Drug-drug interactions with proton pump inhibitors in cancer patients: an underrecognized cause of treatment failure.

New concepts and drugs have revolutionized medical treatment for cancers. These drugs, which are very expensive and usually well tolerated, have dramatically improved cancer prognosis. We must use them wisely for patients to fully benefit. Gastric acid antisecretory drugs and particularly proton pump inhibitors (PPIs) revolutionized the treatment of gastroduodenal ulcers and severe gastroesophageal reflux, but are frequently overused for symptomatic treatment of epigastric pain or heartburn. Long-term acid suppression may alter the efficacy of many anticancer drugs, such as tyrosine kinase inhibitors (TKIs), cyclin-dependent kinase (CDK) 4/6 inhibitors and immune checkpoint inhibitors (ICIs), by either decreasing gastric acid secretion and thus drug absorption, or by modifying the gut microbiome that modulates the response to ICIs. Oncologists thus need to pay particular attention to the concomitant use of PPIs and anticancer drugs. These interactions translate into major clinical impacts, with demonstrated loss of efficacy for some TKIs (erlotinib, gefitinib, pazopanib), and conflicting results with many other oral drugs, including capecitabine and CDK 4/6 inhibitors. Furthermore, the profound changes in the gut microbiome due to using PPIs have shown that the benefit of using ICIs may be suppressed in patients treated with PPIs. As the use of PPIs is not essential, we must apply the precautionary principle. The first sentence of a recent Comment in Nature was "Every day, millions of people are taking medications that will not help them". We fear that every day millions of cancer patients are taking medications that harm them. While this may well be only association and not causation, there is enough to make us pause until we reach a clear answer. All these data should encourage medical oncologists to refrain from prescribing PPIs, explaining to patients the risks of interaction in order to prevent inappropriate prescription by another physician.

Patterns of care and outcomes of 417 patients with METAstatic SYNovial sarcoma (METASYN): real-life data from the French Sarcoma Group (FSG).

BACKGROUND: Synovial sarcoma (SS) occurs in both adult and pediatric patients. The primary aim of this study is to describe the outcomes, prognostic factors, and treatment of patients with metastatic SS within a nationwide cohort. PATIENTS AND METHODS: All pediatric and adult patients with metastatic SS are registered in the French Sarcoma Group database. Data were collected from the national database https://conticabase.sarcomabcb.org/ up to March 2020. Descriptive and comparative analyses were conducted using SAS 9.4 and Stata Special Edition 16.1 software. RESULTS: Between January 1981 and December 2019, 417 patients with metastatic SS from 17 French sarcoma centers were included, including 64 (15.3%) under the age of 26 years. Median age was 42.5 years (range 9-87 years). The metastases were synchronous (cohort 1) or metachronous (cohort 2) in 18.9% (N = 79) and 81.1% (N = 338) patients, respectively. Median overall survival (OS) from the date of metastasis was 22.3 months (95% confidence interval 19.7-24.1 months). First-line chemotherapy without ifosfamide and/or doxorubicin was unfavorable for progression-free survival and OS (P < 0.001). Concerning cohort 1, young age, surgery of the primary tumor, and single metastatic site were independent favorable prognostic factors for OS. In cohort 2, surgery within an expert French Sarcoma Group center, absence of chemotherapy in the perioperative setting, the lungs as a single metastatic site, time to first metastasis >12 months, local therapy, and ifosfamide in the first metastatic line were independent favorable prognostic factors. CONCLUSIONS: The outcome of patients with metastatic SS is influenced by local treatment, management in reference centers, and cytotoxic treatments given in the perioperative and metastatic setting.

Impact of the timing of tumor assessments on median progression-free survival in clinical trials in advanced cancer patients.

BACKGROUND: Survival-based surrogate endpoints such as progression-free survival (PFS) are commonly used in oncology clinical trials. The evaluation-time bias in the assessment of median disease progression in randomized trials has been suggested by several simulation studies, but never demonstrated in the clinic. We aimed to demonstrate the existence of potential evaluation-time bias by assessing the impact of the timing of tumor assessments on median PFS from control arms without any active treatment of randomized controlled trials involving advanced cancer patients. MATERIALS AND METHODS: A systematic literature search of English language publications from 1 January 2000 to 7 January 2021 was performed using MEDLINE (PubMed). Eligible trials for our meta-analysis included all randomized clinical trials evaluating anticancer drugs in adult patients with advanced cancers with a control arm without any anticancer drug consisting of best supportive care with or without a placebo. We performed a meta-regression analysis to analyze the correlation between the timing of the first tumor assessment and median PFS in patients randomized in the control arms without any active treatment. RESULTS: Of 3551 studies screened, 97 eligible trials were retrieved involving 36  747 patients, including 14  229 patients randomized into the control arms. A later first tumor assessment correlated with a prolonged median PFS (R2 = 0.44, P < 10-5). CONCLUSIONS: Our results confirm the existence of potential evaluation-time bias in clinical research that had been suggested by simulation studies. The timing of tumor assessments should be kept the same in precision medicine trials using the PFS ratio as an efficacy endpoint.

The relative importance of behavioral issues during long-duration ICE missions.

Previous studies of isolated and confined environments (ICEs) have been unable to assign relative priority to the many behavioral issues affecting participants. The current study analyzed psychologically relevant entries in the journals of nine leaders and physicians of French circumpolar expeditions. More than 100 specific themes emerged, distributed across 22 categories. Group Interaction was found to be the most salient of the categories, followed by Outside Communications, Workload, Recreation and Leisure, Medical Support, Adjustment, Leadership, Event, and Food. Substantial evidence of a third quarter phenomenon was found in all expeditions. Unexpectedly, shorter missions (69-180 d) generated more negative reactions than longer missions (230-363 d) and diaries from the sub-Antarctic stations were more negative than those from the Antarctic. The study provides quantitative bases for judgments concerning the relative importance of psychological issues.

[A methodological study in a space flight simulation context]. / Une etude methodologique lors d'une simulation espace.

To study the effects of isolation and confinement on small groups during long space flights, it is habitual to use closed hyperbaric ground chambers. For the first time, the European Space Agency made use of a nautral environment taking advantage of an Antarctic winter-over at the French Dumont d'Urville Station. The main objective of that study ("International Antarctic Psychological Programme"), was to compare different Russian tests used for training cosmonauts to a W. European approach validated during previous winter studies and European ground chamber simulations. Russian techniques appeared to be oriented to a narrow range of phenomena and unsuited to discern the adjustment to stress conditions.

Psychological study of a crew in long-term space flight simulation.

This research derives from a 60-day isolation study realized for the European Space Agency (ESA) as a simulation of space flights. Three goals were pursued in this study: (a) to study individual and group responses to the stress factors specific to the simulation; (b) to make a critical comparison of a variety of tools and methods used for this purpose; and (c) to express recommendations for future research. Direct methods (questionnaires, tests) and indirect methods (observation) were used in an individual and a whole group assessment. The group did not show important stress manifestations during the isolation period. It maintained its cohesion by opposing the external authority. Some tools were more efficient than others: The qualitative and indirect methods have revealed much more information than the quantitative or direct methods that reinforced one's defense to avoid criticism.

Group dynamics during the EXEMSI isolation study. Experimental Campaign for the European Manned Space Infrastructure.

The objectives of this study were to investigate the social behavior, interrelations, cohesion, efficiency and team formation of the crew during 60 days of isolation and confinement, to make a critical comparison of a variety of test methods used for this purpose and to formulate recommendations for their applications in selection, training and support for future studies of this kind. The study consisted of three phases: (1) the pre-isolation period, in which initial individual and group assessment were made to understand the motivation, characteristics, and styles of the crew members, the state of the crew, and to make a prognosis for the behavior of the group and its members, (2) the isolation period, with tests and observations to follow and analyze behavior and group dynamics of the crew, and to detect manifestations of stress, and (3) the post-isolation period with final assessment and debriefing. During these three periods individual and group tests were carried out. Direct methods, questionnaires and tests, as well as indirect methods, observations of behavior, were used. These had cognitive, affective-emotional and social components; they were quantitative, qualitative or a combination. Before isolation the crew members expressed strong confidence in the team and in their own personal capability. The leadership of the Commander seemed uncontested. Crew functioning during this period was conflict-free, but was structured in a rather rigid and defensive way (isolation of affects, denial of anxiety). Apparently, the members strongly needed to present a good image image of themselves. The relatively short period of the experiment, and the absence of real risk suggested that the crew would be able to maintain their cohesion, but in a real spaceflight situation this behavior could be inadequate and even dangerous. The pre-isolation prognosis for crew behavior during isolation was validated to a large extent. During isolation there were no clear manifestations of stress. Nevertheless, the confinement and isolation were experienced as the major stress factors. The crew members described themselves as a heterogeneous but harmonious group that was successful in their mission. In fact, the team maintained its cohesion by opposing external authority, using management as a scapegoat. Occasionally, in times of crisis, they also criticized ground crew. The Commander supported this attitude. Strongly differences in personality and behavior were noted. Analysis of the sociometric data showed that the asserted harmony was more apparent than real. It is questionable whether the group cohesion would have persisted in a life threatening crisis or even in a prolongation of the experiment. The most reliable instruments for this type of survey seem to be: group methods, non-obstructive tests, indirect instruments, and qualitative tools. The least reliable are: strictly quantitative methods, self-evaluations, standard debriefing techniques, since these reinforced in most cases subjects' defenses in an unconscious avoidance of criticism. Several recommendations were made for the organization, definition of objectives, experiment selection, crew selection, roles of external management and personnel. In particular, it is felt to be necessary to explain the aims of the mission to the subjects, to give clear and complete information, to establish confident and cooperative relations with the crew. It is essential to allow dialogue, to take opinions and suggestions of the crew seriously, and to establish clear rules of confidentiality.

The stability of psychometric performance during the International Biomedical Expedition to the Antarctic (IBEA).

A selection of tests designed to measure certain cognitive and psychomotor functions was administered to 11 subjects on an Antarctic expedition, some of whom had been preacclimatized with cold baths. No evidence was found of deterioration due to the Antarctic climate, or to the lack of preacclimatization. It was concluded that the motivation of the subjects was the crucial factor in maintaining their performance.