Effect of radium-223 dichloride on symptomatic skeletal events in patients with castration-resistant prostate cancer and bone metastases: results from a phase 3, double-blind, randomised trial

BACKGROUND: Bone metastases frequently cause skeletal events in patients with metastatic castration-resistant prostate cancer. Radium-223 dichloride (radium-223) selectively targets bone metastases with high-energy, short-range α-particles. We assessed the effect of radium-223 compared with placebo in patients with castration-resistant prostate cancer and bone metastases.

METHODS: In this phase 3, double-blind, randomised ALSYMPCA trial, we enrolled patients who had symptomatic castration-resistant prostate cancer with two or more bone metastases and no known visceral metastases, who were receiving best standard of care, and had previously either received or were unsuitable for docetaxel. Patients were stratified by previous docetaxel use, baseline total alkaline phosphatase level, and current bisphosphonate use, then randomly assigned (2:1) to receive either six intravenous injections of radium-223 (50 kBq/kg) or matching placebo; one injection was given every 4 weeks. Randomisation was done with an interactive voice response system, taking into account trial stratification factors. Participants and investigators were masked to treatment assignment. The primary endpoint was overall survival, which has been reported previously. Here we report on time to first symptomatic skeletal event, defined as the use of external beam radiation to relieve bone pain, or occurrence of a new symptomatic pathological fracture (vertebral or non-verterbal), or occurence of spinal cord compression, or tumour-related orthopeadic surgical intervention. All events were required to be clinically apparent and were not assessed by periodic radiological review. Statistical analyses of symptomatic skeletal events were based on the intention-to-treat population. The study has been completed and is registered with ClinicalTrials.gov, number NCT00699751.

FINDINGS: Between June 12, 2008, and Feb 1, 2011, 921 patients were enrolled, of whom 614 (67%) were randomly assigned to receive radium-223 and 307 (33%) placebo. Symptomatic skeletal events occurred in 202 (33%) of 614 patients in the radium-223 group and 116 (38%) of 307 patients in the placebo group. Time to first symptomatic skeletal event was longer with radium-223 than with placebo (median 15·6 months [95% CI 13·5-18·0] vs 9·8 months [7·3-23·7]; hazard ratio [HR]=0·66, 95% CI 0·52-0·83; p=0·00037). The risks of external beam radiation therapy for bone pain (HR 0·67, 95% CI 0·53-0·85) and spinal cord compression (HR=0·52, 95% CI 0·29-0·93) were reduced with radium-233 compared with placebo. Radium-223 treatment did not seem to significantly reduce the risk of symptomatic pathological bone fracture (HR 0·62, 95% CI 0·35-1·09), or the need for tumour-related orthopaedic surgical intervention (HR 0·72, 95% CI 0·28-1·82).

INTERPRETATION: Radium-223 should be considered as a treatment option for patients with castration-resistant prostate cancer and symptomatic bone metastases.

FUNDING: Algeta and Bayer HealthCare Pharmaceuticals.

Beyond the Academy: Applying Anthropological Research, A Case Study of Demonstrating Impact in the U.K. 2014 REF

The 2014 Research Excellence Framework sought for the first time to assess the impact that research was having beyond the boundaries of the university and the wider academic sphere. While the REF continued the approach of previous research assessment exercises in attempting to measure the overall quality of research and teaching within the higher-education sector, it also expected institutions to evidence how some of their research had had ‘an effect on, change or benefit to the economy, society, culture, public policy or services, health, the environment or quality of life, beyond academia’ (REF 2012: 48). This article provides a case study in how researchers in one U.K. anthropology department were able to demonstrate the impact of their work in the public sphere successfully as part of this major audit exercise.

Parades, Flags, Carnivals and Riots: Public Space, Contestation and Transformation in Northern Ireland

This paper explores one of the defining aspects of politics and identity in Northern Ireland: the control and utilization of public space, particularly urban public space. Ethnopolitical conflict consistently reveals itself through contestation over public space. The role of ritual events is important in the development of political identity and group cohesion. The symbolic landscape will be constructed through displays of identity by dominant groups and their ability to control that landscape by inhibiting displays by other groups. This will reveal itself through frequent contests over rituals and symbols. This paper looks at the role of ritual events in civic spaces in Belfast but particularly asks what role they might play in conflict transformation. The 1998 agreement offered political structures that provided for shared power after 30 years of violent conflict. At the same time, there was an increase in contestation over public space as political groups within the previously marginalized Catholic community demanded recognition within the public sphere and a rebalancing of the public space through changes to the previously dominant Protestant and Unionist expression of identity. The paper concludes by suggesting that in “shared space” a new civic identity that spans the political and ethnic divisions has started to develop in Belfast and that this might evolve despite an increased residential division throughout the urban area.

Flags: Towards A New Understanding

This report examines the 'symbolic conflicts' over flags in Northern Ireland. It looks at the history of the use of flags since 1921, the development of legislations and policy to deal with conflicts, the higher profile of disputes since 1998 and the policy options going forward. Using attitudes surveys and interviews with key individuals the report explores the strengths and weaknesses in potential legislation and in 'ground-up' guidelines. The report concludes with a set of voluntary guidelines and the tasks facing politicians.

Ritual, identity and nation: when the historian becomes the high priest of commemoration

This paper questions the use of 'memory', 'remembering' and 'collective memory' as a conceptual tool in historical study. It will ague that a synchronic model for commemorative practice needs to be highlighted, and in doing so questions the role of historians in commemorative practice.