Call for cancer trials at the start of treatment
ENROLLING adult patients with cancer in clinical trials at the start of their treatment could improve the cancer cure rate, according to a letter published in the MJA. Professor Catherine Cole, of the school of paediatrics and child heath at the University of WA, wrote that clinical trials were currently more common for recurrent or metastatic disease, and were usually undertaken by drug companies marketing new and expensive drugs for patients with incurable cancer. The availability of targeted therapies had transformed many incurable cancers into chronic diseases, and this imposed costs that threatened the health budget. “A simple way to reduce these costs is to cure patients when they present with de novo disease”, Professor Cole wrote. She said that improving the cure rate could be achieved by embedding clinical research in all cancer treatment centres. This research would be performed by committed oncologists (including surgeons, radiation oncologists and the entire multidisciplinary team) setting aside time to take part in cooperative group trials. Professor Cole said that the costs of these group trials would be minimal, as most expenses associated with cancer were incurred whether the patient was in a trial or not. However, government commitment and hospital administrative support would be needed for data management and statistical analysis. “To see an example of how this system works in practice, look no further than the paediatric oncologists who have worked collaboratively for half a century, enrolling patients in embedded clinical trials, and are now curing over 80% of children with cancer”, Professor Cole wrote.
Perinatal depression linked to previous depressive symptoms
AUSTRALIAN research has found that the great majority of women with perinatal depressive symptoms had previously experienced episodes of depression and anxiety at levels that would have been of concern to their GP. The 20-year prospective study, published in The Lancet, was based on a stratified, random sample of 1000 female adolescents originally recruited in 1992 and 1993 from 44 Victorian secondary schools and assessed for depressive and anxiety symptoms at nine time points between the ages of 14 and 29 years. The current research was based on 384 women (aged 29‒35 years) and 564 pregnancies prospectively identified among cohort participants during 6-monthly screening. The authors found that 80 of the women (21%) reported mental health problems only during adolescence, 56 (15%) only as young adults and 117 (30%) during both adolescence and young adulthood. “Overall, two-thirds of all participants reported a mental health problem either during adolescence or young adulthood”, the researchers wrote. Of 256 primiparous mothers, 56 (22%) reported depressive symptoms during at least one assessment and 20 (8%) at two or three assessments. In the 308 women with second and subsequent pregnancies, 53 (17%) reported high depressive symptoms during at least one assessment and 14 (5%) at two or three assessments. Of the 384 women, 98 (25%) reported depressive symptoms at one or more perinatal assessment for one or more pregnancies. The authors wrote that the research “further challenge the view that perinatal depression is distinct from previous mental health problems”. They said that perinatal depressive symptoms were reported in only one in 13 pregnancies in women with no preconception history of depression. The extent of mental health problems before conception suggested a “window of intervention should extend to the years before pregnancy”. An accompanying commentary said the research “powerfully reinforced our knowledge that past depression is a strong predictor” of perinatal depression.
Long-term survival possible with pancreatic cancer
ALTHOUGH pancreatic ductal adenocarcinoma (PADC) remains a deadly disease, long-term survival (LTS) is possible, even beyond the 10-year mark, according to research published in JAMA Surgery. The US study was based on data collected from a national cancer database of patients with PADC who underwent pancreatic surgical resection to remove a primary tumour between 1998 and 2002. The authors developed a multivariable logistic regression model to predict the likelihood of patients achieving LTS, which was defined as surviving at least 10 years after the initial diagnosis. Of the 11 081 patients with complete survival information, 431 achieved LTS. In order of importance, the significant predictors of LTS were lymph node positivity ratio, adjuvant chemotherapy, pathologic T stage, patient age, tumour grade, surgical margin, pathologic M stage, tumour size, educational level and insurance status. The authors predicted that patients with the most favourable characteristics had an 18.1% chance of LTS. Survival curves showed that the probability of dying following the initial diagnosis of PADC reached a plateau of approximately 10% per year after 7 years of survival. The authors said that the positive association between the use of adjuvant chemotherapy and LTS “could be interpreted as a possible surrogate marker for a less-complicated postoperative course and better overall patient performance status, even though a direct tumour-toxic effect of chemotherapy is not excluded”. An accompanying commentary said the study highlighted the importance of systemic therapy in treating pancreatic cancer, and that with “the advances in pancreatic cancer research and the growth of multidisciplinary management, we expect a growing number of patients will realize the benefits of incremental improvement in the management of this lethal disease”.
Bystander CPR improves survival
CARDIOPULMONARY resuscitation (CPR) performed by a bystander on a person having an out-of-hospital cardiac arrest increased their 30-day survival rate to twice that of those who did not receive CPR, according to research published in the New England Journal of Medicine. The study analysed 30 381 out-of-hospital cardiac arrests witnessed in Sweden between 1990 and 2011. It found that CPR was performed before the arrival of emergency medical services (EMS) in 15 512 (51.1%) cases. The 30-day survival rate was 10.5% when CPR was performed before EMS arrival versus 4.0% when it was not. The positive correlation between early CPR and survival rate remained stable throughout the study period. An association was also observed between the time from collapse to the start of CPR and the 30-day survival rate. The researchers also found that, despite the findings, the time between collapse and the arrival of EMS, and the time between collapse and first defibrillation, were longer in cases where CPR was given. “Thus, the survival rate among patients who received CPR before EMS arrived was increased despite the fact that the time to defibrillation was prolonged”, they wrote. A second study found that a mobile-phone positioning system for dispatching lay volunteers trained in CPR to assist out-of-hospital cardiac arrest patients was associated with significantly increased rates of bystander-initiated CPR. An accompanying editorial said improvement in rates of bystander-initiated CPR was a critical public health issue. “To increase the rate of CPR that is performed by volunteers, we must empower people who are trained in CPR by integrating them into the EMS system and alerting them when a cardiac arrest occurs”, it said.
One dose of HPV vaccine provides protection
AN analysis of two phase 3, double-blinded, randomised controlled trials to test the clinical efficacy of the HPV-16/18 AS04-adjuvanted vaccine in young women has found that those who had one and two doses vaccine doses had similar protection against cervical infections 4 years after vaccination to those who received the three-dose schedule. The research, published in The Lancet Oncology, was a post-hoc analysis combining data from the Costa Rica Vaccine Trial (CVT) of 7466 healthy women aged 18–25 years and the Papilloma Trial against Cancer in Young Adults (PATRICIA) of 18 644 healthy women aged 15–25 years from the Asia-Pacific, Europe, Latin America and North America. Women in each trial were randomly assigned to receive the HPV-16/18 vaccine or a control (hepatitis A) vaccine, given in three doses — at enrolment, at 1 month and at 6 months. However, some women received fewer than three doses. In the vaccinated cohort, 22 327 women received three doses, 1185 two doses and 543 one dose. The researchers found a vaccine efficacy of 77% for three doses, 76.0% for two doses, and 85.7% for one dose against incident HPV-16/18 infections. Vaccine efficacy against incident HPV-31/33/45 infections for three doses was 59.7%, two doses 37.7% and one dose 36·6%. Vaccine efficacy against incident HPV-16/18 infection for two-dose women who received their second dose at 1 month was 75.3% and 82.6% for those who received the second dose at 6 months (CVT data only). “If one-dose HPV vaccine administration provides strong protection against HPV-16/18 for the long term, this approach might be what is necessary to overcome the barriers prohibiting vaccine uptake in many world regions”, the researchers wrote, saying the data argued for a direct assessment of one-dose efficacy of the HPV-16/18 vaccine. An accompanying commentary said that if the findings were confirmed “it opens up a great opportunity to extend the reach of protection using HPV vaccines to more people than we would have previously thought possible”. The research was funded in part by GlaxoSmithKline.
Memory loss linked to lipid-lowering drugs
BOTH statin and non-statin lipid-lowering drugs (LLDs) are strongly associated with acute memory loss in the first 30 days of use when compared with non-users, but there was no difference between the effects of the two drug classes, research has found. The retrospective cohort study, published in JAMA Internal Medicine, used information documented in a UK database of general practice medical records from between 1987 and 2013. The authors compared 482 543 statin users with two comparison groups: 482 543 controls who did not use any LLDs and 26 484 users of non-statin LLDs (cholestyramine, colestipol hydrochloride, colesevelam, clofibrate, gemfibrozil, fenofibrate and niacin). Diagnostic codes were used to identify memory impairment, with a secondary case-crossover study of patients with incident acute memory loss. The authors found that there was a nearly four-fold increase in the risk of developing acute memory loss in the 30 days immediately following the first statin exposure when statin users were compared with non-users of LLDs. However, the comparison between statin and non-statin LLDs users showed no significant difference in risk. The authors said these findings might indicate that all LLDs, regardless of drug class, caused acute memory loss. However, it was more likely that this association resulted from detection bias, where patients using these medications had more contact with their physicians, and were therefore more likely to detect any memory loss, the authors wrote.