Thomas E. Lad

Standardizing patient-reported outcomes assessment in cancer clinical trials: a patient-reported outcomes measurement information system initiative.

Patient-reported outcomes (PROs), such as symptom scales or more broad-based health-related quality-of-life measures, play an important role in oncology clinical trials. They frequently are used to help evaluate cancer treatments, as well as for supportive and palliative oncology care. To be most beneficial, these PROs must be relevant to patients and clinicians, valid, and easily understood and interpreted. The Patient-Reported Outcomes Measurement Information System (PROMIS) Network, part of the National Institutes of Health Roadmap Initiative, aims to improve appreciably how PROs are selected and assessed in clinical research, including clinical trials. PROMIS is establishing a publicly available resource of standardized, accurate, and efficient PRO measures of major self-reported health domains (eg, pain, fatigue, emotional distress, physical function, social function) that are relevant across chronic illnesses including cancer. PROMIS is also developing measures of self-reported health domains specifically targeted to cancer, such as sleep/wake function, sexual function, cognitive function, and the psychosocial impacts of the illness experience (ie, stress response and coping; shifts in self-concept, social interactions, and spirituality). We outline the qualitative and quantitative methods by which PROMIS measures are being developed and adapted for use in clinical oncology research. At the core of this activity is the formation and application of item banks using item response theory modeling. We also present our work in the fatigue domain, including a short-form measure, as a sample of PROMIS methodology and work to date. Plans for future validation and application of PROMIS measures are discussed.

Development of skeletal metastasis by human prostate cancer in athymic nude mice.

The biology of skeletal metastasis is poorly understood. In order to establish an animal model of bone metastasis, cells from a human prostate cancer cell line (PC-3) were injected into the tail veins of athymic nude mice while the inferior vena cava was occluded. This technique was used in order to divert cells into the vertebral venous plexus. A control group of animals received tumor cells without caval occlusion. Bone lesions developed in 3/16 (19 per cent) experimental mice and in none of the control mice. The incidence of lung metastasis was significantly decreased in the experimental mice (5/16) as compared with non-occluded control mice (14/16). Two tumor sublines were established from explant cultures of bone lesions. Injection of these cells resulted in bone metastasis in 19/36 (53 per cent) mice (P=0.03 compared with the parent line). The incidence of lung lesions was also increased. The predominant site of bone metastasis was the lumbar vertebrae; other affected sites were the pelvis and femurs. All bone lesions resulted in extensive bone destruction. The successful development of bone metastasis using the technique of caval occlusion lends support to the hypothesis that entry of cells into the vertebral circulation is an important step in the development of these lesions. This model should be of value in understanding the pathogenesis of bone metastasis, and in studying the effects of various agents on the prevention and control of these lesions.

A phase II study of 9-aminocamptothecin in advanced non-small-cell lung cancer

BACKGROUND 9-Aminocamptothecin (9-AC) is a synthetic analogue of camptothecin. Phase I studies, identified the maximum tolerated dose as 1416 micrograms/m2/day x 3 as continuous intravenous infusion (CVI) with dose-limiting neutropenia. PATIENTS AND METHODS Eligible patients had stage IIIB or IV non-small-cell lung cancer (NSCLC) with measurable disease. Patients were initially treated at 1416 micrograms/m2/d x 3 by CVI followed by granulocyte-colony stimulating factor (G-CSF) support. This dose was decreased to 1100 micrograms/m2/d after the first 13 patients. Cycles were repeated every 14 days until tumor progression. RESULTS Fifty-eight patients were treated, thirteen at 1416 micrograms/m2/d and 45 at 1100 micrograms/m2/d. Fifty percent had adenocarcinoma and 17% squamous cell carcinoma. Seventy-one percent had stage IV disease. Five patients had a partial response (response duration 9-28 weeks) for an overall response rate of 8.6%, (95% confidence intervals (CI): 2.9%-19%). Median time to progression was 2.3 months and the median survival for the entire study population 5.4 months with a one-year survival rate of 30%. The one-year survival rate for 27 patients who received second line chemotherapy was 56.7%. Toxicities at 1416 micrograms/m2/d included grade 4 neutropenia and thrombocytopenia in six and five of 13 patients, respectively; at 1100 micrograms/m2/d these toxicities were observed in 12 and three of 45 patients, respectively. CONCLUSION 9-AC has modest single-agent activity in previously untreated NSCLC. Its further evaluation at the dose and schedule employed in this study does not seem indicated. Exploration of more prolonged administration schedules may be warranted.

Hypocalcemia in patients with prostate cancer

SummaryWe report a case of severe hypocalcemia in a patient with prostate cancer and extensive metastatic bone disease. The hypocalcemia in this patient was most likely on the basis of extensive accretion of calcium into the bones. We further studied 112 patients with prostate cancer, 15 of whom were discovered to be hypocalcemic on the basis of serum total calcium measurement. Fourteen of these 15 patients had bone metastases. Serum total calcium, total protein, and albumin levels were significantly lower in patients with bone metastases (n=61) than those without (n=51). Hypocalcemia could be explained on the basis of hypoalbuminemia or renal failure in these patients. Plasma ionized Ca measurements were made in 47 of the total 112 patients. Only one patient with extensive bone metastases was found to be hypocalcemic on the basis of ionized calcium measurement. Therefore, apparent hypocalcemia based on total calcium measurement is common in patients with prostate cancer (14% of all and 23% of those with bone metastases), whereas true hypocalcemia based on ionized calcium determinations is unusual.

Cis-platinum treatment for malignancy-associated humoral hypercalcemia in an athymic mouse model

SummaryWe have established a model for malignancy-associated humoral hypercalcemia (MAHH) in athymic mice, utilizing a human squamous cell lung carcinoma. In the present studies, we evaluated cis-platinum (DDP), a cytotoxic agent known to produce hypomagnesemia, and occasionally hypocalcemia, in the treatment of MAHH. Upon development of significant hypercalcemia, defined as serum calcium (Ca)⩾11.5 mg/dl, tumor-bearing mice received either normal saline (NS) alone (1.5 ml/day, i.p.), or NS+DDP. The DDP was given as a single dose of 6 µg/g body weight i.p. Serum Ca was determined on day 6 in surviving mice (6 of 10 survived in the NS-alone group; 7 of 10 survived in the NS+DDP group). Serum Ca (mean±SE) decreased from 14.3±0.46 to a nadir of 12.7±0.33 mg/dl in the NS-alone group, and from 13.5±0.46 to a nadir of 10.4±0.48 mg/dl in the NS+DDP group. Nadir serum Ca levels were significantly lower in the NS+DDP group (P=0.003). Three of 7 surviving NS+DDP mice achieved normocalcemia, whereas none of the NS-alone animals became normocalcemic. Tumor volumes increased in all animals. There was no change in the serum Ca in 5 tumor-free mice treated with NS+DDP. There were no significant differences in serum magnesium levels among groups of control mice, tumor-free mice treated with NS+DDP, tumor-bearing mice treated with NS+DDP, and tumor-bearing mice treated with NS-alone. We conclude that DDP is an effective agent for the treatment of MAHH, through a mechanism distinct from its antitumor cytotoxic effect and its potential to produce hypomagnesemia.

Phase II trial of aminocamptothecin (9-AC/DMA) in patients with advanced squamous cell head and neck cancer.

Fourteen patients with squamous cell carcinoma of the head and neck received 9-AC/DMA infusions of 850 mg/M2/day over 72 hours. Eligibility criteria included good performance status, advanced disease incurable by conventional means, no prior treatment of metastatic disease, and measurable lesions for objective response assessment. The infusions wererepeated at 21 day intervals until progression or prohibitive toxicity occurred.A median of 3 cycles (range 1–7) was given. No objective responses wereobserved. Median survival of the group was 6 months. Toxicity was hematologicwhich was modest and promptly reversible. 9-AC/DMA is inactive against this tumortype at the dose and schedule employed in this study.

Long-term Suppression of Luteinizing Hormone, Follicle-stimulating Hormone and Testosterone by Daily Administration of Leuprolide

The chronic effect of long-term injections of leuprolide on the hypothalamic, pituitary and gonadal axes have been studied in men with advanced prostatic cancer. The possibility of transient acute changes in luteinizing hormone, follicle-stimulating hormone and testosterone after each daily injection was studied in 31 patients treated for more than 1 year. No evidence of escape from daily 1.0 mg. doses was noted. No pituitary responsiveness was observed at any time point examined. Thus, daily administration of 1.0 mg. leuprolide acetate subcutaneously produces durable, complete suppression of gonadotropins and testosterone for prolonged periods.

A phase II study of adriamycin in previously untreated squamous cell carcinoma of the head and neck

Twenty patients with squamous cell carcinoma of the head and neck (SCC H/N) were treated with Adriamycin (doxorubicin) at a dosage of 60 mg/m2 at 3‐week intervals. No patient had received surgery, radiation, or chemotherapy before treatment with Adriamycin. Responses were observed in 44% of 18 evaluable tumors. We conclude that Adriamycin is a highly active drug in SCC H/N when no prior treatment has been administered.

Phase II trial of caracemide (NSC 253272) in advanced unresectable non-small cell bronchogenic carcinoma

Caracemide (NacetylN(methylcarbamoyloxy)N-methylurea) is a nonspecific inhibitor of macromolecular synthesis [1]. It has in vitro activity against ribonucleotide reductase [2], but whether this is its mechanism in vivo is not known. Caracemide interferes most effectively with DNA synthesis in a concentration-dependent manner. In phase I testing, neurotoxicity was found to be dose limiting [3]. The dose recommended by phase I studies for use in human phase II trials was 650 mg/m2/ day for 5 consecutive days as a continuous intravenous infusion [4].

Phase II trial of fludarabine phosphate in advanced renal cell carcinoma: An Illinois Cancer Council study

SummaryFludarabine Phosphate (FP), the 2-fluoro, 5′ phosphate derivative of adenosine arabinoside (ara-A), was studied in 18 patients with advanced renal cell carcinoma. These patients had measurable disease and had not received chemotherapy. FP was administered at a loading dose of 20 mg/m2 followed by a 48-hour infusion at 30 mg/m2/day given every 21 days. There were no complete or partial responses seen. Toxicity was mainly hematologic, with leukopenia most commonly observed. FP given in this manner had no activity in advanced renal cell carcinoma.