1
|
Hay S, Mowitz M, Dukhovny D, Viner C, Levin J, King B, Zupancic JAF. Unbiasing costs? An appraisal of economic assessment alongside randomized trials in neonatology. Semin Perinatol 2021; 45:151391. [PMID: 33583609 DOI: 10.1016/j.semperi.2021.151391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Economic evaluations performed alongside randomized controlled trials benefit from the protections against bias inherent in randomization. In this systematic review, we assessed the frequency and quality of economic assessments alongside randomized controlled trials of interventions in neonates published between 1990 and 2016. Over that period, 58 economic assessments were published, corresponding to approximately 2% of RCTs. We noted significant methodological limitations of these studies, including limitation of included costs to the health sector or payer rather than broader categories such as family or community expenditures (81%), short time horizon for cost measurement (less than one year in 60%), lack of reporting of uncertainty (26%), and infrequent analysis of costs and effects in a single metric (combined in 45%). Strategies for improving the quality and frequency of economic evaluations in neonatology are discussed, including selection of appropriate trials, funding, and peer review.
Collapse
Affiliation(s)
- Susanne Hay
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Division of Newborn Medicine, Harvard Medical School, Boston, Massachusetts, USA.
| | - Meredith Mowitz
- Division of Neonatology, University of Florida, Gainesville, Florida, USA
| | - Dmitry Dukhovny
- Division of Neonatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Christine Viner
- Department of Pediatrics, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Jonathan Levin
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Brian King
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Division of Newborn Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Chiniara LN, Viner C, Palmert M, Bonifacio H. Perspectives on fertility preservation and parenthood among transgender youth and their parents. Arch Dis Child 2019; 104:739-744. [PMID: 30894340 DOI: 10.1136/archdischild-2018-316080] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 02/13/2019] [Accepted: 02/15/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the views of young people (YP) with gender dysphoria and their parents concerning fertility preservation and reproductive and life priorities. DESIGN A cross-sectional questionnaire-based study assessed knowledge of potential effects of treatments for gender dysphoria on fertility, current and future life priorities and preferences regarding future fertility/parenting options among YP and parents. RESULTS A total of 79 YP (81% assigned female at birth [AFAB], 19% assigned male at birth [AMAB], aged 12-18 years, 68% between ages 16 years and 18 years) and 73 parents participated. The top current life priority for YP among eight options was being in good health; the least important priority was having children. Anticipated life priorities 10 years from now were ranked similarly. Parents' rankings paralleled the YP responses; however, parents ranked having children as a significantly higher priority for AFAB compared with AMAB YP in 10 years. The majority of YP (66% AFAB, 67% AMAB) want to be a parent in the future. However, most do not envision having a biological child. A large majority (72% AFAB, 80% AMAB) were open to adoption. None of the YP surveyed pursued fertility preservation. CONCLUSION Fertility is a low current and future life priority for transgender YP. The majority of YP wish to become parents but are open to alternative strategies for building a family. These data may explain in part the reported low rates of fertility preservation among this population. Further studies are needed to assess if life priorities change over time.
Collapse
Affiliation(s)
- Lyne Noelle Chiniara
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christine Viner
- Department of Pediatrics, Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark Palmert
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Herbert Bonifacio
- Department of Pediatrics, St-Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Chadi N, Weisbaum E, Malboeuf-Hurtubise C, Kohut SA, Viner C, Palaniyar N, Kaufman M, Locke J, Vo DX. In-person vs. eHealth Mindfulness-based Intervention for Adolescents with Chronic Illnesses: A Pilot Randomized Trial. APS 2019. [DOI: 10.2174/2210676608666181031102235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Mindfulness-Based Interventions (MBIs) can improve mental health
and well-being in adolescents with chronic illnesses. However, there are many barriers such
as reduced mobility and distance which compromise accessibility to MBIs.
Objective:
The aim of this study was to determine the effectiveness of the Mindful
Awareness and Resilience Skills for Adolescents (MARS-A) program in youth with chronic
illnesses delivered in person or via eHealth.
Method:
In this mixed method randomized controlled trial, participants received weekly 90-
minute long MARS-A sessions for 8 weeks, either in person or via a secure eHealth audiovisual
platform allowing group interactions in real time. Data was collected at baseline,
immediately after and two months post-MBI through saliva analyses, electronic participant
logs and validated questionnaires assessing mindfulness skills and mental health outcomes.
Results:
Seven participants per group completed the intervention (total n=14, completion
rate 77.8%). Paired t-test analyses revealed a significant reduction in depression/anxiety
scores immediately post-intervention (p=0.048, Cohen’s d=0.934) and a significant reduction
in pre-post mindfulness cortisol levels at week 8 (p=0.022, Cohen’s d=0.534) in the eHealth
group. Frequency and duration of weekly individual home practice (eHealth: 6.5 times; 28.8
minutes; in-person: 6.0 times; 30.6 minutes) were similar in both groups and maintained at
follow-up.
Conclusion:
This is the first study comparing in-person and eHealth delivery of an 8-week
MBI for adolescents with chronic illnesses. Although the study was limited by the small size
of the sample, our results suggest that eHealth delivery of MBIs may represent a promising
avenue for increasing availability in this population.
Collapse
Affiliation(s)
- Nicholas Chadi
- Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Elli Weisbaum
- Institute of Medical Sciences and University of Toronto, Toronto, ON, Canada
| | | | - Sara Ahola Kohut
- Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Christine Viner
- Downstate Medical Center and State University of New York, New York, NY, United States
| | - Nades Palaniyar
- Peter Gilgan Centre for Research and Learning and University of Toronto, Toronto, ON, Canada
| | - Miriam Kaufman
- Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Jake Locke
- British Columbia Children's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Dzung X. Vo
- British Columbia Children's Hospital and University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
4
|
Chadi N, Weisbaum E, Malboeuf-Hurtubise C, Ahola Kohut S, Viner C, Kaufman M, Locke J, Vo DX. Can the Mindful Awareness and Resilience Skills for Adolescents (MARS-A) Program Be Provided Online? Voices from the Youth. Children (Basel) 2018; 5:children5090115. [PMID: 30154368 PMCID: PMC6162431 DOI: 10.3390/children5090115] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 01/13/2023]
Abstract
Mindfulness-based interventions (MBIs) have been shown to improve health and well-being in adolescents with chronic illnesses. Because they are most often delivered in person in a group setting, there are several barriers that limit access to MBIs for youth with limited mobility or who cannot access in-person MBIs in their communities. The objective of this study was to determine if eHealth is a viable platform to increase accessibility to MBIs for teens with chronic illnesses. This study reports the qualitative results of a mixed method randomized trial describing the experience of the Mindful Awareness and Resilience Skills for Adolescents (MARS-A) program, an eight-week MBI, delivered either in person or via eHealth. Participants were adolescents between the ages of 13 and 18 with a chronic illness recruited at a tertiary pediatric hospital in Toronto, Canada. Individual semi-structured post-participation audio-video interviews were conducted by a research assistant. A multiple-pass inductive process was used to review interview transcripts and interpret emergent themes from the participants’ lived experiences. Fifteen participants (8 online and 7 in person) completed post-participation interviews. Four distinct themes emerged from participants in both groups: Creation of a safe space, fostering peer support and connection, integration of mindfulness skills into daily life, and improved well-being through the application of mindfulness. Direct quotations representative of those four themes are reported. Results from this study suggest that eHealth delivery of an adapted MBI for adolescents with chronic illnesses may be an acceptable and feasible mode of delivery for MBIs in this population. EHealth should be considered in future studies of MBIs for adolescents with chronic illnesses as a promising avenue to increase access to MBIs for youth who might not be able to access in-person programs.
Collapse
Affiliation(s)
- Nicholas Chadi
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Elli Weisbaum
- Institute of Medical Sciences, University of Toronto, 1 King's College Circle, Room 2374, Toronto, ON M5S 1A8, Canada.
| | | | - Sara Ahola Kohut
- Department of Psychiatry, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Christine Viner
- Department of Pediatrics, Downstate Medical Center, State University of New York, 450 Clarkson Ave, Brooklyn, NY 11203, USA.
| | - Miriam Kaufman
- Division of Adolescent Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Jake Locke
- Department of Child and Adolescent Psychiatry, British Columbia Children's Hospital, University of British Columbia, Vancouver, BCV6H 3N1, Canada.
| | - Dzung X Vo
- Division of Adolescent Health and Medicine, Department of Pediatrics, BC Children's Hospital, University of British Columbia, 4480 Oak St, Vancouver, BC V6H 3N1, Canada.
| |
Collapse
|
5
|
Chadi N, Kaufman M, Weisbaum E, Malboeuf-Hurtubise C, Kohut SA, Viner C, Locke J, Vo DX. In-Person Versus eHealth Mindfulness-Based Intervention for Adolescents With Chronic Illness: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2017; 6:e241. [PMID: 29180345 PMCID: PMC5725624 DOI: 10.2196/resprot.7700] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 09/03/2017] [Accepted: 10/30/2017] [Indexed: 01/22/2023] Open
Abstract
Background Eight-week mindfulness-based interventions (MBIs) have a beneficial impact on mental health and well-being in adolescents with chronic health conditions. Usually delivered in person in a group setting, these programs are difficult to access for teens with disabilities or who do not have in-person MBIs available in their communities. Objective This paper outlines the rationale, development, and design of a randomized controlled trial comparing the effects of an MBI delivered in person or via eHealth in adolescents with a chronic illness. Quantitative outcomes will include mindfulness skills acquisition (primary outcome), effects of the MBI on self-reported mood, anxiety, self-esteem, illness perception, and physiological stress (via salivary cortisol), and qualitative outcomes will include individual practice, participant appreciation, and adaptation of the MBI for eHealth. Methods This is a randomized noninferiority mixed methods study comparing 2 MBI arms: in-person and eHealth. Participants are eligible to participate if they are aged 13 to 18 years, have a diagnosis of chronic medical condition, live close enough to the recruitment hospital to participate in the in-person arm of the study, and are currently followed by a health care provider. Each participant will receive an adapted 8-week MBI delivered either in person at a tertiary pediatric hospital or via a secure audio-visual platform allowing group interactions in real time. Groups will be facilitated by 2 experienced mindfulness providers. Quantitative and qualitative data will be collected through standardized research questionnaires administered via a secure, youth-friendly online platform and through semistructured interviews, participant log books, facilitator log books, and salivary cortisol analysis. Qualitative data will be analyzed using a grounded theory model. Results Data collection is currently underway. Data analysis, manuscript writing, and additional publications are expected to be completed in the winter and spring of 2018. Conclusions Based on previous results from in-person trials conducted in adolescents and eHealth trials conducted in adults, we anticipate that both modes of delivery will significantly improve mindfulness skills acquisition, mood, anxiety, self-esteem, illness perception, and stress and that the magnitude of the effects will be correlated to the level of home practice. We predict that participants in both arms will show similar levels of home practice and that both modes of delivery will have high levels of feasibility and acceptability. If successful, this study could provide evidence for the use of eHealth in the delivery of 8-week MBIs in clinical adolescent populations, potentially increasing availability to MBIs for a large group of youth with mobility issues or living away from large urban centers. Trial Registration ClinicalTrials.org NCT03067207; https://clinicaltrials.gov/ct2/show/NCT03067207 (archived by WebCite at http://www.webcitation.org/6v4ZK8RBH)
Collapse
Affiliation(s)
- Nicholas Chadi
- Division of Adolescent Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Miriam Kaufman
- Division of Adolescent Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Elli Weisbaum
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Catherine Malboeuf-Hurtubise
- Research Group on Mindfulness, Montreal, QC, Canada.,Department of Educational Sciences, Université du Québec en Outaouais, Gatineau, QC, Canada
| | - Sara Ahola Kohut
- Medical Psychiatry Alliance, Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Christine Viner
- Division of Adolescent Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, Downstate Medical Center, State University of New York, New York, NY, United States
| | - Jake Locke
- Department of Child and Adolescent Psychiatry, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Dzung X Vo
- Division of Adolescent Health and Medicine, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
6
|
Hay SC, Kirpalani H, Viner C, Soll R, Dukhovny D, Mao WY, Profit J, DeMauro SB, Zupancic JAF. Do trials reduce uncertainty? Assessing impact through cumulative meta-analysis of neonatal RCTs. J Perinatol 2017; 37:1215-1219. [PMID: 28880258 DOI: 10.1038/jp.2017.126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/24/2017] [Accepted: 05/15/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess the impact of the latest randomized controlled trial (RCT) to each systematic review (SR) in Cochrane Neonatal Reviews. STUDY DESIGN We selected meta-analyses reporting the typical point estimate of the risk ratio for the primary outcome of the latest study (n=130), mortality (n=128) and the mean difference for the primary outcome (n=44). We employed cumulative meta-analysis to determine the typical estimate after each trial was added, and then performed multivariable logistic regression to determine factors predictive of study impact. RESULTS For the stated primary outcome, 18% of latest RCTs failed to narrow the confidence interval (CI), and 55% failed to decrease the CI by ⩾20%. Only 8% changed the typical estimate directionality, and 11% caused a change to or from significance. Latest RCTs did not change the typical estimate in 18% of cases, and only 41% changed the typical estimate by at least 10%. The ability to narrow the CI by >20% was negatively associated with the number of previously published RCTs (odds ratio 0.707). Similar results were found in analysis of typical estimates for the outcomes of mortality and mean difference. CONCLUSION Across a broad range of clinical questions, the latest RCT failed to substantially narrow the CI of the typical estimate, to move the effect estimate or to change its statistical significance in a majority of cases. Investigators and grant peer review committees should consider prioritizing less-studied topics or requiring formal consideration of optimal information size based on extant evidence in power calculations.
Collapse
Affiliation(s)
- S C Hay
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - H Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - C Viner
- Department of Obstetrics and Gynecology, New York University, New York, NY, USA
| | - R Soll
- Division of Neonatal Perinatal Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| | - D Dukhovny
- Division of Neonatology, Oregon Health and Science University, Portland, OR, USA
| | - W-Y Mao
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - J Profit
- Division of Neonatology, Stanford University, Stanford, CA, USA
| | - S B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
7
|
McElwain TJ, Selby PJ, Gore ME, Viner C, Meldrum M, Millar BC, Malpas JS. High-dose chemotherapy and autologous bone marrow transplantation for myeloma. Eur J Haematol Suppl 2009; 51:152-6. [PMID: 2697587 DOI: 10.1111/j.1600-0609.1989.tb01509.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In three studies we have attempted to increase the complete remission rate in a series of patients with multiple myeloma under the age of 69. A CR rate of 27% was seen in 63 patients treated with intravenous high-dose melphalan 140 m/m2 with or without the addition of high-dose methyl prednisolone 1 g/m2 for 5 days (in 22 patients). In a third study a CR rate of 50% was seen in 50 patients treated in a programme in which vincristine, adriamycin and methyl prednisolone was first given and patients then received high-dose melphalan 140-200 mg/m2 with an autologous bone marrow transplant where possible. Median remission duration in the first two studies was 19 months with a median survival of 5 years. A definition of complete remission in myeloma is proposed.
Collapse
|
8
|
Cunningham D, Powles R, Malpas J, Raje N, Milan S, Viner C, Montes A, Hickish T, Nicolson M, Johnson P, Treleaven J, Raymond J, Gore M. A randomized trial of maintenance interferon following high-dose chemotherapy in multiple myeloma: long-term follow-up results. Br J Haematol 1998; 102:495-502. [PMID: 9695964 DOI: 10.1046/j.1365-2141.1998.00795.x] [Citation(s) in RCA: 127] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
High-dose chemotherapy (melphalan) with autologous marrow stem cell support (AMSCS) results in high response rates in multiple myeloma (MM), with up to 50% of patients achieving complete remission. However, these remissions are generally not durable. As the cytokine interferon alpha has been shown to prolong partial response following conventional chemotherapy, this trial was conducted to evaluate its role following high-dose chemotherapy. 85 patients were randomly assigned to maintenance treatment with interferon alpha, 3 x 10(6) units/m2 subcutaneously three times weekly until relapse or no further treatment following recovery from high-dose chemotherapy (melphalan 140-200 mg/m2 or busulphan 16 mg/kg) combined with AMSCS. At 5.8 years following the accrual of the last patient in this trial, 38 patients had died, 17 in the interferon arm and 21 in the control arm. The median progression-free survival (PFS) in the 42 patients randomized to interferon alpha was 46 months versus 27 months in the controls. Both overall survival and PFS, which were highly significant at median follow-up of 52 months, have now ceased to be significant, because most patients have ultimately succumbed to their disease. Interferon was tolerated by the majority of patients with very good compliance. Toxicity consisted mainly of flu-like symptoms and malaise which were usually self-limiting. The results of such a pilot study should be carefully interpreted and the benefits of interferon should be confirmed in larger multicentre studies in the setting of minimal residual disease following autologous transplantation.
Collapse
Affiliation(s)
- D Cunningham
- The Cancer Research Campaign, Section of Medicine, The Institute of Cancer Research and The Royal Marsden Hospital, Sutton, Surrey
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Dougherty L, Viner C, Young J. Establishing ambulatory chemotherapy at home. Prof Nurse 1998; 13:356-8. [PMID: 9534556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The use of infusional ambulatory chemotherapy is increasing. Careful patient selection and a structured programme of teaching and home support is required. Continuous ambulatory chemotherapy can improve clinical outcomes and provide both psychological and financial benefits.
Collapse
|
10
|
Powles R, Raje N, Milan S, Millar B, Shepherd V, Mehta J, Singhal S, Kulkarni S, Viner C, Gore M, Cunningham D, Treleaven J. Outcome assessment of a population-based group of 195 unselected myeloma patients under 70 years of age offered intensive treatment. Bone Marrow Transplant 1997; 20:435-43. [PMID: 9313875 DOI: 10.1038/sj.bmt.1700917] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A single centre series of 195 consecutive newly diagnosed untreated myeloma patients under 70 years, seen between September 1986 and March 1994, were analysed to assess the impact of current intensive treatment methods upon remission rate, response rate and subsequent outcome. They were predominantly an unselected population based group of patients (other than by age) that could be used by purchasers of health care as a model for outcome assessment. All patients were scheduled to receive a care plan which included a sequential package of treatment consisting initially of courses of infusional chemotherapy using vincristine, adriamycin and methyl prednisolone (VAMP) and 90 of these also received cyclophosphamide (C-VAMP). Thirty-eight patients received verapamil in addition to C-VAMP(V-C-VAMP). After VAMP all patients were planned to receive high-dose treatment with melphalan and an autograft (marrow or blood) and 112 received this treatment; a further 29 patients received modified high-dose treatment with melphalan alone (23) or busulfan (6) and 54 (28%) did not proceed to high-dose treatment because of refusal, resistant disease, poor performance or treatment-related death. The patients who received melphalan or busulfan alone instead of high-dose melphalan/autografts did so because of increasing age (P = 0.001) and a raised creatinine (P = 0.05). The complete remission rate was 53% for the whole group and 74% for those receiving high-dose melphalan and an autograft. From July 1988, the sequential therapy package included continuous three times weekly interferon (IFN) after high-dose treatment as maintenance therapy, initially as part of a controlled randomised trial and then for all suitable patients. Fifty-seven patients received IFN. The median overall survival (OS) and progression-free survival (PFS) from first treatment for the whole group of 195 patients is 4.5 years and 25 months, respectively. The 112 patients receiving the melphalan autografts fared significantly better than the rest of the patients with OS and PFS (from high-dose treatment) of 6.6 years and 27 months, respectively (P < 0.005), and the 57 patients also receiving IFN have a OS yet to reach a median at 8 years and a PFS of 44 months, significantly better than non IFN high-dose patients (P < 0.0036). However, although we showed benefit for selected patients in studies and trials (particularly with IFN) during the 8-year period of the series, this did not translate into overall PFS benefit in our study for unselected cohorts of patients for 1986-1988 (64 patients) 1989-1992 (100 patients) and 1992-1994 (34 patients) in spite of progressive increases in the proportion of patients receiving IFN (respectively 6, 35 and 58%). This is likely to be due to the dilution of benefit to specific patients by the overall number of patients involved. Outcome data from unselected patients are now expected by purchasers and presented in this way, help qualify the activity impact of advances made from research trials for the treatment of population-based cancer problems.
Collapse
Affiliation(s)
- R Powles
- Royal Marsden NHS Trust, Sutton, Surrey, UK
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Raje N, Powles R, Kulkarni S, Milan S, Middleton G, Singhal S, Mehta J, Millar B, Viner C, Raymond J, Treleaven J, Cunningham D, Gore M. A comparison of vincristine and doxorubicin infusional chemotherapy with methylprednisolone (VAMP) with the addition of weekly cyclophosphamide (C-VAMP) as induction treatment followed by autografting in previously untreated myeloma. Br J Haematol 1997; 97:153-60. [PMID: 9136958 DOI: 10.1046/j.1365-2141.1997.d01-2122.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In a sequential nonrandomized study, 204 consecutive unselected patients aged < 70 years received induction chemotherapy with infusional vincristine and adriamycin with oral methyl prednisolone (VAMP: n = 75) or with additional cyclophosphamide, C-VAMP (n = 129). 38/129 C-VAMP patients also received verapamil during induction as part of a controlled trial with the aim to overcome drug resistance. A median of five courses (range 1-11) of chemotherapy were required before maximal response was attained and this was similar in both groups. An over-all response rate of 71% was noted at the end of induction. The complete remission (CR) rate with C-VAMP was 24%, which was significantly higher (P = 0.04) than the CR rate with VAMP alone (8%). The addition of verapamil did not alter the response rate of C-VAMP. Compliance to VAMP was overall 83% and not affected by the addition of cyclophosphamide. The proportion of patients going on to receive high-dose chemotherapy and an autograft was the same for VAMP and C-VAMP treated patients (71%). The median overall survival (OS) and progression-free survival (PFS) for the whole group were 4.4 years and 2.0 years and no difference in outcome was observed between the different treatment groups. Therefore the addition of weekly cyclophosphamide to VAMP induction therapy has significantly improved the response rates of previously untreated myeloma patients. C-VAMP was not more toxic and did not compromise the chances of receiving an autograft. Verapamil was without influence on any parameters in this study.
Collapse
Affiliation(s)
- N Raje
- Myeloma Unit, Royal Marsden NHS Trust, Sutton, Surrey
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
O'Brien ME, Milan S, Cunningham D, Jones AL, Nicolson M, Selby P, Hickish T, Hill M, Gore ME, Viner C. High-dose chemotherapy and autologous bone marrow transplant in relapsed Hodgkin's disease--a pragmatic prognostic index. Br J Cancer 1996; 73:1272-7. [PMID: 8630292 PMCID: PMC2074518 DOI: 10.1038/bjc.1996.244] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
High-dose chemotherapy with autologous bone marrow transplantation is used in the treatment of relapsed or high-risk Hodgkin's disease. As prospective randomised studies have proved difficult to accrue to, current recommendations are based on the reports of large series of prospectively collected data. We have looked at the outcome of 89 patients treated in this way at a single institution and have developed an index to predict outcome. Of 89 patients, with a median age of 29 years (range 15-51 years), eight patients were in first complete remission/partial remission (CR/PR), 17 in second or later CR, 37 were responding relapses, 13 resistant relapses, 11 primary refractory and three untested relapses. Combinations of melphalan, BCNU and etoposide were given in all cases except in ten patients who received melphalan alone. The median follow-up was 43 months (range 6-77 months). A total of 24 patients were in CR at the time of autologous bone marrow transplantation (ABMT), 33 achieved CR with ABMT, 16 PR, to give a response rate to ABMT of 49/65 = 74% (95% CI 60-83%) with a CR rate of 51% (CI 36-62%). In a Cox's multivariate analysis the most important factors in predicting outcome after ABMT were response to treatment before entry, number of previous treatments and previous chemosensitivity. Using these factors we devised a prognostic index which reliably selects a group of patients (65%) with at least a 70% chance of being progression free from 1 year onwards. Patients who have never achieved a CR and have received three or more chemotherapy regimens do not benefit from high-dose chemotherapy as used in this study.
Collapse
Affiliation(s)
- M E O'Brien
- Cancer Research Campaign, Section of Medicine, Sutton, Surrey, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Powles R, Raje N, Horton C, Mehta J, Singhal S, Hickish T, Viner C, Milan S, Treleaven J, Cunningham D. Comparison of interferon tolerance after autologous bone marrow or peripheral blood stem cell transplants for myeloma patients who have responded to induction therapy. Leuk Lymphoma 1996; 21:421-7. [PMID: 9172806 DOI: 10.3109/10428199609093439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Interferon (INF) has been incorporated as part of maintenance therapy after high dose treatment in order to make remissions more durable. In this study we have compared peripheral blood stem cell transplant (PBSCT) versus autologous bone marrow transplant (ABMT) with respect to INF tolerance. Thirty nine PBSCT patients have been compared to 37 ABMT patients for INF tolerance. This is followed by a comparison of 15 PBSCT patients versus 21 ABMT patients for engraftment details, response and survival. INF was started at a median of 61 days in the PBSCT and 58 days in the ABMT patients (P = NS). It was well tolerated in both groups without a significant difference in toxicity in the two arms. Engraftment was more rapid in the PBSCT patients with platelet recovery being significantly faster. Response and survival showed a favourable trend for ABMT patients though statistical significance was not reached and the cost of PBSCT was 12% cheaper. We were thus able to conclude that PBSCT grafts were as durable and could tolerate INF just as well as ABMT. Engraftment was more rapid and the procedure of PBSCT was also cheaper. Further studies with a larger group of patients will be required before comments on the efficacy of treatment can be made.
Collapse
Affiliation(s)
- R Powles
- Royal Marsden Hospital, Sutton, Surrey, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Raje N, Powles R, Horton C, Middleton G, Hickish T, Mehta J, Singhal S, Morton C, Porter H, Viner C, Treleaven J. 814 Peripheral blood transplants followed by maintenance interferon in myeloma. Eur J Cancer 1995. [DOI: 10.1016/0959-8049(95)96063-j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
15
|
Singhal S, Powles R, Cunningham D, Hickish T, Middleton G, Raje N, Viner C, Mehta J. 801 Second autografts for relapsed myeloma. Eur J Cancer 1995. [DOI: 10.1016/0959-8049(95)96050-n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
16
|
Powles R, Raje N, Hickish T, Middleton G, Milan S, Mehta J, Singhal S, Viner C, Treleaven J, Cunningham D. 797 Single centre results of therapy including autografts in previously untreated myeloma. Eur J Cancer 1995. [DOI: 10.1016/0959-8049(95)96046-g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
17
|
Raje N, Powles R, Milan S, Mehta J, Singhal S, Viner C, Treleaven J, Cunningham D. 798 Prognostic factors in multiple myeloma. Eur J Cancer 1995. [DOI: 10.1016/0959-8049(95)96047-h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
18
|
Singhal S, Powles R, Milan S, Raje N, Viner C, Treleaven J, Raymond J, Cunningham D, Mehta J. Kinetics of paraprotein clearance after autografting for multiple myeloma. Bone Marrow Transplant 1995; 16:537-40. [PMID: 8528169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The kinetics of paraprotein clearance after autografting for multiple myeloma have not been described. We studied 33 myeloma patients in plateau phase with detectable paraprotein (3-34 milligrams, median 10 milligrams) at the time of ABMT who received melphalan (200 mg/m2) and methylprednisolone (1.5 g x 5) for conditioning. Fifteen patients received interferon-alpha post-transplant as part of a randomized study. Twenty-four of 33 (72.7%) patients eventually cleared the paraprotein at a median of 47 days (range 5-783) post-transplant. The probability of clearance was lower (46.7 vs 94.4%, P = 0.004) and the time taken to clear paraprotein longer (142 vs 29 days, P = 0.003) in patients with a higher level (> 10 milligrams) at the time of the transplant. However, clearance occurred within 6 months in 23 of 24 (95.8%) patients who ultimately cleared the paraprotein. Interferon-alpha did not influence the clearance of paraprotein. We conclude that after autografting for myeloma, the time taken to clear paraprotein is longer and the probability of clearance lower with higher levels at the time of ABMT, and most patients who eventually clear the paraprotein do so within 6 months. Because the probability of clearing paraprotein (and thus attaining remission) in patients with detectable paraprotein 6 months post-transplant is low, a decision about further treatment may be made at this point.
Collapse
Affiliation(s)
- S Singhal
- Myeloma Unit, Royal Marsden Hospital, Sutton, Surrey, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Powles R, Raje N, Cunningham D, Malpas J, Milan S, Horton C, Mehta J, Singhal S, Viner C, Treleaven J. Maintenance therapy for remission in myeloma with Intron A following high-dose melphalan and either an autologous bone marrow transplantation or peripheral stem cell rescue. Stem Cells 1995; 13 Suppl 2:114-7. [PMID: 8520498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Eighty-four patients with myeloma were randomized to receive maintenance Intron A (Schering-Plough, Suffolk, UK), 3 mega units/m2 s.c. three times weekly or no treatment following induction therapy with cyclophosphomide, vincristine, doxorubicin, methyl prednisolone (C-VAMP), consolidated with high-dose melphalan (HDM) 200 mg/m2 + autologous bone marrow transplantation (ABMT). The patients have been followed up for a median of 52 months. Overall, median progression-free survival (PFS) from HDM was 27 months in the control group and 46 months in the Intron A group (< 0.025). For the 65 patients who achieved complete remission (CR) with HDM, there was a significant prolongation of remission (p = 0.02) for those who received Intron A and 49% of these patients remained in remission four years after high-dose treatment. However, for partial responders (PR) and nonresponders to HDM there was no significant prolongation of PFS. Overall, survival was also significantly better for the Intron A group, with 5 deaths versus 14 deaths in the control group (p = 0.006). Subsequently, 54 consecutive patients received the same HDM followed by rescue with peripheral blood stem cells after induction chemotherapy which included C-VAMP. Intron A was started in 45 of these patients at a median of 62 days which was comparable to the ABMT arm. The overall response rate in these patients was 79.62% (43/54-CR+PR) and the probability of survival at 18 months was 74.2% by the Kaplan Meier method.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- R Powles
- Royal Marsden Hospital, Sutton, Surrey, United Kingdom
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Cunningham D, Paz-Ares L, Milan S, Powles R, Nicolson M, Hickish T, Selby P, Treleavan J, Viner C, Malpas J. High-dose melphalan and autologous bone marrow transplantation as consolidation in previously untreated myeloma. J Clin Oncol 1994; 12:759-63. [PMID: 8151319 DOI: 10.1200/jco.1994.12.4.759] [Citation(s) in RCA: 153] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE We report the results of intensive chemotherapy with high-dose melphalan (HDM) following conventional-dose cytoreductive chemotherapy in previously untreated patients with myeloma. PATIENTS AND METHODS From 1986 to 1991, 53 previously untreated patients with myeloma received HDM 200 mg/m2 plus methylprednisolone 1.5 g daily (MP) for 5 days with autologous bone marrow transplantation (ABMT) after cytoreductive chemotherapy. RESULTS At the time of HDM administration, responses to induction therapy were complete remission (CR) in nine patients, partial remission (PR) in 38, and no response (NR) in six. Following HDM, all but one patient responded, with 40 patients achieving a CR (75%). There was one treatment-related death following HDM. The median time to reach a WBC count more than 1,000/microL and platelet count more than 25,000/microL was 19 days (range, 13 to 30) and 24 days (range, 15 to 55), respectively. The median duration of response has not been reached at 20 months, and it is significantly longer for patients in CR than for those in PR (P < .025). Currently, with a median follow-up duration of 31 months (range, 6 to 58), 12 patients are dead and 40 are alive, and the estimated probability of survival at 54 months is 63%. Multivariate analysis found hemoglobin (Hb) more than 10 g/dL (P = .012), and stage A disease (P = .001) at diagnosis to be favorable indicators for survival. CONCLUSION Myeloma patients who are able to receive HDM plus ABMT following conventional chemotherapy achieve a high proportion of CRs, which may be associated with prolonged survival.
Collapse
Affiliation(s)
- D Cunningham
- Cancer Research Campaign Section of Medicine, Royal Marsden Hospital, Sutton, Surrey, United Kingdom
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Cunningham D, Paz-Ares L, Gore ME, Malpas J, Hickish T, Nicolson M, Meldrum M, Viner C, Milan S, Selby PJ. High-dose melphalan for multiple myeloma: long-term follow-up data. J Clin Oncol 1994; 12:764-8. [PMID: 8151320 DOI: 10.1200/jco.1994.12.4.764] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To present long-term follow-up data of patients with myeloma treated with high-dose melphalan HDM, including an assessment of prognostic factors. PATIENTS AND METHODS Between November 1981 and April 1986, 63 previously untreated patients with multiple myeloma received HDM 140 mg/m2 without autologous bone marrow transplantation. RESULTS The overall response rate was 82% (51 of 62), with 32% (20 of 62) patients entering complete remission (CR). The median duration of response was 18 months, and six patients remain alive and free from disease progression at 60+ to 84+ months. Improvements in quality of life associated with remission were immediate in terms of pain grade (89% of patients) and performance status (92%), and later in terms of bone healing (29%). Currently, at a median follow-up duration of 74 months (range, 63 to 100) since HDM, 23 patients are alive with a median survival duration of 47 months, and 35% of patients are expected to be alive at 9 years. Apart from early-stage disease, no factors were found to predict long-term survival. No second malignancies or other late side effects have been recorded. CONCLUSION Single-agent HDM without autologous bone marrow transplantation is a feasible therapeutic option in myeloma, and is associated with a high objective response rate, relatively long remission durations, and good symptom control.
Collapse
Affiliation(s)
- D Cunningham
- Cancer Research Center Section of Medicine, Royal Marsden Hospital, Sutton, Surrey, United Kingdom
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
At a median time of 20 months following high dose melphalan for myeloma, 29 patients relapsed and were treated with induction chemotherapy to maximum response followed by a second course of high dose melphalan. The majority (90%) of patients received 200 mg m-2 with an autologous bone marrow transplant. Sixteen (55%) patients achieved complete remission and 11 (38%) a partial response. The median duration of remission was 17 (4-42) months. The median survival has not been reached, with 50% of patients alive at 58+ months after presentation. The period of neutropenia was similar during both first and second high dose procedures, but the duration of thrombocytopenia was longer in patients receiving melphalan for a second time (median 22 (16-56) days and 41 (18-69) days respectively). There was one treatment-related death due to thrombocytopenic haemorrhage. Repeated administration of high dose melphalan is a feasible approach for patients with relapsed myeloma.
Collapse
Affiliation(s)
- J L Mansi
- CRC Section of Medicine, Institute of Cancer Research, Sutton, Surrey, UK
| | | | | | | | | | | | | |
Collapse
|
23
|
Patel PM, Selby PJ, Graham MA, Viner C, Newell DR, McElwain TJ. Pharmacokinetics of high dose methylprednisolone and use in hematological malignancies. Hematol Oncol 1993; 11:89-96. [PMID: 8406379 DOI: 10.1002/hon.2900110206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The pharmacokinetics of oral and intravenous high dose methylprednisolone (Solu-medrone, Upjohn) were compared in patients with hematological malignancies. The aim of the study was to determine the oral bioavailability of high dose methylprednisolone and to establish whether this is a feasible and more convenient route of administration. The plasma pharmacokinetics were described by a one-compartment open model with peak plasma levels of 6.9 +/- 2.5 micrograms/ml. Total area under the plasma concentration versus time curve was similar by either route. Mean relative oral bioavailability was generally high (91 +/- 27 per cent). Retrospective analysis of 34 patients with chronic lymphocytic leukemia (CLL), non-Hodgkin's and Hodgkin's lymphoma treated with high dose methylprednisolone showed 11 responses including two complete remissions among nine patients with CLL. There was significant improvement in platelet counts in thrombocytopenic patients and treatment was well tolerated and toxicity was relatively low. High dose methylprednisolone may therefore be a useful palliative treatment for hematological malignancies, particularly where marrow suppression is a problem.
Collapse
MESH Headings
- Administration, Oral
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biological Availability
- Dose-Response Relationship, Drug
- Doxorubicin/administration & dosage
- Female
- Hodgkin Disease/drug therapy
- Hodgkin Disease/metabolism
- Humans
- Injections, Intravenous
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/metabolism
- Male
- Methotrexate/administration & dosage
- Methylprednisolone/adverse effects
- Methylprednisolone/pharmacokinetics
- Methylprednisolone/therapeutic use
- Middle Aged
- Procarbazine/administration & dosage
- Reproducibility of Results
- Retrospective Studies
- Vincristine/administration & dosage
Collapse
Affiliation(s)
- P M Patel
- Section of Medicine, Royal Marsden Hospital, Sutton, Surrey, U.K
| | | | | | | | | | | |
Collapse
|
24
|
Tilby MJ, Newell DR, Viner C, Selby PJ, Dean CJ. Application of a sensitive immunoassay to the study of DNA adducts formed in peripheral blood mononuclear cells of patients undergoing high-dose melphalan therapy. Eur J Cancer 1993; 29A:681-6. [PMID: 8471325 DOI: 10.1016/s0959-8049(05)80346-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The levels of DNA adducts formed in peripheral blood mononuclear cells of 13 patients undergoing high-dose melphalan therapy were determined 0-24 h after drug administration using a modification of a previously described immunoassay. This assay was validated for DNA extracted from drug-treated cells. Adduct levels in normal mononuclear blood cells 1 h after drug administration correlated well (r = 0.846) with drug dose (expressed as mg/m2) and with area under the curve for plasma levels of melphalan during the first h (r = 0.842). 1 patient sustained a high degree of toxic side-effects from the melphalan treatment and showed a high level of adducts. Plasma cell leukaemia tumour cells from another patient showed a level of adducts approximately six times higher than those in the normal blood cells of the other patients. The levels of DNA adducts in normal peripheral blood mononuclear cells did not change markedly between 1 and 24 h after drug administration.
Collapse
Affiliation(s)
- M J Tilby
- Leukaemia Research Fund Unit, New Medical School, Newcastle University, Newcastle upon Tyne, U.K
| | | | | | | | | |
Collapse
|
25
|
Abstract
PURPOSE To evaluate the use of high-dose busulfan (HDB) with autologous bone marrow transplantation (ABMT) in patients with myeloma. PATIENTS AND METHODS Fifteen patients received HDB (16 mg/kg), eight of whom received high-dose melphalan (HDM) but had experienced a short remission or progression-free interval. Two patients had received HDM on two previous occasions, one had no response to low-dose melphalan, and four had impaired renal function (edathamil clearance < 40 mL/min). All patients received induction chemotherapy before HDB. RESULTS Two patients were in complete remission (CR) after induction chemotherapy before HDB. Of the remaining 13 patients, four (31%) achieved CR and two (15%) achieved a partial remission for an overall response rate of 46%. There were three treatment-related deaths, but the toxicity was otherwise predictable and manageable. CONCLUSIONS In heavily pretreated patients, HDB results in a relatively high response rate. It can also be used safely in patients with renal impairment who are not suitable for HDM.
Collapse
Affiliation(s)
- J Mansi
- Cancer Research Campaign Section of Medicine, Royal Marsden Hospital, Sutton, Surrey, United Kingdom
| | | | | | | | | | | |
Collapse
|
26
|
Jones AL, O'Brien ME, Lorentzos A, Viner C, Hanrahan A, Moore J, Millar JL, Gore ME. A randomised phase II study of carmustine alone or in combination with tumour necrosis factor in patients with advanced melanoma. Cancer Chemother Pharmacol 1992; 30:73-6. [PMID: 1586984 DOI: 10.1007/bf00686489] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Laboratory data suggest a synergistic interaction between carmustine (BCNU) and tumour necrosis factor (TNF) in melanoma. We therefore studied the activity of 200 mg/m2 BCNU given alone or in combination with 88 micrograms/m2 recombinant human TNF-alpha (rhTNF alpha) as a daily i.v. infusion for 5 days at 48-day intervals to patients with metastatic melanoma. In this randomised phase II trial, the rate of response to BCNU alone was 20% [95% confidence interval (CI), 2%-38%], and this was not improved by the addition of TNF (response rate, 10.5%; 95% CI, 1.3%-33%). Toxicity was higher in the combination arm, and there was no difference in survival.
Collapse
Affiliation(s)
- A L Jones
- Department of Medicine, Royal Marsden Hospital, London, U.K
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Harding M, Selby P, Gore M, Perren T, Treleavan J, Mansi J, Zulian G, Milan S, Meldrum M, Viner C. High-dose chemotherapy and autologous bone marrow transplantation for relapsed and refractory Hodgkin's disease. Eur J Cancer 1992; 28A:1396-400. [PMID: 1515256 DOI: 10.1016/0959-8049(92)90528-a] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The results of high-dose chemotherapy with melphalan or melphalan (carmustine) etoposide for 66 consecutive patients with relapsed or resistant Hodgkin's disease are described. 55 patients were evaluable for response and 22% of these achieved complete remission and 59% partial remission. The actuarial survival at 2 years was 45% and the principal factors determining survival were the sensitivity of the disease to therapy given before high-dose chemotherapy and the type of treatment received. Intensive chemotherapy with autologous bone marrow transplantation can produce long-term survivors among patients for whom long-term survival would otherwise be improbable. However, this treatment remains toxic with an uncertain place in management.
Collapse
Affiliation(s)
- M Harding
- Yorkshire Cancer Research Campaign, Institute for Cancer Studies, St. James's University Hospital, U.K
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Mansi J, Ellis E, Viner C, Mundy J, Smith T, Millar J, Milan S, Gore M, Cunningham D. Gut protection by cyclophosphamide "priming" in patients receiving high-dose melphalan--effect of drug scheduling. Cancer Chemother Pharmacol 1992; 30:149-51. [PMID: 1600595 DOI: 10.1007/bf00686408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A "priming" injection of cyclophosphamide (400 mg/m2 given i.v. on day -7) has been shown to reduce intestinal permeability and thus gut toxicity in patients receiving high-dose melphalan. To determine the optimal timing for this injection, patients receiving 200 mg/m2 melphalan with an autologous bone marrow transplant were randomly assigned to receive cyclophosphamide at 5, 7 or 9 days before the melphalan. The median percentage of [51Cr]-ethylenediaminetetraacetic acid excretion was similar (9.1% vs 7.1% vs 7.7%, respectively), with equivalent duration of WHO grade 2-4 mucositis and diarrhoea being recorded for each group. Thus, the timing of the cyclophosphamide prime is not critical, and the priming injection may be given between 5 and 9 days prior to high-dose melphalan.
Collapse
Affiliation(s)
- J Mansi
- CRC Section of Medicine, Institute of Cancer Research, Sutton, Surrey, U.K
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Bell JB, Millar BC, Montes-Borinaga A, Joffe JK, Cunningham D, Mansi J, Treleaven J, Viner C, McElwain TJ. Decrease in clonogenic tumour cells in bone marrow aspirates from multiple myeloma patients due to the incorporation of cyclophosphamide into treatment with vincristine, adriamycin and methyl prednisolone. Hematol Oncol 1990; 8:347-53. [PMID: 2286358 DOI: 10.1002/hon.2900080607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A study of 32 patients receiving cyclophosphamide (CY) and verapamil (VER) in addition to the drug combination vincristine, adriamycin and methyl prednisolone (VAMP) was made in which the clinical response and growth of clonogenic myeloma cells (MY-CFUc) from bone marrow aspirates were compared. At presentation, MY-CFUc were grown from 72 per cent (23/32) of the patients. After treatment with CY-VAMP or VERCY-VAMP, MY-CFUc were grown from 25 per cent (8/32) of patients of whom only 50 per cent responded clinically. The overall clinical response rate for patients receiving CY-VAMP and VERCY-VAMP was 64 per cent (9/14) and 72 per cent (13/18) respectively of whom 14 per cent in each group achieved complete remission. There was no concomitant increase in normal tissue toxicity as measured by granulocyte-macrophage colony (GM-CFUc) formation. Comparison of these data with our previous study of patients receiving VAMP alone, suggests that the addition of CY to the regimen may increase the tumour cell kill. Further clinical studies will determine whether there is a significant increase in the complete remission rate.
Collapse
Affiliation(s)
- J B Bell
- Section of Medicine, Institute of Cancer Research, Sutton, Surrey, U.K
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Affiliation(s)
- A Jones
- Section of Medicine, Royal Marsden Hospital, Sutton, Surrey
| | | | | | | | | | | |
Collapse
|
31
|
Millar BC, Bell JB, Montes A, Millar JL, Maitland JA, Treleaven J, Viner C, Gore M, McElwain TJ. Colony stimulating activity in the serum of patients with multiple myeloma is enhanced by interleukin 3: a possible role for interleukin 3 after high dose melphalan and autologous bone marrow transplantation for multiple myeloma. Br J Haematol 1990; 75:366-72. [PMID: 2201402 DOI: 10.1111/j.1365-2141.1990.tb04350.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sera from 36/37 multiple myeloma patients and 19/21 sera from patients with other solid or liquid tumours had granulocyte-macrophage colony stimulating activity (CSA) towards normal human donor bone marrow whereas 1/16 sera from normal donors had this activity. Unlike human rhGM-CSF and GM-CSF from 5637 (human bladder cell line) conditioned medium which is heat stable, CSA from serum is heat labile (56 degrees C/30 min). In multiple myeloma patients, CSA was detectable more than 2 years after treatment with 'high dose melphalan. Although multiple myeloma patients, at relapse, have sufficient CSA in their serum to produce maximal stimulation of GM-CFUc from normal donor bone marrow in vitro, their own GM population responds poorly. The results suggest that the failure of patients own bone marrow to respond to endogenous CSA may be due to damage to the stem cells of the marrow or the failure of precursor cells to respond to CSA. Addition of rhIL-3 to myelomatous serum increased the number of GM-CFUc from both normal and myelomatous bone marrow but did not stimulate the growth of MY-CFUc significantly. The results suggest that rhIL-3 may assist bone marrow recovery in multiple myeloma patients after intensive chemotherapy.
Collapse
Affiliation(s)
- B C Millar
- Section of Medicine, Institute of Cancer Research, Sutton, Surrey, U.K
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Hardy J, Jones A, Gore ME, Viner C, Selby P, Wiltshaw E. Treatment of advanced ovarian cancer with intraperitoneal tumour necrosis factor. Eur J Cancer 1990; 26:771. [PMID: 2144175 DOI: 10.1016/0277-5379(90)90146-k] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
33
|
McElwain TJ, Gore ME, Meldrum M, Viner C, Judson IR, Malpas JS. VAMP followed by high dose melphalan and autologous bone marrow transplantation for multiple myeloma. Bone Marrow Transplant 1989; 4 Suppl 4:109-12. [PMID: 2697419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Fifty previously untreated patients with myeloma were entered into a 2-phase treatment programme: vincristine, adriamycin and methyl prednisolone (VAMP) followed by high dose intravenous melphalan (HDM) with autologous bone marrow transplantation where possible. The complete remission rate of 50% was associated with very good quality of life and the reversal of humoral immunosuppression. Complete remission is important in younger patients with myeloma as it represents a first step in achieving long, symptom- free survival.
Collapse
|
34
|
Gore ME, Selby PJ, Viner C, Clark PI, Meldrum M, Millar B, Bell J, Maitland JA, Milan S, Judson IR. Intensive treatment of multiple myeloma and criteria for complete remission. Lancet 1989; 2:879-82. [PMID: 2571812 DOI: 10.1016/s0140-6736(89)91548-1] [Citation(s) in RCA: 133] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
50 previously untreated patients with multiple myeloma received two-phase treatment: repeated cycles of 4 day infusion with vincristine, doxorubicin, and methylprednisolone (VAMP) followed by high-dose melphalan (HDM), with autologous bone marrow transplantation where possible. The overall response rate was 74% (37/50), with 25 patients (50%) achieving complete haematological and biochemical remission. These remissions were associated with a good quality of life as measured by performance status, pain grade, and the reversal of humoral immunosuppression. 6 patients died during the VAMP phase and there was 1 death related to HDM. The achievement of complete remission, as defined here, in such a high proportion of patients is exceptional and may represent a useful advance in the management of myeloma.
Collapse
Affiliation(s)
- M E Gore
- CRC Section of Medicine, Institute of Cancer Research, Sutton, Surrey
| | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Forgeson GV, Selby P, Lakhani S, Zulian G, Viner C, Maitland J, McElwain TJ. Infused vincristine and adriamycin with high dose methylprednisolone (VAMP) in advanced previously treated multiple myeloma patients. Br J Cancer 1988; 58:469-73. [PMID: 3207601 PMCID: PMC2246797 DOI: 10.1038/bjc.1988.243] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Forty-five patients with relapsed or refractory multiple myeloma received continuous infusions of vincristine (0.4 mg total dose daily for 4 days) and adriamycin (9 mg m-2 daily for 4 days) with a high dose of methylprednisolone (1 g m-2 i.v. or p.o. daily by 1 h infusion), the VAMP regimen. Sixteen (36%) responded, with a median duration of remission of 11 months and median survival of 20 months. Major toxicities encountered were infective and cardiovascular. Two smaller groups of myeloma patients were treated with high dose methylprednisolone (HDMP) alone, or VAMP plus weekly low dose cyclophosphamide (Cyclo-VAMP). HDMP produced short responses in 25% of patients with less toxicity than VAMP. Cyclo-VAMP was used in a highly selected group of patients who had previously responded to high dose melphalan. It was well tolerated and produced responses in 61% of this group.
Collapse
Affiliation(s)
- G V Forgeson
- Institute of Cancer Research, Royal Marsden Hospital, Surrey, UK
| | | | | | | | | | | | | |
Collapse
|
36
|
Selby P, Zulian G, Forgeson G, Nandi A, Milan S, Meldrum M, Viner C, Osborne R, Malpas JS, McElwain TJ. The development of high dose melphalan and of autologous bone marrow transplantation in the treatment of multiple myeloma: Royal Marsden and St Bartholomew's Hospital studies. Hematol Oncol 1988; 6:173-9. [PMID: 3292375 DOI: 10.1002/hon.2900060218] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- P Selby
- Section of Medicine, Institute of Cancer Research, Royal Marsden Hospital, Sutton, Surrey, U.K
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
|
38
|
Selby P, Hobbs S, Viner C, Jackson E, Jones A, Newell D, Calvert AH, McElwain T, Fearon K, Humphreys J. Tumour necrosis factor in man: clinical and biological observations. Br J Cancer 1987; 56:803-8. [PMID: 3435706 PMCID: PMC2002406 DOI: 10.1038/bjc.1987.294] [Citation(s) in RCA: 165] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Eighteen patients with advanced cancer have been treated intravenously with human recombinant tumour necrosis factor (rhTNF). The drug produced febrile reactions at all doses although these were preventable by steroids and indomethacin. Doses at or above 9 x 10(5) units (400 micrograms)m-2 were associated with hypotension, abnormal liver enzymes, leucopenia and mild renal impairment in a substantial proportion of patients. RhTNF was cleared from plasma with a half life of approximately 20 minutes but non-linear pharmacokinetics lymphoma, improvements in their tumours were recorded. RhTNF was noted to produce rapid increases in serum C-reactive protein concentrations. Endogenous TNF levels were not found to be elevated in 72 cancer patients. TNF deserves further therapeutic evaluation and these observations support its biological importance as an endogenous pyrogen, mediator of acute phase protein responses, and a mediator of endotoxic shock.
Collapse
Affiliation(s)
- P Selby
- Institute of Cancer Research, Royal Marsden Hospital, Sutton, Surrey, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Viner C. Pressure sores. Floating on a bed of beads. Nurs Times 1986; 82:62-6. [PMID: 3634380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|