Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial

BACKGROUND: Long-term hormone therapy has been the standard of care for advanced prostate cancer since the 1940s. STAMPEDE is a randomised controlled trial using a multiarm, multistage platform design. It recruits men with high-risk, locally advanced, metastatic or recurrent prostate cancer who are starting first-line long-term hormone therapy. We report primary survival results for three research comparisons testing the addition of zoledronic acid, docetaxel, or their combination to standard of care versus standard of care alone.

METHODS: Standard of care was hormone therapy for at least 2 years; radiotherapy was encouraged for men with N0M0 disease to November, 2011, then mandated; radiotherapy was optional for men with node-positive non-metastatic (N+M0) disease. Stratified randomisation (via minimisation) allocated men 2:1:1:1 to standard of care only (SOC-only; control), standard of care plus zoledronic acid (SOC + ZA), standard of care plus docetaxel (SOC + Doc), or standard of care with both zoledronic acid and docetaxel (SOC + ZA + Doc). Zoledronic acid (4 mg) was given for six 3-weekly cycles, then 4-weekly until 2 years, and docetaxel (75 mg/m(2)) for six 3-weekly cycles with prednisolone 10 mg daily. There was no blinding to treatment allocation. The primary outcome measure was overall survival. Pairwise comparisons of research versus control had 90% power at 2·5% one-sided α for hazard ratio (HR) 0·75, requiring roughly 400 control arm deaths. Statistical analyses were undertaken with standard log-rank-type methods for time-to-event data, with hazard ratios (HRs) and 95% CIs derived from adjusted Cox models. This trial is registered at ClinicalTrials.gov (NCT00268476) and ControlledTrials.com (ISRCTN78818544).

FINDINGS: 2962 men were randomly assigned to four groups between Oct 5, 2005, and March 31, 2013. Median age was 65 years (IQR 60-71). 1817 (61%) men had M+ disease, 448 (15%) had N+/X M0, and 697 (24%) had N0M0. 165 (6%) men were previously treated with local therapy, and median prostate-specific antigen was 65 ng/mL (IQR 23-184). Median follow-up was 43 months (IQR 30-60). There were 415 deaths in the control group (347 [84%] prostate cancer). Median overall survival was 71 months (IQR 32 to not reached) for SOC-only, not reached (32 to not reached) for SOC + ZA (HR 0·94, 95% CI 0·79-1·11; p=0·450), 81 months (41 to not reached) for SOC + Doc (0·78, 0·66-0·93; p=0·006), and 76 months (39 to not reached) for SOC + ZA + Doc (0·82, 0·69-0·97; p=0·022). There was no evidence of heterogeneity in treatment effect (for any of the treatments) across prespecified subsets. Grade 3-5 adverse events were reported for 399 (32%) patients receiving SOC, 197 (32%) receiving SOC + ZA, 288 (52%) receiving SOC + Doc, and 269 (52%) receiving SOC + ZA + Doc.

INTERPRETATION: Zoledronic acid showed no evidence of survival improvement and should not be part of standard of care for this population. Docetaxel chemotherapy, given at the time of long-term hormone therapy initiation, showed evidence of improved survival accompanied by an increase in adverse events. Docetaxel treatment should become part of standard of care for adequately fit men commencing long-term hormone therapy.

FUNDING: Cancer Research UK, Medical Research Council, Novartis, Sanofi-Aventis, Pfizer, Janssen, Astellas, NIHR Clinical Research Network, Swiss Group for Clinical Cancer Research.

Electron-impact excitation of W 44+ and W 45+

Plans to employ tungsten in the divertor region of the International Thermonuclear Experimental Reactor require radiative and collisional data for modelling x-ray emissions of highly ionized stages of tungsten. In an earlier paper, we reported on the results of fully relativistic R -matrix calculations for W 46+ that included the effects of radiation damping on the resonance contributions. In this paper, we present the results of similar fully relativistic, radiatively damped R -matrix calculations for W 44+ and W 45+ . Radiation damping is found to be small for W 45+ , but is appreciable for many of the excitations from the ground and metastable levels of W 44+ . Rates from the present calculations will be combined with those from the calculations for W 46+ and employed for collisional-radiative modelling for these ions.

Dielectronic recombination of W 35 +

Accurate data for dielectronic recombination (DR) of the ions of tungsten are of significant interest in the modelling of tungsten impurity transport and radiative power loss in current tokamaks and in ITER. However, the complexity of the atomic structure for many of these ions makes level-resolved DR calculations untenable on currently available computers, especially for open d- and f-subshell ions. The majority of DR data presently available for ITER modelling are based on an average-atom approximation. To improve upon these baseline calculations, we investigate the use of the configuration-average distorted-wave (CADW) method to calculate DR rate coefficients for complex open d-shell systems. The aim is to produce rate coefficients that are sufficiently accurate in terms of modelling, yet greatly reduced in term of computational complexity compared to level-resolved calculations. In this paper, we consider the DR of W 35 + . Initially, we carry out several large-scale level-resolved calculations for the DR associated with the 4d → 4f and 4p → 4d excitations in this ion, using both the level-resolved distorted-wave and Dirac R -matrix methods. These calculations allow us to test the validity of the CADW approach on these same excitations by comparing cross sections and rate coefficients. These comparisons demonstrate that the CADW method is relatively accurate in relation to these level-resolved methods for the temperature range for which W 35 + should exist in a collisionally ionized plasma. We then present results for CADW rate coefficients for both Δ n = 0 and Δ n = 1 excitations for this ion. This study indicates that it is now feasible to generate a much improved comprehensive set of DR data for the entire tungsten isonuclear sequence.

Electron-impact excitation and ionization of W 3+ for the determination of tungsten influx in a fusion plasma

Tungsten will be employed as a plasma facing material in the ITER fusion reactor under construction in Cadarache, France; therefore, there is a significant need for accurate electron-impact excitation and ionization data for the ions of tungsten. We report on the results of extensive calculations of ionization and excitation for W 3+ that are intended to provide the atomic data needed for the determination of impurity influx diagnostics of tungsten in several existing tokamak reactors. The electron-impact excitation rate coefficients for this study were determined using the relativistic R -matrix method. The contribution to direct electron-impact ionization was determined using the distorted-wave approximation, the accuracy of which was verified by an R -matrix with pseudo states calculation. Contributions to total ionization from excitation autoionization were also generated from the relativistic R -matrix method. These results were then employed to calculate values of ionization per emitted photon, or SXB ratios, for four carefully selected spectral lines; these data will allow the determination of impurity influx from tungsten facing surfaces. For the range of densities of importance in the edge region of a tokamak reactor, these SXB ratios are found to be nearly independent of electron density but vary significantly with electron temperature.

Single-photon single ionization of W+ ions: experiment and theory

Experimental and theoretical results are reported for photoionization of Ta-like (W+) tungsten ions. Absolute cross sections were measured in the energy range 16–245 eV employing the photon–ion merged-beam setup at the advanced light source in Berkeley. Detailed photon-energy scans at 100 meV bandwidth were performed in the 16–108 eV range. In addition, the cross section was scanned at 50 meV resolution in regions where fine resonance structures could be observed. Theoretical results were obtained from a Dirac–Coulomb R-matrix approach. Photoionization cross section calculations were performed for singly ionized atomic tungsten ions in their 5s²5p⁶5d⁴(⁵D)6s ⁶Dj.  J = 1/2, ground level and the associated excited metastable levels with J = 3/2, 5/2, 7/2 and 9/2. Since the ion beams used in the experiments must be expected to contain long-lived excited states also from excited configurations, additional cross-section calculations were performed for the second-lowest term, 5d⁵⁶Sj, J = 5/2, and for the 4F term, 5d³6s^{2 4}Fj, with J = 3/2, 5/2, 7/2 and 9/2. Given the complexity of the electronic structure of W+ the calculations reproduce the main features of the experimental cross section quite well.

Hotel W Barcelona: style department (housekeeping)

Este relatório pretende descrever a experiência proporcionada pelo estágio efetuado no departamento de Style do hotel W Barcelona, enquanto supervisor de housekeeping. Para melhor conseguir definir esta experiência, é feita uma caraterização da entidade de acolhimento, referindo os elementos diferenciadores associados à brand do hotel, assim como aspetos gerais da cadeia hoteleira a que esta está liga. Segue-se uma revisão de literatura onde é explorada a descrição do departamento de alojamento e do subdepartamento de housekeeping. Nesta revisão focam-se as funções dos vários colaboradores pertencentes ao subdepartamento, assim como os variados documentos inerentes ao decorrer da operação. Posteriormente é feita uma descrição da realidade do hotel, ao nível da área de housekeeping: relata-se as funções dos vários elementos do departamento, dando-se especial destaque à função de supervisor de andares. Refere-se quais os procedimentos e relatórios exigidos, durante a operativa do hotel. Comenta-se, também, a implementação de um sistema (REX), que visa melhorar o desempenho deste departamento. Comparando os conceitos obtidos através da revisão da literatura com a realidade do hotel verifica-se que não é fácil implementar grandes inovações, dentro da área do housekeeping, e que a forma de operar não conheceu profundas alterações nos últimos dez anos e conclui-se que este hotel estabeleceu para a operativa, procedimentos estandardizados.