Variations in the screening history and appropriateness of management of cervical cancer in South East England.

In seven health districts in southern England, an audit of the management of cervical cancer compared with regionally developed guidelines was undertaken between 1988 and 1991. Four hundred and sixty-nine regional residents were treated in the study district hospitals. 73 (15.6%) women were appropriately staged, with increasing likelihood of appropriate staging investigations observed with higher stages (P < 0.0001) and type of hospital [Teaching 23 (21%), Non-Teaching with oncology support 11 (11.5%), Non-teaching 4 (7%), P < 0.0001] but with no change over the study period. There was no significant trend in the proportion of women treated appropriately over time, with 270 (59%) being appropriately treated, 91 (20%) under-treated and 98 (21%) over-treated overall. Appropriateness of treatment increased with higher stages (P < 0.0001) and hospital workload for cancer of the cervix (P = 0.038). Multivariable analysis indicated that survival independently and significantly decreased with age and stage, under-treatment and in cases where lymph nodes were involved or not examined. There was no change in the appropriateness of management over the 4 years, with high levels of inappropriate care. Survival was not only influenced by biological and demographic factors, but by inappropriate care.

Variations in the management and survival of women under 50 years with breast cancer in the South East Thames region.

A retrospective, population-based study was undertaken to determine variations in the management of women aged less than 50 years with primary breast cancer in different hospital settings and the influence of these variations on survival. A total of 1757 women who were resident in the South East Thames Health Region aged less than 50 years at the time of diagnosis of breast cancer and who presented during a 5 year period (January 1984 to December 1988) were recorded by the Thames Cancer Registry. The hospitals at which primary surgery was undertaken were categorised as teaching or non-teaching hospitals. The non-teaching hospitals were grouped according to the mean number of patients treated annually during the study period (< or = 2, 3-9, > or = 10 each year). The following factors were compared between these groups: age, extent of disease, tumour morphology, extent of primary surgery (mastectomy vs less than mastectomy), use of axillary surgery (any vs none) and use of systemic adjuvant therapy. Survival rates for the different groups were compared. Registration rates did not differ significantly between health districts. A total of 1485 (85%) women underwent surgery in over 90 different hospitals. In 1324 (86%) of these cases the surgery was undertaken in a total of 42 NHS hospitals within SE Thames Health Region or in seven teaching hospitals in adjacent regions. Mastectomy rates decreased from 52% in 1984 to 28% in 1988 (P<0.0001), but were consistently higher in teaching hospitals (P=0.01). The use of any form of axillary surgery decreased from 49% to 36% over the 5 year period (P=0.003), with significantly lower rates of axillary surgery being performed in non-teaching hospitals (P<0.0001). The proportion of cases recorded as having non-specific morphology was higher in nonteaching than in teaching hospitals (P<0.0001). On multivariate analysis survival was significantly (P<0.001) influenced by stage and tumour histology. Among patients who underwent surgery, the type of hospital in which this was undertaken did not appear to influence survival significantly. This analysis of routine cancer registry data indicates that patients were widely dispersed in a large number of different hospitals and that there were marked variations in practice according to the type of hospital to which patients presented. The treatments provided were frequently at variance with those recommended at a consensus conference held during the study period, particularly in relation to the use of axillary surgery and adjuvant systemic therapy. The way in which services are currently provided may hamper the delivery of appropriate management and comprehensive support. These data thus have implications for the purchasing and provision of services for this common condition.

The reliability of Cancer Registry records.

Data from the Thames Cancer Registry were compared with data independently abstracted from medical records for 466 patients with confirmed cancer of the bladder diagnosed in 1982. High levels of agreement were observed for five continuous variables and for tumour morphology. Data concerning tumour stage did not clearly distinguish superficial from invasive tumours. Cancer registry data were found to be reliable except for tumour stage which may not be clearly documented in clinical records.

Selection for oesophagectomy and postoperative outcome in a defined population.

OBJECTIVE: To measure the extent of use of, and perioperative mortality from, oesophagectomy for carcinoma of the oesophagus, and to examine the association between oesophagectomy and long term survival. DESIGN: Retrospective cohort study of cases of oesophageal carcinoma notified to the Thames Cancer Registry. SETTING: South East Thames and South West Thames health regions. PATIENTS: 3273 patients first registered with carcinoma of the oesophagus during 1985-9, 789 of whom were excluded because of incomplete data, leaving 2484 (75.9%) for further analysis. MAIN MEASURES: Treatment of oesophagectomy, mortality within 30 days of oesophagectomy, and duration of survival from date of diagnosis to death, according to patient and tumour characteristics. RESULTS: Oesophagectomy was performed in 571(23.0%) patients. Its use decreased with increasing age (odds ratio (95% confidence interval) 0.935(0.925 to 0.944) per year) and was less common for tumours of the middle or upper third of the oesophagus than the lower third (0.56(0.42 to 0.75)). The proportion of patients undergoing oesophagectomy varied threefold among the 28 districts of residence. The perioperative mortality rate was 15.1(86/571) (12% to 18%); it increased with age (odds ratio 1.05(1.02 to 1.08) per year) and for tumours of the middle or upper third of the oesophagus compared with the lower third (2.52(1.31 to 4.84)). Long term survival was slightly higher for patients undergoing oesophagectomy (0.5% v 0.2%). CONCLUSIONS: Despite a high perioperative mortality rate patients selected for oesophagectomy showed better long term survival than those who were not, suggesting that clinical judgements used in selection were independent markers of a better prognosis. The nature of this selection needs to be more completely characterised to permit a valid evaluation of outcome of oesophagectomy.

An analysis of human oocytes and follicles from stimulated cycles: oocyte morphology and associated follicular fluid characteristics.

The aim of this study was to determine whether certain characteristics of the follicular biochemistry, previously shown by us to be associated with oocyte developmental capacity, also reflected differences in oocyte appearance, and to determine the range of oocyte characteristics induced by ovarian stimulation. A representative sample of 33 human oocytes and associated follicular fluids was obtained after a follicular growth period considered suitable for IVF. Individual follicular fluid protein and proteoglycan levels, and follicular volume were compared with the morphological characteristics of each oocyte. Oocytes which retained the germinal vesicle nuclear status after exposure to human chorionic gonadotrophin tended to occur in small follicles (less than or equal to 2 ml) and to be highly vacuolated and with characteristic predicted a low potential for cleavage. Among those oocytes which had progressed to MII nuclear maturity [in the medium (2.5-6.5 ml) and large (greater than or equal to 7 ml) volume follicles] the degree of oocyte vacuolation was negatively correlated with alpha 1-antitrypsin level, while the degree of organelle clumping was correlated with proteoglycan and immunoglobulin levels. Only five of the oocytes (15%) in this sample had follicular characteristics consistent with a normal potential for pregnancy. These MII oocytes occurred within the medium volume range, had low vacuolation levels, and a low degree of organelle clumping. In contrast, those oocytes with a low potential for cleavage based on their follicular biochemistry, showed high cytoplasmic vacuolation levels.