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.

Lee O. Case's "Elements of the Phase Rule", Chapter 1, One component systems

One component systems are treated from the point of view of the Gibbs' phase rule.

Bayesian generalized linear models for meta-analysis of diagnostic tests

With the recognition of the importance of evidence-based medicine, there is an emerging need for methods to systematically synthesize available data. Specifically, methods to provide accurate estimates of test characteristics for diagnostic tests are needed to help physicians make better clinical decisions. To provide more flexible approaches for meta-analysis of diagnostic tests, we developed three Bayesian generalized linear models. Two of these models, a bivariate normal and a binomial model, analyzed pairs of sensitivity and specificity values while incorporating the correlation between these two outcome variables. Noninformative independent uniform priors were used for the variance of sensitivity, specificity and correlation. We also applied an inverse Wishart prior to check the sensitivity of the results. The third model was a multinomial model where the test results were modeled as multinomial random variables. All three models can include specific imaging techniques as covariates in order to compare performance. Vague normal priors were assigned to the coefficients of the covariates. The computations were carried out using the 'Bayesian inference using Gibbs sampling' implementation of Markov chain Monte Carlo techniques. We investigated the properties of the three proposed models through extensive simulation studies. We also applied these models to a previously published meta-analysis dataset on cervical cancer as well as to an unpublished melanoma dataset. In general, our findings show that the point estimates of sensitivity and specificity were consistent among Bayesian and frequentist bivariate normal and binomial models. However, in the simulation studies, the estimates of the correlation coefficient from Bayesian bivariate models are not as good as those obtained from frequentist estimation regardless of which prior distribution was used for the covariance matrix. The Bayesian multinomial model consistently underestimated the sensitivity and specificity regardless of the sample size and correlation coefficient. In conclusion, the Bayesian bivariate binomial model provides the most flexible framework for future applications because of its following strengths: (1) it facilitates direct comparison between different tests; (2) it captures the variability in both sensitivity and specificity simultaneously as well as the intercorrelation between the two; and (3) it can be directly applied to sparse data without ad hoc correction. ^

A Bayesian analysis for spatial processes with application to mapping

In geographical epidemiology, maps of disease rates and disease risk provide a spatial perspective for researching disease etiology. For rare diseases or when the population base is small, the rate and risk estimates may be unstable. Empirical Bayesian (EB) methods have been used to spatially smooth the estimates by permitting an area estimate to "borrow strength" from its neighbors. Such EB methods include the use of a Gamma model, of a James-Stein estimator, and of a conditional autoregressive (CAR) process. A fully Bayesian analysis of the CAR process is proposed. One advantage of this fully Bayesian analysis is that it can be implemented simply by using repeated sampling from the posterior densities. Use of a Markov chain Monte Carlo technique such as Gibbs sampler was not necessary. Direct resampling from the posterior densities provides exact small sample inferences instead of the approximate asymptotic analyses of maximum likelihood methods (Clayton & Kaldor, 1987). Further, the proposed CAR model provides for covariates to be included in the model. A simulation demonstrates the effect of sample size on the fully Bayesian analysis of the CAR process. The methods are applied to lip cancer data from Scotland, and the results are compared. ^

Calcareous nannofossil species richness across the Paleocene-Eocene Thermal Maximum

The Paleocene-Eocene Thermal Maximum (PETM, ~5 million years ago) was an interval of global warming and ocean acidification attributed to rapid release and oxidation of buried carbon. We show that the onset of the PETM coincided with a prominent increase in the origination and extinction of calcareous phytoplankton. Yet major perturbation of the surface-water saturation state across the PETM was not detrimental to the survival of most calcareous nannoplankton taxa and did not impart a calcification or ecological bias to the pattern of evolutionary turnover. Instead, the rate of environmental change appears to have driven turnover, preferentially affecting rare taxa living close to their viable limits.

Selección y estimación de parámetros genéticos en bovinos lecheros

La estimación de parámetros genéticos en bovinos lecheros requiere ajustar modelos estadísticos para datos longitudinales (modelos de regresión aleatoria y/o medidas repetidas). Es esencial en regresión aleatoria determinar el orden correcto de los polinomios que describen los coeficientes aleatorios en el tiempo. Tradicionalmente, esta tarea se desarrolló empleando criterios de selección como AIC o BIC, que no siempre logran dilucidar claramente el modelo apropiado. Esta tesis introduce el criterio PAL para la selección del orden del polinomio en modelos de regresión aleatoria, empleando una penalización adaptativa de la función de verosimilitud. Comparativamente, PAL presentó un desempeño superior a AIC y BIC, y su aplicación a datos de producción produjo un modelo parsimonioso, con buena bondad de ajuste y habilidad de predicción. Se abordó además el problema de estimar parámetros genéticos bajo un modelo de medidas repetidas para caracteres que muestran distribución asimétrica. Para evitar desvíos del supuesto de normalidad de los errores, se presentó un modelo alternativo basado en asumir una distribución Normal asimétrica. Se implementó un enfoque bayesiano con muestreo de Gibbs en datos de intervalos entre partos. Incluyendo un parámetro adicional, se obtuvieron estimaciones más precisas de los parámetros genéticos. Estos desarrollos metodológicos estuvieron motivados por los desafíos que enfrenta actualmente el programa de mejoramiento genético de la raza Holstein en Colombia. Entre ellos, figura también el impacto de introducir toros extranjeros provenientes del programa de selección genómica norteamericana. En este marco, se estimó el progreso genético esperado en la población comercial colombiana. Los cálculos reflejaron que utilizar toros genómicos jóvenes se traducirá en una respuesta genética acelerada y en una disminución de la diferencia genética entre el hato comercial y el núcleo del cual provienen.

Mineralogy and geochemistry of Holocene sediments from the North Atlantic

Bulk mineralogy, Sm, Nd and Pb elemental and isotopic compositions of the clay-size fraction of Holocene sediments were analyzed in three deep North Atlantic cores to trace the particle provenance. The aims of the present paper are to identify the origin of the particles driven by deep currents and to reconstruct deep circulation changes over the Holocene in the North Atlantic. The three cores are retrieved in fracture zones; two of them are located in the Island Basin along the gyre of North Atlantic Deep Water, and the third core is located off the present deep circulation gyre in the Labrador Sea. Whereas sedimentary supplies in the Labrador Sea were constantly derived from proximal sources, the geochemical mixing trends in the Iceland Basin samples indicate pronounced changes in the relative contribution of continental margin inputs over the past 6 kyr. Supplies from western European margin that sharply increased at 6 kyr were progressively diluted by a larger contribution of Scandinavian margins over the last 3 kyr. Changes in composition of the particles imply significant reorganization of paleocirculation of the deep North Atlantic components in the eastern basins: mainly reorganizations for both Iceland-Scotland Overflow Water and Norwegian Sea Overflow Water. Moreover the unusual Pb isotopic composition of the oldest sediments from the southern Iceland Basin indicates that distal supplies from Greenland margin were driven into the Iceland Basin, supporting a deep connection between Labrador Sea and Iceland Basin through the Charlie Gibbs Fracture Zone prior the Holocene Transition period.

Eocene sedimentary calcium carbonate contents and stable isotope composition of benthic foraminifera

'Hyperthermals' are intervals of rapid, pronounced global warming known from six episodes within the Palaeocene and Eocene epochs (~65-34 million years (Myr) ago) (Zachos et al., 2005, doi:10.1126/science.1109004; 2008, doi:10.1038/nature06588; Roehl et al., 2007, doi:10.1029/2007GC001784; Thomas et al., 2000; Cramer et al., 2003, doi:10.1029/2003PA000909; Lourens et al., 2005, doi:10.1038/nature03814; Petrizzo, 2005, doi:10.2973/odp.proc.sr.198.102.2005; Sexton et al., 2006, doi:10.1029/2005PA001253; Westerhold et al., 2007, doi:10.1029/2006PA001322; Edgar et al., 2007, doi:10.1038/nature06053; Nicolo et al., 2007, doi:10.1130/G23648A.1; Quillévéré et al., 2008, doi:10.1016/j.epsl.2007.10.040; Stap et al., 2010, doi:10.1130/G30777.1). The most extreme hyperthermal was the 170 thousand year (kyr) interval (Roehl et al., 2007) of 5-7 °C global warming (Zachos et al., 2008) during the Palaeocene-Eocene Thermal Maximum (PETM, 56 Myr ago). The PETM is widely attributed to massive release of greenhouse gases from buried sedimentary carbon reservoirs (Zachos et al., 2005; 2008; Lourenbs et al., 2005; Nicolo et al., 2007; Dickens et al., 1995, doi:10.1029/95PA02087; Dickens, 2000; 2003, doi:10.1016/S0012-821X(03)00325-X; Panchuk et al., 2008, doi:10.1130/G24474A.1) and other, comparatively modest, hyperthermals have also been linked to the release of sedimentary carbon (Zachos et al., 2008, Lourens et al., 2005; Nicolo et al., 2007; Dickens, 2003; Panchuk et al., 2003). Here we show, using new 2.4-Myr-long Eocene deep ocean records, that the comparatively modest hyperthermals are much more numerous than previously documented, paced by the eccentricity of Earth's orbit and have shorter durations (~40 kyr) and more rapid recovery phases than the PETM. These findings point to the operation of fundamentally different forcing and feedback mechanisms than for the PETM, involving redistribution of carbon among Earth's readily exchangeable surface reservoirs rather than carbon exhumation from, and subsequent burial back into, the sedimentary reservoir. Specifically, we interpret our records to indicate repeated, large-scale releases of dissolved organic carbon (at least 1,600 gigatonnes) from the ocean by ventilation (strengthened oxidation) of the ocean interior. The rapid recovery of the carbon cycle following each Eocene hyperthermal strongly suggests that carbon was resequestered by the ocean, rather than the much slower process of silicate rock weathering proposed for the PETM (Zachos et al., 2005; 2003). Our findings suggest that these pronounced climate warming events were driven not by repeated releases of carbon from buried sedimentary sources (Zachos et al., 2008, Lourens et al., 2005; Nicolo et al., 2007; Dickens, 2003; Panchuk et al., 2003) but, rather, by patterns of surficial carbon redistribution familiar from younger intervals of Earth history.

Planktic foraminiferal sieve size specific d13C and d18O values and maximum test diameter from ODP sites 171-1051 and 120-748

Many genera of modern planktic foraminifera are adapted to nutrient-poor (oligotrophic) surface waters by hosting photosynthetic symbionts, but it is unknown how they will respond to future changes in ocean temperature and acidity. Here we show that ca. 40 Ma, some fossil photosymbiont-bearing planktic foraminifera were temporarily 'bleached' of their symbionts coincident with transient global warming during the Middle Eocene Climatic Optimum (MECO). At Ocean Drilling Program (ODP) Sites 748 and 1051 (Southern Ocean and mid-latitude North Atlantic, respectively), the typically positive relationship between the size of photosymbiont-bearing planktic foraminifer tests and their carbon isotope ratios (d13C) was temporarily reduced for ~100 k.y. during the peak of the MECO. At the same time, the typically photosymbiont-bearing planktic foraminifera Acarinina suffered transient reductions in test size and relative abundance, indicating ecological stress. The coincidence of minimum d18O values and reduction in test size-d13C gradients suggests a link between increased sea-surface temperatures and bleaching during the MECO, although changes in pH and nutrient availability may also have played a role. Our findings show that host-photosymbiont interactions are not constant through geological time, with implications for both the evolution of trophic strategies in marine plankton and the reliability of geochemical proxy records generated from symbiont-bearing planktic foraminifera.

Growth rates and biometric measurements of coccolithophores (Coccolithus pelagicus, Coccolithus braarudii, Emiliania huxleyi) during experiments

Coccolithophores, a diverse group of phytoplankton, make important contributions to pelagic calcite production and export, yet the comparative biogeochemical role of species other than the ubiquitous Emiliania huxleyi is poorly understood. Here we examined the relative importance of E. huxleyi and two Coccolithus species (Coccolithus pelagicus and Coccolithus braarudii), in terms of daily calcite production, by culturing E. huxleyi and Coccolithus in parallel, and comparing growth rates and biometrically determined cellular carbon calcite quotas. Biometric measurements of Coccolithus species, and E. huxleyi cell diameters, were performed using polarised light microscopy. Scanning electron microscopy was used for all other biometric measurements of E. huxleyi.

Nannofossil assemblages of mid-Pliocene sediments from the equatorial Atlantic

Downcore cyclic variation in high-resolution nannofossil abundance records from mid-Pliocene equatorial Atlantic ODP Sites 662 and 926 demonstrate the direct response by several Pliocene taxa (notably Discoaster, Sphenolithus and Florisphaera profunda) to orbitally forced climatic variation. In particular, these records display strong obliquity and precessional signals reflecting primarily high latitude, Southern hemisphere changes influencing upwelling intensity and local low-latitude, insolation-driven climatic changes (via the productivity and/or turbidity influence of Amazon-sourced terrigenous material) at Sites 622 and 926 respectively. In seasonal studies of coccolithophorid assemblages, only part of the variation observed can be explained by abiotic processes, so it is perhaps not surprising that in this study few Pliocene nannofossil taxa demonstrate significant correlations with each other or with physical environmental parameters. Only some variance in nannofossil abundances can be explained by the primary controls of temperature and productivity. The rest is attributed to nonlinear responses to climatic changes; biotic processes such as grazing, predation, viral infection and competition, and/or, abiotic factors for which there is no readily available proxy (e.g. salinity). The lack of strong, consistent intra- and inter-relationships of the nannoflora and the environment reflects an ecologically complex, differentiated original community producing a complex integrated signal transmitted into the fossil record.

Benthic foraminiferal communities at DSDP Sites 94-609 to 94-611

Benthic foraminiferal assemblages from northeast Atlantic DSDP Sites 609, 610, and 611 have been interpreted with reference to modern assemblages known to be linked with the overlying bottom-water masses. It is shown that the water masses in the late Miocene to Pleistocene were similar to those of today. The distribution of the water masses changed with time, however. Antarctic Bottom Water ("AABW"), which at present is restricted to the area south of the Azores, reached as far north as the Gibbs Fracture Zone in the early Pliocene. Increased production of North Atlantic Deep Water in the late Pliocene displaced the AABW to the south