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Keywords:

  • dexamethasone;
  • cytarabine;
  • carboplatin;
  • childhood;
  • large cell;
  • lymphoma

Abstract

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

BACKGROUND.

The purpose of the current study was to evaluate the activity and toxicity of dexamethasone, high-dose cytarabine, and carboplatin (DAC) combination therapy in children with newly diagnosed large-cell non-Hodgkin lymphoma (NHL) and to estimate the event-free and overall survival rates achieved when DAC is incorporated into a conventional regimen.

METHODS.

From 1991 to 1997, 20 boys and 5 girls aged 4.2 to 17.7 years who had stage III (according to the St. Jude staging system) (n = 21) or stage IV (n = 4) large-cell NHL were treated in this study. DAC therapy was administered at the beginning of the induction phase in 2 sequential cycles and incorporated throughout a continuation phase (modified from the ACOP+ regimen, which features doxorubicin, cyclophosphamide, vincristine, and prednisone) with doxorubicin, cyclophosphamide, vincristine, and dexamethasone. The total duration of treatment was approximately 10 months.

RESULTS.

DAC therapy yielded a response in 22 of 25 patients (88%; 95% confidence interval [95% CI], 68%-97%): complete remission in 13 cases (52%), and partial response in 9 (36%). After additional treatment with doxorubicin, cyclophosphamide, vincristine, and dexamethasone, complete remission was attained in 18 patients (72%) and partial remission in 3 (12%). The event-free survival rate (± the standard error [SE]) was 64% ± 9% and the overall survival rate was 80% ± 8% at 5 years.

CONCLUSIONS.

The results of the current study indicate that the DAC regimen is well tolerated and effective for pediatric patients with large-cell NHL. Cancer 2008. © 2008 American Cancer Society.

The non-Hodgkin lymphomas (NHLs) of childhood are primarily high-grade lesions, as defined by the National Cancer Institute (NCI) Working Formulation.1 When classified according to the more recent World Health Organization (WHO) classification system, pediatric NHLs comprise the Burkitt, lymphoblastic, and large-cell subtypes.2 Significant progress has been made in improving treatment outcomes for children with these tumors. The most effective treatments for Burkitt lymphomas are intensive, cyclophosphamide-based (cyclophosphamide, doxorubicin, vincristine, and prednisone [CHOP])regimens given over a relatively short period (4-8 months),3-13 whereas those for lymphoblastic disease are often derived from regimens used to treat high-risk acute lymphoblastic leukemia (ALL) that feature intensive chemotherapy given over a prolonged period (18-30 months).14-20 Determining the optimal therapy for large-cell NHL has proved problematic, partly because of the biologic heterogeneity of these tumors and because of the wide spectrum of treatment strategies reported.14, 21-33 For example, in Europe treatment has been based on immunophenotype, whereas in the U.S. patients have historically been treated according to histologic findings and disease stage, regardless of immunophenotype.10, 12, 33, 34 The histology-directed treatment approach has resulted in a 50% to 70% long-term event-free survival rate for children with advanced-stage large-cell NHL14, 19, 21, 28-32 (Table 1). The histology-based treatment approaches rely heavily on anthracyclines and alkylating agents and are frequently CHOP-based regimens; however, some regimens include other agents such as methotrexate, mercaptopurine, bleomycin, and cytarabine.

Table 1. Reported Treatment Outcomes After Histology-directed Therapy for Patients With Advanced Stage, Large-cell NHL
RegimenNo. of PatientsDisease StageOutcomeStudy
  • NHL indicates non-Hodgkin lymphoma; COMP: cyclophosphamide, vincristine, methotrexate, and prednisone; FFS, failure-free survival; LSA2L2, cyclophosphamide, vincristine, prednisone, daunorubicin, cytarabine, and L-asparaginase; DFS, disease-free survival; ACOP+, doxorubicin, cyclophosphamide, vincristine, prednisone, low-dose methotrexate, 6-mercaptopurine, and L-asparaginase; APO, doxorubicin, prednisone, vincristine, and mercaptopurine; EFS, event-free survival; D-COMP, daunorubicin plus the COMP regimen; CHOP, vincristine, prednisone, cyclophosphamide, and doxorubicin; MACOP-B, methotrexate, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin; DAC+, dexamethasone, high-dose cytarabine, carboplatin, cyclophosphamide, doxorubicin, vincristine, mercaptopurine, and L-asparaginase.

  • *

    The study was a randomized trial in which no significant difference with regard to EFS was found between the COMP and D-COMP regimens.28

COMP30III and IV3-y FFS, 46%Anderson 199314
LSA2L216III and IV3-y FFS, 44%Anderson 199314
Modified LSA2L213III3-y DFS, 70%Sullivan 198519
ACOP+22III and IV4-y DFS, 67%Hvizdala 199130
APO62III and IV5-y EFS, 72% ± 6%Laver 200131
Vs    
ACOP+58III and IV5-y EFS, 62% ± 7%Laver 200131
COMP vs D-COMP*106I-III10-y EFS, 48% ± 4.9%Sposto 200128
 14IV10-y EFS, 44% 
CHOP21III and IV3-y EFS, 62% ± 11%Sandlund 199421
MACOP-B11III and IV3-y EFS, 55% ± 16%Santana 199332
DAC+25III and IV5-y EFS, 64% ± 9%Current study

We and others have demonstrated that the combination of dexamethasone, high-dose cytarabine, and cisplatin (DHAP) is active against recurrent large-cell NHL.32 In an effort to improve treatment outcome while reducing the total anthracycline and cyclophosphamide exposure, we incorporated a modified DHAP regimen into the treatment for patients with newly diagnosed large-cell NHL; we used carboplatin instead of cisplatin to minimize ototoxicity and nephrotoxicity. The combination of dexamethasone, cytarabine, and carboplatin (DAC) was administered at the beginning of the induction phase as 2 sequential courses and incorporated throughout a continuation phase modified from the ACOP+ regimen, which features doxorubicin, cyclophosphamide, vincristine, and prednisone.30 Herein we report the activity of the initial courses of DAC given during induction, as well as the treatment efficacy and toxicity of the entire treatment program.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Twenty-five children (20 boys and 5 girls ages 4.2-17.7 years) with advanced-stage large-cell NHL, as defined by the NCI Working Formulation,1 were evaluated and treated at our institution between 1991 and 1997. More recently, classification according to the WHO system was performed in cases for which there was available tissue.2 Staging workup included computed tomography (CT) imaging of the neck, chest, abdomen, and pelvis; nuclear imaging (eg, gallium scan, bone scan); bilateral posterior iliac crest bone marrow aspiration and biopsy examination and lumbar puncture for examination of cerebrospinal fluid. Upon completion of this workup, lymphomas were staged according to the St. Jude system as described by Murphy.35 The treatment protocol was approved by our Institutional Review Board and informed consent permission for treatment was obtained for all research participants or their legal guardians.

The treatment scheme, including dosing and scheduling of therapy, is summarized in Table 2. Of note, the carboplatin was delivered as a continuous intravenous infusion over 24 hours to achieve a systemic exposure (area under the curve [AUC]) of 8 mg/mL·min.36 We calculated the carboplatin dose (in mg/m2) from AUC × ([0.93 × GFR] + 15); the GFR (glomerular filtration rate, measured in ml/min/m2) was estimated from99mtechnetium DTPA (Tc99)-based serum clearance studies.

Table 2. Outline of the DAC Regimen
  • DAC indicates dexamethasone, high-dose cytarabine, and carboplatin; iv, intravenously; CI, continuous intravenous infusion; G-CSF, granulocyte–colony-stimulating factor; sc, subcutaneously; CHOD, vincristine, cyclophosphamide, doxorubicin, and dexamethasone; VAML, vincristine, doxorubicin, mercaptopurine, and L-asparaginase; im, intramuscularly; VMMD, vincristine, mercaptopurine, methotrexate, and dexamethasone; CNS, central nervous system; IT, intrathecally.

  • Therapy is administered only when the absolute neutrophil count (ANC) is ≥300 × 106/L (300/mm3) and the platelet count is >100 × 109/L (100,000/mm3) before each block.

  • *

    20 mg for children aged <5 years.

  • Area under the concentration versus time curve (AUC).

Induction: 9 wk  
Block 1 (DAC)  
 DexamethasoneDays 1-440 mg*, iv
 CytarabineDay 22 g/m2 per dose iv ×2, 12 h apart
 CarboplatinDay 1To achieve a systemic exposure of 8 mg/mL·min; CI over 24 h
 G-CSFDay 4 onward10 μg/kg per day, sc, daily
Block 2 (DAC)  
 Same as Block 1  
Block 3 (CHOD)  
 CyclophosphamideDay 1800 mg/m2, iv
 DoxorubicinDay 175 mg/m2, iv
 VincristineDay 11.5 mg/m2, iv (maximum, 2 mg)
 DexamethasoneDays 1-1412 mg/m2, iv or orally, in 3 divided doses, daily
Consolidation (VAML): 3 wk
 VincristineDay 11.5 mg/m2, iv
 DoxorubicinDay 130 mg/m2, iv
 MercaptopurineDays 1-5225 mg/m2, orally, in 3 divided doses, daily
 L-asparaginase3 times per wk (eg, every Monday-Wednesday-Friday)10,000 U/m2, im, ×6 (ie, for 2 wk)
Continuation (×3): 27 wk
Block 1 (DAC)  
 DexamethasoneDays 1-440 mg*, iv
 CytarabineDay 22 g/m2 per dose, iv, ×2, 12 h apart
 CarboplatinDay 1To achieve a systemic exposure of 8 mg/mL·min; CI over 24 h
Block 2 (VMMD)  
 VincristineDay 11.5 mg/m2, iv
 MercaptopurineDays 1-5225 mg/m2, orally, in 3 divided doses, daily
 MethotrexateDay 160 mg/m2, iv
 DexamethasoneDays 1-540 mg*, iv
Block 3 (CHOD)  
 VincristineDay 11.5 mg/m2, iv
 CyclophosphamideDay 1800 mg/m2, iv
 DoxorubicinDay 130 mg/m2
 DexamethasoneDays 1-540 mg*, iv
Prophylaxis and Treatment for CNS Involvement
 Bone marrow is positive or there are primary  tumors in the head or neckAdminister methotrexate, IT, on Days 1, 8, 22, and 43 of induction and on Day 1 of each continuation cycleDose by age: <1 y: 6 mg 1-2 y: 8 mg 3-8 y: 10 mg ≥9 y: 12 mg
 CNS is positive at diagnosisAbove plus additional doses of methotrexate, IT, on induction Days 15, 29, and 36

Response evaluation included the designation of complete response (CR) for the complete disappearance of disease and partial response (PR) as indicated by a 50% reduction in tumor size (product of perpendicular dimensions). In some cases designated as CR there were minimal diagnostic imaging abnormalities of questionable clinical significance; these have been footnoted as such in Table 3. Overall survival time was measured from the date of diagnosis to the date of death or date of last contact. Event-free survival was measured from the date of diagnosis to the date of induction failure, recurrence, death, or last follow-up examination. Overall survival and event-free survival were estimated with Kaplan-Meier methods37; the associated standard errors (SEs) were calculated by the method of Peto et al.38

Table 3. Clinical Features of 25 Children Given Treatment With the DAC Regimen
No.Disease StageSites of DiseasePathologyResponse
DACDAC + CHODRecurrenceStatus
  • DAC indicates dexamethasone, high-dose cytarabine, and carboplatin; CHOD, vincristine, cyclophosphamide, doxorubicin, and dexamethasone; DLBCL, diffuse large B-cell lymphoma; CR, complete response; A, alive; MLBCL, mediastinal large B-cell lymphoma; PR, partial response; LC-T, T-large cell; NOS, not otherwise specified; D, dead; ALCL, anaplastic large cell lymphoma; LC-B, B-large cell; NR, no response; LC, large cell.

  • *

    Incomplete resection (microscopic residual disease).

  • Emergency mediastinal irradiation administered at the time of diagnosis.

  • Treatment failure (NR or PR with progressive disease); patient was taken off study.

  • §

    Nine patients in whom diagnostic imaging revealed a minimal abnormality of questionable significance at the primary site of disease were categorized provisionally as having achieved a CR.

1IIIBones, soft tissueDLBCLCR§A
2IIILymph nodesDLBCLCRA
3IIIMediastinum, lungMLBCLPRPRMediastinumA
4III*IntestineDLBCLCRA
5IIIMediastinum, lymph nodesLC-T, NOSPRPR—-D
6IIIMediastinum, bone, pancreasLC-T, NOSCRA
7IIISkin, lymph nodes, boneALCLPRA
8IIIMediastinum, bones, lymph nodes, soft tissueALCLPRCR§Bones, lungD
9IIIMediastinum, abdominal mass, lymph nodesALCLPRCR§A
10IIIParaspinal mass, bonesALCLPRPRD
11IIIMediastinum, soft tissue, boneALCLNRD
12IIILymph nodes, pleural massALCLNR (mixed)A
13IIILung, lymph nodes, skin, bonesALCLCRA
14IVLymph nodes, bone, spleen, bone marrowALCLCR§A
15IIILymph nodes, spleenALCLCR§A
16IIILymph nodes, spleenALCLCRA
17IIILymph nodesALCLCRA
18IIIBones, mediastinum, skin, lymph nodes, kidneyALCLCRSkin, lymph nodeD
19IIIMediastinum, lymph nodesLC-B, NOSNRA
20IIIMediastinumMLBCLPRCR§A
21IVBone, mediastinum, lymph nodes, bone marrowLC-B, NOSPRCR§Mediastinum, bone, bone marrowD
22IIILymph node, bone, soft tissueDLBCLCR§A
23IIIMediastinum, lymph nodes, bonesLC, NOSCRA
24IV*BrainLC, NOSCRA
25IVMediastinum, pericardium, bone marrowLC, NOSPRCR§A

Toxicity was graded according to the NCI's Common Toxicity Criteria. Complete blood counts and blood chemistry values were checked before the initiation of each course of chemotherapy, which was delayed if the absolute neutrophil count was <0.3 × 109/L or the platelet count was <100 × 109/L. We assessed renal function by measuring serum creatinine and blood urea nitrogen concentration and by estimating the GFR from Tc99 clearance measurements. Echocardiography and electrocardiography were performed before each cycle of cyclophosphamide, doxorubicin, vincristine, and dexamethasone (CHOD) to evaluate anthracycline-induced cardiac toxicity. Audiograms were performed before each dose of carboplatin to evaluate ototoxicity. After the completion of therapy, we performed a physical examination, blood chemistry analyses, complete blood counts, and diagnostic imaging studies (as outlined above for initial staging) to evaluate remission status and treatment-related toxicity. These evaluations were made monthly for the first 6 months, every 2 months for the next 6 months, every 3 months in the second year after therapy, and annually thereafter. Echocardiograms, electrocardiograms, and audiograms were obtained annually to screen for chemotherapy-related organ dysfunction.

RESULTS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Twenty-one patients had stage III disease and 4 had stage IV disease. The clinical features, including sites of disease at the time of diagnosis, are summarized in Table 3.

Twenty-two of the 25 patients (88%; 95% confidence interval [95% CI], 68%-97%) achieved a CR (n = 13) or PR (n = 9) to the initial 2 sequential courses of DAC. With additional therapy (the CHOD regimen), some of the patients who had achieved a PR to DAC had CRs, resulting in a CR rate of 72% and a PR rate of 12%. The 5-year event-free survival rate (±SE) was 64% ± 9% (median follow-up, 9.1 years) (Fig. 1). With retrieval therapy, including autologous hematopoietic stem cell transplantation (6 patients), a 5-year overall survival rate of 80% ± 8% was achieved (Fig. 1). With respect to immunophenotype (Table 3), the 5-year event-free survival (±SE) and overall survival rates for those with B-cell immunophenotype (diffuse large B-cell lymphoma [DLBCL], mediastinal large B-cell lymphoma [MLBCL], and B-large cell, not otherwise specified [LC-B NOS]) were 63% + 16% and 88% + 11%, respectively, and for those with a non-B-cell immunophenotype (anaplastic large-cell lymphoma [ALCL] and T-large cell, not otherwise specified [LC-T, NOS]), these rates were 57% + 13% and 71% + 12%, respectively.

thumbnail image

Figure 1. Event-free survival and overall survival for 25 children treated with the DAC (dexamethasone, high-dose cytarabine, and carboplatin) regimen. The triangles denote patients who remained at risk for adverse events.

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Grade 4 hematologic toxicity was observed in 73% of patients. Overall, episodes of fever with neutropenia occurred after 1 of every 3 blocks of DAC administered. There were 4 episodes of grade 3 mucositis and grade 3 transaminase elevation and 1 episode of grade 3 hyperbilirubinemia; none of these episodes followed treatment with DAC. There was no evidence of substantial renal toxicity as shown by stable serum creatinine concentration and Tc99 clearance rates. No patients had a significant decrease in the shortening fraction on the echocardiogram. Six patients had loss of high-frequency hearing, with decreased acuity above 2000 hertz (Hz) (n = 2), 6000 Hz (n = 2), or 8000 Hz (n = 2). None of these patients required hearing amplification.

DISCUSSION

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Improving the treatment outcome for children with large-cell NHL while reducing morbidity and the risk of late adverse effects remains a challenge. Various approaches to address this problem have been investigated. For example, the former Pediatric Oncology Group piloted a regimen that incorporates intermediate-dose methotrexate and cytarabine into the APO regimen, which features doxorubicin, vincristine, and prednisone.39 The addition of intermediate-dose methotrexate and cytarabine, however, failed to significantly improve outcome.39 High-dose methotrexate and agents such as ifosfamide have been featured in successful European trials performed by the German (BFM) and French (SFOP) cooperative groups.40-45 In an attempt to find new, active drug combinations that have fewer acute and late adverse effects, we piloted the current study, in which DAC was given during both induction and continuation therapy. The CHOP component of the ACOP+ regimen is widely accepted as being active against large-cell lymphoma in adults, but to our knowledge reports of the activity of low-dose methotrexate, mercaptopurine, and L-asparaginase against large-cell NHL are lacking. Nonetheless, because these drugs were components of the successful ACOP+ regimen, we maintained their use in this regimen.

In the current study the DAC combination was very active, as shown by the 88% CR or PR rate after 2 cycles of treatment. However, after completion of the entire treatment regimen (induction, consolidation, and continuation), the 5-year event-free survival rate was 64% ± 9%, which is similar to those obtained with more conventional histology-directed, CHOP-based regimens (Table 1). Likewise, Fisher et al46 made a similar observation that the incorporation of additional agents in the treatment of large-cell NHL in adults did not improve long-term outcome over that obtained with CHOP treatment alone.

Although the inclusion of DAC in the current study did not appear to improve the event-free survival rate, it is important to note that with this regimen we achieved similar results to those obtained previously, but with lower cumulative doses of anthracycline and cyclophosphamide. Thus, DAC is a potential option for patients in whom there is a clinical indication or desire to reduce either total anthracycline (compared with APO) or cyclophosphamide (compared with ACOP+) exposure. The most severe acute toxicity associated with this DAC-based regimen was myelosuppression with associated febrile neutropenia, which occurred after approximately one-third of the DAC courses administered. For this reason, granulocyte-colony-stimulating factor was given after the first 2 courses of DAC, during induction. Rarely, grade 3 mucositis and grade 3 transaminase elevation occurred, but not after the DAC cycles. Of note, the use of carboplatin did not produce significant renal toxicity, as determined by serum creatinine and Tc99 clearance studies. A few patients developed mild ototoxicity, which resulted primarily in hearing loss involving high-frequency tones; such loss would not affect conversational speech and hearing.

Sequelae of existing CHOP-based therapy that are the most concerning include cardiac toxicity,47-56 infertility,57 and second malignancies. Cyclophosphamide and other alkylating agents result in a dose-related depletion of germinal cells that is generally more severe in males than in females. Recovery of spermatogenesis after cyclophosphamide-induced azoospermia is dose-related. Sterility is likely at cumulative doses ≥7.5 g/m2, whereas fertility is usually maintained at doses <4 g/m2.57 Our regimen prescribed a cumulative cyclophosphamide dose of 3.2 g/m2, which should permit the preservation of fertility in most patients. The Pediatric Oncology Group published the results of a study comparing APO with ACOP+ that indicated that cyclophosphamide could be eliminated if the regimen maintained a relatively anthracycline-rich backbone.31

The desire to avoid anthracycline-related cardiac toxicity is an important factor influencing protocol development in pediatric oncology patients. Whereas cumulative doses of doxorubicin of 550 mg/m2 are generally well tolerated in adults, cumulative doses of doxorubicin of 45 mg/m2 to 300 mg/m2 may cause abnormalities of ventricular after load and contractility in children.48 Factors predictive of cardiac dysfunction include a high cumulative anthracycline dose and higher intensity of anthracycline dosage, female sex, young age, use of mediastinal irradiation, and a long time interval since the completion of therapy.47, 49, 50, 53-56 All of the patients in the current study had normal cardiac function according to routine echocardiography and electrocardiography during and after completion of therapy. Our regimen prescribed a total cumulative dose of 195 mg/m2 of doxorubicin, which we anticipate will be associated with a low risk of late-onset cardiac toxicity. However, continued monitoring of cardiac function in these children is essential to evaluate delayed effects that may emerge with time.

Other groups have examined the need for anthracyclines as well as novel ways to preserve cardiac function when anthracyclines are used. The former Children's Cancer Group's randomized trial of cyclophosphamide, vincristine, methotrexate, and prednisone (COMP) versus D-COMP (daunorubicin plus the COMP regimen)(Table 1) demonstrated that the addition of doxorubicin did not improve outcome compared with that achieved with COMP alone.28 Nevertheless, as suggested by the Pediatric Oncology Group Study,31 anthracyclines remain an important class of agents in large-cell NHL treatment. Although cardioprotectants, such as dexrazoxane, may reduce cardiotoxicity in patients who receive a high cumulative dose of anthracyclines, careful monitoring of such use is recommended because of the potentially increased risk of therapy-related myeloid neoplasms.58

Previous exposure to alkylating agents, anthracyclines, epipodophyllotoxins, and radiotherapy has been associated with the development of second malignancies. For patients treated with the DAC regimen, we anticipate a low risk of treatment-related secondary carcinogenesis, because this regimen comprises relatively low cumulative doses of cyclophosphamide and doxorubicin, and does not incorporate any epipodophyllotoxins or involved-field radiotherapy. Additional follow-up of this cohort is required to establish this supposition.

Studies suggest that an immunophenotype-directed approach may be more effective in the management of large-cell NHL in children.10, 12, 41, 42, 59 In a Pediatric Oncology Group study comparing the APO and ACOP+ regimens, children with B-cell tumors had a significantly better treatment outcome than did those with a non-B-cell immunophenotype; however, the sample size in that study was relatively small.59 The French cooperative group (SFOP) reported an excellent result for the treatment of B-cell large-cell NHLs with their LMB89 regimen, which they use for all B-cell NHL, including Burkitt lymphoma.10, 42 The German BFM cooperative group, which also uses an immunophenotype-directed approach, has reported excellent results for treatment of B-cell large-cell NHL.12, 41 All 6 patients with diffuse large B-cell lymphoma in the current study (2 with mediastinal large B-cell disease), were alive and free of disease at the time of last follow-up (1 patient is in second disease remission after salvage therapy). In contrast, the 5-year event-free and overall survival in the current study for those with a non-B-cell immunophenotype was found to be 57% + 13% and 71% + 12%, respectively. Therefore, it appears that a novel or more intensive regimen may be necessary to treat the large-cell lymphomas of non-B-cell immunophenotype.

In summary, the DAC combination is active in previously untreated pediatric large cell lymphoma and the entire DAC+ regimen is effective and well tolerated. Although DAC+ did not produce a result superior to other CHOP-based regimens, the low cumulative dosages of cyclophosphamide and anthracycline should be associated with the preservation of fertility and a low rate of clinically significant cardiac toxicity, therefore making DAC a consideration in patients for whom these toxicities are of increased concern. Many of the patients who experienced treatment failure were successfully salvaged with autologous hematopoietic stem cell transplantation, resulting in an excellent overall survival rate (80% ± 8% at 5 years).

Acknowledgements

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

We thank Dr. Janet R. Davies for scientific editing, Annette Stone and Mary Green for data management, Gwen Anthony for nursing care coordination, and Peggy Vandiveer for typing the article.

REFERENCES

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES
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