The Royal College of Radiologists National Vulvar Cancer Audit

AIMS

This audit examined UK vulvar cancer practice from March 2018 to January 2019 and compared it to standards from national and international recommendations. Follow-up data collection in 2020 examined patient outcomes and toxicity.

MATERIALS AND METHODS

Audit standards were based on Royal College of Radiologists (RCR) guidance and published literature. A web-based questionnaire was sent to the audit leads at all cancer centres in the UK. Prospective data collection included patient demographics, tumour characteristics, radiotherapy indications, dosimetry, timelines, and follow-up data. The audit targets were 95% compliance with the RCR dose/fractionation schemes in definitive and adjuvant patients, 40% use of intensity modulated radiotherapy (IMRT), 100% of radical patients treated as category 1, and 95% use of gap compensation for category 1 patients.

RESULTS

34/54 UK radiotherapy centres (63%) completed data entry for 152 patients. 23 out of 34 (68%) centres submitted follow-up data for 94 patients. One indicator exceeded the audit target: 98% of radical patients received IMRT. The indicators of RCR dose/fractionation compliance for adjuvant/definitive radiotherapy were achieved by 80%/43% for the primary, 80%/86% for elective lymph nodes, and 21%/21% for pathological lymph nodes. The use of concomitant chemotherapy with radical radiotherapy in suitable patients was achieved by 71%. Other indicators demonstrated that 78% were treated as category 1 and 27% used gap compensation. Acute toxicity was mostly related to skin, gastrointestinal, and genitourinary sites. Grade 3 and Grade 4 toxicities were seen at acceptable rates within the radical and adjuvant groups. Late toxicity was mostly grade 0.

CONCLUSION

This audit provides a comprehensive picture of UK practice. IMRT is widely used in the UK, and treatment-related toxicity is moderate. The dose fractionation was very heterogeneous. The designation of vulvar cancer as category 1 was not regularly followed for radical/adjuvant patients, and there was minimal gap compensation during treatment.

Defining the Optimal Treatment Strategy in Patients With Uterine Serous Carcinoma

AIMS

Uterine serous carcinoma (USC) is an aggressive subtype of endometrial cancer with high rates of relapse and death. As adjuvant therapy might be beneficial in early-stage disease, the impact of standard complete surgical staging is questioned. Therefore, we wanted to explore the optimal treatment strategy for women diagnosed with USC.

MATERIALS AND METHODS

A retrospective multicentre study of women diagnosed with primary USC in the UK and the Netherlands. Treatment strategy in relation to overall survival and progression-free survival was recorded and evaluated with Kaplan-Meier and Cox regression analysis. Furthermore, primary surgical staging and/or adjuvant treatment in relation to patterns of recurrence were evaluated.

RESULTS

In total, 272 women with a median age of 70 years were included. Most patients presented with International Federation of Gynecology and Obstetrics (FIGO) stage I disease (44%). Overall, 48% of patients developed recurrent disease, most (58%) with a distant component. Women treated with chemotherapy showed significantly better overall survival (hazard ratio 0.50, 95% confidence interval 0.31-0.81; P = 0.005) and progression-free survival (hazard ratio 0.48, 95% confidence interval 0.28-0.80; P = 0.04) in multivariable analysis. Furthermore, even in surgically staged women with FIGO stage IA disease, a high recurrence rate of 42% was seen.

CONCLUSION

Women with USC who received adjuvant chemotherapy showed better survival rates compared with those who received other or no adjuvant treatment. The benefit of adjuvant chemotherapy was observed across all tumour stages, including surgically staged FIGO stage IA. These data question the role of surgical staging in the absence of macroscopic disease in USC.

Risk factors and mortality associated with permanent pacemaker after surgical or transcatheter aortic valve replacement: Early versus late implantation

INTRODUCTION

Inflation of transcatheter aortic valve replacement (TAVR) procedures compared to surgical aortic valve replacement (SAVR) has increased the number of patients requiring a postprocedure permanent pacemaker (PPM). We investigate the impact of PPM on mid-term mortality comparing SAVR versus TAVR procedures and risk factors for early and late (>14 days) need of PPM.

METHODS

We conducted a retrospective, single-center evaluation of 903 patients that underwent either SAVR or TAVR procedures at the Yale New Haven Hospital from 2012 to 2017. Patients were stratified into PPM and non-PPM groups. We performed Kaplan-Meier and Cox proportional hazard analysis to characterize mid-term mortality. Further subgroup analysis was performed to identify risk factors for early and late PPM implantation in the TAVR cohort.

RESULTS

There was no correlation between PPM implantation and mid-term mortality in both SAVR (hazard ratio [HR] = 0.69; confidence interval [CI] = 0.21-2.30; p = .56) and TAVR (HR = 0.70; CI = 0.42-1.17; p = .18) patients. The presence of the right bundle branch block (Odds ratio = 24.07; 95% CI = 2.34-247.64, p = .007) was associated with higher odds of early PPM requirement after TAVR procedures.

CONCLUSION

PPM placement after SAVR or TAVR procedures is not associated with increased mid-term mortality. In-depth characterization of risk factors for early and late PPM implantation will require further analysis in the growing TAVR patient population.

A randomized evaluation of the TriGuard™ HDH cerebral embolic protection device to Reduce the Impact of Cerebral Embolic LEsions after TransCatheter Aortic Valve ImplanTation: the REFLECT I trial

AIMS

The REFLECT I trial investigated the safety and effectiveness of the TriGuard™ HDH (TG) cerebral embolic deflection device in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS AND RESULTS

This prospective, multicentre, single-blind, 2:1 randomized (TG vs. no TG) study aimed to enrol up to 375 patients, including up to 90 roll-in patients. The primary combined safety endpoint (VARC-2 defined early safety) at 30 days was compared with a performance goal. The primary efficacy endpoint was a hierarchical composite of (i) all-cause mortality or any stroke at 30 days, (ii) National Institutes of Health Stroke Scale (NIHSS) worsening at 2-5 days or Montreal Cognitive Assessment worsening at 30 days, and (iii) total volume of cerebral ischaemic lesions detected by diffusion-weighted magnetic resonance imaging at 2-5 days. Cumulative scores were compared between treatment groups using the Finkelstein-Schoenfeld method. A total of 258 of the planned, 375 patients (68.8%) were enrolled (54 roll-in and 204 randomized). The primary safety outcome was met compared with the performance goal (21.8% vs. 35%, P < 0.0001). The primary hierarchical efficacy endpoint was not met (mean efficacy score, higher is better: -5.3 ± 99.8 TG vs. 11.8 ± 96.4 control, P = 0.31). Covert central nervous system injury was numerically lower with TG both in-hospital (46.1% vs. 60.3%, P = 0.0698) and at 5 days (61.7 vs. 76.2%, P = 0.054) compared with controls.

CONCLUSION

REFLECT I demonstrated that TG cerebral protection during TAVR was safe in comparison with historical TAVR data but did not meet the predefined effectiveness endpoint compared with unprotected TAVR controls.

Randomized Evaluation of TriGuard 3 Cerebral Embolic Protection After Transcatheter Aortic Valve Replacement: REFLECT II

OBJECTIVES

The REFLECT II (Randomized Evaluation of TriGuard 3 Cerebral Embolic Protection After Transcatheter Aortic Valve Implantation) trial was designed to investigate the safety and efficacy of the TriGUARD 3 (TG3) cerebral embolic protection in patients undergoing transcatheter aortic valve replacement.

BACKGROUND

Cerebral embolization occurs frequently following transcatheter aortic valve replacement and procedure-related ischemic stroke occurs in 2% to 6% of patients at 30 days. Whether cerebral protection with TriGuard 3 is safe and effective in reducing procedure-related cerebral injury is not known.

METHODS

This prospective, multicenter, single-blind, 2:1 randomized (TG3 vs. no TG3) study was designed to enroll up to 345 patients. The primary 30-day safety endpoint (Valve Academic Research Consortium-2 defined) was compared with a performance goal (PG). The primary hierarchical composite efficacy endpoint (including death or stroke at 30 days, National Institutes of Health Stroke Scale score worsening in hospital, and cerebral ischemic lesions on diffusion-weighted magnetic resonance imaging at 2 to 5 days) was compared using the Finkelstein-Schoenfeld method.

RESULTS

REFLECT II enrolled 220 of the planned 345 patients (63.8%), including 41 roll-in and 179 randomized patients (121 TG3 and 58 control subjects) at 18 US sites. The sponsor closed the study early after the U.S. Food and Drug Administration recommended enrollment suspension for unblinded safety data review. The trial met its primary safety endpoint compared with the PG (15.9% vs. 34.4% (p < 0.0001). The primary hierarchal efficacy endpoint at 30 days was not met (mean scores [higher is better]: -8.58 TG3 vs. 8.08 control; p = 0.857). A post hoc diffusion-weighted magnetic resonance imaging analysis of per-patient total lesion volume above incremental thresholds showed numeric reductions in total lesion volume >500 mm³ (-9.7%) and >1,000 mm³ (-44.5%) in the TG3 group, which were more pronounced among patients with full TG3 coverage: -51.1% (>500 mm³) and -82.9% (>1,000 mm³).

CONCLUSIONS

The REFLECT II trial demonstrated that the TG3 was safe compared with a historical PG but did not meet its pre-specified primary superiority efficacy endpoint.

Adjunctive Antithrombotic Therapy for Patients With Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

Importance

Transcatheter aortic valve replacement (TAVR) is an established alternative to surgery for patients with severe symptomatic aortic stenosis. Adjunctive antithrombotic therapy used to mitigate thrombotic risks in patients undergoing TAVR must be balanced against bleeding complications, since both are associated with increased mortality.

Observation

Stroke risk associated with TAVR is lower than that associated with surgical aortic valve replacement in recent trials including patients at intermediate or low risk, but it is constant beginning at the time of implant and accrues over time based on patient risk factors. Patients with aortic stenosis undergoing TAVR also have a sizable risk of life-threatening or major bleeding. Although dual antiplatelet therapy for 3 to 6 months after TAVR is the guideline-recommended regimen, this practice is not well supported by current evidence. In patients with no indication for oral anticoagulation, current registry-based evidence suggests that single antiplatelet therapy may be safer than dual antiplatelet therapy. Similarly, oral anticoagulation monotherapy appears superior to anticoagulation plus antiplatelet therapy in those where oral anticoagulant use is indicated. To date, no risk prediction models have been established to guide antithrombotic therapy.

Conclusions and Relevance

Despite the growing volume of TAVR procedures to treat patients with severe aortic stenosis, evidence for adjunctive antithrombotic therapy remains rather scarce. Ongoing clinical trials will provide better understanding to guide antithrombotic therapy.

Comparison of a Complete Percutaneous Versus Surgical Approach to Aortic Valve Replacement and Revascularization in Patients at Intermediate Surgical Risk: Results From the Randomized SURTAVI Trial

BACKGROUND

For patients with severe aortic stenosis and coronary artery disease, the completely percutaneous approach to aortic valve replacement and revascularization has not been compared with the standard surgical approach.

METHODS

The prospective SURTAVI trial (Safety and Efficiency Study of the Medtronic CoreValve System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement) enrolled intermediate-risk patients with severe aortic stenosis from 87 centers in the United States, Canada, and Europe between June 2012 and June 2016. Complex coronary artery disease with SYNTAX score (Synergy Between PCI with Taxus and Cardiac Surgery Trial) >22 was an exclusion criterion. Patients were stratified according to the need for revascularization and then randomly assigned to treatment with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Patients assigned to revascularization in the TAVR group underwent percutaneous coronary intervention, whereas those in the SAVR group had coronary artery bypass grafting. The primary end point was the rate of all-cause mortality or disabling stroke at 2 years.

RESULTS

Of 1660 subjects with attempted aortic valve implants, 332 (20%) were assigned to revascularization. They had a higher Society of Thoracic Surgeons risk score for mortality (4.8±1.7% versus 4.4±1.5%; P<0.01) and were more likely to be male (65.1% versus 54.2%; P<0.01) than the 1328 patients not assigned to revascularization. After randomization to treatment, there were 169 patients undergoing TAVR and percutaneous coronary intervention, 163 patients undergoing SAVR and coronary artery bypass grafting, 695 patients undergoing TAVR, and 633 patients undergoing SAVR. No significant difference in the rate of the primary end point was found between TAVR and percutaneous coronary intervention and SAVR and coronary artery bypass grafting (16.0%; 95% CI, 11.1-22.9 versus 14.0%; 95% CI, 9.2-21.1; P=0.62), or between TAVR and SAVR (11.9%; 95% CI, 9.5-14.7 versus 12.3%; 95% CI, 9.8-15.4; P=0.76).

CONCLUSIONS

For patients at intermediate surgical risk with severe aortic stenosis and noncomplex coronary artery disease (SYNTAX score ≤22), a complete percutaneous approach of TAVR and percutaneous coronary intervention is a reasonable alternative to SAVR and coronary artery bypass grafting.

CLINICAL TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov. Unique identifier: NCT01586910.

Risk factors associated with excessive negative energy balance in commercial United Kingdom dairy herds

This study assessed risk factors associated with excessive negative energy balance (eNEB) in UK dairy cows between April 2006 and March 2015. Blood samples were analysed for β-hydroxybutyrate (BHB), non-esterified fatty acids (NEFA) and glucose. Following removal of all potential duplicate cows, a final dataset of 69,161 unique individual cows was obtained including biochemical results, individual cow and feed data. Generalised linear mixed-effect models and multivariable classification tree-based models showed that individual cow risk factors for eNEB included: (1) days relative to predicted calving date (dry cows); (2) days in milk (lactating cows); (3) body condition score (BCS; lactating cows ≥ BCS 4; OR 2.1); (4) milk yield (around 40 L per day); (5) parity (first lactation heifers; odds ratio [OR] 0.46 compared to older cows during lactation); and (6) chronic inflammatory conditions as assessed by globulin concentrations ≥ 50 g/L (OR 0.79 for cows with evidence of chronic inflammation). There was a higher prevalence during April to October (OR 1.19), and the lowest prevalence was in November. Feeding grass silage and wholecrop (silage made from cereal crops) to dry cows was associated with a reduced prevalence of eNEB, whereas access to grazed grass was associated with a higher prevalence in both the dry period (OR 1.32) and lactation (OR 1.33). Knowledge of the risk factors associated with eNEB in commercial dairy herds assists in both the implementation of herd monitoring programs and reduction of eNEB in dairy herds, with associated reductions in the risk of periparturient diseases and improved dairy cow performance.

Prevalence of excessive negative energy balance in commercial United Kingdom dairy herds

The objectives of this study were to determine the individual animal and herd level prevalence of excessive negative energy balance (eNEB) in commercial UK dairy herds. Between April 2006 and March 2015, blood samples from 84,369 individual cows from 1748 different UK farms were received by a commercial laboratory service specializing in dairy cow nutritional monitoring. Following removal of all potential duplicate cows, the final dataset comprised 69,161 unique individual cows. The prevalence of eNEB was determined using plasma thresholds of β-hydroxybutyrate (BHB), non-esterified fatty acids (NEFA) and glucose. Overall prevalence of subclinical ketosis (SCK) in the first 20 days of lactation was 28.5%, 17.3% and 11.7% using BHB thresholds of 1.0, 1.2 and 1.4 mmol/L respectively. Prevalence of NEFA values ≥0.5 mmol/L in the last 10 days prior to calving was 26.0%, and 40.3% of cows had NEFA values ≥0.7 mmol/L in the first 20 days in milk (DIM). Combining BHB, NEFA and glucose showed that 52.0% of cows had one or more of the three biochemical measures of energy balance outside the respective threshold value in the last 10 days pre-calving, and 75.2% of cows showed a similar biochemical pattern in the first 20 DIM. The median herd prevalence of elevated BHB and/or NEFA was 37.5% in late pregnancy and 59.8% in the first 20 DIM, with substantial herd variation. Using multiple measures for the assessment of energy balance, this study has shown that eNEB affects substantial numbers of UK dairy cows.

Impact of Hospital Volume on Outcomes of Lower Extremity Endovascular Interventions (Insights from the Nationwide Inpatient Sample [2006 to 2011])

Our primary objective was to study postprocedural outcomes and hospitalization costs after peripheral endovascular interventions and the multivariate predictors affecting the outcomes with emphasis on hospital volume. The study cohort was derived from Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2006 to 2011). Peripheral endovascular interventions were identified using appropriate International Classification of Diseases, Ninth Revision diagnostic and procedural codes. Annual institutional volumes were calculated using unique identification numbers and then divided into quartiles. Two-level hierarchical multivariate mixed models were created. The primary outcome was inhospital mortality; secondary outcome was a composite of inhospital mortality and postprocedural complications. Amputation rates and hospitalization costs were also assessed. Multivariate analysis (odds ratio, 95% confidence interval, p value) revealed age (1.46, 1.37 to 1.55, p <0.001), female gender (1.28, 1.12 to 1.46, p <0.001), baseline co-morbidity status as depicted by a greater Charlson co-morbidity index score (≥2: 4.32, 3.45 to 5.40, p <0.001), emergent or urgent admissions(2.48, 2.14 to 2.88, p <0.001), and weekend admissions (1.53, 1.26 to 1.86, p <0.001) to be significant predictors of primary outcome. An increasing hospital volume quartile was independently predictive of improved primary (0.65, 0.52 to 0.82, p <0.001 for the fourth quartile) and secondary (0.85, 0.73 to 0.97, 0.02 for the fourth quartile) outcomes and lower amputation rates (0.52, 0.45 to 0.61, p <0.001). A significant reduction hospitalization costs ($-3,889, -5,318 to -2,459, p <0.001) was also seen in high volume centers. In conclusion, a greater hospital procedural volume is associated with superior outcomes after peripheral endovascular interventions in terms of inhospital mortality, complications, and hospitalization costs.

Highly enhanced Raman scattering of graphene using plasmonic nano-structure

Highly enhanced Raman scattering of graphene on a plasmonic nano-structure platform is demonstrated. The plasmonic platform consists of silver nano-structures in a periodic array on top of a gold mirror. The gold mirror is used to move the hot spot to the top surface of the silver nano-structures, where the graphene is located. Two different nano-structures, ring and crescent, are studied. The actual Raman intensity is enhanced by a factor of 890 for the G-peak of graphene on crescents as compared to graphene on a silicon dioxide surface. The highest enhancement is observed for the G-peak as compared to the 2D-peak. The results are quantitatively well-matched with a theoretical model using an overlap integral of incident electric field intensities with the corresponding intensities of Raman signals at the G- and 2D-peaks. The interaction of light with nano-structures is simulated using finite element method (FEM).

Uptake of Dissolved Sulfide by Spartina alterniflora: Evidence from Natural Sulfur Isotope Abundance Ratios

The difference in the stable sulfur isotope ratios of sulfate and sulfide in marsh pore water was used to verify the uptake of hydrogen sulfide by the salt marsh cordgrass Spartina alterniflora in a North Carolina salt marsh. Most of the plant sulfur derived from pore-water sulfide was recovered as sulfate, an indication that the sulfide had been oxidized within the plant. The analysis of the sulfur isotope ratios of other coastal halophytes may be a useful technique for determining whether sulfide is taken up by plants in saline wetlands.

Toremifene improves lipid profiles in men receiving androgen-deprivation therapy for prostate cancer: interim analysis of a multicenter phase III study

PURPOSE

Androgen-deprivation therapy (ADT) is associated with greater risk of incident coronary heart disease and hospital admission for myocardial infarction; treatment-related increases in serum lipids may contribute to greater cardiovascular disease risk. We evaluated the effects of toremifene, a selective estrogen-receptor modulator, on fasting serum lipid levels in men receiving ADT for prostate cancer.

PATIENTS AND METHODS

In an ongoing, multicenter, double-blind, placebo-controlled phase III fracture-prevention study, 1,389 men receiving ADT for prostate cancer were randomly assigned to receive toremifene (80 mg/d) or placebo. In this interim analysis of 188 patients, changes in fasting serum lipids from baseline to month 12 were compared between the placebo and toremifene groups.

RESULTS

Changes in serum lipids differed significantly between the groups. Mean (+/- SE) total cholesterol decreased by 1.0% +/- 1.7% from baseline to month 12 in the placebo group and decreased by 8.1% +/- 1.4% in the toremifene group (P = .001 for between group comparison). Low-density lipoprotein (LDL) cholesterol increased by 0.8% +/- 2.5% in the placebo group and decreased by 8.2% +/- 2.5% in the toremifene group (P = .003). In contrast, high-density lipoprotein (HDL) cholesterol decreased by 4.9% +/- 1.2% in the placebo group and increased by 0.5% +/- 2.2% in the toremifene group (P = .018). Triglycerides increased by 6.9% +/- 4.2% in the placebo group and decreased by 13.2% +/- 3.6% in the toremifene group (P = .003).

CONCLUSION

Toremifene significantly decreased total cholesterol, LDL cholesterol, and triglycerides, and increased HDL cholesterol in men receiving ADT for prostate cancer.

Improvement in sexual functioning in patients with interstitial cystitis/painful bladder syndrome

INTRODUCTION

Sexual functioning is one of the strongest predictors of poorer quality of life (QOL) in patients diagnosed with interstitial cystitis/painful bladder syndrome (IC/PBS).

AIMS

To examine the relationship between symptom reduction and sexual functioning in patients with IC/PBS.

METHODS

Patients with IC/PBS were treated with 300 mg/day pentosan polysulfate sodium for 32 weeks.

MAIN OUTCOME MEASURES

Patients completed the O'Leary-Sant Interstitial Cystitis Symptom Index, Short Form-12 QOL, and Medical Outcomes Study Sexual Functioning Scale at baseline, and at 8, 16, 24, and 32 weeks. Treatment responders were defined as those achieving a >/=30% reduction in symptom index from baseline.

RESULTS

A total of 128 patients were included in the analyses. At baseline, mean symptom index, QOL (physical and mental), and sexual functioning scores were 12.3, 41.7, 45.9, and 56.1, respectively. Patients showed statistically significant improvement in symptom and sexual functioning scores at weeks 8, 16, 24, and 32. At week 32, the mean change in symptom index score from baseline was -2.97 (standard deviation [SD] = 4.66, P < 0.0001), and the mean change in sexual functioning score from baseline was 8.9 (SD = 32.9, P = 0.0054). Reduction in symptom index score was moderately correlated with improvement in sexual functioning score at the end of study (r = -35, P = 0.0002). Positive correlation was observed at the end of the study between the mean change scores of sexual functioning score and physical and mental QOL components (r = 0.46, P < 0.0001 and r = 0.29, P = 0.0023, respectively). Patients achieving a >/=30% reduction in symptom index (responder, N = 47; 44%) had an adjusted mean change in sexual functioning score of 19.8 (standard error [SE] = 4.69), while nonresponders (N = 59, 56%) had an adjusted mean change -0.49 (SE = 4.17) (between groups, P = 0.0020).

CONCLUSIONS

Sexual dysfunction is moderate to severe in patients with IC/PBS and impacts significantly on QOL. Reduction in symptoms was associated with improvement in the patient-reported outcomes of sexual function.

Toremifene increases bone mineral density in men receiving androgen deprivation therapy for prostate cancer: interim analysis of a multicenter phase 3 clinical study

PURPOSE

We evaluated the effects of toremifene on bone mineral density, a surrogate for fracture risk, in men receiving androgen deprivation therapy for prostate cancer.

MATERIALS AND METHODS

In an ongoing, multicenter, phase 3 fracture prevention study 1,392 men 50 years or older with prostate cancer receiving androgen deprivation therapy were randomized to 80 mg toremifene per day or placebo. Bone mineral density of the lumbar spine, total hip and femoral neck was assessed using dual energy x-ray absorptiometry. In this planned interim analysis of the first 197 subjects we compared bone mineral density changes from baseline to month 12 between the placebo and toremifene groups.

RESULTS

Compared with the placebo group men in the toremifene group had significant increases in bone mineral density at each evaluated skeletal site. Lumbar spine bone mineral density decreased 0.7% in the placebo group and increased 1.6% in the toremifene group (between group comparison p <0.001). Total hip bone mineral density decreased 1.3% in the placebo group and increased 0.7% in the toremifene group (p = 0.001). Femoral neck bone mineral density decreased 1.3% in the placebo group and increased 0.2% in the toremifene group (p = 0.009). Between group differences in the change in bone mineral density from baseline to month 12 were 2.3%, 2.0% and 1.5% for the lumbar spine, total hip and femoral neck, respectively.

CONCLUSIONS

Toremifene significantly increased hip and spine bone mineral density in men receiving androgen deprivation therapy for prostate cancer. The effect of toremifene on the fracture risk is being assessed in the ongoing randomized, controlled trial.

Effect of toremifene in lowering total cholesterol, LDL, and triglycerides and raising HDL in prostate cancer patients on androgen deprivation therapy

5124

Introduction: Androgen deprivation therapy (ADT) is the standard treatment for men with advanced prostate cancer. ADT has been shown to detrimentally affect lipids (average 9% increase in total cholesterol and 26% increase in triglycerides) and is associated with increased risk of coronary heart disease and myocardial infarction. Toremifene, a selective estrogen receptor modulator (SERM), improves bone mineral density and lipid profiles in women. An ongoing phase III trial will assess the safety and efficacy of toremifene in treating multiple side effects of ADT including osteoporosis, hot flashes, gynecomastia and lipid profiles. Given the emerging recognition of increased cardiovascular risk during ADT, an interim analysis was conducted to assess the effects of toremifene on lipid profiles in the ongoing phase III study. Methods: 1,392 men = 50 years old with histologically documented prostate cancer and receiving ADT were randomized to toremifene (80 mg/day) or placebo. An interim analysis evaluated changes in lipids from baseline to month 12 in the first 197 subjects to complete one-year follow up. The outcomes measured in this interim analysis were total cholesterol, LDL cholesterol, triglycerides, total cholesterol/HDL ratio, and HDL cholesterol. Results: Compared to treatment with placebo, toremifene decreased total cholesterol (7.1%; p=0.001 for between group comparison), LDL cholesterol (9.0%; p=0.003), and triglycerides (20.1%; p=0.009) levels, and the total cholesterol/HDL ratio (11.7%; p<0.001). Toremifene also significantly increased HDL levels (5.4%; p=0.018) compared to placebo. The effects of toremifene were observed in both statin users and nonusers. Conclusions: Toremifene decreases total cholesterol, LDL cholesterol, and triglycerides and increases HDL cholesterol in men receiving ADT for advanced prostate cancer compared to placebo. Conclusions regarding the clinical significance of these observations will be based on the full cohort of patients at the conclusion of the trial.

No significant financial relationships to disclose.

Prevalence of osteoporosis and osteopenia during androgen deprivation (ADT) for prostate cancer: Baseline data from a large randomized controlled trial

5116

Background: Androgen deprivation therapy (ADT) is the standard treatment for men with advanced prostate cancer. ADT decreases bone mineral density (BMD) and increases fracture risk although there is limited information about the prevalence of osteopenia and osteoporosis during ADT. We evaluated the baseline data from a large fracture prevention study to better characterize the prevalence of ostepenia and osteoporosis in men receiving ADT for prostate cancer. Methods: In an ongoing phase 3 fracture prevention study, 1,392 men = 50 years old with histologically documented prostate cancer and receiving ADT were randomized to placebo or toremifene 80 mg, a selective estrogen receptor modulator. The phase 3 study included men at increased risk of fracture based on age = 70 years or low baseline BMD of the hip or spine as assessed by dual energy x-ray absorptiometry. Subjects with metabolic bone disease or receiving treatment for osteoporosis were excluded. In the current analyses, we report the baseline BMD and prevalence of osteopenia (T score -1.0 to -2.5 total hip, femoral neck or spine) and osteoporosis (T score = -2.5 total hip, femoral neck or spine) for the 1,139 subjects older than 70 years. The analyses were restricted to subjects =70 years because these subjects were included in the study regardless of baseline BMD. Results: Mean (± standard deviation) age was 76 ± 7 years. Mean duration on ADT was 39 ± 36 months. For men 70 years of age or older, mean T scores for the total hip, femoral neck, and spine are -1.01 ± 1.14, -1.50 ± 1.06 and 0.37 ± 1.88 respectively. A total of 73% of subjects 70 years of age or older were classified with osteopenia (55%) or osteoporosis (18%). Conclusions: In this large cross- sectional analysis, the vast majority of older men receiving ADT for prostate cancer have either osteopenia or osteoporosis. These observations provide further evidence that close attention to skeletal health is warranted during ADT for prostate cancer.

No significant financial relationships to disclose.