Barriers and facilitators to social prescribing in child and youth mental health: perspectives from the frontline

There is growing interest in the role of Social Prescribing (SP) to help promote mental well-being and support individuals with mental health difficulties. Yet, implementation of SP to children and young people (CYP) has proved slow and underdeveloped compared with adult populations. Understanding the barriers and facilitators will help key stakeholders to better embed SP for CYP into practice. Using the Theoretical Domains Framework (TDF), a comprehensive, theoretical-led framework, underpinned by 33 behaviour change theories and 128 constructs, perceived barriers and facilitators to SP were investigated. The sample comprised of 11 Link Workers and 9 individuals involved in facilitating SP with CYP, who took part in semi-structured interviews. Transcripts were analysed using a deductive thematic analysis, and themes were coded under each theoretical domain. Overall, 33 barriers and facilitators for SP were identified across 12 domains of the TDF. Under capability, barriers and facilitators were found for knowledge, skills, memory/attention/decision making processes, and behavioural regulation. For opportunity, barriers and facilitators were found for social/professional influences, as well as environmental context and resources. Finally, for motivation, domains covered included: beliefs about consequences, beliefs about capabilities, optimism, motivations/goals, reinforcement, and emotions. Findings suggest that a wide range of barriers and facilitators affect the implementation of CYP SP to improve mental health and well-being. Interventions which target different domains related to capability, opportunity and motivation should be developed to better facilitate CYP SP.

CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings

BACKGROUND

Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU.

METHODS AND DESIGN

This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old).

AIM AND OBJECTIVES

The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks.

DISCUSSION

The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis.

TRIAL REGISTRATION

ISRCTN Number: 37176025, IRAS Number: 1004947.

TRIAL STATUS

In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.

The experiences and impact of the COVID-19 pandemic on young carers: practice implications and planning for future health emergencies

BACKGROUND

Young carers are children or young people aged up to 25 years old who undertake unpaid caring responsibilities for a friend or family member. Young carers faced significant challenges brought on by the COVID-19 pandemic. We explored the impact of the pandemic and associated restrictions on mental health, wellbeing and access to support in young carers in the United Kingdom (UK) to understand how to improve services, as well as support this population in future health emergencies.

METHOD

We conducted 22 qualitative semi-structured interviews from May to November 2021 with 14 young carers and eight staff working in organisations that supported them. Interviews took place remotely over video or telephone call and explored participant experiences of the pandemic and its impact on their health, wellbeing and caring responsibilities. We used reflexive thematic analysis to analyse interview transcripts.

RESULTS

We identified four overarching themes pertaining to the impact of the pandemic and associated restrictions on mental health, wellbeing and access to support in young carers in the UK: (1) challenges in protecting loved ones from the virus, (2) changes to and loss of routine, (3) reduced access to pre-pandemic informal and formal support structures and (4) better understanding of inner resilience and goals. Many participants struggled with their mental health and wellbeing as a result of pandemic related restrictions which impacted on support structures for themselves and the individual they cared for. However, positive impacts pertained to additional support provided by local authority and third sector organisations.

CONCLUSIONS

Our findings highlight some of the changes that affected young carers during the COVID-19 pandemic. The impact of changes to routine and a reduction in pre-pandemic support were the greatest concerns reported by participants in this study. The additional support provided by local authority and third sector organisations during social restrictions suggests such organisations could play a greater role in supporting this population going forward and that schools and Governments may wish to put in additional strategies and provisions to protect young carers in the future.

Eliminating Leakage Errors in Hyperfine Qubits

Population leakage outside the qubit subspace presents a particularly harmful source of error that cannot be handled by standard error correction methods. Using a trapped ^{171}Yb^{+} ion, we demonstrate an optical pumping scheme to suppress leakage errors in atomic hyperfine qubits. The selection rules and narrow linewidth of a quadrupole transition are used to selectively pump population out of leakage states and back into the qubit subspace. Each pumping cycle reduces the leakage population by a factor of ∼3, allowing for an exponential suppression in the number of cycles. We use interleaved randomized benchmarking on the qubit subspace to show that this pumping procedure has negligible side effects on the qubit subspace, bounding the induced qubit memory error by ≤2.0(8)×10^{-5}  per cycle, and qubit population decay to ≤1.4(3)×10^{-7}  per cycle. These results clear a major obstacle for implementations of quantum error correction and error mitigation protocols.

IUPAC Collaborative Trial Study of a Method To Detect Genetically Modified Soy Beans and Maize in Dried Powder

This paper presents results of a collaborative trial study (IUPAC project No. 650/93/97) involving 29 laboratories in 13 countries applying a method for detecting genetically modified organisms (GMOs) in food. The method is based on using the polymerase chain reaction to determine the 35S promoter and the NOS terminator for detection of GMOs. Reference materials were produced that were derived from genetically modified soy beans and maize. Correct identification of samples containing 2% GMOs is achievable for both soy beans and maize. For samples containing 0.5% genetically modified soy beans, analysis of the 35S promoter resulted also in a 100% correct classification. However, 3 false-negative results (out of 105 samples analyzed) were reported for analysis of the NOS terminator, which is due to the lower sensitivity of this method. Because of the bigger genomic DNA of maize, the probability of encountering false-negative results for samples containing 0.5% GMOs is greater for maize than for soy beans. For blank samples (0% GMO), only 2 false-positive results for soy beans and one for maize were reported. These results appeared as very weak signals and were most probably due to contamination of laboratory equipment.

P4698Survival outcomes in patients with Eisenmenger syndrome after heart-lung or bilateral sequential lung transplantation

Background

Eisenmenger syndrome (ES) is defined as pulmonary hypertension secondary to a right to left intracardiac shunt, commonly an atrial septal defect (ASD) or ventricular septal defect (VSD). Heart-lung (HLTx) or bilateral sequential lung transplantation (BSLT) are both treatment options for some candidates. The choice between these two procedures has varied historically and according to transplant centre preference and donor availability. We completed a retrospective study to determine if BSLT with cardiac repair was associated with better outcomes compared to HLTx.

Aim

This study compared post-transplant survival in patients with ES undergoing HLTx or BSLT.

Method

Using the International Society Heart and Lung Transplantation Registry data, we identified all patients with ES between October 1, 1987 and March 31, 2018.

Results

A total of 177 patients underwent HLTx for ES ASD and 101 who underwent BSLT with cardiac repair. Median follow up was 890 days (range 0–9888 days) for the entire post-transplant cohort. 126 HLTx and 66 BSLT patients died in the follow up period.

A total of 173 ES VSD patients underwent HLTx in the database, and 52 underwent BSLT with cardiac repair. Median follow up was 460 days (range 0–8406 days) for the entire post-transplant cohort. 116 HLTx and 36 BSLT patients died during the follow up period.

Figure 1 demonstratres the comparative Kaplan-Meier survival curves following BSLT or HLTx for Eisenmenger's ASD and VSD patients. No statistically significant difference in Eisenmenger survival between combined heart-lung transplantation or bilateral sequential lung transplantation group (ASD log rank test p value = 0.99, VSD log rank test p value = 0.1 performed for the first 6 year).

Figure 1

Conclusions

Our analysis determined that patients with ES and either VSD or ASD had similar long-term survival comparing HLTx with BSLT and cardiac repair.

4974Waitlist outcomes for Eisenmengers patients listed for bilateral sequential lung transplant or heart-lung transplant

Background

Eisenmenger's syndrome (ES) is the end-stage of a longstanding intracardiac shunt, commonly an atrial septal defect (ASD) or ventricular septal defect (VSD). Transplantation is the final option to address the pulmonary hypertension and right heart failure that results. Both combined heart-lung (HLTx) and bilateral sequential lung transplantation (BSLT) have been performed for ES. Overall, BSLT are performed more commonly than HLTx because of donor organ availability. We postulated that ES patients would have higher waitlist mortality and longer time to transplant compared to patients listed for other indications, and BSLT patients would have reduced waitlist mortality and reduced time to transplant compared to HLTx based on availability.

Aim

This study compared waitlist outcomes between ES ASD, ES VSD and all patients listed for BSLT or HLTx.

Methods

We analysed the Organ Procurement and Transplant Network (OPTN) database for all patients listed for BSLT or HLTx between October 1, 1987 and March 31, 2018. Mood's median test was used for all tests of significance.

Results

Table 1 summarises the results of the analysis. A total of 56,698 patients were on the waitlist for BSLT for all aetiologies, which included 176 ES ASD patients and 156 ES VSD patients. A total of 3231 patients were on the waitlist for HLTx for all aetiologies, which included 89 ES ASD and 176 ES VSD patients. Median time to transplant was significantly longer for all ES patients on the waitlist for BSLT or HLTx compare to patients listed for other indications. Comparing time to transplant for BSLT to HLTx for either ES ASD or VSD did not reach statistical significance. Waitlist mortality was substantially higher for all ES patients regardless whether they were listed for BSLT or HLTx compared to patients listed for other indications.

Table 1 ES ASD ES VSD All patients BSLT HLTx BSLT HLTx BSLT HLTx Total number of patients listed 176 89 156 176 56698 3231 Transplanted 58 (33.0%) 38 (42.7%) 41 (25.8%) 78 (44.3%) 36441 (64.3%) 1229 (38.0%) Median time to transplant in days 330 (24 to 2723)* 431 (11 to 4527)$ 517 (10 to 2345)# 292 (16 to 2399)& 99 (0 to 6592) 174 (0 to 3606) p=0.54 p=0.08 *p≤0.001, #p=≤0.0001 $p=0.000, &p=0.003 Wait list mortality 27 (15.3%) 25 (28.1%) 23 (14.5%) 46 (26.1%) 2366 (4.2%) 371 (11.5%)

Conclusion

Our analysis identified longer waitlist time and higher mortality for all ES patients listed for BSLT or HLTx in the United States. These findings indicate current listing methods and prognostication place the ES population at disadvantage for thoracic transplantation.

Barriers and facilitators to shared decision making in child and youth mental health: clinician perspectives using the Theoretical Domains Framework

Shared decision making (SDM) is increasingly being suggested as an integral part of mental health provision. Yet, there is little research on what clinicians believe the barriers and facilitators around practice to be. At the same time, there is also increasing recognition of a theory-practice gap within the field, with calls for more pragmatic uses of theory to inform and improve clinical practice. Using the Theoretical Domains Framework (TDF), a comprehensive, theoretical-led framework, underpinned by 33 behaviour change theories and 128 constructs, clinician perceived barriers and facilitators to SDM are investigated. The sample comprised of 15 clinicians across two sites in England, who took part in qualitative semi-structured interviews and focus groups. Transcripts were analysed using a deductive thematic analysis, and themes were coded under each theoretical domain. Overall, 21 barriers and facilitators for SDM in child and youth mental health were identified across ten domains of the TDF. Under capability, barriers and facilitators were found for knowledge, skills, memory/attention/decision making processes, and behavioural regulation. For opportunity, barriers and facilitators were found for social influences, as well as environmental context and resources. Finally, for motivation, domains covered included: beliefs about consequences, beliefs about capabilities, emotions, and professional role and identity. Findings suggest that a range of barriers and facilitators affect clinicians' abilities to engage in SDM with young people and parents. Interventions which target different domains related to capability, opportunity and motivation should be developed to better facilitate young people and their families in care and treatment decisions.

Use of “Months of the Year Backwards” (MOTYB) as a Screening Tool for Delirium in Palliative Care Patients in the Acute Hospital Setting

Introduction Delirium is common in palliative care. It effects up to 88% of patients with advanced cancer at end of life and has a point prevalence of 20% in the acute hospital setting across all diagnoses. It is under diagnosed and not optimally treated. “Months of the Year Backwards” (MOTYB) is an ideal screening tool for delirium with a sensitivity of 83.8%. It is brief to perform and carries low burden for patients. The aim of this study is to investigate the use of MOTYB as a screening tool for delirium in palliative care patients in the acute hospital setting. Methods All patients who were referred to the hospital palliative care team in September 2016 were screened. Results Forty five patients were screened using MOTYB. Fifteen patients (33%) screened positive for delirium. Conclusion MOTYB is a simple screening tool that was easily integrated into practice in a hospital service. It has the potential to identify missed cases of delirium and therefore improve management and ultimately patient outcomes.

Age-Dependent Association Between Pre-transplant Blood Transfusion and Outcomes of Pediatric Heart Transplantation

Avoidance of red blood cell (RBC) transfusions in patients awaiting heart transplantation (HTx) has been suggested to minimize the risk of allosensitization. Although recent studies have suggested that an immature immune system in younger HTx recipients may reduce risks associated with RBC transfusion, the role of age in moderating the influence of transfusion on HTx outcomes remains unclear. We used available data from a national transplant registry to explore whether the association between pre-transplant transfusions and outcomes of pediatric HTx varies by patient age. De-identified data were obtained from the United Network for Organ Sharing registry, including first-time recipients of isolated HTx performed at age 0-17 years in 1995-2015. The primary exposure was receiving blood transfusions within 2 weeks prior to HTx. Patient survival after HTx was evaluated using multivariable Cox proportional hazards, where age at transplant was interacted with exposure to pre-transplant transfusion. Age-specific hazard ratios (HRs) of pre-transplant transfusion were plotted across ages at transplant. There were 4883 patients meeting inclusion criteria, of whom 1258 died during follow-up (mean follow-up duration 6 ± 5 years). Patients receiving pre-transplant transfusions were distinguished by younger age, higher prevalence of prior cardiac surgery, greater likelihood of being in the intensive care unit, and greater use of left ventricular assist device bridge to transplant. In multivariable analysis, pre-transplant transfusions were associated with increased mortality hazard among infants < 1 year of age (HR = 1.46; 95% CI 1.23, 1.74; p < 0.001). For each additional year of age, the excess hazard associated with pre-transplant transfusions decreased by 3% (interaction HR = 0.97; 95% CI 0.98, 0.99; p = 0.003). By age 8, the association between pre-transplant transfusions and post-transplant mortality was no longer statistically significant (HR = 1.15; 95% CI 0.99, 1.32; p = 0.060). Pre-transplant transfusions were associated with increased mortality hazard only among younger children (age < 8 years) undergoing HTx. These data support the current practices of transfusion avoidance prior to HTx, particularly in younger patients.

Survivorship care delivery: From a consultative clinic to an integrative program based on patient outcome and resource analyses

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Background: Delivery of survivorship care plan (SCP) using a multidisciplinary approach is optimal (Hewitt et al., 2006). However, many institutions experience implementation barriers (Dulko et al., 2013). The pilot study aim compared the effectiveness of two SCP delivery methods (extended vs. brief) on self-reported confidence in disease management (breast cancer). Secondary aim evaluated timeliness and patient/provider burden. Methods: Quasi-experimental pre- and post-survey design with control group (brief explanation/ delivery of SCP) and treatment group (comprehensive consultative visit). Pretesting included distress screening and self-efficacy survey. Post-testing included self-efficacy survey, tracking of referral activity, and patient satisfaction. Time study data and process mapping were included. Descriptive data analyses and Mixed ANOVA; significance set p < .05. Results: 73 eligible patients identified (age 61.93 ±11.6 years), 36 completing pre/post testing, and 62% declined consultative visit. At pre-testing, 45% rated distress > 3 [emotional (58%), physical (50%), nutritional (30%)]. Post-testing showed 94% compliance with support service referral(s). 89% felt understanding improved, 66% found SCP helpful, 59% said SCP prepared them for transition, and 77% were satisfied. Time main effect was significant for self-efficacy, Wilks Lambda = .89, F (1,34) = 4.2, p = .048. Follow-up paired-samples t-test showed significant improvement in consultative group, t (21) = -2.56, p = .018. Group differences not significant, but both groups demonstrated positive change (7% consultative; 4% control). Time study data revealed overall time spent per patient was 3.7 hours for consultative group vs. 2.2 hours for control group. New process change to integrative model reduced time by 65%. Conclusions: Both SCP delivery methods demonstrated improved patient confidence in managing disease and positive satisfaction. However, the extended visit did not yield outcomes justifying the increased program cost and resource. The pilot fostered a multidisciplinary approach to SCP delivery and yielded a process for improved timeliness and optimal delivery model.

Patient or client? The opinions of people attending a psychiatric clinic

Aims and Method

The use of the term ‘client’ has become increasingly popular among non-medical staff in psychiatric practice. We sought to describe the preferences and attitudes of people attending a psychiatric clinic to the terms patient and client. A questionnaire and case note review was employed.

Results

147 people completed the questionnaire, of these 77% preferred the term patient. There was no subgroup that preferred the term client. Attitudes towards the two terms were significantly different, with a greater antipathy demonstrated towards the term client.

Clinical Implications

The majority of people attending a psychiatric clinic prefer the use of the term patient; the term client is disliked.

Critical success factors in implementing an e-rostering system in a healthcare organisation

Effective and efficient staff scheduling has always been a challenging issue, especially in health service organisations. Both the extremes of staff shortage and overage have an adverse impact on the performance of healthcare organisations. In this case, an electronic and systematic staff scheduling (e-rostering) system is the often seen as the best solution. Unless an organisation has an effective implementation of such a system, possible cost savings, efficiency, and benefits could be minimal. This study is aimed to research key success factors for the successful effective implementation of an electronic rostering system, especially at healthcare organisations. A case study research method was used to evaluate critical success factors for effectively implementing an e-rostering system. The data were collected through interviews and observations. The findings indicate that technical support, an effective policy, leadership, clear goals and objectives, gradual change, evidence of the advantages of the new system, senior management support, and effective communication are the critical success factors in implementing an e-rostering system in healthcare organisations. Prior to this study, no such factors were grounded in the current context, so this research would help in bridging the gap towards effective implementation of an e-rostering system in the healthcare sector. This research also suggests future studies in different cultures and contexts.

Uncertainty in the response of terrestrial carbon sink to environmental drivers undermines carbon-climate feedback predictions

Terrestrial ecosystems play a vital role in regulating the accumulation of carbon (C) in the atmosphere. Understanding the factors controlling land C uptake is critical for reducing uncertainties in projections of future climate. The relative importance of changing climate, rising atmospheric CO2, and other factors, however, remains unclear despite decades of research. Here, we use an ensemble of land models to show that models disagree on the primary driver of cumulative C uptake for 85% of vegetated land area. Disagreement is largest in model sensitivity to rising atmospheric CO2 which shows almost twice the variability in cumulative land uptake since 1901 (1 s.d. of 212.8 PgC vs. 138.5 PgC, respectively). We find that variability in CO2 and temperature sensitivity is attributable, in part, to their compensatory effects on C uptake, whereby comparable estimates of C uptake can arise by invoking different sensitivities to key environmental conditions. Conversely, divergent estimates of C uptake can occur despite being based on the same environmental sensitivities. Together, these findings imply an important limitation to the predictability of C cycling and climate under unprecedented environmental conditions. We suggest that the carbon modeling community prioritize a probabilistic multi-model approach to generate more robust C cycle projections.

Collaborating to Compete: Blood Profiling Atlas in Cancer (BloodPAC) Consortium

The cancer community understands the value of blood profiling measurements in assessing and monitoring cancer. We describe an effort among academic, government, biotechnology, diagnostic, and pharmaceutical companies called the Blood Profiling Atlas in Cancer (BloodPAC) Project. BloodPAC will aggregate, make freely available, and harmonize for further analyses, raw datasets, relevant associated clinical data (e.g., clinical diagnosis, treatment history, and outcomes), and sample preparation and handling protocols to accelerate the development of blood profiling assays.

Lung Transplant Center Volume Ameliorates Adverse Influence of Prolonged Ischemic Time on Mortality

The influence of prolonged ischemic time on outcomes after lung transplant is controversial, but no research has investigated ischemic time in the context of center volume. We used data from the United Network for Organ Sharing to estimate the influence of ischemic time on patient survival conditional on center volume in the post-lung allocation score era (2005-2015). The analytic sample included 14 877 adult lung transplant recipients, of whom 12 447 were included in multivariable survival analysis. Patient survival was improved in high-volume centers compared with low-volume centers (log-rank test p = 0.001), although mean ischemic times were longer at high-volume centers (5.16 ± 1.70 h vs. 4.83 ± 1.63 h, p < 0.001). Multivariable Cox proportional hazards regression stratified by transplant center found an adverse influence of longer ischemic time at low-volume centers but not at high-volume centers. At centers performing 50 transplants in the period 2005-2015, for example, 8 versus 6 h of ischemia were associated with an 18.9% (95% confidence interval 6.5-32.7%; p < 0.001) greater mortality hazard, whereas at centers performing 350 transplants in this period, no differences in survival by ischemic time were predicted. Despite longer mean ischemic time at high-volume transplant centers, these centers had favorable patient outcomes and no adverse survival implications of prolonged ischemia.

Circumpolar distribution and carbon storage of thermokarst landscapes

Thermokarst is the process whereby the thawing of ice-rich permafrost ground causes land subsidence, resulting in development of distinctive landforms. Accelerated thermokarst due to climate change will damage infrastructure, but also impact hydrology, ecology and biogeochemistry. Here, we present a circumpolar assessment of the distribution of thermokarst landscapes, defined as landscapes comprised of current thermokarst landforms and areas susceptible to future thermokarst development. At 3.6 × 106 km2, thermokarst landscapes are estimated to cover ∼20% of the northern permafrost region, with approximately equal contributions from three landscape types where characteristic wetland, lake and hillslope thermokarst landforms occur. We estimate that approximately half of the below-ground organic carbon within the study region is stored in thermokarst landscapes. Our results highlight the importance of explicitly considering thermokarst when assessing impacts of climate change, including future landscape greenhouse gas emissions, and provide a means for assessing such impacts at the circumpolar scale.

The Pathology of Devil Facial Tumor Disease (DFTD) in Tasmanian Devils (Sarcophilus harrisii)

A disfiguring and debilitating neoplastic condition known as devil facial tumor disease (DFTD) has been discovered in wild Tasmanian Devils ( Sarcophilus harrisii) across 51% of its natural range, with population declines of up to 80% in some areas (C. Hawkins, personal communication). Between 2001 and 2004, 91 cases were examined. The tumors presented as large, solid, soft tissue masses usually with flattened, centrally ulcerated, and exudative surfaces. They were typically multicentric, appearing first in the oral, face, or neck regions. Histologically, the tumors were composed of circumscribed to infiltrative nodular aggregates of round to spindle-shaped cells, often within a pseudocapsule and divided into lobules by delicate fibrous septae. They were locally aggressive and metastasized in 65% of cases. There was minimal cytologic differentiation among the tumor cell population under light and electron microscopic examination. The results indicate DFTD to be an undifferentiated soft tissue neoplasm.

Abiraterone acetate, exemestane or the combination in postmenopausal patients with estrogen receptor-positive metastatic breast cancer

Resistance to nonsteroidal aromatase inhibitors is a major obstacle in the management of estrogen receptor-positive postmenopausal metastatic breast cancer. The addition of abiraterone acetate to exemestane did not improve clinical outcomes compared with exemestane alone in an androgen receptor-enriched population, potentially due to induced serum progesterone as a resistance mechanism.

Background

Androgen receptor (AR) signaling and incomplete inhibition of estrogen signaling may contribute to metastatic breast cancer (MBC) resistance to a nonsteroidal aromatase inhibitor (NSAI; letrozole or anastrozole). We assessed whether combined inhibition of androgen biosynthesis with abiraterone acetate plus prednisone and estradiol synthesis with exemestane (E) may be of clinical benefit to postmenopausal patients with NSAI-pretreated estrogen receptor-positive (ER+) MBC.

Patients and methods

Patients (N = 297) were stratified by the number of prior therapies for metastatic disease (0–1 versus 2) and by prior NSAI use (adjuvant versus metastatic), and randomized (1 : 1 : 1) to receive oral once daily 1000 mg abiraterone acetate plus 5 mg prednisone (AA) versus AA with 25 mg E (AAE) versus 25 mg E alone (E). Each treatment arm was well balanced with regard to the proportion of patients with AR-positive breast cancer. The primary end point was progression-free survival (PFS). Secondary end points included overall survival, clinical benefit rate, duration of response, and overall response rate.

Results

There was no significant difference in PFS with AA versus E (3.7 versus 3.7 months; hazard ratio [HR] = 1.1; 95% confidence interval [CI] 0.82–1.60; P = 0.437) or AAE versus E (4.5 versus 3.7 months; HR = 0.96; 95% CI 0.70–1.32; P = 0.794). Increased serum progesterone concentrations were observed in both arms receiving AA, but not with E. Grade 3 or 4 treatment-emergent adverse events associated with AA, including hypokalemia and hypertension, were less common in patients in the E (2.0% and 2.9%, respectively) and AA arms (3.4% and 1.1%, respectively) than in the AAE arm (5.8% for both).

Conclusions

Adding AA to E in NSAI-pretreated ER+ MBC patients did not improve PFS compared with treatment with E. An AA-induced progesterone increase may have contributed to this lack of clinical activity.

ClinicalTrials.gov

NCT01381874.