A mixed methods evaluation of Multiple Mini Interviews for entry into the Bachelor of Midwifery.

BACKGROUND: Multiple-mini interviews (MMI) are increasingly used as part of the admission process into healthcare degrees. Evaluations have found MMIs to be a fair assessment tool in terms of reliability and validity and viewed positively by those involved in the MMI process. The use of MMIs in midwifery is novel and evaluation is lacking. AIM: To evaluate the use of MMIs as part of the admission process for the Bachelor of Midwifery in one Australian university. METHODS: A basic convergent mixed methods study design was utilised. Data included linked data sets, Likert scale responses to survey questions, focus groups and open-ended survey questions. Integration took place at the interpretation and reporting stage. FINDINGS: Participants viewed the MMI experience positively. The study confirmed the reliability of the MMIs as an assessment tool. Most variance in MMI scores was attributed to the candidate at 31.4 % with the interviewer and the interview station having less influence on the MMI score at 11 % and 6.4 % variance. Older applicants on average achieved higher MMI scores, and those who spoke a language other than English at home or were first in family to attend university had lower on average MMI scores. Being born overseas did not impact an applicant's MMI score. The overall experience was seen as fair, offering further opportunity to gain entry into the Bachelor of Midwifery. CONCLUSION: MMIs were viewed positively and findings support the use of MMIs as part of an admissions process for the Bachelor of Midwifery.

Analytical performance and potential clinical utility of the GenMark Dx ePlex® blood culture identification gram-positive panel.

The test performance and potential clinical utility of the ePlex® BCID Gram-Positive (GP) Panel was evaluated relative to MALDI-TOF mass spectrometry on bacterial isolates and traditional antimicrobial susceptibility testing. All GP bacteria (n = 100) in the study were represented on the panel including 50 common skin contaminants, and 7/7 coinfections. The positive percent agreement (PPA) was 97/97 with 2 false positives. Detection of vanA yielded a PPA of 4/4 and NPA of 9/9. mecA gene detection exhibited a PPA of 14/14 and NPA of 14/14 for S. aureus and a PPA of 31/32(97%) and NPA of 16/16 for CNS with 1 false negative. Chart reviews (n = 80) identified a mean 24.4h faster time to organism identification, 53.4h earlier optimization in 15(18.8%) patients based on AMR gene detection, 29.2h earlier optimization for 8(10%) patients infected with organisms, such as streptococci, with very low resistance rates, and 42.9h earlier discontinuation of antimicrobials for 14(17.5%) patients with contaminant cultures.

The impact of Multiple Mini Interviews on the attrition and academic outcomes of midwifery students.

BACKGROUND: Admission to the Bachelor of Midwifery (BMid) in Australia has traditionally been based on academic ranking. The BMid is a high demand course offered to a limited number of students and therefore choosing applicants who complete the degree is important. Multiple Mini Interviews (MMIs) are used to assess non-cognitive skills and select students into healthcare degrees. One university in Australia has introduced MMIs as part of the application process for the BMid. AIM: Compare attrition rates and Grade Point Average (GPA) scores between students admitted into the BMid using both academic ranking and MMIs, to those admitted on academic ranking alone. METHODS: A basic convergent mixed methods design, using an explanatory unidirectional framework to integrate data. Attrition rates, GPA, and multiple mini interview scores (2013-2019), were linked and compared for before and after the use of MMI's. Focus groups with students, interviewers, and hospital-based educators, explored stakeholder experiences. Open-ended questions from an applicant survey were added to the qualitative data set, which was analysed thematically. FINDINGS: Students who enrolled via the MMI's had significantly lower attrition rates than those enrolled before MMI's were introduced. GPA scores were significantly higher for students who enrolled via the MMI's. Integration of data found MMI's identified students passionate to undertake midwifery, and that success at the interviews increased students' confidence to successfully complete their studies. CONCLUSION: MMI's as part of the entry process into the BMid enabled identification of applicants more likely to remain in the course and succeed in their studies.

Blocking hyaluronan synthesis alleviates acute lung allograft rejection.

Lung allograft rejection results in the accumulation of low-molecular weight hyaluronic acid (LMW-HA), which further propagates inflammation and tissue injury. We have previously shown that therapeutic lymphangiogenesis in a murine model of lung allograft rejection reduced tissue LMW-HA and was associated with improved transplant outcomes. Herein, we investigated the use of 4-Methylumbelliferone (4MU), a known inhibitor of HA synthesis, to alleviate acute allograft rejection in a murine model of lung transplantation. We found that treating mice with 4MU from days 20 to 30 after transplant was sufficient to significantly improve outcomes, characterized by a reduction in T cell-mediated lung inflammation and LMW-HA content and in improved pathology scores. In vitro, 4MU directly attenuated activation, proliferation, and differentiation of naive CD4+ T cells into Th1 cells. As 4MU has already been demonstrated to be safe for human use, we believe examining 4MU for the treatment of acute lung allograft rejection may be of clinical significance.

Association between atopic dermatitis and conjunctivitis in adults: a population-based study in the United States.

BACKGROUND: The association between atopic dermatitis (AD) and conjunctivitis in adults has not been well established. METHODS: We conducted a cross-sectional study of the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2002 to 2015 in order to evaluate the association between AD and conjunctivitis in U.S. adults. We performed multivariable logistic regression analyses adjusting for sociodemographic factors. RESULTS: An estimated total [95% CI] of 8,581,098 [7,592,037-9,570,160] weighted AD visits and 12,853,199,920 [12,808,269,186-12,898,131,033] weighted non-AD visits were utilized for our analyses. When compared to adults without AD, adults with AD had a fourfold higher risk of conjunctivitis (OR = 4.38; 95% CI, 1.39-13.79; p = .012) and specifically, an eight-fold higher risk of allergic conjunctivitis (OR = 8.03; 95% CI, 1.76-36.58; p = .007). Among adults with AD, 67.6% of their visits for conjunctivitis were for allergic conjunctivitis. Among adults without AD, 35.4% of their visits for conjunctivitis were for allergic conjunctivitis. CONCLUSIONS: Results of this study suggest that adults with AD have a significantly higher risk of conjunctivitis and specifically, allergic conjunctivitis when compared to those without AD. It is important for dermatology providers to be aware of this association and learn to recognize and potentially manage conjunctivitis in AD patients.

Erectile Dysfunction is a Transient Complication of Prostate Biopsy: A Systematic Review and Meta-Analysis.

PURPOSE: Because the association between erectile dysfunction and prostate biopsy is variable in the available literature, we sought to perform a systematic review and meta-analysis of sexual dysfunction in males within 6 months of prostate biopsy. MATERIALS AND METHODS: We conducted a systematic literature search in 4 databases: MEDLINE® (via PubMed®), Embase® (via Ovid®), Web of Science™ and the Cochrane Library. We included studies focused on sexual dysfunction in men of all age groups undergoing transrectal or transperineal prostate biopsy for suspicion of prostate cancer. We included studies with International Index of Erectile Function 5 scores pre-biopsy and post-biopsy at 1, 3 or 6 months. We performed an effect size meta-analysis comparing patient baseline International Index of Erectile Function 5 (IIEF-5) scores with post-biopsy IIEF-5 scores. RESULTS: We identified 9 studies that met our inclusion criteria, of which 6 examined transrectal prostate biopsy, 2 examined transperineal prostate biopsy and 1 examined both. At 1 month after biopsy, the mean IIEF-5 score decreased by approximately 2.2 points as determined by the effect size (-0.43, p=0.002). However, at 3 and 6 months after biopsy, there was no difference compared to baseline (effect size=-0.08, p=0.52 and effect size=-0.11, p=0.18, respectively). An exploratory subgroup analysis examining transrectal prostate biopsy at 3 months showed a statistically significantly lower mean IIEF-5 score compared to baseline (p=0.047), corresponding to an approximately 1.25-point decrease in IIEF-5. CONCLUSIONS: Prostate biopsy does cause a mild, transient decrease in average IIEF-5 scores at 1-month post-biopsy. However, this resolves at 3 months on average, and average IIEF-5 remains at baseline at 6 months post-biopsy.

FK506 induces lung lymphatic endothelial cell senescence and downregulates LYVE-1 expression, with associated decreased hyaluronan uptake.

BACKGROUND: Therapeutic lymphangiogenesis in an orthotopic lung transplant model has been shown to improve acute allograft rejection that is mediated at least in part through hyaluronan drainage. Lymphatic vessel endothelial hyaluronan receptor (LYVE-1) expressed on the surface of lymphatic endothelial cells plays important roles in hyaluronan uptake. The impact of current immunosuppressive therapies on lung lymphatic endothelial cells is largely unknown. We tested the hypothesis that FK506, the most commonly used immunosuppressant after lung transplantation, induces lung lymphatic endothelial cell dysfunction. METHODS: Lung lymphatic endothelial cells were cultured in vitro and treated with FK506. Telomerase activity was measured using the TRAP assay. Protein expression of LYVE-1 and senescence markers p21 and ß-galactosidase was assessed with western blotting. Matrigel tubulation assay were used to investigate the effects of FK506 on TNF-α-induced lymphangiogenesis. Dual luciferase reporter assay was used to confirm NFAT-dependent transcriptional regulation of LYVE-1. Flow cytometry was used to examine the effects of FK506 on LYVE-1 in precision-cut-lung-slices ex vivo and on hyaluronan uptake in vitro. RESULTS: In vitro, FK506 downregulated telomerase reverse transcriptase expression, resulting in decreased telomerase activity and subsequent induction of p21 expression and cell senescence. Treatment with FK506 decreased LYVE-1 mRNA and protein levels and resulted in decreased LEC HA uptake. Similar result showing reduction of LYVE-1 expression when treated with FK506 was observed ex vivo. We identified a putative NFAT binding site on the LYVE-1 promoter and cloned this region of the promoter in a luciferase-based reporter construct. We showed that this NFAT binding site regulates LYVE-1 transcription, and mutation of this binding site blunted FK506-dependent downregulation of LYVE-1 promoter-dependent transcription. Finally, FK506-treated lymphatic endothelial cells show a blunted response to TNF-α-mediated lymphangiogenesis. CONCLUSION: FK506 alters lymphatic endothelial cell molecular characteristics and causes lymphatic endothelial cell dysfunction in vitro and ex vivo. These effects of FK506 on lymphatic endothelial cell may impair the ability of the transplanted lung to drain hyaluronan macromolecules in vivo. The implications of our findings on the long-term health of lung allografts merit more investigation.

Hyaluronan and LYVE-1 and allograft function in lung transplantation recipients.

Hyaluronan (HA) is associated with innate immune response activation and may be a marker of allograft dysfunction in lung transplant recipients. This was a prospective, single center study comparing levels of bronchioalveolar lavage (BAL) and serum HA and the HA immobilizer LYVE-1 in lung transplant recipients with and without acute cellular rejection (ACR). Chronic lung allograft dysfunction (CLAD)-free survival was also evaluated based on HA and LYVE-1 levels. 78 recipients were enrolled with a total of 115 diagnostic biopsies and 1.5 years of median follow-up. Serum HA was correlated with BAL HA (r = 0.25, p = 0.01) and with serum LYVE-1 (r = 0.32, p = 0.002). There was significant variation in HA and LYVE-1 over time, regardless of ACR status. Levels of serum HA (median 74.7 vs 82.7, p = 0.69), BAL HA (median 149.4 vs 134.5, p = 0.39), and LYVE-1 (mean 190.2 vs 183.8, p = 0.72) were not associated with ACR. CLAD-free survival was not different in recipients with any episode of elevated serum HA (HR = 1.5, 95% CI = 0.3-7.7, p = 0.61) or BAL HA (HR = 0.94, 95% CI = 0.2-3.6, p = 0.93). These results did not differ when stratified by bilateral transplant status. In this small cohort, serum HA, BAL HA, and LYVE-1 levels are not associated with ACR or CLAD-free survival in lung transplant recipients.

Glycogen synthase kinase 3-ß inhibition induces lymphangiogenesis through ß-catenin-dependent and mTOR-independent pathways.

Lymphatic vessels play an important role in health and in disease. In this study, we evaluated the effects of GSK3-ß inhibition on lung lymphatic endothelial cells in vitro. Pharmacological inhibition and silencing of GSK3-ß resulted in increased lymphangiogenesis of lung lymphatic endothelial cells. To investigate mechanisms of GSK3-ß-mediated lymphangiogenesis, we interrogated the mammalian/mechanistic target of rapamycin pathway and found that inhibition of GSK3-ß resulted in PTEN activation and subsequent decreased activation of AKT, leading to decreased p-P70S6kinase levels, indicating inhibition of the mTOR pathway. In addition, consistent with a negative role of GSK3-ß in ß-catenin stability through protein phosphorylation, we found that GSK3-ß inhibition resulted in an increase in ß-catenin levels. Simultaneous silencing of ß-catenin and inhibition of GSK3-ß demonstrated that ß-catenin is required for GSK3-ß-induced lymphangiogenesis.

Serum endostatin levels are associated with diffusion capacity and with tuberous sclerosis- associated lymphangioleiomyomatosis.

Endostatin is a naturally occurring collagen fragment with anti-angiogenic properties. We investigated the association between serum endostatin levels and DLCO in a cohort of patients with lymphangioleiomyomatosis (LAM). Associations of endostatin levels to clinical features of LAM were explored using logistic regression models. Endostatin levels were associated with DLCO and were higher in subjects with TSC-associated LAM compared to sporadic LAM. These data suggest that endostatin could be a predictive biomarker of decline in DLCO and that germline mutational inactivation of the TSC1 or TSC2 gene is associated with higher endostatin levels. These findings could offer novel insights into the pathogenesis of LAM.

The efficacy of acupressure and acustimulation wrist bands for the relief of chemotherapy-induced nausea and vomiting. A University of Rochester Cancer Center Community Clinical Oncology Program multicenter study.

As an adjunct to standard antiemetics for the relief of chemotherapy-induced nausea and vomiting (NV), 739 patients were randomly assigned to either: 1) acupressure bands, 2) an acustimulation band, or 3) a no band control condition. Patients in the acupressure condition experienced less nausea on the day of treatment compared to controls (P<0.05). There were no significant differences in delayed nausea or vomiting among the three treatment conditions. Additional analyses revealed pronounced gender differences. Men in the acustimulation condition, but not the acupressure condition, had less NV compared to controls (P<0.05). No significant differences among the three treatment conditions were observed in women, although the reduction in nausea on the day of treatment in the acupressure, compared to the no band condition, closely approached statistical significance (P=0.052). Expected efficacy of the bands was related to outcomes for the acupressure but not the acustimulation conditions.

Volatile compounds released by disturbed and calm adults of the tarnished plant bug, Lygus lineolaris.

Volatile compounds released by disturbed and calm female and male Lygus lineolaris were collected and analyzed. Six major compounds were present in samples from disturbed bugs and from calm females: (E)-2-hexenal, 1-hexanol, (E)-2-hexenol, hexyl butyrate, (E)-2-hexenyl butyrate, and (E)-2,4-oxohexenal. (E)-2-hexenal was lacking in volatiles collected from calm males. Hexyl butyrate accounted for approximately 68% and 66% of volatiles released by agitated and calm females, and 87% and 88% of volatiles released by agitated and calm males, respectively. Blends released by disturbed insects differed quantitatively from blends released by calm insects, with amounts of compounds increasing 75-350 times in samples from disturbed insects. In static air bioassays, both females and males were repelled by natural volatiles collected from females and by five-component [(E)-2,4-oxohexenal excluded] and six-component synthetic blends at doses of 1 and 10 bug-hours, indicating that these volatiles may serve an alarm or epideictic function, as well as a possible role as defensive allomones. Adults also avoided hexyl butyrate, (E)-2-hexenyl butyrate, (E)-2-hexenol, and (E)-2,4-oxohexenal, but not 1-hexanol and (E)-2-hexenal when compounds were assayed individually in static air bioassays at doses equal to 1 bug-hour. When tested over 1 day in two-choice cage trials, adults did not prefer untreated bean plants over bean plants surrounded by vials releasing up to 8.1 mg/hr (= 234 bug-hours) of the five-component synthetic blend. Therefore, the volatiles produced by disturbed adults would not be useful as a repellent for L. lineolaris.

A single nucleotide polymorphism in the 5' untranslated region of RAD51 and risk of cancer among BRCA1/2 mutation carriers.

RAD51 colocalizes with both BRCA1 and BRCA2, and genetic variants in RAD51 would be candidate BRCA1/2 modifiers. We searched for RAD51 polymorphisms by sequencing 20 individuals. We compared the polymorphism allele frequencies between female BRCA1/2 mutation carriers with and without breast or ovarian cancer and between population-based ovarian cancer cases with BRCA1/2 mutations to cases and controls without mutations. We discovered two single nucleotide polymorphisms (SNPs) at positions 135 g-->c and 172 g-->t of the 5' untranslated region. In an initial group of BRCA1/2 mutation carriers, 14 (21%) of 67 breast cancer cases carried a "c" allele at RAD51:135 g-->c, whereas 8 (7%) of 119 women without breast cancer carried this allele. In a second set of 466 mutation carriers from three centers, the association of RAD51:135 g-->c with breast cancer risk was not confirmed. Analyses restricted to the 216 BRCA2 mutation carriers, however, showed a statistically significant association of the 135 "c" allele with the risk of breast cancer (adjusted odds ratio, 3.2; 95% confidence limit, 1.4-40). BRCA1/2 mutation carriers with ovarian cancer were only about one half as likely to carry the RAD51:135 g-->c SNP. Analysis of the RAD51:135 g-->c SNP in 738 subjects from an Israeli ovarian cancer case-control study was consistent with a lower risk of ovarian cancer among BRCA1/2 mutation carriers with the "c" allele. We have identified a RAD51 5' untranslated region SNP that may be associated with an increased risk of breast cancer and a lower risk of ovarian cancer among BRCA2 mutation carriers. The biochemical basis of this risk modifier is currently unknown.

The effect of different definitions of a patient on immunization assessment.

OBJECTIVES: In this report, the authors compare immunization assessment using 2 definitions of a patient. METHODS: Two Clinical Assessment Software Application (CASA) assessments were performed. The first sampled 200 two-year-olds seen at least once since birth. The second sampled 200 two-year-olds seen in the previous year. Children with incomplete immunizations in the first sample were contacted. RESULTS: In the second sample, 72% of children had complete immunizations, compared with 46% in the first sample. In the first sample, 78% of children with incomplete immunizations had not been seen during the past year. Of 134 children in the first sample seen in the past year or successfully contacted, 75% had complete immunizations. CONCLUSIONS: The CASA assessment's definition of a patient underestimates immunization rates.

Oral clonidine in postmenopausal patients with breast cancer experiencing tamoxifen-induced hot flashes: a University of Rochester Cancer Center Community Clinical Oncology Program study.

BACKGROUND: Hot flashes are the most frequently reported side effect of tamoxifen treatment. Although hormones are an effective treatment, their safety is questionable in women with breast cancer. It is therefore important to evaluate nonhormonal treatments for hot flashes. OBJECTIVE: To evaluate the effectiveness of oral clonidine for control of hot flashes associated with tamoxifen therapy in postmenopausal women with breast cancer. DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: University of Rochester Cancer Center Community Clinical Oncology Program. PATIENTS: 194 postmenopausal women with breast cancer who were receiving adjuvant tamoxifen therapy. INTERVENTION: Oral clonidine hydrochloride, 0.1 mg/d, or placebo for 8 weeks. MEASUREMENTS: In a daily diary, patients recorded number, duration, and severity of hot flashes and overall quality-of-life score (on a 10-point scale) during a 1-week baseline period and during the 4th, 8th, and 12th weeks of the study. RESULTS: Patients in the placebo and treatment groups were similar in age, duration of tamoxifen use, reported frequency and duration of hot flashes at baseline, and dropout rates. One hundred forty-nine patients completed 12 weeks of follow-up. The mean decrease in hot flash frequency was greater in the clonidine group than in the placebo group after 4 weeks of treatment (37% compared with 20% [95% CI for difference, 7% to 27%]) and 8 weeks of treatment (38% compared with 24% [CI for difference, 3% to 27%]). Patients receiving clonidine were more likely than patients receiving placebo to report difficulty sleeping (41% compared with 21%; P = 0.02). A significant difference was seen in the mean change in quality-of-life scores (0.3 points in the clonidine group compared with -0.2 points in the placebo group; P = 0.02) at 8 weeks, although the median difference was 0 in both groups. CONCLUSION: Oral clonidine, 0.1 mg/d, is effective against tamoxifen-induced hot flashes in postmenopausal women with breast cancer.

Malignant fibrous histiocytoma: inherited and sporadic forms have loss of heterozygosity at chromosome bands 9p21-22-evidence for a common genetic defect.

Hereditary cancers represent a unique opportunity to investigate the genetic etiology of their more common sporadic forms. We recently established genetic linkage for the rare autosomal-dominant bone dysplasia/cancer syndrome, diaphyseal medullary stenosis with malignant fibrous histiocytoma (DMS-MFH), to a 3-cM region on chromosome bands 9p21-22. This hereditary cancer syndrome is characterized by bone infarctions, cortical growth abnormalities, pathologic fractures, and painful debilitation. Most notably, 35% of affected individuals develop bone MFH, a sarcoma that, in its sporadic form, accounts for 6% of all bone cancers. To determine whether the hereditary and sporadic forms of bone MFH are genetically linked, we performed loss of heterozygosity (LOH) studies of the DMS-MFH critical region. In addition to the hereditary specimen, 71% (5/7) of informative sporadic bone MFH specimens displayed LOH for markers within that same region. Definition of the minimal region of LOH overlap effectively limited the DMS-MFH gene to a 2-cM region between markers D9S736 and D9S171. In summary, these studies suggest that a common genetic etiology underlies the autosomal-dominant and sporadic forms of this sarcoma and provide the basis for identifying the putative MFH tumor suppressor gene. Genes Chromosomes Cancer 27:191-195, 2000.

Group psychotherapy for recently diagnosed breast cancer patients: a multicenter feasibility study.

As many as 80% of breast cancer patients report significant distress during initial treatment, yet there is little in the way of systematic psychotherapeutic interventions for women coping with the stress of a recent diagnosis of breast cancer. The literature on psychotherapeutic treatment of cancer patients provides uniform evidence for an improvement in mood, coping and adjustment as a result of group therapy. The present study examined the feasibility of implementing a manualized treatment, supportive-expressive group psychotherapy, in busy oncology practices across the US. This intervention was applied to women with primary breast cancer in a manner which tests not only the efficacy of the approach but also its accessibility to group therapists not previously experienced in its use. One hundred and eleven breast cancer patients within 1 year of diagnosis were recruited from ten geographically diverse sites of the National Cancer Institute's Community Clinical Oncology Program (CCOP) and two academic medical centers. Two therapists from each site were trained in supportive-expressive group psychotherapy. Training consisted of participation in a workshop, reading a treatment manual, and viewing explanatory videotapes. Each patient participated in a supportive-expressive group that met for 12 weekly sessions lasting 90 min. Assessment of mood disturbance was made at entry, 3, 6, and 12 months. Results indicated a significant 40% decrease in the Total Mood Disturbance (TMD) scores of the Profile of Mood States (POMS) (ANOVA F [2,174]=3.98, p<0.05). The total symptom score of the Hospital Anxiety and Depression Scale (HADS) was likewise significantly reduced over the 6-month period (F [2, 174]=5.2, p<0.01). Similarly, the total score of the Impact of Event Scale (IES) was significantly reduced (F [2,174]=4.0, p<0.05). There was substantial uniformity of treatment effect across sites. Outcome was independent of stage of disease (I vs. II). We conclude that this treatment program can be effectively implemented in a community setting and results in reduced distress among breast cancer patients.

Further evaluation of intensified and increased total dose of cyclophosphamide for the treatment of primary breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-25.

PURPOSE: In 1989, the National Surgical Adjuvant Breast and Bowel Project initiated the B-22 trial to determine whether intensifying or intensifying and increasing the total dose of cyclophosphamide in a doxorubicin-cyclophosphamide combination would benefit women with primary breast cancer and positive axillary nodes. B-25 was initiated to determine whether further intensifying and increasing the cyclophosphamide dose would yield more favorable results. PATIENTS AND METHODS: Patients (n = 2,548) were randomly assigned to three groups. The dose and intensity of doxorubicin were similar in all groups. Group 1 received four courses, ie, double the dose and intensity of cyclophosphamide given in the B-22 standard therapy group; group 2 received the same dose of cyclophosphamide as in group 1, administered in two courses (intensified); group 3 received double the dose of cyclophosphamide (intensified and increased) given in group 1. All patients received recombinant human granulocyte colony-stimulating factor. Life-table estimates were used to determine disease-free survival (DFS) and overall survival. RESULTS: No significant difference was observed in DFS (P =.20), distant DFS (P =.31), or survival (P =.76) among the three groups. At 5 years, the DFS in groups 1 and 2 (61% v 64%, respectively; P =. 29) was similar to but slightly lower than that in group 3 (61% v 66%, respectively; P = 08). Survival in group 1 was concordant with that in groups 2 (78% v 77%, respectively; P =.71) and 3 (78% v 79%, respectively; P =.86). Grade 4 toxicity was 20%, 34%, and 49% in groups 1, 2, and 3, respectively. Severe infection and septic episodes increased in group 3. The decrease in the amount and intensity of cyclophosphamide and delays in therapy were greatest in courses 3 and 4 in group 3. The incidence of acute myeloid leukemia increased in all groups. CONCLUSION: Because intensifying and increasing cyclophosphamide two or four times that given in standard clinical practice did not substantively improve outcome, such therapy should be reserved for the clinical trial setting.

'Neo-FAC' (5-fluorouracil, doxorubicin, and cyclophosphamide) for poor-prognosis stage IV breast cancer: a Southwest Oncology Group Phase II Study.

The authors report a phase II pilot investigation in the Southwest Oncology Group examining a combination of 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) incorporating modulated 5-FU in patients with poor-prognosis stage IV breast cancer. Patients with poor-prognosis stage IV breast cancer were treated with this "neo-FAC" as front-line therapy. The regimen consisted of 5-fluorouracil by continuous ambulatory infusion pump at 200 mg/m2/day for 42 days, repeated at 56-day intervals; doxorubicin at 20 mg/m2/week intravenously to a maximum cumulative total dose (including adjuvant therapy, if any) of 500 mg/m2; cyclophosphamide 60 mg/m2/day taken orally; methotrexate 15 mg/m2/week intravenously beginning 1 week after termination of doxorubicin; and oral prednisone decreasing from 60 mg/day on a tapering schedule for a total of 7 weeks of treatment. Treatment was continued until progression, unacceptable toxicity, or patient refusal. Twenty-four patients were accrued to this study. Of these, two were ineligible, and the remaining 22 were evaluable for response. Ten patients experienced grade 3 toxicity, and six had grade 4. There were no treatment-associated deaths. Best responses were a complete response in one patient (5%) and partial responses in 6, for an overall response rate of 32% (7/22 evaluable patients). Overall survival in five pilot studies in the Southwest Oncology Group in this poor-prognosis population are relatively superimposable. The present regimen, with its relatively poor outcome and the expense and inconvenience of administering chemotherapy by ambulatory infusion pump, will not be pursued further.