Success of Maternal and Child Health Pipeline Training Programs: Alumni Survey Results

INTRODUCTION

The Maternal and Child Health (MCH) Pipeline Training Program, promotes development of a diverse health workforce by training undergraduate students from underrepresented minorities. We aimed to evaluate the success of this program based on three domains: (1) demographic characteristics, (2) academic and career development, and (3) attitudes towards the field of MCH and the training programs among graduates.

METHODS

Three domains of success were determined through a collaborative effort between current program directors and the funding agency project officers. The survey with questions related to the three domains was distributed via an online platform to graduates from seven sites (one former site and six current sites). Data were analyzed and presented utilizing descriptive statistics.

RESULTS

The survey was distributed to 550 graduates, 162 responded (37% response rate). Demographically, 78% were female, 54% were Black/African American, 22% were Latinx and 83% did not report any disability. Eighty percent of respondents applied to graduate/professional schools, 67% received admission. Graduates often continued to work in MCH fields (70%). Majority felt confident and knowledgeable in the field (89%) and agreed the faculty were supportive at their training sites (90%).

CONCLUSION

The study highlights successes in recruiting from underrepresented minorities, particularly Black/African Americans and first-time college goers in the family into the MCH Pipeline Training Programs. Programs were successful in furthering academic and career development for most trainees. Attitudes towards MCH and the training programs were overwhelmingly positive. Continued support of these programs is critical in addressing health disparities and achieving health equity.

Abstract OT3-02-08: Scalp cooling alopecia prevention trial (SCALP) for patients with early stage breast cancer

Background

Adjuvant chemotherapy treats micro-metastatic disease and decreases the risk of breast cancer recurrence. However, it may be associated with distressing side effects, including alopecia. Women with breast cancer rate chemotherapy-induced alopecia as one of the most severe, troublesome, and distressing side effects of chemotherapy. In many countries, scalp cooling has been introduced to prevent or reduce chemotherapy-induced alopecia. The theory is that scalp cooling causes cutaneous vasoconstriction, which reduces blood flow to the hair follicles during peak plasma concentrations of the chemotherapeutic agents and therefore reduces cellular uptake of these agents. It also results in reduced biochemical activity, which makes hair follicles less susceptible to the damage of the chemotherapy agents. Historically success rates are have been variable, but based on non-randomized studies, scalp cooling appears to be effective in preventing chemotherapy-induced alopecia especially in more recent studies.

Methods

We are conducting a prospective multi-center randomized controlled non-blinded trial to evaluate the safety and efficacy of the Orbis Paxman Hair Loss Prevention System in reducing the incidence of chemotherapy-induced alopecia. Women with stage I-II breast cancer who will receive neoadjuvant or adjuvant anthracycline- or taxane-based chemotherapy, for at least four cycles are eligible. Participants are randomized in a 2:1 ratio to scalp-cooling or no cooling. Scalp-cooling is done using the Orbis Paxman Hair Loss Prevention System prior to, during and after each chemotherapy administration. The primary efficacy endpoints are hair preservation, defined as CTCAE v4 alopecia <2, and device safety. Two hundred and thirty five (235) patients are planned to be enrolled which will provide 85% power to detect a 20% difference in hair preservation, 15% in control group and 35% in scalp-cooling group . Secondary endpoints include: wig/scarf use and quality of life assessed by the EORTC QLQ-30, HADS and BIS. Study participants will be followed for 5 years post-study for time to first recurrence, overall survival, site of first recurrence, and incidence of isolated scalp metastasis.

Citation Format: Nangia JR, Wang T, Rude M, Osborne C, Papish S, Abraham J, Holmes F, Savin M, Paxman R, Hilsenbeck SG, Osborne CK, Rimawi M. Scalp cooling alopecia prevention trial (SCALP) for patients with early stage breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-02-08.

Abstract PD07-03: A Genomic Predictor of Survival Following Taxane-Anthracycline Chemotherapy for Breast Cancer

Background: There is currently no predictive assay for patients with clinical Stage II-III breast cancer from which predicted sensitivity to treatment is associated with high probability of survival following chemotherapy.

Patients & Methods: We performed Affymetrix gene expression microarrays of prospectively collected tumor biopsies from 508 patients with newly diagnosed HER2-normal invasive breast cancer prior to neoadjuvant taxane-anthracycline chemotherapy followed by adjuvant endocrine therapy (if hormone receptor-positive). The predictor was developed from 310 samples (from MDACC & I-SPY) by combining: 1) a signature to predict sensitivity to endocrine therapy (SET); 2) estrogen receptor (ER)-stratified predictive signatures of resistance to chemotherapy, defined as extensive residual cancer burden (RCB-III) or relapse within 3 years; and 3) ER-stratified predictive signatures of response to chemotherapy, defined as pathologic complete response (pCR) or minimal RCB (RCB-I). The predictor classified tumors as treatment sensitive if high or intermediate SET, or if predicted to be responsive (and not resistant) to chemotherapy. Otherwise, tumors were classified as treatment insensitive. The predictor was then tested on an independent cohort (N= 198, 98% with clinical Stage II-III) who received neoadjuvant (N= 180) or adjuvant (N= 18) taxane-anthracycline chemotherapy (from MDACC, USO, GEICAM, Peru, LBJ). Distant relapse-free survival (DRFS) was evaluated at a 3-year median follow up using negative predictive value (NPV, absence of event if predicted to be sensitive), and absolute risk reduction (ARR) for those predicted to be sensitive (versus insensitive), with 95% confidence interval (CI). The independent predictive value was assessed in multivariate Cox regression analysis based on the likelihood ratio test (P≥0.05). Results: Patients in the independent validation cohort who were predicted to be treatment sensitive (28%) had excellent DRFS, with NPV 92% (CI 85-100) and significant absolute risk reduction (ARR 18%, CI 6-28) at 3 years, compared to those predicted to be insensitive. This was similar to the DRFS observed in patients who achieved pCR after they completed neoadjuvant chemotherapy (NPV 93%, CI 85-100). Predictions were accurate in each phenotypic subset: ER+/HER2- (30% predicted sensitive, NPV 97%, CI 91-100; ARR 11%, CI 0.1-21) and ER-/HER2- (26% predicted sensitive, NPV 83%, CI 68-100; ARR 26%, CI 4-28). Predicted treatment sensitivity (HR 0.20, CI 0.07-0.57), ER+ status (HR 0.32, CI 0.17-0.63), clinical tumor stage T3-4 (HR 2.04, CI 1.07-3.88) and age >50 (HR 0.50, CI 0.25-0.98) were significant in a multivariate model that also included clinical nodal status, grade, and type of taxane used.

Conclusion: We report validation results for the first molecular predictor of sensitivity to neoadjuvant/adjuvant systemic therapy for clinical Stage II-III breast cancer that is independently associated with excellent DRFS in those predicted to be sensitive. Predictions were accurate for both ER+/HER2- and ER-/HER2- invasive breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD07-03.

Cardiac Safety Results of a Phase II Trial of Adjuvant Docetaxel/Cyclophosphamide Plus Trastuzumab (Her TC) in HER2+ Early Stage Breast Cancer Patients

Background: Docetaxel/cyclophosphamide (TC) has superior activity to doxorubicin/cyclophosphamide (AC) in the adjuvant treatment of patients (pts) with early breast cancer and is devoid of known cardiac toxicity (Jones et al, JCO 27:1177-1183, 2009). Although the addition of trastuzumab (H) to anthracycline-based adjuvant regimens is effective, it is associated with increased cardiac toxicity. Therefore, a short course of the nonanthracycline TC regimen coupled with H appeared to be a logical combination for women with lower risk HER2+ breast cancer. We report the cardiac safety of the TC+H regimen for the first group of women to complete 1 year of treatment.Patients and Methods: 263 pts were registered to the study and stratified by nodal status (positive/negative). Pts must have had baseline left ventricular ejection fraction (LVEF) ≥50% by MUGA or ECHO. On Day 1 of each 21-day cycle for a total of 4 cycles, pts received: (T) 75 mg/m2 IV, followed by (C) 600 mg/m2 IV. Weekly (H) was also given at 4 mg/kg IV (loading dose, over 90 minutes Day 1, Cycle 1 only) and 2 mg/kg IV Days 1, 8, 15 thereafter throughout chemotherapy. After completion of chemotherapy, H was administered at 6 mg/kg IV every 3 weeks to complete 12 months of therapy with H. Decreased LVEF was defined as a decrease from baseline (start of treatment) to completion of TC+H, or when assessed at 3-month intervals until the completion of H treatment. H was withheld if there was a 15% or more decline in LVEF (absolute %). Treatment was discontinued after 2 or 3 treatment delays at investigator's discretion (same rules as prior studies). This report focuses on cardiac safety occurring during the 3 months of chemotherapy plus 1 year of H therapy.Results: To date, 260 pts completed 1 year of treatment and comprised the cardiac safety population; median age was 55 yrs (30-76); 90% of pts had ECOG 0; 64% were ER+, 47% were PR+, and 77% had no lymph node involvement. 184 pts (70%) completed planned treatment and 23 pts (9%) discontinued treatment due to adverse events. A total of 61 pts (23.5%) had declines of ≥10% LVEF; 8 pts (3.1%) had 2 or more LVEF declines ≥10% and were taken off treatment before 1 year of H was completed, and 16 pts (6.1%) had declines of LVEF below 50% during treatment. No patient had clinical CHF.Scheduled MUGA/ECHO ResultsMonthPatients, no.Median LVEF, % (range)Patients with decrease LVEF ≥10%, no.Patients with LVEF <50%, no.Baseline26064 (49,89)––1-324163 (40,85)154-623062 (40,85)2157-921763 (36,89)265≥1018763 (48,80)131Conclusions: H combined with 4 cycles of the nonanthracycline TC regimen produced a low rate of cardiac events, mainly asymptomatic drops in LVEF, but no reported cases of CHF.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5082.

Feasibility of testing core needle biopsies ex vivo in the ChemoFx assay

20073

Background: Multiple chemotherapy options exist for the treatment of primary breast cancer. While response rates are good, many patients are treated with unnecessary or ineffective chemotherapy. Inadequate treatments are partly due to the lack of accurate predictors of response in individual patients. To predict an individual’s response to therapy, ex vivo chemosensitivity and resistance assays (CSRAs) have long been evaluated, but have been limited by technical difficulties, including the need for large (1–2 gm) amounts of fresh tissue. However, these problems have largely been overcome with new technology. Novel methods used in Precision Therapeutics’ ChemoFx assay allow for testing smaller amounts of tissue (35 mg). The reduced tissue requirement is crucial in the breast cancer setting, as the diagnosis is often made by percutaneous biopsy. The goals of the study were to determine the growth success rate of culturing epithelial cells from breast tissue core needle biopsies and the feasibility of testing the cells in the assay. Methods: A prospective feasibility study involving women with invasive primary breast cancer. One to four core needle biopsy specimens were collected using a 14 gauge needle (est. per patient yield <50 mg) and submitted to Precision Therapeutics. A primary culture of each specimen was established and the ex vivo chemoresponse profiles of each culture were evaluated. Drugs tested included capecitabine, cisplatin, cyclophosphamide, docetaxel, doxorubicin, epirubicin, etoposide, 5-fluorouracil, gemcitabine, irinotecan, paclitaxel, and vinorelbine. Results: 21 of 25 (84%, 95% CI: 68% to 97%) specimens grew successfully; all 21 were tested for chemoresponsiveness with the assay. Of the 4 subjects with unsuccessful ex vivo cultures, 2 had no growth, 1 failed plating for culture, and 1 failed IHC testing due to overgrowth of non-epithelial cells. The average number of drugs tested for each specimen was 7 (range: 1–15). Conclusions: This study demonstrates that core needle biopsies from primary breast tumors can be successfully cultured and tested for chemoresponsiveness using the ChemoFx assay. The ability to perform ex vivo chemoresponse testing on core needle biopsies greatly increases the utility of the assay in adjuvant or neoadjuvant primary breast cancer settings.

[Table: see text]

Agricultural use of organophosphate pesticides and the risk of non-Hodgkin's lymphoma among male farmers (United States)

OBJECTIVE

Data from three population-based case-control studies conducted in Kansas, Nebraska, Iowa, and Minnesota were pooled to evaluate the relationship between the use of organophosphate pesticides and non-Hodgkin's lymphoma (NHL) among white male farmers.

METHODS

The data set included 748 cases of non-Hodgkin's lymphoma and 2236 population-based controls. Telephone or in-person interviews were utilized to obtain information on the use of pesticides. Odds ratios (OR) adjusted for age, state of residence, and respondent status, as well as other pesticide use where appropriate, were estimated by logistic regression.

RESULTS

Use of organophosphate pesticides was associated with a statistically significant 50% increased risk of NHL, but direct interviews showed a significantly lower risk (OR = 1.2) than proxy interviews (OR = 3.0). Among direct interviews the risk of small lymphocytic lymphoma increased with diazinon use (OR = 2.8), after adjustment for other pesticide exposures.

CONCLUSIONS

Although we found associations between the risk of NHL and several groupings and specific organophosphate pesticides, larger risks from proxy respondents complicate interpretation. Associations, however, between reported use of diazinon and NHL, particularly diffuse and small lymphocytic lymphoma, among subjects providing direct interviews are not easily discounted.

Galanin regulates the postnatal survival of a subset of basal forebrain cholinergic neurons

The neuropeptide galanin colocalizes with choline acetyltransferase, the synthetic enzyme for acetylcholine, in a subset of cholinergic neurons in the basal forebrain of rodents. Chronic intracerebroventricular infusion of nerve growth factor induces a 3- to 4-fold increase in galanin gene expression in these neurons. Here we report the loss of a third of cholinergic neurons in the medial septum and vertical limb diagonal band of the basal forebrain of adult mice carrying a targeted loss-of-function mutation in the galanin gene. These deficits are associated with a 2-fold increase in the number of apoptotic cells in the forebrain at postnatal day seven. This loss is associated with marked age-dependent deficits in stimulated acetylcholine release, performance in the Morris water maze, and induction of long-term potentiation in the CA1 region of the hippocampus. These data provide unexpected evidence that galanin plays a trophic role to regulate the development and function of a subset of septohippocampal cholinergic neurons.

US-guided implantation of metallic markers for permanent localization of the tumor bed in patients with breast cancer who undergo preoperative chemotherapy

Metallic markers were implanted with ultrasonographic guidance in 51 malignant breast tumors in 49 patients to tag the tumor bed in anticipation of complete or almost complete response to preoperative neoadjuvant induction chemotherapy before breast-conservation surgery. The markers were the only remaining evidence of the original tumor site in 47% (23 of 49) of the patients preoperatively. This technique effectively addresses the problem of preoperative localization of the tumor bed in complete or nearly complete response of breast cancer to neoadjuvant chemotherapy.

Chemotherapy immediately following autologous stem-cell transplantation in patients with advanced breast cancer

Most patients relapse after high-dose chemotherapy (HDCT) with autologous stem-cell transplantation (ASCT) for metastatic breast cancer. Further chemotherapy immediately after hematopoietic recovery from ASCT is not given for fear of irreversibly damaging the newly engrafted stem cells. In a pilot chemoprotection trial, autologous CD34+ cells from patients with metastatic breast cancer were exposed to a replication-incompetent retroviral vector carrying MDR-1 cDNA and then reinfused after HDCT. Immediately on recovery, patients received multiple courses of escalating dose paclitaxel. All of the 10 patients tolerated reinfusion of modified cells without any toxicity and had myeloid engraftment within 12 days (range, 11-14). The bone marrow cells of three patients contained vector MDR-1-positive cells only at the time of the first course of posttransplant paclitaxel, indicating that the MDR-1 vector-modified cells had only short-term engrafting potential. A total of 83 courses of paclitaxel were administered starting at a median of 30 (range, 21-32) days from ASCT. The median dose of paclitaxel was 225 mg/m2 and the median interval between paclitaxel cycles of therapy was 21 (range, 20-41) days. Five of the six CR patients were able to receive all of the 12 courses of paclitaxel. Three patients who had achieved less than a complete response to the HDCT (2 patients) and partial response (1 patient) were converted to complete clinical responses during the 12 cycles of paclitaxel. No delayed toxicity or bone marrow failure was noted in these patients with a median follow-up of 2 years from ASCT. This is the first study of chemotherapy immediately after transplantation with autologous CD34+ cells. These data indicate that paclitaxel can be safely administered immediately after ASCT without any delayed toxicities. Paclitaxel given immediately after ASCT can further improve the response to pretransplant chemotherapy in patients with advanced breast cancer.

Phase II study of semisynthetic paclitaxel in metastatic breast cancer

The aim of this phase II study was to characterise the efficacy and toxicity of semisynthetic paclitaxel in patients with metastatic breast cancer. Eligible patients had measurable disease and had been treated with one prior chemotherapy regimen either as adjuvant or for metastatic disease. Semisynthetic paclitaxel was given at a dose of 175 mg/m2 over 3 h every 21 days with dexamethasone, cimetidine and diphenhydramine premedications. 31 patients were entered. All were evaluable for toxicity. 30 patients were evaluable for response because 1 patient was lost to follow-up after receiving one cycle. One patient achieved a complete response and 10 patients achieved partial responses for an overall response rate (CR + PR) of 37% (95% confidence interval 20-56%). 17 patients (55%) experienced at least one episode of grade 3 or 4 neutropenia. There were two episodes of febrile neutropenia complicating 155 cycles of therapy. One of these resulted in a treatment-related death in a patient with pulmonary metastasis. 3 patients required dose reductions for grade 3 sensory neuropathy. Our study shows that the antitumour activity and toxic effects of semisynthetic paclitaxel appear to be identical to the naturally occurring product.

Results of MDR-1 vector modification trial indicate that granulocyte/macrophage colony-forming unit cells do not contribute to posttransplant hematopoietic recovery following intensive systemic therapy

To formally test the hypothesis that the granulocyte/macrophage colony-forming unit (GM-CFU) cells can contribute to early hematopoietic reconstitution immediately after transplant, the frequency of genetically modified GM-CFU after retroviral vector transduction was measured by a quantitative in situ polymerase chain reaction (PCR), which is specific for the multidrug resistance-1 (MDR-1) vector, and by a quantitative GM-CFU methylcellulose plating assay. The results of this analysis showed no difference between the transduction frequency in the products of two different transduction protocols: "suspension transduction" and "stromal growth factor transduction." However, when an analysis of the frequency of cells positive for the retroviral MDR-1 vector posttransplantation was carried out, 0 of 10 patients transplanted with cells transduced by the suspension method were positive for the vector MDR-1 posttransplant, whereas 5 of 8 patients transplanted with the cells transduced by the stromal growth factor method were positive for the MDR-1 vector transcription unit by in situ or in solution PCR assay (a difference that is significant at the P = 0.0065 level by the Fisher exact test). These data suggest that only very small subsets of the GM-CFU fraction of myeloid cells, if any, contribute to the repopulation of the hematopoietic tissues that occurs following intensive systemic therapy and transplantation of autologous hematopoietic cells.

Paclitaxel: severe mucocutaneous toxicity in a patient with hyperbilirubinemia

Paclitaxel is a novel anticancer drug that is being increasingly used to treat cancer of the breast and other organs. We describe a patient with metastatic breast cancer and liver dysfunction who had severe mucocutaneous toxicity after administration of a standard dose of paclitaxel. Another interesting finding in this patient was that the administration of paclitaxel led to a prompt resolution of parathyroid hormone-related protein (PTHrP)-mediated hypercalcemia, which had previously proven to be refractory to multiple conventional antihypercalcemic agents as well as anthracycline-containing chemotherapy combination. The need for definitive guidelines for paclitaxel administration in the setting of hepatic dysfunction and the potentially unique sensitivity of PTHrP--producing cells to paclitaxel are discussed.

Phase II study of deoxyspergualin in metastatic breast cancer

We conducted a phase II trial of the novel immunomodulatory/cytotoxic agent 15-deoxyspergualin in patients with metastatic breast cancer who had failed treatment with front-line chemotherapy. Thirty-eight courses of treatment were administered to fourteen patients enrolled in this trial, 25 at a dose of 1800 mg/m2/d (dose level 0) and 13 at a dose of 2150 mg/m2/d (dose level +1) administered by continuous intravenous infusion for 5 days. Treatment was well tolerated with neuromuscular side-effects (myalgias, paresthesias) and granulocytopenia (nadir granulocyte count of 0.50-0.99 x 10(9)/l) in two and three courses, respectively, as the only grade III toxicities. The neuromuscular toxicity of deoxyspergualin is probably related to the occurrence of hypomagnesemia. No partial or complete responses were observed in this study. One patient achieved a minor response but had progressive disease 65 weeks after enrollment. The response was observed coincident with an increase in T4/T8 ratio in the peripheral blood. The median time to progression for the entire cohort was eight weeks (range, 4-65 weeks). There was no clinical evidence of immunosuppression and no decrease in total peripheral blood lymphocyte counts or helper T-cells was observed. At the doses and schedule employed in this trial, deoxyspergualin does not appear to have significant activity against metastatic breast cancer resistant to front-line chemotherapy. The correlation between hypomagnesemia and neuromuscular toxicity of deoxyspergualin is an intriguing, previously unknown observation and requires further investigation.

Genetic therapy of human neoplastic disease

Molecular biology has provided clinical investigators and basic scientists with the tools to identify those changes present within neoplastic hematopoietic and epithelial cells that lead to the evolution of unregulated patterns of cell growth. This information has made possible the development of therapy that involves genetic modification of either the normal hematopoietic cells (for chemoprotection), or the tumor cells themselves to suppress the growth of these cells. This article will summarize the clinical and laboratory data that is evolving in this area.

Salvage treatment for loco-regional recurrence following breast conservation therapy for early breast cancer

We reviewed the management of 55 cases of loco-regional recurrence after limited surgery and irradiation for breast cancer. Forty-three patients had disease localized to the breast, with axillary involvement in seven. Four had axillary relapse without tumor recurrence in the breast. Eight had breast recurrence extending to involve the chest wall. Mastectomy was used successfully for 41 first recurrences, and seven were controlled by wide excision; 21 of 48 patients also received chemotherapy and/or hormonal manipulation. Diffuse soft-tissue tumor required systemic therapy first, followed by wide excision when possible. Eighty-nine percent of first recurrences were controlled but disease recurred again in eight patients. Overall, 80% of cases were free of loco-regional disease at a median follow-up of 27 months. Reconstructive surgery was valuable for wound closure after wide resections, and for cosmetic procedures. Despite the previous irradiation, surgery complications were acceptable.

Long survival and prognostic factors in hepatocellular carcinoma

We studied survival and prognostic factors in all cases of hepatocellular carcinoma seen at a Midwestern teaching hospital from 1947 through 1986. Of the 70 cases, 56 were diagnosed during life and 14 at autopsy. There were 47 males and 23 females with age at diagnosis ranging from 14 to 88. Median survival for the 56 patients diagnosed during life was 106 days. Only 11 patients lived longer than one year. Two patients were long survivors and presumed cured, one living 27 years after diagnosis and surgical treatment and the other 19 years. Cox regression model showed young age at diagnosis and low stage of disease at diagnosis to be significant predictors of long survival. White patients survived nearly twice as long as black patients but the difference was not significant. Gender and year of diagnosis did not appear to be important determinants of survival. Pathologic material was still available for one of the two long survivors and the histology was that of fibrolamellar carcinoma of young adults.

A phase II study of mitoxantrone, etoposide, and thiotepa with autologous marrow support for patients with relapsed breast cancer

To further improve the effect of high-dose chemotherapy in the treatment of locally advanced and metastatic breast cancer, we sought to develop a second active high-dose noncross-resistant regimen to use in tandem with our customary high-dose regimen of cyclophosphamide, etoposide, and cisplatin (CVP). We performed a phase II trial of high-dose mitoxantrone 30 mg/m2, etoposide 200 mg/m2 every 12 hours x 6, and thiotepa 250 mg/m2 x 3 days (MVT) in 31 patients with heavily pretreated metastatic breast cancer and one with locally advanced chemotherapy-refractory breast cancer. These patients were ineligible for high-dose CVP chemotherapy because of the amount of prior treatment and poor-response status. Of the 32 patients, 14 responded to cycle 1, did not experience any grade 4 toxicity, and received a second cycle of MVT. Overall, seven of 31 patients achieved a complete response (CR; 23%). Four of the 14, who were partial responders to the first cycle, achieved a CR after the second cycle. The overall response rate was 19 of 31 (61%) with an overall median freedom from progression of 4 to 5 months and an overall median survival of 9 months. Toxicity consisted primarily of mucositis (grade 3 or 4 in 69%). The results indicate that high-dose MVT produces significant activity, even in heavily pretreated patients. Administration of a second cycle of high-dose therapy with MVT increased the CR rate, and the morbidity and mortality from the second cycle were not greater than that for the first cycle. Because of the high incidence of grade 3 or 4 mucositis with this regimen, we are currently completing a follow-up study of high-dose mitoxantrone and thiotepa alone.

Treatment of patients with isolated axillary nodal metastases from an occult primary carcinoma consistent with breast origin

The records of 42 patients who had axillary metastases compatible with a clinically occult breast primary were reviewed. Forty patients had mammography performed as part of their evaluations. Mastectomy yielded the primary tumor in one of 13 patients; biopsy yielded positive results in one of five. Among the 29 patients who did not undergo mastectomy, 16 received breast irradiation, and 13 were simply observed for signs of the primary tumor. For the patients who did not undergo mastectomy, the 5-year actuarial risk for appearance of a primary was 17% in the irradiated group versus 57% in the nonirradiated group (P = 0.06). Patterns of failure are correlated with stage and local and systemic therapy. The results affirm our belief that patients with axillary metastases histologically consistent with breast tumor should be treated identically to patients with similar nodal stages and proven breast primaries.

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A Forum for Our Readers Jim Blankenship, MD Danville, Pennsylvania Forum is intended to provide a sounding board for our readers. Perhaps you have a special way to treat a common medical problem, or you may want to air your views on a controversial topic. You may object to an article that we have published, or you may want to support one. You may have a new trend to report, identified through an interesting case or a series of patients. Whatever your ideas, we invite you to send them to us. Illustrative figures are welcomed. Address correspondence to Forum, THE PHYSICIAN AND SPORTSMEDICINE, 4530 W 77th St, Minneapolis, MN 55435.

Treatment of estrogen receptor-negative or hormonally refractory breast cancer with double high-dose chemotherapy intensification and bone marrow support

We have used high-dose therapy followed by randomization to receive or not receive autologous bone marrow infusion in 58 stage IV breast cancer patients (all were estrogen receptor-negative [ER-] or primary hormonal refractory). Patients received a median of four courses of induction chemotherapy and if stable or responding received two courses of intensive therapy with cyclophosphamide 4.5 to 5.25 g/m2, etoposide 750 to 1,200 mg/m2, and cisplatin 120 to 180 mg/m2 (CVP). The complete remission (CR) rate after completion of the induction and intensive phases was 55%. Median progression-free interval from induction is 57 weeks with a projected 2-year progression-free survival of approximately 25%. Six of seven patients followed for greater than 2 years are still progression-free. Three favorable features predicted for improved progression-free survival are the following: (1) absent liver involvement, (2) absent soft tissue involvement, and (3) less than or equal to two disease sites (P values of .001, .013, and .048, respectively). Hormonal and menopausal status did not predict for progression-free survival. Major toxicities were infectious secondary to neutropenia, with a 93% incidence of fever and a 38% incidence of sepsis. The treatment-related mortality rate was 9%, with three infectious, one coronary, and one late hemorrhage-related death of unknown cause. Longer follow-up is still needed to truly evaluate the possibility of long-term disease-free survival, but further studies of this approach to high-dose intensification in poor prognostic groups of stage IV breast cancer appear warranted.

Survival in acute leukemia in elderly patients. No improvement in the 1980s

Acute leukemia is more common in older people than in the young or middle-aged. However, the possibilities of achieving remission or prolonging survival are both inversely correlated with increasing age. We studied survival in 118 acute leukemia patients over the age of 64 seen at a university hospital from 1970 to 1987. Seventy percent had myeloid morphology. Median survival times were 106 days in those diagnosed in the 1970s and 71 days for those diagnosed in the 1980s. This was little changed from an earlier series from the same hospital extending back to the 1940s in which median survival was 69 days. Considering the two decades separately, age at diagnosis, sex, race, type of leukemia, and whether or not disease-specific treatment was applied had no significant effect on survival duration. Acute leukemia in the older patient demands difficult medical and ethical choices. Supportive therapy provides immediate comfort and relatively limited morbidity with certainty of death within a few months. Disease-specific therapy causes immediate morbidity for all, shortened life for the majority, and extended life for the minority.

Relationship of age to histologic grade in prostate cancer

We studied 4,968 cases of prostatic carcinoma to determine if there is a relationship between tumor grade and patient age at diagnosis. Cases were stratified into arbitrary age groups and classified as either better differentiated (Grades I and II) or worse differentiated (Grades III and IV). The 4,596 graded cases were distributed by stage as follows: Local 3,451 (75%), Regional 509 (11%), and Distant 636 (14%). When patients in all stages were considered together, the percentage of men with better differentiated tumors dropped from 77.8% of patients under 60 to 67.5% of patients 80 or older (P less than 0.00001). This trend for older patients to have more poorly differentiated tumors was also seen in patients with localized disease (P less than 0.0005). The fact that occult, biologically inactive prostate cancer is common in older men has led some to extrapolate that clinically apparent disease follows a more benign course in the elderly. Our findings suggest that, on the contrary, elderly men with clinically apparent disease have worse differentiated tumors than their younger counterparts.

Beta-lactam regimens for the febrile neutropenic patient

A total of 535 evaluable febrile episodes in neutropenic patients were randomly assigned to treatment with ticarcillin-clavulanate plus vancomycin (TV), ceftazidime plus vancomycin (CV), or all three antibiotics (TCV). The TCV regimen was significantly more effective than TV, considering all evaluable episodes, documented infections, gram-negative infections, and infections in patients with persistent severe neutropenia (less than 100 neutrophils/mm3). The results with CV were intermediate between TV and TCV. The toxicities were similar with all three regimens and consisted primarily of skin rashes. The TCV regimen is effective for empiric therapy of fever in neutropenic patients and probably should be utilized in preference to CV or TV, although its superiority over CV in this study was inconclusive.

Oral ciprofloxacin therapy for infections in cancer patients

Forty six episodes of infection in 43 cancer patients were treated with oral ciprofloxacin at a dose of 750 mg every 8 h. The overall clinical response was 85%. Patients with microbiologically proven infections had a higher response rate (90%) than patients with infections from whom no causative organism(s) could be isolated (69%). Two of three neutropenic patients responded favourably. Favourable responses were seen in a variety of infections including bacteraemia, urinary tract infection, respiratory tract infection and skin and soft-tissue infection. Resistance to ciprofloxacin developed in one isolate of Pseudomonas aeruginosa. Side effects were mild and were predominantly gastrointestinal in nature. Orally administered ciprofloxacin is safe and effective for the therapy of many serious infections in cancer patients. However, more data are required in patients who are neutropenic.

Anal cancer in women

We studied predisposing factors in 56 women with anal cancer, comparing them with 56 matched controls drawn from the population. A detailed pretested questionnaire was administered to each study subject in a structured interview and blood was drawn for detection of herpes simplex virus antibodies by radioimmunoassay. Pathologic material from cases was obtained and evidence of human papilloma virus infection was sought. By univariate analyses we found associations between anal cancer and positive herpes simplex virus 2 titer (p = 0.0017), cigarette smoking (p = 0.0028), previous positive or questionable cervical Papanicolaou smear (p = 0.0124), and increasing number of sexual partners (p = 0.0224). By the multivariate technique of logistic regression there were independent and significant associations with cigarette smoking (p = 0.0126), previous use of hemorrhoid preparations (p = 0.0149), and history of disturbed bowel habits for greater than 1 mo (p = 0.0273). Anal cancer in women is a rare disease associated with cigarette smoking and sexual experience. Its association with previous anorectal disease is unclear and deserving of further study.

Phase II evaluation of Ly156758 in metastatic breast cancer

Fourteen patients with disseminated breast cancer with primary or secondary resistance to tamoxifen were treated with LY156758. There were no complete or partial responses and 1 patient showed a minor response. These data illustrate that LY156758 did not have significant antitumor activity in patients previously treated with tamoxifen therapy.

Evaluation of mitoxantrone cardiac toxicity by nuclear angiography and endomyocardial biopsy: an update

Sixty-six patients who underwent endomyocardial biopsy for detection of mitoxantrone (Novantrone; dihydroxyanthracenedione) cardiac toxicity were evaluated. All but one had breast cancer, 29 had received prior doxorubicin and 29 of the 37 patients who had not had prior doxorubicin received it or another anthracycline subsequently. Endomyocardial biopsy was carried out initially after four courses of chemotherapy with increasing intervals thereafter. Although cardiac ejection fraction was determined before each course of chemotherapy, our data are limited to cardiac ejection fractions from our own institution which were repeated approximately every four courses. Endomyocardial biopsy changes consisting of dilatation of the sarcoplasmic reticulum with vacuole formation, and myofibrillar dropout are similar to the early changes of anthracycline cardiomyopathy. While there was a slight suggestion of increasing biopsy grade with increasing mitoxantrone dose, no significant changes in cardiac ejection fraction could be associated, regardless of prior doxorubicin therapy. We concluded that mitoxantrone does show morphologic evidence of cardiac toxicity; however, the structural changes are minor and are haemodynamically insignificant. Determination of how much mitoxantrone treatment may contribute to the deterioration of pre-existing doxorubicin damage must await the outcome of longer follow-up.

Simultaneous Streptococcus and picornavirus infection. Muscle involvement in acute rhabdomyolysis

Streptococci seldom invade muscle in healthy people with intact integument. However, infection with another agent simultaneously may change this general observation. In a two-week period we encountered dual infections with group A, beta-hemolytic streptococci and a picornavirus in each of two hospitalized patients. Both were acutely ill; one died. Renal failure developed in the patient who survived and rhabdomyolysis was demonstrated in the patient who died. Picornavirus titer increases were demonstrated in the patient who survived, and viral inclusions in muscle cells were demonstrated by light microscopy in necropsy specimens and confirmed by electron microscopy in the second patient. We believe that streptococcal invasion of muscle may be facilitated during an outbreak of certain picornavirus infections.

Subarachnoid spinal analgesia. A comparative survey of current practice in Scotland and Sweden

A postal inquiry into the current use of subarachnoid spinal analgesia obtained replies from approximately 70% of consultants in both Scotland and Sweden. Although medico-legal anxiety was still an important feature of Scottish practice, the publication of large series with a low incidence of complications had also exerted some influence, and 40% of consultants employed the technique. In contrast, 70% of Swedish replies indicated current use of spinal analgesia and the individual frequency of administration was considerably higher. The present popularity of epidural analgesia has contributed to some decline in the use of subarachnoid spinal analgesia in Sweden, particularly in the case of longer surgical procedures. Anaesthetists in both countries expressed dissatisfaction with the limited choice of available spinal agents and considered their duration of action to be inadequate. In Scotland, conditional indications, such as diabetes mellitus and respiratory disease, were of major importance, whereas Swedish users more often specified surgical procedures for which subarachnoid spinal analgesia was considered to be the anaesthetic of choice. Few anaesthetists had experience of complications and no major neurological sequelae were reported. More than 80% of replies indicated that subarachnoid spinal anaesthesia had a useful place in anaesthetic practice.