not improve activity of weekly paclitaxel in platinum-resistant ovarian cancer. Taxane-free interval of ≥6 months/no prior taxane was associated with better outcome in both groups.

TRIALS REGISTRATION

Clinicaltrials.gov NCT01196741; ISRCTN 32163062.

A phase II study of weekly neoadjuvant chemotherapy followed by radical chemoradiation for locally advanced cervical cancer

Background:

We investigated the feasibility of dose-dense neoadjuvant chemotherapy (NACT) with paclitaxel and carboplatin before radical chemoradiation (CRT) and assessed the response rate to such a regimen.

Methods:

CxII is a single-arm phase II trial of 46 patients, with locally advanced cervical cancer (stage Ib2-IVa). Patients received dose-dense carboplatin (AUC2) and paclitaxel (80 mg m⁻²) weekly for six cycles followed by CRT (40 mg m⁻² of weekly cisplatin, 50.4 Gy, 28 fractions plus brachytherapy). The primary end point was response rate 12 weeks post-CRT.

Results:

Baseline characteristics were: median age at diagnosis 43 years; 72% squamous, 22% adenocarcinoma and 7% adenosquamous histologies; FIGO stage IB2 (11%), II (50%), III (33%), IV (7%). Complete or partial response rate was 70% (95% CI: 54–82) post-NACT and 85% (95% CI: 71–94) post-CRT. The median follow-up was 39.1 months. Overall and progression-free survivals at 3 years were 67% (95% CI: 51–79) and 68% (95% CI: 51–79), respectively. Grade 3/4 toxicities were 20% during NACT (11% haematological, 9% non-haematological) and 52% during CRT (haematological: 41%, non-haematological: 22%).

Conclusion:

A good response rate is achieved by dose-dense weekly NACT with carboplatin and paclitaxel followed by radical CRT. This treatment regimen is feasible as evidenced by the acceptable toxicity of NACT and by the high compliance to radiotherapy (98%).

Imaging alcohol cue exposure in alcohol dependence using a PET 15O-H2O paradigm: results from a pilot study

Craving is a commonly used term to describe an intense desire for a substance or behaviour; however, its underlying neurobiology is not fully characterized. We have successfully used a cue exposure paradigm with functional neuro-imaging (H2 15O PET; PET, positron emission tomography) in abstinent opiate addicts. This study showed that salient cue exposure results in activation in the left anterior cingulate/mediofrontal cortex and elicited craving correlated with activity in the left orbitofrontal cortex. We therefore aimed to replicate this study in alcohol dependence to see if a similar pattern of neural activation occurred. We recruited six abstinent alcohol-dependent and six non-dependent subjects who each underwent a 12-run PET scan using H2 15O to measure changes in regional blood flow during exposure to an alcoholic drink or its visually matched non-alcoholic drink. Physiological data and subjective ratings were also recorded. Statistical parametric mapping (SPM99) was used to analyse the PET images. Compared with control subjects, abstinent alcohol-dependent subjects rated their alcohol craving higher at baseline and throughout the study, but there was no significant change in the scores in response to the cues in either group. SPM analysis across all subjects showed significant activation in the occipital cortex in response to the alcohol cue as compared with the neutral one. Analysis of the same regions that were activated in the opiate study, revealed significant increases in signal activation in the left medial prefrontal area, but only in abstinent alcohol-dependent subjects. In conclusion, in abstinent alcohol dependence we suggest that a simple cue exposure paradigm is not sufficiently powerful in functional imaging studies to determine the underlying neurobiology of subjective craving. Comparisons with the finding in opiate dependence suggest a shared region, the anterior cingulate/left medial prefrontal cortex is involved in the cue response in dependent subjects but not controls.

GABA-benzodiazepine receptor function in alcohol dependence: a combined 11C-flumazenil PET and pharmacodynamic study

RATIONALE

Gamma-aminobutyric acid (GABA)-benzodiazepine receptor function is hypothesised to be reduced in alcohol dependence.

OBJECTIVES

We used positron emission tomography (PET) with [11C]flumazenil, a non-selective tracer for brain GABA-benzodiazepine (GABA-BDZ) receptor binding, to determine in vivo the relationship between BDZ receptor occupancy by an agonist, midazolam, and its functional effects.

METHODS

Abstinent male alcohol dependent subjects underwent [11C]flumazenil PET to measure occupancy of BDZ receptors by midazolam whilst recording its pharmacodynamic effects on behavioural and physiological measures. Rate constants describing the exchange of [11C]flumazenil between the plasma and brain compartments were derived from time activity curves.

RESULTS

A 50% reduction in electroencephalography (EEG)-measured sleep time was seen in the alcohol dependent group despite the same degree of occupancy by midazolam as seen in the control group. The effects of midazolam on other measures of benzodiazepine receptor function, increasing EEG beta1 power and slowing of saccadic eye movements, were similar in the two groups. No differences in midazolam or flumazenil metabolism were found between the groups.

CONCLUSIONS

In summary, our study suggests that alcohol dependence in man is associated with a reduced EEG sleep response to the benzodiazepine agonist, midazolam, which is not explained by reduced BDZ receptor occupancy, and is consistent with reduced sensitivity in this measure of GABA-BDZ receptor function in alcohol dependence. The lack of change in other functional measures may reflect a differential involvement of particular subtypes of the GABA-BDZ receptor.

The suppression of q card selections: evidence for deductive inference in Wason's selection task

The results of three experiments investigating the role of deductive inference in Wason's selection task are reported. In Experiment 1, participants received either a standard one-rule problem or a task containing a second rule, which specified an alternative antecedent. Both groups of participants were asked to select those cards that they considered were necessary to test whether the rule common to both problems was true or false. The results showed a significant suppression of q card selections in the two-rule condition. In addition there was weak evidence for both decreased p selection and increased not-q selection. In Experiment 2 we again manipulated number of rules and found suppression of q card selections only. Finally, in Experiment 3 we compared one- and two-rule conditions with a two-rule condition where the second rule specified two alternative antecedents in the form of a disjunction. The q card selections were suppressed in both of the two-rule conditions but there was no effect of whether the second rule contained one or two alternative antecedents. We argue that our results support the claim that people make inferences about the unseen side of the cards when engaging with the indicative selection task.

Socioeconomic and sex differentials in reason for sickness absence from the Whitehall II Study

OBJECTIVES

Large socioeconomic differences exist in disease and mortality. This paper describes the distribution of specific medical reasons for sickness absence by grade of employment in the Whitehall II study and validates the medical reason by comparison with general practitioners' records.

METHODS

Analysis of sickness absence data on 5620 male and female civil servants aged 35-55 years. Data have been collected from 12 of the 20 London based civil service departments participating in the Whitehall II study, where medical reason for absence was available. Rates and distributions of reasons for absence for short spells (< or = 7 days) and long spells (> 7 days) were analysed.

RESULTS

Respiratory disorders and gastroenteritis accounted for over half of all spells of absence, with headache and migraine, musculoskeletal disorders, injury, and neurosis accounting for a further 20%-30% of absences. There was an inverse association with employment grade, the lower the grade the higher the rate of absence for both short spells (< or = 7 days) and long spells (> 7 days). In general, women had higher rates of absence than men. Comparison of reason for very long spells of absence (> 21 days) showed moderate agreement between civil service and general practitioner.

CONCLUSION

There is a lack of national comprehensive data on sickness absence and medical reason for absence, in particular for women and for spells of different duration. Data from the Whitehall II study show large employment grade and sex differences in the distribution of medical reasons for absence that are similar to socioeconomic differences in morbidity documented in other studies. Possible explanations include the subjective nature of illness and disease; the work/family interface; and the influence of the absence culture. Longer term follow up will provide information on whether sickness absence relates to serious morbidity and mortality.

General explanations for social inequalities in health

Life expectancy has always differed according to status in society, with a higher mortality among those of lower social status. Although cancer and cardiovascular diseases are more common as causes of death in rich than in poor societies, in industrialized countries the major causes of death are more common in those of lower social status. In this chapter, the magnitude of socioeconomic differences in health is examined using different measures of socioeconomic status, and methodological issues relating to these measures are discussed. Much of the discussion about social inequalities in health has been focused on the health disadvantage of those of lowest socioeconomic status. However, data from the Whitehall studies show that the social gradient in morbidity and mortality exists across employment grades in British civil servants, none of whom is poor by comparison with people in developing countries, suggesting that there are factors that operate across the whole of society. A number of potential explanations are considered here. The magnitude of socioeconomic differences in health varies between societies, and over time within societies. This suggests that identification of factors that influence socioeconomic status and health, and the pathways by which they operate, is an important public health task that could lay the basis for a reduction in inequalities in health.

A prospective audit of wound infection rates after caesarean section in five West Yorkshire hospitals

A three month prospective audit of wound infection following emergency and elective caesarean section was carried out in five West Yorkshire hospitals. Among 4076 women undergoing delivery in the five obstetric departments, the caesarean rate was 15.4%. The overall infection rate was 45/628 (7.2%) with a range of 2.5-17.2% between the five centres. The infection rate was 14/226 (6.2%) when antibiotics were used compared with 31/402 (7.7%) without antibiotics. The use of prophylactic antibiotics made no significant difference to the infection rate, which did not correlate with duration of labour or of ruptured membranes. The number of vaginal examinations correlated with the infection rate. In conclusion, the caesarean section rate observed was higher than that estimated for the UK as a whole, but was distorted by one centre with a high rate. For the other four hospitals the caesarean rate was unexceptional. The ratio of emergency to elective operations was comparable with recently reported values in the UK and the wound infection rate was within the widely varying limits found in previous studies. In view of the relatively low infection rate recorded without antibiotics, in the interests of cost effectiveness, prophylaxis may be limited in future to selected women at high risk. Because this was an audit rather than a randomized study we cannot exclude that this is already happening on an empirical basis.

Psychosocial work environment and sickness absence among British civil servants: the Whitehall II study

OBJECTIVES

This study sought to examine the association between the psychosocial work environment and subsequent rates of sickness absence.

METHODS

The analyses were based on a cohort of male and female British civil servants (n=9072). Rates of short spells (<or=7 days) and long spells (>7 days) of sickness absence were calculated for different aspects of the psychosocial work environment, as measured by self-reports and personnel managers' ratings (external assessments).

RESULTS

Low levels of work demands, control, and support were associated with higher rates of short and long spells of absence in men and, to a lesser extent, in women. The differences were similar for the self-reports and external assessments. After adjustment for grade of employment, the differences were diminished but generally remained significant for short spells. The combination of high demands and low control was only associated with higher rates of short spells in the lower grades.

CONCLUSIONS

The psychosocial work environment predicts rates of sickness absence. Increased levels of control and support at work could have beneficial effects in terms of both improving the health and well-being of employees and increasing productivity.

Sickness absence in the Whitehall II study, London: the role of social support and material problems

STUDY OBJECTIVE

To investigate the role of social supports, social networks, and chronic stressors: (i) as predictors of sickness absence; and (ii) as potential explanations for the socioeconomic gradient in sickness absence.

DESIGN

A prospective cohort study (Whitehall II study) with sociodemographic factors, health and social support measured at baseline, and spells of sickness absence measured prospectively.

SETTING

Twenty London based non-industrial departments of the British civil service.

PARTICIPANTS

Participants were civil servants (n = 10,308), aged 35-55 years at baseline, of whom 67% (6895) were men and 33% (3413) were women. The overall response rate for Whitehall II was 73% (74% for men and 71% for women). The analysis is based on 41% of the sample who had data on reasons for sickness absence and were administered all social support questions. Only 4.3% of participants did not complete all necessary questions and were excluded.

MEASUREMENTS AND MAIN RESULTS

High levels of confiding/emotional support from the "closest person" predicted higher levels of both short and long spells of sickness absence. After adjusting for baseline physical and psychological health the effects were increased, suggesting that high levels of confiding/emotional support may encourage illness behaviour rather than generate illness. Social network measures showed a consistent but less striking pattern. Increased levels of negative aspects of social support resulted in higher rates of sickness absence. Material problems strongly predicted sickness absence, but the effect was diminished once adjustment for the covariables was made, suggesting that health status may be functioning as an intervening variable between chronic stressors and sickness absence. In addition, social support may buffer the effects of chronic stressors. Social support did not contribute to explaining the gradient in sickness absence by employment grade beyond that explained by the baseline covariables.

CONCLUSIONS

Sickness absence from work is a complex phenomenon, combining illness and coping behaviours. High levels of confiding/emotional support, although not entirely consistent across samples, may either encourage people to stay at home when they are ill or may be accompanied by more social obligations at home prolonging sickness absence. Negative aspects of close relationships may jeopardize health and hence increase sickness absence.

Sickness absence as a measure of health status and functioning: from the UK Whitehall II study

STUDY OBJECTIVE

To investigate the relationship between self reported health status and sickness absence.

DESIGN

Analysis of questionnaire and sickness absence data from the first phase of the Whitehall II study--a longitudinal study set up to investigate the degree and causes of the social gradient in morbidity and mortality.

SETTING

London offices of 20 civil service departments.

PARTICIPANTS

Altogether 6895 male and 3413 female civil servants aged 35-55 years. Analysis was conducted on 88% of participants who had complete data for the present analysis.

MAIN RESULTS

A strong inverse relation between the grade of employment (measure of socioeconomic status) and sickness absence was observed. Men in the lowest grade had rates of sickness absence six times higher than those in the highest grade. For women the corresponding differences were two to five times higher. In general, the longer the duration of absence, the more strongly did baseline health predict rates of absence. However, the health measures also predicted shorter spells, although to a lesser extent. Job satisfaction was strongly related to sickness absence with higher rates in those who reported low job satisfaction. After adjusting for health status the association remained for one to two day absences, but was greatly reduced for absences longer than three days.

CONCLUSION

There was a strong association between ill health and sickness absence, particularly for longer spells. The magnitude of the association may have been underestimated because of the strength of the association between grade of employment and sickness absence. It is proposed that sickness absence be used as an integrated measure of physical, psychological, and social functioning in studies of working populations.

Sickness absence for psychiatric illness: the Whitehall II Study

Over the past 20 years, rates of sickness absence have increased and psychiatric disorders have become an important cause of sickness absence. The socio-demographic associations for psychiatric sickness absence are reported from the Whitehall II study, a longitudinal survey of 10,308 London-based male and female civil servants between 35-55 years. Short spells (< or = 7 days), long spells (> 7 days) and very long spells (> 21 days) of sickness absence were examined in 5620 civil servants for whom reason for absence was available in civil service records. Civil service coding of reasons for absence was validated against report of general practitioners' diagnoses. Psychiatric disorder, largely neurosis and neurosis ill-defined, was the third most common cause of long spells of sickness absence in women and the fourth most common in men. For both men and women it was the second most common cause of very long spells of absence. Psychiatric sickness absence for short, long and very long spells was more frequent in lower employment grades than higher employment grades in keeping with the pattern for other illnesses. This partly explains the higher rate of sickness absence in women than men. Widowed and single men, and divorced women had high rates of psychiatric sickness absence. Comparing reason codes based on sickness certificates with general practitioners reports, there appeared to be evidence of under-reporting of psychosis on certificates.(ABSTRACT TRUNCATED AT 250 WORDS)

Alcohol consumption and sickness absence: from the Whitehall II study

Previous studies suggest that problem drinkers have markedly increased sickness absence. However, it is not clear how more moderate alcohol consumption and abstinence relate to sickness absence. As part of the Whitehall II study the relationship between different drinking patterns and sickness absence is examined. A total of 10,314 male and female civil servants completed a baseline questionnaire about their drinking habits--the amount of alcohol consumed over the past 7 days and the frequency of drinking over the past 12 months. All sickness absence has been recorded prospectively. Drinking patterns and sickness absence are examined for short spells (< or = 7 days) and long spells (> 7 days) adjusting for other causes of sickness absence: age, grade of employment, smoking, work characteristics and baseline health. Alcohol consumption was strongly related to employment grade, the lower the grade the higher proportion of men and women reporting no alcohol consumption. For men the relation of alcohol intake to short spells of sickness absence (< or = 7 days) appeared to be U-shaped, for long spells (> 7 days) increased rates of absence were found only in frequent drinkers. There was no clear relationship for women, however higher rates of sickness absence were found in non-drinkers.

Explaining socioeconomic differences in sickness absence: the Whitehall II Study

OBJECTIVE

To describe and explain the socioeconomic gradient in sickness absence.

DESIGN

Analysis of questionnaire and sickness absence data collected from the first phase of the Whitehall II study. Grade of employment was used as a measure of socioeconomic status.

SETTING

20 civil service departments in London.

SUBJECTS

6900 male and 3414 female civil servants aged 35-55 years.

MAIN OUTCOME MEASURES

Rates of short spells (< or = 7 days) and long spells (> 7 days) of sickness absence.

RESULTS

A strong inverse relation between grade of employment and sickness absence was evident. Men in the lowest grade had rates of short and long spells of absence 6.1 (95% confidence interval 5.3 to 6.9) and 6.1 (4.8 to 7.9) times higher than those in the highest grade. For women the corresponding rate ratios were 3.0 (2.3 to 3.9) and 4.2 (2.5 to 6.8) respectively. Several risk factors were identified, including health related behaviours (smoking and frequent alcohol consumption), work characteristics (low levels of control, variety and use of skills, work pace, and support at work), low levels of job satisfaction, and adverse social circumstances outside work (financial difficulties and negative support). These risk factors accounted for about one third of the grade differences in sickness absence.

CONCLUSION

Large grade differences in sickness absence parallel socioeconomic differences in morbidity and mortality found in other studies. Identified risk factors accounted for a small proportion of the grade differences in sickness absence. More accurate measurement of the risk factors may explain some of the remaining differences in sickness absence but other factors, as yet unrecognised, are likely to be important.

Health inequalities among British civil servants: the Whitehall II study

The Whitehall study of British civil servants begun in 1967, showed a steep inverse association between social class, as assessed by grade of employment, and mortality from a wide range of diseases. Between 1985 and 1988 we investigated the degree and causes of the social gradient in morbidity in a new cohort of 10,314 civil servants (6900 men, 3414 women) aged 35-55 (the Whitehall II study). Participants were asked to answer a self-administered questionnaire and attend a screening examination. In the 20 years separating the two studies there has been no diminution in social class difference in morbidity: we found an inverse association between employment grade and prevalence of angina, electrocardiogram evidence of ischaemia, and symptoms of chronic bronchitis. Self-perceived health status and symptoms were worse in subjects in lower status jobs. There were clear employment-grade differences in health-risk behaviours including smoking, diet, and exercise, in economic circumstances, in possible effects of early-life environment as reflected by height, in social circumstances at work (eg, monotonous work characterised by low control and low satisfaction), and in social supports. Healthy behaviours should be encouraged across the whole of society; more attention should be paid to the social environments, job design, and the consequences of income inequality.