Impact of Chemotherapy Stock-Out on Standard Therapy Delivery Among Cancer Patients in Botswana

Background: Cancer drug shortages represent a complex global issue with potentially adverse survival outcomes. Up to 98% of oncologists and pharmacists surveyed in North America reported at least 1 drug shortage in the prior year and 66% reported at least one patient who had clinical care impacted by the shortage. In low- and middle-income countries (LMICs), these shortages are even more frequent. No studies to our knowledge have evaluated the impact of chemotherapy stock-out on receipt of standard cancer therapy in LMICs. Aim: Quantify the association between the duration of chemotherapy stock-out and the risk of having a suboptimal therapy delivery event, compared with standard delivery of therapy among cancer patients in Botswana. Methods: Prevalent cohort study of patients with cervical, breast, prostate, esophagus, Kaposi sarcoma, head and neck cancers, lung, uterine, ovarian and colorectal cancers who received any systemic therapy between 01/01/16-12/31/16 at Princess Marina Hospital, Botswana. Primary exposure was stock-out duration per cycle interval calculated by generating a code for the six different patterns for chemotherapy stock-out, using stock data at the Central Medical Stores. Primary outcome was suboptimal therapy delivery defined as a dose reduction, dose delay or switch in intended therapy. We measured statistical associations using two sample t-test and mixed effects univariate and multivariate logistic regression models. Results: 378 patients were identified who met diagnostic criteria and received systemic chemotherapy in 2016. Of these, 293 received commonly prescribed standard regimens who contributed 1452 cycle intervals and were included in our analysis. Majority of the patients (48%) had breast cancer. The mean duration of stock-out for receipt of standard therapy without events was 3.2 days (95% CI: 2.8-3.7) compared with 7.8 days for patients who had a suboptimal therapy delivery event (95% CI: 6.6-9) ( P < 0.0001). Male sex, age < 65 and HIV-positive status were also significantly associated with an increased risk of experiencing dose reduction, change in therapy or switch in therapy. Adjusting for these factors in a mixed effects logistic regression, each week of stock-out was independently associated with an 80% increased risk of having a suboptimal therapy delivery event (OR=1.8 (95% CI: 1.6-2.0, P < 0.0001)). Conclusion: Chemotherapy stock-out is independently associated with an 80% increased risk of a patient experiencing dose reduction, change in therapy or delay in therapy. The risk increases with longer duration of stock out. Given prior data showing that these events lead to worse survival outcomes, our further analysis is focusing on quantifying risk of stock-out on survival outcomes in this population. to determine whether interventions promoting standard therapy delivery are warranted to optimize survival outcomes.

First Things First: Adopting a Holistic, Needs-Driven Approach to Improving the Quality of Routinely Collected Data

Background and context: Routine collection of quality oncology data remains underprioritized in resource limited settings. For breast cancer (BC) care at Princess Marina Hospital (PMH) in Botswana, this hampers its use for oncology program evaluation and clinical research. The Peo Data Acquisition Core (DAC), part of a consortium for planning of a noncommunicable diseases center for research excellence in Southern Africa, engaged relevant stakeholders and departments at PMH to establish health care worker driven processes that support sustained improvements in the quality of routinely collected breast cancer data. Aim: Assess PMH BC care needs to support the improvement of routinely collected data. Strategy/Tactics: Conventional routine data quality assessments guide iterative identification of data quality gaps for improvement, but tend to consume additional human resources to implement and prioritize data quality over existing provider concerns. We undertook a holistic approach to identifying needs challenging the improvement of data routinely collected about PMH BC patients. Program/Policy process: A need assessment began with mapping of patient care process, capturing process steps, including subprocesses, actors, and an inventory of related data capture systems. The assessment also gathered care providers' perceptions of challenges to providing care as well as perceptions of the up-time of an existing electronic health record (EHR). Outcomes: BC patient management involves multiple care providers who attend to patients in different locations within the hospital. Except for EHR captured laboratory data, nearly all other documentation of patient care occurred through paper-based registers, diaries and general clinical forms. Providers indicated the overbooking of patient appointments and use of different formats to manage patient data as key challenges for them. EHR appointment scheduling components appear underutilized by providers, and a brief monitoring of provider perceptions of the EHR's speed and reliability suggests it is poorest in the mornings - at a time when providers are the busiest attending to patients. What was learned: Needs assessment findings suggest several opportunities to respond to provider recognized challenges through greater adoption of EHR usage. Establishment of a Quality Improvement (QI) group that champions improvements in routine BC data quality should integrate standardization of patient data formats and EHR centralized appointment booking. QI group composition should include both care providers and an EHR IT technician.

Patterns of Treatment Noninitiation and Early Loss to Follow-Up in Breast Cancer Care in Haiti

Background: Loss to follow-up after treatment initiation is a recognized and well-studied problem in cancer care programs in low- and low-middle income countries (LMIC). However, there is less literature on causes of treatment noninitiation in LMIC breast cancer programs. Hôpital Universitaire de Mirebalais (HUM) in Haiti established the main public comprehensive cancer center in the country in 2013. The facility is located in the Centre Department but serves patients from all the other nine departments (regions) of the country. Care provided within the facility is free after an initial nominal deposit, as a result of a multi-institutional collaboration with Zanmi Lasante, a local arm of Partners In Health, an international nonprofit organization, and US academic institutions. Aim: To determine the causes of treatment noninitiation and early loss to follow-up (LTFU) among a retrospective cohort of patients seen in the HUM breast cancer program. Methods: We evaluated 1371 women who had their first visit between July 1, 2013 and December 31, 2016. The list of breast cancer patients was generated from electronic medical record diagnosis codes. We identified individuals who were followed for less than 90 days (Under-90). We reviewed the patient's record to determine reason for care noninitiation and early losses. We used logistic regression analysis to determine if distance from HUM contributed to being Under-90, while controlling for demographic factors. Results: 339 (24.6%) patients in the breast cancer program were seen for less than 90-days. The two most common periods of early LTFU were prior to obtaining diagnostic biopsy (113 patients- 33%), and after referral for staging diagnostic imaging (83 patients- 24%). 49 patients (14%) had confirmed diagnosis and completed staging but never initiated treatment, while only 23 (7%) did not initiate treatment due to confirmed advanced metastatic disease or death. Majority of the patients 1254 (91.5%) came from outside the Centre region; early LTFU was more common among these patients (25.6%) compared with Centre region patients (16.2%). Using logistic regression analysis, controlling for age and rural/urban home classification, we found that the odds of Under-90 was 2.05 (95% CI: 1.22-3.45), P = 0.007, for those living outside the Centre region, compared with living in hospital's region. We repeated the analysis comparing the Centre region to the immediately adjacent regions, and more distant regions; we found the odds of Under-90 was 1.88 (95% CI: 1.12-3.18) for the adjacent regions, and 2.92 (95% CI: 1.61-5.31) for the distant regions. Conclusion: Treatment noninitiation and early losses are a significant problem in the HUM breast cancer program. As anticipated, living farther from HUM increased the odds of early LTFU. Effective interventions are needed to reduce the number of patients failing to initiate therapy, and these interventions must begin at the first contact with the oncology program.

Association Between Living in Urban Areas and Obesity in Haitian Breast Cancer Patients

Background: Obesity and metabolic syndrome (MS) have been linked to increased risk of breast cancer recurrence and mortality in prospective cohorts. These studies have mostly occurred in high-income countries. Little is known about rates of obesity and what factors predict obesity in breast cancer patients from low- and low-middle income countries (LMIC). However, there are increasing rates of obesity in the general population of LMICs. Hôpital Universitaire de Mirebalais (HUM) in Haiti established the main public comprehensive cancer center in the country in 2013. The facility serves patients from all around the country. Aim: To establish the prevalence of obesity in a retrospective cohort of breast cancer patients at HUM, and evaluate the association between living in urban areas and obesity in this population. Methods: We evaluated 1035 women who had their first visit between July 1, 2013 and December 31, 2016, with a coded diagnosis of breast cancer, and who had been followed in the HUM program for ≥ 90 days. We abstracted their first recorded height, weight and blood pressure (BP). We identified individuals who met criteria for obesity (body mass index [BMI] ≥ 30 kg/m2), systolic hypertension (systolic BP [SBP] ≥ 135 mmHg), and diastolic hypertension (diastolic BP [DBP] ≥ 90 mmHg). After exclusion of missing data in the variables of interest, the final analysis cohort was 678. We classified home commune location as rural or urban based on World Bank and UN standards. We used logistic regression analysis to determine the odds of being obese for individuals living in urban areas compared with rural dwellers. Results: 179 breast cancer patients (26.4%) had BMI ≥ 30, of which 58 (8.5%) were morbidly obese (BMI ≥ 35). 309 (45.6%) patients had systolic hypertension (HTN) and 180 (26.6%) had diastolic HTN. 417 (61.5%) lived in urban areas; 125 (30%) of urban dwellers were obese while only 20.7% of rural dwellers were obese. The crude OR for obesity in urban versus rural areas was 1.64 (95% CI: 1.16-2.36). Using logistic regression analysis and controlling for age the OR for obesity in urban areas was 1.67 (95% CI: 1.15-2.40), P = 0.0162. We did a similar analysis for morbid obesity, while controlling for age, the OR in urban compared with rural patients was 2.16 (95% CI: 1.15-4.03), P = 0.0162. There were no statistically significant differences in SBP and DBP comparing rural and urban patients. Conclusion: HUM breast cancer patients from urban areas were more likely to be obese than rural dwellers. Urban patients were twice as likely to be morbidly obese. There were no differences in HTN between the groups. Higher rates of obesity in the HUM breast cancer population is partly driven by the higher proportion of urban patients. Further studies need to be done to evaluate the causes and mediators of obesity as well as its effect on patient cancer outcome in Haiti.

Workforce Capacity and Capability Building Through Metrics-Based Mentoring Partnerships

Background: Globally, cancer is the second leading cause of death. Low- and middle-income countries (LMICs) especially lack the sufficient healthcare and oncology workforces needed to screen, diagnose and treat individuals with cancer. While traditional academic and training programs designed to produce healthcare professionals in these countries fill a critical role, few programs exist that maintain, develop, and increase the knowledge, skills, and professional performance of current healthcare and oncology workforces. Mentoring partnerships and twinning programs can provide ongoing education and training that strengthen and build workforce capacity and capability for the full scope of cancer care. Aim: The goal is to achieve resource-appropriate multimodality cancer-care using guideline- and protocol-based education and training and also to develop the capability to conduct world quality research. The model utilizes in-person, in-country site visits lasting from several weeks to months and ongoing connectivity through weekly telemedicine video conferences. Methods: The International Cancer Expert Corps (ICEC) and partner organizations are establishing a network of global and multisectoral partnerships that builds human capacity and capability needed to establish sustainable cancer programs that function at world-class standards. The three-fold mentor-mentee approach ( www.iceccancer.org ) is built by 1) enlisting hubs of expertise to include academic medical centers/universities, private practices and an ICEC Central Hub, 2) enrolling the breadth of expert-mentors needed from a university, practice, professional society and interested individuals, and 3) identifying centers in LMICs - clinics/hospitals/and other care delivery sites in underserved areas, and associates - physicians/allied healthcare workers- seeking mentoring and education. Results: Recent implementation of the ICEC 5-Step Progression Plan provides guidance and serves as an assessment tool for measuring progress between the hubs-centers programs and expert-associate. Twinning programs (hubs-ICEC centers) have been established in multiple sites worldwide including in Africa, Asia and Eurasia. Conclusion: Implementation of the ICEC 5-Step Progression Plan provides a platform from which to track the current stages and progress of twinning mentor-mentee programs, and to evaluate new programs. This information guides the programs and also provides metric-based investment in global health. Critically as the skills in associates and ICEC centers grows, they achieve expert-mentor status and centers become hubs to serve the surrounding regions, thereby enabling geometric growth in cancer care to meet the needs of the growing global burden of cancer. The content is the personal opinion of the authors and not their organizations.

Abstract P1-06-08: Independent validation of EarlyR gene signature in E2197: A randomized clinical trial comparing doxorubicin plus docetaxel to doxorubicin plus cyclophosphamide as adjuvant chemotherapy in breast cancer

Background: EarlyR is a prognostic gene signature score in ER+ breast cancer (BC) computed from the expression values of ESPL1, SPAG5, MKI67, PLK1 and PGR using a nonlinear mathematical formula. EarlyR has been validated in multiple cohorts profiled on Affymetrix and Illumina microarrays and by RNA-seq. This study sought to assess the prognostic features of EarlyR in a cohort of E2197.

Patients and Methods: Illumina DASL assay was used to measure gene expression in FFPE tissue of primary BC from a case-cohort sampling subset of women in E2197 treated with doxorubicin plus docetaxel (AT) or doxorubicin plus cyclophosphamide (AC). ER+ patients received hormone therapy at physician's discretion. After 79.5 months median follow-up, disease-free survival was 85% in both treatment arms. Among patients centrally reviewed with sufficient RNA material for the DASL assay, 319 with ER+ status and assessed for EarlyR are included in the analytic cohort. EarlyR scores and pre-specified risk strata (≤25=low, 26-75=intermediate, &gt;75=high) were computed, while blinded to clinical data. The analysis endpoint was disease-free survival (DFS), defined as the time from randomization to date of invasive BC recurrence or death from any cause within 8 years. Weighted Cox proportional hazards models were used to associate EarlyR score or risk strata with DFS. Variances of the estimated coefficients were adjusted to account for the case-cohort design.

Results: The distribution of the EarlyR risk groups was 59% low, 11% intermediate and 30% high risk in this ER+ cohort. The continuous EarlyR score was significantly prognostic of DFS up to 8 years after randomization (p = 0.02). Patients with low EarlyR score (≤ 25) had significantly lower risk of BC recurrence within 8 years (p = 0.031, univariate HR=0.562, 95%CI: 0.334-0.948) compared to those with high EarlyR score (&gt; 75). Analysis within the AC arm showed that patients with low EarlyR score had significantly lower risk of 8-year BC recurrence (p = 0.023, univariate HR=0.392, 95%CI: 0.175-0.878) compared to those with high EarlyR score. Within the AT arm there was no significant difference in 8-year DFS prognosis between any of the EarlyR risk groups.

Conclusions: This study confirmed the prognostic significance of EarlyR using FFPE tissue in a cohort of patients treated with AC chemotherapy from E2197. Patients with high EarlyR score who were treated with AC had significantly higher risk of recurrence than low EarlyR score patients treated with AC. On the other hand, prognosis of high EarlyR score AT-treated patients was not significantly lower than the prognosis of low EarlyR score AT-treated patients. Further study in a larger cohort is needed to assess the relative benefits of AC versus AT within the EarlyR high risk group and the EarlyR low risk group.

Citation Format: Badve S, Wang V, Willis S, Leyland-Jones B, Gokmen-Polar Y, Shulman L, Martino S, Sparano J, Davidson N, Goldstein L, Buechler S. Independent validation of EarlyR gene signature in E2197: A randomized clinical trial comparing doxorubicin plus docetaxel to doxorubicin plus cyclophosphamide as adjuvant chemotherapy in breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-06-08.

Involvement of Interleukin-6 in the Autocrine Stimulation of Chronic Lymphocytic Leukemia B Cells by Tumor Necrosis Factor

Tumor necrosis factor α (TNFα) acts as an autocrine growth factor in chronic B cell malignancies. TNF also induces production of interleukin 6 (IL-6) which stimulates B cell growth and differentiation. We have previously demonstrated increased TNFα production by (Rai) stage 0 chronic lymphocytic leukemia (B-CLL) cells and the absence of TNF production by cells from stage IV patients. In an attempt to elucidate a possible role for TNF in the malignant progression of B-CLL we investigated the possibility of IL-6 involvment in the stimulatory action of TNF on B-CLL cells. We observed that: (1) the in vitro proliferative response of B-CLL cells to recombinant human (rh)THFα was consistently inhibited by a monoclonal antibody (MoAb) against IL-6, (2) the release of IL-6 by B-CLL cells could be augmented by rhTNFα, (3) no differences were detected in the foregoing parameters between stage 0 and stage IV-derived cells and (4) despite the inhibitory action of an anti-IL-6 MoAb on the TNF-induced proliferative response of B-CLL cells, IL-6 receptor expression was undetectable in these cells. Although these findings are suggestive of an autocrine or paracrine mechanism involving TNF and IL-6, the importance of the release and action of these cytokines in the regulation of B-CLL cell growth and malignant progression still remains to be elucidated.

Modeling the spread of polio in an IPV-vaccinated population: lessons learned from the 2013 silent outbreak in southern Israel

BACKGROUND

Polio eradication is an extraordinary globally coordinated health program in terms of its magnitude and reach, leading to the elimination of wild poliovirus (WPV) in most parts of the world. In 2013, a silent outbreak of WPV was detected in Israel, a country using an inactivated polio vaccine (IPV) exclusively since 2005. The outbreak was detected using environmental surveillance (ES) of sewage reservoirs. Stool surveys indicated the outbreak to be restricted mainly to children under the age of 10 in the Bedouin population of southern Israel. In order to curtail the outbreak, a nationwide vaccination campaign using oral polio vaccine (OPV) was conducted, targeting all children under 10.

METHODS

A transmission model, fitted to the results of the stool surveys, with additional conditions set by the ES measurements, was used to evaluate the prevalence of WPV in Bedouin children and the effectiveness of the vaccination campaign. Employing the parameter estimates of the model fitting, the model was used to investigate the effect of alternative timings, coverages and dosages of the OPV campaign on the outcome of the outbreak.

RESULTS

The mean estimate for the mean reproductive number was 1.77 (95 % credible interval, 1.46-2.30). With seasonal variation, the reproductive number maximum range was between zero and six. The mean estimate for the mean infectious periods was 16.8 (8.6-24.9) days. The modeling indicates the OPV campaign was effective in curtailing the outbreak. The mean estimate for the attack rate in Bedouin children under 10 at the end of 2014 was 42 % (22-65 %), whereas without the campaign the mean projected attack rate was 57 % (35-74 %). The campaign also likely shortened the duration of the outbreak by a mean estimate of 309 (2-846) days. A faster initiation of the OPV campaign could have reduced the incidence of WPV even if a lower coverage was reached, at the risk of prolonging the outbreak.

CONCLUSIONS

OPV campaigns are essential for interrupting WPV transmission, even in a developed country setting with a high coverage of IPV. In this setting, establishing ES of WPV circulation is particularly crucial for early detection and containment of an outbreak.

Tracking intervention delivery in the ‘Tobacco-Free Teachers/Tobacco-Free Society’ program, Bihar, India

In health education and behavior change interventions, process tracking monitors the delivery of an intervention and its receipt to the intended audience. A randomized controlled trial in the state of Bihar, India was conducted to help school teachers become tobacco free through appropriately designed intervention program and delivery system. We describe the results from process tracking of this intervention delivery. The intervention program was centred on six topics delivered in each school through 12 sessions over 6 successive months. The program deliverers recorded the process measures as total number of sessions and program-components implemented (fidelity); time spent conducting sessions (dose) and proportion of teachers attending at least one session (reach). The outcome measures (teachers’ exposure to intervention messages and tobacco policy adoption) were assessed post-intervention. All 12 sessions were delivered in 33 out of 36 schools. Thirty-one schools implemented all six program components. In 18 schools, ≥95% of the teachers participated in one or more sessions. Thirty-three schools received 12 or more hours of dose. In 29 schools, 100% teachers reported exposure to all program messages. Tobacco policy was adopted by all schools. Thus, the intervention was generally delivered as planned and it had a positive impact on teachers and schools.

Neurophysiological indices of atypical auditory processing and multisensory integration are associated with symptom severity in autism

Atypical processing and integration of sensory inputs are hypothesized to play a role in unusual sensory reactions and social-cognitive deficits in autism spectrum disorder (ASD). Reports on the relationship between objective metrics of sensory processing and clinical symptoms, however, are surprisingly sparse. Here we examined the relationship between neurophysiological assays of sensory processing and (1) autism severity and (2) sensory sensitivities, in individuals with ASD aged 6-17. Multiple linear regression indicated significant associations between neural markers of auditory processing and multisensory integration, and autism severity. No such relationships were apparent for clinical measures of visual/auditory sensitivities. These data support that aberrant early sensory processing contributes to autism symptoms, and reveal the potential of electrophysiology to objectively subtype autism.

Severity of depression and anxiety are predictors of response to antidepressant treatment in Parkinson's disease

BACKGROUND

Antidepressants have appeared to be more effective than placebo treatment in treating depressive syndromes in patients with Parkinson's disease (PD).

OBJECTIVE

To identify factors that predict improvement in depressive symptoms during antidepressant treatment in depressed PD patients.

METHODS

A secondary analysis was performed on the dataset of the Randomized Placebo-controlled Study of Antidepressants in PD (SAD-PD), in which 76 patients received active treatment with either paroxetine or venlafaxine extended release (XR), and 39 patients received placebo treatment. Backward stepwise regression analyses were conducted with change in 24-item Hamilton Depression Rating Scale (HAMD-24) score between assessments at baseline and week 12 as the main outcome measure, and sex, age, baseline HAMD-24 score, Unified Parkinson's Disease Rating Scale section III (UPDRS-III) score, Mini-Mental State Examination (MMSE), and the Clinical Anxiety Scale (CAS) as independent variables.

RESULTS

In both the active treatment and placebo groups, higher baseline HAMD-24 score and lower UPDRS-III score were associated with greater reduction in HAMD-24 score. Higher anxiety scores predicted less response in the active treatment group. Higher MMSE scores predicted greater response only in the placebo-treated group. Sex and age were no predictors of response.

CONCLUSIONS

Higher pre-treatment depression scores and lower pre-treatment anxiety scores are the two most important predictors for improvement during antidepressant treatment in depressed PD patients, which is in line with those found in treatment studies of depressed non-PD patients. Furthermore, our results indicate the requirement for different or more intensive treatment for depressed PD patients with more severe anxiety symptoms.

A randomized, double-blind, placebo-controlled trial of antidepressants in Parkinson disease

OBJECTIVE

To evaluate the efficacy and safety of a selective serotonin reuptake inhibitor (SSRI) and a serotonin and norepinephrine reuptake inhibitor (SNRI) in the treatment of depression in Parkinson disease (PD).

METHODS

A total of 115 subjects with PD were enrolled at 20 sites. Subjects were randomized to receive an SSRI (paroxetine; n = 42), an SNRI (venlafaxine extended release [XR]; n = 34), or placebo (n = 39). Subjects met DSM-IV criteria for a depressive disorder, or operationally defined subsyndromal depression, and scored >12 on the first 17 items of the Hamilton Rating Scale for Depression (HAM-D). Subjects were followed for 12 weeks (6-week dosage adjustment, 6-week maintenance). Maximum daily dosages were 40 mg for paroxetine and 225 mg for venlafaxine XR. The primary outcome measure was change in the HAM-D score from baseline to week 12.

RESULTS

Treatment effects (relative to placebo), expressed as mean 12-week reductions in HAM-D score, were 6.2 points (97.5% confidence interval [CI] 2.2 to 10.3, p = 0.0007) in the paroxetine group and 4.2 points (97.5% CI 0.1 to 8.4, p = 0.02) in the venlafaxine XR group. No treatment effects were seen on motor function.

CONCLUSIONS

Both paroxetine and venlafaxine XR significantly improved depression in subjects with PD. Both medications were generally safe and well tolerated and did not worsen motor function.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that paroxetine and venlafaxine XR are effective in treating depression in patients with PD.

Qualitative needs assessment of HIV services among Dominican, Mexican and Central American immigrant populations living in the New York City area

This paper reports on research designed to assess access to care by Latino immigrant populations in the New York area. A qualitative approach and methods were employed, involving focus groups with PLWAs (persons living with AIDS) and affected men and women from Mexico, the Dominican Republic and Central America to explore the perceptions, beliefs, experiences and knowledge of HIV care issues. A total of 57 men and women participated, ranging in age from 19-61. Results included detailed information on cultural meanings of HIV/AIDS; experience of stigma and rejection; gendered health-seeking behaviour; testing issues; and satisfaction with services. Data support the conclusion that to be effective in reaching and providing services to these immigrant groups, it is crucial to understand the environment from which they come and the impact of immigration. Poverty, repressive governments, lack of education/literacy, ethnicity, class, colour-based stigma and cultural norms are crucial factors in determining their attitudes, motivations, decisions and behaviour. AIDS agencies were seen to play a crucial role in connecting PLWAs to services and resources. The key elements for the provision of services to this population appear to be those that build on cultural norms and network human and institutional resources.

Gene Expression Profiling of Phenotypically-Defined Hormone-Receptor Positive Breast Cancer: Evidence for Increased Transcriptional Activity of the Insulin Growth Factor Receptor Pathway and Other Pathways

Background: Approximately 70% of all breast cancers are hormone receptor (HR)-positive tumors that are sensitive to endocrine therapy, but some patients have recurrence despite adjuvant endocrine therapy. We performed an exploratory analysis of gene expression in HR-pos operable breast cancer in order to identify potential novel therapeutic targets and biomarkers associated with recurrence. Methods: RNA was extracted from primary tumor samples obtained from 776 patients with stage I-III breast cancer treated with adjuvant chemohormonal therapy in trial E2197 (JCO 2008; 26: 4092-4099), of whom 458 had HR-pos disease (defined in a central lab; JCO 2008; 26: 2473). We evaluated RNA expression patterns (by quantitative RT-PCR using a panel of 371 rationally selected genes) in HR-pos cases compared with the HR-neg cases using weighted T statistics, and determined which genes in the HR-pos, HER2-neg group were associated with recurrence (using Cox proportional hazards model score test, Korn's adjusted P value &lt;5% with false discovery rate &lt; 10%).Results: The top 10 genes exhibiting significantly higher expression in the HR-pos group (p≤ 6.17e-160) included ESR1 plus 5 estrogen regulated genes, confirming our approach of evaluating gene expression in phenotypically-defined subsets. Other pathways that exhibited higher expression in the HR-pos group (among the 40 top genes with higher expression, p&lt;8.66e-53) included the insulin growth factor (IGF) (IRS1, IGFR1, IGFB2), Ras (RhoB, RhoC, RAB27B, GGPS1), and HER pathways (ERBB2, ERBB3, ERBB4), and other genes involved in apoptosis (BCL2, BCL2L1, BAG1, NME6, BBC3), signaling (MAPK3, SEMA3F, RXRA), mismatch repair (MSH3), cell cycle regulation (CCND1), stress response (HSPB1), and tumor suppressor genes (TP53BP1, APC). These patterns were similar in HER2-pos cases. Pathway analysis (Ingenuity) revealed substantial interconnectivity among these genes, especially between IGFR1, ERB2/3/4, MAPK3, BCL2, and CCND1, but not RhoB/RhoC. Genes for which increased expression was associated with increased recurrence included those associated with proliferation (TOP2A, AURKB, PLK1) and apoptosis (BIRC5 - survivin).Conclusions: This exploratory analysis reveals several pathways that exhibit higher transcriptional expression in HR-pos disease, some of which are also associated with a higher risk of recurrence, suggesting that they may be potential therapeutic targets. This provides rationale for testing agents currently available in the clinic that inhibit the IGF and other pathways.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5165.

Copy number variations in three children with sudden infant death

Sudden death of an infant is a devastating event that needs an explanation. When an explanation cannot be found, the case is labeled as sudden infant death syndrome or unclassified sudden infant death. The influence of genetic factors has been recognized for sudden infant death, but copy number variations (CNVs) as potential risk factors have not been evaluated yet. Twenty-seven families were enrolled in this study. The tissue specimens from deceased children were obtained and array-based comparative genomic hybridization (array-CGH) experiments were performed on the genomic DNA isolated from these specimens using Agilent Technologies Custom 4 x 44K arrays. Quantitative polymerase chain reaction experiments were performed to confirm the overlapping duplication and deletion region in two different cases. A de novo CNV is detected in 3 of 27 cases (11%). In case 1, an approximately 3-Mb (chr 8: 143,211,215-qter) duplication on 8q24.3-qter and a 4.4-Mb deletion on the 22q13.3-qter (chr 22: 45,047,068-qter) were detected. Subtelomeric chromosome analysis of the father and the surviving sibling of case 1 showed a balanced reciprocal translocation, 46,XY,t(8;22)(q24.3;q13.3). A 240-kb (chr 6: 26,139,810-26,380,787) duplication and a 1.9-Mb deletion (chr 6: 26,085,971-27,966,150) at chromosome 6p22 were found in cases 2 and 3, respectively. Array-CGH and conventional cytogenetic studies did not reveal the observed CNVs in the parents and the siblings of cases 2 and 3. The detected CNVs in cases 2 and 3 encompassed several genes including the major histone cluster genes. Array-CGH analysis may be beneficial during the investigations after sudden infant death.

Mosquito vectors of West Nile Fever in Israel

West Nile fever (WNF) is endemic in Israel. In 1999, country-wide adult mosquito surveys were initiated and intensified after the 2000 country-wide outbreak of WNF in humans. In 8 consecutive yr, groups of male and female specimens of different species and from different locations were tested for infection with West Nile virus (WNV). Three species made up >87% of the total catch: Culex pipiens L. (52%), with an infection rate (IR) of 0.5; Cx. perexiguus Theobald (20%), with an IR of 2.7; and Aedes caspius Pallas (15%), with an IR of 0.6. The geographical and temporal distribution of WNV-infected mosquitoes was similar but was not parallel to the seasonal abundance of the populations. The seasonal occurrence of human cases is in correlation with the finding of WNV-positive mosquito specimens reaching a peak 1 mo later than the mosquito peak. The relative importance of the mosquito species in the epidemiology of WNF is discussed. Cx. perexiguus is considered the major vector of WNF in Israel.

Fatigue in levodopa-naive subjects with Parkinson disease

BACKGROUND

Fatigue is a common complaint in Parkinson disease (PD). We investigated fatigue in a cohort of previously untreated patients with early PD enrolled in the Earlier vs Later Levodopa (ELLDOPA) clinical trial.

METHODS

A total of 361 patients were enrolled in the randomized, double-blind, placebo-controlled ELLDOPA trial and assigned to receive placebo or carbidopa-levodopa 37.5/150 mg, 75/300 mg, or 150/600 mg daily for 40 weeks, followed by a 2-week medication washout period. Subjects who scored >4 on the Fatigue Severity Scale were classified as fatigued. PD severity was assessed using the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn-Yahr scale, and Schwab-England Activities of Daily Living Scale. A subgroup of subjects underwent [(123)I]-beta-CIT SPECT to measure striatal dopamine transporter density.

RESULTS

Of the 349 ELLDOPA subjects who completed fatigue measures, 128 were classified as fatigued at baseline. The fatigued group was significantly more impaired neurologically (UPDRS, all subscales and Hoehn and Yahr staging) and functionally (Schwab-England Scale) but no significant differences were observed in beta-CIT measurements between the two groups. Analysis of covariance showed a greater increase in fatigue score from baseline to the end of the 2-week washout in the placebo group (0.75 points) than in the three groups receiving levodopa (increases of 0.30 [150 mg/day], 0.36 [300 mg/day], and 0.33 [600 mg/day]; p = 0.03 for heterogeneity).

CONCLUSIONS

Fatigue is a frequent symptom in early, untreated, non-depressed patients with Parkinson disease (PD), affecting over 1/3 of the patients in this cohort at baseline and 50% by week 42. Fatigue was associated with the severity of PD, and progressed less in patients treated with levodopa.

Measles outbreaks affecting children in Jewish ultra-orthodox communities in Jerusalem

In 2003 and 2004 two measles outbreaks occurred in Jewish ultra-orthodox communities in Jerusalem. The index case of the first outbreak (March 2003) was a 2-year-old unvaccinated child from Switzerland. Within 5 months, 107 cases (mean age 8.3+/-7.5 years) emerged in three crowded neighbourhoods. The first cases of the second outbreak (June 2004) were in three girls aged 4-5 years in one kindergarten in another community. By November 2004, 117 cases (mean age 7.3+/-6.5 years) occurred. The virus genotypes were D8 and D4 respectively. Altogether, 96 households accounted for the two outbreaks, with two or more patients per family in 79% of cases. Most cases (91.5%) were unvaccinated. Immunization coverage was lower in outbreak than in non-outbreak neighbourhoods (88.3% vs. 90.3%, P=0.001). Controlling the outbreaks necessitated a culture-sensitive approach, and targeted efforts increased MMR vaccine coverage (first dose) to 95.2%. Despite high national immunization coverage (94-95%), special attention to specific sub-populations is essential.

Mutant p53 protein in serum could be used as a molecular marker in human breast cancer

p53 wild-type is a tumor suppressor gene involved in DNA gene transcription or DNA repair mechanisms. When damage to DNA is unrepairable, p53 induces programmed cell death (apoptosis). The mutant p53 gene is the most frequent molecular alteration in human cancer, including breast cancer. Here, we analyzed the genetic alterations in p53 oncogene expression in 55 patients with breast cancer at different stages and in 8 normal women. We measured by ELISA assay the serum levels of p53 mutant protein and p53 antibodies. Immunohistochemistry and RT-PCR using specific p53 primers as well as mutation detection by DNA sequencing were also evaluated in breast tumor tissue. Serological p53 antibody analysis detected 0/8 (0%), 0/4 (0%) and 9/55 (16.36%) positive cases in normal women, in patients with benign breast disease and in breast carcinoma, respectively. We found positive p53 mutant in the sera of 0/8 (0.0%) normal women, 0/4 (0%) with benign breast disease and 29/55 (52.72%) with breast carcinoma. Immunohistochemistry evaluation was positive in 29/55 (52.73%) with mammary carcinoma and 0/4 (0%) with benign breast disease. A very good correlation between p53 mutant protein detected in serum and p53 accumulation by immunohistochemistry (83.3% positive in both assays) was found in this study. These data suggest that detection of mutated p53 could be a useful serological marker for diagnostic purposes.

Localized thigh swelling mimicking a neoplastic process: involvement of coxsackie virus type A21

A 4-y-old girl was admitted because of a left leg limp with an isolated swollen upper thigh and normal muscle enzymes. A radioisotope scan showed increased uptake especially in the bone and soft tissue of the left thigh, while magnetic resonance imaging of that region demonstrated widespread oedema in striated muscle. On muscle biopsy perivascular infiltrates were demonstrated but muscle fibres were not shown to be affected. Sequence analysis of reverse transcription-polymerase chain reaction amplified fragments from the 5'-non-coding region of human enteroviruses identified a local strain of coxsackie virus A21 in the muscle. Clinical symptomatology subsided with oral steroids.

CONCLUSION

Local swelling mimicking a neoplasm may be related to infestation of coxsackie virus in muscle tissue.

West Nile fever in Israel 1999-2000: from geese to humans

West Nile virus (WNV) caused disease outbreaks in Israel in the 1950s and the late 1970s. In 1998 an outbreak of WNV in goose farms and evidence of infection in dead migratory birds were reported. Consequently, human diagnostic services for WNV were resumed, including virus isolation, serology, and RT-PCR. Risk factors for infection were assessed by a serological survey in 1999, which revealed a seroprevalence of (a) 86% in people who had close contact with sick geese, (b) 28% in people in areas along bird migration routes, and (c) 27% in the general population. Following two fatal cases in Tel Aviv in September 1999 and one encephalitis case in the southern Eilot region, a regional serological survey was initiated there. The survey revealed two more WNV-associated acute encephalitis cases, an IgG seroprevalence of 51%, and an IgM seroprevalence of 22%. In the summer of 2000, acute cases of WN disease were identified in the central and northern parts of Israel, involving 439 people. The outbreak started in mid-August, peaked in September, and declined in October, with 29 fatal cases, primarily in the elderly. During the outbreak, diagnosis was based on IgM detection. Four virus isolates were subsequently obtained from preseroconverted frozen sera. Sequence and phylogenetic analysis of 1662 bases covering the PreM, M, and part of the E genes revealed two lineages. One lineage was closely related to a 1999 Israeli bird (gull) isolate and to a 1999 New York bird (flamingo) isolate, and the other lineage was closely related to a 1997 Romanian mosquito isolate and to a 1999 Russian human brain isolate.

Language regression in childhood

Language regression is observed both in autistic regression and as part of acquired epileptic aphasia (Landau-Kleffner Syndrome). We prospectively identified 177 children with language regression at four major medical centers, and their clinical characteristics were recorded. Their mean age at regression was 22.8 months. The mean time-to-specialist referral was 38 months of age. Most children (88%) met criteria for autism or manifested autistic features. Males (P = 0.02) and children less than 3 years of age who regressed (P = 0.016) had a higher probability of developing autistic behaviors. Seizures were more common in children who regressed after they reached 3 years of age (P < 0.001), and children with seizures were less likely to have associated autistic regression (P < 0.001). Electroencephalogram abnormalities were reported in 37% of patients and were more common in children with seizures (P < 0.001). At last follow-up, language function was impaired in 88% of the children, although some improvement was noted in 57%. We conclude that the loss of previously acquired language at any age, even if that language only includes a few words or communicative gestures, is often associated with a more global regression in cognition and/or behavior and has serious implications for future function. Early identification and referral of these children is necessary to allow for diagnosis and intervention.

A randomized, controlled trial of remacemide for motor fluctuations in Parkinson's disease

BACKGROUND

Preclinical studies suggest that glutamate antagonists help ameliorate motor fluctuations in patients with PD treated with levodopa.

METHODS

In a multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-ranging study, the authors assessed the safety, tolerability, and efficacy of the glutamate receptor blocker remacemide hydrochloride in 279 patients with motor fluctuations treated with levodopa. The primary objective was to assess the short-term tolerability and safety of four dosage levels of remacemide during 7 weeks of treatment. Patients were also monitored with home diaries and the Unified PD Rating Scale (UPDRS) to collect preliminary data on treatment efficacy.

RESULTS

Remacemide was well tolerated up to a dosage of 300 mg/d on a twice daily schedule and 600 mg/d on a four times daily schedule. The most common dosage-related adverse events were dizziness and nausea, as observed in previous studies of remacemide. The percent "on" time and motor UPDRS scores showed trends toward improvement in the patients treated with 150 and 300 mg/d remacemide compared with placebo-treated patients, although these improvements were not significant.

CONCLUSION

Remacemide is a safe and tolerable adjunct to dopaminergic therapy for patients with PD and motor fluctuations. Although this study had limited power to detect therapeutic effects, the observed improvement is consistent with studies of non-human primates with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced parkinsonian signs and symptoms. Additional studies are warranted to confirm these results over an extended period of observation, and to explore the potential neuroprotective effects of remacemide in slowing the progression of PD.

Effect of premedication guidelines and leukoreduction on the rate of febrile nonhaemolytic platelet transfusion reactions

Platelet transfusion reactions were prospectively studied in haematology/oncology patients at five university teaching hospitals over three consecutive summers. The initial summer study provided baseline information on the use of premedications and the rate of platelet transfusion reactions (fever, chills, rigors and hives). Most (73%) platelet recipients were premedicated and 30% (95% CI 28-33%) of transfusions were complicated by reactions. The second study followed implementation of guidelines for premedicating platelet transfusions. Despite a marked reduction in premedication (50%), there was little change in the platelet transfusion reaction rate, 26% (95% CI 24-29%), or the type of reactions. The third study followed implementation of prestorage platelet leukoreduction while maintaining the premedication guidelines. The reaction rate decreased to 19% (95% CI 17-22%). For nonleukoreduced platelets, there was a statistically significant association between the platelet age and reaction rate (P = 0.04). For leukoreduced platelets, there was no statistically significant association between platelet age and reaction rate (P = 0.5). Plasma reduction of nonleukoreduced platelet products also reduced the reaction rate. These prospective studies document a high rate of platelet transfusion reactions in haematology/oncology patients and indicate premedication use can be reduced without increasing the reaction rate. Prestorage leukoreduction and/or plasma reduction of platelet products reduces but does not eliminate febrile nonhemolytic platelet transfusion reactions.

Should anticoagulant therapy be stopped or reversed before venous intervention?

PURPOSE

To determine the safety of venous intervention and the incidence of complications in patients undergoing venous interventional radiological procedures while receiving anticoagulant therapy.

METHOD

Data were collected prospectively for a 1-year period. One hundred patients receiving anticoagulant therapy underwent interventional radiological procedures requiring venous cannulation. Of these, 87 had documented prolonged bleeding times. There were 50 inferior vena cavograms obtained and filters placed (29 transfemoral, 21 transjugular), and 50 transfemoral pulmonary angiogram obtained, all in patients with thrombo-embolic disease who were receiving anticoagulant therapy. In most cases venous access was achieved with real-time sonographic guidance.

RESULTS

Venous access was gained in all patients in all groups. There were 41/50 filter placements and 46/50 pulmonary angiograms performed in the patients with prolonged clotting times in or above the therapeutic range. There were no cases of arterial puncture and no cases of venous bleeding either during or after the procedures. No other complications were recorded.

CONCLUSION

Venous intervention in patients receiving therapeutic anticoagulation is safe, with no complications reported in our series. There is no need to discontinue anticoagulant therapy in patients with life-threatening thrombo-embolic disease. Real-time sonographic guidance greatly facilitates venous cannulation and avoids inadvertent arterial puncture.

Detection of poliovirus circulation by environmental surveillance in the absence of clinical cases in Israel and the Palestinian authority

The global eradication of poliomyelitis, believed to be achievable around the year 2000, relies on strategies which include high routine immunization coverage and mass vaccination campaigns, along with continuous monitoring of wild-type virus circulation by using the laboratory-based acute flaccid paralysis (AFP) surveillance. Israel and the Palestinian Authority are located in a geographical region in which poliovirus is still endemic but have been free of poliomyelitis since 1988 as a result of intensive immunization programs and mass vaccination campaigns. To monitor the wild-type virus circulation, environmental surveillance of sewage samples collected monthly from 25 to 30 sites across the country was implemented in 1989 and AFP surveillance began in 1994. The sewage samples were processed in the laboratory with a double-selective tissue culture system, which enabled economical processing of large number of samples. Between 1989 and 1997, 2,294 samples were processed, and wild-type poliovirus was isolated from 17 of them in four clusters, termed "silent outbreaks," in September 1990 (type 3), between May and September 1991 (type 1), between October 1994 and June 1995 (type 1), and in December 1996 (type 1). Fifteen of the 17 positive samples were collected in the Gaza Strip, 1 was collected in the West Bank, and 1 was collected in the Israeli city of Ashdod, located close to the Gaza Strip. The AFP surveillance system failed to detect the circulating wild-type viruses. These findings further emphasize the important role that environmental surveillance can play in monitoring the eradication of polioviruses.

Involvement of tumor necrosis factor alpha and interleukin-1beta in enhancement of pentylenetetrazole-induced seizures caused by Shigella dysenteriae

Neurologic manifestations, mainly convulsions, are the most frequent extraintestinal complications of shigellosis. We used an animal model to study the roles of tumor necrosis factor alpha (TNF-alpha) and interleukin-1 beta (IL-1beta) in Shigella-related seizures. Administration of Shigella dysenteriae 60R sonicate enhanced the sensitivity of mice to the proconvulsant pentylenetetrazole (PTZ) within 7 h. This was indicated by a significantly higher mean convulsion score and an increased number of mice responding with clonic-tonic seizures in the Shigella-pretreated group. Preinjection of mice with anti-murine TNF-alpha (anti-mTNF-alpha) or anti-murine IL-1beta (anti-mIL-1beta) 30 min prior to administration of Shigella sonicate abolished their enhanced response to PTZ at 7 h. Mean convulsion scores were reduced by anti-mTNF-alpha from 1.2 to 0.8 (P = 0.017) and by anti-mIL-1beta from 1.3 to 0.7 (P = 0.008). Preinjection of anti-mTNF-alpha also reduced the percentage of mice responding with clonic-tonic seizures, from 48 to 29% (P = 0.002), and preinjection of anti-mIL-1beta reduced it from 53 to 21% (P = 0. 012). Neutralization of TNF-alpha or IL-1beta did not protect the mice from death due to S. dysenteriae 60R. These findings indicate that TNF-alpha and IL-1beta play a role in the very early sensitization of the central nervous system to convulsive activity after S. dysenteriae administration. Similar mechanisms may trigger neurologic disturbances in other infectious diseases.

Why and how to combine chemotherapy and radiation therapy in breast cancer patients

The ideal sequencing of CT and radiation therapy in early-stage breast cancer treated with breast-conserving surgery and RT is not known. There is evidence that delaying CT might have an adverse impact on systemic control, while delaying RT might adversely affect local control. Concurrent CT and full-dose RT might minimize the above tradeoffs, but is associated with increased toxicity. Concurrent CT and reduced-dose RT is a novel approach to address these issues, but requires additional formal evaluation before clinical use. In the absence of definitive information, clinicians should balance each patient's risk for systemic recurrence and local-regional recurrence. For example, a patient with a large number of positive nodes but clearly negative margins would be an appropriate candidate for adjuvant therapy starting with CT and continuing with RT at the completion of CT. Alternatively, a patient with node-negative disease with close or focally positive margins might be an appropriate candidate for initiating RT sooner. Current treatment regimens which deliver CT in a "short" time period [i.e., Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide) delivered in four 3-week cycles] may represent a reasonable tradeoff with regard to promptly starting systemic therapy while initiating RT within 3 months of surgery. It is possible that optimizing the way RT and CT are combined is important in achieving the highest survival rate and in reducing long-term adverse effects. There is unfortunately very little solid information from randomized clinical trials addressing this question, and considerable controversy remains regarding the optimal approach to integrating these modalities. Additional randomized clinical trials addressing this important clinical question are needed.

Neoadjuvant therapy for surgically staged IIIA N2 non-small cell lung cancer (NSCLC)

INTRODUCTION

Neoadjuvant therapy in patients with Stage IIIA NSCLC is associated with a 50-70% resection rate and a 3-5 year survival of 20-32%, but few trials have required meticulous staging of the mediastinum to ensure homogeneity of the study population. Continuous infusion cisplatin 25 mg/m2/day 1-5, 5-fluorouracil 800 mg/m2/day 2-5, and high-dose leukovorin 500 mg/m2/day 1-5 (PFL) given every 4 weeks achieved a 41% response rate in metastatic NSCLC (Lynch TJ, Kalish LA, Kass F, Strauss G, Elias A, Skarin A, Shulman L, Sugarbaker D, Frei E. Continuous infusion cisplatin, 5-fluorouracil, and leukovorin for advanced non-small cell lung cancer. Cancer 1994; 73: 1171-1176). The regimen was therefore evaluated in 34 patients with pathologic Stage IIIA N2 disease between 3/91 and 10/92.

METHODS

Staging consisted of chest, liver, brain computerized tomography and bone scan, bronchoscopy and surgical mediastinal node mapping. Patients received PFL for 3 cycles, followed by thoracotomy and thoracic radiotherapy (TRT) to 54-60 Gy.

RESULTS

Median age was 57 (42-68) years. Demographic factors included: male 56%; adenocarcinoma 59%, squamous cell carcinoma 24%; Stage T3N2 26%, T2N2 56%, and T1N2 18%. No treatment related deaths occurred. Radiographically defined response to PFL was 65% (6% complete). Thoracotomy was performed in 28 patients (82%) (6 had no attempt due to disease progression). Complete resection was achieved in 21 (75%) and seven were unresectable. Pathologic complete response was observed in five patients (15%) and an additional unresectable patient had fibrosis-only documented at thoracotomy for an overall clinicopathologic response rate of 76% (18% pathologic CR). Another ten patients had residual primary with or without hilar disease with resolution of previously documented mediastinal involvement. Six (18%) patients remain alive and disease-free with a median follow-up of 46 (33-50) months, four of whom had achieved pathologic complete response at time of surgery.

CONCLUSIONS

Long-term event-free survival was associated with complete surgical resection which in turn was associated with clinical response to chemotherapy. There was a possible trend associating pathologic downstaging (absent residual disease in mediastinal nodes), particularly pathologic complete response observed in patients with non-bulky mediastinal disease, with improved event-free survival. Pathologic downstaging might therefore be a useful surrogate endpoint in trials evaluating the preoperative activity of new chemotherapy regimens. While radiographic response generally correlated with findings at surgery, response as determined by histologic examination of resected tissue was generally more extensive and may more accurately reflect the systemic impact of the chemotherapy regimen.

Trials of 9-amino-20(S)-camptothecin in Boston

9-Amino-20(S)-camptothecin (9-AC) is an analog of camptothecin with limited water solubility which has shown significant preclinical activity in a variety of human solid tumor xenografts. A Phase I trial using a soluble formulation of 9-AC, given as a 72-hour continuous infusion, has been completed. Thirty-one patients with resistant cancers received 5-60 micrograms/M2/h at three week intervals. The Maximum Tolerated Dose (MTD) was 45 micrograms/M2/hour. Neutropenia was the dose limiting toxicity, with few significant non-myelosuppressive toxicities. Minor responses were seen in 3/31 patients. Pharmacokinetic studies of 9-AC lactone (closed ring) showed substantial interpatient variability with a predicted half-life of 36 hours. A phase I/II trial of the same formulation of 9-AC is ongoing in refractory leukemia. Stomatitis and diarrhea are the non-myelosuppressive dose limiting toxicities. Evidence of antineoplastic activity has been seen in 3/15 patients. A Phase II trial in previously untreated metastatic breast cancer is also underway. A Phase I trial of a colloidal dispersion formulation, not yet completed, is better tolerated with a MTD > 45 micrograms/M2/h as a 72-hour continuous infusion. Evidence of antineoplastic activity has also been demonstrated.