Joäo Joaquim de Oliveira

Adjuvant chemotherapy with TAC (docetaxel, doxorubicin, and cyclophosphamide) in patients with breast cancer--incidence of neutropenic fever outside clinical trials.

To the Editor: In a phase III trial in node-positive breast cancer, adjuvant chemotherapy with TAC improved diseasefree and overall survival as compared to FAC (5FU, doxorubicin and cyclophosphamide) but with a high incidence of neutropenic fever (NF, 24.7% versus 2.5% of patients) (1). A subsequent trial showed that primary prophylaxis with granulocyte colony-stimulating factor (G-CSF) reduces the incidence of NF with TAC from 24% to 6.5% of patients (2) but there are little data outside the clinical trials setting. Our aim was to assess the hematologic toxicity of TAC chemotherapy with primary prophylaxis with filgrastim, in patients treated in our referral cancer centre outside clinical trials. All consecutive women treated with adjuvant TAC chemotherapy for node-positive breast carcinoma at our Institution between October 2004 and April 2007 were included. Patients were identified through hospital pharmacy and day-hospital records. Clinical charts and pharmacy dispensing records were reviewed for collection of patient and disease characteristics, treatment administration, toxicity, and filgrastim prophylaxis administration. All patients had a blood cell count before day one of each cycle. No routine cell blood counts were done in between, unless determined by clinical events that led to nonprogrammed hospital visits. NF was defined as axillary temperature above 38 C associated with an absolute neutrophil count (ANC) below 500 ⁄lL, regardless of the need for hospital admission. Descriptive statistics are described as median and ranges. Two-sided 95% confidence intervals (CI) for sample proportions were estimated. This retrospective study included 147 female patients (median age 52 years, range 27–70 48% premenopausal) who had completed treatment at the time of analysis. The majority had T1 (40%) and T2 (56%) tumors; all but one had at least one positive axillary lymph node on pathologic examination (55% one to three, 29% four to nine and 16% ten or more positive nodes); 76% tumors were hormone-receptor positive; 29 tumors were HER-2 ⁄ neu positive and 108 were negative (10 undetermined ⁄ unknown). All patients had undergone primary surgery – breastconserving surgery in 57% and modified radical mastectomy in 43%. All patients received TAC as described by Martin et al. (1) but no prophylactic antimicrobials. Of the 147 patients, 134 received all six scheduled cycles while 12 received less due to prior neutropenic fever or infection (six), neurotoxicity (one), docetaxelhypersensitivity (four) and neutropenia without fever or infection (one); one patient received seven cycles of TAC. Overall, 840 cycles of TAC were administered, (median 6 per patient, range 1–7). There were 31 treatment delays and two dose reductions (Table 1). All patients received primary prophylaxis with filgrastim. Two patients switched to pegfilgrastim (Neulasta; Amgen, Thousand Oaks, CA) on the first and fifth cycles of chemotherapy, respectively. One hundred and thirty-one (89%) started filgrastim prophylaxis between cycle day 2 and 4 and 16 (11%) between days 5 and 9. Thirty patients (20%) received filgrastim for less than 7 days in at least one cycle. The duration of filgrastim administration was less than 7 days in 104 (12%) cycles and 7 days or more in 729 (87%) cycles; pegfilgrastim was given in seven cycles (1%). In some patients filgrastim treatment was continued beyond 7 days due to the development of NF, persistence of neutropenia or NF in a prior cycle. There were 27 NF episodes (3.2% of cycles; CI 2.2–4.7%). Twenty patients had one single episode, Address correspondence and reprint requests to: JL Passos-Coelho, MD, PhD, IPOLFG, Rua Professor Lima Bastos, 1099-023 Lisboa, Portugal, or e-mail: passoscoelho@sapo.pt.

Valor diagnóstico do teste ergométrico na detecção da isquemia miocárdica silenciosa no paciente idoso com hipertensão sistólica

PURPOSE To evaluate the diagnosis value of exercise testing for silent myocardial ischemia in systolic hypertension of the elderly. METHODS We compared 110 patients with systolic hypertension (group A) with 104 patients without hypertension (group B). They were submitted to an exercise test according to the Bruce protocol, between January/91 to December/94. Exercise was discontinued if target heart rate was achieved, or fatigue, dyspnea, severe arrhythmia, hypotension or significant ST segment depression > or = 2 mm/0.2 mV developed. RESULTS Exercise testing showed ischemic ST depression in 22 (20%) of the elderly patients with hypertension systolic and 12 (11.5%) of control elderly patients. The exercise time was shorter in the hypertensives 7.1 +/- 2.9 min vs 8.8 +/- 2.5 min. The ST depression was greater in the hypertensives than the control group: 2.5 +/- 0.8 min vs 1.9 +/- 0.4 min. Also the duration or ischemic ST depression was longer in the hypertensive patients than the control group 5.4 +/- 2.8 min vs 3.4 +/- 1.9 min. CONCLUSION Elderly hypertensive patients with systolic hypertension have more silent myocardial ischemia than elderly without hypertension. Among the elderly hypertensive patients there was a prevalence of silent ischemia that was 1.7 times higher than in the normotensive elderlies (20% vs 11.5% P < 0.003).