Patterns of response and progression in bone and soft tissue during and after treatment with radium-223 for metastatic castrate-resistant prostate cancer.

BACKGROUND: Radium-223 improves survival and time to first symptomatic skeletal event in symptomatic bone predominant metastatic castrate-resistant prostate cancer (mCRPC). The imaging response to radium-223 has not been well characterized. METHODS: To describe patterns of response and progression with radium-223, we performed a retrospective review of all mCPRC patients who received radium-223 at Duke from 1 June 2013 to 1 June 2015. Radionuclide bone scans obtained at baseline, during, and after treatment were reviewed by two radiologists. The automated bone scan index (aBSI) was generated at each time point using EXINI boneBSI version 2.4. Computed tomography (CT) and magnetic resonance imaging (MRI) clinical radiology reports were reviewed to evaluate for soft tissue, visceral, epidural, and bone progression. Clinical data were abstracted from the electronic health record. RESULTS: We identified 61 men who received at least one dose of radium-223 at Duke during the study period (median, 5 doses; range, 1-6). Among men with imaging during treatment, 2 of 14 (14.3%) had resolution of greater than or equal to 1 lesion on bone scan, 4 of 14 (28.6%) had zero new bone lesions, 10 of 14 (71.4%) had greater than or equal to 1 new bone lesion, 14 of 26 (53.9%) progressed on CT. After radium-223, 6 of 39 (15.4%) had resolution of 1 to 4 bone lesions, 15 of 39 (38.5%) demonstrated zero new bone lesions, 24 of 39 (61.5%) progressed on bone scan, 15 of 37 (40.5%) progressed on CT, and 10 of 34 (29.4%) progressed on both bone scan and CT. No men with zero new bone lesions after radium-223 ultimately progressed in bone alone and only 3 of 15 eventually demonstrated any progression in the bone. aBSI decreased significantly from baseline to after radium-223 among men with zero new bone lesions (median change in aBSI -0.23 [IQR, -1.5, 0.02]) and increased significantly for men with greater than or equal to 1 new postradium bone lesions (median change in aBSI 1.41 [IQR, -0.05, 3.63] [P = 0.018]). CONCLUSIONS: Bone and soft tissue progression during and following radium-223 is common in heavily pretreated men with mCRPC. However, stable disease and responses were observed in a subset of patients and may be associated with durable treatment response in the bone. Prospective studies are needed to further investigate the change in aBSI as a biomarker of bone scan response/stabilization and progression following treatment with radium-223.

Acceptance and Impact of Point-of-Use Water Filtration Systems in Rural Guatemala.

PURPOSE: Infants and children in developing countries bear the burden of diarrheal disease. Diarrheal disease is linked to unsafe drinking water and can result in serious long-term consequences, such as impaired immune function and brain growth. There is evidence that point-of-use water filtration systems reduce the prevalence of diarrhea in developing countries. In the summer of 2014, following community forums and interactive workshops, water filters were distributed to 71 households in a rural Maya community in Guatemala. The purpose of this study was to evaluate the uptake of tabletop water filtration systems to reduce diarrheal diseases. DESIGN: A descriptive correlational study was used that employed community partnership and empowerment strategies. One year postintervention, in the summer of 2015, a bilingual, interdisciplinary research team conducted a house-to-house survey with families who received water filters. METHODS: Survey data were gathered from the head of household on family demographics, current family health, water filter usage, and type of flooring in the home. Interviews were conducted in Spanish and in partnership with a village leader. Each family received a food package of household staples for their participation. Descriptive statistics were calculated for all responses. Fisher's exact test and odds ratios were used to determine relationships between variables. FINDINGS: Seventy-nine percent (n = 56) of the 71 households that received a water filter in 2014 participated in the study. The majority of families (71.4%; n = 40) were using the water filters and 16 families (28.6%) had broken water filters. Of the families with working water filters, 15% reported diarrhea, while 31% of families with a broken water filter reported diarrhea. Only 55.4% of the homes had concrete flooring. More households with dirt flooring and broken water filters reported a current case of diarrhea. A record review of attendees at an outreach clinic in this village noted a decrease in intestinal infections from 2014 (53%) to 2015 (32%). CONCLUSIONS: A trend suggests that water filter usage was both practically and clinically significant in reducing the incidence of diarrheal disease in this sample. Some homes did not have flat surfaces for water filter storage. Housing conditions should be taken into consideration for future diarrheal disease prevention initiatives. CLINICAL RELEVANCE: Point-of-use water filters using a community-university partnership can reduce diarrheal disease in rural regions of Guatemala.

Hospice Use Among Patients With Cancer: Trends, Barriers, and Future Directions.

Patients with advanced cancer and their families frequently encounter clinical and logistical challenges related to end-of-life care. Hospice provides interdisciplinary and holistic care to meet patients' biomedical, psychosocial, and spiritual needs in the last phases of life. Despite increasing general acceptance and use among patients with cancer, hospice remains underused. Underuse stems from ongoing misconceptions regarding hospice and its purpose, coupled with the rapid development of novel anticancer treatments, such as immunotherapies and targeted therapies, that have changed the landscape of possibilities. Furthermore, rapid evolutions in how end-of-life care is structured and reimbursed for will affect how oncology patients will intersect with hospice care. In this review, we explore the current and future challenges to greater integration of hospice care in the care of patients with advanced cancer and propose five recommendations as part of the path forward.