Elderly cancer patients tolerate radiotherapy
AN Australian study of patients aged 85 years and over who received curative radiotherapy for cancer has found they can tolerate aggressive treatment regimens, challenging the notion that they may be too old for treatment. The retrospective analysis, published in the MJA , included 325 patients who underwent 327 radiotherapy courses between 2000 and 2010. The most common sites treated were pelvis (30%), head and neck (25%), breast (18%) and thorax (13%). Skin cancer cases were not included. The researchers wrote that poor treatment tolerability was observed in 70 patients (21%) and only 16 patients (5%) ceased treatment prematurely. Cancer-specific survival estimates at 1, 3, 5 and 8 years were 87%, 66%, 56% and 44%, respectively. The median follow-up period was 6 years and median survival 3.3 years. “Our data show that, with judicious patient selection, patients over the age of 85 years can tolerate aggressive radiotherapy regimens”, the researchers wrote. “The treatment completion rate of 95% was higher than in other cohort studies with less stringent entry criteria.” They challenged the assumption that a high rate of natural attrition in those aged over 85 years lessened the need for long-term cancer control. “Patients of advanced age whose performance status is good should still be referred to be assessed for treatment”, they wrote.

Fasting diets impact on medications
RESEARCHERS have urged all health professionals to consider the possible impact of fasting diets on medications in a letter published in the MJA. The authors wrote that the popular weight loss 5:2 diet, where calorie intake was unrestricted for 5 days a week and limited on 2 days a week to 500 calories for women and 600 calories for men, could affect particular medications which fell into two categories — those for which absorption may be significantly altered while fasting, and those for which increased gastrointestinal or other adverse effects could result when taken on an empty stomach. They used the example of the bioavailability of telaprevir for chronic hepatitis C, which if taken while fasting was 27% of that when taken with a standard meal. Similarly, while the absorption of warfarin was not affected by fasting, it was possible that an altered diet (particularly diets high in vitamin K foods) could lead to volatility in the international normalised ratio. Glibenclamide, glimepiride and insulin also carried a high risk of hypoglycaemia if normal doses were taken while fasting. “Information regarding potential clinical significance of the diet may be evaluated via the full product information for individual medications and through community and hospital pharmacies”, the authors wrote.

Care of NSCLC patients useful as a quality benchmark
THE care of patients with metastatic non-small cell lung cancer (NSCLC ) is a “reasonable benchmark of the quality” of end-of-life or palliative care for patients with eventually fatal oncological disease, according to the authors of research published in the MJA. Their retrospective cohort study included 6041 patients from first hospitalisation for metastatic NSCLC until death based on data from Victorian hospital, emergency department and death registration data from 2003 to 2010, which found “gaps in service provision” for such patients. The authors found that although the patients underwent limited aggressive treatment such as intensive care and chemotherapy at the end of life, 42% died in acute hospitals and 61% had a length of stay of greater than 14 days in the last month of life. The odds ratio of dying in an acute hospital bed compared with death at home or in a hospice unit decreased with receipt of palliative care and multimodality supportive care. “Perhaps the most important finding is the low numbers of patients discharged from hospital following the diagnosis of metastatic disease who were referred to hospital palliative care services during the first admission for metastasis (10%)”, the authors wrote. “This is a group of patients with poor prognostic disease, who are not being identified as requiring palliative care services.” They found the majority of referrals to palliative care occurred later in the illness. “Future work is required to determine appropriate targets for quality end-of-life care in this and other cancer patient cohorts, with particular focus on timely palliative care engagement”, the authors wrote.

HRT increases risk of ovarian cancer
A META-analysis of 52 prospective and retrospective epidemiological studies has found that the risk of ovarian cancer was significantly increased in current users of hormone replacement therapy (HRT), even in those with less than 5 years use. The research, published in The Lancet included 21 488 postmenopausal women with ovarian cancer, almost all from North America, Europe and Australia. The authors wrote the 17 prospective studies provided more than half of the cases (12 110 women), and showed 55% of those who developed ovarian cancer had used HRT. They found that combining current-or-recent use (for any duration, but stopped <5 years before diagnosis) resulted in a relative risk (RR) of 1.37. “In current-or-recent users (all of whom had used hormone therapy within the past 5 years), the RRs did not differ significantly between users of oestrogen-only and of oestrogen-progestogen preparations, or between women who had started hormone therapy before the age of 50 years or during their 50s”, they wrote. However, they found that the RR varied substantially by tumour type, increasing only for the two most common histological types, serous and endometrioid tumours. “The findings that ovarian cancer risk is greatest in current users of hormone therapy, falls after use ceases, and varies by tumour type, strongly suggest a causal relationship—ie, that among otherwise similar women, use of hormone therapy increases the probability of developing the two most common types of ovarian cancer, and hence ovarian cancer as a whole”, the authors wrote. An accompanying commentary said the research underlined the “importance and limitations of observational data for rare and long-term outcomes, especially for the complex associations between regimen, dose, duration, route of administration, and timing of hormone therapy use with ovarian, breast, and endometrial cancers”.

HPV vax not associated with increase in STIs
HUMAN papillomavirus (HPV) vaccination is not associated with increases in sexually transmitted infections (STIs) among teenaged girls, a US longitudinal study has found. The research, published in JAMA Internal Medicine, used information from a large, insurance database of girls aged 12‒18 years to compare the rate of STIs among 21 610 who were vaccinated and 186 501 who were not. The authors found HPV vaccination use increased over the study period from 2005 to 2010, from 2.5% at the end of the year it became available in 2006, to 27.3%. The rates of STIs before vaccination were higher among HPV-vaccinated participants than the age-matched controls but, while the prevalence of STIs increased in both groups in the year after vaccination began, the increase was not significantly greater in the vaccinated than the non-vaccinated group. Similar associations were found in subgroups aged 12‒14 years and 15‒18 years, and among girls using contraception, the authors said. “Given low rates of HPV vaccination among adolescent females in the United States, our findings should be reassuring to physicians, parents and policy makers that HPV vaccination is unlikely to promote unsafe sexual activity”, the authors wrote. An accompanying commentary said the results highlighted the need to improve the delivery of information to all key partners, including adolescents, their parents and their health care professionals, to reduce the stigma associated with HPV vaccination.

Iron supplement a boost for blood donors
LOW-dose iron supplementation given to blood donors reduces the time to 80% haemoglobin recovery compared with those who do not receive a supplement, research has found. The study, published in JAMA included 215 participants aged 18‒79 years with normal haemoglobin levels who had not donated whole blood or red blood cells within 4 months. The researchers randomly assigned donors to receive one tablet of ferrous gluconate (37.5 mg of elemental iron) daily or no iron for 24 weeks, after donating a 500 mL unit of whole blood. The iron stores of each donor were assessed and categorised as either low ferritin (≤26 ng per mL) or higher ferritin (>26 ng/mL). The authors found that donors who received an iron supplement had a shortened time to 80% haemoglobin recovery in both the low-ferritin and higher-ferritin groups, compared with those who did not take a supplement. The recovery of iron stores among donors took a median of 76 days in the supplement group and 168 days in the non-supplement group. Without iron supplements, 67% of donors did not recover iron stores by 168 days. The authors wrote that while absolute haemoglobin decrease was relatively small after a single blood donation, “donating blood is an iterative process that leads to progressive iron loss and anemia in some frequent blood donors, so it is important that the hemoglobin decrease after blood donation be recovered before the next blood donation”. They said that prolonging the minimum donation interval for blood donation from the current minimum of 56 days to 12 or 16 weeks could “significantly compromise” the blood supply in the US.

Shorter hours do not help patient outcomes
CANADIAN research has found that shorter duty hours for hospital residents do not reduce the number of adverse events for patients or relieve residents’ daytime sleepiness. The trial, published in CMAJ, included 47 residents on 2-month rotation blocks to two university-affiliated intensive care units (ICUs). The residents were randomly assigned to in-house overnight schedules of 24, 16 or 12 hours. The researchers evaluated 971 ICU admissions, 5894 patient-days and 452 staff surveys. They found 166 adverse events (81.3 per 1000 patient-days) with the 24-hour schedule, 126 (76.3 per 1000) with the 16-hour schedule and 172 (78.2 per 1000) with the 12-hour schedule. In the ICU staff surveys, which were completed by nurses, respiratory therapists and physicians, residents working the 16-hour schedule were reported as being less familiar with the clinical and social details of their patients, and the decisions of the residents were perceived to be more suboptimal. Residents working the 12-hour schedule were judged most alert overnight. “Residents reported more somatic symptoms with the 24-hour schedule and sleepiness that was not significantly different across schedules”, the researchers wrote. “Our findings do not support the purported advantages of shorter duty and highlight trade-offs between residents’ symptoms and multiple secondary measures of patient safety.” An accompanying commentary said there was increasing, albeit anecdotal, concern that increased resident duty-hour limits would shift responsibilities to attending physicians, saying future research on resident hours reform should also identify and track indicators of attending physician wellbeing.

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