Abiraterone acetate plus prednisolone for metastatic patients starting hormone therapy: 5-year follow-up results from the STAMPEDE randomised trial (NCT00268476).

Abiraterone acetate plus prednisolone (AAP) previously demonstrated improved survival in STAMPEDE, a multiarm, multistage platform trial in men starting long-term hormone therapy for prostate cancer. This long-term analysis in metastatic patients was planned for 3 years after the first results. Standard-of-care (SOC) was androgen deprivation therapy. The comparison randomised patients 1:1 to SOC-alone with or without daily abiraterone acetate 1000 mg + prednisolone 5 mg (SOC + AAP), continued until disease progression. The primary outcome measure was overall survival. Metastatic disease risk group was classified retrospectively using baseline CT and bone scans by central radiological review and pathology reports. Analyses used Cox proportional hazards and flexible parametric models, accounting for baseline stratification factors. One thousand and three patients were contemporaneously randomised (November 2011 to January 2014): median age 67 years; 94% newly-diagnosed; metastatic disease risk group: 48% high, 44% low, 8% unassessable; median PSA 97 ng/mL. At 6.1 years median follow-up, 329 SOC-alone deaths (118 low-risk, 178 high-risk) and 244 SOC + AAP deaths (75 low-risk, 145 high-risk) were reported. Adjusted HR = 0.60 (95% CI: 0.50-0.71; P = 0.31 × 10-9 ) favoured SOC + AAP, with 5-years survival improved from 41% SOC-alone to 60% SOC + AAP. This was similar in low-risk (HR = 0.55; 95% CI: 0.41-0.76) and high-risk (HR = 0.54; 95% CI: 0.43-0.69) patients. Median and current maximum time on SOC + AAP was 2.4 and 8.1 years. Toxicity at 4 years postrandomisation was similar, with 16% patients in each group reporting grade 3 or higher toxicity. A sustained and substantial improvement in overall survival of all metastatic prostate cancer patients was achieved with SOC + abiraterone acetate + prednisolone, irrespective of metastatic disease risk group.

Management of newly diagnosed metastatic hormone-sensitive prostate cancer: A survey of UK Uro-oncologists.

AIM: To explore the practice and views of uro-oncologists in the United Kingdom regarding their use of chemotherapy and androgen receptor-targeted agents (ARTAs) in patients with newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC). METHODS: An expert-devised paper or online questionnaire was completed by members of the British Uro-oncology Group. RESULTS: All respondents stated that they would offer patients with newly diagnosed mHSPC docetaxel and androgen deprivation therapy (ADT) if they were sufficiently fit to receive chemotherapy (this was the only option available at the time of the survey); 64% would strongly recommend docetaxel for those with high-volume metastatic disease and 31% for those with low-volume disease. Hypothetically, if both docetaxel and ARTAs were available in the United Kingdom for mHSPC, almost 65% of respondents would recommend an ARTA with ADT to these patients in at least one-half of all cases, with the strongest recommendations to patients with high-risk disease. Imaging for the response was conducted according to suspicion of disease progression, regardless of treatment, with the minority of clinicians recommending routine imaging. If a choice of therapy was available, docetaxel would be more likely to be offered to patients with liver or lung metastases, and ARTAs to patients with bone or lymph node only metastases. Almost all respondents would offer local radiotherapy to the primary tumour in patients with low-volume disease. CONCLUSION: All the UK uro-oncologists surveyed stated that they would offer docetaxel in combination with ADT to all newly diagnosed patients with mHSPC if fit enough for chemotherapy. ARTAs would be offered to many patients if available, especially those with high-risk disease or those unfit to receive chemotherapy. Scanning was typically conducted following treatment only at the suspicion of disease progression.

The relationship of mental and behavioral disorders to all-cause mortality in a 27-year follow-up of 4 epidemiologic catchment area samples.

Subjects from the Epidemiologic Catchment Area Program, interviewed during 1979-1983, were linked to data in the National Death Index through 2007 to estimate the association of mental and behavioral disorders with death. There were more than 25 years of follow-up for 15,440 individuals, with 6,924 deaths amounting to 307,881 person-years of observation. Data were analyzed by using age as the time scale and parametric approaches to quantify the years of life lost due to disorders. Alcohol, drug use, and antisocial personality disorders were associated with increased risk of death, but there was no strong association with mood and anxiety disorders. Results of high- and low-quality matches with the National Death Index were similar. The 3 behavioral disorders were associated with 5-15 years of life lost, estimated along the life course via the generalized gamma model. Regression tree analyses showed that risk of death was associated with alcohol use disorders in nonblacks and with drug disorders in blacks. Phobia interacted with alcohol use disorders in nonblack women, and obsessive-compulsive disorder interacted with drug use disorders in black men. Both of these anxiety disorders were associated with lower risk of death early in life and higher risk of death later in life.

Research participant-centered outcomes at NIH-supported clinical research centers.

BACKGROUND: Although research participation is essential for clinical investigation, few quantitative outcome measures exist to assess participants' experiences. To address this, we developed and deployed a survey at 15 NIH-supported clinical research centers to assess participant-centered outcomes; we report responses from 4,961 participants. METHODS: Survey questions addressed core aspects of the research participants' experience, including their overall rating, motivation, trust, and informed consent. We describe participant characteristics, responses to individual questions, and correlations among responses. RESULTS: Respondents broadly represented the research population in sex, race, and ethnicity. Seventy-three percent awarded top ratings to their overall research experience and 94% reported no pressure to enroll. Top ratings correlated with feeling treated with respect, listened to, and having access to the research team (R(2) = 0.80-0.96). White participants trusted researchers more (88%) than did nonwhite participants collectively (80%; p < 0.0001). Many participants felt fully prepared by the informed consent process (67%) and wanted to receive research results (72%). CONCLUSIONS: Our survey demonstrates that a majority of participants at NIH-supported clinical research centers rate their research experience very positively and that participant-centered outcome measures identify actionable items for improvement of participant's experiences, research protections, and the conduct of clinical investigation.

Lowering whole-body radiation doses in pediatric intensity-modulated radiotherapy through the use of unflattened photon beams.

PURPOSE: Intensity modulated radiotherapy (IMRT) has been linked with an increased risk of secondary cancer induction due to the extra leakage radiation associated with delivery of these techniques. Removal of the flattening filter offers a simple way of reducing head leakage, and it may be possible to generate equivalent IMRT plans and to deliver these on a standard linear accelerator operating in unflattened mode. METHODS AND MATERIALS: An Elekta Precise linear accelerator has been commissioned to operate in both conventional and unflattened modes (energy matched at 6 MV) and a direct comparison made between the treatment planning and delivery of pediatric intracranial treatments using both approaches. These plans have been evaluated and delivered to an anthropomorphic phantom. RESULTS: Plans generated in unflattened mode are clinically identical to those for conventional IMRT but can be delivered with greatly reduced leakage radiation. Measurements in an anthropomorphic phantom at clinically relevant positions including the thyroid, lung, ovaries, and testes show an average reduction in peripheral doses of 23.7%, 29.9%, 64.9%, and 70.0%, respectively, for identical plan delivery compared to conventional IMRT. CONCLUSIONS: IMRT delivery in unflattened mode removes an unwanted and unnecessary source of scatter from the treatment head and lowers leakage doses by up to 70%, thereby reducing the risk of radiation-induced second cancers. Removal of the flattening filter is recommended for IMRT treatments.

Collaborating with patients and their families.

Patient- and family-centered care is a healthcare approach that emphasizes collaboration among patients, families, and healthcare providers. The key concepts of patient- and family-centered care can be applied in any healthcare setting to enhance patient safety, reduce the risk of medical errors, improve risk management processes, and create an organizational culture supportive of risk managers and open, honest communication.

Patient and family involvement in contemporary health care.

OBJECTIVE: The objective of this article was to provide a guide to health care providers on patient and family involvement in health care. METHODS: This article evaluated the latest published studies for patient and family involvement and reexamined the objectives, the requirements for achieving these objectives, and the evidence of how to involve patients and families. RESULTS: Critical components for patient safety include changing the organizational culture; including patients and families on teams; listening to patients and families; incorporating their input into leadership structures and systems; providing full detail about treatment, procedures, and medication adverse effects; involving them on patient safety and performance improvement committees; and disclosing medical errors. CONCLUSIONS: The conclusion of this article is that, for the future, patient and family involvement starts with educating patients and families and ends with listening to them and taking them seriously. If patient and family input is emphatically built into systems of performance improvement, and if patients and families are taken seriously and are respected for their valuable perspectives about how care can be improved, then organizations can improve at improving. Resources in health care are in short supply, yet the resources of patient and family help and time are almost limitless, are ready to be tapped, and can have a huge impact on improving the reliability and overall success for any health care organization.