Development Of Supportive Care Research Articles

Transplantace jater pro akutní selhání jater

Summary: Acute liver failure is a rare, highly devastating, potentially reversible condition characterised by the sudden onset of severe liver dysfunction in individuals without pre-existing liver disease and with a poor prognosis. In recent decades, advances in the diagnosis of the disease, a better understanding of its pathophysiology and the development of supportive care have improved the prognosis of patients with acute liver failure. However, despite the success of conservative therapy, urgent liver transplantation remains the only chance of survival for a large proportion of patients with acute liver failure. Early diagnosis of the disease, implementation of supportive care and identification of patients indicated for urgent liver transplantation are essential measures in the management of patients with acute liver failure. Key words: acute liver failure – transplantation – supportive therapy – prognostic criteria

Children's Oncology Group 2023 blueprint for research: Adolescent and young adult oncology.

Over the past few decades, 5-year cancer survival has steadily improved for all adolescents and young adults (AYA, 15-39years at diagnosis) combined. While encouraging, this progress simultaneously highlights a compelling need for improving survival in higher risk AYA subsets and for addressing health outcomes and health-related quality of life (HRQoL) among long-term survivors. The Children's Oncology Group (COG), in collaboration with the National Cancer Institute (NCI) and the adult network groups within the NCI National Clinical Trials Network (NCTN), has developed a large and growing portfolio of therapeutic AYA cancer clinical trials to identify optimal treatment approaches for common AYA cancers. Additional initiatives, led by the COG AYA Oncology Discipline Committee for increasing collaboration between the COG and the adult network groups, optimizing AYA clinical trial enrollment, and standardizing the assessment of HRQoL, have been highly successful to date. Further, NCTN-wide collaborations are currently underway focused on improving survival for AYA malignancies with poor prognosis and, through development of supportive care and care delivery trials, reducing the short- and long-term toxicity caused by cancer treatment. Leveraging the research infrastructure within the NCTN and the NCI Community Oncology Research Program, the COG will continue to champion meaningful advancements in health and survival for AYAs with cancer.

リアルワールドデータに基づく抗がん剤支持療法の開発；スタチン系薬剤による末梢神経障害治療および予防効果の検証

リアルワールドデータに基づく抗がん剤支持療法の開発；スタチン系薬剤による末梢神経障害治療および予防効果の検証

Improvement of the Treatment Results in Childhood Acute Myeloid Leukemia in Poland from 1983 to 2017

Introduction: Acute myeloid leukemia (AML), heterogeneous group of malignant neoplasm of hematopoietic system, comprises of 15% of all leukemias in children. Standardized AML-BFM based protocols of the treatment of AML introduced in Poland from 1983 enabled successive improvement of survival rates. Before 1983 only 10% of children with AML in our country had chance to survive.The aim of the study was analysis of the treatment results in five consecutive periods: AML-PGPLBC83 (1983-1993, group I), AML-PGPLBC94 (1994 -1997, group II), AML-PGPLBC98 (1998-2004, group III), AML-BFM2004 Interim (2005-2014, group IV ) and AML-BFM 2012 (2015-2017, group V).Patients: Eight hundred and two patients diagnosed with AML from 1983 to 2016 in Poland were eligible for evaluation (187, 74, 149, 351 and 41 respectively in group I, II, III, IV and V). Patients with acute promyelocytic leukemia, AML in Down syndrome and secondary AML were excluded from analysis. Median observation time was 128, 73, 119, 65 and 12 months in consecutive groups respectively.Results: Complete remission rate in the groups I to V was: 72%, 66%, 84%, 87% and 83%, respectively. Percentage of early deaths (before 42. day of the treatment) was 22%, 14%, 5% , 4%, and 7% respectively. Non-responders comprised of 6% of all patients in the first group, 18% in the second, 10% in the third, 8% in the fourth and 9% in the last group. Among patients who achieved remission in the group I 16% died in remission and 42% relapsed, in the group II 16% died in remission and 33% relapsed, in the group III 11% died in remission and 40% relapsed, in the group IV 7% died in remission and 34% relapsed, in the last group 3% died in remission and 9% relapsed. Probability of the 5-years overall survival (OS) was 33%, 38%, 53% and 63% in four consecutive periods, respectively. Probability of the 5-years event free survival (EFS) was 32%, 36%, 46% and 49%, respectively in groups I-IV. Probability of relapse free survival (RFS) in patients who achieved remission was 51%, 62%, 55%, 62% respectively in groups I-IV. Because of too short observation time in the last group (V), 12-months survival rates were counted: OS - 74% (compared to 50%, 52%, 68% and 80% in groups I-IV), EFS - 70% (compared to 34%, 44%, 58%, 66% in the groups I-IV) and RFS - 89% (67%, 74%, 72%, 78% in the groups I-IV).Discussion: Systematic improvement of the treatment results, increase in proportion of achieved remission and reduction of early deaths and deaths in remission in the four consecutive groups treated from 1983 to 2015 was observed. The progress was achieved by modification of protocols with more accurate stratification to the risk groups, development of supportive care and gaining experience in reducing number of toxic deaths. Unfortunately proportion of relapses was still high. Therefore in 2015 new treatment protocol AML-BFM 2012 with stratification to the risk group based on cytogenetic and molecular genetics changes, as well as treatment responses was introduced. Number of patients in the group V treated with that protocol is low with short observations time however preliminary results seem to be encouraging. Further progress in AML therapy seems to be possible due to further oncology centers' cooperation within large international study groups. DisclosuresNo relevant conflicts of interest to declare.

Anti-cancer therapy made easier: a 25-year update.

In 1993, the Internal Medicine Journal published ‘Chemotherapy made easier’, outlining developments in supportive care of patients undergoing chemotherapy. This described the contemporary state of anti‐emetics, colony stimulating factors, cardiac toxicity, neurotoxicity, development of drug analogues and venous access devices. Twenty‐five years later, we update the measures that improve the tolerability of the plethora of new anti‐cancer therapies, which have extended well beyond traditional chemotherapy agents to include immunotherapy and targeted therapies. Optimisation of supportive care is paramount to allow safe delivery with the least possible impact on quality of life of these new treatments, many of which have resulted dramatically improved outcomes across multiple cancer types. This state of the art update summarises advances in supportive care therapies relating to improving the patient experience during and after anti‐cancer treatment, including new anti‐emetics, hair preservation techniques, bone marrow support and improved venous access devices; the ongoing challenge of neurotoxicity; and the advent of multidisciplinary sub‐specialised fields such as cardio‐oncology and oncofertility. Supportive care medications for immuno‐oncology therapies is a new section; these highly effective (although not universally so) agents were a mere illusion in 1993.

A supportive care dedicated hospitalization ward in comprehensive cancer center.

Supportive care development has created new needs in patients' care pathway. In order to anticipate, evaluate, and take care of patients' needs, a supportive care dedicated hospitalization ward was created in late 2016 in our comprehensive cancer center, including 15 beds (11 for week care and 4 for day care). We aimed to assess the activity of this supportive care ward in 2018. Data were extracted from weekly activity reports of supportive care ward and retrospectively analyzed. Those reports are automatically generated from hospitalization scheduling software. In week care ward, 627 stays were recorded. Occupancy rate was 88%. Mean stay duration was 3.01days. Main indications for week stay were pain evaluation and management (47.4%) and nutritional management (31.7%). In day care ward, 1191 stays were registered. Turnover rate was 1.18 patients/bed/day. Main indications for day stay were pain management (41.6%) and comprehensive geriatric assessment in oncology (22.8%). The 2018 supportive care ward evaluation showed its viability in comprehensive cancer center. The main activity was based on pain and nutritional management.

Supportive Care Needs Among Mexican Breast Cancer Patients: From Diagnosis to Post-Treatment Follow-Up Visit

Background: In Latin America, where 7.8% of worldwide new cancer cases occur, the implementation of supportive care services for cancer patients within public hospitals is not common practice and it is often a low priority. Identifying the priority care needs of these cancer patients is relevant to improve care provision, especially in Mexico, where breast cancer is highly prevalent and it is among the three leading causes of death in Mexican women. Objective: To investigate the course and predictors of supportive care needs among Mexican breast cancer patients for different cancer treatment trajectories. Methods: In this observational longitudinal study data from 172 patients were considered. Participants were assessed after diagnosis, neoadjuvant treatment, surgery, adjuvant treatment and the first posttreatment follow-up visit. The Supportive Care Needs Survey (SCNS-SF34) was used to assess psychological, health system and information, physical and daily living, patient care and support, sexual, and additional care needs dimensions. Linear mixed models with maximum-likelihood estimation were computed. Results: The supportive care needs course was similar across the different cancer treatment trajectories. Supportive care needs declined significantly from diagnosis to the first posttreatment follow-up visit. The highest care needs over time were those from the health system and information dimension. Depressive symptoms and time since diagnosis were the most consistent predictors of changes in development of supportive care needs of these patients. Conclusion: Health system and information care needs of Mexican breast cancer patients need to be addressed with priority because these needs are the least met. Furthermore, patients with high depressive symptoms at the start of the disease trajectory have greater needs for supportive care throughout the disease trajectory.

Inequalities and Barriers to the Use of Supportive Care Among Young Breast Cancer Survivors: a Qualitative Understanding.

The development of supportive care for cancer patients has been shown to have a positive impact on both mortality rates and many aspects of life after cancer, particularly in young women. Meanwhile, there are still numerous inequalities in terms of cancer mortalities and quality of life among cancer survivors in France. The processes leading to unequal access to supportive care services, and the impact this has on the post-treatment period, have been poorly documented, however. The goal of this study was to understand the barriers to using supportive care services among young women breast cancer survivors under the age of 50 and to find out how this can contribute to inequalities. Thirty-six young breast cancer survivors, one third of which deemed socially deprived, were interviewed using a qualitative, inductive approach at two comprehensive care centres in France. Our findings primarily show that there are still a number of barriers to accessing supportive care for a large number of patients. The way information about supportive services is delivered is a major cause of inequalities in the use of these services. The guidance provided does not take into account either the patients' needs or their capacity to integrate the information and anticipate problems. Certain specific post-treatment issues have yet to be addressed. Some systemic barriers could be lifted by changing the way information on supportive care services is currently organised and thereby prevent the survivorship plans now being implemented in cancer care settings from reinforcing health inequalities.

Cyclophosphamide Related Cardiac Complication in Hematopoietic Transplantation: Analysis of 1091 Cases in Fukuoka Blood and Marrow Transplantation Group

▪<Background and Method> Cyclophosphamide (CPM) is one of key drugs for conditioning therapy in hematopoietic transplantation in terms of anti-tumor effect as well as immune-suppressant activity. On the other hand, high dose CPM administration is related to rare but life-threatening cardiac complications, of which incidence and pathogenesis are not fully understood. We retrospectively reviewed the hematopoietic transplantation cases in Fukuoka Blood and Marrow Transplantation Group (FBMTG) during 2000/1/1 to 2013/7/31 and analyzed the cases with the cardiac complications.<Results> There were 1091 cases, which contained CPM administration in their conditioning regimens. Of which, 23 cases (2.1%) were considered as cardiac complications related to CPM. The mean age at transplantation was 51 (20-74). All of the cases underwent cardiac function surveillance with ultrasound echocardiogram and were administrated more than 45mg/kg/day of CPM. The clinical cardiac manifestation occurred one to seven (mean 3) days after the first administration of CPM. The electrocardiogram showed the statistically significant diminishment of SV1 + RV5 and increase of heart rate. Lowered ejection fraction was observed in ultrasound echocardiogram. Myocardial enzymes such as CPK, Troponins and H-FABP were not very reliable because some cases were negative especially in early phase. Fourteen cases (1.3%) developed acute circulatory failure soon after the first presentation of clinical manifestation and all of them end up with poor prognosis. On the other hand, of the 9 cases (0.8%) who survived first 20 days, 6 of them were alive at 100 days after the transplantation. The incidence of cardiac complication tends to be high in elderly patients especially when they were over 70.<Conclusion> Cardiac complication related to CPM is rare but it remains to be fatal in present. The development of supportive care has provided higher limit of age that undergo hematopoietic transplantation. However, the administration of high dose CPM in conditioning regimen should be aware especially in elderly recipients. DisclosuresNo relevant conflicts of interest to declare.

Supportive cancer care in-patient unit: A 3-year experience.

185 Background: An in-patient unit for supportive care in oncology (USSO) was created in 2011 in the Georges Pompidou European Hospital. Its primary objective is to improve patient care and manage the complications of cancer as well as their specific treatment. Patients are previously screened by a cross disciplinary team at an early stage before complication. Methods: A prospective observational study was performed through a yearly evaluation of the unit’s activity from January 1st, 2011 to December 31st, 2013. Results: 594 patients were admitted in the unit during the three years period of study. Most of them (64.3%) came directly from home, with an increase of this rate along this period (59.4% to 67.6%). The early screening thereby rendered emergency admission from 17.7% (2011) to 6.5% (2013). The predominant diseases observed were head and neck cancer (42.4%) and lung cancer (23%), followed by breast (7.2%) and ovarian cancer (7.2%). The main grounds for hospitalization were state of health impairment 32%, pain 12.8%, and invasive procedures 11.8%, increasing from 2011 to 2013. Therefore, an interdisciplinary approach is the cornerstone of the unit with the daily collaboration of dieticians (for 90% of inpatients), social workers, psychologists, physiotherapists and pain specialists (34%, 46%, 56% and 50% of inpatients respectively). The average length of stay decreased from 2011 (10.2 days) to 2013 (8.3 days) and 58.4% of the patients were home discharged. With the help of a social worker, 12% of the patients were transferred to a recovery unit and 9.7% to a palliative care unit while 9% died in the unit. Conclusions: With the opening of the in-patient USSO, and the development of its interdisciplinary strategy, most of the patients recover faster and regain better health. Preventive care can accommodate a majority of patients coming from home and allows for ambulatory secured discharge. These positive results conducted to enhance the USSO’s beds capacity and supportive care development in order to improve cancer care organisation in the hospital as well as patient’s quality of life.

Supportive Cancer Care In-Patient Unit: a Three Years Experience

ABSTRACT Aim: An in-patient unit for supportive care in oncology (USSO) was created in 2011 in the Georges Pompidou European Hospital. Its primary objective is to improve patient care and manage the complications of cancer as well as their specific treatment. Patients are previously screened by a cross disciplinary team at an early stage before complication. Methods: A prospective observational study was performed through a yearly evaluation of the unit's activity from January 1st 2011 to December 31st 2013. Results: 594 patients were admitted in the unit during the three years period of study. Most of them (64.3%) came directly from home, with an increase of this rate along this period (59.4% to 67.6%). The early screening thereby rendered emergency admission from 17.7% (2011) to 6.5% (2013). The predominant diseases observed were head and neck cancer (42.4%) and lung cancer (23%), followed by breast (7.2%) and ovarian cancer (7.2%). The main grounds for hospitalization were state of health impairment 32%, pain 12.8%, and invasive procedures 11.8%, increasing from 2011 to 2013. Therefore, an interdisciplinary approach is the cornerstone of the unit with the daily collaboration of dieticians (for 90% of inpatients), social workers, psychologists, physiotherapists and pain specialists (34%, 46%, 56% and 50% of inpatients respectively). The average length of stay decreased from 2011 (10.2 days) to 2013 (8.3 days) and 58.4% of the patients were home discharged. With the help of a social worker, 12% of the patients were transferred to a recovery unit and 9.7% to a palliative care unit while 9% died in the unit. Conclusions: With the opening of the in-patient USSO, and the development of its interdisciplinary strategy, most of the patients recover faster and regain better health. Preventive care can accommodate a majority of patients coming from home and allows for ambulatory secured discharge. These positive results conducted to enhance the USSO's beds capacity and supportive care development in order to improve cancer care rganization in the hospital as well as patient's quality of life. Disclosure: All authors have declared no conflicts of interest.

Supportive care in hemato-oncology: a review in light of the latest guidelines.

Recent developments in cancer therapy have resulted in increases in treatment success rates and survival. One of thebasic goals of such therapy is improving patient quality of life. Chemotherapy protocols for solid or hematologicalmalignancies-most of which include multiple agents-negatively impact patient quality of life. Additionally, there havebeen developments in supportive care, which seeks to ameliorate or minimize the negative effects of chemotherapy.Herein we present a review and brief summarization of some of the agents used for supportive care in cancer patientsin light of the latest guidelines.

Pharmacotherapy update in the management of paediatric cancer

Great advances in the treatment of childhood cancer have been made over the last 30 years because of developments in supportive care, the increasing use of advanced technology to detect and diagnose disease, developments in the understanding and relevance of cell biology and by the successful recruitment of children into nationally co-coordinated clinical trials. For some childhood malignancies where the survival rate is high, trials are ongoing to see if treatment can be stratified and directed according to patient risk, with those that fall into a favourable risk category potentially being cured with less treatment and therefore less short term and long term toxicity.

BEAM as a Frontline High Dose Chemotherapy Supported by Autologous PBSCT in Elderly Patients (≥60 Years) with Diffuse Large B-Cell Lymphoma (DLBCL): Comparison with Younger Cohort of Patients.

Recent developments in supportive care increase the number of elderly patients available for high dose therapy (HDT) supported by autologous PBSCT. In several clinical trials high dose chemotherapy supported by PBSCT as a part of first-line treatment in young NHL patients with poor prognostic features suggested survival benefit. It is not clear if the same strategy is applicable into the older patients. The Institute Paoli-Calmettes database was reviewed for all DLBCL patients received BEAM followed by PBSCT in two age cohorts: 50–59 years old and >=60 years old between January 1998 and December 2006 (9 years). All patients were HIV-negative and received BEAM intensification as a part of front-line treatment. All of them were grafted in situation of complete or partial response after CHOP or R-CHOP induction. There was no significant difference into the aaIPI score between the groups (aaIPI score ≥ 2: 17 pts (63%) in elderly and 17 pts (61%) in younger group. Factors evaluated included treatment-related mortality (TRM), overall survival (OS) and event-free survival (EFS). Fifty five patients were identified, among them 27 into the older cohort (median age 63 y, range 60–68) and 28 patients into the younger cohort (median age 55 y, range 51–59). The median follow-up for the whole group was 23,5 months (0,5–93 months). TRM into the older group (1/27 pts (3,7%)) was not statistically different from the younger patients (0/28 pts) and was comparable with previously published data. The estimated 5-year OS (figure 1) was 75,5% (95%CI 52–90%) for the older group (curve 1) compared to 85% (95%CI 63–95%) in the younger group (p=0,47) (curve 2). There were 8 events (1 TRM and 7 relapses) in the older group and 3 events (all relapses) in the younger group (3-year EFS (figure 2) 66% (curve 1) vs 85,5% (curve 2), p=0,16 and 5-year EFS 49,4% vs 85,5%, p=0.051). We conclude that front-line autologous PBSCT with BEAM conditioning can be safely performed in patients 60 years old and older with DLBCL after CHOP of R-CHOP induction. The toxicity profile and TRM may not be different from that of younger patients. The high rate of OS in older group is encouraging, but the relapse still remains the important obstacle for durable remission. [Display omitted]

Autologous stem cell transplantation beyond 60 years of age

Along with improved supportive care and thus reduced treatment-related mortality, an increasing number of elderly patients (> 60 years) with haematological malignancies are now considered for high-dose therapy (HDT) supported by autologous stem cell transplantation (ASCT). ASCT is feasible in selected elderly patients with multiple myeloma and those with non-Hodgkin's lymphoma. As elderly patients have generally been excluded from randomized studies evaluating efficacy of ASCT in comparison with non-transplant approaches, limited data are available on the efficacy of ASCT in this patient population. Recent developments in supportive care including amifostine and palifermin may increase feasibility of ASCT in elderly patients. Prospective studies are needed to evaluate feasibility and efficacy of ASCT in patients over 60 years of age. Also, further studies are needed in order to decrease toxicity of high-dose regimens in this patient group where co-morbid conditions may modify the toxicity of HDT in a clinically significant manner.

The importance of clinical practice guidelines (CPGs) for the quality and development of supportive care in Central and Eastern European (CEE) countries.

Supportive care CPGs are intended to improve the quality of supportive care received by cancer patients. They hold potential benefits for health-care professionals, health-care organizations and patients. In order to provide an effective influence of CPGs on supportive care development in CEE countries their validity and successful implementation in clinical practice must be ensured. This would involve several important steps: (1) achievement of a consensus across Europe about what constitutes supportive care in cancer; (2) identification of supportive care priorities in CEE countries to be covered by the guidelines; and (3) searching existing CPGs relevant to previously identified priorities. Valid international CPGs could then be translated and adapted to local resources and circumstances in CEE countries and used to prepare national supportive care CPGs which could assist in the development of national supportive care standards. Skills, expertise and additional investment are required for local adaptation, dissemination and implementation of international supportive care CPGs.

Are Central Eastern European countries involved in clinical trials of supportive care?

Clinical trials are the most widely accepted tools in the search for more effective supportive care drugs/interventions. The aim of our study was to determine Central Eastern European countries' (CEEC) involvement and future interest in conducting supportive care clinical trials. Our study was a part of an ESMO/MASCC program launched to support the development of supportive care in CEEC. The study was designed as a mailed questionnaire survey within the ESMO CEE Task Force. It involves national representatives from 18 countries. The purpose of the questionnaire was to assess the involvement and interest in conducting clinical trials in 13 representative supportive care fields: antiemetic therapy, cancer pain control, infections/febrile neutropenia, mucositis, fatigue, hypercalcemia, dyspnea, anorexia/cachexia, psychosocial support, toxicity reducing agents, hematopoietic growth factors, communication/education and quality of life. A total of 15 completed questionnaires were returned (83.3%). CEEC were mainly involved in clinical trials of hematopoietic growth factors (7/15), quality of life (6/15), antiemetic therapy (5/15), and cancer pain control (4/15). Increased interest was observed in the trials of fatigue, dyspnea, psychosocial support, infections / febrile neutropenia, communication / education and toxicity reducing agents. Clusters of CEEC that are similar in terms of their previous involvement and future interest in supportive care trials were identified. Our survey may prove to be a significant first step for CEEC active involvement in multinational clinical trials, which are crucial for improving supportive care standards.

Nursing care adaptations during clinical trials with weekly high-dose cisplatin: evaluation of a process plan

Cisplatin is among the most active chemotherapeutic agents available today for the treatment of a variety of cancers. Toxic side-effects have up until now prevented dose escalation and schedule intensification which might be interesting in view of the dose-response relationship and the schedule-response relationship. Recent developments in supportive care and pharmacology limited these side-effects and thereby rendered dose-intensification feasible. Currently, we have treated 71 patients with high-dose cisplatin administered in hypertonic saline weekly for 6 weeks. Most cycles were supported by 5HT3 antagonists to achieve maximal anti-emetic control. The patients participated in a phase I study (MTD 85 mg/m2) or phase II studies (80 mg/m2) in head and neck cancer/mesothelioma/non-small cell lung carcinoma or a pilot study of cisplatin weekly in combination with etoposide orally(MTD 70mg CDDP/m2 dl + 8 + 15 etoposide50mg/dd p.o. dl-15 qd282 cycles). The phase II studies are ongoing. The major problem associated with this treatment schedule was myelosuppression. Less frequently observed side-effects were: nausea/vomiting, nephrotoxicity, anorexia, neuro- and ototoxicity. Besides, the weekly treatment schedule has an impact on the patient's quality of life due to frequent hospitalizations. In order to optimize the care of these patients, continuity of care was provided by a process plan. Optimal patient information and education improved patient motivation and compliance with this regime. This paper will present information on this process plan and the nursing implications of this regime.

The therapy of acute leukemia in the adult: a progress report.

Complete remissions in adult patients with acute leukemia were unusual, if not rare, fifteen years ago. The discovery of highly effective antileukemic drugs such as cytosine arabinoside and daunorubicin and the development of more effective combinations of active chemotherapeutic agents largely through empiric clinical trial and error have dramatically changed that situation so that today 70 % or more of previously untreated patients achieve complete remission status. This improvement has been facilitated by major developments in supportive care. The use of allopurinol for the prevention of urate nephropathy has eliminated that serious complication of antileukemic therapy. Newer antibiotics active against Pseudomonas aeruginosa have allowed for the successful treatment of many life threatening infections which occur in the granulocytopenic leukemia patient. Laminar air flow rooms which provide essentially sterile air, and oral nonabsorbable antibiotics which sterilize the gastrointestinal tract, protect the leukemia patient in large measure from microbial hazards in his external and internal environments. Blood cell component therapy allows for replacement of platelets and granulocytes in cytopenic patients. It is the purpose of this paper to detail some of these achievements.

The effect of chemotherapy on acute myelogenous leukemia in children

From 1956 to 1968, 60 children were diagnosed as having acute myelogenousleukemia or one of its morphologic subgroups. All patients received chemotherapy, and until early 1968, this consisted of conventional agents used alone or in combination. After mid-1968, a therapeutic departure was made, and 7 patients were treated with a combination of cyclophosphamide and cytosine arabinoside intravenously. The median duration of survival for all patients was 1.5 months; there was no significant improvement from 1956 to early 1968. However, after mid-1968, the median duration was 9.5 months. This experience and that of others suggests that improved response and prolonged survival can be attributed to intensified use of the newer chemotherapeutic agents and by recent developments in supportive care.