The STAR (Study of Tamoxifen and Raloxifene) trial in West Virginia

Female breast cancer is a major medical problem with significant public health ramifications. In 1999, more than 170,000 women were diagnosed with breast cancer in the U.S. and more than 40,000 died from this disease. The STAR trial will determine if raloxifene (Evista) is either more or less effective than tamoxifen (Nolvadex in reducing the incidence of invasive breast cancer in postmenopausal women who are at increased risk for the disease. A secondary goal is to compare raloxifene and tamoxifen with regard to their side effects. Approximately 22,000 postmenopausal women, 35 years of age or older, who are at increased risk for developing breast cancer will be randomly assigned in this double-blind trial to receive either 20 mg of tamoxifen plus a placebo or 60 mg of raloxifene plus a placebo, for five years. A substudy to evaluate the effect of raloxifene and tamoxifen therapy on study participants' quality-of-life will also be conducted.

Breast cancer risks and prevention: implications of the Breast Cancer Prevention Trial results

Breast cancer is a major health concern for women in the U.S. Several factors determine a woman's risk for developing breast cancer including age, genetics, hormonal exposure and others. It is possible to estimate a woman's risk for developing breast cancer by using a statistical model known as the Gail model. Using this model, the Breast Cancer Prevention Trial (BCPT) found that women at high risk for breast cancer could have their incidence of breast cancer reduced by 49% by taking tamoxifen. The serious side effects of tamoxifen therapy were almost exclusively seen in women over age 50. Women under 50 with a high risk of breast cancer are, therefore, most likely to benefit from taking tamoxifen for five years. Thus, a benefit-to-risk estimate should be made for each woman before advising her to take tamoxifen. A new trial (Study of Tamoxifen And Raloxifene, STAR) will compare tamoxifen with raloxifene for their effectiveness in reducing breast cancer and for side effects. West Virginia women participated in the BCPT and will be able to participate in the STAR trial through centers in Morgantown and Charleston.

Severe, disabling neurologic toxicity following cisplatin retreatment

OBJECTIVE

To describe a severe neurotoxic reaction following the second cycle of cisplatin-based chemotherapy.

CASE SUMMARY

A patient with unresectable non-small-cell lung cancer was treated with combined chemotherapy and radiotherapy. Thirty-six hours after the second course of chemotherapy, the patient developed severe mental status changes consisting of aphasia, confusion, and agitation. Complete neurologic workup was most consistent with an acute vascular event.

DISCUSSION

Reports of acute cisplatin-induced neurologic toxicity involving the central nervous system are rare. Potential risk factors are described. Mechanisms of chemotherapy-induced vascular damage are discussed.

CONCLUSIONS

Total dosage and administration schedule of cisplatin are associated with an increased incidence of neuropathy. However, factors predicting the development of early, acute neurotoxicity are limited by the rarity of these events. It is probable that acute neurotoxic reactions in cancer patients are caused by an unknown complex of interactions involving drugs, tumor, and host factors.

Breast cancer--a medical disease?

The treatment of breast cancer has changed significantly over the last 20 years. It is now believed that breast cancer usually spreads early and that removal of neither lymph nodes nor the breast prolongs survival, although these procedures do improve local control of the disease. Involvement of lymph nodes is prognostically important as a reflection of the body's defenses against spreading cancer cells. Systemic adjuvant therapy with tamoxifen improves survival in estrogen receptor (ER)-positive women and chemotherapy does so in ER-positive or negative women. This article gives an overview of the evolution in the treatment of breast cancer over the past 20 years, and describes the Breast Cancer Prevention Trial (BCPT) and several trials of adjuvant therapy which are now being conducted by the National Surgical Adjuvant Breast Project (NSABP).

The chemohormonal therapy of metastatic melanoma: possible benefit of tamoxifen

Metastatic melanoma is difficult to treat because of low response rates to most chemotherapy regimens and short remission durations. Recently, a new chemohormonal regimen containing BCNU, cisplatin, DTIC and tamoxifen (BCDT) has been reported to be more promising. We have treated eight patients with this regimen and five patients responded, including three with complete responses (CR). One of these patients remains in CR beyond two years. Others have also reported response rates of 50% with this regimen with a few long-term remissions also. Two of our patients developed deep venous thromboses (DVT). The increased incidence of DVT with BCDT is attributed to the tamoxifen, which nevertheless appears to be a necessary component of this regimen. In two of our patients, short courses of tamoxifen were used and they both obtained responses (one CR, one PR) without DVT. The possibility of using short-course tamoxifen to reduce the incidence of DVT in this regimen, without impairing its efficacy, should be investigated.

The Breast Cancer Prevention Trial (BCPT) in West Virginia

Female breast cancer is a major medical problem with significant public health ramifications. During the next decade, more than 1.5 million women in the United States will be newly diagnosed with invasive breast cancer. The Breast Cancer Prevention Trial (BCPT) is an NIH-sponsored study which will determine whether long-term tamoxifen therapy is effective in: 1) Preventing invasive breast cancer, 2) Lowering the incidence of fatal and nonfatal myocardial infarction, and 3) Reducing the incidence of bone fractures. Sixteen thousand women, including at least 100 from West Virginia who are > or = 35 years of age at increased risk for breast cancer, will be randomized between placebo and tamoxifen during a two-year period. For each participant, the annual and lifetime probability of developing breast cancer will be estimated utilizing a computerized model of risk assessment. The placebo or tamoxifen will be administered for at least five years. Toxicity, compliance, monitoring of quality-of-life assessment, and lipid and lipoprotein evaluations are major components of this trial.

Prognostic factors and outcome of therapy in adult acute lymphoblastic leukemia

We conducted a ten-year review of our patients of adult acute lymphoblastic leukemia. Most patients received vincristine and prednisone for induction. Twenty-four patients additionally received doxorubicin. Serious pretreatment morbidity included intracerebral haemorrhage (8 patients), septicaemia (22 patients), pneumonia (8 patients) and CNS leukemia (3 patients). Our complete remission (CR) rate was 41%, predicted median duration of remission was 20.8 months and predicted median duration of overall survival was 10.4 months. Significantly higher CR rates were observed for lower age, female sex and lesser degrees of haemorrhage and infection. High initial WBC count was the only adverse prognostic factor for remission duration. Survival was significantly inferior for nonresponders, age greater than 20 years, and severe haemorrhage and infection. Remission attainment remains the chief obstacle to enhancing overall survival in adult acute lymphoblastic leukemia. However responders often experience years of good quality life.

IL-2/LAK cell treatment for advanced cancers with emphasis on a novel administration

Interleukin-2 (IL-2) is a substance produced by activated blood cells called helper T-lymphocytes and has been shown to stimulate the body's immune system. IL-2 may cause certain tumors to regress when administered intravenously to laboratory animals and humans. Lymphokine activated killer (LAK) cells are white blood cells that have been stimulated with IL-2 in vitro. LAK cells are capable of killing tumor cells both in vitro and in vivo, especially when given along with IL-2. Although this form of treatment has been found to be effective in patients with certain cancers who no longer benefit from standard forms of therapy, the anti-cancer effects of IL-2/LAK cell treatment are limited by the serious, life-threatening side effects of high-dose intravenous administration, and by the high cost. A treatment program with low-dose, intralymphatically-administered LAK/IL-2 in patients with advanced cancer is a promising alternative which circumvents these major problems and concerns, while maintaining high response rates.

Depression of erythrocyte glucose-6-phosphate dehydrogenase (G6PD) activity in enteric fever

Ninety adult Indian typhoid and paratyphoid fever (enteric fever, EF) patients and 91 controls were tested for glucose-6-phosphate dehydrogenase (G6PD) deficiency using the fluorescent spot test (FST) and the quantitative methaemoglobin reduction test ( QMRT ). There was a threefold higher incidence of G6PD deficiency in North Indian EF patients (10.6%) than in controls (3.6%) (P = 0.15) which may be attributable to the greater morbidity of the G6PD-deficient EF patients; six of nine had haemolytic anaemia. A transient depression of mean erythrocyte G6PD activity was observed in a subgroup of 49 non-deficient EF patients in whom the spectrophotometric G6PD assay was done. It did not appear to be related to reticulocyte count, chloramphenicol therapy, or differences in leucocyte contamination of the haemolysate used for the G6PD assay. If this depression of G6PD activity occurs in deficient patients as well, it may help to explain the haemolysis seen in them during EF. Of the three tests used, the QMRT and the spectrophotometric assay clearly identified G6PD deficiency in males during haemolysis, whereas the FST was unreliable in this situation.

Intrathecal anti-tetanus serum (ATS) and parenteral betamethasone in the treatment of tetanus

217 cases of tetanus admitted to Christian Medical College and Brown Memorial Hospital, Ludhiana, from June 1977 to April 1980 were studied. Three treatment regimes were used during this period. The addition of intrathecal horse antitetanus serum (ATS) (Group II) to the routine treatment (Group I) reduced the mortality from 63% to 53% but this was not statistically significant. Following a further addition of parenteral betamethasone to the regimen (Group III) the mortality decreased to 27% which was significantly lower than in Groups I and II. A similar trend in mortality was demonstrated when the severe cases were analysed separately. Groups I and III were comparable in terms of various prognostic factors and the nursing care received but Group II had a higher incidence of unfavourable prognostic factors, which may have obscured the benefit of intrathecal ATS. The combination of parenteral betamethasone and intrathecal ATS seems to be beneficial in the treatment of tetanus.

Age and treatment response in acute nonlymphoblastic leukemia

Treatment of older acute leukemia patients has been the subject of recent debate. We treated 101 acute leukemia patients in a prospective randomized trial. Fifty-seven per cent of the population was over 50. Half were treated with a mild induction program (VAMP) and half with a vigorous program (CAT). The older patients who received vigorous treatment did better than those who received mild treatment. We suggest that patients over 50 should be regarded as a separate category in design of treatment protocols in order to further maximize the benefits of therapy.

Factor VIII inhibition associated with chlorpromazine-induced hepatic injury

A 90-year-old man was given chlorpromazine for sedation and 2 weeks later developed cholestatic jaundice and subsequently a factor VIII inhibitor. His death 4 weeks after institution of chlorpromazine, from massive bleeding, coupled with the autopsy finding of intrahepatic cholestatic jaundice, suggests that both adverse reactions were due to the drug.

Platelet-latelet-

Two patients with thrombotic thrombocytopenic purpura were seen. Aspirin, dipyridamole, and sulfinpyrazone were administered to patient 1 after splenectomy, and administration of high-dose prednisone and methylprednisolone failed to induce remission. The platelet count rose, but the patient had a relapse when the dipyridamole dose was tapered. This condition responded to an increase of the drug, and the patient obtained a long-lasting remission. A splenectomy was not performed on patient 2, and all three platelet-inhibiting drugs, together with prednisone, were given. This resulted in a prompt remission that has been sustained for 29 weeks. Morphologic changes in the peripheral blood smear remained for several weeks after other features of the disease had resolved. Thus, in both cases, platelet-inhibiting drugs appeared to induce a remission.

Randomized prospective trial of continuous vs intermittent heparin therapy

Forty-one patients with clinical indications for heparin therapy were randomized to receive continuous intravenous heparin sodium therapy or intermittent (four-hourly bolus) heparin therapy, with control by the activated partial thromboplastin time. Seven of 21 patients receiving intermittent therapy had major bleeding episodes, whereas none of the 20 patients receiving continuous heparin therapy had major bleeding (P = .005). One patient on continuous therapy had a pulmonary embolus, while none on intermittent therapy had recurrent thromboembolism. Two heavily bleeding patients on intermittent therapy were switched to continuous treatment after bleeding was controlled. The use of continuous heparin therapy appears significantly safer with regard to hemorrhagic complications than the use of intermittent therapy.

Platelet aggregation in partially obstructed vessels and its elimination with aspirin

In 35 open chest anesthetized dogs coronary and aortic blood flow were measured with electromagnetic flowmeters while aortic and distal coronary blood pressure and an epicardial ECG were recorded. A fixed amount of stenosis (60-80%) was produced in the coronary artery by an externally applied plastic cylinder. In 24 of the 35 dogs the coronary blood flow showed cyclical reductions to near zero, with a sudden spontaneous return to near control levels. During reduced flow the epicardial ECG showed ST-segment depression suggestive of ischemia, and ventricular premature beats were often noted. Six animals died acutely during episodes of reduced flow. After 35 mg/kg of aspirin were given intravenously the cyclical reductions in coronary blood flow were abolished and the in vitro platelet aggregations were reduced from a control of 62.1 +/- 15 units (Born technique) to an average of 23.7 +/- 12 units. Histologic sections of the narrowed coronary artery obtained when coronary flow was reduced show an amorphous mass in the lumen which was thought to be a platelet aggregate. Perhaps a similar process of platelet aggregation occurs in the stenosed coronary arteries in man, producing acute coronary obstruction, ischemia, and sudden death.

Platelet adhesion and contact activation time tests on HEMA coated cellulose acetate membranes

Surface modification of cellulose acetate dialysis membranes was carried out by 60Co radiation induced graft copolymerization of the hydrogel, hydroxyethyl methacrylate (HEMA). The degree of grafting was controlled by varying the HEMA monomer concentration in the grafting solution and the radiation dose. A continuous flow platelet adhesion test was designed which allows testing under conditions more closely approximating hemodialysis than other small scale in vitro tests. Platelet adhesion on treated membranes fell substantially with increasing surface HEMA concentration. The presence of HEMA on the membrane surface did not affect the membrane activated clotting times significantly.

Observations on a factor-V inhibitor

A 67-year-old man developed a potent inhibitor of factor V shortly after undergoing blood transfusions and surgery. The inhibitor reacted in a time-dependent manner with factor V and gave a non-linear concentration graph. Studies with specific antisera indicated that it contained gamma and mu heavy chains and both kappa and lambda light chains. The plasma from two patients with congenital factor-V deficiency did not neutralize the inhibitor.