Emergency Department Use in Adolescent and Young Adult Cancer Early Survivors from 2006 to 2020

Purpose: Understanding emergency department (ED) use in adolescent and young adult (AYA) survivors could identify gaps in AYA survivorship. Methods: We conducted a cohort study of 7925 AYA survivors (aged 15-39 years at diagnosis) who were 2-5 years from diagnosis in 2006-2020 at Kaiser Permanente Southern California. We calculated ED utilization rates overall and by indication of the encounter (headache, cardiac issues, and suicide attempts). We estimated rate changes by survivorship year and patient factors associated with ED visit using a Poisson model. Results: Cohort was 65.4% women, 45.8% Hispanic, with mean age at diagnosis at 31.3 years. Overall, 38% of AYA survivors had ≥1 ED visit (95th percentile: 5 ED visits). Unadjusted ED rates declined from 374.2/1000 person-years (PY) in Y2 to 327.2 in Y5 (p change < 0.001). Unadjusted rates declined for headache, cardiac issues, and suicide attempts. Factors associated with increased ED use included: age 20-24 at diagnosis [relative risk (RR) = 1.30, 95% CI 1.09-1.56 vs. 35-39 years]; female (RR = 1.27, 95% CI 1.11-1.47 vs. male); non-Hispanic Black race/ethnicity (RR 1.64, 95% CI 1.38-1.95 vs. non-Hispanic white); comorbidity (RR = 1.34, 95% CI 1.16-1.55 for 1 and RR 1.80, 95% CI 1.40-2.30 for 2+ vs. none); and public insurance (RR = 1.99, 95% CI 1.70-2.32 vs. private). Compared with thyroid cancer, cancers associated with increased ED use were breast (RR = 1.45, 95% CI 1.24-1.70), cervical (RR = 2.18, 95% CI 1.76-2.71), colorectal (RR = 2.34, 95% CI 1.94-2.81), and sarcoma (RR = 1.39, 95% CI 1.03-1.88). Conclusion: ED utilization declined as time from diagnosis elapsed, but higher utilization was associated with social determinants of health and cancer types.

An evaluation of patient-reported outcomes in sickle cell disease within a conceptual model

PURPOSE

To examine the relations between patient-reported outcomes (PROs) within a conceptual model for adults with sickle cell disease (SCD) ages 18 - 45 years enrolled in the multi-site Sickle Cell Disease Implementation Consortium (SCDIC) registry. We hypothesized that patient and SCD-related factors, particularly pain, and barriers to care would independently contribute to functioning as measured using PRO domains.

METHODS

Participants (N = 2054) completed a 48-item survey including socio-demographics and PRO measures, e.g., social functioning, pain impact, emotional distress, and cognitive functioning. Participants reported on lifetime SCD complications, pain episode frequency and severity, and barriers to healthcare.

RESULTS

Higher pain frequency was associated with higher odds of worse outcomes in all PRO domains, controlling for age, gender and site (OR range 1.02-1.10, 95% CI range [1.004-1.12]). Reported history of treatment for depression was associated with 5 of 7 PRO measures (OR range 1.58-3.28 95% CI range [1.18-4.32]). Fewer individual barriers to care and fewer SCD complications were associated with better outcomes in the emotion domain (OR range 0.46-0.64, 95% CI range [0.34-0.86]).

CONCLUSIONS

Study results highlight the importance of the biopsychosocial model to enhance understanding of the needs of this complex population, and to design multi-dimensional approaches for providing more effective interventions to improve outcomes.

Barriers to hydroxyurea use from the perspectives of providers, individuals with sickle cell disease, and families: Report from a U.S. regional collaborative

Sickle cell disease (SCD) is an inherited blood disorder that affects about 100,000 people in the U.S., primarily Blacks/African-Americans. A multitude of complications negatively impacts quality of life. Hydroxyurea has been FDA approved since 1998 as a disease-modifying therapy for SCD, but is underutilized. Negative and uninformed perceptions of hydroxyurea and barriers to its use hinder adherence and promotion of the medication. As the largest real-world study to date that assessed hydroxyurea use for children and adults with SCD, we gathered and analyzed perspectives of providers, individuals with SCD, and families. Participants provided information about socio-demographics, hospital and emergency admissions for pain, number of severe pain episodes interfering with daily activities, medication adherence, and barriers to hydroxyurea. Providers reported on indications for hydroxyurea, reasons not prescribed, and current laboratory values. We found that hydroxyurea use was reported in over half of eligible patients from this large geographic region in the U.S., representing a range of sickle cell specialty clinical settings and practices. Provider and patient/caregiver reports about hydroxyurea use were consistent with one another; adults 26 years and older were least likely to be on hydroxyurea; and the likelihood of being on hydroxyurea decreased with one or more barriers. Using the intentional and unintentional medication nonadherence framework, we found that, even for patients on hydroxyurea, challenges to taking the medicine at the right time and forgetting were crucial unintentional barriers to adherence. Intentional barriers such as worry about side effects and “tried and it did not work” were important barriers for young adults and adults. For providers, diagnoses other than HgbSS or HgbS-β0 thalassemia were associated with lower odds of prescribing, consistent with evidence-based guidelines. Our results support strengthening provider understanding and confidence in implementing existing SCD guidelines, and the importance of shared decision making. Our findings can assist providers in understanding choices and decisions of families; guide individualized clinical discussions regarding hydroxyurea therapy; and help with developing tailored interventions to address barriers. Addressing barriers to hydroxyurea use can inform strategies to minimize similar barriers in the use of emerging and combination therapies for SCD.

In vivo fermentation production of humanized noncoding RNAs carrying payload miRNAs for targeted anticancer therapy

Rationale: Noncoding RNAs (ncRNAs) such as microRNAs (miRs or miRNAs) play important roles in the control of cellular processes through posttranscriptional gene regulation. However, ncRNA research is limited to utilizing RNA agents synthesized in vitro. Recombinant RNAs produced and folded in living cells shall better recapitulate biologic RNAs.

Methods: Herein, we developed a novel platform for in vivo fermentation production of humanized recombinant ncRNA molecules, namely hBERAs, carrying payload miRNAs or siRNAs. Target hBERAs were purified by anion exchange FPLC method. Functions of hBERA/miRNAs were investigated in human carcinoma cells and antitumor activities were determined in orthotopic osteosarcoma xenograft spontaneous lung metastasis mouse models.

Results: Proper human tRNAs were identified to couple with optimal hsa-pre-miR-34a as new fully-humanized ncRNA carriers to accommodate warhead miRNAs or siRNAs. A group of 30 target hBERAs were all heterogeneously overexpressed (each accounting for >40% of total bacterial RNA), which facilitated large-scale production (8-31 mg of individual hBERAs from 1L bacterial culture). Model hBERA/miR-34a-5p and miR-124-3p were selectively processed to warhead miRNAs in human carcinoma cells to modulate target gene expression, enhance apoptosis and inhibit invasiveness. In addition, bioengineered miR-34a-5p and miR-124-3p agents both reduced orthotopic osteosarcoma xenograft tumor growth and spontaneous pulmonary metastases significantly.

Conclusion: This novel ncRNA bioengineering technology and resulting recombinant ncRNAs are unique additions to conventional technologies and tools for basic research and drug development.

American Society of Hematology 2019 guidelines for sickle cell disease: cardiopulmonary and kidney disease

BACKGROUND

Prevention and management of end-organ disease represent major challenges facing providers of children and adults with sickle cell disease (SCD). Uncertainty and variability in the screening, diagnosis, and management of cardiopulmonary and renal complications in SCD lead to varying outcomes for affected individuals.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about screening, diagnosis, and management of cardiopulmonary and renal complications of SCD.

METHODS

ASH formed a multidisciplinary guideline panel that included 2 patient representatives and was balanced to minimize potential bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including performing systematic evidence reviews up to September 2017. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 10 recommendations for screening, diagnosis, and management of cardiopulmonary and renal complications of SCD. Recommendations related to anticoagulation duration for adults with SCD and venous thromboembolism were also developed.

CONCLUSIONS

Most recommendations were conditional due to a paucity of direct, high-quality evidence for outcomes of interest. Future research was identified, including the need for prospective studies to better understand the natural history of cardiopulmonary and renal disease, their relationship to patient-important outcomes, and optimal management.

Disparities in the occurrence of late effects following treatment among adolescent and young adult melanoma survivors

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Background: Melanoma is the third most common cancer in the adolescent and young adult (AYA) population and the incidence worldwide is increasing. However, no studies have addressed the occurrence of late effect medical conditions following melanoma treatment in these young survivors. Methods: All patients ages 15-39 diagnosed with cutaneous melanoma from the 1996-2012 and surviving ≥ 2 years were obtained from the California Cancer Registry and linked to statewide hospitalization data. The influence of age at diagnosis, sex, race/ethnicity, neighborhood socioeconomic status (SES), and health insurance on the development of late effects by system was evaluated using multivariable Cox proportional hazards regression models. Results: Of 8,524 patients, 35.6% were male, 83.1% non-Hispanic white, 82.1% had private health insurance, 60.3% were considered high SES, and 70.7% had no documented co-morbidities at diagnosis. After controlling for competing factors, males had an increased risk of developing late effects across all systems, including cardiac [HR:2.13, 95%CI 1.87-2.42], neurologic (HR:2.24, CI 1.92-2.63), lymphedema (HR:2.22, CI 1.89-2.62), bleeding events (HR:2.35, CI 2.00-2.77), major infection/sepsis (HR:2.23, CI 1.95-2.56), and second cancers [HR:1.66, CI 1.47-1.89]. In addition, patients with public or no insurance (vs. private) had a greater risk of developing all studied late effects, including lymphedema (HR:2.48, CI 2.04-3.01), respiratory illness (HR:2.21, CI 1.85-2.64) renal dysfunction (HR:2.31, CI 1.90-2.81), and subsequent cancers (HR:1.82, CI 1.54-2.16). AYA patients residing in low SES neighborhoods had a similar increased risk of developing late effects. However, neither age nor race/ethnicity had an impact on the occurrence of late effects. Conclusions: Of AYA melanoma survivors, males, those with public or no health insurance, and those living in low SES neighborhoods had a much greater likelihood of developing of late effects. Strategies to improve surveillance and secondary prevention of these late effects is needed among AYA melanoma survivors, particularly for this demographic.

Effect of race/ethnicity on long-term cytopenias and major infections in adolescent young adult breast cancer survivors

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Background: Many Adolescent and Young Adult (AYA) Breast Cancer (BC) patients receive chemotherapy as part of their initial treatment. Long-term bone marrow suppression is a potential complication, but no studies have evaluated the impact of race/ethnicity on the development in AYA BC survivors. Methods: Female patients ages 15-39 diagnosed with BC during 1996-2012 and surviving ≥ 2 years were obtained from the California Cancer Registry and linked to statewide hospitalization data. We estimated the cumulative incidence of developing anemia, leukopenia, or major infection/sepsis (≥ 2 years after diagnosis), accounting for death as a competing risk, and examined the impact of race/ethnicity using multivariable Cox proportional hazards regression. Results: Of 14,729 patients, 48.8% were non-Hispanic white, 8.3% non-Hispanic black, 25.5% Hispanic, and 16.5% Asian/Pacific Islander. At diagnosis, 95.5% had local or regional disease (27.7% stage I, 49.4% stage II), and were mostly treated with surgery (96.2%) and chemotherapy (74.3%). The 10-year cumulative incidence of anemia (16.8% vs 11.7%), leukopenia (4.6% vs 2.1%), and major infection/sepsis (13.2% vs 7.9%) was greater following initial treatment with chemotherapy (p < 0.0001 for all vs no chemotherapy). In multivariable analyses controlling for sociodemographic factors, baseline comorbidities, treatment and stage, Blacks had the highest risk (vs. non-Hispanic whites) of medical late effects, including anemia [HR: 1.62, CI 1.41-1.86], leukopenia (HR: 1.53, CI 1.17-2.00), and major infection/sepsis (HR: 1.36, CI 1.16-1.60). Similarly, Hispanic and Asian/Pacific Islanders had a higher risk of developing anemia (HR: 1.16, CI 1.04-1.29; HR: 1.17, CI 1.03-1.33) and trended toward developing more leukopenia (HR: 1.24, CI 1.00-1.54; HR: 1.25, CI 0.98-1.61). Conclusions: AYAs of Black, Hispanic, and Asian/Pacific Islander race/ethnicity are at an increased risk of anemia and leukopenia after chemotherapy compared with non-Hispanic Whites. With improvements in prognostic testing resulting in potential decreased chemotherapy usage, there may be a decrease in long-term late effects for these young cancer survivors.

Bioengineered Noncoding RNAs Selectively Change Cellular miRNome Profiles for Cancer Therapy

Noncoding RNAs (ncRNAs) produced in live cells may better reflect intracellular ncRNAs for research and therapy. Attempts were made to produce biologic ncRNAs, but at low yield or success rate. Here we first report a new ncRNA bioengineering technology using more stable ncRNA carrier (nCAR) containing a pre-miR-34a derivative identified by rational design and experimental validation. This approach offered a remarkable higher level expression (40%-80% of total RNAs) of recombinant ncRNAs in bacteria and gave an 80% success rate (33 of 42 ncRNAs). New FPLC and spin-column based methods were also developed for large- and small-scale purification of milligrams and micrograms of recombinant ncRNAs from half liter and milliliters of bacterial culture, respectively. We then used two bioengineered nCAR/miRNAs to demonstrate the selective release of target miRNAs into human cells, which were revealed to be Dicer dependent (miR-34a-5p) or independent (miR-124a-3p), and subsequent changes of miRNome and transcriptome profiles. miRNA enrichment analyses of altered transcriptome confirmed the specificity of nCAR/miRNAs in target gene regulation. Furthermore, nCAR assembled miR-34a-5p and miR-124-3p were active in suppressing human lung carcinoma cell proliferation through modulation of target gene expression (e.g., cMET and CDK6 for miR-34a-5p; STAT3 and ABCC4 for miR-124-3p). In addition, bioengineered miRNA molecules were effective in controlling metastatic lung xenograft progression, as demonstrated by live animal and ex vivo lung tissue bioluminescent imaging as well as histopathological examination. This novel ncRNA bioengineering platform can be easily adapted to produce various ncRNA molecules, and biologic ncRNAs hold the promise as new cancer therapeutics.

Co-targeting of DNA, RNA, and protein molecules provides optimal outcomes for treating osteosarcoma and pulmonary metastasis in spontaneous and experimental metastasis mouse models

Metastasis is a major cause of mortality for cancer patients and remains as the greatest challenge in cancer therapy. Driven by multiple factors, metastasis may not be controlled by the inhibition of single target. This study was aimed at assessing the hypothesis that drugs could be rationally combined to co-target critical DNA, RNA and protein molecules to achieve saturation attack against metastasis. Independent actions of the model drugs DNA-intercalating doxorubicin, RNA-interfering miR-34a and protein-inhibiting sorafenib on DNA replication, RNA translation and protein kinase signaling in highly metastatic, human osteosarcoma 143B cells were demonstrated by the increase of? H2A.X foci formation, reduction of c-MET expression and inhibition of Erk1/2 phosphorylation, respectively, and optimal effects were found for triple-drug combination. Consequently, triple-drug treatment showed a strong synergism in suppressing 143B cell proliferation and the greatest effects in reducing cell invasion. Compared to single- and dual-drug treatment, triple-drug therapy suppressed pulmonary metastases and orthotopic osteosarcoma progression to significantly greater degrees in orthotopic osteosarcoma xenograft/spontaneous metastases mouse models, while none showed significant toxicity. In addition, triple-drug therapy improved the overall survival to the greatest extent in experimental metastases mouse models. These findings demonstrate co-targeting of DNA, RNA and protein molecules as a novel therapeutic strategy for the treatment of metastasis.

Secondary acute lymphoblastic leukemia is a distinct clinical entity with prognostic significance

The effect of prior malignancy on the risk of developing, and prognosis of, acute lymphoblastic leukemia (ALL) is unknown. This observational study utilized the California Cancer Registry to estimate the risk of developing ALL after a prior malignancy using standardized incidence ratios (SIRs, 95% confidence intervals). ALL occurring after a malignancy with an SIR>1 (increased-risk (IR) malignancies) was considered secondary ALL (s-ALL). Adjusted hazard ratios (aHRs, 95% confidence intervals) compared the effect of s-ALL with de novo ALL on overall survival. A total of 14 481 patients with ALL were identified (1988–2012) and 382 (3%) had a known prior malignancy. Any prior malignancy predisposed patients to developing ALL: SIR 1.62 (1.45–1.79). Hematologic malignancies (SIR 5.57, 4.38–6.98) and IR-solid tumors (SIR 2.11, 1.73–2.54) increased the risk of developing ALL. s-ALL increased the risk of death compared with de novo ALL (aHR 1.38 (1.16–1.63)) and this effect was more pronounced among younger patients (age<40 years: aHR 4.80 (3.15–7.30); age⩾40 years: aHR 1.40 (1.16–1.69)) (interaction P<0.001). This population-based study demonstrates that s-ALL is a distinct entity that occurs after specific malignancies and carries a poor prognosis compared with de novo ALL, particularly among patients <40 years of age.

Mortality in young adults with Ewing sarcoma treated at specialized cancer centers in California

10538

Background: Ewing sarcoma is a rare malignancy of the soft tissue or bone that is most frequently seen in children and adolescents. One study suggested that care at specialized cancer centers (SCC) may mitigate survival disparities associated with public insurance in patients with sarcoma, but no large population-based studies have considered how location of care affects survival outcomes. Methods: We performed a retrospective, population-based cohort analysis of patients hospitalized within one year of diagnosis with primary Ewing sarcoma between 2000–2013 using the California Cancer Registry linked with state hospitalization data. Patients were divided into two groups based on whether they received inpatient treatment at a SCC [Children’s Oncology Group (if age ≤25) and/or National Cancer Institute-designated center] or not. We excluded 12 patients whose location of cancer treatment could not be determined. Multivariable Cox proportional hazards regression identified factors associated with mortality. Results are presented as adjusted hazard ratios (HR) and 95% confidence intervals (CI). Results: Of the 470 patients with newly diagnosed Ewing sarcoma, 40% were female, 52% were non-Hispanic white, and 53% had private health insurance. Sixty-one percent received their inpatient care at a SCC. Multivariable analysis across all ages demonstrated that higher mortality was associated with increasing age, metastatic disease, and large tumors, but mortality was not impacted by treatment at an SCC (HR 0.77, CI: 0.55-1.08; p = 0.134). However, when analyses were stratified by age, treatment at a SCC was associated with lower mortality among patients ages 19–39 years, but not among younger or older patients, and this association was only apparent within 2 years of diagnosis (HR = 0.43, CI: 0.23-0.79; p = 0.007). Conclusions: Our results suggest that treatment for Ewing sarcoma at a SCC significantly improves survival in young adults adjusted for other factors known to be associated with poor prognosis (metastatic disease, larger tumor size and older age). The lower mortality in this age group may be due to access to clinical trials and other specialized services specific to young adults available at SCCs.

Difference in cardiovascular disease incidence by sociodemographic factors in adolescent and young adult (AYA) cancer survivors

6565

Background: AYA cancer survivors are at increased risk of developing cardiovascular disease (CVD) compared to AYAs without a history of cancer. In AYA cancer survivors, few population-based studies have focused on CVD risk and none have considered whether the occurrence of CVD differs by sociodemographic factors. Methods: Analyses focused on 64,918 patients aged 15-39 y at diagnosis for one of 14 first primary cancers during 1996-2010 and surviving > 2 years after diagnosis, with follow-up through 2013. Data were obtained from the California Cancer Registry and State hospital discharge data. CVD included coronary artery disease, heart failure, and stroke. We estimated the cumulative incidence of developing CVD, accounting for death as a competing risk, stratified by race/ethnicity, neighborhood socioeconomic status (SES) at diagnosis, health insurance status at diagnosis/initial treatment and cancer type. We examined the impact of CVD on mortality using multivariable Cox proportional hazards regression with CVD as a time-dependent covariate. Results: Overall, 2374 (3.7%) patients developed CVD, and 7690 (11.9%) died over the follow-up period. Survivors of acute myeloid leukemia (12.6%), acute lymphoid leukemia (11.1%), central nervous system cancer (9.0%) and non-Hodgkin lymphoma (6.0%) had the highest incidence of CVD at 10-years. Incidence was significantly higher among Blacks (6.7%) at 10-years than non-Hispanic Whites (3.0%), Hispanics (3.7%) and Asian/Pacific Islanders (3.7%) (p < 0.001). AYA survivors with public or no insurance (vs private) had a higher 10-year incidence of CVD (5.8% vs 2.9%; p < 0.001), as did survivors residing in low (vs high) SES neighborhoods (4.1% vs 2.7%; p < 0.001). These sociodemographic differences in CVD incidence were apparent across most cancer sites. The risk of death was increased by five-fold or higher among AYAs who developed CVD. Conclusions: AYA cancer survivors who were uninsured or publicly insured, of Black race/ethnicity, or who resided in lower SES neighborhoods are at increased risk for developing CVD and experiencing higher mortality. The proactive management of CVD risk factors in these subgroups may improve patient outcomes.

Changes in clinical trial participation among adolescent and young adult (AYA) cancer patients from 2006 to 2013 in the United States

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Background: Stagnant outcomes for AYAs (15 to 39 years) with cancer are partly attributed to poor enrollment onto clinical trials. Initiatives have focused on increasing accrual, but changes at the population-level are unknown. We examined patterns of clinical trial participation over time in AYA cancer patients. Methods: We utilized medical record data from AYAs in two National Cancer Institute Patterns of Care Studies identified through the Surveillance, Epidemiology and End Results (SEER) Program. Among 1,358 AYAs diagnosed with non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), acute lymphoblastic leukemia (ALL), germ cell cancer, and sarcoma in 2006 and 3,560 AYAs diagnosed with NHL, HL, ALL, sarcoma, and breast cancer in 2012/2013, we used unconditional logistic regression to evaluate patient and provider characteristics associated with enrollment by year of diagnosis. Analyses were weighted to reflect the SEER populations and associations are summarized as adjusted odds ratios (OR) with 95% confidence intervals (CI). Results: From 2006 to 2012/2013, clinical trial participation increased from 14.8% to 17.9% among AYAs diagnosed with NHL, HL, ALL and sarcoma (p < 0.0001), primarily due to increased participation among ALL patients (2006: 37.4%; 2012/2013: 42.3%). In 2012/2013, participation varied by type of cancer, with the highest among those with ALL and sarcoma (31.2%), followed by HL (9.4%), NHL (6.9%) and breast cancer (4.3%). In both study years, multivariate analyses demonstrated that younger patients and those treated by pediatric oncologists (OR = 3.5; CI: 2.6-4.7) were more likely to enroll onto clinical trials. Uninsured AYAs were less likely to enroll in 2006 but no association was observed in 2012/2013. Hispanic (OR = 0.5; CI: 0.4-0.6), Black (OR = 0.6; CI: 0.5-0.9) and Asian (OR = 0.4; CI: 0.3-0.6) AYAs were less likely to enroll in 2012/2013 but not 2006. Conclusions: Our study identified increasing overall clinical trial participation over time. Disparities in likelihood of participating for racial/ethnic minority groups increased suggesting the need to improve access to clinical trials for all racial/ethnic groups to improve care and outcomes.

High Concentrations of Thrombopoietin Activate Platelets In Vitro

Thrombopoietin (TPO), the ligand for the proto- oncogene c-mpl, has been cloned and expressed from both human and murine sources. Thrombopoietin increases platelet counts when given in vivo and acts on progenitor cells to in crease their proliferation and maturation into megakaryocytes. The effects of TPO on mature platelets were investigated by evaluating platelet aggregation and platelet activation- dependent antigen expression. Platelet aggregation score, a quantitative representation of aggregation, showed potentiation of response to ADP-induced aggregation but no direct agonist response to TPO alone. Soluble c-mpl blocked the effect of TPO on the platelet aggregation score. Flow cytometry showed that TPO at concentrations >250 U/ml (50 ng/ml) caused a minority population of platelets to express the activation mark ers CD62, CD63 and activated glycoprotein IIb/IIIa. While stem cell factor and interleukins-3 and -6 did not affect platelet activation antigen expression, interleukin-11 increased CD62 expression on platelets in vitro. The effects of TPO on antigenic expression and aggregability were partially inhibited in vitro by preincubation with aspirin. We conclude that high concentra tions of TPO promote platelet activation antigen expression on a proportion of platelets and potentiate platelet aggregability to ADP in vitro by a process that is partially inhibited by aspirin.

Bioengineering Novel Chimeric microRNA-34a for Prodrug Cancer Therapy: High-Yield Expression and Purification, and Structural and Functional Characterization

Development of anticancer treatments based on microRNA (miRNA/miR) such as miR-34a replacement therapy is limited to the use of synthetic RNAs with artificial modifications. Herein, we present a new approach to a high-yield and large-scale biosynthesis, in Escherichia coli using transfer RNA (tRNA) scaffold, of chimeric miR-34a agent, which may act as a prodrug for anticancer therapy. The recombinant tRNA fusion pre-miR-34a (tRNA/mir-34a) was quickly purified to a high degree of homogeneity (>98%) using anion-exchange fast protein liquid chromatography, whose primary sequence and post-transcriptional modifications were directly characterized by mass spectrometric analyses. Chimeric tRNA/mir-34a showed a favorable cellular stability while it was degradable by several ribonucleases. Deep sequencing and quantitative real-time polymerase chain reaction studies revealed that tRNA-carried pre-miR-34a was precisely processed to mature miR-34a within human carcinoma cells, and the same tRNA fragments were produced from tRNA/mir-34a and the control tRNA scaffold (tRNA/MSA). Consequently, tRNA/mir-34a inhibited the proliferation of various types of human carcinoma cells in a dose-dependent manner and to a much greater degree than the control tRNA/MSA, which was mechanistically attributable to the reduction of miR-34a target genes. Furthermore, tRNA/mir-34a significantly suppressed the growth of human non-small-cell lung cancer A549 and hepatocarcinoma HepG2 xenograft tumors in mice, compared with the same dose of tRNA/MSA. In addition, recombinant tRNA/mir-34a had no or minimal effect on blood chemistry and interleukin-6 level in mouse models, suggesting that recombinant RNAs were well tolerated. These findings provoke a conversation on producing biologic miRNAs to perform miRNA actions, and point toward a new direction in developing miRNA-based therapies.

B cell reductive therapy in the treatment of autoimmune diseases: A focus on monoclonal antibody treatment of rheumatoid arthritis

The therapeutic approach to patients with autoimmune disorders is in the midst of a dramatic change. Monoclonal antibody technology has allowed us to dissect and now manipulate the human immune system with greater precision. It is now widely recognized that B lymphocytes play a role in the pathogenesis of many autoimmune diseases, though the extent and contribution is a matter of debate and active investigation. There is emerging data to suggest that both antibody-dependent and independent mechanisms contribute to disease pathogenesis. However, given the heterogeneous nature of autoimmune diseases, and the varied responses to B lymphocyte reduction, the role of B lymphocytes is likely disease-specific. The two clinical trials discussed in this review demonstrate remarkable consistency in the ability of B cell reduction to ameliorate the clinical manifestations of rheumatoid arthritis with minimal toxicity. B lymphocyte targeted approaches to autoimmune disease in general, and RA specifically, will not only provide an effective and potentially less toxic alternative treatment option, but also allow for a better understanding of the pathogenesis of these complex and morbid diseases.

Predictors of survival for younger patients (pts) less than 50 years of age with non-small cell lung cancer (NSCLC): A California Cancer Registry (CCR) analysis

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Background: Lung cancer is often seen in older pts, with a median age at diagnosis of 70 years (yrs). Epidemiology and outcomes are reportedly different among younger NSCLC pts (< 50 yrs). We hypothesized that these pts have longer cause-specific survival (CSS) and that baseline clinical features prognostic for CSS would be identified. Methods: NSCLC pts in the CCR diagnosed between 1/98 through 12/09 were included. The primary outcome was CSS. Hazard ratios (HR) for CSS were calculated using Cox Proportional Hazards (PH) models for all ages & for pts <50 years, adjusted for baseline variables. Results: We identified 132,671 lung cancer pts: 114,451 (86.3%) had NSCLC. 6,389 (5.6%) were < 50 yrs (median, 46 yrs). Demographics: White (3,557, 56%); Histology: AdenoCA (AC) (3,406, 53%), Squamous (781, 12%), BAC (291, 4.6%); Stage IV (3,655, 57%). Fewer pts < 50 yrs were diagnosed in later yrs: from 37% in ‘98-’01 to 29% in ‘06-‘09. Results of Cox PH models for all ages and < 50 years are shown. Conclusions: The relative proportion of pts < 50 yrs has declined by 22% over the past decade. Age < 50 years was an independent predictor of improved CSS (HR 0.83, p<0.001). In younger pts, AC histology was not prognostic for CSS (versus squamous) despite known differences in clinical and biologic behavior between subtypes.Importantly, clinical variables strongly prognostic for CSS were identified in pts < 50 yrs. [Table: see text]

Recurrent venous thromboembolism after surgery-provoked versus unprovoked thromboembolism

SUMMARY BACKGROUND

The incidence of recurrent venous thromboembolism (VTE) varies depending on the nature of the initial provoking risk factor(s).

OBJECTIVES

To compare the incidence and time course of recurrent VTE after unprovoked VTE vs. VTE provoked by nine different types of surgery.

METHODS

Retrospective analysis of linked California hospital and emergency department discharge records. Between 1997 and 2007, all surgery-provoked VTE cases had a first-time VTE event diagnosed within 60 days after undergoing a major operation. The incidence of recurrent VTE was compared during specified follow-up periods by matching each surgery-provoked case with three unprovoked cases based on age, race, gender, VTE event, calendar year and co-morbidity.

RESULTS

The 4-year Kaplan-Meier cumulative incidence of recurrent VTE was 14.7% (95%CI: 14.2-15.1) in the matched unprovoked VTE group vs. 7.6% (CI: 7.0-8.2) in 11 797 patients with surgery-provoked VTE (P < 0.001). The overall risk reduction was 48%, which ranged from 64% lower risk (P < 0.001) after coronary bypass surgery to 25% lower risk (P = 0.06) after disc surgery. The risk of recurrent VTE 1-5 years after the index event was significantly lower in the surgery group (HR = 0.47, CI: 0.41-0.53). Within the surgery-provoked group, the risk of recurrent VTE was similar in men and women (HR = 1.0, CI: 0.8-1.3).

CONCLUSIONS

The risk of recurrent VTE after surgery-provoked VTE was approximately 50% lower than after unprovoked VTE, confirming the view that provoked VTE is associated with a lower risk of recurrent VTE. However, there was appreciable heterogeneity in the relative risk of recurrent VTE associated with different operations.

Vasopressin and platelets: a concise review

Arginine vasopressin (AVP or vasopressin) is a neurophypophyseal peptide hormone with both vasopressor and antidiuretic properties. This review will briefly discuss the chemistry and physiology of AVP, with the main focus being on AVP and the hemostatic system. Recent data on the effects of AVP, and its analogues, on platelet function will be highlighted. AVP-induced platelet activation could explain, in part, the benefit seen with AVP infusions in gastrointestinal bleeding. These data also suggest that AVP may have a role in physiologic hemostasis and platelet activation.

The incidence of venous thromboembolism among patients with primary lung cancer

BACKGROUND

The incidence of venous thromboembolism (VTE) by lung cancer histology and stage is unknown.

OBJECTIVES

To determine the incidence of VTE and the risk factors associated with development of VTE in a large population-based study of patients with non-small cell and small cell lung cancer.

METHODS

The California Cancer Registry was merged with the Patient Discharge Data Set to determine the incidence of VTE among lung cancer cases diagnosed between 1993 and 1999.

RESULTS

Among 91 933 patients with newly diagnosed lung cancer, the 1-year and 2-year cumulative VTE incidences were 3.0% and 3.4%, respectively, with a person-time rate of 7.2 events/100 patient-years during the first 6 months. The 1-year incidence of VTE was significantly increased in comparison to the general population [standardized incidence ratio = 21.2, 95% confidence interval (CI) = 20.4-22.0]. In a multivariate model, significant predictors of developing VTE within 1 year of non-small cell lung cancer (NSCLC) diagnosis were: younger age, the number of chronic medical comorbidities [hazard ratio (HR) = 2.8 if 3 vs. 0, 95% CI = 2.5-3.1], advancing cancer stage (HR = 4.0 for metastatic vs. local disease, 95% CI = 3.4-4.6) and adenocarcinoma histology (HR = 1.9 vs. squamous cell, 95% CI = 1.7-2.1). In multivariate models, VTE was a significant predictor of death within 2 years for both NSCLC and small cell lung cancer (SCLC), HR = 2.3, 95% CI = 2.2-2.4, and HR = 1.5, 95% CI = 1.3-1.7, respectively.

CONCLUSIONS

Approximately 3% of lung cancer patients developed VTE within 2 years. The diagnosis of VTE was associated with a higher risk of death within 2 years for NSCLC and SCLC.

Polyurethane shape-memory polymers demonstrate functional biocompatibility in vitro

Shape memory polymers (SMPs) are a class of polymeric materials used in various medical interventions such as vascular stents. In this work, two SMPs, thermoplastic (TP) and thermoset (TS), have been measured in vitro for the degree of cellular and protein adhesion, their ability to stimulate inflammatory cytokine production, as well as the effects of the SMPs on the haemostatic system. The stimulatory properties of SMPs on neutrophils have also been directly addressed. Based on the studies of SMP biocompatibility as defined by inflammation, thrombogenesis, and the activation of both platelets and neutrophils, the TS and TP SMP materials are unlikely to stimulate an inflammatory response in vivo. [figure: see text]

Incidence of venous thromboembolism and the impact on survival in breast cancer patients

PURPOSE

The incidence of venous thromboembolism (VTE) and the risk factors associated with development of VTE have not been reported in a large population-based study of breast cancer patients.

PATIENTS AND METHODS

The California Cancer Registry was merged with the Patient Discharge Data Set, and the number of VTE events determined among patients diagnosed between 1993 and 1999.

RESULTS

Among 108,255 patients with breast cancer, the 2-year cumulative VTE incidence was 1.2%, with a rate of 1.2 and 0.6 events/100 patient-years during the first and second half-year, respectively. The 1-year incidence of VTE was significantly increased compared with the general population (standardized incidence ratio of VTE, 4.2; 95% CI, 3.9 to 4.4). In a multivariate model, significant predictors of developing VTE within 2 years were: age (hazard ratio [HR], 2.0 if > 75 years v < 45; 95% CI, 1.6 to 2.6), the number of chronic medical comorbidities (HR, 2.9 if 3 v 0; 95% CI, 2.4 to 3.5), and advancing cancer stage (HR, 6.3; 95% CI, 5.3 to 7.5 for metastatic v local disease). In multivariate models, VTE was a significant predictor of decreased 2-year survival (HR, 2.3; 95% CI, 2.1 to 2.6) and when stratified by initial cancer stage, the effect was highest in patients with localized (HR, 5.1; 95% CI, 3.6 to 7.1) or regional stage (HR, 3.5; 95% CI, 2.5 to 4.8) cancer compared with patients with metastatic disease (HR, 1.9; 95% CI, 1.5 to 2.4).

CONCLUSION

Approximately 1% of breast cancer patients developed VTE within 2 years, with the highest incidence in the first 6 months after diagnosis. Metastatic disease and comorbidities were the strongest predictors. The diagnosis of VTE was associated with a higher risk of death within 2 years.

Impact of a mass media campaign (MMC) on awareness of and willingness to participate in cancer clinical trials (CCT): Results from 2,269 survey respondents

6012

Background: Annually, only 3% of patients (pt) participate in CCT. Accrual barriers include lack of CCT awareness and uncertain third party coverage. In 1/02, a California law (SB37) required all third party payers to reimburse pt care costs related to CCT. We sought to increase awareness of CCT/SB37 through a MMC, and assessed willingness to participate. Methods: Following a pre-MMC survey of 1,188 cancer pt and/or their caregivers’ awareness and willingness levels (JCO 2005; 23:9282–89), a TV/radio/print/internet MMC was conducted in a 9-county catchment area for UC Davis Cancer Center from 4/05–6/05. The MMC emphasized CCT/SB37 availability and used an iconic “Big C” logo. The survey was repeated post-MMC in two pt/caregiver cohorts: from the UC Davis Cancer Center catchment area (C1), and a control group from the UC San Diego area (C2) who did not see the MMC. Changes in CCT/SB37 awareness and willingness to participate were probed pre- vs. post-MMC and C1 vs. C2 by Pearson χ2 & logistic regression. Results: Of 2,269 respondents, 1,081 were post-MMC: 957 from C1 and 124 from C2. Post-MMC respondents differed from pre-MMC by respondent type (pt > caregivers), age (older), race (more blacks), and income (more $75k+/yr). Pre- vs. post-MMC, C1 respondents had greater awareness of CCT (59% to 65%, p < 0.01) and SB37 (17% vs. 32%, p < 0.01); no significant change was seen in C2. Adjustment for demographic variables in C1 resulted in p > 0.05 for CCT/SB37 awareness. Willingness to participate in CCT did not change pre- vs. post-MMC in C1 or C2. Awareness level predicted willingness (OR = 2.3, p < 0.01), but this was not true for the lowest income/education groups. Blacks/Asians/lowest income (< $25K/yr) groups were least willing to participate (p < 0.01/0.04/0.02). Conclusions: Although CCT/SB37 awareness increased in C1 following the MMC, it is unclear whether this was wholly attributable to the MMC due to varying demographic variables. Awareness of CCT/SB37 did not universally translate into willingness to participate in all subgroups. Enhancing pt willingness (to increase CCT accrual) will require targeting other variables, such as physician or resource barriers, rather than just CCT/SB37 awareness. (R21 CA-03501).

No significant financial relationships to disclose.

Venous thromboembolism in 9,489 patients with glioma

1538

Background: Venous thromboembolic events (VTE) are a commonly reported complication of brain tumors. The objective of this study was to define the incidence, risk factors, and outcomes associated with VTE in a population-based cohort. Methods: This was a retrospective analysis of all glioma cases diagnosed in California between 1993–1995 and 1997–1999. Glioma cases in the California Cancer Registry were linked to the California Patient Discharge Database to identify incident VTE. Cox models were generated to analyze the association of pre-specified risk factors with VTE or death within one year of the cancer diagnosis. Results: There were 9489 cases: 76% were Caucasians and 56% were men. The 1-year cumulative incidence of VTE was 663 (7%) with an incidence rate during the first year of 11.1 events per 100 person-years. Sixty-six percent of all VTE diagnosed in the first year occurred within 3 months of the cancer diagnosis with a corresponding incidence rate of 21.6 events per 100 person-years. Of 663 first year VTE, 405 (61%) occurred <2 months after an invasive neurosurgical procedure. Glioblastoma multiforme (GBM) was associated with an increased risk of VTE (HR=1.6, CI: 1.3–2.0) compared to other gliomas. The risk of VTE was strongly associated with the number of chronic co-morbidities (HR=4.0, CI: 3.1–5.0 for ≥3 chronic co-morbidities). Asian race was associated with significantly lower risk of VTE (HR=0.3, CI: 0.2–0.6) and female gender conferred a modestly lower risk (HR=0.8, CI: 0.7–0.9). A VTE in the first year was associated with slightly lower risk of death (HR = 0.8; CI: 0.8–0.9), whereas increasing age (HR=6.3, CI: 5.6–7.0 for age≥75), number of co-morbidities (HR=1.9, CI: 1.7–2.0 for ≥3 chronic co-morbidities), and GBM (HR=2.2, CI: 2.0–2.4) or anaplastic astrocytoma (HR=1.5, CI: 1.3–1.7) histology were associated with a higher risk of death within 1 year. Conclusions: In this large glioma cohort, the incidence of symptomatic VTE was very high. Two-thirds of all VTE occurred early after the diagnosis of glioma, and most of these occurred within 2 months of an invasive neurosurgical procedure. The presence of chronic medical co-morbidities and GBM histology were strong predictors of VTE. A diagnosis of VTE was not associated with an increased risk of death within 1 year.

No significant financial relationships to disclose.

Incidence of Venous Thromboembolism and Its Effect on Survival Among Patients With Common Cancers

BACKGROUND

The incidence of venous thromboembolism after diagnosis of specific cancers and the effect of thromboembolism on survival are not well defined.

METHODS

The California Cancer Registry was linked to the California Patient Discharge Data Set to determine the incidence of venous thromboembolism among cancer cases diagnosed between 1993 and 1995. The incidence and timing of thromboembolism within 1 and 2 years of cancer diagnosis and the risk factors associated with thromboembolism and death were determined.

RESULTS

Among 235 149 cancer cases, 3775 (1.6%) were diagnosed with venous thromboembolism within 2 years, 463 (12%) at the time cancer was diagnosed and 3312 (88%) subsequently. In risk-adjusted models, metastatic disease at the time of diagnosis was the strongest predictor of thromboembolism. Expressed as events per 100 patient-years, the highest incidence of thromboembolism occurred during the first year of follow-up among cases with metastatic-stage pancreatic (20.0), stomach (10.7), bladder (7.9), uterine (6.4), renal (6.0), and lung (5.0) cancer. Adjusting for age, race, and stage, diagnosis of thromboembolism was a significant predictor of decreased survival during the first year for all cancer types (hazard ratios, 1.6-4.2; P<.01).

CONCLUSIONS

The incidence of venous thromboembolism varied with cancer type and was highest among patients initially diagnosed with metastatic-stage disease. The incidence rate of thromboembolism decreased over time. Diagnosis of thromboembolism during the first year of follow-up was a significant predictor of death for most cancer types and stages analyzed. For some types of cancer, the incidence of thromboembolism was sufficiently high to warrant prospective clinical trials of primary thromboprophylaxis.

Incidence of Venous Thromboembolism in the Year Before the Diagnosis of Cancer in 528 693 Adults

BACKGROUND

It is unclear how frequently unprovoked venous thromboembolism (VTE) reflects the presence of an occult cancer.

METHODS

The California Cancer Registry was used to identify diagnosed cases of 19 common malignancies during a 6-year period. Cases were linked to a hospital discharge database to identify incident VTE events in the year before the cancer diagnosis date. The standardized incidence ratio (SIR) of unprovoked VTE was determined by using the age-, race-, and sex-specific incidence rates in California.

RESULTS

Among 528,693 cancer cases, 596 (0.11%) were associated with a diagnosis of unprovoked VTE within 1 year of the cancer diagnosis, compared with 443.0 expected cases (SIR, 1.3; 95% confidence interval, 1.2-1.5; P<.001). Among cases with metastatic-stage cancer, the SIR was 2.3 (95% confidence interval, 2.0-2.6; P<.001), whereas for all other stages, the SIR was 1.07 (95% confidence interval, 0.97-1.18; P = .09). The incidence of preceding VTE was increased over that expected only during the 4-month period immediately preceding the cancer diagnosis date (P<.001). Only 7 cancer types were associated with a significantly elevated SIR: acute myelogenous leukemia; non-Hodgkin lymphoma; and renal cell, ovarian, pancreatic, stomach, and lung cancer (SIR range, 1.8-4.2).

CONCLUSIONS

In the year preceding the diagnosis of cancer, the number of cases with unprovoked VTE was modestly higher than expected, and almost all of the unexpected VTE cases were associated with a diagnosis of metastatic-stage cancer within 4 months. Given the timing and advanced stage of the unexpected cases, it is unlikely that earlier diagnosis of these cancers would have significantly improved long-term survival.

An Evaluation of Barriers to Accrual in the Era of Legislation Requiring Insurance Coverage of Cancer Clinical Trial Costs in California

PURPOSE

Clinical trials are essential to improve cancer therapy, but only 3% of newly diagnosed adult cancer patients enroll annually. We previously conducted a prospective analysis of factors affecting trial accrual at the UC Davis Cancer Center between 1997 and 2000. It was found that the accrual rate was 14% and that patients with private insurance were significantly less likely than patients with government insurance to enroll, suggesting that fear of insurance denial was a barrier. In 2002, a new California law (SB37) required insurers to reimburse routine costs of care for cancer trials.

METHODS

To assess the impact of SB37 on accrual, we repeated our study using the same sur vey instrument. Oncologists seeing new patients at the UC Davis Cancer Center from August to November 2002 completed questionnaires that inquired about patient characteristics and eligibility, protocol availability, and patient willingness to participate.

RESULTS

Physicians considered clinical trials for 55% (118/216) of patients, but trials were available for only 53% (62/118). Eligibility criteria were met by 82% (51/62). Of these, 69% (35/51) agreed to participate (vs 51% previously). No patient declined to participate because of insurance limitations (vs 8% previously). Furthermore, insurance type was no longer a significant factor in determining whether patients would enroll. This suggests that although the overall rate of accrual is only slightly increased after passage of SB37, patients may be more willing to enroll. Efforts to increase participation must include enhancing physician and patient awareness of SB37.

Blastic mantle cell lymphoma developing concurrently in a patient with chronic myelogenous leukemia and a review of the literature

Non-Hodgkin's lymphoma (NHL) occurring as a synchronous malignancy with chronic myelogenous leukemia (CML) is rare. To our knowledge, this is the first case reported of a patient who developed mantle cell lymphoma (MCL) after therapy with imatinib mesylate for CML. After a 3-year history of CML, the patient developed a lymphocytosis associated with diarrhea, anorexia, and weight loss. Imaging studies revealed abdominal adenopathy and extensive lymphomatous infiltration of the liver, stomach, pancreas, and kidneys. Flow cytometric and cytogenetic studies were consistent with MCL. Fluorescence in situ hybridization (FISH) of the bone marrow revealed a genetically distinct lymphoid neoplasm rather than an extramedullary blast crisis of CML. The development of lung cancer, prostate cancer, CML and MCL in this patient suggests a genetic predisposition, although other factors, including environmental exposures and therapy with imatinib mesylate could have had a contributory or synergistic role in the development of MCL.

Early diagnosis and successful treatment of a patient with transfusion-associated GVHD with autologous peripheral blood progenitor cell transplantation

BACKGROUND

Transfusion-associated GVHD (TA-GVHD) is an uncommon complication of blood transfusion. Diagnosis of TA-GVHD is difficult, and it is usually rapidly fatal. There are few documented sur- vivors of TA-GVHD.

CASE REPORT

A 61-year-old woman with chronic lymphocytic leukemia (CLL) was treated with fludarabine followed by combination chemotherapy and high-dose radioimmunotherapy and peripheral blood progenitor cell (PBPC) rescue. She was transfused with nonirradiated blood components at an outside hospital and presented 10 days later with rash, elevated liver enzymes, and progressive pancytopenia. Skin biopsy was consistent with GVHD, and HLA typing of lymphocytes from the patient demonstrated mixed chimerism. The patient was treated with solumedrol and cyclosporin A, followed by high-dose cyclophosphamide and antithymocyte globulin and autologous PBPC infusion. She had rapid engraftment, resolution of skin rash, and normalization of liver function abnormalities. She is in good health with normal blood counts and no evidence of CLL 34 months after transplantation.

CONCLUSION

TA-GVHD occurs in the setting of an immunocompromised recipient receiving nonirradiated blood components. A typical presentation includes skin rash, liver function abnormalities, and pancytopenia. Demonstration of mixed chimerism by HLA typing facilitated diagnosis in this patient. High-dose immunosuppression, facilitated by the availability of autologous PBPCs, resulted in a successful outcome.

Filgrastim treatment of acute myelogenous leukemia (M7) relapse after allogeneic peripheral stem cell transplantation resulting in both graft-versus-leukemia effect with cytogenetic remission and chronic graft-versus-host disease manifesting as polyserositis and subsequent bronchiolitis obliterans with organizing pneumonia

Filgrastim (granulocyte colony-stimulating factor) has recently been reported to successfully treat patients with leukemic relapse after allogeneic peripheral stem cell transplantation (PSCT). However, the majority of the patients who responded also developed graft-versus-host disease (GVHD). Polyserositis as a manifestation of GVHD is a rare phenomenon. We report the first case of polyserositis following the use of filgrastim to treat a patient with acute myelogenous leukemia (M7), who had relapsed after an initially successful allogeneic PSCT. The polyserositis manifested with effusions and was initially controlled with high doses of steroids and pericardial stripping; however, after a quiescent period the patient eventually developed bronchiolitis obliterans with organizing pneumonia that required additional immunosuppressive therapy. We review the literature on GVHD-associated polyserositis and offer potential explanations for its pathogenesis.

Postprandial lipemia is associated with platelet and monocyte activation and increased monocyte cytokine expression in normolipemic men

The activation of platelets and monocytes has been implicated in the development of cardiovascular diseases. We asked the question if postprandial lipemia following a fat- containing meal is associated with platelet and monocyte activation and increased platelet-monocyte interaction. Thirteen healthy, normal weight, normolipemic males, 20 to 49 years, consumed a 40% fat meal of whole foods. Blood samples were obtained at fasting and 3 1/2 and 6 hours after ingestion. Triglyceride levels increased to 48% over baseline at 3 1/2 hours postconsumption and returned to fasting levels by 6 hours. Multiparameter flow cytometry using monoclonal antibodies showed that the percentage of platelets expressing surface P-selectin and the activated conformation the GPIIb-IIa receptor was significantly higher at 3 1/2 hours compared to fasting. The percentage of platelet-monocyte aggregates increased by 36% at 3 1/2 hours and 43% at 6 hours postconsumption. The percentage of monocytes expressing intracellular tumor necrosis factor-alpha (TNF-alpha) increased seven and eightfold at 3 1/2 and 6 hours, respectively. The expression of interleukin-1beta (IL-1beta increased in a similar manner. These data suggest activation of platelets and monocytes after a moderate fat meal. Repetitive activation of platelets and monocytes could be an early event in the initiation and development of atherosclerosis.

Isolated cavernous sinus extramedullary relapse of chronic myelogenous leukemia following allogeneic stem cell transplant

Isolated extramedullary relapse of chronic myelogenous leukemia (CML) after allogeneic stem cell transplant is rare. A case is reported of a patient who developed a granulocytic sarcoma of the cavernous sinus 7 months after allogeneic transplant for CML. He presented with neurologic deficits, and a mass lesion was found on imaging. No evidence of hematologic relapse was identified by bone marrow histology or cytogenetics. A premortem diagnosis was not possible, and the patient died 2 months later of an intracerebral hemorrhage after receiving various therapies directed against a presumed infectious etiology. Granulocytic sarcoma should be considered in the differential diagnosis of mass lesions presenting after allogeneic transplant for CML, even if there is no evidence of medullary disease.

Purified poloxamer 188 for treatment of acute vaso-occlusive crisis of sickle cell disease: A randomized controlled trial

CONTEXT

Sickle cell disease (SCD) can cause severe painful episodes that are often thought to be caused by vaso-occlusion. The current therapy for these uncomplicated painful episodes includes hydration, oxygen, and analgesics. Purified poloxamer 188 may increase tissue oxygenation and thereby reduce inflammation, pain, and the overall duration of such painful episodes in patients with SCD.

OBJECTIVE

To compare the duration of painful episodes in patients with SCD treated with purified poloxamer 188 to that of similar episodes experienced by patients who receive a placebo.

DESIGN AND SETTING

Randomized, double-blind, placebo-controlled, intention-to-treat trial conducted between March 1998 and October 1999 in 40 medical centers in the United States.

PARTICIPANTS

Two hundred fifty-five patients with SCD (aged 9-53 years) who had a painful episode sufficiently severe to require hospitalization and narcotic analgesics.

INTERVENTION

Patients were randomly assigned to receive an intravenous infusion of purified poloxamer 188, 100 mg/kg for 1 hour followed by 30 mg/kg per hour for 47 hours (n = 127), or a matching volume of saline placebo (n = 128).

MAIN OUTCOME MEASURE

Duration of the painful episode, from randomization to crisis resolution.

RESULTS

Mean (SD) duration of the painful episodes was 141 (42) hours in the placebo group compared with 133 (41) hours in those treated with purified poloxamer 188, a 9-hour reduction (P =.04). Subset analyses indicated an even more pronounced purified poloxamer 188 effect in children aged 15 years or younger (21 hours; P =.01) and in patients who were receiving hydroxyurea (16 hours; P =.02). Finally, the proportion of patients achieving crisis resolution was increased by purified poloxamer 188 (65/126 [52%] vs 45/123 [37%]; P =.02). Similar results were observed in children aged 15 years or younger (22/37 [60%] vs 10/36 [28%]; P =.009) and in patients who were also receiving hydroxyurea (12/26 [46%] vs 4/28 [14%]; P =.02).

CONCLUSIONS

A decrease in the duration of painful episodes and an increase in the proportion of patients who achieved resolution of the symptoms were observed when the purified poloxamer 188-treated patients were compared with the patients receiving placebo. However, the difference between these groups was significant but relatively small. In subgroup analysis, a more significant effect on both parameters was observed in children and in patients who were receiving concomitant hydroxyurea. It is important to confirm both of these observations in further prospective trials.

Radioimmunotherapy: potential as a therapeutic strategy in non-Hodgkin's lymphoma

Lymphomas are the fifth most common malignancy in the United States and are increasing in incidence. Despite being among the most responsive malignancies to radiation and chemotherapy, the majority of patients relapse or have progressive disease. Monoclonal antibodies (MAbs) directed at cell-specific surface antigens have been useful in the diagnosis of lymphomas and, more recently, the therapeutic mouse-human chimeric MAb rituximab has demonstrated effectiveness in B cell lymphomas. Conjugating MAbs to radionuclides is a strategy for improving the efficacy of MAb lymphoma therapy by delivering radiation in close proximity to the tumour (radioimmunotherapy or RIT). In addition, the low dose rate of the delivered radiation may exert a greater antitumour activity than an equivalent dose of conventional external beam radiation. The antigenic targets for MAb therapy have included CD20, CD22, HLA-DR, and B cell idiotype. Radionuclides that have been used include iodine-131, yttrium-90, and copper-67; there are relative merits and disadvantages to each source of radiation. Clinical studies to date have focused on relapsed and refractory patients with both indolent and aggressive lymphomas, although more recent studies have included previously untreated patients with indolent lymphoma. Radioimmunoconjugate has been delivered as either single or multiple doses. Response rates have varied widely, dependent on the patient population and the response criteria. Of note, complete responses can be achieved in this typically refractory patient group. Toxicities have generally consisted of mild infusion-related nausea, fever, chills, and asthenia. Neutropenia and thrombocytopenia are the dose-limiting toxicities and have prompted the incorporation of autologous stem cell support as a means of achieving dose escalation. To date, RIT has been delivered to highly selected patients in relatively few centres with requisite equipment and specialised personnel. In addition to these requirements, cost is likely to be a barrier to widespread use. The combination of RIT with chemotherapy at conventional or high dose, or with biological agents is a fertile area for investigation. The potential of RIT in the treatment for lymphomas will be defined only by well designed comparative prospective clinical studies.

Correlation of abnormal intracranial vessel velocity, measured by transcranial Doppler ultrasonography, with abnormal conjunctival vessel velocity, measured by computer-assisted intravital microscopy, in sickle cell disease

The Stroke Prevention Trial has confirmed that utilization of transcranial Doppler ultrasonography (TCD), which examines blood flow in large intracranial vessels, can identify children with sickle cell disease (SCD) who are at high risk of developing a premature stroke. It is not known to what extent the vasculopathy in SCD involves small vessels and whether the abnormalities, if present, correlate with large-vessel vasculopathy. Eighteen children with SCD were examined with TCD to determine middle cerebral artery (MCA) velocity and computer-assisted intravital microscopy (CAIM) to determine bulbar conjunctival vessel velocity during the same visit for vasculopathy correlation. High MCA velocity (≥ 200 cm/sec) was found by TCD in 4 patients who also showed abnormal conjunctival velocity (&lt; 0.2 mm/sec or intermittent trickle flow) by CAIM. Three patients had conditional (≥ 170 cm/sec and &lt; 200 cm/sec) MCA velocity: 2 showed abnormal (trickle) and 1 showed normal conjunctival velocity (1.9 mm/sec). One patient with unmeasurable MCA velocity had abnormal (trickle) conjunctival velocity. Of the remaining 10 patients who had normal MCA velocity, 2 showed abnormal (0.05 mm/sec and 0.1 mm/sec) and 8 showed normal conjunctival velocities (1.1-2.4 mm/sec). The MCA velocities correlated significantly with bulbar conjunctival flow velocities (P ≤ .008, Fisher exact test). A correlation exists between MCA (large-vessel) and conjunctival (small-vessel) flow velocities. CAIM is a noninvasive quantitative technique that might contribute to the identification of SCD patients at high risk of stroke. Small-vessel vasculopathy might be an important pathological indicator and should be further explored in a large-scale study.

Prospective evaluation of cancer clinical trial accrual patterns: identifying potential barriers to enrollment

PURPOSE

Well-conducted cancer clinical trials are essential for improving patient outcomes. Unfortunately, only 3% of new cancer patients participate in clinical trials. Barriers to patient accrual in cancer clinical trials must be identified and overcome to increase patient participation.

MATERIALS AND METHODS

We prospectively tracked factors that potentially affected patient accrual into cancer clinical trials at the University of California Davis Cancer Center. Oncologists seeing new outpatients were asked to complete questionnaires regarding patient characteristics and the physician's decision-making on patient eligibility, protocol availability, and patient opinions on participation. Statistical analysis was performed to correlate these parameters with subsequent protocol accrual.

RESULTS

There were 276 assessable patients. At the initial visits, physicians did not consider clinical trials in 38% (105/276) of patients principally because of a perception of protocol unavailability and poor performance status. Physicians considered 62% (171/276) of patients for participation in clinical trials. Of these, only 53% (91/171) had an appropriate protocol available for site and stage of disease. Seventy-six of 90 patients (84%) with available protocols met eligibility criteria for a particular study. Only 39 of 76 patients (51%) agreed to participate in cancer clinical trials, for an overall accrual rate of 14% (39/276). The remainder (37/76, 49%) declined trial participation despite meeting eligibility criteria. The most common reasons were a desire for other treatment (34%), distance from the cancer center (13%), patient refusal to disclose reason (11%), and insurance denial (8%). Patients with private insurance were less likely to enroll in clinical trials compared to those with government-funded insurance (OR, 0.34; P =.03; 95% CI, 0.13 to 0.9).

CONCLUSION

Barriers to cancer clinical trial accrual can be prospectively identified and addressed in the development and conduct of future studies, which may potentially lead to more robust clinical trials enrollment. Investigation of patient perceptions regarding the clinical trials process and the role of third party-payers is warranted.

Comparison of the L10M consolidation regimen to an alternative regimen including escalating methotrexate/L-asparaginase for adult acute lymphoblastic leukemia: a Southwest Oncology Group Study

The effectiveness of intensive post-remission chemotherapy regimens for adult patients with acute lymphoblastic leukemia (ALL) is limited by both a high rate of disease recurrence and a substantial incidence of treatment toxicity. To evaluate a potentially more effective and less toxic approach, we conducted a multicenter phase III trial of consolidation therapies comparing the standard L10M regimen with one combining the brief, intensive L17M regimen and escalating methotrexate (MTX) and L-asparaginase (L-asp). Patients over age 15 with previously untreated ALL were eligible. Induction therapy included vincristine, prednisone, doxorubicin, cyclophosphamide and intrathecal methotrexate administered over 36 days. Patients who achieved complete remission (CR) were randomized to receive consolidation with either the L10M regimen or with DAT (daunomycin, cytosine arabinoside, 6-thioguanine) and escalating MTX and L-asp. The randomization was stratified by age, WBC and Ph chromosome status. Maintenance therapy was the same in both arms. Of 353 eligible patients, 218 (62%) achieved CR and 195 were randomized. The treatment arms did not differ significantly with respect to disease-free survival (DFS; P= 0.46) or overall survival (P= 0.39). Estimated DFS at 5 years was 32% (95% confidence interval (CI) 23-42%) in the L10M arm and 25% (95% CI 16-33%) in the DAT/MTX/L-asp arm. In each arm, 4% of patients died of toxicities (infection in all but one case). Infections and nausea/vomiting were somewhat more common in the L10M arm (occurring in 68% and 53% of patients respectively) than the DAT/MTX/L-asp arm (56% and 33%). The DAT/MTX/L-asp consolidation regimen was associated with some reduction in nonfatal toxicities, but no significant improvement in DFS, overall survival or non-relapse mortality when compared to the standard L10M regimen.

A phase I study of 90Y-2IT-BAD-Lym-1 in patients with non-Hodgkin's lymphoma

BACKGROUND

Prior clinical trials proved that all histologic grades of chemotherapy-resistant B-cell non-Hodgkin's lymphoma (NHL) could respond to radio-immunotherapy (RIT) with 131I-Lym-1 and 67Cu-2IT-BAT-Lym-1. This Phase I study was conducted to determine the safety and maximum tolerated dose (MTD) of 90Y-2IT-BAD-Lym-1.

METHODS

Lym-1 is a mouse monoclonal antibody that preferentially targets malignant B-lymphocytes. 90Y has beta emissions suitable for therapy but no gamma emissions, therefore, 111In-2IT-BAD-Lym-1 is used for imaging. The macrocyclic chelator, DOTA, bound 90Y tightly to form a stable drug. Patients with chemotherapy-resistant NHL received 90Y-2IT-BAD-Lym-1 at administered doses of: 0.185, 0.278, or 0.370 GBq/m2.

RESULTS

Myelotoxicity, especially thrombocytopenia, was dose-limiting. No significant non-hematologic toxicity occurred. Human anti-mouse antibody (HAMA) developed in 3/8 patients. The mean radiation dose to the 33 imaged tumors was 7.0 Gy/GBq. Lung, kidney and liver received mean radiation doses of 1.3, 2.4, and 6.4 Gy/GBq, respectively from 90Y-2IT-BAD-Lym-1. The tumor: body and tumor:bone marrow (by imaging) ratios were 16.4:1 and 5.8:1, respectively. In this Phase I study, 5/8 patients that failed prior chemotherapy had a partial response or stabilization of NHL after RIT.

CONCLUSION

The safety and toxicity of 90Y-2IT-BAD-Lym-1 were determined and the MTD was 0.370 GBq/m2, a dose used in 4 patients. 90Y-2IT-BAD-Lym-1 may be useful for future clinical trials because 90Y is readily available and can deliver potent beta emissions to NHL. Bone marrow support however, will be required for further dose escalation.