Abstract OT3-01-03: A phase I trial of the safety and immunogenicity of a DNA plasmid based vaccine (WOKVAC) encoding epitopes derived from three breast cancer antigens (IGFBP2, HER2, and IGF1R) in patients with breast cancer

Background: Three proteins insulin like growth factor binding protein 2 (IGFBP2), human epidermal growth factor receptor 2 (HER2), and insulin like growth factor receptor-1 (IGF1R) are overexpressed in in pre-invasive and high risk breast lesions and are associated with progression to invasive breast cancer. These proteins are immunogenic and elicit both humoral and cellular immunity in breast cancer patients. It is hypothesized that immunization with a plasmid vaccine (WOKVAC) targeting antigens from these proteins will be safe and immunogenic. WOKVAC has been designed to include extended sequences of the immunizing antigens that are predominantly associated with eliciting Type I immune responses. Type I immunity results in immune cells called T-cells secreting high levels of inflammatory cytokines (called Th1) that stimulate tumor destruction as well as the generation of cytotoxic T-cells that can directly kill the tumors.

Trial design: Phase I dose escalation study of 3 doses of WOKVAC admixed with 100mcg of GM-CSF. Patients will be assigned sequentially to one of three arms (10 patients/arm): Arm 1=150mcg, Arm 2=300mcg, Arm 3=600mcg. Each dose arm will have a staggered enrollment to assess toxicity. If the Arm 1 dose is determined to be safe, Arm 2 patients can be enrolled. If the Arm 2 dose is safe and immunologically more efficacious than Arm 1 then Arm 3 patients can be enrolled. Study treatment includes 3 monthly vaccines, two evaluations at 1 and 6 months post vaccine and a 5 year follow-up to collect reports from the patient's primary oncologist. Toxicity is assessed at baseline through the end of the study. Serial blood draws for immunologic monitoring is done.

Eligibility criteria: Patients with non-metastatic, node positive, HER2 negative breast cancer that is in remission and defined as no evidence of disease. Patients must have a good performance status, be at least 28 days from last cytotoxic chemotherapy and/or radiotherapy and 28 days from any use of systemic steroids.

Specific aims: (1) Determine safety of 3 escalating doses of WOKVAC, (2) Determine the most immunogenic dose, (3) Determine whether a WOKVAC Th1 polyepitope plasmid based vaccine elicits a persistent memory T-cell and (4) Determine whether WOKVAC vaccination modulates T regulatory cells and myeloid derived suppressor cells.

Statistical methods: (1) Safety will be assessed per NCI CTCAE v. 4.0, (2) Immunogenicity will be defined by the magnitude of the Th1 IFN-gamma antigen specific immune response. Successful immunization is a protein specific IFN-g precursor frequency greater than 1:20,000 PBMC for each antigen or 2 fold increase if baseline immune response (3) The IGFBP2, HER2, and IGF1R specific IFN-g/IL-10 ratios by ELISPOT will be evaluated to determine that a predominantly Th1 immune response is stimulated, and (4) Humoral immune response will be measured by ELISA and serum antibody avidity for IGFBP2, HER2, and IGF1R to determine an avidity index (AI) before and after vaccination.

Targeted Accrual: 30 patients

Contact information:

University of Washington: 866-392-8588/TrialTVG@uw.edu

University of Wisconsin: 608-265-2493/prevention@uwcarbone.wisc.edu.

Citation Format: Childs JS, Higgins DM, DeShong K, Heckman-Stoddard BM, Wojtowicz ME, Stanton SE, Bailey HH, Wisinski KB, Disis ML. A phase I trial of the safety and immunogenicity of a DNA plasmid based vaccine (WOKVAC) encoding epitopes derived from three breast cancer antigens (IGFBP2, HER2, and IGF1R) in patients with breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-01-03.

Abstract P2-11-03: Phase I/II randomized study of combination immunotherapy with or without polysaccharide krestin (PSK) concurrently with a HER2 ICD peptide-based vaccine in patients with stage IV breast cancer receiving HER2-targeted monoclonal antibody therapy

Natural killer (NK) cell defects, commonly seen in metastatic breast cancer (MBC) lead to decrease in dendritic cell (DC) maturation, proinflammatory cytokine production, and tumor infiltrating T-cells (TILs). This results in a protumorigenic Th2 immune microenvironment with low response rates to immunotherapy (i.e., immune checkpoint blockade) and standard chemotherapy. PSK, a potent TLR-2 agonist, activates NK cells to produce IFN-γ and IL-12 and promote DC maturation/differentiation toward a Th1 profile in the tumor microenvironment which results in antigen specific TIL that can eradicate tumor. The combination immunotherapy of PSK and HER2 directed therapy described here, aims at inducing Th1 immunity and tumor specific T-cells. This proposed regimen could eradicate microscopic residual disease and prevent recurrence in optimally treated HER2+ MBC patients. Moreover, the regimen could result in enhanced trafficking of TILs to the site of tumor and improve the efficacy of checkpoint inhibitors and other therapies. A phase I/II randomized 2 arm study of combination immunotherapy with oral PSK (or placebo) given with a HER2 peptide vaccine and HER2 mAb therapy (trastuzumab (TZ) +/- pertuzumab (PZ)) was initiated to assess the safety of the approach and evaluate the effect of PSK on NK cell activity, pro-inflammatory cytokine/chemokine profile; and HER2 vaccine-induced T cell immunity.

Methods: Up to 30 patients with HER2+ MBC who are without evidence of disease after definitive therapy and currently on maintenance TZ +/- PZ are enrolled and randomly assigned in equal numbers to 1 of 2 arms (15 patients/arm): Arm 1: HER2 ICD vaccine + placebo or Arm 2: HER2 ICD vaccine + PSK. All patients receive concomitant treatment with 4 months of daily oral PSK or placebo, 3 monthly intradermal HER2 ICD vaccinations and continued TZ +/- PZ. Toxicity is evaluated per CTEP CTCAE 4.0, during and post vaccination. Serial blood draws for immunologic evaluation of NK cell activity and antigen-specific T cell immunity via flow cytometry and IFN-γ ELISPOT, respectively; and pro-inflammatory cytokines/chemokines.

Results: 24 subjects have been enrolled and 60 vaccines have been given. 16 subjects have completed all 3 vaccines and PSK/placebo; and 6 subjects are currently in progress. 2 subjects received < 3 vaccines and were taken off study. Of 144 reported adverse events (AEs), 97% were Grade 1-2; 66 (46%) were possibly, probably, or definitely related to study treatment. Most common AEs are injection site reaction and flu-like symptoms. There have been a total of four Grade 3 AEs, 1 episode of self-limited nausea/vomiting attributed to study treatment; and cognitive disturbance, fatigue, and lymphopenia all in 1 subject and attributed to disease progression. There have been no Grade 4 AEs. Immunologic analyses are ongoing and will be presented along with completed clinical data on all patients.

Conclusion: Combination immunotherapy with PSK/placebo and concurrent HER2 directed therapy is safe and well-tolerated. Further ongoing immunologic studies will help define the immunogenicity of the approach.

Citation Format: Salazar LG, Higgins D, Childs J, Coveler AL, Liao J, Stanton S, Gooley T, Standish LJ, Sasagawa M, DISIS ML. Phase I/II randomized study of combination immunotherapy with or without polysaccharide krestin (PSK) concurrently with a HER2 ICD peptide-based vaccine in patients with stage IV breast cancer receiving HER2-targeted monoclonal antibody therapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-11-03.

Abstract P6-05-06: Association of HER2/neu single nucleotide polymorphism with trastuzumab-related cardiotoxicity

Background: Treatment with trastuzumab prolongs overall survival when given to patients (pts) with Her2/neu+ breast cancer (BC). The primary toxicity of trastuzumab is cardiotoxicity and the incidence is estimated at 2-4% in the adjuvant setting. The mechanism for trastuzumab-induced cardiotoxicity is not known. Although Her2neu expression is usually not seen on cardiac myocytes, its expression has been shown to be upregulated after chemotherapy. Trastuzumab is a monoclonal antibody that binds to the extracellular domain of Her2/neu. We hypothesized that single nucleotide polymorphisms (SNPs) in the Her2/neu receptor may play a role in trastuzumab associated cardiotoxicity.

Methods: 140 pts with BC who were treated with chemotherapy and trastuzumab were enrolled into an IRB approved protocol at the Weill Cornell Medical College between July 2008 and March 2013. Cardiotoxicity was defined as either symptomatic CHF, or a decline in LVEF of 15% (or if LVEF <55% a decline in LVEF of 10%) that required management with medications and led to temporary or permanent discontinuation of trastuzumab. 11 nonsynonomous human ErbB2 SNPs were identified in the National Center for Biotechnology Information SNP database (rs1136201, rs2172826, rs28933368, rs28933369, rs28933370, rs34602395, rs36085723, rs4252633, rs55943169, rs56366519, rs61552325). Genotyping of SNPs was performed on DNA prepared from blood or buccal washes. The relationship between SNP characteristics and cardiotoxicity status was assessed by the chi-square test and multivariable logistic regression analysis.

Results: 140 subjects (29 with cardiotoxicity and 111 without) had 11 SNPs sequenced. Median age of subjects was 56 years (range: 32-85), mean baseline LVEF was 65% (±6%). 16.4% of subjects had hypertension (HTN). 80% of patients were Caucasian, 10% East Asian, 7.1% African American, 2.9% South Asian. There were two SNPs for which there was variation seen among subjects: rs 1136201 (corresponding to codon 655) and rs61552325 (codon 1170). The frequencies of the codon 655 polymorphisms were: AA (Ile/Ile) 67.9%, AG (Ile/Val) 29.3%, and GG (Val/Val) 2.9%. The frequencies of the codon 1170 polymorphisms were: CC (Pro/Pro) 20.7%, GC (Ala/Pro) 45.7%, and GG (Ala/Ala) 33.6%. There was no association observed between the codon 655 polymorphism and cardiotoxicity (p = 0.96). A significant association between cardiotoxicity and the codon 1170 polymorphism was observed, with subjects having cardiotoxicity being more likely to carry the CC allele compared with subjects without cardiotoxicity (34.5% vs 17.1%, p = 0.04). This association persisted after multivariable adjustment for age, race, and HTN status (adjusted OR = 2.60, 95% CI = 1.02-6.62, p = 0.046).

Conclusion: In this study, the Her2/neu 1170 Pro/Pro polymorphism was associated with trastuzumab cardiotoxicity. If confirmed in a larger series, this polymorphism could be used to identify pts who may be at increased risk for cardiotoxicity and who may benefit from treatments associated with less cardiotoxicity. Furthermore, the Her2/neu 1170 SNP has previously been implicated as a minor histocompatibility antigen, and our findings raise the possibility that immune mediated mechanisms may play a role in trastuzumab related cardiotoxicity.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-05-06.

Abstract P5-01-09: Early tumor antigens discovered in TgMMTV-neu mice may provide targets for early breast cancer diagnosis and prevention

Breast cancer is immunogenic and breast tumor proteins stimulate both an antibody and a T cell immune response. Identification of cancer related proteins that become immunogenic prior to the clinical development of cancer may allow the use of humoral immunity to identify those “exposed” to the cancer phenotype. Alternatively, these proteins that become aberrant enough to trigger such early immune recognition may be ideal targets for a vaccine aimed at preventing the development of breast cancer. We used the TgMMTV-neu mouse model to discover immunogenic proteins i.e. proteins expressed in pre-invasive breast cancer. The mammary tumors in these mice are genotypically similar to human luminal breast cancer and can be evaluated longitudinally, allowing for collection of pre-diagnostic sera prior to tumor development to use for antigen discovery.

We identified 6 antigens that were present in mice prior to the development of mammary cancer (Pdhx, Otud6b, Stk39, Zpf238, Lgals8, and Vps35). These proteins were associated with inflammation, autoimmunity, and cellular homeostasis. In mouse validation cohorts, detecting IgM and IgG antibody responses against a panel of three “pre-diagnostic” tumor antigens discriminated pre-diagnostic sera from non-transgenic control sera with an AUC of 0.924. We next evaluated samples obtained from the Women's Health Initiative Study and demonstrated women with autoantibodies to the human homologues of these proteins. IgM and IgG autoantibodies to the “pre-diagnostic” antigen panel could discriminate the samples of women who eventually developed breast cancer from matched controls. The discriminatory potential of the pre-diagnostic autoantibodies was enhanced if samples were collected more than 5 months prior to diagnosis (AUC 0.68; CI 0.565-0.787). We questioned whether these antigens, which could predict women who would eventually develop breast cancer, could mediate anti-tumor immunity. When TgMMTV-neu mice (n = 5/group) were vaccinated with the individual antigens, vaccination with Pdhx inhibited tumor growth by 62.1%, Otud6B inhibited tumor growth by 23.5%, and Stk39 inhibited tumor growth by 50.3% as compared to empty vector vaccinated control at 27 weeks (p<0.001 for each of the individual antigens as compared to empty vector). Spontaneous tumorigenesis was inhibited in TgMMTV-neu mice (n = 20 mice/group) vaccinated with a panel of three of the “pre-diagnostic” antigens (Pdhx, Otud6b, and Stk39) inhibited tumor growth by 27.3% by 37 weeks as compared to vector vaccinated mice (p<0.05). These data suggest that the same pre-invasive breast tumor proteins are found in mice and women and vaccines against these pre-invasive breast cancer proteins inhibit tumorigenesis in mice, future studies will address if these antigens elicit T-cell responses in patients with high risk breast lesions.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-01-09.

Total versus subtotal hysterectomy: a survey of current views and practice among British gynaecologists

This paper reports the results of a postal questionnaire, with a response rate of 61 per cent. It is clear from the results that subtotal hysterectomy is an unpopular operation in the United Kingdom. Although a majority of consultants felt that subtotal hysterectomy was less likely to affect urinary, bowel and sexual function, this did not seem to affect decision making. Seventy-eight per cent of female gynaecologists would prefer a total hysterectomy for themselves rather than a subtotal procedure.

Loss-of-heterozygosity analysis of small-cell lung carcinomas using single-nucleotide polymorphism arrays

Human cancers arise by a combination of discrete mutations and chromosomal alterations. Loss of heterozygosity (LOH) of chromosomal regions bearing mutated tumor suppressor genes is a key event in the evolution of epithelial and mesenchymal tumors. Global patterns of LOH can be understood through allelotyping of tumors with polymorphic genetic markers. Simple sequence length polymorphisms (SSLPs, or microsatellites) are reliable genetic markers for studying LOH, but only a modest number of SSLPs are used in LOH studies because the genotyping procedure is rather tedious. Here, we report the use of a highly parallel approach to genotype large numbers of single-nucleotide polymorphisms (SNPs) for LOH, in which samples are genotyped for nearly 1,500 loci by performing 24 polymerase chain reactions (PCR), pooling the resulting amplification products and hybridizing the mixture to a high-density oligonucleotide array. We characterize the results of LOH analyses on human small-cell lung cancer (SCLC) and control DNA samples by hybridization. We show that the patterns of LOH are consistent with those obtained by analysis with both SSLPs and comparative genomic hybridization (CGH), whereas amplifications rarely are detected by the SNP array. The results validate the use of SNP array hybridization for tumor studies.

Recurrent allelic deletions of chromosome arms 15q and 16q in human small cell lung carcinomas

The genetic lesions that lead to the development of small cell lung carcinoma (SCLC) remain incompletely defined. To identify recurrent allelic deletions in specific chromosomal regions that could serve as markers for tumor suppressor gene (TSG) inactivation in SCLC, we performed a comprehensive allelotype analysis of all 39 nonacrocentric autosomal arms. Alterations in 158 polymorphic microsatellite alleles were examined in 24 pairs of human SCLC tumor and normal control DNA samples. A total of 2,107 informative reactions were analyzed. This analysis revealed allelic losses of 100% on chromosome arm 3p, >85% loss within chromosome arms 13q and 17p, and >70% loss within chromosome arms 4q, 5q, 15q, and 16q. The allelic deletions on chromosome arms 15q and 16q have not been defined previously for SCLC and are candidate regions to harbor novel TSGs. Genes Chromosomes Cancer 27:323-331, 2000.

Ambulatory urodynamics: do they help clinical management?

OBJECTIVE

To assess the contribution of ambulatory urodynamics to the treatment of women with urinary incontinence.

DESIGN

A retrospective casenote review of all women referred from the urogynaecology clinic for ambulatory urodynamic monitoring from 1 April 1994 to 31 December 1997.

SETTING

A teaching hospital tertiary referral centre urodynamic laboratory.

PARTICIPANTS

Notes were retrieved of 71 women, 80% of whom had had the investigation because the conventional cystometrogram had been normal.

RESULTS

Technical difficulties occurred in 30 traces, two of which were not interpretable. Detrusor instability was diagnosed in 32 women, including three women who also had stress incontinence (42% of interpretable traces). Of these, 20 women were treated with anticholinergics compared with nine of 37 women where detrusor instability was not diagnosed. None of the women with detrusor instability were offered anti-incontinence surgery, compared with five of those where the bladder remained stable. Less than half the women who were treated with anticholinergic medication improved, but none were considered suitable for more aggressive treatment.

CONCLUSIONS

Although the diagnosis of detrusor instability may be increased by ambulatory urodynamics, this does not always translate into more effective treatment. Ambulatory urodynamic testing does not yet result in clinical improvements in diagnosis and treatment.

Periurethral collagen injection: a long-term follow-up study

OBJECTIVE

To determine the long-term success of the periurethral injection of collagen (Contigen(R), Bard UK) in women with genuine stress incontinence.

PATIENTS AND METHODS

Sixty-one women with genuine stress incontinence were enrolled in a trial of periurethral collagen injections between 1 September 1990 and 31 August 1992. They were assessed at 1, 3, 6, 12 and 24 months after the last collagen injection. In 1998, their notes were reviewed, and a standardized questionnaire was sent to 46 women who were still alive and had undergone no further anti-incontinence surgery.

RESULTS

Of the 53 women who were either known failures or who had follow-up information beyond 5 years, 26% were subjectively improved. Women who had a maximum urethral closure pressure of >20 cmH2O and those who had urinary incontinence for <10 years before their first injection were more likely to have had long-term success. There was no correlation between long-term success and the number of previous operations, body mass index, age or preoperative pad loss. Neither the number of injection sessions, total volume of collagen injected nor perceived bulking at the time of surgery affected long-term success rates. Of the 14 women who considered themselves subjectively improved, seven had daily incontinence and only one was completely dry. Urinary retention and urinary tract infection were the most common complications. In addition, one woman reported a flare-up of her skin test and transient 'flu-like symptoms 2 weeks after the injection, and one woman developed a right upper lobe pneumonia 2 weeks after the collagen injection.

CONCLUSION

The long-term results of periurethral collagen injections are disappointing. We found no evidence to support the use of periurethral collagen injections in women with intrinsic sphincter deficiency, who had a higher failure rate than those with hypermobility. Further research is essential to develop agents that are not immunogenic, produce minimal inflammatory response and yet are durable.

How process enterprises really work

Many companies have succeeded in reengineering their core processes, combining related activities from different departments and cutting out ones that don't add value. Few, though, have aligned their organizations with their processes. The result is a form of cognitive dissonance as the new, integrated processes pull people in one direction and the old, fragmented management structures pull them in another. That's not the way it has to be. In recent years, forward-thinking companies like IBM, Texas Instruments, and Duke Power have begun to make the leap from process redesign to process management. They've appointed some of their best managers to be process owners, giving them real authority over work and budgets. They've shifted the focus of their measurement and compensation systems from unit goals to process goals. They've changed the way they assign and train employees, emphasizing whole processes rather than narrow tasks. They've thought carefully about the strategic trade-offs between adopting uniform processes and allowing different units to do things their own way. And they've made subtle but fundamental cultural changes, stressing teamwork and customers over turf and hierarchy. These companies are emerging from all those changes as true process enterprises--businesses whose management structures are in harmony, rather than at war, with their core processes. And their organizations are becoming much more flexible, adaptive, and responsive as a result.

Women's attitudes to urodynamics: a questionnaire survey

OBJECTIVE

To obtain a measure of how well women tolerate urodynamic investigations and to determine how well they thought the test was explained.

DESIGN

Prospective questionnaire survey.

SETTING

A teaching hospital tertiary referral centre urodynamic laboratory.

PARTICIPANTS

Three hundred and twenty-four women attending for urodynamic investigations on 331 occasions. Questionnaires were returned from 297 women (91.7%) with six women returning two questionnaires.

RESULTS

Urodynamic investigations were well tolerated by most women, with 45% feeling that the procedure was not as bad as they expected. Moderate or severe anxiety about the test was experienced by 42% and 40% felt moderately or severely embarrassed. Pain was noted by 27% of women during investigation, and by 13% after investigation. Overall distress from the procedure was less in older women and in those who had been referred from a specialist urogynaecology clinic. Distress was higher when difficulties were encountered during the investigation and in women who had investigations other than a standard cystometrogram. Women were likely to find the test less distressing when they felt they had been given adequate information about the test.

CONCLUSIONS

Although urodynamic investigations are generally well tolerated, there is a significant minority of women who find the test embarrassing, painful and distressing.

Iontophoresis as a new method of delivering local anesthesia to the urethra: a pilot study

OBJECTIVES

To test the feasibility of using the iontophoretic catheter as a means of delivering local anesthetic (lidocaine hydrochloride) to the urethra for periurethral injection of collagen.

METHODS

Eight women with urodynamically proven genuine stress incontinence underwent periurethral collagen injections. Local anesthesia was provided by 4% lidocaine with 1 in 100,000 epinephrine administered over 10 minutes using an iontophoretic catheter. Pain was assessed by Likert and visual analogue scales. Cystoscopic appearance of the urethra was noted.

RESULTS

The periurethral bulking procedure was completed without further anesthetic in 7 women, 1 of whom had no pain. There was no evidence of urethral damage from the iontophoresis.

CONCLUSIONS

Iontophoresis shows promise as a method of providing analgesia to the urethra. However, the degree of analgesia is variable, and further research is needed on catheter design to ensure transport of anesthetic agent into the periurethral tissues.

Assessing the impact of staff development on nursing practice

The purpose of the study was to evaluate the influence of a geriatric nursing education workshop on nursing staff competency. Forty-three nurses participated in the study, which used an intervention and comparison group research design with pretest and posttest measures. The results indicated that participation in the workshop increased nurses' knowledge of gerontologic issues and improved nurses' ability to assess patients and to plan and document nursing interventions in patient charts. The intervention did not have a significant impact on collaborative practice, role ambiguity, or job satisfaction.

Auditory evoked potentials in cats with neonatal high frequency hearing loss. Evidence of abnormal frequency representation in the midbrain

We have recorded auditory evoked potentials, of both neurogenic and myogenic origin, in cats having neonatal high frequency cochlear hearing loss. Using frequency specific stimuli (tone pips) and by measuring responses near to threshold, we have probed tonotopic (or cochleotopic) representation within the brainstem-midbrain auditory pathway. At stimulus frequencies corresponding to the high frequency cut-off of the cats' audiograms we have observed enhanced amplitudes of both auditory brainstem evoked responses (ABR) and postauricular myogenic (PAM) potentials. We interpret our findings as evidence of a larger than normal population of neurons tuned to this frequency region. We suggest that such abnormal frequency representation results from a long-term sensory deficit caused by lesions to the basal, high frequency region of the cochleas.

Reorganization of auditory cortex after neonatal high frequency cochlear hearing loss

Cochleotopic representation in cortex (AI) is extensively reorganized in cats having neonatal, bilateral high frequency cochlear hearing loss. Anterior areas of AI, normally devoted to high frequencies, contain neurons which are almost all tuned to one lower frequency. This frequency corresponds, at the level of the cochlea, to the border between normal and damaged haircell regions.

Cochlear nerve monitoring during cerebellopontine angle operations

The authors present their experience with intraoperative monitoring of cochlear nerve action potentials (AP) in 30 adult patients. Operative procedures were acoustic neuroma excision with attempted hearing preservation and selective vestibular neurectomy in patients with incapacitating Meniere's disease and serviceable hearing (SRT less than 50 db, discrimination greater than 60%). Loss of AP is detected rapidly and has been demonstrated after manipulation of the cochlear nerve and after coagulation of small arteries on the tumour capsule. Presence of an AP at the end of the procedure usually correlates with postoperative preservation of hearing. AP monitoring appears to be a reliable means of detecting potentially reversible changes in cochlear nerve function intraoperatively.

Concern about cancer in women undergoing elective gynaecological surgery

Interviews were conducted with 63 women aged 18-75 shortly after their admission to hospital for routine non-cancer gynaecological surgery. Three groups were studied: major surgery, chiefly hysterectomy, carried out for benign conditions (n = 25); minor surgery such as dilatation and curettage (n = 29); fertility investigations and sterilisations (n = 9). Women were asked whether they worried if they were suffering from seven serious illnesses including heart disease, breast cancer and gynaecological cancer (cancer of the cervix, womb or ovaries). Significantly more women were concerned that they suffered from gynaecological cancer than any other illness. When asked why they were worried, over 85% of those expressing concern believed that their current gynaecological problem stemmed from cancer. Worry about gynaecological cancer was positively associated with psychiatric status and gynaecological knowledge, and negatively with satisfaction with treatment. A link with presenting clinical symptoms was also identified. This study revealed high levels of unwarranted distress in women undergoing routine surgery. Such fears may not be allayed, since surgeons and staff may not consider cancer to be relevant to the patient's clinical condition.