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Gabapentin is used for the treatment of hot flashes and neuropathic pain in breast cancer survivors, and is commonly used off-label for the treatment of anxiety. Yet, clinical trial evidence to support the use of gabapentin for anxiety symptoms is lacking. In a randomized, double-blinded controlled trial we compared 300 mg gabapentin versus 900 mg gabapentin versus placebo. Subjects were 420 breast cancer patients who had completed all chemotherapy cycles. Anxiety traits and current (state) anxiety were measured using the Speilberger Strait-Trait Anxiety Inventory at baseline, 4 and 8 weeks. Pain was measured at baseline using a 10-point scale. Analyses included analysis of covariance and ordinary least squares regression. At 4 weeks, state anxiety change scores were significantly better for gabapentin 300 and 900 mg (p = 0.005) compared to placebo. The magnitude of improvement was proportional to baseline state anxiety. At 8 weeks, the anxiolytic effects of gabapentin compared to placebo persisted (p < 0.005). We found no significant interactions. The lower dose (300 mg) was associated with the best treatment outcomes for all patients except those with the highest baseline anxiety. Given its similar pharmacology, efficacy in the treatment of hot flashes, and low cost, gabapentin may provide a low cost and parsimonious alternative treatment choice for breast cancer survivors presenting in primary care practices with anxiety symptoms. Gabapentin is effective for hot flashes, and, therefore, may provide therapeutic benefit for both anxiety and hot flashes at a generic drug price. For patients reluctant to take a controlled substance, such as a benzodiazepine, gabapentin may offer an alternative therapy. Similarly, patients with a history of substance use may benefit from gabapentin without risk of addiction or abuse. For cancer survivors experiencing both hot flashes and anxiety, gabapentin may provide a single effective treatment for both and is an alternative therapy for anxiety for patients unwilling to take a benzodiazepine or those with a history of substance use.

This article discusses the care process among three groups (primary care, radiology, and surgery) aiding a 57-year-old woman during her screening mammography and diagnosis of breast cancer. This is the first in a series of articles exploring principles and topics relevant to teams guiding clinicians involved in cancer care. The challenges demonstrated in this case illustrate how clinicians work within and between groups to deliver this first phase of cancer care. The case helps demonstrate the differences between groups and teams. Focusing on the patient and the overall process of care coordination can help move groups toward becoming teams who deliver better care by identifying and managing goals, roles, and interdependent care tasks. Care providers and researchers can use the case to consider their own work and essential aspects of teamwork needed to improve care, patient outcomes, and the evidence that supports each.

Fourteen patients with metastatic renal cell carcinoma (RCC) were treated on a Phase II trial with imatinib. Eligible patients had histologically confirmed RCC, metastatic and measurable disease by Response Evaluation Criteria in Solid Tumors (RECIST), Karnofsky performance status (KPS) of at least 70%, life expectancy of more than 3 months, and adequate hematological, renal, and liver function. Imatinib was given orally at a dose of 400 mg bid. The most common toxicities were Grade II/III nausea (28%) and Grade II renal insufficiency (14%). All patients had tumor tested by immunohistochemistry (IHC) for KIT protein (CD117, DAKO). One tumor (7%) demonstrated strong, diffuse expression and the rest were negative. No complete or partial responses were observed in 12 evaluable patients treated with imatinib.

Background:Gemcitabine is the standard chemotherapy for the treatment of advanced pancreatic cancer. The novel multitargeted antifolate pemetrexed (Alimta®) has also demonstrated activity in this disease. These two drugs are synergistic in vitro, and a phase I study has demonstrated activity of single-agent pemetrexed in pancreatic cancer. Aim:To evaluate pemetrexed plus gemcitabine in a multicenter phase II study in patients with advanced pancreatic cancer. Patients and methods:Chemonaive patients with advanced pancreatic adenocarcinoma, metastatic or locally advanced, not amenable to curative resection, received intravenous gemcitabine 1250 mg/m2 over 30 minutes on days 1 and 8 and intravenous pemetrexed 500 mg/m2 over 10 minutes on day 8 every 21 days. The primary endpoint was objective response rate. Patients were evaluated for time-to-event variables including overall survival, time-to progression, time-to-treatment failure, and duration of response. Patients who were symptomatic were evaluated weekly for clinical benefit response. CT scans were obtained every two cycles. Results:Forty-two patients were treated; 41 were evaluable for efficacy. Ninety-five percent of patients had metastatic disease. There were five partial responses (objective response rate 12%), and 44% of patients had stable disease. The 1-year survival rate was 32%; median survival was 6.6 months (95% CI 4.4, 9.9). Of 30 eligible patients, four (13%) had a clinical benefit response. Grade 3 and 4 hematologic toxicities included neutropenia (84%), febrile neutropenia (12%), and thrombocytopenia (33%). Non-hematologic toxicities were minimal. Conclusion:The combination of pemetrexed and gemcitabine is active in advanced pancreatic cancer, and has acceptable toxicity; a 1-year survival rate of 32% is encouraging. A phase III trial comparing pemetrexed plus gemcitabine with gemcitabine has completed accrual. 1 The use of trade names is for product identification purposes only and does not imply endorsement.

Treatment of patients with metastatic renal cell cancer (RCC) with interferon-alpha-2a (IFN) and 13-cis-retinoic acid (CRA) was first reported to be tolerable on an outpatient basis and to yield a 30% objective response rate. We sought to confirm these preliminary results by conducting a phase II trial of therapy with IFN/CRA in patients with bidimensionally measurable RCC. Twenty-five patients were enrolled. The median age was 58 (range, 47-75 years) and the median Karnofsky performance status was 90 (range 60-100). Seventeen patients (60%) had undergone prior nephrectomy and none had received prior systemic therapy. Treatment consisted of oral CRA at 1 mg/kg/day and IFN self-administered by subcutaneous injection at 3 MU/day with weekly escalation to 6 and 9 MU/day. Treatment was well tolerated, with cheilitis, influenza-like symptoms, and fatigue the most common toxicities. Severe toxicity was reversible and consisted of grade 4 cheilitis in one patient and grade 3 malaise/fatigue in two patients. One complete and four partial responses were observed, for an objective response rate of 20% (95% confidence interval, 4-36%). We conclude that treatment with CRA/IFN for RCC is tolerable on an outpatient basis and induces objective responses in some patients. The contribution, if any, of CRA to the responses observed will be determined in ongoing randomized phase III trials.

PURPOSE De novo B-cell prolymphocytic leukemia (B-PLL) is a distinct clinicopathologic entity usually characterized by marked lymphocytosis, massive splenomegaly, an aggressive course, and refractoriness to therapy. Cladribine (2-chlorodeoxyadenosine [2-CdA]; Ortho Biotech, Raritan, NJ) is a newer purine analog with potent activity against indolent lymphoproliferative disorders. PATIENTS AND METHODS We treated eight patients with cladribine 0.1 mg/kg/d for 7 days by continuous infusion or 0.14 mg/kg/d over 2 hours for 5 days, every 28 to 35 days, for a median of three courses (range, two to five). There were five men and three women, with a median age of 62 years and a median pretreatment duration of 6 months; four patients were previously untreated. RESULTS All eight patients were assessable: five achieved a complete response with a median response duration of 14 months (range, 1+ to 55+), and three achieved a partial response with a median duration of 3 months (range, 1 to 3). Of four patients who achieved a complete response and in whom a peripheral-blood immunophenotypic analysis was performed, two had no circulating B-PLL cells and one had no residual disease on Southern blot analysis. Myelosuppression and infection were the major toxicities: three patients developed grade 3 or 4 myelosuppression, four had bacterial infections, and two had herpes zoster infections. CONCLUSION In this small study of patients with de novo B-PLL, cladribine was an active agent that induced a high overall and complete response rate. These results require confirmation in larger numbers of B-PLL patients.

To identify risk factors for chemotherapy-related nausea. We examined risk factors for nausea in 1,696 patients from three multicenter studies conducted from 1998 to 2004. All patients were beginning a chemotherapy regimen containing cisplatin, carboplatin, or doxorubicin. Nausea was assessed on a 1–7 scale four times a day for 4 days by diary. First, average nausea for breast cancer patients receiving doxorubicin (mean = 2.31) was significantly greater than for other patients receiving doxorubicin (mean = 1.82), patients receiving cisplatin (mean = 1.88), and patients receiving carboplatin (mean = 1.45), Ps

BACKGROUND Patients may use their past experiences with nausea, as well as information about the incidence of nausea from chemotherapy that other patients have experienced, to form a prediction, or response expectancy, of nausea from their own upcoming chemotherapy. Mounting evidence suggests that these expectancies relating to nausea are significant predictors, and, likely, contributing factors to the development of treatment-related nausea. METHODS The patients in the current study were participants in the control arm of a multicenter clinical trial conducted between November 1999 and July 2001 by the University of Rochester Community Clinical Oncology Program. All patients in the current report were age ≥ 18 years and were about to begin a first cancer treatment regimen containing doxorubicin. RESULTS Expectancy of nausea assessed before patients received their first doxorubicin-based chemotherapy treatment was found to be a strong predictor of subsequent nausea and in fact was stronger than previously reported predictive factors, including age, nausea during pregnancy, and susceptibility to motion sickness. Women who believed it was “very likely” that they would have severe nausea from chemotherapy were five times more likely to experience severe nausea than fellow patients who thought its occurrence would be “very unlikely.” CONCLUSIONS Further studies confirming an expectancy of nausea as a risk factor are warranted as are studies examining the benefit to a patient's quality of life from modifying antiemetic treatment guidelines to take into account symptom expectancies. Finally, ethically acceptable interventions that are designed to reduce patients' nausea expectancies or increase their expectancies of nausea control should be developed and studied. Cancer 2004. © 2004 American Cancer Society.

Objective: This study was undertaken to determine the degree of toxicity, response rate, and evaluate quality of life (QOL) in women receiving gemcitabine in combination with doxorubicin for platinum-resistant and refractory ovarian or peritoneal cancer. Study Design: This was a phase I/II prospective trial. Materials And Methods: Nine patients were enrolled in the phase I portion. Initial doses of gemcitabine, 800 mg/m 2 intravenously on days 1, 8, and 15, and doxorubicin, 25 mg/m 2 intravenously on days 1, 8, and 15 in a 28-day cycle resulted in dose limiting toxicity secondary to thrombocytopenia and neutropenia. Forty patients were treated on the phase II portion with gemcitabine, 700 mg/m 2 intravenously on days 1 and 8, and doxorubicin 20 mg/m 2 intravenously on days 1 and 8 with granulocyte colony-stimulating factor administered on days 2 to 7 and 9 to 14 in a 21-day cycle. QOL was assessed with Fact-O. Results: The median number of previous chemotherapy regimens for the 49 women was 2 (range 1-5). There were 2 complete and 9 partial responses, for an overall response rate of 24%. Median duration of response was 5 months. Fourteen women (31%) had stable disease with median duration of response of 5 months. Median survival for the entire group was 12 months. Toxicity was primarily hematologic, and only 3 patients discontinued therapy because of toxicity. QOL surveys indicated that this was a well-tolerated regimen. Conclusion: The combination of gemcitabine and doxorubicin can be safely administered. Overall, approximately 55% of women with platinum-resistant ovarian or peritoneal cancer benefit from this regimen with response or stabilization of disease. (Am J Obstet Gynecol 2003;188:1556-64.)

9113 Background: Various symptom cluster combinations of pain, fatigue, sleep disturbance (SD), and depression have been identified in cancer patients. The presence of symptom clusters has not been assessed in patients with persistent CINP. This exploratory analysis aimed to determine which symptoms statistically clustered with pain in cancer survivors with CINP. Methods: The University of Rochester Cancer Center Community Clinical Oncology Program recruited 461 patients with CINP > 4 (on a 0-10 scale) who had completed chemotherapy (median 7 months ago) for a pain intervention trial. At baseline, groups of highly associated symptoms that included pain were identified empirically using factor and cluster analyses of the 11 symptoms in the University of Rochester Symptom Inventory plus the Hospital Anxiety and Depression Scale (HADS) scores. To investigate if associated symptoms track together over time, multiple linear regression (MLR) analysis was performed using changes in symptom severity between baseline and week 6, controlling for gender, age, education, race, and marital status. Results: Subjects were 88% white and 71% female, and on average 61 years old. Mean (standard deviation) baseline pain, fatigue, and SD were 5.7 (2.8), 5.0 (2.7), and 4.2 (3.1), respectively; 26% of subjects had borderline or abnormal HADS scores. Factor analysis identified 3 factors that accounted for 88% of the variance. One factor included pain, fatigue, SD, but not HADS, and accounted for 37% of the variance. Variable clustering also identified pain, SD, and fatigue as 1 symptom cluster. Changes in severity of SD and fatigue (p < 0.0001), but not HADS, were associated with changes in pain (adjusted R2 = 0.168) in MLR analysis. Conclusions: Pain, fatigue, and SD were identified as a symptom cluster by factor and cluster analyses, and were found to track together over time by MLR. Since these data suggest that pain is associated with sleep quality and fatigue in patients with persistent CINP, targeting one of these symptoms may lead to reductions in the others. Future research should investigate interventions that target pain, fatigue, and SD concurrently in cancer survivors suffering from CINP.

9119 Background: Cognitive difficulties affect up to 75% of cancer patients receiving chemotherapy, and these difficulties linger in up to 35% of survivors years after treatment. The extent to whic...