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A S Coates

Publications and source records attributed to A S Coates.

At least 37 records · Page 2Linked to original sources
PubMed2001

Patient preferences for adjuvant chemotherapy of early breast cancer: how much benefit is needed?

Adjuvant chemotherapy for early-stage breast cancer has been shown to delay recurrence and improve survival. However, the benefits are modest and must be balanced against the adverse treatment effects. We assessed the size of the survival benefit needed to justify the toxicity of chemotherapy, based on the preferences of women who had previously received adjuvant cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). We also attempted to identify circumstances in which larger survival gains would be needed. In semistructured interviews, 104 women who had received adjuvant CMF chemotherapy were asked to rate the survival benefit that would justify 6 months of such treatment, using a series of hypothetical trade-offs between shorter survival without treatment and longer survival with treatment. Similar preferences were sought for a greater probability of 5-year survival. Most patients considered 6 months of adjuvant CMF chemotherapy worthwhile for relatively modest survival gains: 77% considered an increase of from 5 to 6 years worthwhile, 74% thought an increase of from 15 to 17 years worthwhile, and more than 70% considered such treatment justified for a 5% greater chance of living 5 or more years. Smaller survival benefits were needed for women who had experienced less toxicity (P =.01), had not received initial radiotherapy (P =.01), had better social support (P =.02), and had others at home dependent on their support (P =.0001). Modest survival benefits are sufficient to justify adjuvant cytotoxic chemotherapy for most women with early-stage breast cancer. Individual preferences are important when weighing trade-offs between survival and adverse treatment effects.

Adult↗
PubMed2001

Adjuvant therapy for very young women with breast cancer: need for tailored treatments.

Breast cancer rarely occurs in women below the age of 35 years. Data from various sources indicate that diagnosis at such an age is associated with a dire prognosis mainly because of a more aggressive presentation. Although the effect of chemotherapy for premenopausal patients is substantial, recent evidence on 2233 patients suggested that very young women with endocrine-responsive tumors had a statistically significantly higher risk of relapse than older premenopausal patients with such tumors. In contrast, results for younger and older premenopausal patients were similar if their tumors were classified as endocrine nonresponsive. Information from studies on 7631 patients who were treated with chemotherapy alone in trials of three major U.S. cooperative groups showed a similar interaction between the effect of age and steroid hormone receptor status of the primary tumor. Better treatments for very young patients are required and may involve ovarian function suppression in addition to other endocrine agents in patients with endocrine responsive tumors and a more precise investigation of chemotherapy and its timing, duration, and intensity in those with endocrine nonresponsive tumors. Very young women with this disease are faced with personal, family, professional, and quality-of-life issues, which further complicate the phase of treatment decision making. The development of more effective therapies for younger patients requires tailored treatment investigations and cannot rely on information predominantly contributed from older premenopausal women.

Adult↗
PubMed2000

Identifying breast cancer patients at high risk for bone metastases.

PURPOSE: To identify patient populations at high risk for bone metastases at any time after diagnosis of operable breast cancer, because these patients are potential beneficiaries of treatment with bisphosphonates. PATIENTS AND METHODS: We evaluated data from 6,792 patients who were randomized in International Breast Cancer Study Group clinical trials between 1978 and 1993. Median follow-up was 10. 7 years. A total of 1,275 patients (18.7%) presented with node-negative disease, whereas 3,354 patients (49.4%) had one to three and 2,163 patients (31.9%) had four or more involved axillary lymph nodes. We also assessed the incidence of subsequent bone metastases in the cohort of 1,220 patients who had a first event in local or regional sites or soft tissue alone. Median follow-up for this cohort was 7.7 years from first recurrence. RESULTS: For the entire population with operable disease, the cumulative incidence of bone metastases at any time was 8.2% at 2 years from randomization and 27.3% at 10 years. The highest cumulative incidences of bone metastases at any time were among patients who had four or more involved axillary nodes at the time of diagnosis (14.9% at 2 years and 40.8% at 10 years) and among patients who had as their first event a local or regional recurrence or a recurrence in soft tissue, without any other overt metastases (21.1% at 2 years from first recurrence and 36.7% at 10 years). CONCLUSION: Treatments to prevent bone metastases may have a major impact on the course of breast cancer and may be most efficiently studied in populations with several involved axillary nodes at the time of presentation and in populations with local or regional recurrence or recurrence in soft tissue.

Aged↗
PubMed2000

Quality-of-life scores predict outcome in metastatic but not early breast cancer. International Breast Cancer Study Group.

PURPOSE: We compared the prognostic value of quality-of-life (QL) scores in the adjuvant setting and after relapse in two randomized trials of the International Breast Cancer Study Group. PATIENTS AND METHODS: More than 2,000 premenopausal and postmenopausal patients with node-positive breast cancer who were participating in randomized trials that compared adjuvant therapies completed QL assessments for physical well-being, mood, appetite, and coping at study entry and at months 3 and 18 if they remained relapse-free and, in case of relapse, at 1 month and at 6 months after relapse. Cox regression models were used to test the relationship between QL scores and disease-free survival (DFS), in the adjuvant setting, or overall survival, in the case of postrelapse QL measurement. All models were stratified by language/country group and included other factors related to QL and/or outcome. RESULTS: DFS was not significantly predicted by QL scores at baseline or month 18, or by changes in QL score between baseline and months 3 or 18. In contrast, after relapse, QL scores were predictive for subsequent overall survival. One month after relapse, better mood (P =.04) in premenopausal patients and better appetite (P =.005) in postmenopausal patients were associated with longer survival. Six months after relapse, better physical well-being (P =.03) and appetite (P =.03) in premenopausal patients and better physical well-being (P <.0001), mood (P =.002), appetite (P =.0001), and coping (P =.0001) in postmenopausal patients predicted longer survival. CONCLUSION: Any prognostic significance of QL scores in the adjuvant setting is minimal or obscured by chemotherapy effects, but there is strong prognostic significance of QL scores after disease relapse. The contrast suggests that patient perception of the severity of underlying illness may determine reported QL scores.

Breast Neoplasms↗
PubMed2000

Is chemotherapy alone adequate for young women with oestrogen-receptor-positive breast cancer?

BACKGROUND: The prognosis of breast cancer in very young women is generally considered to be unfavourable. Therefore, the outcome of adjuvant therapy was analysed in a population of young (<35 years) premenopausal patients treated in four randomised controlled trials. METHODS: Between 1978 and 1993 the International Breast Cancer Study Group (IBCSG) treated 3700 premenopausal and perimenopausal patients with various timing and duration of adjuvant cyclophosphamide, methotrexate, and fluorouracil (CMF with or without low-dose prednisone and oophorectomy). 314 of these women were less than 35 years old at randomisation. FINDINGS: Relapse and death occurred earlier and more often in younger (<35 years) than in older (> or = 35) patients with a 10 year disease-free survival of 35% (SE 3) versus 47% (1) (hazard ratio 1.41 [95% CI 1.22-1.62], p<0.001) and overall survival of 49% (3) versus 62% (1) (1.50 [1.28-1.77], p<0.001). Younger patients with oestrogen-receptor positive tumours had a significantly worse disease-free survival than younger patients with oestrogen-receptor negative tumours. By contrast, among older patients the disease-free survival was similar irrespective of oestrogen-receptor status. INTERPRETATION: Young premenopausal breast cancer patients treated with adjuvant CMF chemotherapy had higher risk of relapse and death than older premenopausal patients, especially if their tumours expressed oestrogen receptors. The endocrine effects of chemotherapy alone are insufficient for the younger age group and these patients should strongly consider additional endocrine therapies (tamoxifen or ovarian ablation) if their tumours express oestrogen receptors.

Adult↗
PubMed2000

Psychosocial predictors of survival: metastatic breast cancer.

BACKGROUND: Research interest in psychosocial predictors of the onset and course of cancer has been active since the 1950s. Recently we reported associations between psychological factors and survival in patients with metastatic melanoma. We now report a replication of this study in a sample of women with metastatic breast cancer. PATIENTS AND METHODS: Ninety-nine patients with metastatic breast cancer completed questionnaires measuring cognitive appraisal of threat, coping, psychological adjustment, perceived aim of treatment, social support and quality of life, approximately four months after diagnosis. Survival was measured from date of study entry to date of death or censored at the date of last follow-up for surviving patients. RESULTS: In a multivariate analysis, four factors independently predicted outcome. Patients with metastases in the liver, lung or pleura survived for a shorter duration (P < 0.001); older patients (P < 0.001) and those with a better appetite (P < 0.05) also lived for a shorter time. Patients who minimised the impact of cancer survived longer (a median of 29.1 vs. 23.9 months after study entry, P < 0.01). CONCLUSIONS: Minimisation was also significantly associated with outcome in patients with metastatic melanoma who participated in an identically designed study, reported elsewhere. This suggests that minimisation may have a general impact on cancer progression and deserves closer scrutiny in other cancers.

Adaptation, Psychological↗
PubMed2000

Patterns over time in quality of life, coping and psychological adjustment in late stage melanoma patients: an application of multilevel models.

BACKGROUND: Quality of life (QOL) assessment is an important component within cancer research. There is often variability in QOL scores both between patients and across time. Understanding this variability in terms of personal characteristics and psychosocial factors would be useful but is often obstructed by the types of analyses that are applied to longitudinal data sets. Improved understanding can be gained with the application of multi-level or hierarchical models that allow for greater flexibility for modelling individual patterns of change over time. METHODS AND PATIENTS: Questionnaires were sent to a cohort of stage IV melanoma patients seen at the Sydney Melanoma Unit between 1991 and 1996, approximately every 3 months for up to 2 years. The data reported here are from a sub-sample of 44 patients who each completed between 3 and 8 questionnaires. Three aspects of QOL were measured (effort to cope, mood and physical well-being), each with a single LASA line. Multilevel techniques were used to model the patterns of QOL over time. Covariates were added to explain variation between patients in their average QOL and change in QOL over time. RESULTS: The scores of each of the three QOL measures showed marked fluctuations over time. However, there was little systematic change during the study in either effort to cope (p = 0.32) or mood (p = 0.06). In contrast, the physical well-being scores of some patients improved while others deteriorated (p < 0.001). On average, physical well-being deteriorated (p < 0.001). Variability between patients accounted for 60% (effort to cope), 45% (mood) and 44% (physical well-being) of the total variance of each scale. A range of psycho-social factors including active and avoidant coping styles and psychological adjustment accounted for significant amounts of the variability between patients in each QOL measure. CONCLUSION: Individual coping and psychological adjustment are related to individual changes in QOL and to differences among patients' QOL. The study illustrates the use of multi-level techniques to further our understanding of differences between patients in their QOL and how it changes over time.

Adaptation, Psychological↗
PubMed2000

Psychosocial predictors of outcome: time to relapse and survival in patients with early stage melanoma.

This study explored psychosocial predictors of relapse and survival in early stage melanoma patients. Patients with locoregional melanoma whose tumour thickness exceeded 0.69 mm, seen at the Sydney Melanoma Unit between 1991 and 1996 participated in the study. Questionnaires were sent to participating patients every 3 months for 2 years. Domains measured included cognitive appraisal of threat, coping, psychological adjustment, quality of life and perceived aim of treatment. Disease and demographic data were obtained from medical records. Multivariate analyses from baseline data used the Cox proportional hazards model. Of the 682 patients invited to participate 426 (62%) agreed. 91 (21%) relapsed and 60 (14%) died within the follow-up period, that ended in October 1997. After controlling for known prognostic indicators, several psychosocial variables predicted time to relapse and/or survival duration. Patients who perceived their aim of treatment to be cured, who did not use avoidance as a coping strategy or who were concerned about their disease experienced longer periods without relapse. Shorter survival duration was associated with a positive mood, the use of avoidance as a coping strategy, not being concerned with their disease and concern about the impact of the disease on family. There is still much to learn about the potential relationships between psychological well being, human behaviours and cancer outcome. Research in this area needs to clarify the psychological processes, as well as understand the biological and/or behavioural mechanisms that may link them to outcome.

Adaptation, Psychological↗
PubMed2000

Early start of adjuvant chemotherapy may improve treatment outcome for premenopausal breast cancer patients with tumors not expressing estrogen receptors. The International Breast Cancer Study Group.

PURPOSE: The proper time to commence adjuvant chemotherapy after primary surgery for breast cancer is unknown. An analysis of the International (Ludwig) Breast Cancer Study Group (IBCSG) Trial V at a median follow-up of 11 years suggested that early initiation of adjuvant chemotherapy might improve outcome for premenopausal, node-positive patients whose tumors did not express any estrogen receptor (ER). PATIENTS AND METHODS: We investigated the relationship between early initiation of adjuvant chemotherapy, ER status, and prognosis in 1,788 premenopausal, node-positive patients treated on IBCSG trials I, II, and VI. The disease-free survival for 599 patients (84 with ER-absent tumors) who commenced adjuvant chemotherapy within 20 days (early initiation) was compared with the disease-free survival for 1,189 patients (142 with ER-absent tumors) who started chemotherapy 21 to 86 days after surgery (conventional initiation). The median follow-up was 7.7 years. RESULTS: Among patients with ER-absent tumors, the 10-year disease-free survival was 60% for the early initiation group compared with 34% for the conventional initiation group (226 patients; hazard ratio [HR], 0. 49; 95% confidence interval [CI], 0.33 to 0.72; P =.0003). This difference remained statistically significant in a Cox multiple regression analysis controlling for study group, number of positive nodes, tumor size, age, vessel invasion, and institution (HR, 0.60; 95% CI, 0.39 to 0.92; P =.019). Conversely, early initiation of chemotherapy did not significantly improve disease-free survival for patients with tumors expressing ER (1,562 patients; multiple regression HR, 0.93; 95% CI, 0.79 to 1.10; P =.40). CONCLUSION: In premenopausal patients with ER-absent tumors, early initiation of systemic chemotherapy after primary surgery might improve outcome. Further confirmatory studies are required before any widespread modification of current clinical practice. In premenopausal patients with tumors expressing some ER, gains from early initiation are unlikely to be clinically significant.

Adult↗
PubMed2000

Burdens and benefits of adjuvant cyclophosphamide, methotrexate, and fluorouracil and tamoxifen for elderly patients with breast cancer: the International Breast Cancer Study Group Trial VII.

PURPOSE: Information on the tolerability and efficacy of adjuvant chemoendocrine therapy for older women is limited. We studied these issues using the data collected as part of the International Breast Cancer Study Group Trial VII. PATIENTS AND METHODS: Postmenopausal women with operable, node-positive breast cancer were randomized to receive either tamoxifen alone for 5 years (306 patients) or tamoxifen plus three consecutive cycles of classical cyclophosphamide (100 mg/m(2) orally days 1 to 14), methotrexate (40 mg/m(2) intravenous days 1 and 8), and fluorouracil (600 mg/m(2) intravenous days 1 and 8) every 28 days (CMF; 302 patients). The median follow-up was 8.0 years. RESULTS: Among the 299 patients who received at least one dose of CMF, women 65 years of age or older (n = 76) had higher grades of toxicity compared with women less than 65 years old (n = 223) (P =.004). More women in the older age group compared with the younger women experienced grade 3 toxicity of any type (17% v 7%, respectively), grade 3 hematologic toxicity (9% v 5%, respectively), and grade 3 mucosal toxicity (4% v 1%, respectively). Older patients also received less than their expected CMF dose compared with younger postmenopausal women (P =.0008). The subjective burdens of treatment, however, were similar for younger and older patients based on quality-of-life measures (performance status, coping, physical well-being, mood, and appetite). For older patients, the 5-year disease-free survival (DFS) rates were 63% for CMF plus tamoxifen and 61% for tamoxifen alone (hazards ratio [HR], 1.00; 95% confidence interval [CI], 0.65 to 1.52; P =.99). For younger patients, the corresponding 5-year DFS rates were 61% and 53% (HR, 0.70; 95% CI, 0.53 to 0.91; P =.008), but the test for heterogeneity of CMF effect according to age group was not statistically significant. The reduced effectiveness of CMF among older women could not be attributed to dose reductions according to dose received. CONCLUSION: CMF tolerability and effectiveness were both reduced for older patients compared with younger postmenopausal node-positive breast cancer patients who received tamoxifen for 5 years. The development and evaluation of less toxic and more effective chemotherapy regimens are required for high-risk elderly patients.

Age Factors↗
PubMed1999

Psychosocial predictors of survival in metastatic melanoma.

PURPOSE: Research interest in psychosocial predictors of the onset and course of cancer has been active since the 1950s. However, results have been contradictory and the literature is noted for methodologic weaknesses. In this prospective study, we aimed to systematically obtain data on psychosocial factors associated with human response to illness. PATIENTS AND METHODS: One hundred twenty-five patients with metastatic melanoma completed questionnaires measuring cognitive appraisal of threat, coping, psychologic adjustment, perceived aim of treatment, social support, and quality of life (QOL). Questionnaires were completed, where possible, every 3 months for 2 years after diagnosis. Survival was measured from date of study entry to date of death or was censored at the date of last follow-up for surviving patients. RESULTS: In a multivariate Cox regression analysis of baseline data, which controlled for demographic and disease predictors, the psychologic variables of perceived aim of treatment (P <.001), minimization (P <. 05), and anger (P <.05) were independently predictive of survival. Patients who were married (P <.01) and who reported a better QOL (P <.05) also survived longer. CONCLUSION: The prognostic significance of psychologic and QOL scores remained after allowance for conventional prognostic factors. If these associations reflect an early perception by the patient or doctor of disease progression, then measures are at least valuable early indicators of such progression. If psychologic processes have a more direct influence on the course of the underlying illness, then it may be possible to manipulate them for therapeutic effect. We are now conducting a randomized controlled trial of a psychologic intervention to further elucidate these issues.

Adaptation, Psychological↗
PubMed1998

Desmoplastic and desmoplastic neurotropic melanoma: experience with 280 patients.

BACKGROUND: It has been suggested that desmoplastic melanoma (DM) and desmoplastic neurotropic melanoma (DNM) are associated with worse prognoses and higher local recurrence rates than other forms of melanoma. In the current study, a large series of patients with DM and DNM treated at a tertiary referral center was reviewed. METHODS: For 190 patients with DM and 90 patients with DNM accrued over a 10-year period, clinical features were recorded and all available histopathology was reviewed. The associations between clinical and pathologic variables, biologic behavior, and eventual outcome were analyzed. RESULTS: The male-to-female ratio was 1.75:1 and the median patient age 61 years. The median tumor thickness was 2.5 mm, and 44% of cases were amelanotic. Five-year survival was 75%. Significant predictors of overall survival were a high mitotic rate (P=0.003) and tumor thickness (P=0.011). All the DNMs exceeded 1.5 mm in thickness and were graded as Clark's level IV or V. There was a significant increase in local recurrence when neurotropism was present (P < 0.001). The rate of local recurrence was not higher for DM than for other cutaneous melanomas. CONCLUSIONS: There was no statistically significant difference in survival for patients with DM and those with DNM, and overall survival for both was similar to that for patients with other cutaneous melanomas. However, there was a lower rate of regional lymph node metastasis at initial presentation and as the first recurrence for both DM and DNM. The local recurrence rate was higher when the surgical clearance margin was <1 cm and when neurotropism was present.

Adult↗