Proportional Risk Reduction Research Articles

Long-term fracture risk in rheumatoid arthritis: impact of early sustained DAS28-remission and restored function, progressive erosive disease, body mass index, autoantibody positivity and glucocorticoids. A cohort study over 10 years

BackgroundRisk of fragility fractures in patients with rheumatoid arthritis (RA) is increased. Disease-related inflammation in RA is associated with low Bone Mineral Density (BMD). However, effects of specific disease factors on fracture occurrence and whether or not such disease effects are independent of BMD are unknown.MethodsAnalysis of fracture outcome in the prospective cohort of 2557 patients with early RA (67% women, mean age 58.1 ± 15.6 years) during an observation period of 10.6 ± 4.7 years. In 602 patients BMD was measured at baseline. The first major fragility fractures were considered. Kaplan-Meier and Cox regression analysis, adjusted for traditional factors, prior fracture, disease activity and period of inclusion, were used to estimate the risk of the outcome.ResultsDuring follow-up fracture occurred in 352 patients (13.8%), a rate of 13/1000 p-y. A proportional risk reduction for the outcome was associated with Body Mass Index (BMI) at baseline, BMI ≥ 30 kg/m2, and over the first two years sustained Disease Activity Score (DAS28)-remission, DAS28-low disease activity and Health Assessment Questionnaire (HAQ) ≤ 0.5. The proportional risk elevation for fractures was associated with BMI ≤ 20 kg/m2, DAS28 at baseline, 6-month and at 1-year, cumulative DAS28 over the two years, RF, erosion score progression at 2-year, HAQ score and HAQ ≥ 1 at 6-month and 1-year and showed a trend for ACPA positivity. The estimated fracture risk was increased in users of glucocorticoids (GC), associated with a higher GC-dosage at follow-ups and a higher cumulative dosage over two years, independently of disease activity. With adjustment for BMD, there was no difference in fracture outcome by exposure to GC. The effects of a higher BMI, DAS28-remission and low HAQ ≤ 0.5 attained at 6-month of treatment initiation and sustained up to 2 years, RF, ACPA, and erosion score progression at 2-year were independent of low BMD.ConclusionsThis analysis supports importance of RA-specific risk factors in early RA for future major fragility fractures. Treat-to-target strategy and restored functional capacity in early RA-disease are important to prevent fractures. Autoantibody positivity, progressively erosive disease, and low weight could have additional value for personalized fracture preventive strategies in early RA.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Age-stratified and blood-pressure-stratified effects of blood-pressure-lowering pharmacotherapy for the prevention of cardiovascular disease and death: an individual participant-level data meta-analysis

SummaryBackgroundThe effects of pharmacological blood-pressure-lowering on cardiovascular outcomes in individuals aged 70 years and older, particularly when blood pressure is not substantially increased, is uncertain. We compared the effects of blood-pressure-lowering treatment on the risk of major cardiovascular events in groups of patients stratified by age and blood pressure at baseline.MethodsWe did a meta-analysis using individual participant-level data from randomised controlled trials of pharmacological blood-pressure-lowering versus placebo or other classes of blood-pressure-lowering medications, or between more versus less intensive treatment strategies, which had at least 1000 persons-years of follow-up in each treatment group. Participants with previous history of heart failure were excluded. Data were obtained from the Blood Pressure Lowering Treatment Triallists' Collaboration. We pooled the data and categorised participants into baseline age groups (<55 years, 55–64 years, 65–74 years, 75–84 years, and ≥85 years) and blood pressure categories (in 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg systolic blood pressure and from <70 mm Hg to ≥110 mm Hg diastolic). We used a fixed effects one-stage approach and applied Cox proportional hazard models, stratified by trial, to analyse the data. The primary outcome was defined as either a composite of fatal or non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring hospital admission.FindingsWe included data from 358 707 participants from 51 randomised clinical trials. The age of participants at randomisation ranged from 21 years to 105 years (median 65 years [IQR 59–75]), with 42 960 (12·0%) participants younger than 55 years, 128 437 (35·8%) aged 55–64 years, 128 506 (35·8%) 65–74 years, 54 016 (15·1%) 75–84 years, and 4788 (1·3%) 85 years and older. The hazard ratios for the risk of major cardiovascular events per 5 mm Hg reduction in systolic blood pressure for each age group were 0·82 (95% CI 0·76–0·88) in individuals younger than 55 years, 0·91 (0·88–0·95) in those aged 55–64 years, 0·91 (0·88–0·95) in those aged 65–74 years, 0·91 (0·87–0·96) in those aged 75–84 years, and 0·99 (0·87–1·12) in those aged 85 years and older (adjusted pinteraction=0·050). Similar patterns of proportional risk reductions were observed for a 3 mm Hg reduction in diastolic blood pressure. Absolute risk reductions for major cardiovascular events varied by age and were larger in older groups (adjusted pinteraction=0·024). We did not find evidence for any clinically meaningful heterogeneity of relative treatment effects across different baseline blood pressure categories in any age group.InterpretationPharmacological blood pressure reduction is effective into old age, with no evidence that relative risk reductions for prevention of major cardiovascular events vary by systolic or diastolic blood pressure levels at randomisation, down to less than 120/70 mm Hg. Pharmacological blood pressure reduction should, therefore, be considered an important treatment option regardless of age, with the removal of age-related blood-pressure thresholds from international guidelines.FundingBritish Heart Foundation, National Institute of Health Research Oxford Biomedical Research Centre, Oxford Martin School.

Effects of Dapagliflozin in Patients With Kidney Disease, With and Without Heart Failure

ObjectivesThe purpose of this paper was to investigate the effects of dapagliflozin in chronic kidney disease (CKD) patients, with and without heart failure (HF). BackgroundPatients with CKD, with and without type 2 diabetes, were enrolled in the DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease) trial. Some patients had HF at baseline. MethodsA total of 4,304 participants were randomized to dapagliflozin 10 mg daily or placebo. The primary composite endpoint was ≥50% decline in estimated glomerular filtration rate, end-stage kidney disease, or kidney/cardiovascular death. Secondary endpoints were a kidney composite (primary endpoint minus cardiovascular death), the composite of cardiovascular death/HF hospitalization, and all-cause death. Analysis of outcomes according to HF history was prespecified. ResultsHF patients (n = 468; 11%) were older and had more coronary disease, atrial fibrillation, and type 2 diabetes. Mean estimated glomerular filtration rate was similar in patients with and without HF. Rates of HF hospitalization/cardiovascular death and death from any cause were higher in HF patients, but the secondary kidney failure outcome occurred at the same rate in people with and without HF. Dapagliflozin reduced the risk of the primary outcome equally in patients with HF (HR: 0.58 [95% CI: 0.37-0.91]) and without HF (HR: 0.62 [95% CI: 0.51-0.75]) (P interaction = 0.59). The proportional risk-reductions were similar in patients with and without HF for the cardiovascular death/HF hospitalization composite (HR: 0.68 [95% CI: 0.44-1.05] vs HR: 0.70 [95% CI: 0.51-0.97], respectively; P interaction = 0.90), and all-cause death (HR: 0.56 [95% CI: 0.34-0.93] vs HR: 0.73 [95% CI: 0.54-0.97], respectively; P interaction = 0.39), although absolute risk reductions were larger in HF patients. Adverse event rates were low and did not differ among patients with or without HF. ConclusionsDapagliflozin reduced the risk of kidney failure and cardiovascular death/HF hospitalization and prolonged survival in CKD patients with or without type 2 diabetes, independently of history of HF. (A Study to Evaluate the Effect of Dapagliflozin on Renal Outcomes and Cardiovascular Mortality in Patients With Chronic Kidney Disease [DAPA-CKD]; NCT03036150)

Short-term mortality from HIV-infected persons diagnosed from 2012 to 2016: Impact of late diagnosis of HIV infection.

We investigated the temporal trends of short-term mortality (death within 1 year of diagnosis) and cause-specific deaths in human immunodeficiency virus (HIV)-infected persons by stage of HIV infection at diagnosis. We also assessed the impact of late diagnosis (LD) on short-term mortality.Epidemiological records of HIV-infected Singapore residents from the National HIV Registry were linked to death records from the Registry of Births and Deaths for observational analyses. Newly-diagnosed HIV cases with available cluster of differentiation 4 count at time of diagnosis in a 5-year period from 2012 to 2016 were included in the study. Hazard ratios (HRs) and 95% confidence interval (CI) of LD for all deaths excluding suicides and self-inflicted or accidental injuries, and HIV/ acquired immunodeficiency syndrome (AIDS)-related deaths occurring within 1 year post-diagnosis were calculated using Cox proportional hazards regression models with adjustment for age at HIV/AIDS diagnosis. Population attributable risk proportions (PARPs) were then calculated using the adjusted HRs.Of the 1990 newly-diagnosed HIV cases included in the study, 7.2% had died by end of 2017, giving an overall mortality rate of 2.16 per 100 person-years (PY) (95% CI 1.82–2.54). The mortality rate was 3.81 per 100 PY (95% CI 3.15–4.56) in HIV cases with LD, compared with 0.71 (95% CI 0.46–1.05) in non-LD (nLD) cases. Short-term mortality was significantly higher in LD (9.1%) than nLD cases (1.1%). Of the 143 deaths reported between 2012 and 2017, 58.0% were HIV/AIDS-related (nLD 28.0% vs LD 64.4%). HIV/AIDS-related causes represented 70.4% of all deaths which occurred during the first year of diagnosis (nLD 36.4% vs LD 74.7%). The PARP of short-term mortality due to LD was 77.8% for all deaths by natural causes, and 87.8% for HIV/AIDS-related deaths.The mortality rate of HIV-infected persons with LD was higher than nLD, especially within 1 year of diagnosis, and HIV/AIDS-related causes constituted majority of these deaths. To reduce short-term mortality, persons at high risk of late-stage HIV infection should be targeted in outreach efforts to promote health screening and remove barriers to HIV testing and treatment.

P1028EFFECTS OF CANAGLIFLOZIN ON MAJOR ADVERSE CARDIOVASCULAR OUTCOMES IN PATIENTS WITH DIFFERENT BASELINE LEVELS OF TYPE 2 DIABETES MELLITUS DISEASE SEVERITY: RESULTS FROM THE CANVAS PROGRAM

Abstract Background and Aims Patient with type 2 diabetes mellitus (T2DM) included in trials of sodium-glucose cotransporter 2 inhibitors are heterogeneous in terms of disease severity. We assessed the effects of canagliflozin compared to placebo on cardiovascular and renal outcomes in the CANVAS program according to severity of T2DM as indicated by intensity of treatment, duration of diabetes and glycaemic control. Method We compared effects on major adverse cardiovascular events ([MACE], defined as cardiovascular death, non-fatal myocardial infarction or non-fatal stroke) according to three indicators of T2DM severity at study baseline: number of oral glucose lowering treatments or insulin therapy (0-1, 2, 3+, insulin), duration of diabetes (&amp;lt;10, 10-16, &amp;gt;16 years) and HbA1c (&amp;lt;7.0, 7.0-7.5, 7.5-8.0, 8.0-8.5, 8.5-9, &amp;gt;9.0%). We also assessed effects on other pre-specified cardiovascular outcomes, and an adjudicated composite of end-stage kidney disease, renal death or sustained 40% decline in estimated glomerular filtration rate. We assessed for constancy of hazard ratios across subgroups by fitting an interaction term that tested for linear trend. Results Of 10,142 participants in the CANVAS Program, 1011 experienced a MACE during a mean follow-up of 3.6 years. Event rates for MACE were higher in those with longer duration of diabetes and higher HbA1c at baseline. The effect of canagliflozin on MACE in the overall population (HR 0.86, 95 % CI 0.75-0.97) was consistent irrespective of the number of glucose lowering treatments (p=0.509), duration of diabetes (p=0.174) and baseline HbA1c (p =0.314). Effects were also consistent across different levels of T2DM disease severity for all other outcomes studied. Conclusion Higher event rates were observed in those with longer disease duration and higher HbA1c. The proportional risk reductions achieved with canagliflozin were comparable regardless of diabetes duration, number of therapies or HbA1C at baseline.

Statins Reduce Major Vascular Events in All Age Groups

According to this study: Statin therapy significantly reduces the risk of major vascular events in all age groups, but the proportional reductions in risk decreased slightly with increasing age.

Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trials

SummaryBackgroundStatin therapy has been shown to reduce major vascular events and vascular mortality in a wide range of individuals, but there is uncertainty about its efficacy and safety among older people. We undertook a meta-analysis of data from all large statin trials to compare the effects of statin therapy at different ages.MethodsIn this meta-analysis, randomised trials of statin therapy were eligible if they aimed to recruit at least 1000 participants with a scheduled treatment duration of at least 2 years. We analysed individual participant data from 22 trials (n=134 537) and detailed summary data from one trial (n=12 705) of statin therapy versus control, plus individual participant data from five trials of more intensive versus less intensive statin therapy (n=39 612). We subdivided participants into six age groups (55 years or younger, 56–60 years, 61–65 years, 66–70 years, 71–75 years, and older than 75 years). We estimated effects on major vascular events (ie, major coronary events, strokes, and coronary revascularisations), cause-specific mortality, and cancer incidence as the rate ratio (RR) per 1·0 mmol/L reduction in LDL cholesterol. We compared proportional risk reductions in different age subgroups by use of standard χ2 tests for heterogeneity when there were two groups, or trend when there were more than two groups.Findings14 483 (8%) of 186 854 participants in the 28 trials were older than 75 years at randomisation, and the median follow-up duration was 4·9 years. Overall, statin therapy or a more intensive statin regimen produced a 21% (RR 0·79, 95% CI 0·77–0·81) proportional reduction in major vascular events per 1·0 mmol/L reduction in LDL cholesterol. We observed a significant reduction in major vascular events in all age groups. Although proportional reductions in major vascular events diminished slightly with age, this trend was not statistically significant (ptrend=0·06). Overall, statin or more intensive therapy yielded a 24% (RR 0·76, 95% CI 0·73–0·79) proportional reduction in major coronary events per 1·0 mmol/L reduction in LDL cholesterol, and with increasing age, we observed a trend towards smaller proportional risk reductions in major coronary events (ptrend=0·009). We observed a 25% (RR 0·75, 95% CI 0·73–0·78) proportional reduction in the risk of coronary revascularisation procedures with statin therapy or a more intensive statin regimen per 1·0 mmol/L lower LDL cholesterol, which did not differ significantly across age groups (ptrend=0·6). Similarly, the proportional reductions in stroke of any type (RR 0·84, 95% CI 0·80–0·89) did not differ significantly across age groups (ptrend=0·7). After exclusion of four trials which enrolled only patients with heart failure or undergoing renal dialysis (among whom statin therapy has not been shown to be effective), the trend to smaller proportional risk reductions with increasing age persisted for major coronary events (ptrend=0·01), and remained non-significant for major vascular events (ptrend=0·3). The proportional reduction in major vascular events was similar, irrespective of age, among patients with pre-existing vascular disease (ptrend=0·2), but appeared smaller among older than among younger individuals not known to have vascular disease (ptrend=0·05). We found a 12% (RR 0·88, 95% CI 0·85–0·91) proportional reduction in vascular mortality per 1·0 mmol/L reduction in LDL cholesterol, with a trend towards smaller proportional reductions with older age (ptrend=0·004), but this trend did not persist after exclusion of the heart failure or dialysis trials (ptrend=0·2). Statin therapy had no effect at any age on non-vascular mortality, cancer death, or cancer incidence.InterpretationStatin therapy produces significant reductions in major vascular events irrespective of age, but there is less direct evidence of benefit among patients older than 75 years who do not already have evidence of occlusive vascular disease. This limitation is now being addressed by further trials.FundingAustralian National Health and Medical Research Council, National Institute for Health Research Oxford Biomedical Research Centre, UK Medical Research Council, and British Heart Foundation.

Impact of Apolipoprotein(a) Isoform Size on Lipoprotein(a) Lowering in the HPS2-THRIVE Study.

Genetic studies have shown lipoprotein(a) (Lp[a]) to be an important causal risk factor for coronary disease. Apolipoprotein(a) isoform size is the chief determinant of Lp(a) levels, but its impact on the benefits of therapies that lower Lp(a) remains unclear. HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is a randomized trial of niacin-laropiprant versus placebo on a background of simvastatin therapy. Plasma Lp(a) levels at baseline and 1 year post-randomization were measured in 3978 participants from the United Kingdom and China. Apolipoprotein(a) isoform size, estimated by the number of kringle IV domains, was measured by agarose gel electrophoresis and the predominantly expressed isoform identified. Allocation to niacin-laropiprant reduced mean Lp(a) by 12 (SE, 1) nmol/L overall and 34 (6) nmol/L in the top quintile by baseline Lp(a) level (Lp[a] ≥128 nmol/L). The mean proportional reduction in Lp(a) with niacin-laropiprant was 31% but varied strongly with predominant apolipoprotein(a) isoform size (PTrend=4×10-29) and was only 18% in the quintile with the highest baseline Lp(a) level and low isoform size. Estimates from genetic studies suggest that these Lp(a) reductions during the short term of the trial might yield proportional reductions in coronary risk of ≈2% overall and 6% in the top quintile by Lp(a) levels. Proportional reductions in Lp(a) were dependent on apolipoprotein(a) isoform size. Taking this into account, the likely benefits of niacin-laropiprant on coronary risk through Lp(a) lowering are small. Novel therapies that reduce high Lp(a) levels by at least 80 nmol/L (≈40%) may be needed to produce worthwhile benefits in people at the highest risk because of Lp(a). URL: https://clinicaltrials.gov. Unique identifier: NCT00461630.

Value of retaining HBsAg donor screening where HBV NAT and anti‐HBc donor screening apply

Hepatitis B virus (HBV) is a transfusion‐transmissible human DNA virus with a global distribution. Since the early 1970s, hepatitis B surface antigen (HBsAg) detection has been the mainstay to identify donors infected with HBV. The implementation of donor HBsAg screening substantially reduced but did not eliminate the risk of transfusion‐transmitted HBV (TT‐HBV). In the late 1970s, it was recognized that TT‐HBV occurred more commonly from HBsAg‐negative donations containing detectable antibodies to the viral core (anti‐HBc) leading to some countries subsequently implementing universal anti‐HBc screening in addition to HBsAg.Since the late 1990s, HBV nucleic acid tests (NATs) have been applied to donation screening to ‘close’ the acute window period, thereby reducing the residual risk of TT‐HBV. Their implementation also identified HBsAg‐negative/anti‐HBc‐positive individuals with detectable HBV DNA, a novel pattern of infection termed occult hepatitis B infection. A number of countries now combine HBsAg, anti‐HBc and HBV NAT donation testing, which provides the opportunity to determine the proportional HBV risk reduction contribution of each test. The cumulative published data indicate HBV‐infected donors with HBsAg as the only marker are exceedingly rare, occurring at a rate of about 1 in 4 million in the largest published study. There are no recorded cases of TT‐HBV involving ‘HBsAg‐only’ positive donors.Ultimately, HBsAg testing retains value for characterizing the HBV infection stage, but the accumulating data strongly suggest that HBsAg testing now adds little, if any, TT‐HBV risk reduction value where sensitive HBV NAT and anti‐HBc screening also apply.

A Decision-theory Approach to Cost-effective Population Supplementation for Imperiled Species

Despite decades of managing endangered species, few have been successfully recovered. One option to reduce this gap is to use decision analysis to weigh alternative recovery actions. Using decision analysis, we evaluated tradeoffs between recovery actions to reduce extinction risk and financial cost for the imperiled Oregon spotted frog (Rana pretiosa). We simulated population supplementation via captive breeding or head-starting, and releasing offspring into the wild as larvae or young of the year. We ranked the efficacy of recovery scenarios, represented by a culmination of a series of decision points, to reduce the 10-year extinction risk below 10% while minimizing financial costs. We explored how rankings varied with respect to the extinction risk target, the endangered population size, and the reproductive output captive females. Our top-ranked pathway was to supplement with captive bred larvae, resulting in a 3% reduction in extinction risk for every $100,000 spent. In general, supplementing with captive bred larvae resulted in the biggest reduction in extinction risk per dollar invested. Additionally, we found that increasing spending does not always result in a proportional reduction in extinction risk. These results link quantitative and applied conservation by considering the biological and economic efficacy to recover endangered species.

Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis

The benefits of blood pressure lowering treatment for prevention of cardiovascular disease are well established. However, the extent to which these effects differ by baseline blood pressure, presence of comorbidities, or drug class is less clear. We therefore performed a systematic review and meta-analysis to clarify these differences. For this systematic review and meta-analysis, we searched MEDLINE for large-scale blood pressure lowering trials, published between Jan 1, 1966, and July 7, 2015, and we searched the medical literature to identify trials up to Nov 9, 2015. All randomised controlled trials of blood pressure lowering treatment were eligible for inclusion if they included a minimum of 1000 patient-years of follow-up in each study arm. No trials were excluded because of presence of baseline comorbidities, and trials of antihypertensive drugs for indications other than hypertension were eligible. We extracted summary-level data about study characteristics and the outcomes of major cardiovascular disease events, coronary heart disease, stroke, heart failure, renal failure, and all-cause mortality. We used inverse variance weighted fixed-effects meta-analyses to pool the estimates. We identified 123 studies with 613,815 participants for the tabular meta-analysis. Meta-regression analyses showed relative risk reductions proportional to the magnitude of the blood pressure reductions achieved. Every 10 mm Hg reduction in systolic blood pressure significantly reduced the risk of major cardiovascular disease events (relative risk [RR] 0·80, 95% CI 0·77-0·83), coronary heart disease (0·83, 0·78-0·88), stroke (0·73, 0·68-0·77), and heart failure (0·72, 0·67-0·78), which, in the populations studied, led to a significant 13% reduction in all-cause mortality (0·87, 0·84-0·91). However, the effect on renal failure was not significant (0·95, 0·84-1·07). Similar proportional risk reductions (per 10 mm Hg lower systolic blood pressure) were noted in trials with higher mean baseline systolic blood pressure and trials with lower mean baseline systolic blood pressure (all ptrend>0·05). There was no clear evidence that proportional risk reductions in major cardiovascular disease differed by baseline disease history, except for diabetes and chronic kidney disease, for which smaller, but significant, risk reductions were detected. β blockers were inferior to other drugs for the prevention of major cardiovascular disease events, stroke, and renal failure. Calcium channel blockers were superior to other drugs for the prevention of stroke. For the prevention of heart failure, calcium channel blockers were inferior and diuretics were superior to other drug classes. Risk of bias was judged to be low for 113 trials and unclear for 10 trials. Heterogeneity for outcomes was low to moderate; the I(2) statistic for heterogeneity for major cardiovascular disease events was 41%, for coronary heart disease 25%, for stroke 26%, for heart failure 37%, for renal failure 28%, and for all-cause mortality 35%. Blood pressure lowering significantly reduces vascular risk across various baseline blood pressure levels and comorbidities. Our results provide strong support for lowering blood pressure to systolic blood pressures less than 130 mm Hg and providing blood pressure lowering treatment to individuals with a history of cardiovascular disease, coronary heart disease, stroke, diabetes, heart failure, and chronic kidney disease. National Institute for Health Research and Oxford Martin School.

Dyslipidemia

Dyslipidemia

Abstract S1-2: ATLAS – 10 v 5 years of adjuvant tamoxifen (TAM) in ER+ disease: Effects on outcome in the first and in the second decade after diagnosis

Abstract Background: In ER+ early breast cancer, 5 years of tamoxifen greatly reduces recurrence throughout the first decade (years 0–9) with little further gain later, and reduces breast cancer mortality (BCM) substantially throughout years 0–14 (EBCTCG, Lancet 2011; 378: 771–84 – see Table). It is not known how 10 years TAM compares with the current standard of just 5 years TAM. Methods: In 1996–2005 the international ATLAS trial randomized 6846 women with ER+ disease who had had ∼5 years of adjuvant TAM to continue another 5 years (to year 10) or stop at year 5 (control). Annual follow-ups recorded compliance, hospital admissions, breast cancer recurrence (including new contralateral), any other new primary cancer and cause of death. Results: Compliance was ∼80%, as after 2 years 84% of those allocated continue and 4% of those allocated stop were still taking endocrine treatment (&amp;gt;99% TAM). With mean 7.1 woman-years follow-up (30,000 w-y in years 5–9, 16,000 in years 10–14, 2000 later), 1328 recurrences were reported (900 in years 5–9, 379 in years 10–14). Recurrence was significantly lower with10 than 5 years TAM (Table: logrank 2p = 0.002, rate ratio (RR)=0.90 se 0.06 in years 5–9 and 0.75 se 0.08 in years 10+). So were both BCM (2p = 0.01, RR = 0.97 se 0.10 in years 5–9 and 0.71 se 0.09 in years 10+) and all-cause mortality (2p = 0.01, with no increase in non-BCM). Proportional risk reductions were homogeneous by country, age and stage. Kaplan-Meier risks in years 5–14 (K-M) were: recurrence 21.4 vs 25.1%, BCM 12.2 vs 15.0%. Uterine cancer K-Ms in those randomized at age 50+ were: incidence 2.6 vs 1.6% (2p = 0.08), mortality 0.2 vs 0.2%. In pre-menopausal women (where AIs are not an alternative to TAM) there was no apparent excess of uterine cancer. Discussion: Compared with just 5 years TAM, continuing TAM to year 10 safely protects further against recurrence and, particularly during the second decade, BCM. Combining results from ATLAS and the EBCTCG meta-analyses of 5 years TAM vs none (both had ∼80% compliance), in a hypothetical trial of 10 vs 0 years TAM with ∼80% compliance, 15-year BCM would be reduced by at least one-third. Hence, full compliance with 10 years TAM would yield even greater benefit (Table). Further follow-up of ATLAS will assess more reliably the apparently substantial mortality reduction in the second decade after diagnosis. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S1-2.

Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100 000 women in 123 randomised trials

SummaryBackgroundModerate differences in efficacy between adjuvant chemotherapy regimens for breast cancer are plausible, and could affect treatment choices. We sought any such differences.MethodsWe undertook individual-patient-data meta-analyses of the randomised trials comparing: any taxane-plus-anthracycline-based regimen versus the same, or more, non-taxane chemotherapy (n=44 000); one anthracycline-based regimen versus another (n=7000) or versus cyclophosphamide, methotrexate, and fluorouracil (CMF; n=18 000); and polychemotherapy versus no chemotherapy (n=32 000). The scheduled dosages of these three drugs and of the anthracyclines doxorubicin (A) and epirubicin (E) were used to define standard CMF, standard 4AC, and CAF and CEF. Log-rank breast cancer mortality rate ratios (RRs) are reported.FindingsIn trials adding four separate cycles of a taxane to a fixed anthracycline-based control regimen, extending treatment duration, breast cancer mortality was reduced (RR 0·86, SE 0·04, two-sided significance [2p]=0·0005). In trials with four such extra cycles of a taxane counterbalanced in controls by extra cycles of other cytotoxic drugs, roughly doubling non-taxane dosage, there was no significant difference (RR 0·94, SE 0·06, 2p=0·33). Trials with CMF-treated controls showed that standard 4AC and standard CMF were equivalent (RR 0·98, SE 0·05, 2p=0·67), but that anthracycline-based regimens with substantially higher cumulative dosage than standard 4AC (eg, CAF or CEF) were superior to standard CMF (RR 0·78, SE 0·06, 2p=0·0004). Trials versus no chemotherapy also suggested greater mortality reductions with CAF (RR 0·64, SE 0·09, 2p<0·0001) than with standard 4AC (RR 0·78, SE 0·09, 2p=0·01) or standard CMF (RR 0·76, SE 0·05, 2p<0·0001). In all meta-analyses involving taxane-based or anthracycline-based regimens, proportional risk reductions were little affected by age, nodal status, tumour diameter or differentiation (moderate or poor; few were well differentiated), oestrogen receptor status, or tamoxifen use. Hence, largely independently of age (up to at least 70 years) or the tumour characteristics currently available to us for the patients selected to be in these trials, some taxane-plus-anthracycline-based or higher-cumulative-dosage anthracycline-based regimens (not requiring stem cells) reduced breast cancer mortality by, on average, about one-third. 10-year overall mortality differences paralleled breast cancer mortality differences, despite taxane, anthracycline, and other toxicities.Interpretation10-year gains from a one-third breast cancer mortality reduction depend on absolute risks without chemotherapy (which, for oestrogen-receptor-positive disease, are the risks remaining with appropriate endocrine therapy). Low absolute risk implies low absolute benefit, but information was lacking about tumour gene expression markers or quantitative immunohistochemistry that might help to predict risk, chemosensitivity, or both.FundingCancer Research UK; British Heart Foundation; UK Medical Research Council.

A Pilot Study Evaluating Multiple Risk Factor Interventions by Community Pharmacists to Prevent Cardiovascular Disease: The PAART CVD Pilot Project

There is insufficient evidence for the efficacy of comprehensive multiple risk factor interventions by pharmacists in the primary prevention of cardiovascular disease (CVD). Given the proven benefits of pharmacist interventions for individual risk factors, it is essential that evidence for a comprehensive approach to care be generated so that pharmacists remain key members of the health care team for individuals at risk of initial onset of CVD. To establish the feasibility of an intervention delivered by community pharmacists to reduce the risk of primary onset of CVD. A single-cohort intervention study was undertaken in 2008-2009. Twelve community pharmacists from 10 pharmacies who were trained to provide lifestyle and medicine management support to reduce CVD risk recruited 70 at-risk participants aged 50-74 years who were free from diabetes or CVD. Participants received a baseline assessment to establish CVD risk and health behaviors. An assessment report provided to patients and pharmacists was used to collaboratively establish treatment goals and, over 5 sessions, implement treatment strategies. Follow-up assessment at 6 months measured changes in baseline parameters. The primary outcome was the average change to overall 5-year risk of CVD onset. Sixty-seven participants were included in the analysis. The mean participant age was 60 years and 73% were female. We observed a 25% (95% CI 17 to 33) proportional risk reduction in overall CVD risk. Significant reductions also occurred in mean blood pressure (-11/-5 mm Hg) and waist circumference (-1.3 cm), with trends toward improvement for most other observed risk factors. Findings support previous evidence of positive cardiovascular health outcomes following pharmacist intervention in other patient groups; we recommend generating randomized controlled trial evidence for a primary prevention population.

Adjuvant chemotherapy is not for everyone

The history of breast cancer therapy is cyclical [1]. Each new treatment, whether surgery, hormone therapy, or chemotherapy is initially applied to all patients, but with time, usually 10–20 years, it becomes clear that the overall benefit is substantially smaller than first anticipated because only a portion of treated patients derive any benefit. With further study and time (another 10? years) the clinical, pathological, and, more recently, molecular characteristics of the tumors unlikely to benefit from the new treatment are identified. This was true for mastectomy; clinical staging was introduced to exclude inappropriate patients. With endocrine therapy it became evident after 10–20 years that patients who did not benefit had more rapidly growing tumors (e.g. those with a short disease-free interval). Ten years after that the estrogen receptor (ER) was identified and it was shown that patients without an ER did not respond to endocrine therapy. (It is easy to forget that it took yet another decade for all clinicians to accept the validity of the estrogen receptor! [2, 3]). It has been clear for some time that not all patients derive equal benefit from chemotherapy or from any specific chemotherapy. The importance of ER in determining the likelihood of responding to chemotherapy was first suggested in 1978 [4], but that hypothesis was quickly rejected by many [5–8]. Recently, however, more compelling evidence on the relationship between ER status and benefits from adjuvant chemotherapy make it difficult to ignore this relationship [9, 10] (Table 1). Oncologists are more likely to use lymph node status than estrogen receptor status to decide whether a patient should receive adjuvant chemotherapy, but the proportional reduction in risk is constant for patients in different node categories [9]. In contrast, patients with ER negative tumors derive greater benefit from chemotherapy than those with ER positive tumors. Since most older women have ER positive tumors, summary estimates of either the proportional reduction in odds of recurrence or absolute differences in disease-free survival or overall survival seriously underestimate the benefit for older women with ER negative tumors. The possibility of a similar correlation between benefit and another well-established prognostic factor, HER2/neu, was first made in studies of doxorubicin dose effect [11]. Subsequently, retrospective analyses were performed on the relationship between HER2/neu and outcome in 10 adjuvant chemotherapy studies that compared an anthracycline with a non-anthracycline regimen [12]. There was a statistically significant correlation in only three of these trials, but in a meta-analysis of the six studies that provided sufficient information, there was a significant improvement in both disease-free and overall survival for the anthracycline-treated patients among those with HER-2/neu positive tumors but no advantage for those without overexpression of HER2/neu. [Table 2] The first report of a correlation between HER2/neu and the use of taxane therapy was from a planned subset analysis of CALGB protocol 9344 in which patients were randomized to either four cycles of doxorubicin/cyclophosphamide or the same plus an additional four cycles of paclitaxel [13] (Table 3). In this analysis, those patients who had tumors that were both ER? and HER2/neu negative (52% of the patients) derived no advantage from the added paclitaxel, but there was a 20–30% reduction in the This is an invited commentary to article doi:10.1007/s10549-009-0663-z.

Aspirin for Prevention of Cardiovascular Events in a General Population Screened for a Low Ankle Brachial Index&lt;subtitle&gt;A Randomized Controlled Trial&lt;/subtitle&gt;

A low ankle brachial index (ABI) indicates atherosclerosis and an increased risk of cardiovascular and cerebrovascular events. Screening for a low ABI can identify an asymptomatic higher risk group potentially amenable to preventive treatments. To determine the effectiveness of aspirin in preventing events in people with a low ABI identified on screening the general population. The Aspirin for Asymptomatic Atherosclerosis trial was an intention-to-treat double-blind randomized controlled trial conducted from April 1998 to October 2008, involving 28,980 men and women aged 50 to 75 years living in central Scotland, free of clinical cardiovascular disease, recruited from a community health registry, and had an ABI screening test. Of those, 3350 with a low ABI (< or = 0.95) were entered into the trial, which was powered to detect a 25% proportional risk reduction in events. Once daily 100 mg aspirin (enteric coated) or placebo. The primary end point was a composite of initial fatal or nonfatal coronary event or stroke or revascularization. Two secondary end points were (1) all initial vascular events defined as a composite of a primary end point event or angina, intermittent claudication, or transient ischemic attack; and (2) all-cause mortality. After a mean (SD) follow-up of 8.2 (1.6) years, 357 participants had a primary end point event (13.5 per 1000 person-years, 95% confidence interval [CI], 12.2-15.0). No statistically significant difference was found between groups (13.7 events per 1000 person-years in the aspirin group vs 13.3 in the placebo group; hazard ratio [HR], 1.03; 95% CI, 0.84-1.27). A vascular event comprising the secondary end point occurred in 578 participants (22.8 per 1000 person-years; 95% CI, 21.0-24.8) and no statistically significant difference between groups (22.8 events per 1000 person-years in the aspirin group vs 22.9 in the placebo group; HR, 1.00; 95% CI, 0.85-1.17). There was no significant difference in all-cause mortality between groups (176 vs 186 deaths, respectively; HR, 0.95; 95% CI, 0.77-1.16). An initial event of major hemorrhage requiring admission to hospital occurred in 34 participants (2.5 per 1000 person-years) in the aspirin group and 20 (1.5 per 1000 person-years) in the placebo group (HR, 1.71; 95% CI, 0.99-2.97). Among participants without clinical cardiovascular disease, identified with a low ABI based on screening a general population, the administration of aspirin compared with placebo did not result in a significant reduction in vascular events. isrctn.org Identifier: ISRCTN66587262.

Greater absolute reductions in LDL cholesterol should yield greater proportional reductions in risk of cardiovascular disease

Greater absolute reductions in LDL cholesterol should yield greater proportional reductions in risk of cardiovascular disease

Adjuvant therapy decisions in breast cancer: comparison of a multi disciplinary team's decisions with the recommendations of web-based computer programme “Adjuvant Online”.

Abstract Abstract #2117 Introduction: Adjuvant therapy decisions in breast cancer impact on survival, recurrence and quality of life. We compared the hormonal and chemotherapy recommendations of a multi-disciplinary team (MDT) with the “best treatment” recommended by an evidence-based online computer programme “Adjuvant Online” (AO).&amp;#x2028; Materials and Methods: We prospectively monitored a breast cancer MDT for a period of one year. Among 218 breast cancer patients discussed, patients who had DCIS, neoadjuvant therapy, primary hormonal therapy, multifocal disease and micrometastases only in the axillary lymph nodes and recurrent disease were excluded leaving 122 suitable for input into AO. The MDT recommendation and actual treatment received were recorded. Ten-year cancer-related death and relapse rates were calculated using AO and estimates of proportional risk reduction with MDT recommended therapy and AO “best treatment” were made.&amp;#x2028; Results: Median age was 61 years (range 28-86). MDT recommended endocrine therapy (ET) to all patients with ER/PR positive cancers (n=103). Among 30 women aged 55 years or less with ER/PR positive cancers, 25 had tamoxifen, 4 had an aromatase inhibitor (AI) and one switched from tamoxifen to an AI. AO suggested AI or tamoxifen-AI switch as the best treatment for post-menopausal women. Among 73 women aged over 55 years with ER/PR positive cancers, 46% (n=34) received tamoxifen as per local cancer-network guidelines, which recommended tamoxifen for low-risk (T1 N0 M0) post-menopausal breast cancer. Others received an AI (n=38) except one patient who declined ET. There were 54 patients with &amp;gt;10% risk of cancer-related death in 10 years. Among these 36 were offered and 29 received chemotherapy. Chemotherapy was not offered to 17 patients due to age and/or comorbidity. Only 1 suitable patient with &amp;gt;10% risk was not offered chemotherapy by the MDT. Among those who had chemotherapy, only 31% had 3rd generation chemotherapy as recommended by AO, the main reason being national guidelines in the United Kingdom limiting the use of this regimen.&amp;#x2028; Discussion: There are differences between the adjuvant therapy decisions by the MDT and the “best treatment” recommended by Adjuvant Online. This study shows that in the majority of these cases the differences are due to either local or national guidelines that are in force in the United Kingdom. Cancer MDTs in the UK National Health Service are expected to adhere to these guidelines. However, calculation of the risk of death and recurrence rates using AO may be useful to facilitate decision making of the MDT by giving quantitative prognostic estimates and this could be a useful adjunct to help patients make informed decisions. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2117.