Abstract P3-08-04: Survivorship care involving a nurse-led survivorship consultation, community support and shared care with primary practitioners

Background

Survivorship care (SC) has gained prominence as the number of patients disease free after breast cancer treatment increases, the specific needs of those patients become recognised, and funding to meet these demands is constrained. Involvement of Primary Care Practitioners in SC is seen as a solution, but models of Shared Care have met varying degrees of success. We report on a model that involves Specialist centres, Primary Care Practitioners and organisations, and a community based patient support organisation.

Patients and Methods

A consortium comprising two hospital based breast services – the Royal Melbourne/Royal Women's and Western Hospitals – a regional consortium of Primary Care Physicians, and BreaCan, a non-government peer support organisation for women diagnosed with breast cancer, collaborated to obtain and implement a government-supported Survivorship Care Program. Patients completing definitive treatment for early breast cancer were invited to a Nurse-led consultation where the disease, its pathology, treatment and follow-up were reviewed. Psychosocial and other issues were explored and a personalised SC plan was devised and agreed upon. This plan included Shared Care with the Primary Care Practitioner in the majority of cases. Unmet needs were identified and addressed. The SC plan was signed off by a senior breast cancer clinician and forwarded to the primary care physician for ratification. Evaluation included satisfaction surveys and interviews with patients and primary care physicians. Intensity of use of hospital based services was calculated and compared to a previous cohort of early breast cancer patients.

Results

282 patients completing definitive treatment were offered Nurse-led survivorship consultation. 29 declined, and 28 cancelled. At 31 May 2013, 148 care plans were completed, 38 were in preparation and 39 appointments were booked. Response to this initiative from hospital based specialists was positive. All believed that this program would reduce the amount of routine consultations and increase capacity for new or returning patients requiring specialist care. Primary care doctors overwhelmingly believed the survivorship care plan contained information needed to allow them to manage breast cancer survivors, and gave them confidence to take on this role, although there was some uncertainty regarding role delineation between Primary Care and hospital. Patient evaluation of the Nurse-led clinics was strongly positive. All reported finding out something during the consultation, and 94% said they considered the hospital and GP to be partners in their on-going follow-up care. Modelling suggests that about 5 fewer hospital appointments will be required for each patient managed under this program compared to routine hospital-based care.

Conclusions

Hospital based specialists embrace Survivorship care including shared care and patients expect it, while Primary physicians will participate if offered education, support and specific direction. A model including an end-of –treatment consultation and Shared care with Primary Practitioners appears to address many of the requirements for a successful Survivorship program.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-04.

Disposition of gemfibrozil and gemfibrozil acyl glucuronide in the rat isolated perfused liver

Acyl glucuronides are reactive electrophilic metabolites and in vivo are readily hydrolyzed, undergo intramolecular rearrangement, and bind covalently to proteins. The isolated perfused liver preparation, using male Sprague-Dawley rats, was used to examine the hepatic disposition of the fibrate hypolipidemic agent gemfibrozil and its acyl glucuronide metabolite, 1-O-gemfibrozil-beta-D-glucuronide. Using a recirculating design, erythrocyte-free perfusion medium containing 1% (w/v) albumin was delivered to the liver via the portal vein at a flow rate of 30 ml/min, and for each experiment was spiked with either gemfibrozil (N = 4) or 1-O-gemfibrozil-beta-D-glucuronide (N = 4) at initial concentrations of 120 microM and 21 microM, respectively. In the gemfibrozil perfusions, the mean (SD) total perfusate clearance, half-life, hepatic extraction ratio of gemfibrozil, and the fraction of eliminated gemfibrozil excreted in bile as the glucuronide conjugate were 2.73 (0.30) ml/min, 76.9 (5.6) min, 0.091 (0.012), and 0.347 (0.154), respectively. In the 1-O-gemfibrozil-beta-D-glucuronide perfusions, the mean (SD) total perfusate clearance, half-life, hepatic extraction ratio, and fraction excreted in bile as the glucuronide conjugate were 19.5 (2.1) ml/min, 8.7 (0.9) min, 0.649 (0.068), and 0.534 (0.077), respectively. The higher hepatic extraction ratio for 1-O-gemfibrozil-beta-D-glucuronide could mostly be attributed to its higher unbound fraction in perfusate (0.182), compared with that of the parent drug (0.004), because the conjugate had a lower intrinsic clearance (305 ml/min) compared with the aglycone (751 ml/min). Control perfusions, conducted in the absence of a liver, showed negligible degradation of 1-O-gemfibrozil-beta-D-glucuronide over 90 min. However, in the presence of a liver, approximately 25% of 1-O-gemfibrozil-beta-D-glucuronide added to perfusate was hydrolyzed to gemfibrozil over 90 min. The study demonstrates the importance of the liver in the formation, uptake, hydrolysis, and excretion of 1-O-gemfibrozil-beta-D-glucuronide.

Comparison of one or two weeks of lansoprazole, amoxicillin, and clarithromycin in the treatment of Helicobacter pylori

BACKGROUND

The simplest, most effective, and least expensive Helicobacter pylori therapy remains to be determined. Two weeks of 30 mg lansoprazole bid, 1 gm amoxicillin bid, and 500 mg clarithromycin bid (LAC2) had been shown to be an effective therapy for H. pylori. The aim of this study was to assess whether 1 week of this regimen (LAC1) would have a similar efficacy.

MATERIALS AND METHODS

H. pylori-positive patients assessed histologically, by rapid urease test, microbiologically, and by a 13C-urea breath test (13C-UBT) were randomized to receive either LAC1 or LAC2 in a single-center open study. Patients were interviewed 1 to 3 days after completion of therapy to evaluate adverse events and compliance. Efficacy was determined by 13C-UBT at least 4 weeks after antibiotic therapy.

RESULTS

Seventy evaluable patients were randomized to receive LAC1 (n = 33) LAC2 (n = 37). Of the 33 LAC1 patients, 30 (91%) were treated successfully (95% confidence interval (CI) = 76-98%), compared with 32 of 37 (86%) in the LAC2 group (95% CI = 71-96%). There was no difference in efficacy between the two groups (Fisher's exact test p = 1.0; 95% CI = -10.3%-19.2%). Patients taking LAC1 experienced significantly fewer severe adverse events than those taking LAC2 (Mann-Whitney U test). One of 64 patients had primary resistance to clarithromycin, and treatment was unsuccessful in this case. Six of the 7 remaining treatment failures developed secondary resistance to clarithromycin.

CONCLUSIONS

LAC1 is as effective as LAC2 and is associated with less toxicity. Posttreatment clarithromycin resistance is common in patients who do not experience success with therapy.

Disposition of L-carnitine and acetyl-L-carnitine in the isolated perfused rat kidney

The isolated perfused rat kidney was used to investigate the regulation, specificity and concentration-dependence of the renal tubular disposition of L-carnitine (LC) and its ester, acetyl-L-carnitine (ALC). Tritiated markers were used to study the renal disposition of LC and ALC and HPLC was used to purify 3H-LC and 3H-ALC before radiochemical analysis. At perfusate concentrations comparable to those found in plasma in vivo (50 microM for LC and 5 microM for ALC), the renal clearance of both analogues was substantially less than GFR (P < .05) which, in view of their negligible binding to perfusate proteins, is indicative of extensive reabsorption. During the first 20 min of perfusion, the percent tubular reabsorption (%TR) of LC and ALC was 94 +/- (SD) 2.6% and 97 +/- 0.6%, respectively. The extent of 3H-ALC and 3H-LC enrichment of perfusate in experiments with 3H-LC and 3H-ALC, respectively, provided evidence for the capability of the rat kidney to acetylate LC and deacetylate ALC. In addition, a portion of renally generated 3H-ALC and 3H-LC was found to undergo leakage into renal tubules and escape subsequent reabsorption. It was also found that the %TR of both compounds decreased substantially when the perfusate concentration was increased above endogenous levels; each compound was capable of decreasing the %TR of the other; and trimethylamine-N-oxide, a metabolite of LC, had no significant effect on the renal handling of the carnitine derivatives.

The disposition of morphine and its metabolites in the in-situ rat isolated perfused liver

A specific HPLC method with UV detection was used to investigate the disposition of morphine and its metabolites in the in-situ rat isolated perfused liver preparation. Livers of male Sprague-Dawley rats (n = 4) were perfused under single pass conditions with protein- and erythrocyte-free perfusate, containing 2.66 microM morphine, for up to 90 min. The concentration of morphine, normorphine and morphine-3-glucuronide (M3G) in outflow perfusate, and the biliary excretion of M3G and normorphine glucuronide, all reached steady-state levels within 15-20 min after commencing perfusion. At steady-state, the mean (+/- s.d.) extraction ratio of morphine was 0.87 +/- 0.06 and clearance (26.0 +/- 1.7 mL min-1) approached perfusate flow rate (30 mL min-1). Although M3G was the main metabolite, accounting for 72.8 +/- 12.7% of eliminated morphine, a significant proportion (21.6 +/- 13.5%) was N-demethylated to normorphine and was recovered as unchanged normorphine in outflow perfusate and normorphine glucuronide in bile. The biliary extraction ratio of hepatically-formed M3G was 0.61 +/- 0.31. Results from an additional six experiments, in which livers were perfused with 1.33 and 2.66 microM of morphine for 30 min each in a balanced cross-over manner, indicated that the disposition of morphine and its metabolites was approximately linear within this concentration range.