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Fenwick N, Weston R, Wheatley K, Hodgson J, Marshall L, Elliott M, Makin G, Ng A, Brennan B, Lowis S, Adamski J, Kilday JP, Cox R, Gattens M, Moore A, Trahair T, Ronghe M, Campbell M, Campbell H, Williams MW, Kirby M, Van Eijkelenburg N, Keely J, Scarpa U, Stavrou V, Fultang L, Booth S, Cheng P, De Santo C, Mussai F. PARC: a phase I/II study evaluating the safety and activity of pegylated recombinant human arginase BCT-100 in relapsed/refractory cancers of children and young adults. Front Oncol 2024; 14:1296576. [PMID: 38357205 PMCID: PMC10864630 DOI: 10.3389/fonc.2024.1296576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Background The survival for many children with relapsed/refractory cancers remains poor despite advances in therapies. Arginine metabolism plays a key role in the pathophysiology of a number of pediatric cancers. We report the first in child study of a recombinant human arginase, BCT-100, in children with relapsed/refractory hematological, solid or CNS cancers. Procedure PARC was a single arm, Phase I/II, international, open label study. BCT-100 was given intravenously over one hour at weekly intervals. The Phase I section utilized a modified 3 + 3 design where escalation/de-escalation was based on both the safety profile and the complete depletion of arginine (defined as adequate arginine depletion; AAD <8μM arginine in the blood after 4 doses of BCT-100). The Phase II section was designed to further evaluate the clinical activity of BCT-100 at the pediatric RP2D determined in the Phase I section, by recruitment of patients with pediatric cancers into 4 individual groups. A primary evaluation of response was conducted at eight weeks with patients continuing to receive treatment until disease progression or unacceptable toxicity. Results 49 children were recruited globally. The Phase I cohort of the trial established the Recommended Phase II Dose of 1600U/kg iv weekly in children, matching that of adults. BCT-100 was very well tolerated. No responses defined as a CR, CRi or PR were seen in any cohort within the defined 8 week primary evaluation period. However a number of these relapsed/refractory patients experienced prolonged radiological SD. Conclusion Arginine depletion is a clinically safe and achievable strategy in children with cancer. The RP2D of BCT-100 in children with relapsed/refractory cancers is established at 1600U/kg intravenously weekly and can lead to sustained disease stability in this hard to treat population. Clinical trial registration EudraCT, 2017-002762-44; ISRCTN, 21727048; and ClinicalTrials.gov, NCT03455140.
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Affiliation(s)
- Nicola Fenwick
- Children’s Cancer Trials Team, Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, United Kingdom
| | - Rebekah Weston
- Children’s Cancer Trials Team, Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, United Kingdom
| | - Keith Wheatley
- Children’s Cancer Trials Team, Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, United Kingdom
| | - Jodie Hodgson
- Children’s Cancer Trials Team, Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, United Kingdom
| | | | - Martin Elliott
- Leeds Teaching Hospital, St James University Hospital, Leeds, United Kingdom
| | - Guy Makin
- Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Antony Ng
- Bristol Royal Hospital for Children, Bristol, United Kingdom
| | | | - Stephen Lowis
- Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Jenny Adamski
- Birmingham Children’s Hospital, Birmingham, United Kingdom
| | - John Paul Kilday
- Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Rachel Cox
- Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Mike Gattens
- Addenbrookes Hospital, Cambridge, United Kingdom
| | - Andrew Moore
- Queensland Children’s Hospital, Brisbane, QLD, Australia
| | - Toby Trahair
- Sydney Children’s Hospital, Sydney, NSW, Australia
| | - Milind Ronghe
- Royal Hospital for Children, Glasgow, United Kingdom
| | | | - Helen Campbell
- Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | | | - Maria Kirby
- Michael Rice Cancer Centre, Women’s and Children’s Hospital, North Adelaide, SA, Australia
| | | | - Jennifer Keely
- Children’s Cancer Trials Team, Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, United Kingdom
| | - Ugo Scarpa
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Victoria Stavrou
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Livingstone Fultang
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Sarah Booth
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Paul Cheng
- Bio-Cancer Treatment International, Hong Kong Science Park, Hong Kong, Hong Kong SAR, China
| | - Carmela De Santo
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Francis Mussai
- Birmingham Children’s Hospital, Birmingham, United Kingdom
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2
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Moreno L, Weston R, Owens C, Valteau-Couanet D, Gambart M, Castel V, Zwaan CM, Nysom K, Gerber N, Castellano A, Laureys G, Ladenstein R, Rössler J, Makin G, Murphy D, Morland B, Vaidya S, Thebaud E, van Eijkelenburg N, Tweddle DA, Barone G, Tandonnet J, Corradini N, Chastagner P, Paillard C, Bautista FJ, Gallego Melcon S, De Wilde B, Marshall L, Gray J, Burchill SA, Schleiermacher G, Chesler L, Peet A, Leach MO, McHugh K, Hayes R, Jerome N, Caron H, Laidler J, Fenwick N, Holt G, Moroz V, Kearns P, Gates S, Pearson ADJ, Wheatley K. Bevacizumab, Irinotecan, or Topotecan Added to Temozolomide for Children With Relapsed and Refractory Neuroblastoma: Results of the ITCC-SIOPEN BEACON-Neuroblastoma Trial. J Clin Oncol 2024:JCO2300458. [PMID: 38190578 DOI: 10.1200/jco.23.00458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/25/2023] [Accepted: 10/05/2023] [Indexed: 01/10/2024] Open
Abstract
PURPOSE Outcomes for children with relapsed and refractory high-risk neuroblastoma (RR-HRNB) remain dismal. The BEACON Neuroblastoma trial (EudraCT 2012-000072-42) evaluated three backbone chemotherapy regimens and the addition of the antiangiogenic agent bevacizumab (B). MATERIALS AND METHODS Patients age 1-21 years with RR-HRNB with adequate organ function and performance status were randomly assigned in a 3 × 2 factorial design to temozolomide (T), irinotecan-temozolomide (IT), or topotecan-temozolomide (TTo) with or without B. The primary end point was best overall response (complete or partial) rate (ORR) during the first six courses, by RECIST or International Neuroblastoma Response Criteria for patients with measurable or evaluable disease, respectively. Safety, progression-free survival (PFS), and overall survival (OS) time were secondary end points. RESULTS One hundred sixty patients with RR-HRNB were included. For B random assignment (n = 160), the ORR was 26% (95% CI, 17 to 37) with B and 18% (95% CI, 10 to 28) without B (risk ratio [RR], 1.52 [95% CI, 0.83 to 2.77]; P = .17). Adjusted hazard ratio for PFS and OS were 0.89 (95% CI, 0.63 to 1.27) and 1.01 (95% CI, 0.70 to 1.45), respectively. For irinotecan ([I]; n = 121) and topotecan (n = 60) random assignments, RRs for ORR were 0.94 and 1.22, respectively. A potential interaction between I and B was identified. For patients in the bevacizumab-irinotecan-temozolomide (BIT) arm, the ORR was 23% (95% CI, 10 to 42), and the 1-year PFS estimate was 0.67 (95% CI, 0.47 to 0.80). CONCLUSION The addition of B met protocol-defined success criteria for ORR and appeared to improve PFS. Within this phase II trial, BIT showed signals of antitumor activity with acceptable tolerability. Future trials will confirm these results in the chemoimmunotherapy era.
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Affiliation(s)
- Lucas Moreno
- Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | - Guy Makin
- Central Manchester and Manchester Children's University Hospitals NHS Trust, Manchester, United Kingdom
| | - Dermot Murphy
- NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Bruce Morland
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Sucheta Vaidya
- The Royal Marsden NHS Foundation Trust & Institute for Cancer Research, London, United Kingdom
| | | | | | - Deborah A Tweddle
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | | | | | | | | | | | | | | | | | - Lynley Marshall
- The Royal Marsden NHS Foundation Trust & Institute for Cancer Research, London, United Kingdom
| | - Juliet Gray
- University Hospital Southampton, Southampton, United Kingdom
| | | | | | - Louis Chesler
- The Royal Marsden NHS Foundation Trust & Institute for Cancer Research, London, United Kingdom
| | - Andrew Peet
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Martin O Leach
- The Royal Marsden NHS Foundation Trust & Institute for Cancer Research, London, United Kingdom
| | - Kieran McHugh
- Great Ormond Street Hospital, London, United Kingdom
| | | | - Neil Jerome
- The Royal Marsden NHS Foundation Trust & Institute for Cancer Research, London, United Kingdom
| | | | | | | | - Grace Holt
- University of Birmingham, Birmingham, United Kingdom
| | | | - Pamela Kearns
- University of Birmingham, Birmingham, United Kingdom
| | - Simon Gates
- University of Birmingham, Birmingham, United Kingdom
| | - Andrew D J Pearson
- The Royal Marsden NHS Foundation Trust & Institute for Cancer Research, London, United Kingdom
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Brennan B, Kirton L, Marec-Bérard P, Gaspar N, Laurence V, Martín-Broto J, Sastre A, Gelderblom H, Owens C, Fenwick N, Strauss S, Moroz V, Whelan J, Wheatley K. Comparison of two chemotherapy regimens in patients with newly diagnosed Ewing sarcoma (EE2012): an open-label, randomised, phase 3 trial. Lancet 2022; 400:1513-1521. [PMID: 36522207 DOI: 10.1016/s0140-6736(22)01790-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Internationally, a single standard chemotherapy treatment for Ewing sarcoma is not defined. Because different chemotherapy regimens were standard in Europe and the USA for newly diagnosed Ewing sarcoma, and in the absence of novel agents to investigate, we aimed to compare these two strategies. METHODS EURO EWING 2012 was a European investigator-initiated, open-label, randomised, controlled phase 3 trial done in 10 countries. We included patients aged 2-49 years, with any histologically and genetically confirmed Ewing sarcoma of bone or soft tissue, or Ewing-like sarcomas. The eligibility criteria originally excluded patients with extrapulmonary metastatic disease, but this was amended in the protocol (version 3.0) in September, 2016. Patients were randomly assigned (1:1) to either the European regimen of vincristine, ifosfamide, doxorubicin, and etoposide induction, and consolidation using vincristine, actinomycin D, with ifosfamide or cyclophosphamide, or busulfan and melphalan (group 1); or the US regimen of vincristine, doxorubicin, cyclophosphamide, ifosfamide, and etoposide induction, plus ifosfamide and etoposide, and consolidation using vincristine and cyclophosphamide, or vincristine, actinomycin D, and ifosfamide, with busulfan and melphalan (group 2). All drugs were administered intravenously. The primary outcome measure was event-free survival. We used a Bayesian approach for the design, analysis, and interpretation of the results. Patients who received at least one dose of study treatment were considered in the safety analysis. The trial was registered with EudraCT, 2012-002107-17, and ISRCTN, 54540667. FINDINGS Between March 21, 2014, and May 1, 2019, 640 patients were entered into EE2012, 320 (50%) randomly allocated to each group. Median follow-up of surviving patients was 47 months (range 0-84). Event-free survival at 3 years was 61% with group 1 and 67% with group 2 (adjusted hazard ratio [HR] 0·71 [95% credible interval 0·55-0·92 in favour of group 1). The probability that the true HR was less than 1·0 was greater than 0·99. Febrile neutropenia as a grade 3-5 treatment toxicity occurred in 234 (74%) patients in group 1 and in 183 (58%) patients in group 2. More patients in group 1 (n=205 [64%]) required at least one platelet transfusion compared with those in group 2 (n=138 [43%]). Conversely, more patients required blood transfusions in group 2 (n=286 [89%]) than in group 1 (n=277 [87%]). INTERPRETATION Dose-intensive chemotherapy with vincristine, doxorubicin, cyclophosphamide, ifosfamide, and etoposide is more effective, less toxic, and shorter in duration for all stages of newly diagnosed Ewing sarcoma than vincristine, ifosfamide, doxorubicin, and etoposide induction and should now be the standard of care for Ewing sarcoma. FUNDING The European Union's Seventh Framework Programme for Research, Technological Development, and Demonstration; The National Coordinating Centre in France, Centre Léon Bérard; SFCE; Ligue contre le cancer; Cancer Research UK.
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Affiliation(s)
- Bernadette Brennan
- Department of Paediatric Oncology and Haematology, Royal Manchester Children's Hospital, Manchester, UK.
| | - Laura Kirton
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Perrine Marec-Bérard
- Centre Léon Bérard, Lyon, France; Société Française de Lutte contre les Cancers et Leucémies de l'Enfant et de l'Adolescent, Paris, France; Groupe Sarcome Français, Paris, France
| | - Nathalie Gaspar
- Société Française de Lutte contre les Cancers et Leucémies de l'Enfant et de l'Adolescent, Paris, France; Groupe Sarcome Français, Paris, France; Institut Gustave Roussy, Villejuif, France
| | - Valerie Laurence
- Société Française de Lutte contre les Cancers et Leucémies de l'Enfant et de l'Adolescent, Paris, France; Groupe Sarcome Français, Paris, France; Institut Curie, Paris, France
| | - Javier Martín-Broto
- Medical Oncology Department, Fundacion Jimenez Diaz University Hospital, Madrid, Spain; Instituto de Investigacion Sanitaria Fundacion Jimenez Diaz, Madrid, Spain; University Hospital General de Villalba, Madrid, Spain
| | - Ana Sastre
- Hospital Universitario La Paz, Madrid, Spain
| | - Hans Gelderblom
- Leiden University Medical Center, Leiden, Netherlands; on behalf of European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | | | - Nicola Fenwick
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Sandra Strauss
- Paediatric Oncology, University College London, London, UK; University College London Hospitals NHS Foundation Trust, London, UK
| | - Veronica Moroz
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Jeremy Whelan
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
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4
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McCabe M, Kirton L, Khan M, Fenwick N, Strauss SJ, Valverde C, Mata C, Gaspar N, Luksch R, Longhi A, Dirksen U, Phillips M, Safwat A, Gelderblom H, Kuehne T, Kanerva J, Westwood AJ, Ferrari S, Whelan J, Wheatley K. Phase III assessment of topotecan and cyclophosphamide and high-dose ifosfamide in rEECur: An international randomized controlled trial of chemotherapy for the treatment of recurrent and primary refractory Ewing sarcoma (RR-ES). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.17_suppl.lba2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
LBA2 Background: 5-year survival of RR-ES is about 15%. rEECur, the first randomized controlled trial in this setting, is defining standard care, balancing efficacy and toxicity. Methods: Patients aged 4-50 with RR-ES were randomly assigned to topotecan and cyclophosphamide (TC), irinotecan and temolozomide (IT), gemcitabine and docetaxel (GD), or high-dose ifosfamide (IFOS). Primary outcome was event-free survival (EFS) for the phase III comparison. Secondary outcomes included overall survival (OS), toxicity, and quality of life (QoL). A probability-based Bayesian approach was used with multiple pairwise comparisons. At the first and second interim assessments, patients allocated to GD and IT, respectively, had worse objective response (OR) and EFS than the other arms, halting recruitment to both. The final intent-to-treat assessment of the original four arms was a phase III evaluation of TC and IFOS. Results: 451 patients recruited between 18/12/14 and 31/08/21, were randomly assigned to TC (163 patients), IT (127 patients), GD (72 patients), and IFOS (83 patients). Median age was 19 years (range 4-49). Patients had: refractory disease (18%), first recurrence (66%), > first recurrence (17%). Initial disease site was bone in 70%. Sites of progression were: primary site only (15%), pleuropulmonary metastases only (34%), and other metastatic (51%). Baseline renal function was similar in both. Median follow-up (reverse Kaplan-Meier method) was 40 months. For the phase III comparison between TC and IFOS (both, 73 patients), median EFS was 3.7 months (95% CI, 2.1-6.2) for TC and 5.7 months (95% CI, 3.8-7.0) for IFOS. Median OS was 10.4 months (95% CI, 7.5-15.5) for TC and 16.8 months (95% CI, 11.1-25.8) for IFOS. Given the observed data, the posterior probability that EFS and OS were better after IFOS than after TC (ie Pr [true hazard ratio < 1 | data]) was 95% for both. A greater survival difference was observed for patients aged under 14 than those aged ≥ 14 for EFS and OS. Subgroup analyses favored IFOS for all minimization factors. The main grade 3/4 adverse events (% patients with an event) for TC (left-hand values) compared with IFOS were: febrile neutropenia (26% vs. 25%), infections (8% vs. 14%), vomiting (1% vs. 1%), nausea (0% vs. 3%), diarrhea (1% vs. 1%), encephalopathy (0% vs. 7%), and renal toxicity (0% vs. 8%). Descriptive statistics of quality of life scores appeared to favor the IFOS arm over the TC arm in children but not in adults. Conclusions: The first randomized trial in RR-ES has shown that high-dose ifosfamide is more effective in prolonging survival than TC, having previously beaten GD and IT, and should be considered as a control arm in future randomized phase II/III studies in RR-ES if combination with IFOS is logical. rEECur is the first study to provide comparative toxicity and survival data for the four most commonly used chemotherapy regimens in RR-ES. Clinical trial information: ISRCTN36453794.
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Affiliation(s)
- Martin McCabe
- University of Manchester, Manchester, United Kingdom
| | - Laura Kirton
- University of Birmingham, Birmingham, United Kingdom
| | - Maria Khan
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Cristina Mata
- Oncología Pediatrica Hospital Gregorio Marañón, Madrid, Spain
| | | | - Roberto Luksch
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Uta Dirksen
- Pediatrics III, University Hospital Essen, West German Cancer Center, Essen, Germany
| | | | - Akmal Safwat
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Thomas Kuehne
- University Children's Hospital Basel, Basel, Switzerland
| | - Jukka Kanerva
- HUS Helsinki University Hospital, New Children’s Hospital Division of Hematology-Oncology and Stem Cell Transplantation, Helsinki, Finland
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McCabe MG, Kirton L, Khan M, Fenwick N, Dirksen U, Gaspar N, Kanerva J, Kuehne T, Longhi A, Luksch R, Mata C, Phillips M, Safwat A, Strauss SJ, Sundby Hall K, Valverde Morales CM, Westwood AJ, Winstanley M, Whelan J, Wheatley K. Results of the second interim assessment of rEECur, an international randomized controlled trial of chemotherapy for the treatment of recurrent and primary refractory Ewing sarcoma (RR-ES). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.11502] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11502 Background: Five-year survival of RR-ES is about 15%. Several chemotherapy regimens are used, but without robust evidence. rEECur, the first randomised controlled trial in this setting, is defining a standard of care, balancing efficacy and toxicity. Methods: Patients aged 4 to 50 with RR-ES and fit to receive chemotherapy were randomised between topotecan & cyclophosphamide (TC), irinotecan & temolozomide (IT), gemcitabine & docetaxel (GD) or high-dose ifosfamide (IFOS). Primary outcome measure was objective response (OR) after 4 cycles by RECIST 1.1. Secondary outcomes included PFS, OS and toxicity. A probability-based Bayesian approach was used with multiple pairwise comparisons. At the first interim analysis patients allocated to GD had worse OR and PFS than the other arms and accrual to the GD arm was halted. The second interim assessment was planned to determine which arm should be closed when at least 75 evaluable patients had been recruited to the remaining arms and evaluated for the primary outcome measure. Results: 366 patients (87% RECIST-evaluable), recruited between 18/12/14 and 17/12/19, were randomised to TC (n=124), IT (118), GD (72) and IFOS (53). Median age was 20 years (range 4-49). Patients had: refractory disease (19%), first recurrence (66%), > first recurrence (14%). Initial disease site was bone in (66%). Sites of progression were: primary site only (16%) pleuropulmonary only (32%), other metastatic (52%). At median follow up of 9.2 months, outcome in the IT arm was: response rate 20%, median PFS 4.7 months (95% CI: 3.4 to 5.7), median OS 13.9 months (95% CI: 10.6 to 18.1). The table shows, for each pairwise comparison of IT with the other open arms (randomly labelled A and B to maintain blinding), the probabilities that OR, PFS and OS were better for X than for each other arm (RR = risk ratio, HR = hazard ratio). For OR, PFS and OS, all comparisons favoured arms A and B. The main grade 3/4 adverse events (% patients with an event) for IT (left hand values) compared with A and B pooled were: vomiting (6% v 1%), nausea (6% v 0%), diarrhoea (17% v 0%), fatigue (3% v 1%) and febrile neutropenia (3% v 24%). Conclusions: The first randomised trial in RR-ES has shown that IT, used as a control arm in planned and ongoing randomised phase II studies in RR-ES, is less effective than A and B in achieving tumour shrinkage or prolonging PFS and OS. The remaining two arms are continuing to recruit patients. Clinical trial information: ISRCTN36453794 . [Table: see text]
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Affiliation(s)
| | - Laura Kirton
- University of Birmingham, Birmingham, United Kingdom
| | - Maria Khan
- University of Birmingham, Birmingham, United Kingdom
| | | | - Uta Dirksen
- Pediatrics III, West German Cancer Center, University Hospital Essen, German Cancer Consortium (DKTK), Essen, Germany
| | | | - Jukka Kanerva
- HUS Helsinki University Hospital, New Children’s Hospital Division of Hematology-Oncology and Stem Cell Transplantation, Helsinki, Finland
| | - Thomas Kuehne
- University Children's Hospital Basel, Basel, Switzerland
| | - Alessandra Longhi
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Roberto Luksch
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Cristina Mata
- Oncología Pediatrica Hospital Gregorio Marañón, Madrid, Spain
| | | | - Akmal Safwat
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Wheatley K, Kadir B, Khan M, Fenwick N, Gaspar N, Kanerva J, Kuehne T, Longhi A, Mata C, Phillips M, Hall K, Safwat A, Valverde Morales C, Westwood AJ, Winstanley M, Evans A, Strauss SJ, Dirksen U, Whelan J, McCabe MG. Correlation of response with progression-free (PFS) and overall (OS) survival in relapsed/refractory Ewing sarcoma (RR-ES): Results from the rEECur trial. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.11524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11524 Background: Survival for RR-ES at 5 years remains < 15%, so novel treatments are needed. Almost all Phase II trials for RR-ES use response as the primary outcome measure. It is unclear whether response is a valid surrogate for survival outcomes. Methods: Patients (pts) were eligible if they had RR-ES and were evaluable for imaging response (primary outcome) if they had measurable disease by RECIST 1.1. The randomization was initially between four chemotherapy regimens: topotecan-cyclophosphamide, irinotecan-temozolomide, gemcitabine-docetaxel (GD), high-dose ifosfamide. Response was assessed after 2, 4 (primary) and 6 cycles of therapy and was classified as complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD). PFS and OS were secondary outcomes. Survival from each assessment point by response status was analyzed, by Cox models, with hazard ratios (HR) given for PR v. SD and CR+PR v. SD. Results: From 2015-19, 241 pts with response data were entered. The relationship between response status and PFS and OS is shown in the table (HR < 1.0 indicates better outcome for PR or CR+PR than SD). Both PFS and OS were similar for pts with PR or CR+PR compared to those with SD. OS was inferior for patients with PD (all p < 0.01) (PFS is by definition zero for patients with PD at that timepoint). Small numbers mean CR results are not reliable. Results were consistent across all treatments and between refractory and relapsed disease. At the first interim assessment the GD arm was dropped, with risk ratios for response compared to the other three arms (blinded as still open) of 0.3, 0.5 and 0.5. If a new outcome – disease control (CR+PR+SD) – is defined, the risk ratios are 0.7, 0.8 and 0.7; i.e. still inferior for GD, but less so. Conclusions: Response does not correlate with survival outcomes in RR-ES, so considering PR, or even CR, a success and SD a failure when evaluating treatments may be misleading. We propose PFS as a better primary outcome for future trials and it will be introduced as such in the rEECur trial. Clinical trial information: ISRCTN36453794 . [Table: see text]
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Affiliation(s)
| | - Bryar Kadir
- University of Birmingham, Birmingham, United Kingdom
| | - Maria Khan
- University of Birmingham, Birmingham, United Kingdom
| | | | | | - Jukka Kanerva
- HUS Helsinki University Hospital, New Children’s Hospital Division of Hematology-Oncology and Stem Cell Transplantation, Helsinki, Finland
| | - Thomas Kuehne
- University Children's Hospital Basel, Basel, Switzerland
| | - Alessandra Longhi
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cristina Mata
- Oncología Pediatrica Hospital Gregorio Marañón, Madrid, Spain
| | | | | | - Akmal Safwat
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | | | - Sandra J Strauss
- University College London Cancer Institute, London, United Kingdom
| | - Uta Dirksen
- Pediatrics III, West German Cancer Center, University Hospital Essen, German Cancer Consortium (DKTK), Essen, Germany
| | - Jeremy Whelan
- University College London Hospital, London, United Kingdom
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Anderton J, Moroz V, Marec-Bérard P, Gaspar N, Laurence V, Martín-Broto J, Sastre A, Gelderblom H, Owens C, Kaiser S, Fernández-Pinto M, Fenwick N, Evans A, Strauss S, Whelan J, Wheatley K, Brennan B. International randomised controlled trial for the treatment of newly diagnosed EWING sarcoma family of tumours - EURO EWING 2012 Protocol. Trials 2020; 21:96. [PMID: 31952545 PMCID: PMC6969439 DOI: 10.1186/s13063-019-4026-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 12/21/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Although there have been multiple randomised trials in newly diagnosed Ewing sarcoma family of tumours (ESFT) and these have been conducted over many years and involved many international cooperative groups, the outcomes for all stages of disease have plateaued. Internationally, the standard treatment of ESFT is not defined, and there is a need to add new agents other than conventional chemotherapy to improve outcomes. This trial will compare two different induction/consolidation chemotherapy regimens: (1) vincristine, ifosfamide, doxorubicin and etoposide (VIDE) induction and vincristine, actinomycin D, ifosfamide or cyclophosphamide, or busulfan and mephalan (VAI/VAC/BuMel) consolidation and (2) vincristine, doxorubicin, cyclophosphamide, ifosfamide and etoposide (VDC/IE) induction and ifosfamide and etoposide, vincristine and cyclophosphamide, vincristine, actinomycin D and ifosfamide, or busulfan and mephalan (IE/VC/VAI/BuMel) consolidation (randomisation 1, or R1). A second randomisation (R2) will determine whether the addition of zoledronic acid to consolidation chemotherapy, as assigned at R1, is associated with improved clinical outcome. METHODS EURO EWING 2012 is an international, multicentre, phase III, open-label randomised controlled trial. There are two randomisations: R1 and R2. Patients are randomly assigned at two different time points: at entry to the trial (R1) and following local control therapy (R2). The primary outcome measure is event-free survival. The secondary outcome measures include overall survival, adverse events and toxicity, histological response of the primary tumour, response of the primary tumour, regional lymph nodes or metastases (or both), and achievement of local control at the end of treatment. DISCUSSION This study will establish which is the "standard regimen" of chemotherapy, taking into account both clinical outcomes and toxicity. This will form the chemotherapy backbone for future interventional studies where we may want to add new targeted agents. It will also determine the role of zoledronic acid in conjunction with the separate EE2008 trial. Any trial in ESFT needs to take into account the rarity of the tumour and consider that international cooperation is needed to provide answers in a timely manner. TRIAL REGISTRATION Registered with EudraCT number 2012-002107-17 on 26 February 2012. Registered with ISRCTN number 54540667 on 4 November 2013.
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Affiliation(s)
- Jennifer Anderton
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Mindelsohn Way, Birmingham, B15 2TT, UK
| | - Veronica Moroz
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Mindelsohn Way, Birmingham, B15 2TT, UK
| | - Perrine Marec-Bérard
- Centre Léon Bérard, 28 rue Laënnec, 69373 Lyon cedex 08, France
- Société Française de Lutte contre les Cancers et Leucémies de l'Enfant et de l'Adolescent (SFCE), 16 boulevard de Bulgarie, 35203 Rennes, France
- Groupe Sarcome Français - Groupe d'Etude des Sarcome Osseux (GSF-GETO), 28 rue Laënnec, 69373 Lyon cedex 08, France
| | - Nathalie Gaspar
- Société Française de Lutte contre les Cancers et Leucémies de l'Enfant et de l'Adolescent (SFCE), 16 boulevard de Bulgarie, 35203 Rennes, France
- Groupe Sarcome Français - Groupe d'Etude des Sarcome Osseux (GSF-GETO), 28 rue Laënnec, 69373 Lyon cedex 08, France
- Gustave Roussy Cancer Campus, 114 rue Édouard-Vaillant, 94805 Villejuif, France
| | - Valerie Laurence
- Société Française de Lutte contre les Cancers et Leucémies de l'Enfant et de l'Adolescent (SFCE), 16 boulevard de Bulgarie, 35203 Rennes, France
- Groupe Sarcome Français - Groupe d'Etude des Sarcome Osseux (GSF-GETO), 28 rue Laënnec, 69373 Lyon cedex 08, France
- Institut Curie, 26 Rue d'Ulm, 75005 Paris, France
| | - Javier Martín-Broto
- Institute of Biomedicine of Sevilla (IBIS, HUVR, CSIC, Universidad de Sevilla), Avda. Manuel Siurot, 41013 Sevilla, Spain
- University Hospital Virgen del Rocio, Av. Manuel Siurot, 41013, Seville, Spain
| | - Ana Sastre
- Hospital Universitario La Paz, 261 Paseo de la Castellana, 28046 Madrid, Spain
| | - Hans Gelderblom
- European Organisation for Research and Treatment of Cancer (EORTC), Avenue Mounier 83, B-1200 Brussels, Belgium
| | - Cormac Owens
- Our Lady's Children's Hospital, Cooley Rd, Dublin D12 N512, Ireland
| | - Sophie Kaiser
- Centre Léon Bérard, 28 rue Laënnec, 69373 Lyon cedex 08, France
| | - Melissa Fernández-Pinto
- Grupo Español de Investigación en Sarcomas (GEIS), Diego de León St, 47th 28006 Madrid, Spain
| | - Nicola Fenwick
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Mindelsohn Way, Birmingham, B15 2TT, UK
| | - Abigail Evans
- University College London, Gower Street, London, WC1E 6BT, UK
| | - Sandra Strauss
- University College London, Gower Street, London, WC1E 6BT, UK
| | - Jeremy Whelan
- University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Mindelsohn Way, Birmingham, B15 2TT, UK
| | - Bernadette Brennan
- Royal Manchester Children's Hospital, Oxford road, Manchester, M13 9WL, UK.
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Lam JR, Liu B, Bhate R, Fenwick N, Reed K, Duffy JMN, Khalil A. Research priorities for the future health of multiples and their families: The Global Twins and Multiples Priority Setting Partnership. Ultrasound Obstet Gynecol 2019; 54:715-721. [PMID: 31600847 DOI: 10.1002/uog.20858] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 08/17/2019] [Accepted: 08/23/2019] [Indexed: 05/27/2023]
Affiliation(s)
- J R Lam
- Twins Research Australia, The University of Melbourne, Melbourne, Australia
| | - B Liu
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - R Bhate
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - N Fenwick
- Twins and Multiple Births Association, London, UK
| | - K Reed
- Twins and Multiple Births Association, London, UK
| | - J M N Duffy
- Institute for Women's Health, University College London, London, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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McCabe MG, Moroz V, Khan M, Dirksen U, Evans A, Fenwick N, Gaspar N, Kanerva J, Kühne T, Longhi A, Luksch R, Mata C, Phillips M, Sundby Hall K, Valverde Morales CM, Westwood AJ, Winstanley M, Whelan J, Wheatley K. Results of the first interim assessment of rEECur, an international randomized controlled trial of chemotherapy for the treatment of recurrent and primary refractory Ewing sarcoma. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11007 Background: 5-year survival of RR-ES is about 15%. Several chemotherapy regimens are used, but without robust evidence. rEECur, the first randomised controlled trial in this setting, is defining a standard of care, balancing efficacy and toxicity. Methods: Patients aged 4 to 50 with RR-ES and fit to receive chemotherapy were randomised 2, 3 or 4 ways between topotecan & cyclophosphamide (TC), irinotecan & temolozomide (IT), gemcitabine & docetaxel (GD) or high-dose ifosfamide (IFOS). Primary outcome measure was objective response (OR) after 4 cycles by RECIST 1.1. Secondary outcomes included PFS, OS and toxicity. A probability-based Bayesian approach was used. The first interim assessment to determine which arm should be closed occurred when 50 evaluable patients had been recruited to 3 arms and evaluated for the primary outcome measure. Results: 242 patients (89% RECIST-evaluable) recruited between 18/12/14 and 21/06/18 were randomised to TC (n=75), IT (71), GD (66) and IFOS (30). Median age was 21 years (range 4 to 49). Patients had: refractory ES (20%), 1st recurrence (63%), >1st recurrence (17%); initial primary disease arose in bone in 60%; disease progression sites were primary site (17%), pleuropulmonary (29%) or other metastatic (54%). Median follow up was 11.3 months. Outcomes in the GD arm were: response rate 11.5% (95% CI: 4.4 to 23%), median PFS 3.0 months (95% CI: 1.6 to 8.0), median OS 13.7 months (95% CI: 10.1 to 23.9). The table shows, for each pairwise comparison of GD with the other arms (randomly labelled A, B, C to maintain blinding of open arms), the probabilities given the observed data that OR, PFS and OS were better for GD than for each other arm (RR: relative risk, HR: hazard ratio). For OR and PFS, all comparisons favoured the other arms. There were fewer grade 3/4 adverse events with GD than with the other arms pooled (58% v. 74%). Conclusions: rEECur has shown that GD is a less effective treatment than TC, IT or IFOS in reducing tumour burden or prolonging PFS in RR-ES. Recruitment continues to the remaining arms. Clinical trial information: ISRCTN36453794. [Table: see text]
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Affiliation(s)
| | - Veronica Moroz
- University of Birmingham, Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom
| | - Maria Khan
- University of Birmingham, Birmingham, United Kingdom
| | - Uta Dirksen
- University of Duisburg-Essen, Essen, Germany
| | | | | | | | | | - Thomas Kühne
- University Children's Hospital Basel, Basel, Switzerland
| | | | - Roberto Luksch
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Cristina Mata
- Oncología Pediatrica Hospital Gregorio Marañón, Madrid, Spain
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Earl HM, Vallier AL, Hiller L, Fenwick N, Young J, Iddawela M, Abraham J, Hughes-Davies L, Gounaris I, McAdam K, Houston S, Hickish T, Skene A, Chan S, Dean S, Ritchie D, Laing R, Harries M, Gallagher C, Wishart G, Dunn J, Provenzano E, Caldas C. Effects of the addition of gemcitabine, and paclitaxel-first sequencing, in neoadjuvant sequential epirubicin, cyclophosphamide, and paclitaxel for women with high-risk early breast cancer (Neo-tAnGo): an open-label, 2×2 factorial randomised phase 3 trial. Lancet Oncol 2014; 15:201-12. [PMID: 24360787 DOI: 10.1016/s1470-2045(13)70554-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anthracyclines and taxanes have been the standard neoadjuvant chemotherapies for breast cancer in the past decade. We aimed to assess safety and efficacy of the addition of gemcitabine to accelerated paclitaxel with epirubicin and cyclophosphamide, and also the effect of sequencing the blocks of epirubicin and cyclophosphamide and paclitaxel (with or without gemcitabine). METHODS In our randomised, open-label, 2×2 factorial phase 3 trial (Neo-tAnGo), we enrolled women (aged >18 years) with newly diagnosed breast cancer (tumour size >20 mm) at 57 centres in the UK. Patients were randomly assigned via a central randomisation procedure to epirubicin and cyclophosphamide then paclitaxel (with or without gemcitabine) or paclitaxel (with or without gemcitabine) then epirubicin and cyclophosphamide. Four cycles of each component were given. The primary endpoint was pathological complete response (pCR), defined as absence of invasive cancer in the breast and axillary lymph nodes. This study is registered with EudraCT (2004-002356-34), ISRCTN (78234870), and ClinicalTrials.gov (NCT00070278). FINDINGS Between Jan 18, 2005, and Sept 28, 2007, we randomly allocated 831 participants; 207 received epirubicin and cyclophosphamide then paclitaxel; 208 were given paclitaxel then epirubicin and cyclophosphamide; 208 had epirubicin and cyclophosphamide followed by paclitaxel and gemcitabine; and 208 received paclitaxel and gemcitabine then epirubicin and cyclophosphamide. 828 patients were eligible for analysis. Median follow-up was 47 months (IQR 37-51). 207 (25%) patients had inflammatory or locally advanced disease, 169 (20%) patients had tumours larger than 50 mm, 413 (50%) patients had clinical involvement of axillary nodes, 276 (33%) patients had oestrogen receptor (ER)-negative disease, and 191 (27%) patients had HER2-positive disease. Addition of gemcitabine did not increase pCR: 70 (17%, 95% CI 14-21) of 404 patients in the epirubicin and cyclophosphamide then paclitaxel group achieved pCR compared with 71 (17%, 14-21) of 408 patients who received additional gemcitabine (p=0·98). Receipt of a taxane before anthracycline was associated with improved pCR: 82 (20%, 95% CI 16-24) of 406 patients who received paclitaxel with or without gemcitabine followed by epirubicin and cyclophosphamide achieved pCR compared with 59 (15%, 11-18) of 406 patients who received epirubicin and cyclophosphamide first (p=0·03). Grade 3 toxicities were reported at expected levels: 173 (21%) of 812 patients who received treatment and had full treatment details had grade 3 neutropenia, 66 (8%) had infection, 41 (5%) had fatigue, 41 (5%) had muscle and joint pains, 37 (5%) had nausea, 36 (4%) had vomiting, 34 (4%) had neuropathy, 23 (3%) had transaminitis, 16 (2%) had acute hypersensitivity, and 20 (2%) had a rash. 86 (11%) patients had grade 4 neutropenia and 3 (<1%) had grade 4 infection. INTERPRETATION Although addition of gemcitabine to paclitaxel and epirubicin and cyclophosphamide chemotherapy does not improve pCR, sequencing chemotherapy so that taxanes are received before anthracyclines could improve pCR in standard neoadjuvant chemotherapy for breast cancer. FUNDING Cancer Research UK, Eli Lilly, Bristol-Myers Squibb.
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Affiliation(s)
- Helena M Earl
- University of Cambridge, Department of Oncology, Addenbrooke's Hospital, Hills Road, Cambridge, UK; National Institute for Health Research, Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Hills Road, Cambridge, UK; Department of Oncology, Cambridge Cancer Trials Centre, Addenbrooke's Hospital, Cambridge, UK; Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK.
| | - Anne-Laure Vallier
- Department of Oncology, Cambridge Cancer Trials Centre, Addenbrooke's Hospital, Cambridge, UK; Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - Louise Hiller
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, UK.
| | - Nicola Fenwick
- Cancer Research UK Clinical Trials Unit, Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jennie Young
- Cancer Research UK Clinical Trials Unit, Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham, UK
| | | | - Jean Abraham
- National Institute for Health Research, Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Hills Road, Cambridge, UK; Department of Oncology, Cambridge Cancer Trials Centre, Addenbrooke's Hospital, Cambridge, UK; Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK; CancerResearch UK Cambridge Institute, Cambridge, UK
| | - Luke Hughes-Davies
- Department of Oncology, Cambridge Cancer Trials Centre, Addenbrooke's Hospital, Cambridge, UK; Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | | | - Karen McAdam
- Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK; Peterborough and Stamford Hospitals NHS Foundation Trust and Cambridge University Hospital NHS Foundation Trust, UK
| | - Stephen Houston
- Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, UK
| | - Tamas Hickish
- Royal Bournemouth Hospital, Castle Lane East, Bournemouth, UK
| | - Anthony Skene
- Department of Surgery, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, UK
| | - Stephen Chan
- Nottingham City Hospital, Hucknall Road, Nottingham, UK
| | - Susan Dean
- Dorset Cancer Centre, Poole Hospital NHS Trust, Poole, UK
| | - Diana Ritchie
- Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, UK
| | - Robert Laing
- Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, UK
| | - Mark Harries
- Breast Oncology Unit, Thomas Guy House, Guys Hospital, St Thomas Street, London, UK
| | - Christopher Gallagher
- Department of Medical Oncology, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Gordon Wishart
- Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - Janet Dunn
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, UK
| | - Elena Provenzano
- National Institute for Health Research, Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Hills Road, Cambridge, UK; Department of Oncology, Cambridge Cancer Trials Centre, Addenbrooke's Hospital, Cambridge, UK; Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - Carlos Caldas
- University of Cambridge, Department of Oncology, Addenbrooke's Hospital, Hills Road, Cambridge, UK; National Institute for Health Research, Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Hills Road, Cambridge, UK; Department of Oncology, Cambridge Cancer Trials Centre, Addenbrooke's Hospital, Cambridge, UK; Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK; CancerResearch UK Cambridge Institute, Cambridge, UK
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Khan J, Yap C, Clark R, Fenwick N, Marin D. Practical implementation of an adaptive phase I/II design in chronic myeloid leukaemia: evaluating both efficacy and toxicity using the EffTox design. Trials 2013. [PMCID: PMC3981036 DOI: 10.1186/1745-6215-14-s1-p20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Provenzano E, Vallier AL, Champ R, Walland K, Bowden S, Grier A, Fenwick N, Abraham J, Iddawela M, Caldas C, Hiller L, Dunn J, Earl HM. A central review of histopathology reports after breast cancer neoadjuvant chemotherapy in the neo-tango trial. Br J Cancer 2013; 108:866-72. [PMID: 23299526 PMCID: PMC3590651 DOI: 10.1038/bjc.2012.547] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Neo-tAnGo, a National Cancer Research Network (NCRN) multicentre randomised neoadjuvant chemotherapy trial in early breast cancer, enroled 831 patients in the United Kingdom. We report a central review of post-chemotherapy histopathology reports on the surgical specimens, to assess the presence and degree of response. Methods: A central independent two-reader review (EP and HME) of histopathology reports from post-treatment surgical specimens was performed. The quality and completeness of pathology reporting across all centres was assessed. The reviews included pathological response to chemotherapy (pathological complete response (pCR); minimal residual disease (MRD); and lesser degrees of response), laterality, the number of axillary metastases and axillary nodes, and the type of surgery. A consensus was reached after discussion. Results: In all, 825 surgical reports from 816 patients were available for review. Out of 4125 data items there were 347 discrepant results (8.4% of classifications), which involved 281 patients. These involved grading of breast response (169 but only 9 involving pCR vs MRD); laterality (6); presence of axillary metastasis (35); lymph node counts (108); and type of axillary surgery (29). Excluding cases with pCR, only 45% of reports included any comment regarding response in the breast and 30% in the axillary lymph nodes. Conclusion: We found considerable variability in the completeness of reporting of surgical specimens within this national neoadjuvant breast cancer trial. This highlights the need for consensus guidelines among trial groups on histopathology reporting, and the participation of histopathologists throughout the development and analysis of neoadjuvant trials.
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Affiliation(s)
- E Provenzano
- Department of Oncology Box 193, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK.
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Earl HM, Vallier A, Hiller L, Fenwick N, Iddawela M, Hughes-Davies L, Provenzano E, McAdam K, Hickish T, Caldas C. Neo-tAnGo: A neoadjuvant randomized phase III trial of epirubicin/cyclophosphamide and paclitaxel ± gemcitabine in the treatment of women with high-risk early breast cancer (EBC): First report of the primary endpoint, pathological complete response (pCR). J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.522] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
522 Background: Neo-tAnGo used a 2-by-2 factorial design, addressing: (i) gemcitabine (G) in a sequential neoadjuvant chemotherapy (CT) regimen of epirubicin/cyclophosphamide (EC) and paclitaxel (T); and (ii) the sequencing of these treatment components (EC then T ± G versus T ± G then EC). Methods: Patients (Pts) with early breast cancer (T2 tumours or above) were randomised to EC then T, T then EC, EC then TG or TG then EC. All components were given x 4 cycles. (E= 90 mg/m2 day (d)1 every (q) 21d; C = 600 mg/m2 d1 q21d; T = 175 mg/m2 d1 q14d; G = 2,000 mg/m2 d1 q14d.) The primary endpoint was pCR, defined as absence of invasive disease in the breast and axillary lymph nodes. 800 pts were required to detect 10% differences in the primary endpoint pCR rates, at the 5% (2-sided) significance level with 85% power. Stratification was by age, inflammatory/locally advanced disease, tumour size, clinical involvement of axillary nodes and oestrogen receptor (ER) status. Results: Between January 2005 and September 2007, 831 pts were randomised by 88 consultants from 57 UK centres. Characteristics were balanced across groups: 63% <50 years old, 25% had inflammatory and/or locally advanced disease, 79% of tumours <50 mm, 50% node positive and 34% ER negative. Two-reader review of 813 (98%) eligible pts'. pathology reports, blinded to treatment arm, were carried out. pCR rates were 17% (95% CI 14–21) for EC&T pts and 17% (95% CI 14–21) for EC&TG pts (p = 0.98). However the sequence T±G then EC, showed pCR of 20% (95% CI 16–24) compared with 15% (95% CI 11–18) for EC then T±G pts (p = 0.03). Adjustment by stratification did not alter results. Conclusions: The Neo-tAnGo results confirm those of the adjuvant tAnGo trial in terms of gemcitabine effect (ASCO 2008). The sequence of T±G-first has demonstrated a significant advantage in pCR compared with the more conventional anthracycline-first sequencing. [Table: see text]
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Affiliation(s)
- H. M. Earl
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
| | - A. Vallier
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
| | - L. Hiller
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
| | - N. Fenwick
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
| | - M. Iddawela
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
| | - L. Hughes-Davies
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
| | - E. Provenzano
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
| | - K. McAdam
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
| | - T. Hickish
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
| | - C. Caldas
- University of Cambridge, Cambridge, United Kingdom; Cambridge Cancer Trials Centre, Cambridge, United Kingdom; Warwick Medical School, University of Warwick, Clinical Trials Unit, Coventry, United Kingdom; Cancer Research UK Clinical Trials Unit, Birmingham, United Kingdom; Cancer Research UK, Cambridge Research Institute, Cambridge, United Kingdom; Addenbrooke's Hospital, Cambridge, United Kingdom; Peterborough Hospital NHS Foundation Trust, Peterborough, United Kingdom; Royal Bournemouth Hospital,
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Wishart GC, Benson JR, Absar MS, Vallier AL, Hiller L, Fenwick N, Champ R, Provenzano E, Caldos C, Earl HM. Sentinel lymph node biopsy (SLNB) prior to primary chemotherapy (PC) in breast cancer patients. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-5111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #5111
Background: Lymph node status is the single most important determinant of prognosis and is used for planning adjuvant therapy. Patient selection and timing of SLNB for PC continue to evolve; SLNB prior to PC may allow more accurate initial staging and prognostication and guide decisions about adjuvant treatment.
 Methods: 78 patients (pts) who were treated in the Cambridge Breast Unit as part of Neo-tAnGo (a multicentre PC trial). 57 were identified as potentially suitable for SLNB pre-PC (clinically node negative, non-inflammatory tumours 2–5cm in size). 38 had axillary ultrasound, and of these, 18 had sonographically suspicious nodes. 12/18 had confirmed nodal metastasis on core biopsy (CB) and had direct ALND post-PC. The remaining 20 patients had innocent nodes or were CB negative, of whom 19 underwent SLNB. A total of 19 patients in this subgroup did not undergo axillary ultrasound; 16 of these proceeded to ALND post-PC and 3 to SLN biopsy pre-PC according to unit policy at the time. A total of 22 (19 + 3) pts were available for analysis of SLN biopsy pre-PC in terms of time to treatment compared to the remainder of the centre's cohort in the Neo-tAnGo study. 42, (22 SLNB + 20 node positive on CB), were analysed as having axillary pathological staging before PC and compared to the other patient cohort on study.
 Results: The SLN was successfully identified in all 22 pts using dual localisation techniques with a mean SLN harvest of 2.8 nodes per patient (range 1–10). 6/22 pts (27%) were node positive, and 5 had single SLN involvement (4 macro-; 1 micro-) and one had a macro- and a micrometastasis in 2 different nodes. The mean time from diagnosis to start of PC in the SLN group was 23 days (range 8–43) compared 18 days (range 7–36) for the comparator cohort on study (p=0.02). When all 42 pts with pathological axillary assessment were analysed (including clinically node positive pts with tumours >5cm), there was no significant difference in time from diagnosis to start of PC for pts undergoing CB and/or SLNB (21 days) compared with no axillary assessment (17 days) (wilcoxon test p=0.10). The mean number of nodes removed on completion ALND was 9 (range 4–16). There was no evidence of any viable tumour or fibrosis in any of the non-SLN's (NSLN) examined. Amongst the group of 18 ultrasound/CB positive pts who underwent ALND without SLNB, nodal disease was found in 9 (50%) with evidence of pathological downstaging in 4 (22%).
 Conclusion: There is potential loss of staging information when SLNB is performed after PC and the clinical significance of a negative SLNB result in this setting is uncertain. A combination of axillary ultrasound (with CB) and SLNB can more accurately stage the axilla without significant overall delays in commencement of PC for clinically node positive and negative pts. Downstaging of disease in NLSN may occur in response to PC with a lower NSLN rate (0%) when compared to primary surgical treatment in smaller tumours (15–25%).
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5111.
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Affiliation(s)
- GC Wishart
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
| | - JR Benson
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
| | - MS Absar
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
| | - AL Vallier
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
| | - L Hiller
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
| | - N Fenwick
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
| | - R Champ
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
| | - E Provenzano
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
| | - C Caldos
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
| | - HM Earl
- 1 Neo-tAnGo Trials Group, Universities of Cambridge, Warwick and Birmingham, Cambridge, Warwick and Birmingham, United Kingdom
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Fenwick N, Morgan M, McKenzie C, Wolfe C. General practitioners' attitudes to the development of midwifery group practices. Br J Gen Pract 1998; 48:1395-8. [PMID: 9800397 PMCID: PMC1313132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND The report Changing childbirth (1993) has led to the development of midwifery-led schemes that aim to increase the continuity of maternity care. AIM To determine the impact of midwifery group practices on the work of general practitioners (GPs) and their perceptions of midwifery group practice care. METHOD Postal questionnaires were sent to 58 GPs referring women to the care of midwifery group practices (group-practice GPs), and a shorter questionnaire was sent to the remaining 67 GPs (non-group-practice GPs) within the same postcode area as a comparison group. In-depth interviews were conducted with 12 GPs. RESULTS Questionnaires were returned by 71% of group-practice GPs and 81% of non-group practice GPs. One third of the group practice GPs felt that they were seeing group practice women too few times, and 50% thought midwives discouraged women from visiting their GP for antenatal checks. Over 80% of group practice GPs believed that midwives had the skills to detect deviation from the normal, and 66% would confidently refer women to their care. However, only 14% of group practice GPs believed that their own role was clear, while 64% agreed that communication with group practice midwives was poor, and concerns were expressed about the level of consultation before establishing schemes. Of the non-group practice GPs, 87% said they would consider referring women to the care of a midwifery group practice in the future. CONCLUSIONS General practitioners were generally positive about the quality of care provided by midwifery group practices but identified issues that require addressing in developing this model of care.
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Affiliation(s)
- N Fenwick
- Department of Public Health Medicine, UMDS, London
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Morgan M, Fenwick N, McKenzie C, Wolfe CD. Quality of midwifery led care: assessing the effects of different models of continuity for women's satisfaction. Qual Health Care 1998; 7:77-82. [PMID: 10180794 PMCID: PMC2483588 DOI: 10.1136/qshc.7.2.77] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Changing Childbirth (1993), a report on the future of maternity services in the United Kingdom, endorsed the development of a primarily community based midwifery led service for normal pregnancy, with priority given to the provision of "woman centred care". This has led to the development of local schemes emphasising continuity of midwifery care and increased choice and control for women. AIMS To compare two models of midwifery group practices (shared caseload and personal caseload) in terms of: (a) the extent to which women see the same midwife antenatally and know the delivery midwife, and (b) women's preference for continuity and satisfaction with their care. METHODS A review of maternity case notes and survey of a cohort of women at 36 weeks of gestation and 2 weeks postpartum who attended the two midwifery group practices. Questionnaires were completed by 247 women antenatally (72% response) and 222 (68%) postnatally. Outcome measures were the level of continuity experienced during antenatal, intrapartum, and postnatal care, women's preferences for continuity of carer, and ratings of satisfaction with care. RESULTS The higher level of antenatal continuity of carer with personal caseload midwifery was associated with a lower percentage having previously met their main delivery midwife (60% v 74%). Women's preferences for antenatal continuity were significantly associated with their experiences. Postnatal rating of knowing the delivery midwife as "very important indeed" was associated with both previous antenatal ratings of its importance, and women's actual experiences. Personal continuity of carer was not a clear predictor of women's satisfaction with care. Of greater importance were women's expectations, their relations with midwives, communication, and involvement in decision making. CONCLUSIONS Midwifery led schemes based on both shared and personal caseloads are acceptable to women. More important determinants of quality and women's satisfaction are the ethos of care consistency of care, good communication, and participation in decisions.
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Affiliation(s)
- M Morgan
- Department of Public Health Medicine, United Medical and Dental Schools, St Thomas' Hospital, London, UK
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Garraway WM, Cuthbertson C, Fenwick N, Ruckley CV, Prescott RJ. Consumer acceptability of day care after operations for hernia or varicose veins. J Epidemiol Community Health 1978; 32:219-21. [PMID: 213459 PMCID: PMC1060950 DOI: 10.1136/jech.32.3.219] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The opinions of patients and of caring persons (usually relatives) were sought in this trial of different methods of providing care for 360 patients after operations for hernia or varicose veins. Analysis of patients' opinions suggested that day care was the most acceptable of the three types of care examined. The reactions of caring persons did not reveal any major criticisms or disadvantages.
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Prescott RJ, Cutherbertson C, Fenwick N, Garraway WM, Ruckley CV. Economic aspects of day care after operations for hernia or varicose veins. J Epidemiol Community Health 1978; 32:222-5. [PMID: 213460 PMCID: PMC1060951 DOI: 10.1136/jech.32.3.222] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In a trial of 360 patients with hernia or varicose veins, day care surgery provided an economic alternative to the provision of surgical aftercare either in the surgical wards of a district hospital or in a convalescent hospital. There was only slightly more work for general practitioners. Most of the additional work for the community services was carried out by district nurses, with an average contact time in the postoperative period of 325 minutes for day care patients, compared with 186 minutes and 204 minutes respectively for patients admitted for 48 hours to the surgical or convalescent wards. Day care produced estimated savings of 30 pounds compared with the costs of a 48-hour stay in the surgical wards, and savings of 22 pounds compared with a 48-hour stay in the convalescent wards.
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Ruckley CV, Cuthbertson C, Fenwick N, Prescott RJ, Garraway WM. Day care after operations for hernia or varicose veins: a controlled trial. Br J Surg 1978; 65:456-9. [PMID: 352473 DOI: 10.1002/bjs.1800650704] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Alternative systems of care after operations for varicose veins or hernia were compared in a total of 360 selected patients, of whom 121 were allocated to be managed in an acute ward for 48 h, 122 in a convalescent hospital for 48 h and 117 to be discharged directly home to the care of the district nursing sister and general practitioner. There were no deaths or major complications. Anaesthetic or surgical problems caused 5 patients (3 convalescent and 2 day care) to be retained in hospital on the day of operation. Minor complications were recorded in approximately one-third of the patients. The majority of these were effectively dealt with by the district nursing sister and only one-third of the complications needed the attention of the general practitioner. Two of the ward patients and 1 of the convalescent patients required readmission to hospital (1 per cent in all). No significant difference was demonstrated in the medical outcome between the three groups after operation. Day care was the most economical of the three systems of care. Inquiry into the patients' opinions elicited the highest proportion of favourable responses in the day care group.
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