Surgical Cancer Care in Safety-Net Hospitals: a Systematic Review

BACKGROUND

Tertiary medical centers in the USA provide specialized, high-volume surgical cancer care, contributing standards for quality and outcomes. For the most vulnerable populations, safety-net hospitals (SNHs) remain the predominant provider of both complex and routine healthcare needs. The objective of this study was to evaluate access to and quality of surgical oncology care within SNHs.

METHODS

A comprehensive and systematic review of the literature was conducted using PubMed, EMBASE, and Cochrane Library databases to identify all studies (January 2000-October 2021) reporting the delivery of surgical cancer care at SNHs in the USA (PROSPERO #CRD42021290092). These studies describe the process and/or outcomes of surgical care for gastrointestinal, hepatopancreatobiliary, or breast cancer patients seeking treatment at SNHs.

RESULTS

Of 3753 records, 37 studies met the inclusion criteria. Surgical care for breast cancer (43%) was the most represented, followed by colorectal (30%) and hepatopancreatobiliary (16%) cancers. Financial constraints, cultural and language barriers, and limitations to insurance coverage were cited as common reasons for disparities in care within SNHs. Advanced disease at presentation was common among cancer patients seeking care at SNHs (range, 24-61% of patients). Though reports comparing cancer survival between SNHs and non-SNHs were few, results were mixed, underscoring the variability in care seen across SNHs.

CONCLUSIONS

These findings highlight barriers in care facing many cancer patients. Continued efforts should address improving both access and quality of care for SNH patients. Future models include a transition away from a two-tiered system of resourced and under-resourced hospitals toward an integrated cancer system.

United States' regulatory approved pharmacotherapies for nuclear reactor explosions and anthrax-associated bioterrorism

INTRODUCTION

Nuclear reactor incidents and bioterrorism outbreaks are concerning public health disasters. Little is known about US Food and Drug Administration (FDA)-approved agents that can mitigate consequences of these events. We review FDA data supporting regulatory approvals of these agents.

AREAS COVERED

We reviewed pharmaceutical products approved to treat Hematopoietic Acute Radiation Syndrome (H-ARS) and to treat or prevent pulmonary infections following Bacillus anthracis (anthrax) exposure. Four drugs were approved for H-ARS: granulocyte-colony stimulating factor (G-CSF), granulocyte/macrophage colony stimulating factor, pegylated G-CSF, and romiplostim. For bioterrorism-associated anthrax, the FDA approved five antibiotics (doxycycline, penicillin-G, levofloxacin, moxifloxacin, and ciprofloxacin), two monoclonal antibodies (obiltoxaximab and raxibacumab), one polyclonal antitoxin (Anthrax Immune Globulin Intravenous) and two vaccines (Anthrax Vaccine Adsorbed and Anthrax Vaccine Adsorbed with an adjuvant). A national stockpile system ensures that communities have ready access to these agents. Our literature search was based on data included in drugs@FDA (2001-2023).

EXPERT OPINION

Two potential mass public health disasters are aerosolized anthrax dissemination and radiological incidents. Five agents authorized for anthrax emergencies only have FDA approval for this indication, five antibiotics have FDA approvals as antibiotics for common infections and for bacillus anthrax, and four agents have regulatory approvals for supportive care for cancer and for radiological incidents.

Davids versus Goliaths: Pharma and academia threats to individual scientists and clinicians

Background

We previously described experiences of clinicians who published adverse drug reaction reports. We now report on threats and intimidations leveled against clinicians and scientists who received publicly documented threats after communicating safety, efficacy, or data integrity findings contrary to corporate interests.

Methods

Data on threats and intimidations were obtained from transcripts of governmental hearings or agencies, university-affiliated reports, media interviews, and investigative journalism articles. Content and timing of threats and intimidation, subsequent harms, numbers of persons seriously injured or who died from individual toxicities, financial payments from sponsors related to safety, efficacy, or data integrity concerns, and civil settlements and criminal findings were evaluated.

Findings

Twenty-six individuals who communicated safety, efficacy, or data integrity concerns were targets of threats and intimidation from corporate employees (twenty-three individuals) or regulatory personnel (three). Seventeen individuals identified instances where pharmaceutical sponsors submitted fraudulent data in support of regulatory approval of a drug or device. Scientist and clinician communications were followed by drug/device withdrawals (fourteen drugs/devices), black box warnings (six drugs), withdrawal of a sponsor’s application for regulatory approval (one device), and delay of approval of a sponsor’s application for regulatory approval (one drug). Actions mainly occurred after persons communicated with pharmaceutical employees (fourteen). Intimidation efforts by corporate personnel included threats of lawsuits (eighteen individuals), hiring private investigators (nine), and public disparagement at conferences (eleven). Related intimidation efforts carried out by academia or regulatory agency superiors included threats of: loss of positions (six), loss of grant funding (two), delays in decisions regarding tenure (two); or reassignment to a low-level position (one). Academic harms included lost: hospital or university appointments (nine and six, respectively), grant funding (two), chairperson title of an international clinical trial group (one), and journal editorial board position (one). Corporate harms included payment of $1 million to defense attorneys in three cases filed against clinicians.

Interpretation

Threats and intimidation carried out by corporate employees and/or academic supervisors followed public communication of concerns regarding patient safety, drug efficacy, or data integrity, including instances where sponsors were identified as having submitted fraudulent data to regulatory or government agencies. Consideration should be given to filing criminal charges against pharmaceutical executives who are discovered by scientists or clinicians to have knowingly submitted fraudulent data to regulatory or governmental agencies, rather than causing the scientists and clinicians who submit such reports to risk losing their reputations and occupations.

Maximum Accuracy Machine Learning Statistical Analysis-A Novel Approach

Logistic regression is a statistical tool of paramount significance in the field of epidemiology¹ and ranks as one of the most frequently published multivariable analyses for designs involving a single binary dependent variable and one or more independent variables in the fields of public health^2,3 and medical⁴ research.

Chemotherapy with paclitaxel for recalcitrant molluscum contagiosum in an HIV-infected patient

Molluscum contagiosum (MC) is a viral skin infection seen in children, sexually active adults and immunocompromised populations. It is usually a self-limiting illness that typically spontaneously resolves without therapeutic intervention. However, when the papules are extensive or refractory causing complications or aesthetic issues, multiple treatment modalities exist to relieve symptoms, limit spread and decrease the social stigma associated with visible lesions. Treatment is especially important in HIV/AIDS infected populations, where prevalence is estimated between 5% and 18% and susceptibility to larger, widespread and recalcitrant lesions involving atypical distributions is more common. We evaluated a 38-year-old woman with a history of AIDS (CD4+ T cell count <25 cells/µL) and poor adherence with antiretroviral therapy who presented with a 9-month history of persistent, progressively worsening facial and truncal umbilicated papules consistent with recalcitrant MC refractory to cidofovir injections. She was successfully treated with paclitaxel with complete resolution of the lesions after four cycles without adverse effects.

The First 2 Years of Biosimilar Epoetin for Cancer and Chemotherapy-Induced Anemia in the U.S.: A Review from the Southern Network on Adverse Reactions

Biosimilars are biologic drug products that are highly similar to reference products in analytic features, pharmacokinetics and pharmacodynamics, immunogenicity, safety, and efficacy. Biosimilar epoetin received Food and Drug Administration (FDA) approval in 2018. The manufacturer received an FDA nonapproval letter in 2017, despite receiving a favorable review by FDA's Oncologic Drugs Advisory Committee (ODAC) and an FDA nonapproval letter in 2015 for an earlier formulation. We discuss the 2018 FDA approval, the 2017 FDA ODAC Committee review, and the FDA complete response letters in 2015 and 2017; review concepts of litigation, naming, labeling, substitution, interchangeability, and pharmacovigilance; review European and U.S. oncology experiences with biosimilar epoetin; and review the safety of erythropoiesis-stimulating agents. In 2020, policy statements from AETNA, United Health Care, and Humana indicated that new epoetin oncology starts must be for biosimilar epoetin unless medical need for other epoetins is documented. Empirical studies report that as of 2012, reference epoetin use decreased from 40%-60% of all patients with cancer with chemotherapy-induced anemia to <5% of such patients because of safety concerns. Between 2018 and 2020, biosimilar epoetin use varied, increasing to 81% among one private insurer's patients covered by Medicare whose cancer care is administered with Oncology Analytics and to 41% with the same private insurer's patients with cancer covered by commercial health insurance and administered by the private insurer, to 0% in several Veterans Administration Hospitals, increasing to 100% in one large county hospital in California, and with yet-to-be-reported data from most oncology settings. We conclude that biosimilar epoetin appears to have overcome some barriers since 2015, although current uptake in the U.S. is variable. Pricing and safety considerations for all erythropoiesis-stimulating agents are primary determinants of biosimilar epoetin oncology uptake. IMPLICATIONS FOR PRACTICE: Few oncologists understand substitution and interchangeability of biosimilars with reference drugs. Epoetin biosimilar is new to the market, and physician and patient understanding is limited. The development of epoetin biosimilar is not familiar to oncologists.

Abstract PS9-56: High compliance with choosing wisely breast procedures at a safety net hospital

The Choosing Wisely campaign has emerged recently in setting guidelines for surgical procedures of low utility and cost-ineffectiveness. Hospitals caring for underserved medical populations represent a unique opportunity to assess for quality of care and adherence to these guidelines. The Choosing Wisely campaign for breast surgery has highlighted: avoiding surgical re-excision for invasive cancer close to margins of excised breast tissue, avoiding double mastectomy in patients who have a single breast with cancer, avoidance of axillary lymph node dissection in women undergoing lumpectomy with limited nodal disease, and avoiding sentinel lymph node biopsy in patients ≥ 70 years of age with early stage breast cancer. Recent studies have shown variable adherence to these recommendations. In order to evaluate cost-effective surgery at our hospital serving a poorer patient population, we retrospectively analyzed patients who underwent surgery for breast cancer from 2015-2020. A total of 231 patients were identified. There were no patients who underwent re-excision for close margins of invasive cancer. Only 0.9% of patients (2/231) received contralateral mastectomy and only 1.6% of eligible patients (3/191) received axillary lymph node dissection instead of sentinel lymph node biopsy. Although 77.7% of patients ≥ 70 years of age with stage 1 hormone positive breast cancer (14/18) received sentinel lymph node biopsy, there was a downward trend during 2015 to 2020 from 100% to 50% of eligible patients receiving sentinel lymph node biopsy. De-implementation of traditional surgical practices, deemed as low-value care, towards newer cost-effective guidelines are achievable even at community hospitals serving a low socioeconomic community while preserving patient outcome and avoiding overtreatment. By avoiding overtreatment, cost savings can be achieved which allow for social distributive justice amongst breast cancer patients by ensuring careful utilization of scarce health economic resources.

Citation Format: Annie Tang, Colin Mooney, Shannon Ugarte, Kevin Knopf, Amal Khoury. High compliance with choosing wisely breast procedures at a safety net hospital [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-56.

Consequences to patients, clinicians, and manufacturers when very serious adverse drug reactions are identified (1997-2019): A qualitative analysis from the Southern Network on Adverse Reactions (SONAR)

BACKGROUND

Adverse drug/device reactions (ADRs) can result in severe patient harm. We define very serious ADRs as being associated with severe toxicity, as measured on the Common Toxicity Criteria Adverse Events (CTCAE)) scale, following use of drugs or devices with large sales, large financial settlements, and large numbers of injured persons. We report on impacts on patients, clinicians, and manufacturers following very serious ADR reporting.

METHODS

We reviewed clinician identified very serious ADRs published between 1997 and 2019. Drugs and devices associated with reports of very serious ADRs were identified. Included drugs or devices had market removal discussed at Food and Drug Advisory (FDA) Advisory Committee meetings, were published by clinicians, had sales > $1 billion, were associated with CTCAE Grade 4 or 5 toxicity effects, and had either >$1 billion in settlements or >1,000 injured patients. Data sources included journals, Congressional transcripts, and news reports. We reviewed data on: 1) timing of ADR reports, Boxed warnings, and product withdrawals, and 2) patient, clinician, and manufacturer impacts. Binomial analysis was used to compare sales pre- and post-FDA Advisory Committee meetings.

FINDINGS

Twenty very serious ADRs involved fifteen drugs and one device. Legal settlements totaled $38.4 billion for 753,900 injured persons. Eleven of 18 clinicians (61%) reported harms, including verbal threats from manufacturer (five) and loss of a faculty position (one). Annual sales decreased 94% from $29.1 billion pre-FDA meeting to $4.9 billion afterwards (p<0.0018). Manufacturers of four drugs paid $1.7 billion total in criminal fines for failing to inform the FDA and physicians about very serious ADRs. Following FDA approval, the median time to ADR reporting was 7.5 years (Interquartile range 3,13 years). Twelve drugs received Box warnings and one drug received a warning (median, 7.5 years following ADR reporting (IQR 5,11 years). Six drugs and 1 device were withdrawn from marketing (median, 5 years after ADR reporting (IQR 4,6 years)).

INTERPRETATION

Because very serious ADRs impacts are so large, policy makers should consider developing independently funded pharmacovigilance centers of excellence to assist with clinician investigations.

FUNDING

This work received support from the National Cancer Institute (1R01 CA102713 (CLB), https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-cancer-institute-nci; and two Pilot Project grants from the American Cancer Society's Institutional Grant Award to the University of South Carolina (IRG-13-043-01) https://www.cancer.org/ (SH; BS).

Abstract P6-13-07: Cost-effective care for newly diagnosed breast cancer patients: Think globally, act locally

Conscientious use of scarce health economic resources allows for social distributive justice by avoiding over-treatment of patients to allow for appropriate treatment for a broader patient population. Lower socioeconomic status patients with breast cancer have a worse outcome compared to higher socioeconomic status patients in the United States. In part, this is due to poor access to medical care and a failure of logistical care. We implemented a community based breast cancer multidisciplinary program with weekly meetings to discuss patients, coordinate care, and provide cost-effective care to a medically under-served and vulnerable patient population. Breast surgery and medical oncology providers saw patients together in a co-located space and expedited timely initiation of neoadjuvant and adjuvant chemotherapy / hormone therapy for appropriate patients. The conjoint clinic allowed for rapid temporal integration of care in our safety net hospital / community. A single breast cancer navigator provided rapid identification of patients, coordination through clinics, and assistance with social work and other needs. Weekly 30 minute discussion sessions reviewing all new and relevant follow up patient issues were implemented in lieu of a breast cancer tumor board for efficiency. The relevant published clinical literature was reviewed on an ongoing basis. Cost-effective care was obtained by implementing: 1) avoidance of post lumpectomy radiation for selected patients based on PRIME2 trial results, 2) judicious use of post-mastectomy radiation based on a careful re-analysis of the data, 3) avoidance of adjuvant/neoadjuvant Perjeta in HER2+ patients based on a lack of overall survival, 4) adoption of 6 month schedule of adjuvant Herceptin, 5) avoidance of excessive imaging by following NCCN guidelines and clinical judgment, 6) limiting dose dense chemotherapy to appropriate patients (ER- high risk node negative or node positive), and 7) No Nernyx. Using a cost-effectiveness analysis methodology, we are reviewing costs, effectiveness of interventions, and risks with outcomes measured from side effects, complications, recurrence, and mortality. The improvement in temporal parameters and economic endpoints are being currently monitored retrospectively and prospectively and will be presented.

Citation Format: Annie Tang, Shannon Ugarte, Rohan John, Amal Khoury, Kevin Knopf. Cost-effective care for newly diagnosed breast cancer patients: Think globally, act locally [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-13-07.

Regulatory and Clinical Experiences with Biosimilar Filgrastim in the U.S., the European Union, Japan, and Canada

Biosimilar filgrastims are primarily indicated for chemotherapy-induced neutropenia prevention. They are less expensive formulations of branded filgrastim, and biosimilar filgrastim was the first biosimilar oncology drug administered in European Union (EU) countries, Japan, and the U.S. Fourteen biosimilar filgrastims have been marketed in EU countries, Japan, the U.S., and Canada since 2008, 2012, 2015, and 2016, respectively. We reviewed experiences and policies for biosimilar filgrastim markets in EU countries and Japan, where uptake has been rapid, and in the U.S. and Canada, where experience is rapidly emerging. U.S. regulations for designating biosimilar interchangeability are under development, and such regulations have not been developed in most other countries. Pharmaceutical substitution is allowed for new filgrastim starts in some EU countries and in Canada, but not Japan and the U.S. In EU countries, biosimilar adoption is facilitated with favorable hospital tender offers. U.S. adoption is reportedly 24%, while the second filgrastim biosimilar is priced 30% lower than branded filgrastim and 20% lower than the first biosimilar filgrastim approved by the U.S. Food and Drug Administration. Utilization is about 60% in EU countries, where biosimilar filgrastim is marketed at a 30%-40% discount. In Japan, biosimilar filgrastim utilization is 45%, primarily because of 35% discounts negotiated by Central Insurance and hospital-only markets. Overall, biosimilar filgrastim adoption barriers are small in many EU countries and Japan and are diminishing in Canada in the U.S. Policies facilitating improved U.S. adoption of biosimilar filgrastim, based on positive experiences in EU countries and Japan, including favorable insurance coverage; larger price discount relative to reference filgrastim pricing; closing of the "rebate trap" with transparent pricing information; formal educational efforts of patients, physicians, caregivers, and providers; and allowance of pharmaceutical substitution of biosimilar versus reference filgrastim, should be considered. IMPLICATIONS FOR PRACTICE: We reviewed experiences and policies for biosimilar filgrastims in Europe, Japan, Canada, and the U.S. Postmarketing harmonization of regulatory policies for biosimilar filgrastims has not occurred. Acceptance of biosimilar filgrastims for branded filgrastim, increasing in the U.S. and in Canada, is commonplace in Japan and Europe. In the U.S., some factors, accepted in Europe or Japan, could improve uptake, including acceptance of biosimilars as safe and effective; larger cost savings, decreasing "rebate traps" where pharmaceutical benefit managers support branded filgrastim, decreased use of patent litigation/challenges, and allowing pharmacists to routinely substitute biosimilar for branded filgrastim.

Abstract A31: Risk stratification of ductal carcinoma in situ: Analytical validation of a prognostic test analyzing live-primary cells via phenotypic biomarkers and machine learning at single-cell resolution

Largely due to tumor heterogeneity, risk stratification of patients diagnosed with ductal carcinoma in situ (DCIS) of the breast remains a significant challenge. Management of DCIS is also problematic as we wish to personalize treatment of a patient’s tumor in order to avoid overtreatment of lower-risk lesions or undertreatment of DCIS that may recur or progress into invasive cancer. Matching treatment to the underlying severity of the illness is key to practicing cost-effective cancer care in an era where this is a very large concern to society. The aim of this study was to analytically validate a precision risk-stratification tool based on phenotype, which is capable of predicting which patients will develop invasive cancer with greater than 80% sensitivity and specificity. Leveraging the novel capability to rapidly culture primary breast biopsy cells, we present a “biopsy-on-a-chip” microfluidic platform that quantifies dynamic and static phenotypic biomarkers via machine vision to generate predictive clinical scores via machine learning algorithms to determine if a DCIS patient will experience invasive cancer. 47 consecutive lumpectomy or mastectomy samples were collected and objectively analyzed in a blinded study, measuring 1000 phenotypic biomarkers with single-cell resolution using machine vision software. Biomarker measurements were input into machine learning algorithms to develop predictive statistical algorithms. Statistical algorithms were able to independently predict surgical adverse pathology features such as extranodal extension, grade, lymphovascular invasion, lymph invasion, lobular carcinoma in situ (LCIS), and DCIS with sensitivities and specificities greater than 90%. Additional machine learning based algorithms were able to predict if DCIS patients were more likely to develop subsequent metastasis as measured by lymphovascular invasion and/or lymphatic invasion with area under the curve (AUC) &gt; 0.85. This study is the first study to demonstrate the prediction of breast cancer adverse pathology features from live primary biopsy cells and provides the basis to develop a powerful precision risk-stratification tool to risk-stratify DCIS. Furthermore, the methodology described and its ability to rapidly analyze primary breast biopsy tissue with single-cell resolution in a high-throughput manner engenders a powerful research tool to further understand tumor heterogeneity in breast cancer towards the development of personalized therapeutics. Applications of cost effectiveness analysis to our methodology will achieve the triple goal of providing cost-effective, patient-centered, and appropriate breast cancer and DCIS care.

Note: This abstract was not presented at the conference.

Citation Format: Ashok Chander, Michael Manak, Jonathan Varsanik, Brad Hogan, Grannum Sant, Kevin Knopf. Risk stratification of ductal carcinoma in situ: Analytical validation of a prognostic test analyzing live-primary cells via phenotypic biomarkers and machine learning at single-cell resolution [abstract]. In: Proceedings of the AACR Special Conference: Advances in Breast Cancer Research; 2017 Oct 7-10; Hollywood, CA. Philadelphia (PA): AACR; Mol Cancer Res 2018;16(8_Suppl):Abstract nr A31.

Heuristic value-based framework for lung cancer decision-making

Heuristics and the application of fast-and-frugal trees may play a role in establishing a clinical decision-making framework for value-based oncology. We determined whether clinical decision-making in oncology can be structured heuristically based on the timeline of the patient's treatment, clinical intuition, and evidence-based medicine. A group of 20 patients with advanced non-small cell lung cancer (NSCLC) were enrolled into the study for extensive treatment analysis and sequential decision-making. The extensive clinical and genomic data allowed us to evaluate the methodology and efficacy of fast-and-frugal trees as a way to quantify clinical decision-making. The results of the small cohort will be used to further advance the heuristic framework as a way of evaluating a large number of patients within registries. Among the cohort whose data was analyzed, substitution and amplification mutations occurred most frequently. The top five most prevalent genomic alterations were TP53 (45%), ALK (40%), LRP1B (30%), CDKN2A (25%), and MYC (25%). These 20 cases were analyzed by this clinical decision-making process and separated into two distinctions: 10 straightforward cases that represented a clearer decision-making path and 10 complex cases that represented a more intricate treatment pathway. The myriad of information from each case and their distinct pathways was applied to create the foundation of a framework for lung cancer decision-making as an aid for oncologists. In late-stage lung cancer patients, the fast-and-frugal heuristics can be utilized as a strategy of quantifying proper decision-making with limited information.

Application of low-frequency sonophoresis and reduction of antibiotics in the aquatic systems

A major concern in aquaculture is the use of chemical therapeutics, such as antibiotics, because of their impact on the environment as well as on the fish product. As a potential tool for reducing antibiotic use, we tested the application of low-frequency ultrasound as a method for enhancing antibiotic uptake. Rainbow trout juveniles (Oncorhynchus mykiss) were exposed to two different concentrations of oxytetracycline (OTC), flumequine (FLU) and florfenicol (FLO), administered by bath after the application of ultrasound. After exposure, concentrations of these substances were measured in the liver and blood of treated fish. Results showed that the ultrasound treatment can significantly increase the uptake for all three antibiotics. The uptake of OTC for example, in fish exposed to an OTC concentration of 20 mg L^-1 after prior treatment with ultrasound, was similar to the OTC concentrations in their liver and blood to fish exposed to 100 mg L^-1 without sonication. For FLU and FLO, the use of ultrasound caused significant differences of uptake in the liver at high antibiotic concentrations. This suggests that the use of ultrasound as a technique to deliver antibiotics to fish can ultimately reduce the amount of antibiotics discharged into the aquatic environment.

Early experience with Puerto Rico: Effective use management of bone agents

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Background: Oncology Analytics is a cancer care decision support group recently entering the Puerto Rican cancer care marketplace. Bone agents are used in metastatic cancer management to delay the progression of lytic bone metastases. These agents are also used for the treatment of demonstrated osteoporosis with bone densitometry (DEXA scan). Oncology Analytics has found these agents are sometimes used in the absence of lytic metastases or osteoporosis. When this is discussed with treating physicians, practice patterns promptly improve. Beginning our work: The following work focuses entirely upon use among patients with bone mets. There is modest use of bone agents for bone mets among PR oncologists. A statistically significant decreasing and sustained trend in the inappropriate utilization of bone agents and especially the use of denosumab in the PR market is closely associated with recent initiation of OA decision support. Methods: We analyzed data from oncology drug preauthorization requests for bone modifying agents for the management of metastatic bone disease submitted by providers to payers serving in Puerto Rico from Jan 1, 2015 through September 30, 2015. Results: Within the 9 months, non-compliant zoledronic acid use diminished by one-third; pamidronate by 40%; and denosumab use was decreased by 75%. Quarterly dynamics demonstrates a statistically significant downward trend in the unnecessary use of these agents among PR oncologists (p,0.05). Conclusions: Oncology Analytics presence in a new market enhances cancer care quality and cancer care value quickly, while at the same time conserving substantial resources.

National Comprehensive Cancer Network petitions: Submissions and outcomes

248

Background: The National Comprehensive Cancer Network (NCCN) invites petitions to its scientific panels. Most ( > 95%) are from the pharmaceutical industry lobbying to include their products in the NCCN Guidelines. Rarely, physicians request scientific scrutiny of the guidelines. We report the experience of Oncology Analytics (OA) with petition submissions and the possible impact on guidelines. Methods: From 2011-2015, OA made 7 petitions to NCCN. The content of each was tracked into subsequent NCCN Guidelines to ascertain whether any changes resulted. Results: 1) The Survivorship Panel was petitioned to add liposomal doxorubicin to the list of cardiotoxic anthracyclines: No changes were made. 2-3) The NSCLC Panel was asked in 2014 to remove the category 2A listing for trastuzumab and afatinib as HER-2 targeted drugs, and cabozantinib as a RET rearrangement target based on absence of phase I-III full text scientific literature. This was done, however, cabozantinib was reverted to 2A status late 2015 based on abstract-only data. 4) Per FDA approval, the NSCLC Panel was asked to recommend bevacizumab only in combination with carboplatin/paclitaxel for 1st line non-squamous NSCLC based on a survival advantage in ECOG 4599: No changes were made. 5) Given the FDA-approval, the Ovarian Cancer Panel was requested to add doxorubicin: This was done. 6) A 2012 Supportive Care Panel petition pointed out the absence of data supporting palonosetron as the preferred 5-HT3 antagonist with aprepitant for moderate or high emetic risk chemotherapy: No change was made upon request; however, preferred status was removed in 2015 from high emetic risk. 7) Based on a preponderance of evidence, a Supportive Care Panel petition requested re-categorization of the febrile neutropenia risk for carboplatin/paclitaxel from intermediate to low except in patients of Japanese ancestry and/or carboplatin AUC > 6: This was done. Conclusions: Majority of NCCN physician petitions came from OA, yet constituted less than 5% of all petitions submitted. NCCN does not provide direct petitioner feedback, so we cannot say for certain that our petitions led to changes in subsequent guidelines. Not all requests resulted in NCCN changes, despite level one supportive data or accentuating an absence of data.

Geographic practice patterns in the selection of adjuvant dose dense (DD) chemotherapy among stage 1 breast cancer (BC) patients

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Background: Oncology Analytics (OA) reviewed drug pre-authorization requests amongst populations with similar demographic features. Small stage I, node-negative, margin-free BC may be treated by observation, hormone therapy or adjuvant chemotherapy. If chemo is used, either standard or DD schedules may be requested. Patient age, HER2 status, and ER expression affect the choice of treatment. Methods: We analyzed data from oncology drug preauthorization requests for BC protocols submitted by providers in FL, GA and TX from October 1, 2013 through September 30, 2015. Pearson chi-square was used to test for association at 95% CL. Risk was bifurcated by consideration of age, putative ER/PR status, and HER2 status. High-risk patients are those with putative ER/PR(-) status and/or Her2(+) status and/or younger than 50 years old. Results: Requests for standard and DD chemotherapy are related to the risk characteristics of the tumor. Oncologists in GA/TX prescribed a greater proportion of adjuvant chemotherapy for stage I BC patients than oncologists in FL (13.13% GA/TX vs 9.97% FL;p = 0.001). About 40% of all stage 1 chemotherapy requests are for dose-dense chemotherapy. Patients with high risk BC have a higher chance of getting dose dense chemotherapy than the low risk subgroup. FL oncologists have a higher likelihood of prescribing dose-dense chemotherapy than GA/TX oncologists (82% FL vs 65% TX p < 001) if the BC risk is high, whereas the opposite is true if the patient is low risk (8% FL vs 17% GA/TX, p = 0002). Conclusions: While these geographical differences may be random, it may also be relevant that OA has worked in Florida for six, Georgia and Texas for two years. This suggests that patients with low risk disease are less likely to get the more toxic DD therapy if OA is in a market for a longer period of time.

Der Aktivierungsquerschnitt von Silicium-30 für thermische Neutronen

Durch gleichzeitige Aktivierung von Gold und Silicium im Wasserreflektor des Reaktors wurde der Wirkungsquerschnitt der Reaktion 30Si (n,γ) 31Si für thermische Neutronen zu σ0= (103 ± 3) mbarn bestimmt.

Survival outcomes in U.S. patients with metastatic colorectal cancer (mCRC)

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Background: The increase in survival seen in recent years in patients with mCRC has been attributed to improvements in treatments, including the introduction of targeted biologic agents. The objectives of this retrospective, observational study are to investigate recent treatment patterns in US mCRC patients and examine real-world survival outcomes. Methods: Data were obtained from a large U.S. database (SDI/IMS Health) of mCRC patients diagnosed from January 1, 2004 to June 30, 2011, ≥18 y at diagnosis, and who received chemotherapy and/or biologic treatment. Complete follow-up was defined as those who either died before June 2011 or who had at least 1 claim within 30 days of June 30, 2011. Kaplan-Meier curves were generated to determine overall survival (OS) from the date of mCRC diagnosis. Results: 1,066 stage IV mCRC patients with complete follow-up were identified (57.5% male; mean age, 61.6 y). Approximately 80% were diagnosed with mCRC after 2006; 51.7% had liver metastases. The most common 1L, 2L, and 3L regimens were FOLFOX plus bevacizumab (34.52%), FOLFIRI plus bevacizumab (21.83%), and irinotecan plus cetuximab (15.83%), respectively. A total of 445 patients died during the study period, yielding a mortality rate of 41.74%. Mean time from diagnosis to first treatment was 3.31 months (SD=7.13). All patients received 1L therapy; OS from diagnosis was 35.77 months (95% CI: 32.57-38.10); 5-year survival was approximately 28%. After 1L, 591/1066 (55%) patients went on to receive 2L therapy; for these patients, median survival from diagnosis was 37.13 months (95% CI: 34.07-40.43) and 5-year survival was approximately 25%. After 2L, 278/591 (47%) patients received 3L therapy; for these patients, median survival from diagnosis was 38.10 months (95% CI: 34.83-43.13); 5-year survival was approximately 25%. Conclusions: In this study, OS (35.77 months) was longer than for other mCRC observational studies that have reported survival from start of treatment, but is more comparable when the ~3 months from diagnosis to start of treatment are not included. Addition of targeted agents and novel chemotherapy has prolonged OS in mCRC patients. Because of poor 5-year survival rates, the need for additional agents in later lines of therapy still exists.

An observational study of outcomes after initial infused therapy in Medicare patients diagnosed with chronic lymphocytic leukemia

The study goal was to characterize older chronic lymphocytic leukemia (CLL) patients and to evaluate outcomes in those patients who initiated infused therapy. Patients 66 years of age and older in the Surveillance, Epidemiology, and End Results (SEER) program with a CLL diagnosis were matched to their Medicare Part A and Part B claims for long-term follow-up. Treatment patterns, survival after initiation of infused therapy, and both hematologic and hospitalization outcomes were assessed. There were 6433 CLL patients identified, and 2040 received infused therapy. Treated patients were categorized as receiving rituximab monotherapy (16%), rituximab plus chemotherapy (14%), and chemotherapy alone (70%) based on the initial 60 days after infusion. Rituximab plus chemotherapy compared with chemotherapy alone was associated with a 25% lower risk of overall mortality (95% confidence interval, 9%-38%). Restricting to patients age 70 years and older did not change the risk reduction for rituximab plus chemotherapy. Hematologic interventions were more common with rituximab plus chemotherapy compared with chemotherapy alone, but there was no difference in all-cause hospitalizations. These analyses, based on observational data, suggest that the benefits of initial therapy with rituximab in a heterogeneous group of older CLL patients are comparable with those demonstrated in younger patients.

Racial differences in treatment and survival in older patients with diffuse large B-cell lymphoma (DLBCL)

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) comprises 31% of lymphomas in the United States. Although it is an aggressive type of lymphoma, 40% to 50% of patients are cured with treatment. The study objectives were to identify patient factors associated with treatment and survival in DLBCL.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER) registry data linked to Medicare claims, we identified 7,048 patients diagnosed with DLBCL between January 1, 2001 and December 31, 2005. Patients were followed from diagnosis until the end of their claims history (maximum December 31, 2007) or death. Medicare claims were used to characterize the first infused chemo-immunotherapy (C-I therapy) regimen and to identify radiation. Multivariate analyses were performed to identify patient demographic, socioeconomic, and clinical factors associated with treatment and with survival. Outcomes variables in the survival analysis were all-cause mortality, non-Hodgkin's lymphoma (NHL) mortality, and other/unknown cause mortality.

RESULTS

Overall, 84% (n = 5,887) received C-I therapy or radiation treatment during the observation period: both, 26%; C-I therapy alone, 53%; and radiation alone, 5%. Median age at diagnosis was 77 years, 54% were female, 88% were white, and 43% had Stage III or IV disease at diagnosis. The median time to first treatment was 42 days, and 92% of these patients had received their first treatment by day 180 following diagnosis. In multivariate analysis, the treatment rate was significantly lower among patients ≥ 80 years old, blacks versus whites, those living in a census tract with ≥ 12% poverty, and extra-nodal disease. Blacks had a lower treatment rate overall (Hazard Ratio [HR] 0.77; P < 0.001), and were less likely to receive treatment within 180 days of diagnosis (Odds Ratio [OR] 0.63; P = 0.002) than whites. In multivariate survival analysis, black race was associated with higher all-cause mortality (HR 1.24; P = 0.01) and other/unknown cause mortality (HR 1.35; P = 0.01), but not mortality due to NHL (HR 1.16; P = 0.19).

CONCLUSIONS

In elderly patients diagnosed with DLBCL, there are large differences in treatment access and survival between blacks and whites.

Estimating recurrences prevented from using trastuzumab in HER-2/neu-positive adjuvant breast cancer in the United States

BACKGROUND

Breast cancer recurrence is associated with significant morbidity, mortality, and cost. Patients with early stage HER2+ tumors are at increased risk of recurrence. The use of trastuzumab for these patients has been shown to reduce recurrences and improve overall survival.

METHODS

A Monte Carlo simulation was conducted based on Surveillance, Epidemiology, and End Results incidence rates for 2005, United States Census data for 2005, and the results of key trials of the adjuvant use of trastuzumab. Patients included in this analysis had incident, HER2+, stage I to III breast cancer. The number of recurrences that could be prevented with trastuzumab, the cardiac adverse events that might occur, and the associated cost savings were estimated.

RESULTS

Approximately 31,200 women had HER2+ breast cancer in 2005, of whom 7298 would have had a recurrence over the subsequent 5 years despite standard of care adjuvant treatment. If trastuzumab were added to their regimen, 2791 women might have avoided recurrence, and 948 may have had an asymptomatic or symptomatic cardiac adverse event, for a ratio of expected recurrences to cardiac adverse events of 3.2 (95% confidence interval, 1.5-5.9). In economic terms, avoidance of future breast cancer recurrences was associated with lifetime reduction in future direct and indirect costs on the order of $240 million to $1.7 billion.

CONCLUSIONS

On the basis of the simulation results, targeting HER2+ tumors with trastuzumab in the adjuvant setting should prevent a significant number of women from recurrence events, with important outcomes for patients, physicians, payers, and society.

Mortality and hospitalization in myelodysplastic syndromes (MDS) using the SEER-Medicare linked database

7091

Background: Mortality in patients with MDS is high, and most require transfusions, emergency department (ED) visits, and hospitalizations. The relationship between these outcomes with the key complications of MDS (anemia, neutropenia, thrombocytopenia) has not been well studied. Methods: Patients who were ≥ 66 years at MDS diagnosis in 2001 or 2002 were identified from SEER registries. Those with both Medicare Part A and B were followed until death or the end of 2005. Mortality, transfusions, ED visits, and hospitalizations were based on Medicare data. The presence of complications was based on diagnosis codes, transfusions, and medication use. Kaplan-Meier incidence was estimated for each outcome. Factors associated with each outcome were based on multivariable Cox models with baseline age, gender, race, co-morbidity level, socio-economic status indicators, and time-varying covariates for each complication. Results: In 1,863 MDS patients, the 3-month incidence of transfusion, ED and hospitalization was 45%, 41%, and 62%, and 3-year incidence was 75%, 87%, and 91% respectively. Median survival was 22 months. The 3-year incidence of anemia, thrombocytopenia and neutropenia was 89%, 37%, and 15% respectively. See table for multivariate results. Conclusions: Starting shortly after diagnosis, MDS patients have high rates of transfusions, ED visits, and hospitalizations. Diagnoses of anemia, neutropenia, and thrombocytopenia are strongly associated with this utilization. The presence of anemia and thrombocytopenia are important independent risk factors for death.

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Adherence to guidelines for use of erythropoiesis-stimulating agents in patients with chemotherapy-induced anemia: results of a retrospective study of an electronic medical-records database in the United States, 2002-2006

BACKGROUND

Chemotherapy-induced anemia (CIA) commonly occurs in cancer patients receiving conventional myelosuppressive chemotherapy. Two national guidelines regarding the use of erythropoiesis-stimulating agents (ESAs) in CIA were released in 2002. Because of poorer disease outcomes and increased risk of adverse events associated with ESAs in recent studies, the use of ESAs has been increasingly restricted in practice guidelines in the years 2007 and 2008.

OBJECTIVE

The aim of this study was to provide a baseline for adherence to national guidelines in the use of ESAs for CIA between 2002 and 2006.

METHODS

This retrospective study used the Varian Medical Oncology database (Varian Medical Systems, Inc., Palo Alto, California) of electronic medical records, representing 17 outpatient oncology organizations at 71 clinic locations in the United States. Adults diagnosed with any malignant neoplasm who started conventional cytotoxic chemotherapy between January 1, 2002, and September 30, 2006, were included. The proportion of patients receiving an ESA was calculated by hemoglobin (Hb) level during each chemotherapy cycle, stratified by line of chemotherapy and year. Logistic regression modeling identified predictors of ESA use in anemic patients during the first chemotherapy cycle.

RESULTS

The records of 17,731 cancer patients were evaluated. Median (SD) age was 61 (13) years, and 58.9% were female. Most patients (84.1%) had a solid tumor. Many patients (41.3%) received platinum containing chemotherapy and 74.4% received combination chemotherapy. During the first 5 cycles of first-line chemotherapy among patients with CIA (Hb <11 g/dL), ESAs were used by 55.8% of patients at cycle 1 and 68.9% at cycle 5. ESA use in CIA patients increased across lines of chemotherapy and time. Few patients (2.8%) received an ESA at Hb >13 g/dL. The statistically significant predictors of ESA use included age >65 years, eastern US residence, private health insurance, community-based care, and solid tumors, especially lung cancer.

CONCLUSION

The patterns we observed were generally consistent with prevailing ESA labels and national guidelines during 2002 through 2006. Although ESA use in patients with CIA increased over chemotherapy cycles, lines of chemotherapy, and time, <70% of CIA episodes were treated with ESAs during the initial 5 chemotherapy cycles.

Total societal costs attributable to the prevention of recurrent HER2+ breast cancer

Abstract #6101

Introduction: Adjuvant therapies are available to prevent breast cancer recurrence that may reduce morbidity and mortality. However, the associated savings to society have not been quantified, particularly for HER2+ patients. Methods: We reviewed the literature (PubMed) to estimate the costs attributable to breast cancer recurrence including direct (medical and non-medical) and indirect (loss income, productivity, informal care) costs. The following sources were used to estimate the recurrence cost. The 10-year average direct medical costs of recurrence were obtained from an analysis of SEER-Medicare data (Stokes 2008). This study compared women with recurrence to similar women without recurrence and accounts for differential costs associated with survival (ie, it did not estimate only the cost of treating recurrent cancer). In the initial year after cancer diagnosis, women required an additional 66 hours of personal time to obtain medical services (Yabroff 2007). After recurrence, an excess of 9% of patients would leave the work force if they were aged 50-64 (Lidgren 2007). Women were found to take an additional 8.5 months away from work during the 3 years following a recurrence compared with those without recurrence (Drolet 2005). The intensity of informal care was similar (0.8 hour/week) in the first year after recurrence as it was for women without recurrence (Lidgren 2007). The valuation of utilization was conducted from a societal perspective and costs reported as 2008 US dollars. Because certain costs were relevant to specific ages, we estimated costs in 3 age cohorts (30-49, 50-69, and ≥70). Lost income from early retirement was calculated as the number of years retired from work before the age 65 times the annual average income derived using the national average wage and benefit data. Patient time required for receiving care, time absent from work, and caregiver time were also valued in the same way. We combined this information into a simulation used to estimate the number of HER2+ women diagnosed in one calendar year in the United States, and whose recurrence could be prevented with trastuzumab. The model accounted for variability of clinical and economic inputs by sampling from distributions using 5,000 replications. The mean costs per person and the middle 95% of the distribution were reported. Results: For ages 50-69, early retirement costs were $39,600. Costs due to work absences were $41,600 (age 30-49) and were $31,200 (age 50-69). The total societal costs attributable to a single recurrence were $60,400 ($32,000 to $129,000) for ages 30-49, $89,600 ($45,000 to $203,000) for ages 50-69, and $18,900 ($13,000 to $25,000) for ages ≥70. Overall, the savings from preventing recurrence with trastuzumab were estimated at over $167 million ($70 million to $385 million) per year of diagnosed cases of HER2+ tumors. Conclusion: Therapies that can prevent breast cancer recurrence can lead to substantial savings to society and represent a considerable opportunity cost.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6101.

Estimating recurrences prevented from using trastuzumab in adjuvant breast cancer in the United States

Abstract #2107

Introduction: Trastuzumab was recently approved for adjuvant use in HER2+ breast cancer. Adjuvant treatment should result in a reduction in recurrences, but this has not been estimated from a US population perspective. Methods: We estimated the number of HER2+ breast cancers in the US in 2005 using SEER data. Because HER2 status is not available in SEER, the number of HER2+ patients was estimated using the known relationship between HER2 status and both estrogen receptor (ER) and progesterone receptor (PR) status. Patients with no ER or PR results were assumed to have no HER2 testing. HER2+ proportions for remaining ER+/PR+, ER+/PR-, ER-/PR+ and ER-/PR- patients were estimated from published data and applied to patients diagnosed in the 17 SEER registries. The resulting rates were applied to the 2005 US female population counts. Estimated HER2+ patient counts were stratified by nodal status (+/-), and age (30-50, 50-70, and &gt;70 years). Patients with significant underlying cardiovascular (CV) disease were assumed not to use trastuzumab. Underlying recurrence rates were pooled across studies that compared doxorubicin and cyclophosphamide followed by a taxane (AC-T) versus the same regimen plus 52 weeks of trastuzumab (AC-TH). Rates were stratified by nodal status. The relative risk of recurrence with trastuzumab (0.53) was assumed to be constant across subgroups based on published data, and assumed to persist for 5 years. One study (NSABP B-31) estimated the proportion experiencing a CV event (primarily defined as ejection fraction decline below threshold or dyspnea with normal activity) based on 5-year follow-up. Probabilistic model inputs were used to reflect the likelihood of possible values where possible. The results were run using 5,000 replications and reported as the mean and middle 95% of the distribution using @Risk (Palisade Corp., Ithaca, NY). Results: The model estimated that there are approximately 28,500 (95% interval 26,400 to 31,500) patients who could be diagnosed with HER2+ breast cancer in one year in the US, 6,128 (95% interval 4,292 to 8,600) of whom will have a recurrence within 5 years, and up to 2,619 of whom (95% interval 1,506 to 3,701) who could be prevented from disease recurrence with trastuzumab use. The number of patients who might experience a CV event is approximately 941 (95% interval 510 to 1,395) giving a ratio of 2.7 recurrences prevented for every CV event (95% interval 1.4 to 5.6). Conclusion: Trastuzumab is capable of preventing at least 2,600 recurrences within 5 years after its initial year of use. Its most clinically important side effect, a CV event, is likely to appear once for every 2.7 recurrences that are prevented, although many cases are asymptomatic and reversible. Extrapolated over 20 years, targeting HER2+ tumors in the adjuvant setting could prevent as many as 50,000 HER2+ patients from recurrence with important clinical, humanistic and economic consequences for patients, physicians and payors.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2107.

The swimbladder nematodeAnguillicola crassusin the European eelAnguilla anguillaand the Japanese eelAnguilla japonica: differences in susceptibility and immunity between a recently colonized host and the original host

The swimbladder nematodeAnguillicola crassusoriginates from Asia where it is a parasite of the Japanese eelAnguilla japonica. After its introduction to Europe about 25 years ago, the parasite spread rapidly within the indigenous populations of the European eelAnguilla anguillaand subsequently the prevalence and mean intensity appeared to stabilize. Under experimental and aquaculture conditions the naïve new host appears to be more susceptible toA. crassuscompared to the original host. Both eel species develop a immune response againstA. crassus. The antibody response is well characterized for the European eel, but poorly characterized for the Japanese eel. It remains unclear if antibodies have any protective function againstA. crassus. Encapsulation of larvae ofA. crassuscan be observed in naturally infected European eels. However, encapsulation of larvae following experimental infection has not been detected in European eels, but only in Japanese eels. Reinfection experiments and intraperitoneal injection ofA. crassushomogenates failed to demonstrate the development of acquired immunity in European eels. Immunization with irradiated third stage larvae provided preliminary evidence for acquired immunity againstA. crassusin the Japanese eel, but not in the European eel.

Estimating patient time costs associated with colorectal cancer care

BACKGROUND

Nonmedical costs of care, such as patient time associated with travel to, waiting for, and seeking medical care, are rarely measured systematically with population-based data.

OBJECTIVES

The purpose of this study was to estimate patient time costs associated with colorectal cancer care.

METHODS

We identified categories of key medical services for colorectal cancer care and then estimated patient time associated with each service category using data from national surveys. To estimate average service frequencies for each service category, we used a nested case control design and SEER-Medicare data. Estimates were calculated by phase of care for cases and controls, using data from 1995 to 1998. Average service frequencies were then combined with estimates of patient time for each category of service, and the value of patient time assigned. Net patient time costs were calculated for each service category, summarized by phase of care, and compared with previously reported net direct costs of colorectal cancer care.

RESULTS

Net patient time costs for the 3 phases of colorectal cancer care averaged dollar 4592 (95% confidence interval [CI] dollar 4427-4757) over the 12 months of the initial phase, dollar 2788 (95% CI dollar 2614-2963) over the 12 months of the terminal phase, and dollar 25 (95% CI: dollar 23-26) per month in the continuing phase of care. Hospitalizations accounted for more than two thirds of these estimates. Patient time costs were 19.3% of direct medical costs in the initial phase, 15.8% in the continuing phase, and 36.8% in the terminal phase of care.

CONCLUSIONS

Patient time costs are an important component of the costs of colorectal cancer care. Application of this method to other tumor sites and inclusion of other components of the costs of medical care will be important in delineating the economic burden of cancer in the United States.

Anguillicola papernai (Nematoda: Anguillicolidae) and other helminths parasitizing the African longfin eel Anguilla mossambica

The swim bladder nematode Anguillicola papernai Moravec & Taraschewski, 1988 has been investigated as regards its occurrence in longfin eels Anguilla mossambica (Peters) in rivers in South Africa. A. papernai revealed a prevalence of around 50% and a mean intensity of about 6 adult worms at 1 sampling site but were less abundant in 3 others. Field observations suggest a more narrow habitat preference than that of Anguillicola crassus and a seasonal pattern of abundance. African longfin eels harboured a poor helminth community. In addition to A. papernai, 2 gastro-intestinal nematodes occurred, the stomach worm Heliconema longissimum Ortlepp, 1923 as the dominant species, and the intestinal Paraquimperia africana Moravec, Boomker & Taraschewski, 2000. Experiments were undertaken using European eels Anguilla anguilla (Linnaeus) and copepods as laboratory hosts. The morphology of larvae and adult parasites obtained from these experimental hosts is described. The ultrastructure of adult worms recovered from wild longfin eels was studied. The 'papilla-like excrescences of fibrous structure' on the adult worms' cuticle, as mentioned in the original description, are in fact the attachment points of thick cords of fibers interconnecting the epicuticle with the hypodermis. Such a structure has not yet been described from any other species of Anguillicola Yamaguti, 1935. At present in South Africa, Mozambique and Madagascar attempts are on the way to establish an eel management like in Asia and Europe including eel farming. In this context, care should be taken to prevent the introduction of non-endemic eel parasites into Africa and Madagascar. On the other hand, the future commercial management of African eel species should not lead to the spread of A. papernai or other parasites of African eel species to Europe or elsewhere. In this study A. papernai has been experimentally demonstrated to be capable of reproducing in the European eel and of using European copepods as intermediate hosts.

Differences in susceptibility of the European eel (Anguilla anguilla) and the Japanese eel (Anguilla japonica) to the swim-bladder nematode Anguillicola crassus

The swim-bladder nematode Anguillicola crassus originates from the Far East where it is a parasite of the Japanese eel (Anguilla japonica). After A. crassus was introduced to Europe, it became a predominant parasite of the European eel (Anguilla anguilla). A study performed with experimentally infected eels (98 days, 23 degrees C) revealed significant differences in the susceptibility of the two eel species to this parasite. The recovery rate of 30 administered infective A. crassus larvae (L3) from A. japonica was less than half of that from A. anguilla (33.2% and 13.8%, respectively). Almost 60% of the worms recovered from A. japonica were found as dead, encapsulated and necrotic larvae in the swimbladder wall. In contrast, no dead larvae were found in A. anguilla. Additionally, the development of the worms was shown to be significantly slower in A. japonica compared with A. anguilla. The lower survival rate of the worms, together with their slower development, resulted in a significantly lower adult worm burden (11 and 428 mg wet weight, respectively) and in a decreased reproductive success in A. japonica compared with A. anguilla. These results demonstrate that the original host, A. japonica, possesses more effective defence mechanisms against A. crassus than does the non-adapted host, A. anguilla.

Individual and combined effects of cadmium and 3,3,4,4,5-pentachlorobiphenyl (PCB 126) on the humoral immune response in European eel (Anguilla anguilla) experimentally infected with larvae of Anguillicola crassus (Nematoda)

The individual and combined effects of cadmium (Cd) and 3,3',4,4',5-pentachlorobiphenyl (PCB 126) on the antibody response of fish against metazoan parasites were tested. Eels experimentally infected with the swim bladder nematode Anguillicola crassus were exposed to sublethal concentrations of Cd and PCB 126. Cd was added to the water resulting in an effective concentration of 21.7 +/- 12.8 microg/l (mean +/- S.D.). PCB 126 was applied orally at a dose of approximately 100 ng PCB 126 per g body weight. At the end of the experiment, 76 days post-infection (p.i.), eels were found to be infected with 2-3 worms. Immunoblot analyses revealed that the body wall of adult worms was the most suitable crude antigen, and was subsequently used for an ELISA to evaluate the immune response of A. anguilla under various conditions. A significant increase of Anguillicola-specific antibodies in the peripheral blood was first detected 61 days p.i., indicating that it was not the invasive larvae but the adult worms which elicit the antibody response. The presence of Cd in the concentrations applied did not appear to modulate the production of antibodies. In contrast, the exposure to PCB 126 resulted in a complete suppression of the antibody response. A similar effect was also found for the combined exposure of the infected eels to Cd and PCB 126. A suppressed immune response, as demonstrated here, may be the reason why hosts exposed to environmental pollution became often much more easily infected than unexposed conspecifics.

Effects of crude extracts of Mucuna pruriens (Fabaceae) and Carica papaya (Caricaceae) against the protozoan fish parasite Ichthyophthirius multifiliis

The ciliate Ichthyophthirius multifiliis is among the most pathogenic parasites of fish maintained in captivity. In the present study, the effects of the crude methanolic extract of leaves of Mucuna pruriens and the petroleum-ether extract of seeds of Carica papaya against I. multifiliis were investigated under in vivo and in vitro conditions. Goldfish (Carassius auratus auratus) infected with the parasites were immersed for 72 h in baths with M. pruriens extract, and for 96 h in baths with C. papaya extract. There was a 90% reduction in numbers of I. multifiliis on fish after treatment in baths of each plant extract at 200 mg l(-1 )compared to untreated controls. Consequently, parasite-induced fish mortality was reduced significantly. A complete interruption of trophont recruitment was achieved by immersion in the M. pruriens extract. In vitro tests led to a 100% mortality of I. multifiliis in 150 mg/l M. pruriens extract, and in 200 mg/l of C. papaya extract after 6 h. Although the active constituents of the medicinal plant extracts are still unknown, we have demonstrated that they have potential for effective control of I. multifiliis.

Patterns of care for the treatment of bladder cancer

PURPOSE

We examined bladder cancer patterns of care and differences in treatments administered to patients by age, race/ethnicity and gender using a population based sample.

MATERIAL AND METHODS

A random sample of bladder cancer patients diagnosed in 1995 without upper urinary tract involvement in 8 Surveillance, Epidemiology and End Results registries were included. Tumor stage and grade were used to assign patients to risk groups and patterns of care were investigated. Descriptive analyses and logistic regression models examined differences in care based on patient age, race/ethnicity and gender.

RESULTS

Of the 669 patients 485 patients had superficial disease, including 222 at low, 151 at intermediate and 112 at high risk, while 154 had muscle invasive disease. Of the patients with superficial bladder cancer 73.4% underwent transurethral bladder resection only. Those with muscle invasive disease were most commonly treated with transurethral bladder resection only (49.1%) or cystectomy only (31%). Intravesical chemotherapy in patients with superficial tumors and aggressive treatment with cystectomy and/or systemic chemotherapy in those with muscle invasive disease increased in relation to risk classification, as may have been expected. However, multivariate analyses suggested an influence of co-morbidities on intravesical therapy in patients with superficial tumors and an influence of patient age and geographic region on aggressive treatment for muscle invasive disease.

CONCLUSIONS

No differences in treatment were identified based on patient race/ethnicity or gender. Treatment for superficial disease is primarily influenced by risk category and co-morbidities, while treatment for muscle invasive disease is influenced by patient age and geographic region.

Quality-of-life outcomes after primary androgen deprivation therapy: results from the Prostate Cancer Outcomes Study

PURPOSE

To compare health-related quality-of-life outcomes after primary androgen deprivation (AD) therapy with orchiectomy versus luteinizing hormone-releasing hormone (LHRH) agonists for patients with prostate cancer.

PATIENTS AND METHODS

Men (n = 431) newly diagnosed with all stages of prostate cancer from six geographic regions who participated in the Prostate Cancer Outcomes Study and who received primary AD therapy but no other treatments within 12 months of initial diagnosis were included in a study of health outcomes. Comparisons were statistically adjusted for patient sociodemographic and clinical characteristics, timing of therapy, and use of combined androgen blockade.

RESULTS

More than half of the patients receiving primary AD therapy had been initially diagnosed with clinically localized prostate cancer. Among these patients, almost two thirds were at high risk of progression on the basis of prognostic factors. Sexual function outcomes were similar by treatment group both before and after implementation of AD therapy. LHRH patients reported more breast swelling than did orchiectomy patients (24.9% v 9.7%, P <.01). LHRH patients reported more physical discomfort and worry because of cancer or its treatment than did orchiectomy patients. LHRH patients assessed their overall health as fair or poor more frequently than did orchiectomy patients (35.4% v 28.1%, P =.01) and also were less likely to consider themselves free of prostate cancer after treatment.

CONCLUSION

Most endocrine-related health outcomes are similar after surgical versus medical primary hormonal therapy. Stage at diagnosis had little effect on outcomes. These results provide representative information comparing surgical and medical AD therapy that may be used by physicians and patients to inform treatment decisions.