Carboplatin dosing in the treatment of ovarian cancer: An NRG oncology group study.

OBJECTIVE: To determine the effects of using National Comprehensive Cancer Network (NCCN) guidelines to estimate renal function on carboplatin dosing and explore adverse effects associated with a more accurate estimation of lower creatinine clearance (CrCl). METHODS: Retrospective data were obtained for 3830 of 4312 patients treated on GOG182 (NCT00011986)-a phase III trial of platinum-based chemotherapy for advanced-stage ovarian cancer. Carboplatin dose per patient on GOG182 was determined using the Jelliffe formula. We recalculated CrCl to determine dosing using Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault (with/without NCCN recommended modifications) formulas. Associations between baseline CrCl and toxicity were described using the area under the receiver operating characteristic curve (AUC). Sensitivity and positive predictive values described the model's ability to discriminate between subjects with/without the adverse event. RESULTS: AUC statistics (range, 0.52-0.64) showed log(CrClJelliffe) was not a good predictor of grade ≥3 adverse events (anemia, thrombocytopenia, febrile neutropenia, auditory, renal, metabolic, neurologic). Of 3830 patients, 628 (16%) had CrCl <60 mL/min. Positive predictive values for adverse events ranged from 1.8%-15%. Using the Cockcroft-Gault, Cockcroft-Gault with NCCN modifications, and MDRD (instead of Jelliffe) formulas to estimate renal function resulted in a >10% decrease in carboplatin dosing in 16%, 32%, and 5.2% of patients, respectively, and a >10% increase in carboplatin dosing in 41%, 9.6% and 12% of patients, respectively. CONCLUSION: The formula used to estimate CrCl affects carboplatin dosing. Estimated CrCl <60 mL/min (by Jelliffe) did not accurately predict adverse events. Efforts continue to better predict renal function. Endorsing National Cancer Institute initiatives to broaden study eligibility, our data do not support a minimum threshold CrCl <60 mL/min as an exclusion criterion from clinical trials.

Evaluating the design and implementation of the whole systems integrated care programme in North West London: why commissioning proved (again) to be the weakest link.

BACKGROUND: Commissioning is a term used in the English National Health Service (NHS) to refer to what most health systems call health planning or strategic purchasing. Drawing on research from a recent in-depth mixed methods study of a major integrated care initiative in North West London, we examine the role of commissioning in attempts to secure large-scale change within and between health and social care services to support the delivery of integrated care for people living with complex long-term conditions. METHODS: We analysed data collected in semi-structured interviews, surveys, workshops and non-participant observations using a thematic framework derived both deductively from the literature on commissioning and integrated care, as well as inductively from our coding and analysis of interview data. RESULTS: Our findings indicate that commissioning has significant limitations in enabling large-scale change in health services, particularly in engaging providers, supporting implementation, and attending to both its transactional and relational dimensions. CONCLUSIONS: Our study highlights the consequences of giving insufficient attention to implementation, and especially the need for commissioners to enable, support and performance manage the delivery of procured services, while working closely with providers at all times. We propose a revised version of Øvretveit's cycle of commissioning that gives greater emphasis to embedding effective implementation processes within models of commissioning large-scale change.

Evaluation Fucoidan Extracts From Undaria pinnatifida and Fucus vesiculosus in Combination With Anticancer Drugs in Human Cancer Orthotopic Mouse Models.

OBJECTIVE: To determine the activity of fucoidan from Undaria pinnatifida (UPF) and Fucus vesiculosus (FVF) when given in combination of chemotherapy drugs using selected human breast or ovarian cancer orthotopic mouse models. METHODS: Mice were inoculated with 1 × 106 cells of TOV-112d, MCF-7, or ZR-75 subcutaneously or SKOV3-GFP-Luc intraperitoneally on day 0. MCF-7 and ZR-75 mice were administered with estradiol valerate 2 mg/kg in 0.2 mL castor oil subcutaneously two days prior to cell inoculation. Mice were randomized to one of six arms (N = 10/arm) paclitaxel, UPF/paclitaxel, FVF/paclitaxel, tamoxifen, UPF/tamoxifen, or FVF/tamoxifen. Tumors were measured three times per week for 28 days. RESULTS: Improved activity was observed with UPF or FVF in combination with tamoxifen in both the MCF-7 and ZR-75D breast cancer mouse models. Decreased activity of paclitaxel was observed when given in combination with UPF or FVF in both breast cancer mouse models. The combination of FVF/tamoxifen in the TOV-112d ovarian cancer mouse model had improved activity but no there was difference observed with the UPF/tamoxifen in either ovarian cancer mouse model. No difference was observed with combination of UPF or FVF with paclitaxel in human ovarian cancer SKOV3 or TOV-112d orthotopic mouse models. CONCLUSION: This study did confirm that UPF/FVF in combination with tamoxifen did not decrease tamoxifen activity in both breast and ovarian cancer, with some potential to improve activity compared to tamoxifen alone in breast cancers. Previous in vitro studies had suggested UPF and FVF had overall synergistic activity with paclitaxel; however, in the current in vivo human cancer mouse model studies there was no change in paclitaxel activity when given in combination with UPF or FVF in either of the two human ovarian cancer models. Furthermore, this study demonstrated that UPF or FVF given in combination with paclitaxel had a potential antagonistic effect in breast cancer models. Additional studies are warranted to delineate mechanisms contributing to variation in the in vivo activity when given in combination with paclitaxel. As a first step, a clinical pharmacokinetic study evaluating impact of FVF/UPF given in combination with chemotherapy in patients with solid tumors is underway.

Preclinical Evaluation of Safety of Fucoidan Extracts From Undaria pinnatifida and Fucus vesiculosus for Use in Cancer Treatment.

OBJECTIVES: To evaluate potential hepatic metabolism-mediated drug interactions with fucoidan from Undaria pinnatifida (UPF) or Fucus vesiculosus (FVF) and potential growth inhibition activity with either fucoidan alone or with chemotherapy. In vivo studies were done to confirm safety and investigate fucoidan-mediated immune modulation. METHODS: Cytochrome P450 (CYP450) 3A4, 2C8, 2C9, and 2D6 inhibition experiments were conducted in vitro followed by an ex vivo human hepatocytes model to evaluate the CYP450 induction potential of each fucoidan at highest theoretical concentrations. Four hepatic metabolism phase II pathways-glutathione S transferase (GST), quinone oxidoreductase (QOR), catechol-O-methyltransferases (COMT), and uridine di-phosphate (UDP)-glucuronosyltransferase (UGT)-were evaluated with validated immunoassays. Growth inhibition assays were performed with each fucoidan alone and in combination with chemotherapy agents in a panel of human cancer cell lines. In vivo studies evaluated safety and immune modualtion. RESULTS: CYP450 inhibition was observed with FVF. The GST, QOR, and UGT pathways had no changes. UPF and FVF both interacted with COMT. No growth inhibitory activity in cancer cell lines was observed. UPF and FVF had synergistic activity with paclitaxel or tamoxifen and additive activity with topotecan. In vivo, FVF decreased HeLa human cervical tumor growth and both FVF and UPF decreased TOV-112D human ovarian tumor growth. Otherwise, no significant change in tumor growth was observed. FVF immune modulation of IgG and IL-6 was observed (p<0.03). CONCLUSION: At higher doses, UPF and FVF may have limited potential for drug-supplement interactions, with either CYP450 or COMT hepatic metabolism pathways. Additional studies are warranted to evaluate to confirm findings of fucoidans in combination with chemotherapy.

Evaluation of Active Hexose Correlated Compound (AHCC) in Combination With Anticancer Hormones in Orthotopic Breast Cancer Models.

OBJECTIVE: To determine the impact on antitumor activity when active hexose correlated compound (AHCC) in combination with anticancer hormonal agents in orthotopic mouse models of human estrogen receptor positive breast cancer and evaluate impact of AHCC on aromatase activity. METHODS: The study consisted of 7 treatment arms (n=10) conducted in 2 breast cancer mouse models: MCF-7 and ZR-75. Treatment groups included untreated, vehicle, AHCC 50 mg/kg, AHCC 50 mg/kg + tamoxifen 10 mg/kg, tamoxifen 10 mg/kg, AHCC 50 mg/kg + letrozole 10 µg/mouse, or letrozole 10 µg/mouse. All treatments were administered daily by oral gavage for 12 weeks. Tumors were measured 3 times a week. In vitro estrone and 17ß-estradiol enzyme immunoassay was used to evaluate aromatase activity. RESULTS: There was no difference in the activity with the combination of AHCC + tamoxifen compared with tamoxifen ( P = 0.29). In the ZR-75 model (catechol- O-methyltransferase [COMT] wild-type), there was no difference in activity with the letrozole + AHCC compared with letrozole. However, in the MCF-7 model (COMT variant), AHCC + letrozole resulted in a decrease in activity compared with letrozole ( P < 0.01). Immunoassay data suggested that AHCC is a potential inducer of aromatase activity. In both tumor models, there was cytotoxicity observed with AHCC compared with untreated ( P < 0.02). CONCLUSION: AHCC did not change the activity of tamoxifen. AHCC may have some interaction with letrozole in patients with COMT variant genotype. AHCC had cytotoxicity that warrents additional studies to evaluate its potential role for consolidation/prevention of breast cancer.

Integration of depression and primary care: barriers to adoption.

OBJECTIVE: Despite the prevailing consensus as to its value, the adoption of integrated care models is not widespread. Thus, the objective of this article it to examine the barriers to the adoption of depression and primary care models in the United States. METHODS: A literature search focused on peer-reviewed journal literature in Medline and PsycInfo. The search strategy focused on barriers to integrated mental health care services in primary care, and was based on previously existing searches. The search included: MeSH terms combined with targeted keywords; iterative citation searches in Scopus; searches for grey literature (literature not traditionally indexed by commercial publishers) in Google and organization websites, examination of reference lists, and discussions with researchers. FINDINGS: Integration of depression care and primary care faces multiple barriers. Patients and families face numerous barriers, linked inextricably to create challenges not easily remedied by any one party, including the following: vulnerable populations with special needs, patient and family factors, medical and mental health comorbidities, provider supply and culture, financing and costs, and organizational issues. CONCLUSIONS: An analysis of barriers impeding integration of depression and primary care presents information for future implementation of services.

Integrated care pilot in north-west London: a mixed methods evaluation.

INTRODUCTION: This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in north-west London. The pilot aimed to integrate care across primary, acute, community, mental health and social care for people with diabetes and/or those aged 75+ through care planning, multidisciplinary case reviews, information sharing and project management support. METHODS: The evaluation team conducted qualitative studies of change at organisational, clinician and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level datasets and a matched control study). RESULTS: The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, the engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes. CONCLUSION: Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that National Health Service managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time.

Use of complementary and alternative medications among patients in an obstetrics and gynecology clinic.

OBJECTIVE: To evaluate the current use of complementary and alternative medication (CAM) products among women in obstetrics and gynecology outpatient clinics. STUDY DESIGN: This study was performed at a major academic center among patients seen at either a faculty-led private clinical practice site (n = 250) or a resident-led clinical practice site (n = 250). Patients were requested to bring a written list and the medication bottles (prescriptions, over-the-counter medications and CAM products) to the clinic, where a survey was then administered. RESULTS: Overall, 18.6% of participants were using CAM products. Significantly more patients reported using CAM products in the faculty private practice as compared to the resident clinic practice (28.4% vs. 8.8%, respectively, p value < 0.05). Only 29.0% of CAM products users had spoken to a healthcare provider regarding CAM products. Multivariate logistic regression model determined that older age (p < 0.0001) and Caucasian ethnicity (p = 0.0245) were associated with higher rates of CAM products use. CONCLUSION: In this study CAM products use was not as prevalent as anticipated for this patient population, however it continues to be underreported to providers. Healthcare professionals should continue to increase their knowledge about CAM products, take a proactive role to improve documentation, and develop an open communication with patients regarding appropriate use of CAM products.

Toward a better understanding of loneliness in community-dwelling older adults.

The purpose of this interpretive phenomenological study was to explore the meaning of loneliness in community-dwelling older adults and to understand their daily practices in coping with loneliness. The sample consisted of 8 women and 4 men. Interviews were conducted with the 12 participants utilizing several tools, including 3 separate interview guides and the UCLA Loneliness Scale, Version 3 (Russell, 1996). A critical finding was that many participants experienced loneliness as a result of disrupted meaningful engagement, due to age-related changes, as well as other losses, including death of spouse, retirement, and giving up the car. Two paradigm cases and themes representing the loneliness and coping experience emerged. Participant coping practices with loneliness included reaching out to others, helping those in need, and seeking companionship with pets. Many older adults are at risk for loneliness because of declining health and other age-related losses that prevent them from remaining engaged in meaningful relationships. Health care professionals can screen for loneliness to identify those at risk and can intervene to help older adults maintain connections. Recommendations for those caring for lonely older adults include active listening, vision and hearing screenings, transportation needs, pet therapy, volunteering, and engagement in social activities.

Surveillance of demographic characteristics and health behaviors among adult cancer survivors--Behavioral Risk Factor Surveillance System, United States, 2009.

PROBLEM/CONDITION: Approximately 12 million people are living with cancer in the United States. Limited information is available on national and state assessments of health behaviors among cancer survivors. Using data from the Behavioral Risk Factor Surveillance System (BRFSS), this report provides a descriptive state-level assessment of demographic characteristics and health behaviors among cancer survivors aged ≥18 years. REPORTING PERIOD COVERED: 2009 DESCRIPTION OF SYSTEM: BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged ≥18 years. BRFSS collects information on health risk behaviors and use of preventive health services related to leading causes of death and morbidity. In 2009, BRFSS added questions about previous cancer diagnoses to the core module. The 2009 BRFSS also included an optional cancer survivorship module that assessed cancer treatment history and health insurance coverage for cancer survivors. In 2009, all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands administered the core cancer survivorship questions, and 10 states administered the optional supplemental cancer survivorship module. Five states added questions on mammography and Papanicolaou (Pap) test use, eight states included questions on colorectal screening, and five states included questions on prostate cancer screening. RESULTS: An estimated 7.2% of the U.S. general population aged ≥18 years reported having received a previous cancer diagnosis (excluding nonmelanoma skin cancer). A total of 78.8% of cancer survivors were aged ≥50 years, and 39.2% had received a diagnosis of cancer >10 years previously. A total of 57.8% reported receiving an influenza vaccination during the previous year, and 48.3% reported ever receiving a pneumococcal vaccination. At the time of the interview, 6.8% of cancer survivors had no health insurance, and 12% had been denied health insurance, life insurance, or both because of their cancer diagnosis. The prevalence of cardiovascular disease was higher among male cancer survivors (23.4%) than female cancer survivors (14.3%), as was the prevalence of diabetes (19.6% and 14.7%, respectively). Overall, approximately 15.1% of cancer survivors were current cigarette smokers, 27.5% were obese, and 31.5% had not engaged in any leisure-time physical activity during the past 30 days. Demographic characteristics and health behaviors among cancer survivors varied substantially by state. INTERPRETATION: Health behaviors and preventive health care practices among cancer survivors vary by state and demographic characteristics. A large proportion of cancer survivors have comorbid conditions, currently smoke, do not participate in any leisure-time physical activity, and are obese. In addition, many are not receiving recommended preventive care, including cancer screening and influenza and pneumococcal vaccinations. PUBLIC HEALTH ACTION: Health-care providers and patients should be aware of the importance of preventive care, smoking cessation, regular physical activity, and maintaining a healthy weight for cancer survivors. The findings in this report can help public health practitioners, researchers, and comprehensive cancer control programs evaluate the effectiveness of program activities for cancer survivors, assess the needs of cancer survivors at the state level, and allocate appropriate resources to address those needs.

Estimated effects of the National Breast and Cervical Cancer Early Detection Program on breast cancer mortality.

BACKGROUND: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast cancer screening to medically underserved, low-income women aged 40-64 years. No study has evaluated NBCCEDP's effect on breast cancer mortality. PURPOSE: This study estimates life-years saved by NBCCEDP breast cancer screening compared with screening in the absence of NBCCEDP and with no screening. METHODS: A breast cancer simulation model based on existing Cancer Intervention and Surveillance Modeling Network models was constructed. The screening module from these models was modified to reflect screening frequency for NBCCEDP participants. Screening data for uninsured women represented what would have happened without the program. Separate simulations were performed for women who received NBCCEDP (Program) screening, women who potentially received screening without the program (No Program), and women who received no screening (No Screening). The impact of NBCCEDP was estimated as the difference in life-years between the Program and No Program, and the Program and No Screening scenarios. The analysis was performed in 2008-2009. RESULTS: Among 1.8 million women who were screened between 1991 and 2006, the Program saved 100,800 life-years compared with No Program and 369,000 life-years compared with No Screening. Per woman screened, the Program saved 0.056 life-years (95% CI=0.031, 0.081) compared with No Program and 0.206 life-years (95% CI=0.177, 0.234) compared with No Screening. Per woman with invasive breast cancer and screen-detected invasive cancer, the Program saved 0.41 and 0.71 life-years, respectively, compared with No Program. CONCLUSIONS: These estimates suggest that NBCCEDP breast cancer screening has reduced mortality among medically uninsured and underinsured low-income women.

Tailoring cancer education and support programs for low-income, primarily African American cancer survivors.

PURPOSE/OBJECTIVES: to identify the information and stress-management topics of most interest to low-income, predominantly African American cancer survivors. RESEARCH APPROACH: descriptive, cross sectional. SETTING: outpatient oncology clinic in a public hospital in Birmingham, Alabama. PARTICIPANTS: 25 patients with cancer; 12 were men, 22 were African Americans, and 16 had a 12th-grade education or less. METHODOLOGIC APPROACH: patients ranked potential topics to be included in an educational curriculum. MAIN RESEARCH VARIABLES: quantitative rankings of information and stress-management priorities. FINDINGS: learning about cancer, understanding cancer treatments, relieving cancer pain, and keeping well in mind and body were the most highly ranked topics among those offered within the American Cancer Society's I Can Cope curriculum, which also included supportive topics such as mobilizing social support. The preferred stress-management topics were humor therapy, music therapy, meditation, and relaxation; lower-ranked topics included pet therapy and art as therapy. CONCLUSIONS: cancer survivors appear most interested in topics specific to their illness and treatment versus supportive topics. Stress management also received high rankings. INTERPRETATION: nurses have a key role in providing patient education and support. Tailoring education programs may better target specific needs and improve the quality of cancer care of underserved patients.

Addressing cancer survivorship through public health: an update from the Centers for Disease Control and Prevention.

Currently, there are nearly 12 million cancer survivors living in the United States. They face a myriad of personal and health issues related to their cancer treatment. Increased recognition of cancer survivorship as a distinct and important phase that follows the diagnosis and treatment of cancer has contributed to the development of public health-related strategies and plans to address those strategies. CDC's Division of Cancer Prevention and Control (DCPC) uses an interdisciplinary public health approach to address the needs of cancer survivors through applied research, public health surveillance and data collection, education, and health promotion, especially among underserved populations that may be at risk for health disparities. Our surveillance activities contribute to population-based descriptions of the health and treatment experiences of cancer survivors in the United States. These data inform applied research activities as well as provide baseline data on cancer survivors for local comprehensive cancer control programs. The knowledge gained by our research efforts informs the development of interventions, awareness and education campaigns, and other outreach activities targeting cancer survivors and those who care for and support them. Our partnerships with national organizations, state health agencies, and other key groups are essential in the development, implementation, and promotion of effective cancer control practices related to cancer survivorship. This article provides an overview of the cancer survivorship activities currently being implemented by DCPC. We highlight several public health surveillance, research, and programmatic outreach and partnership activities currently underway.

Evaluation of intervention to prevent hypomagnesemia in cervical cancer patients receiving combination cisplatin and radiation treatment.

PURPOSE: The purpose of this study was to evaluate the impact of increasing the magnesium (Mg(2+)) supplementation in the pre- and posthydration of patients receiving cisplatin plus radiation (CisXRT) to prevent chemotherapy-induced hypomagnesemia (CIH) events. MATERIALS AND METHODS: The study was conducted on newly diagnosed cervical cancer patients receiving CisXRT. The first prospective intervention to prevent CIH was to increase the pre- and posthydration Mg(2+) from 1 to 2 g. After completion of the first intervention, the analysis demonstrated the persistent occurrence of CIH on cycle 3, and later, a second intervention was implemented to increase Mg(2+) to 3 g in the pre- and posthydration. Patients that failed to complete at least five cycles or received cisplatin in combination with another chemotherapy regimen were excluded from the study. Baseline group included 70 patients that had received CisXRT prior to any changes in magnesium supplementation. RESULTS: There were 62.8% (44/70) and 32.6% (22/70) of patients with episodes of CIH in the baseline and first intervention groups, respectively (P = 0.007). In the second intervention group, a 49.6% decrease in the total number of episodes compared to control group was observed. Patients in the second intervention group showed a 100% improvement incidence of persistent CIH over the two other cohorts (P = 0.001). CONCLUSIONS: The increase of Mg(2+) to 2 g for the initial two cycles and then to 3 g with the third cycle of CisXRT therapy prevented episodes of CIH and decreased associated treatment delays.

Evaluation of active hexose correlated compound hepatic metabolism and potential for drug interactions with chemotherapy agents.

Active hexose correlated compound (AHCC), a Basidiomycotina extract, is a well-tolerated nutritional supplement with no reported adverse effects. It has demonstrated potential antitumor activity and immune modulator activity. However, there is no current information regarding its metabolism and the potential for drug-drug interactions for AHCC in combination with chemotherapy. The objective of this study was to characterize AHCC hepatic metabolism, specifically involving the potential for drug interactions with selected chemotherapy agents. High-throughput cytochrome P-450 (CYP450) metabolism inhibition experiments were conducted in vitro evaluating CYP450 3A4, 2C8, 2C9, and 2D6 followed by an evaluation of AHCC as a substrate of these same isoenzymes. An ex vivo model of cryopreserved human hepatocytes was used to evaluate the CYP450 metabolism induction potential of AHCC for CYP450 3A4, 2C8/2C9, and 2D6. No inhibition of CYP450 activity was observed in presence of AHCC; however, AHCC was a substrate of CYP450 2D6. The CYP450 induction metabolism assays indicate that AHCC is an inducer of CYP450 2D6. AHCC does have the potential for drug-drug interactions involving CYP450 2D6, such as doxorubicin or ondansetron; however, the overall data suggest that AHCC would be safe to administer with most other chemotherapy agents that are not metabolized via the CYP450 2D6 pathway.

Biologic agents for the treatment of juvenile rheumatoid arthritis: current status.

Biologic therapies, primarily anticytokine therapies, are being increasingly used in patients with juvenile rheumatoid arthritis (JRA). Levels of a variety of proinflammatory cytokines have been shown to be elevated in the peripheral blood and synovial fluid and tissue in children with JRA. In a blinded, randomized, controlled trial in children with severe, long-standing, polyarticular-course JRA not responsive to standard therapies, etanercept showed a statistically significantly greater response rate than placebo. Approximately 75% of these children responded to etanercept. Etanercept has been efficacious in 50-60% of children with active systemic JRA in open clinical trials with acceptable tolerance. Adverse events seen in children treated with etanercept have been similar in type and frequency to those reported in adults. Infliximab has been studied in several open clinical trials in both polyarticular and systemic JRA and found to, overall, have demonstrated efficacy in approximately 60% of patients. Approximately 3-5% of patients have demonstrated infusion reactions or frank allergic reactions and 9% developed new autoantibodies. Anakinra has been studied in children with polyarticular JRA. Approximately 65% of patients developed injection-site reactions and 68% demonstrated a response to the medication. Anakinra may have increased efficacy in systemic JRA. Interleukin (IL)-6 is highly related to the systemic disease manifestations in systemic JRA and two patients treated with a monoclonal antibody to the IL-6 receptor have demonstrated significant improvement with prolonged clinical control with continued treatment. A particular pediatric concern is the effect of immunosuppressive biologics in children who are exposed to or develop varicella. These children should be treated, both in terms of prophylaxis and aggressive antivaricella treatment, as for other immunosuppressed children. Anticytokine biologics have demonstrated great promise in the treatment of JRA and a variety of other pediatric rheumatic diseases, although at this time the randomized, placebo-controlled data are limited only to etanercept in children with polyarticular JRA. Randomized trials are ongoing to better define both the efficacy and safety of these novel treatments for children with JRA and other rheumatic diseases.

An assessment of the utilization of complementary and alternative medication in women with gynecologic or breast malignancies.

PURPOSE: To describe and assess the current utilization of complementary and alternative medicines (CAMs) in women with a diagnosis of either gynecologic or breast cancer and evaluate their reasons for use. PATIENTS AND METHODS: This study included 250 female patients from the Multidisciplinary Breast Center and 250 patients from the Gynecologic Oncology Center of The University of Texas M.D. Anderson Cancer Center (Houston, TX). Patients were selected by having an odd-numbered medical record number, and they were contacted before their clinic visit. The goals of the study were explained, and verbal consent was obtained. Patients who agreed to participate were asked to bring a written list and the medication bottles of all over-the-counter prescriptions and CAMs with them to clinic. In clinic, the investigator obtained a written informed consent and administered the survey. All patients and surveys were assessable. RESULTS: The most frequently used herbal products and megavitamins/minerals were identified from the patient medication histories. Overall, we found the proportion of patients using CAM to be 48% (95% CI, 44% to 53%; 241 of 500 patients). CAM use was related to patients' educational status: 62% had postgraduate degrees, 50% had college degrees, 56% had some college, and 33% had a high school education or less. Also, among patients using CAMs, only 53.5% had spoken to a healthcare provider regarding CAM therapy. CONCLUSION: The use of CAM is common among women with cancer. Studies need to be conducted to establish if there are any potential drug interactions and/or therapeutic benefit of CAM products. Moreover, there is a need to educate patients and healthcare providers on appropriate and safe use of CAM products.