Cannabis Use Patterns among Patients with Early-Stage Breast Cancer in a Large Multicenter Cohort from a State with Legalized Adult Non-Medical Cannabis

PURPOSE/OBJECTIVE(S)

Cannabis use among patients with cancer is an area of great interest given its widespread acceptance despite the lack of supporting clinical data. The absence of data limits the understanding of potential clinical benefits of cannabis and the ability of providers to deliver evidence-based recommendations for patient care. We explored cannabis use patterns in patients with early-stage breast cancer in a large multicenter cohort in a state with legalized adult non-medical cannabis.

MATERIALS/METHODS

Initial questions about cannabis use history and frequency were introduced in Michigan Radiation Oncology Quality Consortium (MROQC) breast cancer patient surveys on 2/1/2020 for female patients receiving radiation after lumpectomy for non-metastatic breast cancer. Expanded questions were introduced on 6/28/2022 to assess mode of administration, active ingredient, and reason for use. Summary statistics were generated. A multivariable model using logistic regression identified patient characteristics associated with cannabis use.

RESULTS

Among 3948 eligible patients, 2738 (69.35%) completed survey questions, and 2462/2738 (89.9%) completed the initial question on cannabis use. Among those, 364/2462 (14.8%) noted cannabis use in the last 30 days, 588 (23.9%) noted remote use (>30 days ago), 1462 (59.4%) reported never having used cannabis, 44 (1.8%) preferred not to answer cannabis use questions, and 4 (0.4%) did not provide use history. Younger age [age <50 vs 60-70, OR 2.5 (95% CI 1.65, 3.79) p<0.001)], Hispanic ethnicity [OR 2.20 (95% CI 1.06, 4.56) p = 0.03], history of smoking [OR 2.56 (95% CI 1.88, 3.48) p<0.001], current smoking [OR 4.70 (95% CI 3.22, 6.86) p<0.001)], and prior chemotherapy [OR 1.40 (95% CI 1.00, 1.96) p = 0.05] predicted recent cannabis use in a multivariable model. Of the 364 patients endorsing cannabis use in the last 30 days, 89 (24.5%), 72 (19.8%), 29 (8.0%), 66 (18.1%), 30 (8.2%), and 78 (21.4%) reported using cannabis 1-2 days, 3-5 days, 6-9 days, 10-19 days, 20-29 days, and all 30 days, respectively. The most common modes of administration among 76 individuals who responded to the expanded questionnaire to date were oral (39.4%), smoking (30.3%), and topical (10.5%). The products used contained tetrahydrocannabinol (THC; 26.3%), cannabidiol (CBD; 19.7%), balanced levels of THC and CBD (19.7%), or active ingredients that were unknown to the patient (34.2%). Patients frequently endorsed cannabis use for insomnia, anxiety, and pain.

CONCLUSION

Many patients with early-stage breast cancer are using cannabis. Younger age, Hispanic ethnicity, smoking, and chemotherapy history are predictors of cannabis use. Patients are often unaware of the active ingredients in the products that they use, suggesting an important role for patient education and a need to equip providers to advise patients in their care.

Impact of Breast Volume on Achieving a Conservative Heart and Target Coverage Metric for Patients Receiving Whole Breast Radiotherapy in a Statewide Consortium

PURPOSE/OBJECTIVE(S)

Radiation to large breast volumes (BV) has been associated with increased dose inhomogeneities, breast fibrosis, and induration. Radiation exposure to the heart during breast radiotherapy has been associated with late cardiovascular morbidity and mortality. This study, therefore, investigates the impact of BV on achieving optimal lumpectomy cavity target coverage (V95% [%] >95) while maintaining mean heart dose constraints (MHD, mean [Gy] <1) across a range of BV from patients enrolled in a statewide consortium.

MATERIALS/METHODS

A retrospective analysis was conducted for 2,506 patients receiving left-sided whole breast moderately-hypofractionated (2.5-2.8 Gy/fx) radiotherapy without nodal fields between 2018-2022. The BV was calculated for each patient from contours in the treatment planning system, and the volume distribution partitioned into quartiles. Dosimetric parameters were calculated from dose-volume histograms. The percentage of patients in which the metrics were achieved was calculated for each BV quartile for different treatment positions: all positions, supine, supine with breathing motion management, and prone.

RESULTS

The BV ranges within the quartiles (∼620 patients/quartile) were ≤720.0 cc, 720.1 to ≤1065.0 cc, 1065.1 to ≤1500.0 cc, and >1500.0 cc for quartiles Q1-Q4, respectively. Of the 2,506 patients, 76% were treated supine (of which 41.6% were treated using breathing motion management techniques), 23.5% were treated prone, and 0.5% were treated decubitus. Discrete percentages of patients able to meet the metrics are provided in the table. An increase in BV from Q1 to Q4 correlated with lower percentages of patients meeting the MHD metric, however no correlation was observed between BV and target coverage. Treating supine with breathing motion management resulted in a higher percentage of patients meeting the MHD metric (odds ratio (OR) = 1.96 relative to supine without motion management, p<0.0001), while the prone setup proved to be the superior technique across all quartiles (OR = 3.95 relative to supine, p<0.0001).

CONCLUSION

Increasing BVs resulted in lower percentages of patients receiving MHD≤1 Gy. Thus, cardiac sparing may be more difficult to achieve in patients with larger BV. Utilization of alternate treatment positions, such as supine with breathing motion management and prone, greatly improved the percentage of patients able to meet the MHD metric without sacrificing target coverage in all quartiles. Prone positioning was the technique least susceptible to BV effects in meeting the MHD≤1 Gy goal.

Factors Associated with Cardiac Radiation Dose Reduction Following Hypofractionated Radiation Therapy for Localized, Left-Sided Breast Cancer in a Large Statewide Quality Consortium

PURPOSE/OBJECTIVE(S)

Limiting radiation dose to the heart is important for minimizing the risk of long-term cardiac toxicity in patients with left-sided early-stage breast cancer.

MATERIALS/METHODS

Prospectively collected dosimetric data were analyzed for patients undergoing hypofractionated radiation therapy to the left breast for localized node-negative breast cancer within the Michigan Radiation Oncology Quality Consortium (MROQC) from 2016-2022. Goals for limiting cardiac dose were adjusted over time. From 2016-2020, the cardiac quality metric focused on total mean heart dose (MHD) from the composite whole breast and boost plans, tightening from a goal of MHD ≤2 Gy to MHD ≤1.2 Gy by 2020. In 2021-2022, the cardiac metric transitioned to a combined goal of MHD ≤1.0 Gy from the whole breast plan and ≥95% lumpectomy cavity planning target volume (PTV) receiving 95% of the prescription dose. Separate multivariate logistic regression models were developed to assess for covariates associated with meeting the MHD goal in 2016-2020 and combined MHD/PTV coverage goal in 2021-2022.

RESULTS

In total, 4,165 patients were analyzed with a median age of 64 years. Most patients (86%) had either Tis or T1 disease, and 66% received hormone therapy. Baseline demographic and disease characteristics did not change substantially between treatment periods. Use of breath-hold or motion gating increased from 42% in 2016-2020 to 46% in 2021-2022. Similarly, use of prone positioning increased from 12% to 20%. From 2016-2020, 90.9% of plans achieved the MHD goal, compared to 93.6% of plans achieving the composite MHD/PTV goal from 2021-2022. On multivariate analysis in the 2016-2020 cohort, treatment with motion management (OR 5.20, 95% CI [3.59-7.54], p<0.0001) or prone positioning (OR 3.21, 95% CI [1.85-5.57], p < 0.0001) were associated with meeting the MHD goal, while receipt of boost (OR 0.25, 95% CI [0.17-0.39], p<0.0001) and omission of hormone therapy (OR 0.65, 95% CI [0.49-0.88], p = 0.0047), were associated with not meeting the MHD goal. During the era including composite heart dose and PTV coverage goals (2021-2022), treatment with motion management (OR 1.89, 95% CI [1.12-3.21], p = 0.018) or prone positioning (OR 3.71, 95% CI [1.73-7.95], p = 0.0008) were associated with meeting the combined goal, while larger breast volume (≥1440 cc, OR 0.34, 95% CI [0.13 - 0.91], p = 0.031) and treatment at an academic center (OR 0.36, 95% CI [0.22-0.67], p = 0.0009) were associated with not meeting the combined goal.

CONCLUSION

In our statewide consortium, rates of compliance with aggressive targets for limiting cardiac dose remain high, despite tightening of these goals to include lower mean heart doses and inclusion of a concurrent PTV coverage goal. Treatment using motion management or prone positioning is associated with achieving the cardiac dose goals.

Shifts in learning assistants' self-determination due to COVID-19 disruptions in Calculus II course delivery

BACKGROUND

The Learning Assistant (LA) model with its subsequent support and training has evidenced significant gains for undergraduate STEM learning and persistence, especially in high-stakes courses like Calculus. Yet, when a swift and unexpected transition occurs from face-to-face to online, remote learning of the LA environment, it is unknown how LAs are able to maintain their motivation (competence, autonomy, and relatedness), adapt to these new challenges, and sustain their student-centered efforts. This study used Self-Determination Theory (SDT) to model theoretical aspects of LAs' motivations (persistence and performance) both before and after changes were made in delivery of a Calculus II course at Texas Tech University due to COVID-19 interruptions.

RESULTS

Analysis of weekly written reflections, a focus group session, and a post-course questionnaire of 13 Calculus II LAs throughout Spring semester of 2020 showed that LAs' reports of competence proportionally decreased when they transitioned online, which was followed by a moderate proportional increase in reports of autonomy (actions they took to adapt to distance instruction) and a dramatic proportional increase in reports of relatedness (to build structures for maintaining communication and building community with undergraduate students).

CONCLUSIONS

Relatedness emerged as the most salient factor from SDT to maintain LA self-determination due to the COVID-19 facilitated interruption to course delivery in a high-stakes undergraduate STEM course. Given that online learning continues during the pandemic and is likely to continue after, this research provides an understanding to how LAs responded to this event and the mounting importance of relatedness when LAs are working with undergraduate STEM learners. Programmatic recommendations are given for enhancing LA preparation including selecting LAs for autonomy and relatedness factors (in addition to competence), modeling mentoring for remote learners, and coaching in best practices for online instruction.

Engaging LGBTQ Communities in Community-Partnered Participatory Research: Lessons from the Resilience Against Depression Disparities Study

BACKGROUND

The Resilience Against Depression Disparities (RADD), a community partnered, randomized comparative effectiveness study, aimed to address mental health in Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) racial/ethnic populations in New Orleans and Los Angeles.

OBJECTIVES

To describe engagement methods, lessons learned, and recommendations in engaging LGBTQ individuals and agencies throughout the RADD study.

METHODS

RADD used a community partnered participatory research framework to engage LGBTQ community members and agencies. Observational and quantitative data were collected to describe engagement activities and study adaptations from October 2016 to May 2019.

RESULTS

Our partnered approach resulted in multiple study adaptations. The principles of cultural humility, coleadership, and addressing health determinants were important to successful engagement with LGBTQ community members and study participants. We recommend maintaining cultural humility as the tenant of all research activities.

CONCLUSIONS

This project's engagement plan demonstrates that community-academic partnerships can be forged to create and modify existing study models for LGBTQ communities.

Resilience Against Depression Disparities (RADD): a protocol for a randomised comparative effectiveness trial for depression among predominantly low-income, racial/ethnic, sexual and gender minorities

INTRODUCTION

Depression is the leading cause of adult disability and common among sexual and gender minority (SGM) adults. The current study builds on findings showing the effectiveness of depression quality improvement (QI) and delivery of cognitive behavioural therapy (CBT) skills provided by community health workers in reducing depression. Depression QI approaches across healthcare and social/community services in safety-net settings have shown improvements in mental wellness, mental health quality of life and depression over 12 months. Further, a randomised study showed improved depression among low-income racial/ethnic minorities enrolled in a CBT-informed resiliency class (Building Resilience and Increasing Community Hope (B-RICH)). The current protocol describes a comparativeness effectiveness study to evaluate whether predominantly low-income, SGM racial/ethnic minority adults randomised to a CBT-informed resiliency class have improvements in depressive symptoms over and above community-engaged QI resources and training only.

METHODS AND ANALYSIS

The study approached three clusters of four to five programs serving predominantly SGM and racial/ethnic minority communities in the USA: two clusters in Los Angeles, California, and one in New Orleans, Louisiana. Clusters are comprised of one primary care, one mental health and two to three community agencies (eg, faith-based, social services/support, advocacy). All programs received depression QI training. The current study employed a community-partnered participatory research model to adapt the CBT-informed resiliency class, B-RICH+, to SGM communities. Study participants were screened and recruited in person from participating programs, and will complete baseline, 6- and 12-month survey follow-ups. Participants were depressed adults (8-item Patient Health Questionnaire ≥10; ≥18 years of age) who provided contact information. Enrolled participants were individually randomised to B-RICH+ or depression QI alone. Primary outcomes are depressive symptoms; secondary outcomes are mental health quality of life, mental wellness and physical health quality of life. Data collection for this study is ongoing.

ETHICS AND DISSEMINATION

The current study was approved by the UCLA Institutional Review Board. Study findings will be disseminated through scientific publications and community conferences.

TRIAL REGISTRATION NUMBER

https://clinicaltrials.gov/ct2/show/NCT02986126.

Progesterone signaling during pregnancy in the lab opossum, Monodelphis domestica

To investigate subtle pregnancy-associated changes in the lab opossum, Monodelphis domestica, an induced ovulator, we compared pregnant with non-pregnant and pseudopregnant animals with regard to serum P₄ levels and progesterone receptor (PR) expression. Using video-verified, time-mated lab opossums as sources of biological material, we compared ovaries, uteri and sera obtained on odd-numbered days of the 14.5-day pregnancy in this animal. Females that mated successfully but did not produce embryos were classified as pseudopregnant. P₄ levels differed significantly between pregnant (N = 21) and either non-pregnant (N = 3) or pseudopregnant (N = 3) opossums, but not between the non-pregnant and pseudopregnant groups. A significant decline in serum P₄ occurred between pregnancy days 3 and 5, coinciding with an elevated probability of pregnancy failure between days 5 and 9. PR was detected in the nuclei of uterine-gland epithelial cells on pregnancy days 5 and 7 as well as variably in the corpora lutea (CL) of animals on pregnancy days 3-11. PR expression in the CL suggests that P₄ may be autostimulatory in lab opossums and that certain levels of this steroid are required during normal pregnancy. The significant day-3 drop in P₄ may explain why pregnancy failure in this polyovular metatherian is likeliest to occur between days 5 and 9, an interval during which the extended period of blastocyst morphogenesis and expansion occurs. Taken together, these results suggest that P₄ may have unrecognized signaling roles not only in pregnancy but perhaps embryonic development as well in the lab opossum.

Commentary: Community Partner Experiences in CPPR: What Participation in Partnered Research Can Mean to Community and Patient Stakeholders

Community partners and stakeholders currently engaged in community partnered participatory research (CPPR) can provide personal and professional insight into the processes and outcomes surrounding the CPPR model. This insight may indicate alternative solutions or methods of care delivery that can improve the model and existing interventions. We conducted in-person and phone interviews with five community partners who are currently involved in CPPR. The interviews were audio- and video-recorded, transcribed, and major themes identified. Interviewees recounted their experiences with CPPR and reported various levels of personal (ie, behavioral) and professional growth as a result of their involvement. Interviewees also indicated that CPPR can highlight various aspects of existing interventions (eg, leadership structure, stakeholder representation, methods of provider-to-patient communication, and provision of resources) that may benefit from re-evaluation. Engagement in CPPR may offer various personal and professional benefits for individuals (ie, community partners) involved in stages of development, implementation, and dissemination. The benefits affect these individuals in several ways, from personal growth (eg, emotional maturity, behavioral progress, increased familial resiliency) to professional growth (eg, progression of one's career/role/responsibilities, organizational growth, learned skills). These maturations have secondary effects (eg, increased community resilience, strengthened relationships, community-based mentorships) impacting the communities in which these community partners serve.

The Community and Patient Partnered Research Network (CPPRN): Application of Patient-Centered Outcomes Research to Promote Behavioral Health Equity

Objective

We describe the rationale, development, and progress on the Community and Patient Partnered Research Network (CPPRN). The CPPRN builds on more than a decade of partnered work and is designed to promote health equity by developing partnered research on behavioral health and social risk factors in Los Angeles and New Orleans.

Setting

A community-academic partnership across Los Angeles County and New Orleans.

Methods

Review of rationale, history, structure, activities and progress in applying community partnered participatory research (CPPR) to CPPRN.

Findings

Patient and community stakeholders participated in all phases of development, including local and national activities. Key developments include partnered planning efforts, progress on aggregating a large, de-identified dataset across county agencies, and development of an information technology-supported screening approach for behavioral and social determinants in health care, social, and community-based settings.

Conclusion

The CPPRN represents a promising approach for research data networks, balancing the potential benefit of information technology and data analytic approaches while addressing potential risks and priorities of relevant stakeholders.

A Window of Opportunity: Visions and Strategies for Behavioral Health Policy Innovation

Objective

The New York City's Thrive (ThriveNYC) and the Los Angeles County Health Neighborhood Initiative (HNI) are two local policies focused on addressing the social determinants of behavioral health as a preventive strategy for improving health service delivery. On January 29, 2016, leaders from both initiatives came together with a range of federal agencies in health care, public health, and policy research at the RAND Corporation in Arlington, Virginia. The goal of this advisory meeting was to share lessons learned, consider research and evaluation strategies, and create a dialogue between stakeholders and federal funders - all with the purpose to build momentum for policy innovation in behavioral health equity.

Methods

This article analyzes ethnographic notes taken during the meeting and in-depth interviews of 14 meeting participants through Kingdon's multiple streams theory of policy change.

Results

Results demonstrated that stakeholders shared a vision for behavioral health policy innovation focused on community engagement and social determinants of health. In addition, Kingdon's model highlighted that the problem, policy and politics streams needed to form a window of opportunity for policy change were coupled, enabling the possibility for behavioral health policy innovation.

Conclusions

The advisory meeting suggested that local policy makers, academics, and community members, together with federal agents, are working to implement behavioral health policy innovation.

Case Study of Resilient Baton Rouge: Applying Depression Collaborative Care and Community Planning to Disaster Recovery

BACKGROUND

Addressing behavioral health impacts of major disasters is a priority of increasing national attention, but there are limited examples of implementation strategies to guide new disaster responses. We provide a case study of an effort being applied in response to the 2016 Great Flood in Baton Rouge.

METHODS

Resilient Baton Rouge was designed to support recovery after major flooding by building local capacity to implement an expanded model of depression collaborative care for adults, coupled with identifying and responding to local priorities and assets for recovery. For a descriptive, initial evaluation, we coupled analysis of documents and process notes with descriptive surveys of participants in initial training and orientation, including preliminary comparisons among licensed and non-licensed participants to identify training priorities.

RESULTS

We expanded local behavioral health service delivery capacity through subgrants to four agencies, provision of training tailored to licensed and non-licensed providers and development of advisory councils and partnerships with grassroots and government agencies. We also undertook initial efforts to enhance national collaboration around post-disaster resilience.

CONCLUSION

Our partnered processes and lessons learned may be applicable to other communities that aim to promote resilience, as well as planning for and responding to post-disaster behavioral health needs.

Perfusionist techniques of reducing acute kidney injury following cardiopulmonary bypass: an evidence-based review

Cardiac surgery utilizing cardiopulmonary bypass has come a long way since its introduction nearly 60 years ago. In the early days, end-organ damage was linked to contact of the blood with the extracorporeal circuit. One potential cardiac surgery complication known to result in significant morbidity and mortality is acute kidney injury (AKI). Causes of AKI are multifaceted, but most of them are associated with techniques that perfusionists employ during extracorporeal circuit management. These can cause patients to either go on dialysis or renal replacement therapy. Patients with AKI have longer lengths of stay and consume significant resources beyond those with normal kidney function. Few current evidence-based markers determine if the kidneys are adequately protected during surgery. Most relevant literature does not address perfusion-specific techniques that reduce the incidence of AKI. This paper reviews the pathophysiology of the kidney and focuses on perfusion techniques that may reduce the incidence of AKI.

Local Therapy in BRCA1/2 Carriers with Operable Breast Cancer: Comparison of Breast Conservation and Mastectomy

Background: Women with inherited germline BRCA1/2 mutations have a 55-85% cumulative risk of breast cancer (BC) by age 70. Thus, knowledge of expected outcomes following various treatments is needed to advise these patients should they be diagnosed with BC. It is unclear whether breast conservation (BCT) offers similar rates of tumor control as mastectomy (M) in BRCA1/2 carriers and it is doubtful whether a randomized trial comparing these options could be performed. Thus, this analysis compares the outcomes between similarly staged women with BRCA1/2 mutations treated with BCT vs. M.Methods: Women with deleterious BRCA1/2 mutations diagnosed with operable BC and who consented to longitudinal studies were identified at 10 institutions in the US, Australia, Spain and Israel. Patient, clinical and treatment characteristics were compared between those receiving BCT and those receiving M +/- RT. Time-to-event endpoints included first failure of treatment, diagnosis of contralateral breast cancer (CBC), and overall and BC-specific survival. Cox regression models were constructed to detect significant associations between patient and clinical characteristics and time-to-event endpoints.Results: Clinical characteristics and outcomes for 302 BCT and 353 M patients were compared. With a median F/U of 8.2 years for BCT patients and 8.9 years following M, 15-year local failure as first failure was significantly higher with BCT vs. M (23.5% vs. 5.5%, p&lt;0.0001). Multivariate analysis indicted choice of local therapy as the only factor significantly predicting local recurrence, with a 4.5-fold risk of local failure with BCT compared to M (p&lt;0.0001). Local failure analyses by cohort revealed the presence of a BRCA2 mutation (HR 2.8; p=0.024) and no use of adjuvant chemotherapy (HR 5.4; p=0.0001) as significant predictors within the BCT group; presence of invasive lobular cancer (HR 9.9; p=0.004) was the only significant predictor within the M cohort. No significant differences were seen in distant failure, BC-specific or overall survival by local therapy. 15-year estimates of CBC were 52.1% with BCT; 41.4% with M; and 37.9% with M+RT (p=0.44). Analyses of BCT vs. M +/- RT and surgery +/- RT did not reveal significant differences in CBC by cohort.Conclusions: The higher risk of local failure in BRCA1/2-associated BC treated with BCT compared to M did not translate into an increased risk of distant failure or mortality. RT did not result in a detectable increase in CBC at 15 years above baseline elevated rates. These results at both the involved and contralateral breasts should be discussed when patients with BRCA1/2-associated BC are considering local treatment options.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 959.

First American experience with the Terumo DuraHeart left ventricular assist system

Since the first implantation of a left ventricular assist system (LVAS) 45 years ago, LVAS therapy has emerged as a viable option for the treatment of advanced heart failure. The current generation of LVASs in clinical evaluation has design features enabling longer and more reliable support durations. We describe the operating characteristics of the DuraHeart LVAS (Terumo Heart, Inc., Ann Arbor, MI). The DuraHeart LVAS is a magnetically-levitated centrifugal pump that began a FDA-approved clinical trial for evaluation of bridge to transplant indication in July of 2008. Magnetic levitation of the spinning-pump impeller is hypothesized to improve long-term mechanical reliability and biological compatibility of the pump. Other design features make the DuraHeart LVAS particularly suited for implantation without cardiopulmonary bypass (CPB). A description of the implant procedure for the first six American implants of the DuraHeart LVAS both on-CPB and off-CPB, including CPB techniques employed, are discussed. While it is still very early in the DuraHeart LVAS experience, the initial outcomes of the first six patient implants would suggest that the device is a safe and effective LVAS.

Phase I radiation dose-escalation trial of intensity-modulated radiotherapy (IMRT) with concurrent fixed dose-rate gemcitabine (FDR-G) for unresectable pancreatic cancer

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Background: Current treatments of non-metastatic, unresectable pancreatic cancer result in poor survival and nearly uniform local persistence of disease. We hypothesized that intensification of local therapy would result in better local control and improve survival. The primary objective of this trial was to determine maximum tolerated radiation dose delivered with IMRT and concurrent FDR-G. Methods: Eligibility included tissue diagnosis of adenocarcinoma, unresectable by radiological criteria, Zubrod performance of 0–2, ANC of ≥ 1500/mm3, platelets ≥ 100,000/mm3, creatinine < 2 mg/dl, bilirubin < 3 mg/dl, ALT and AST ≤ 2.5 x ULN, and informed consent. Patients (pts) received FDR-G (1000 mg/m2, 100-minute infusion) on days -22 and -15. IMRT started day 1 (radiation dose levels [L2-L6] 50, 52.5, 55, 57.5 and 60 Gy, all in 25 fractions) with concurrent FDR-G on days 1, 8, 22, and 29. GTV was defined on pancreas protocol CT in the treatment position. PTV was GTV plus 1 cm expansion. Active Breathing Control was used to reduce breathing motion, except in 3 pts, in whom 4D CT was used to generate an ITV. Post IMRT, up to 4 cycles of FDR-G were given. DLT was defined as GI toxicity ≥ G3, neutropenic fever, or deterioration in Zubrod to ≥3 between day 1 and 126. IMRT dose level was assigned using the Time-to-Event Continual Reassessment Method. With a sample size of 50, the design allows concurrent assessment of efficacy. Results: From 8/06, 27 pts have been accrued. DLTs have been observed in 6 (G3 anorexia, nausea vomiting, and/or dehydration [5 pts]; duodenal bleed [1 pt]). The posterior estimates of probability of DLT are 0.17, 0.21, 0.24, 0.27, and 0.28 for L2 to L6, respectively. The response rate is 52.4% (95% CI 29.8% to 74.3%). The median overall survival and progression-free survival are 23.1 months (95% CI 9–23.1) and 7.2 months (95% CI 5.0–8.0), respectively. Only 1 patient (4%) progressed locally. Two patients have undergone resection (R0), and demonstrated near- and complete pathological responses. Conclusions: High dose radiotherapy and concurrent FDR-G, utilizing the techniques above, is well tolerated and results in highly encouraging response rates, local control rates and overall survival.

No significant financial relationships to disclose.

A phase II trial of an adenovirus/PSA vaccine for prostate cancer

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Background: Our phase I adenovirus/PSA vaccine trial has proven the vaccine is safe. We are conducting a phase II clinical trial with two separate protocols for patients with recurrent or hormone-refractory prostate cancer assessing toxicity, immune responses, and change in PSA levels. Methods: In Protocol 1 men with recurrent prostate cancer after definitive initial treatment were randomized to arm A (vaccine injection alone at days 0, 30, and 60) or arm B (vaccine injection 14 days after initiation of androgen deprivation therapy). In Protocol 2 men with hormone-refractory disease receive the vaccine alone at days 0, 30, and 60. Each injection consists of 108 pfu of Ad/PSA vaccine suspended in a collagen matrix. All patients return at regular intervals for physical, chemical, radiologic, and immunologic evaluations. Twenty-five patients will be enrolled in arms A and B in Protocol 1 and 32 in Protocol 2. Results: To date 10 patients have completed 3 monthly injections and have been followed a median of 5 months. Median patient age is 70 years (range 61–84), and median enrollment PSA levels are 0.79 ng/ml (range 0.24–3.93) in Protocol 1 and 5.47 ng/ml (range 0.29–11.17) in Protocol 2. Preliminary results show 86% in both protocols demonstrating anti-PSA T cell responses above preinjection levels. 25% have stable serum PSA levels, 50% have decreased levels, and 25% have increased levels. 11% have stable serum prostatic acid phosphatase (PAP) levels, 56% have decreased levels, and 33% have increased levels. Conclusions: These early results from the first few months of this phase II trial demonstrate the induction of anti-PSA T-cell responses in a high percentage of the vaccinated patients and stabilization or declines in serum PSA and PAP levels. No serious vaccine-related toxicities have been identified.

No significant financial relationships to disclose.

Non-cardiac chest pain: a retrospective cohort study of patients who attended a Rapid Access Chest Pain Clinic

BACKGROUND

Rapid Access Chest Pain Clinics have recently been introduced to assist in the management of primary care patients experiencing suspected cardiac chest pain.

OBJECTIVE

To study the longer term outcome for patients referred to a Rapid Access Chest Pain Clinic and then given a non-cardiac diagnosis.

METHODS

The study collected retrospective data from a cohort of all patients attending the Rapid Access Chest Pain Clinic based in the cardiorespiratory Department at the York District Hospital, England. Questionnaires were sent to all patients who attended the Rapid Access Chest Pain Clinic during the previous 14 months and were diagnosed with non-cardiac chest pain. Participants reported on their chest pain, subsequent episodes of primary and secondary care and their beliefs about causation of pain.

RESULTS

Of the patients referred to the Rapid Access Chest Pain Clinic, 235 (52%) did not have cardiac chest pain. Of these patients, 161 (69%) returned the questionnaire, nearly half of whom reported ongoing chest pain. The mean time since Clinic attendance was approximately 8 months and the median duration of ongoing chest pain was 5.4 months. Women were twice as likely as men to continue to be experiencing pain but did not report more frequent or severe pain on average. More than 50% of the non-cardiac group were not convinced by their negative cardiac diagnosis.

CONCLUSION

There is an ongoing challenge to support patients with non-cardiac chest pain, including the provision of reassurance that their pain is very unlikely to be caused by their heart.

Reperfusion injury in the human forearm is mild and not attenuated by short-term ischaemic preconditioning

1. Ischaemia-reperfusion (IR) injury is an important contributor to tissue damage and has been shown to be attenuated by preconditioning (PC) in some animal models. A recent report has suggested that the forearm can be used for the study of this phenomenon in humans. We aimed to reproduce and further characterize this model. 2. Healthy young adult volunteers (mean (+/-SEM) age 32+/-6 years) were studied on two occasions. During one visit, IR alone was induced by 10 min of upper arm cuff occlusion, whereas on another occasion a PC stimulus (three 3 min cuff inflations) preceded IR. Endothelial function in the ischaemic arm was assessed by measuring arterial flow-mediated dilatation (FMD) and by calculation of forearm blood flow at baseline and 15 and 60 min after IR. Systemic venous blood was sampled from the non-ischaemic arm at baseline, after PC and at 2, 15 and 30 min after IR to assess neutrophil/leucocyte (CD11b) and platelet (bound glycoprotein IIb/IIIa and fibrinogen) activation, as well as numbers of platelet-leucocyte complexes, which were determined by flow cytometry. Because of a lack of measurable effects, the IR experiment was repeated with 20 min ischaemia in six subjects. 3. Five females and eight males completed the study. Flow-mediated dilatation was significantly impaired 30 min after IR (4.1 vs 6.2% at baseline; P<0.05);however, this was not significantly attenuated by ischaemic PC (FMD reduction at 30 min compared with baseline was 2.1+/-0.5% with IR alone and 2.6+/-1.4% with IR after PC; NS). No significant effect was seen on the number of platelet-leucocyte aggregates or on white cell or platelet activation after IR alone or after IR with PC (P>0.6 for all comparisons). Similar results were obtained in six subjects studied subjected to 20 min ischaemia. 4. In conclusion, in healthy young adults, brief periods of skeletal muscle ischaemia lead to arterial endothelial dysfunction, but no significant platelet or white cell activation. Preconditioning does not attenuate this effect on the endothelium. Further experiments with longer ischaemia times and varying PC stimuli may be necessary to produce measurable effects; however, this may prove difficult in conscious human subjects.