Lung organoids and other preclinical models of pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive fatal disease affecting over 100 000 people in Europe with an increasing incidence. Available treatments offer only slowing of disease progression and are poorly tolerated by patients leading to cessation of therapy. Lung transplant remains the only cure. Therefore, alternative treatments are urgently required. The pathology of IPF is complex and poorly understood and thus creates a major obstacle to the discovery of novel treatments. Additionally, preclinical assessment of new treatments currently relies upon animal models where disparities with human lung biology often hamper drug development. At a cellular level, IPF is characterized by persistent and abnormal deposition of extracellular matrix by fibroblasts and alveolar epithelial cell injury which is seen as a key event in initiation of disease progression. In-depth investigation of the role of alveolar epithelial cells in health and disease has been impeded due to difficulties in primary cell isolation and culture ex vivo. Novel strategies employing patient-derived induced pluripotent stem cells engineered to produce type 2 alveolar epithelial cells (iAEC2) cultured as three-dimensional organoids have the potential to overcome these hurdles and inform new effective precision treatments for IPF leading to improved survival and quality of life for patients worldwide.

Natural growth pattern of sporadic renal angiomyolipoma

BACKGROUND

Surveillance of sporadic renal angiomyolipomas is a growing issue for physicians and radiologists. Current treatment recommendations favor active surveillance. However, the evidence underlying these is based on small case series, which also typically include angiomyolipomas associated with tuberous sclerosis.

PURPOSE

To evaluate the natural growth pattern of sporadic renal angiomyolipomas in patients without tuberous sclerosis.

MATERIAL AND METHODS

A retrospective review was performed in three separate tertiary referral centers. A keyword search of each institutions PACS history was performed. Inclusion criteria were angiomyolipomas > 1 cm in size, three years of follow-up, and lesions requiring treatment before reaching three years of follow-up. Exclusion criteria included a diagnosis of tuberous sclerosis, pregnancy, prior treatment with embolization without any prior imaging, and lesions which were treated on presentation. Growth of the angiomyolipomas was evaluated on the basis of maximum dimension on initial and follow-up images.

RESULTS

Sixty-three patients were identified in total, with 64 lesions eligible for inclusion. The majority of patients were women (55/63). The mean age at which the angiomyolipomas discovered was 56.4 years. Mean total growth was 0.085 mm and mean follow-up was 65.5 months. At initial measurement, the mean maximum dimension of the lesions in our cohort was 2.08 cm. After follow-up, this was 2.16 cm. The average rate of growth was 0.015 cm per year.

CONCLUSION

Sporadic angiomyolipomas exhibit minimal, if any, natural growth. Current surveillance strategies could be relaxed.

Study of participation barriers in family-focused prevention: research issues and preliminary results

There is a growing body of literature which argues for more research on barriers to participation in family-focused interventions, particularly among at-risk families. Following a review of research needs and issues suggested by the literature, this article presents results from a study which 1) evaluates reasons for decisions against participation in a family-focused prevention intervention project and 2) compares characteristics of intervention project participants with those of non-participants. Data on reasons for refusing participation were collected from non-participants during a recruitment telephone interview and via a mail survey. Results indicated that the most frequent reasons given for decisions against participation concerned intervention time demands and research-related requirements such as videotaping. There were no significant differences between participants and non-participants on any sociodemographic variables. Analyses of the relationships between reasons for participation refusal and sociodemographic subgroupings of non-participants, however, suggested that variations exist among these subgroups. Overall, results highlight the feasibility and importance of data collection on intervention project non-participants, both to clarify potential participation barriers and to gather data on sample representativeness.

Chondrocytes harvested from osteochondritis dissecans cartilage are able to undergo limited in vitro chondrogenesis despite having perturbations of cell phenotype in vivo

Our objective was to characterize the variation in gene expression for key genes associated with chondrogenic phenotype of osteochondrosis (OC)-affected and normal chondrocytes, and to identify whether OC chondrocytes can redifferentiate and regain a phenotype similar to normal chondrocytes if appropriate chondrogenic signals are given. Equine articular cartilage removed at surgery to treat clinically significant OC lesions was collected (n = 10), and the gene expression evaluated and compared to aged-matched normal samples (n = 10). Cartilage was harvested from normal (n = 4) and OC (n = 3) joints from horses at necropsy. Chondrogenic pellet cultures were established following monolayer proliferation. After 14 days in culture, the pellets were assessed by histochemical and pellet weight analysis, assay of glycosaminoglycan (GAG) content, and gene expression. Chondrocytes from OC cartilage expressed significantly more Coll-I, -II, -III, and -X than chondrocytes from normal cartilage (all p < 0.0001). Furthermore, OC chondrocytes expressed significantly more MMP-13, ADAMTS-4 (both p < 0.0001), and TIMP-1 (p < 0.001) and significantly less TIMP-2 and TIMP-3. Pellets created from OC chondrocytes contained significantly less GAG (p = 0.0069) and expressed significantly less Sox9 and significantly more superficial zone protein (SZP) (p = 0.0105) than pellets created from normal cartilage. The results suggest that chondrocytes from OC cartilage at the time of surgical treatment have perturbations in phenotype compared to cells from normal cartilage. Despite these differences, following monolayer expansion and pellet culture under chondrogenic conditions, chondrocytes derived from OC cartilage retain some ability to undergo chondrogenic differentiation and synthesize an appropriate cartilage-like matrix. However, this chondrogenic differentiation potential is inferior to that seen in aged-matched normal chondrocytes.

MT3-MMP (MMP-16) is downregulated by in vitro cytokine stimulation of cartilage, but unaltered in naturally occurring equine osteoarthritis and osteochondrosis

Matrix degradation by metalloproteinases is considered a key feature in the loss of articular cartilage seen in many joint diseases. Membrane-type matrix metalloproteinase-3 (MT3-MMP) expression is elevated in human cartilage in end-stage osteoarthritis. We investigated whether MT3-MMP is similarly regulated in cartilage in two naturally occurring arthropathies in vivo and whether proinflammatory cytokines regulate its expression in vitro. MT3-MMP expression was evaluated in cartilage from horses with osteoarthritis and osteochondrosis and compared with age- and site-matched normal cartilage. MT3-MMP also was measured in normal cartilage stimulated with proinflammatory cytokines. MT3-MMP expression was not significantly altered in either osteoarthritis or osteochondrosis cartilage. However, gene expression was significantly downregulated by the addition of recombinant human interleukin-1beta, oncostatin M, or tumor necrosis factor-alpha to normal cartilage explants. The results suggest that MT3-MMP may not have a role in matrix destruction in equine cartilage diseases. Further work is required to characterize its regulation and function.

Randomized trial of brief family interventions for general populations: adolescent substance use outcomes 4 years following baseline

This study examined the long-term substance use outcomes of 2 brief interventions designed for general population families of young adolescents. Thirty-three public schools were randomly assigned to 3 conditions: the 5-session Preparing for the Drug Free Years Program, the 7-session Iowa Strengthening Families Program, and a minimal contact control condition. The pretest involved 667 6th graders and their families. Assessments included multiple measures of initiation and current use of alcohol, tobacco, and marijuana. Pretest data were collected in the 6th grade and the reported follow-up data were collected in the 10th grade. Significant intervention-control differences in initiation and current use were found for both interventions. It is concluded that brief family skills-training interventions designed for general populations have the potential to reduce adolescent substance use and thus have important public health implications.

Randomized trial of brief family interventions for general populations: adolescent substance use outcomes 4 years following baseline

This study examined the long-term substance use outcomes of 2 brief interventions designed for general population families of young adolescents. Thirty-three public schools were randomly assigned to 3 conditions: the 5-session Preparing for the Drug Free Years Program, the 7-session Iowa Strengthening Families Program, and a minimal contact control condition. The pretest involved 667 6th graders and their families. Assessments included multiple measures of initiation and current use of alcohol, tobacco, and marijuana. Pretest data were collected in the 6th grade and the reported follow-up data were collected in the 10th grade. Significant intervention-control differences in initiation and current use were found for both interventions. It is concluded that brief family skills-training interventions designed for general populations have the potential to reduce adolescent substance use and thus have important public health implications.

Randomized trial of brief family interventions for general populations: adolescent substance use outcomes 4 years following baseline

This study examined the long-term substance use outcomes of 2 brief interventions designed for general population families of young adolescents. Thirty-three public schools were randomly assigned to 3 conditions: the 5-session Preparing for the Drug Free Years Program, the 7-session Iowa Strengthening Families Program, and a minimal contact control condition. The pretest involved 667 6th graders and their families. Assessments included multiple measures of initiation and current use of alcohol, tobacco, and marijuana. Pretest data were collected in the 6th grade and the reported follow-up data were collected in the 10th grade. Significant intervention-control differences in initiation and current use were found for both interventions. It is concluded that brief family skills-training interventions designed for general populations have the potential to reduce adolescent substance use and thus have important public health implications.

Preparing for the drug free years: session-specific effects of a universal parent-training intervention with rural families

Like their urban counterparts, adolescents from rural areas are at risk for health and behavior problems, including alcohol and other drug use. This study tested the effects on parenting practices of specific sessions of a parent-training intervention, Preparing for the Drug Free Years, designed to prevent adolescent substance abuse and other problem behaviors. Two hundred and nine rural families were randomly assigned to an intervention or a wait-list control condition. Analyses of covariance comparing adjusted posttest scores revealed that parents in the intervention condition reported significant improvements in parenting behaviors targeted by specific intervention sessions when compared with controls. Effects were most pronounced among mothers. No significant effects were found for nontargeted parenting behaviors, and targeted behaviors were most improved among parents attending relevant program sessions. These results strengthen the internal validity of the study and increase the plausibility that reported improvements were due to the intervention.

Modeling factors influencing enrollment in family-focused preventive intervention research

The reported study tests an extension of a previously supported model of family context and health belief predictors of parental inclination to enroll in preventive interventions. The extended model addresses limitations in the prior investigation; it examines the role of intervention-related beliefs and inclinations on actual enrollment in a skills training intervention research project. Model testing was conducted with a sample of 635 parents of 6th graders who completed a prospective participation factor survey and were recruited for an intervention research project 6 months later. The model fit was strong and all but one of the primary hypothesized effects were supported. Notably, both stated inclination to enroll in an intervention and in the research project had significant positive effects on actual project enrollment occurring 6 months later. Perceived intervention benefits and barriers had significant effects on both types of stated inclination to enroll. Examination of modification indices for the model suggested an additional path linking educational attainment with actual enrollment.

Reducing adolescents' aggressive and hostile behaviors: randomized trial effects of a brief family intervention 4 years past baseline

OBJECTIVE

To examine the long-term effects of a brief family intervention on aggressive and hostile behaviors of adolescents in the general population.

DESIGN

Randomized trial including 22 public schools assigned to the Iowa Strengthening Families Program or a control condition. Analyses supported sample representativeness and failed to show differential attrition effects 4 years after baseline.

INTERVENTION

Seven-session intervention for parents and their sixth-grade children.

MEASURES

The multi-informant, multimethod measures included independent observer ratings of adolescent aggressive and hostile behaviors in adolescent-parent interactions, family-member report of aggressive and hostile behaviors in those interactions, and adolescent self-report of aggressive and destructive conduct across settings. Data were collected during the 6th (preintervention and postintervention), 7th, 8th, and 10th grades.

RESULTS

All measures showed a generally positive trend in intervention-control group differences over time. During 10th grade, significant intervention-control differences were found for adolescent self-report of aggressive and destructive conduct (P =. 01), with relative reduction rates ranging from 31.7% to 77.0%. Significant differences were shown for observer-rated aggressive and hostile behaviors in adolescent-parent interactions (P =.01); differences in family member reports of those behaviors were not significant. Supplemental analyses of both interactional behavior measures, specific to parent sex, indicated significant experimental group differences in interactions with mothers (P =.04 for both measures) but not with fathers.

CONCLUSIONS

Brief family competency-training interventions designed for general populations can reduce aggressive and hostile behaviors in adolescents' interactions with parents and adolescent aggressive behaviors outside of the home setting. Thus, this type of intervention has important public health implications. Arch Pediatr Adolesc Med. 2000;154:1248-1257.

The Holistic Nurses Association of New South Wales: our history, our present and our future

The Holistic Nurses Association (HNA) of New South Wales was formed in March 1995 by nurses inspired by the inaugural Natural Therapies Conference held by the New South Wales Nurses Association (NSWNA) in October 1994. A philosophy of providing support to nurses wishing to provide healthcare in a holistic way underpinned the formation of the HNA in a climate of disenchantment with the mechanistic and reductionist methods of modern healthcare. The main aims of the group are to share information, meet regularly for support, identify our goals and to organize presentations and workshops that promote and strengthen our professional goals and identity. The HNA has been recognised as a group to consult with regarding policy formation for the use of natural therapies within the mainstream health service. The Nurses Registration Board of New South Wales and the New South Wales Nurses Association both liaised with HNANSW when formulating their policies on the use of complementary therapies in nursing.

Assessing a public health approach to delay onset and progression of adolescent substance use: latent transition and log-linear analyses of longitudinal family preventive intervention outcomes

This study examined the effects of the Iowa Strengthening Families Program (ISFP) and the Preparing for the Drug-Free Years program (PDFY) on young adolescent transitions from nonuse of substances to initiation and progression of substance use. Analyses incorporated 3 waves of data collected over a 2.5-year period from 329 rural young adolescents. Outcomes were analyzed by using log-linear models that incorporated substance use status frequencies derived from latent transition analyses. Effects on delayed substance use initiation were shown for both the ISFP and the PDFY at a 2-year follow-up. Also at this follow-up, the PDFY showed effects on delayed progression of use among those previously reporting initiation.

Modeling long-term parent outcomes of two universal family-focused preventive interventions: one-year follow-up results

The present investigation extended prior work by R. Spoth, C. Redmond, and C. Shin (1998). These researchers reported findings that 2 universal family-focused preventive intervention programs each had direct effects on a proximal parenting outcome (intervention-targeted parenting behaviors) and indirect effects on 2 global and distal outcomes (parent-child affective quality and general child management) at posttesting. A replication of the previously tested parenting outcome model was conducted with 1-year follow-up data and procedures identical to those used in the earlier study. Results of the present study (N = 404 families) indicate that statistically significant effects on parenting outcomes were sustained through a 1-year period following the posttest.

Assessing a public health approach to delay onset and progression of adolescent substance use: latent transition and log-linear analyses of longitudinal family preventive intervention outcomes

This study examined the effects of the Iowa Strengthening Families Program (ISFP) and the Preparing for the Drug-Free Years program (PDFY) on young adolescent transitions from nonuse of substances to initiation and progression of substance use. Analyses incorporated 3 waves of data collected over a 2.5-year period from 329 rural young adolescents. Outcomes were analyzed by using log-linear models that incorporated substance use status frequencies derived from latent transition analyses. Effects on delayed substance use initiation were shown for both the ISFP and the PDFY at a 2-year follow-up. Also at this follow-up, the PDFY showed effects on delayed progression of use among those previously reporting initiation.

Engaging families in longitudinal preventive intervention research: discrete-time survival analysis of socioeconomic and social-emotional risk factors

This study examined whether family risk factors predicted attrition in a prevention research project that incorporated procedures to increase retention in assessment and intervention activities. Analyses used data from 667 rural families collected over 4 waves and consisted of (a) young adolescent and parent reports of internalizing and externalizing problems, (b) observer ratings of distress in parent-child interactions, and (c) family socioeconomic status (SES). Analyses failed to identify any risk factors as significant predictors of intervention participation. Only SES was found to be significant as a predictor of assessment attrition. This SES result appeared to reflect an association between lower educational attainment and an increased likelihood of attrition.

Alcohol initiation outcomes of universal family-focused preventive interventions: one- and two-year follow-ups of a controlled study

OBJECTIVE

This article summarizes the literature on alcohol initiation outcomes of universal family interventions and examines the long-term effects of the Iowa Strengthening Families Program (ISFP) on these outcomes.

METHOD

A longitudinal, controlled efficacy study of the ISFP was conducted with 446 families from 22 rural school districts in a Midwestern state. Alcohol initiation behaviors were measured by a four-item index (Alcohol Initiation Index [AII]), with low scores representing a lower level of alcohol initiation. The AII was examined using mixed-model analyses of covariance. Relative reduction rates for individual initiation behaviors and initiation differences among higher- and lower-dosage intervention groups were calculated.

RESULTS

AII scores were significantly lower among intervention group adolescents than among control group adolescents at 1- and 2-year follow-up assessments. Relative-reduction rate differences between intervention and control groups on specific alcohol initiation behaviors (e.g., onset of drinking without parental permission, onset of drunkenness) ranged from approximately 30% to 60%. Dosage-related initiation differences were evident only at the 1-year follow-up.

CONCLUSIONS

Studies indicating the public health benefits of universal interventions that delay the initiation of alcohol use also underscore the importance of the current line of investigation. All effect sizes and relative reduction rates of specific alcohol initiation behaviors suggest the practical significance of the findings. The gap in the prevention outcome knowledge base in this area of investigation could be filled with more rigorous universal family-focused intervention studies that address a wide range of implementation and methodological issues.

Engaging families in longitudinal preventive intervention research: discrete-time survival analysis of socioeconomic and social-emotional risk factors

This study examined whether family risk factors predicted attrition in a prevention research project that incorporated procedures to increase retention in assessment and intervention activities. Analyses used data from 667 rural families collected over 4 waves and consisted of (a) young adolescent and parent reports of internalizing and externalizing problems, (b) observer ratings of distress in parent-child interactions, and (c) family socioeconomic status (SES). Analyses failed to identify any risk factors as significant predictors of intervention participation. Only SES was found to be significant as a predictor of assessment attrition. This SES result appeared to reflect an association between lower educational attainment and an increased likelihood of attrition.

Engaging families in longitudinal preventive intervention research: discrete-time survival analysis of socioeconomic and social-emotional risk factors

This study examined whether family risk factors predicted attrition in a prevention research project that incorporated procedures to increase retention in assessment and intervention activities. Analyses used data from 667 rural families collected over 4 waves and consisted of (a) young adolescent and parent reports of internalizing and externalizing problems, (b) observer ratings of distress in parent-child interactions, and (c) family socioeconomic status (SES). Analyses failed to identify any risk factors as significant predictors of intervention participation. Only SES was found to be significant as a predictor of assessment attrition. This SES result appeared to reflect an association between lower educational attainment and an increased likelihood of attrition.

Risk moderation of parent and child outcomes in a preventive intervention: a test and replication

Family risk-related variations in proximal parent and young adolescent outcomes of a universal family-focused preventive intervention were examined using a cumulative index of risk incorporating sociodemographic characteristics and social-emotional adjustment measures. Results of an initial investigation involving 209 families of young adolescents suggested that intervention efficacy was largely unrelated to cumulative family risk. These findings were replicated with a second sample of 428 families. Implications for future intervention applications and outcome research are discussed.

Direct and indirect latent-variable parenting outcomes of two universal family-focused preventive interventions: extending a public health-oriented research base

Recent literature underscores the need for studies of family-based preventive interventions oriented toward public health objectives. This article illustrates a program evaluation approach for the study of family intervention outcomes in general populations. Thirty-three rural schools were randomly assigned to 1 of 3 conditions: the Preparing for the Drug-Free Years Program (PDFY), the Iowa Strengthening Families Program (ISFP), and a minimal-contact control group. Self-report and observational data collected from 523 families were used to develop measurement models of 3 latent parenting constructs that included measurement method effects. Analyses were conducted to ensure initial and attrition-related group equivalencies and to assess school effects. Structural equation models of the hypothesized sequence of direct and indirect effects for both PDFY and ISFP were then fit to the data. All hypothesized effects were significant for both interventions. The discussion addresses the potential public health benefits of evaluation research on universal preventive interventions.

A prospective validation study of inclination, belief, and context predictors of family-focused prevention involvement

Prior research by the authors tested a model of factors influencing parent inclination to participate in parenting interventions. Family context, belief, attitude, and inclination to participate variables from this model were used to predict the actual participation of 1,121 families in assessment and intervention activities of a family-focused preventive intervention research project. Invitations to the project assessment and intervention components were, respectively, about 6 months and 10 months following the initiation of a telephone survey collecting predictor variable data. Logistic regression analyses examining each predictor individually showed that a number of family context, belief, attitude, and inclination variables were predictive of project participation. Subsequently, multiple logistic regressions were conducted, entering variables by blocks corresponding to theoretical model components. These analyses showed that prospectively stated inclination to participate in a parenting intervention and level of education were consistently significant predictors of both assessment participation and intervention enrollment. Implications for both research and practice are discussed.

Experimentally assessed public health risks associated with pigs from farms experiencing anthrax

Following an outbreak of anthrax in an intensive pig rearing unit in north Wales in 1989 a study was initiated by the Ministry of Agriculture, Fisheries and Food to assess public health risks during such an outbreak. Of 50 pigs infected by the addition of Bacillus anthracis spores to their feed, two died of anthrax six and eight days later. The remainder were observed for 21 days and exhibited only mild and transient clinical signs of disease. As judged by the results of bacteriological culture of appropriate tissues from the survivors, it was concluded that meat from healthy pigs killed 21 days after the latest case during an outbreak would not pose a public health risk.

Assessing individual risk for breast cancer: risky business

There is increasing demand for prediction of individual women's risk for breast cancer from women, clinicians, researchers, and health planners. Risk assessment for breast cancer is the process of identifying characteristics of an individual woman that are relevant to her risk, and combining those characteristics into a quantitative or qualitative risk profile. This article reviews and compares available methods of predicting risk, discusses benefits and drawbacks to the methods, and compares risk estimates for several hypothetical subjects using the different methods. Current and future uses for risk assessment are described. Risk assessment, while a promising tool for research now, and for clinical areas in the future, is still too imprecise for accurate prediction of breast cancer occurrence in individuals.

Protective factors and young adolescent tendency to abstain from alcohol use: a model using two waves of intervention study data

Two waves of data from a family-focused preventive intervention project were used to test a model of the influence of protective factors on young adolescents' tendency toward alcohol abstinence. Prior theoretical and empirical work guided the specification of hypothesized effects of the protective factors affectional relationship with parents, affiliation with prosocial peers, and mastery-esteem on tendency toward alcohol abstinence. The tested model controlled for preintervention measures and included specified interrelations of protective factors across time. Structural equation analysis indicated that the model fit the data. Two of the hypothesized cross-time effects, however, were not supported.

Five versus more than five years of tamoxifen therapy for breast cancer patients with negative lymph nodes and estrogen receptor-positive tumors

BACKGROUND

In 1982, the National Surgical Adjuvant Breast and Bowel Project initiated a randomized, double-blinded, placebo-controlled trial (B-14) to determine the effectiveness of adjuvant tamoxifen therapy in patients with primary operable breast cancer who had estrogen receptor-positive tumors and no axillary lymph node involvement. The findings indicated that tamoxifen therapy provided substantial benefit to patients with early stage disease. However, questions arose about how long the observed benefit would persist, about the duration of therapy necessary to maintain maximum benefit, and about the nature and severity of adverse effects from prolonged treatment.

PURPOSE

We evaluated the outcome of patients in the B-14 trial through 10 years of follow-up. In addition, the effects of 5 years versus more than 5 years of tamoxifen therapy were compared.

METHODS

In the trial, patients were initially assigned to receive either tamoxifen at 20 mg/day (n = 1404) or placebo (n = 1414). Tamoxifen-treated patients who remained disease free after 5 years of therapy were then reassigned to receive either another 5 years of tamoxifen (n = 322) or 5 years of placebo (n = 321). After the study began, another group of patients who met the same protocol eligibility requirements as the randomly assigned patients were registered to receive tamoxifen (n = 1211). Registered patients who were disease free after 5 years of treatment were also randomly assigned to another 5 years of tamoxifen (n = 261) or to 5 years of placebo (n = 249). To compare 5 years with more than 5 years of tamoxifen therapy, data relating to all patients reassigned to an additional 5 years of the drug were combined. Patients who were not reassigned to either tamoxifen or placebo continued to be followed in the study. Survival, disease-free survival, and distant disease-free survival (relating to failure at distant sites) were estimated by use of the Kaplan-Meier method; differences between the treatment groups were assessed by use of the logrank test. The relative risks of failure (with 95% confidence intervals [CIs]) were determined by use of the Cox proportional hazards model. Reported P values are two-sided.

RESULTS

Through 10 years of follow-up, a significant advantage in disease-free survival (69% versus 57%, P < .0001; relative risk = 0.66; 95% CI = 0.58-0.74), distant disease-free survival (76% versus 67%, P < .0001; relative risk = 0.70; 95% CI = 0.61-0.81), and survival (80% versus 76%, P = .02; relative risk = 0.84; 95% CI = 0.71-0.99) was found for patients in the group first assigned to receive tamoxifen. The survival benefit extended to those 49 years of age or younger and to those 50 years of age or older. Tamoxifen therapy was associated with a 37% reduction in the incidence of contralateral (opposite) breast cancer (P = .007). Through 4 years after the reassignment of tamoxifen-treated patients to either continued-therapy or placebo groups, advantages in disease-free survival (92% versus 86%, P = .003) and distant disease-free survival (96% versus 90%, P = .01) were found for those who discontinued tamoxifen treatment. Survival was 96% for those who discontinued tamoxifen compared with 94% for those who continued tamoxifen treatment (P = .08). A higher incidence of thromboembolic events was seen in tamoxifen-treated patients (through 5 years, 1.7% versus 0.4%). Except for endometrial cancer, the incidence of second cancers was not increased with tamoxifen therapy.

CONCLUSIONS AND IMPLICATIONS

The benefit from 5 years of tamoxifen therapy persists through 10 years of follow-up. No additional advantage is obtained from continuing tamoxifen therapy for more than 5 years.

Sequential methotrexate and fluorouracil for the treatment of node-negative breast cancer patients with estrogen receptor-negative tumors: eight-year results from National Surgical Adjuvant Breast and Bowel Project (NSABP) B-13 and first report of findings from NSABP B-19 comparing methotrexate and fluorouracil with conventional cyclophosphamide, methotrexate, and fluorouracil

PURPOSE

To compare sequential methotrexate (M) and fluorouracil (F) (M-->F) with surgery (National Surgical Adjuvant Breast and Bowel Project [NSABP] B-13) and cyclophosphamide (C), M, and F with M-->F (NSABP B-19), in patients with estrogen receptor (ER)-negative tumors and negative axillary nodes.

PATIENTS AND METHODS

A total of 760 patients were randomized to B-13; 1,095 patients with the same eligibility requirements were randomized to B-19. Disease-free survival (DFS), distant disease-free survival (DDFS), and survival were determined using life-table estimates.

RESULTS

A significant benefit in overall DFS (74% v 59%; P < .001) was demonstrated at 8 years in all B-13 patients who received M-->F (69% v 56% [P = .006] in those <or= 49 years of age, and 81% v 63% [P = .002] in those >or= 50 years). A survival advantage was evident in older patients (89% v 80%; P = .03). In B-19, through 5 years, an overall DFS advantage (82% v 73%; P < .001) and a borderline survival advantage (88% v 85%; P = .06) were evident with CMF. The DFS (84% v 72%; P < .001) and survival (89% v 84%; P = .04) benefits from CMF were greater in women aged <or= 49 years. M-->F or CMF after lumpectomy and breast irradiation resulted in a low probability of ipsilateral breast tumor recurrence (IBTR). In B-13, the frequency of IBTR was 2.6% following M-->F versus 13.4% in women treated by lumpectomy; it was 0.6% following CMF in B-19. Toxicity >or= grade 3 was more frequent among CMF patients in B-19. The age-related difference in CMF benefit was not related to amount of drug received.

CONCLUSION

M-->F and CMF are effective for node-negative patients with ER-negative tumors. The incidence of local-regional or distant metastases and IBTR decreased after either therapy. The benefit from either therapy was evident in all patients, but the CMF advantage was greater in those <or= 49 years. Because it is less toxic, M-->F may be used in patients with medical problems that would preclude CMF administration.

Base-line quality-of-life assessment in the National Surgical Adjuvant Breast and Bowel Project Breast Cancer Prevention Trial

BACKGROUND

The Breast Cancer Prevention Trial (BCPT) is a large, multicenter chemoprevention trial testing the efficacy of the antiestrogen drug tamoxifen for prevention of breast cancer and coronary heart disease in healthy women at high risk of breast cancer. The BCPT evolved from a series of prior studies in early stage breast cancer demonstrating the efficacy of tamoxifen in the prevention of systemic breast cancer recurrence and in the reduction of contralateral breast cancers.

PURPOSE

The purpose of this article is to describe the methodologic considerations in the collection of health-related quality-of-life (HRQL) data in the BCPT and to present base-line HRQL data on the first 9749 participants.

METHODS

An HRQL questionnaire that included the Center for Epidemiologic Studies-Depression Scale, a symptom checklist, the Medical Outcomes Study 36-item short form (MOS-SF-36), and the MOS sexual problems questions was completed by participants in the BCPT at base line (prior to random assignment). Medical and demographic information, as well as projected risk of breast cancer, were collected as part of study eligibility. Descriptive and correlational data were examined for these study participants.

RESULTS

BCPT participants report high levels of functioning compared with U.S. general population norms but still report an average of 8.9 distinct symptoms during the past 4 weeks. Depression is less prevalent among the participants than in community samples, which reflects the exclusion of clinically depressed individuals. Sixty-five percent reported being sexually active in the past 6 months, with an age-related decline in sexual activity. Younger women reported fewer sexual problems than older women. There is a strong correlation between the two mental health measures, moderate to weak correlations between HRQL scales and levels of self-reported symptoms, and only weak correlations between measures of breast cancer risk and HRQL scales. The MOS-SF-36 scores were examined for three consecutive recruitment samples (0-6 months, 7-12 months, and 13-20 months), and the base-line scores were slightly better for the earliest group of participants.

CONCLUSIONS

This article demonstrates the feasibility of collecting HRQL data in a large, multicenter, chemoprevention trial for women at high risk of breast cancer. The successful integration of HRQL data collection into this clinical trial attests to its value as a safety-monitoring end point and as an explicit and measurable outcome for the entire trial.

IMPLICATIONS

HRQL data are important for studies in which healthy populations are involved and in which the potential for decrements in quality of life are real or perceived.

Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) Protocol B-17. Intraductal carcinoma (ductal carcinoma in situ). The National Surgical Adjuvant Breast and Bowel Project Collaborating Investigators

BACKGROUND

Controversy exists concerning the natural history of ductal carcinoma in situ (DCIS) of the breast, including its pathologic expression and treatment. This controversy has been fostered largely by the retrospective nature and limited sample sizes of extant studies.

METHOD

Resolution of some of these issues was attempted by analyzing the pathologic features of 573 examples of DCIS obtained from a larger cohort of 790 women with DCIS enrolled in Protocol B-17 of the National Surgical Adjuvant Breast Project. This prospective randomized clinical trial was performed to assess the efficacy of local breast irradiation to reduce the incidence of second ipsilateral breast tumors (IBT) after lumpectomy.

RESULTS

Tumor and patient characteristics, including significantly less IBT for those treated by lumpectomy and irradiation than lumpectomy alone, were almost identical for the subset comprising this analysis and the total B-17 cohort reported previously. The presence of moderate/marked comedo necrosis, which was evaluated as an independent parameter rather than as a specific histologic type of DCIS and uncertain/involved lumpectomy margins were the only statistically significant independent predictors of IBT for patients treated by lumpectomy as well as irradiation. The latter markedly reduced the annual hazard rates for the IBT associated with these indicators.

CONCLUSIONS

Although not an endpoint of this study, the authors' findings suggest that the beneficial effect of irradiation in reducing IBT after lumpectomy for DCIS occurs with small (< 1.0 cm.) and larger lesions. Moderate/marked comedo necrosis and uncertain/involved lumpectomy margins represent independent predictors of IBT.

Histological characteristics of breast carcinoma in blacks and whites

Tumor characteristics of 963 newly diagnosed invasive breast cancer cases from the population-based Black/White Cancer Survival Study were evaluated. Representative slides of the tumors were requested from all participating hospitals of three metropolitan areas and reviewed by one expert pathologist, blinded in regard to the age and race of patients. Nine tumor characteristics were evaluated for black and white patients. After adjusting for age, stage, and metropolitan area, blacks were significantly more likely to have high grade nuclear atypia [odds ratio (OR) = 1.97, 95% confidence interval (CI) = 1.27-3.04]; high mitotic activity (OR = 2.05, 95% CI = 1.34-3.14), grade 3 tumors (OR = 1.58, 95% CI = 1.02-2.45), and more necrosis (OR = 1.51, 95% CI = 1.16-1.98); and less likely to have well defined tubular formation (OR = 0.57, 95% CI = 0.42-0.77), marked fibrosis (OR = 0.65, 95% CI = 0.45-0.94), and positive estrogen receptor status (OR = 0.78, 95% CI = 0.58-1.05). These black/white differences remained after controlling for socioeconomic status (SES), body mass index, use of alcohol and tobacco, reproductive experience, and health care access and utilization. No significant racial differences were found for blood vessel invasion and lymphatic invasion. Although white women of high SES had more favorable tumors than those of low SES, the same pattern was not observed for blacks. High SES black women had statistically nonsignificant elevated ORs of a high mitotic index and tumor grade. These racial differences in tumor biology may have etiological and clinical implications.

Cause-specific mortality in long-term survivors of breast cancer who participated in trials of radiotherapy

PURPOSE

To examine long-term cause-specific mortality in patients irradiated for breast cancer as part of a randomized clinical trial.

PATIENTS AND METHODS

We studied all available information from randomized trials initiated before 1975 in which radiotherapy was the randomized option and surgery was the same for both treatment arms. Eight such trials were identified.

RESULTS

The increased all-cause mortality rate in 10-year survivors previously reported is no longer significant, although a numerical difference in favor of non-irradiated patients remains. This result was strongly influenced by the earliest trials, and more recent trials have found a nonsignificant net benefit in overall mortality associated with radiation therapy. An excess of cardiac deaths was apparent in both early and more recent trials (P < .001), but this was offset by a reduced number of deaths due to breast cancer, especially in more recent trials.

CONCLUSION

The reduction of breast cancer deaths suggests that radiation therapy may have a value beyond the clearly established improvements obtainable for local control. Use of techniques that minimize cardiac dose is important in reducing the risks of adjuvant radiotherapy, especially in good-prognosis patients.

Identifying program preferences through conjoint analysis: illustrative results from a parent sample

PURPOSE

The purpose of this article is to illustrate the application of conjoint analysis, a consumer research technique, using data from a survey of parents' preferences for prevention programs.

DESIGN

This study utilized a one-time, cross-sectional telephone survey.

SETTING

Data were collected from subjects living in economically disadvantaged rural midwestern counties.

SUBJECTS

Subjects were 202 randomly selected parents with preadolescents who indicated interest in family-focused prevention programs.

MEASURES

Conjoint analysis software was employed in computer-assisted telephone interviews to evaluate relative preferences for 39 individual features of family-focused prevention programs falling under 11 categories (e.g., program meeting time, facilitator background). The software also guided computer simulations of parent choices among four types of programs.

RESULTS

Findings indicated that meeting time was the most important category of program features. Strongly preferred individual features included meetings scheduled on weekday evenings, instruction by child development specialists, and programs based on extensive research. Two multiple-session programs evaluated via computer simulations incorporated several preferred features and received higher ratings than did single-session programs. Estimated variance z-tests indicated limited differences in perceived importance of program feature categories across sociodemographic subgroups.

CONCLUSIONS

Findings highlight a) differences in the relative value parents place on various features of prevention programs in the surveyed population and b) the importance of practical aspects of program delivery.

The benefit of leucovorin-modulated fluorouracil as postoperative adjuvant therapy for primary colon cancer: results from National Surgical Adjuvant Breast and Bowel Project protocol C-03

PURPOSE

This study was designed to evaluate the efficacy of leucovorin-modulated fluorouracil (5-FU) as adjuvant therapy for patients with Dukes' stage B and C colon cancer.

PATIENTS AND METHODS

Data are presented from 1,081 patients with Dukes' stage B and C carcinoma of the colon entered into National Surgical Adjuvant Breast and Bowel Project (NSABP) protocol C-03 between August 1987 and April 1989. Patients were randomly assigned to receive either lomustine (MeCCNU), vincristine, and 5-FU (MOF), or leucovorin-modulated 5-FU (LV + 5-FU). The mean time on study was 47.6 months.

RESULTS

Comparison between the two groups indicates a disease-free survival advantage for patients treated with LV + 5-FU (P = .0004). The 3-year disease-free survival rate for patients in this group was 73% (95% confidence interval, 69% to 77%), compared with 64% (95% confidence interval, 60% to 68%) for patients receiving MOF. The corresponding percentage of patients surviving was 84% for those randomized to receive LV + 5-FU and 77% for the MOF-treated cohort (P = .003). At 3 years of follow-up, patients treated with postoperative LV + 5-FU had a 30% reduction in the risk of developing a treatment failure and a 32% reduction in mortality risk compared with similar patients treated with MOF.

CONCLUSION

Treatment with LV + 5-FU significantly prolongs disease-free survival and results in a significant benefit relative to overall survival. These findings, when considered together with results from a recent meta-analysis demonstrating a benefit from LV + 5-FU in advanced disease, provide evidence to support the concept of metabolic modulation of 5-FU.

Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer

BACKGROUND AND METHODS

Women with ductal carcinoma in situ have been treated both by lumpectomy and by lumpectomy followed by radiation therapy, but the benefit of combined therapy is uncertain. A group of 818 women with ductal carcinoma in situ were randomly assigned to undergo lumpectomy or lumpectomy followed by breast irradiation (50 Gy). Sufficient tissue was removed that the margins of the resected specimens were histologically tumor-free. The mean duration of follow-up was 43 months (range, 11 to 86). The principal end point of the study was event-free survival, as defined by the presence of no new ipsilateral or contralateral breast cancers, regional or distant metastases, or other cancers and by no deaths from causes other than cancer.

RESULTS

Five-year event-free survival was better in the women who received breast irradiation (84.4 percent, vs. 73.8 percent for the women treated by lumpectomy alone; P = 0.001). The improvement was due to a reduction in the occurrence of second ipsilateral breast cancers; the incidence of each of the other events was similar in the two groups. Of 391 women treated by lumpectomy alone, ipsilateral breast cancer developed in 64 (16.4 percent); it was noninvasive in 32 and invasive in the remaining 32. Of 399 women treated with lumpectomy and breast irradiation, ipsilateral breast cancer developed in 28 (7.0 percent) (noninvasive in 20 and invasive in 8). The five-year cumulative incidence of second cancers in the ipsilateral breast was reduced by irradiation from 10.4 percent to 7.5 percent for noninvasive cancers and from 10.5 percent to 2.9 percent for invasive cancers (P = 0.055 and P < 0.001, respectively).

CONCLUSIONS

Breast irradiation after lumpectomy is more appropriate than lumpectomy alone for women with localized ductal carcinoma in situ.

Pathologic findings from the National Surgical Adjuvant Breast Project protocol B-06. 10-year pathologic and clinical prognostic discriminants

BACKGROUND

Prognostic pathologic and clinical features for 10-year survival were determined from 22 pathologic and 5 clinical variables encountered in 1090 node-negative and 651 node-positive patients enrolled in NSABP protocol B-06.

METHODS

All factors were first screened univariately. Those exhibiting P values < 0.01 were entered into multivariate Cox regression models. The model with the best fit consisted of 951 negative-node and 496 node-positive patients.

RESULTS

Better survival in node-negative patients was noted for whites rather than blacks, for patients with favorable tumor types (tubular, mucinous, papillary) rather than intermediate (lobular invasive, classical medullary, and not otherwise specified [NOS] combinations) or unfavorable forms (NOS pure and atypical medullary), and for tumors with good rather than poor nuclear grade. Number of nodal metastases, degree of tumor elastosis, and patient age younger than 40 years of age and 65 years of age and older in addition to nuclear grade and race were found significant for node-positive patients. Relative risks for combinations of these prognostic factors were multiplicative.

CONCLUSIONS

The prognostic factors for node-negative patients were similar to those observed for this cohort at 8 years. Some differences noted between patients of both nodal groups in NSABP B-04 and B-06 may be related to selection requirements in the latter and hence different patient characteristics or more speculatively a change in tumor biology.

Pathologic findings from the National Surgical Adjuvant Breast Project (Protocol 4). Discriminants for 15-year survival. National Surgical Adjuvant Breast and Bowel Project Investigators

Twenty-one pathologic and five clinical features of Stage I and II invasive breast cancers from 620 patients enrolled in National Surgical Adjuvant Breast Project Protocol B-04 were analyzed to determine their predictive value for 15-year survival. Ten pathologic features had a statistically significant univariate prognostic relationship with long-term survival. These were analyzed further using a Cox regression model that found only the number of nodal metastases (0, 1-3, 4-9, or 10+), tumor size (< or = 2.0 cm versus 2.1-4 and 4.1 + cm), and the presence or absence of nipple involvement to be significant independent prognostic discriminants. Combinations of these three characteristics modestly increased their individual prognostic value. Differences in the findings in this study from those observed in the same patient population at 5 and 10 postoperative years and their relationship to other markers detected by ancillary pathologic techniques briefly are discussed.

Breast tumor recurrence following lumpectomy with and without breast irradiation: an overview of recent NSABP findings

The latest findings from the NSABP B-06 trial on ipsilateral breast tumor recurrence (IBTR) continue to demonstrate that through 9 years of follow-up more patients treated with radiation remained IBTR free as compared to those receiving no radiation (P less than 0.001), regardless of age, nodal status, or tumor size. There is no significant difference in distant disease-free survival (DDFS) or survival between the two lumpectomy groups despite the highly significant difference in their probability of remaining IBTR free. A recent analysis shows that when a patient is diagnosed with an IBTR, the risk of distant metastatic disease increases, indicating that an IBTR is a marker for, not a cause of, distant metastatic disease. An IBTR indicates a greater risk for distant disease when the primary tumor was removed. Mastectomy or breast irradiation following lumpectomy eliminates or reduces the opportunity for identifying a marker of risk for distant disease, thus emphasizing the importance of an IBTR beyond the need for its removal. Since an IBTR is associated with a relative risk of 3.41 for the development of distant metastatic disease, systemic therapy subsequent to an IBTR should be considered. Evidence presented from recent NSABP studies indicates the value of systemic therapy for lowering the incidence of IBTR following lumpectomy and breast irradiation.

Ipsilateral breast tumor recurrence and survival following lumpectomy and irradiation: pathological findings from NSABP protocol B-06

Ipsilateral breast tumor recurrence (IBTR) occurred in 42 of 488 (9%) pathologically evaluable patients enrolled in NSABP protocol B-06 with a mean potential follow-up of 103 months (range 68-161 months) following treatment for Stage I and II invasive breast cancer by lumpectomy and local breast irradiation (LXRT). IBTR were observed at or close to the same quadrant as the index cancers and their histologic types and nuclear grades were similar if not identical in 95 and 93%, respectively. This information confirms our earlier findings which indicated that multicentricity is of little or no clinical significance in the treatment of breast cancer by LXRT; breast cancers rarely if ever change their biologic potential once clinically detected; and lastly, most if not all IBTR represent residual cancer. Cox regression analyses revealed only a patient age less than 35 years to be significantly related to IBTR. No relationship between IBTR and so-called extensive intraductal component (EIC) or 31 other pathologic features of the index cancers was found. Overall survival was significantly related to nodal status (P = 0.01), nuclear grade (P = less than 0.001) histologic tumor type (P = 0.01) and IBTR (P = less than 0.001). This latter was considered as an indicator rather than instigator of distant disease and reduced survival since the latter is no different in patients treated by LXRT, lumpectomy alone after which IBTR is much more frequent, or mastectomy, which precludes its expression. We conclude that there are as yet no viable markers which would contraindicate treating patients with breast cancer by LXRT.

A prospective study of the effectiveness of brief professionally-led support groups for infertility patients

OBJECTIVE

This study prospectively evaluates the effectiveness and patient acceptability of professionally-led support groups in alleviating psychologic distress in infertility patients.

METHOD

Sixty-four consecutive patients in a university hospital infertility program were administered a battery of psychologic tests before and after attendance at an 8 weekly session support group. The comparison group consisted of 35 consecutive infertility referrals to the same unit who were not initially offered the support group and were similarly tested over an 8 week period.

RESULTS

Support group patients had significantly greater (p less than or equal to 0.01) entry than exit scores on several measures of psychologic distress and depression (the Beck Depression Inventory, the Hamilton Rating Scale for Depression, and the Global Severity Index, Anxiety, Depression, Hostility and Obsessive Compulsive Subscales of the Brief Symptom Inventory). The Avoidance Coping Style on the Moos Coping Responses Inventory was correlated with a higher Global Severity Index (p less than or equal to 0.01). Comparison group patients had similar psychometric scores to the support group patients at entry but showed no change over 8 weeks. Attenders expressed a high rate of satisfaction with the support group.

CONCLUSIONS

Professionally-led support groups are a highly acceptable and effective intervention in self-referred patients in alleviating psychological distress related to infertility.

Prognostic factors in NSABP studies of women with node-negative breast cancer. National Surgical Adjuvant Breast and Bowel Project

Twenty-two pathologic (including estrogen and progesterone receptor status) and four clinical features of 950 node-negative stage I invasive breast cancers from 950 women enrolled in the National Surgical Adjuvant Breast and Bowel Project protocol B-06 were analyzed for their possible prognostic significance. Univariate analyses revealed 10 characteristics that were significant at the 1% level. Only three of these--notably nuclear grade, histologic tumor type, and race--were found to be significant when entered into a Cox regression model. Patients whose tumors exhibited a good nuclear grade fared significantly better than those whose tumors were scored as poor. Similarly, a significantly better prognosis was noted when the histologic type of cancer was found to be "favorable" (mucinous, tubular, or papillary) than when it was "intermediate" (NOS, "Not Otherwise Specified," combination; typical medullary; and lobular invasive) or "unfavorable" (NOS pure and atypical medullary). Blacks exhibited a worse prognosis than whites. Survival was 94% at 8 years when the nuclear grade was good and the tumor type favorable, but only 54% when the nuclear grade was poor and tumor type unfavorable. Patients with one favorable and one unfavorable feature exhibited an intermediate survival. A brief overview as well as our own preliminary experience indicates that the combined use of these two prognostic pathologic parameters may be as good as and in some instances a better predictor of survival in node-negative patients than information derived from more "objective" methodologies such as flow cytometry, receptor analyses and tumor labeling indices or the demonstration of oncogene overexpression. Assessment of the pathologic parameters is simple, universally available, and quick and requires only modest training to be reproducible.

DNA flow cytometric analysis of primary operable breast cancer. Relation of ploidy and S-phase fraction to outcome of patients in NSABP B-04

Between 1971 and 1974, 1665 women with primary operable breast cancer were randomized into a National Surgical Adjuvant Breast and Bowel Project (NSABP) trial (B-04) conducted to evaluate the effectiveness of several different regimens of surgical and radiation therapy. No systemic therapy was given. Cells from archival paraffin-embedded tumor tissue taken from 398 patients were analyzed for ploidy and S-phase fraction (SPF) using flow cytometry. Characteristics and outcome of patients with satisfactory DNA histograms were comparable to those from whom no satisfactory cytometric studies were available. In patients with diploid tumors (43%), the mean SPF was 3.4% +/- 2.3%; in the aneuploid population (57%), the SPF was 7.9% +/- 6.3%. Only 29.9% +/- 17.3% of cells in aneuploid tumors were aneuploid. Diploid tumors were more likely than aneuploid tumors to be of good nuclear grade (P less than 0.001) and smaller size (P equals 0.03). More tumors with high SPF were of poor nuclear grade than were tumors with low SPF (P equals 0.002). No significant difference in 10-year disease-free survival (P equals 0.3) or survival (P equals 0.1) was found between women with diploid or aneuploid tumors. Patients with low SPF tumors had a 13% better disease-free survival (P equals 0.0006) than those with a high SPF and a 14% better survival (P equals 0.007) at 10 years than patients with high SPF tumors. After adjustment for clinical tumor size, the difference in both disease-free survival and survival between patients with high and low SPF tumors was only 10% (P equals 0.04 and 0.08, respectively). Although SPF was found to be of independent prognostic significance for disease-free survival and marginal significance for survival, it did not detect patients with such a good prognosis as to preclude their receiving chemotherapy. The overall survival of patients with low SPF was only 53% at 10 years. These findings and those of others indicate that additional studies are necessary before tumor ploidy and SPF can be used to select patients who should or should not receive systemic therapy.