Primecuts – This Week In The Journals

May 9, 2011

By Megha Shah, MD

Faculty Peer Reviewed

This week we were witness to the courage, perseverance, and ultimately, the triumph of the American military in the ongoing efforts against terrorism. In a similar, albeit physically less threatening manner, scientists, researchers, and physicians work everyday to prevent and eradicate disease. In this week’s Primecuts, we celebrate those who fight to eliminate threats to our well-being and bring you the latest in the scientific headlines.

The New York Times reported on a study published in the New England Journal of Medicine comparing the efficacy of Lucentis (ranibizumab) with Avastin (bevacizumab) in the treatment of macular degeneration.[1] Avastin, typically a cancer drug, is much cheaper than Lucentis and, given its similar mechanism of action, has been used off-label for several years. The trial, sponsored by the National Eye Institute, included 1200 patients and showed that patients receiving Avastin could read an average of 8 letters more on an eye chart after a year of treatment, similar to the 8.5 letter improvement seen in those using Lucentis. Though larger and longer studies are pending, the findings show a potential way of saving hundreds of millions of dollars in Medicare costs and making the treatment for macular degeneration more accessible.

In a retrospective cohort study, researchers in Toronto compared survival in older patients with COPD who received either long-acting β-agonists or anticholinergics for treatment. The study, funded by the Government of Ontario and published in the Annals of Internal Medicine, included a total of 46,403 patients and showed that mortality was higher in patients initially prescribed a long-acting anticholinergic than in those initially prescribed a long-acting inhaled β-agonist (adjusted hazard ratio, 1.14 [95% CI, 1.09 to 1.19]).[2] Rates of hospitalizations and emergency room visits were also higher in the former group. Though controlled randomized trials need to be conducted, the study does give some perspective on what treatment options may be more efficacious when initiating COPD management.

 This week’s New England Journal of Medicine published a study that compared watchful waiting with radical prostatectomy in patients with early prostate cancer.[3] A total of 695 men were recruited over a ten year period and randomly assigned to either management arm. At fifteen year follow-up, the cumulative incidence of death from prostate cancer was 14.6% with radical prostatectomy and 20.7% with watchful waiting (a difference of 6.1 percentage points; 95% confidence interval [CI], 0.2 to 12.0), and a relative risk with surgery of 0.62 (P=0.01). In addition, those with extracapsular tumor growth after surgery had a risk of death from prostate cancer that was 7 times that of men without extracapsular tumor growth (95% CI, 2.6 to 18.4). The study highlights that while watchful waiting is often the preferred route of management in early prostate cancer, more aggressive measures with surgery, including adjuvant chemotherapy for those with extracapsular growth, should be more seriously considered.

In an early online publication, a study in The Lancet Infectious Diseases looked at the efficacy of chloroquine in the prevention of influenza.[4] Approximately 1500 healthy young adults were randomly assigned to receive either chloroquine or placebo. Eight of 738 participants had laboratory confirmed clinical influenza in the placebo group versus 12 of 724 in the chloroquine group (P=0.376). A total of 29 in the placebo group versus 38 in the chloroquine group had laboratory confirmed (with or without symptoms) influenza (P=0.261). Approximately 45% of participants in the chloroquine group reported side effects versus 33% in the placebo group (P=0.0001). The study concluded that chloroquine was not an effective drug for the prevention of influenza and that further research and drug development is needed.

Lastly, the Lancet Oncology published a study comparing intravenous and subcutaneous administration of bortezomib (Velcade) in patients with relapsed multiple myeloma.[5] This non-inferiority study included 222 patients who were randomized to either group and received an average of eight cycles of the drug. Overall response rate was 42% in both groups (P=0.002). In addition, there were no significant differences in time to progression (P= 0.387) or one year overall survival (P=0.504). By showing that subcutaneous administration is non-inferior, the results of the study may allow patients to spend less time in the hospital or clinical setting and provide a viable option for patients with difficult vascular access.

Dr. Megha Shah is a second year resident at NYU Langone Medical Center

Peer reviewed by Danise Schiliro, MD, Contributing Editor, Clinical Correlations

Image courtesy of Wikimedia Commons

References:

1.  Pollack, Andrew. Cheaper Drug to Treat Macular Degeneraton. New York Times. Published online April 28, 2011. http://www.nytimes.com/2011/04/29/business/29eye.html?_r=3&ref=research

2.  Gershon A., Croxford R. et al. Comparison of Inhaled Long-acting Beta Agonist and Anticholinergic Effectiveness in Older Patients with Chronic Obstructive Pulmonary Disease. Annals of Internal Medicine. 2011; 154 (9): 583-592. http://www.annals.org/content/154/9/583.abstract

3.  Bill-Axelson A., Holmberg L. et al. Radical Prostatectomy versus Watchful Waiting in Early Prostate Cancer. New England Journal of Medicine. 2011; 364: 1708-1717. http://www.nejm.org/doi/full/10.1056/NEJMoa1011967

4.  Paton NI, Lee L et al. Chloroquine for influenza prevention: a randomized, double-blind, placebo controlled trial. The Lancet Infectious Diseases. Early online publication. May 6,2011. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70065-2/fulltext

5.  Moreau P., Pylypenko H. et al. Subcutaneous versus intravenous administration of bortezomib in patients with relapsed multiple myeloma: a randomized, phase 3, non-inferiority study. 2011; 12(5): 431-440. http://www.thelancet.com/journals/lanonc/article/PIIS147020451170081X/fulltext

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