Identifying the unmet supportive care needs of individuals affected by testicular cancer: a systematic review.

PURPOSE: To critically appraise studies to identify experiences of unmet supportive care needs of individuals affected by testicular cancer. METHODS: A registered priori systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. CINAHL, PsycINFO, and MEDLINE were searched for quantitative, qualitative, and mixed methods studies using a wide range of search terms. All articles were double screened according to a pre-determined eligibility criterion. Reference lists of the final included studies were checked for further eligible studies. The review process was managed using Covidence systematic review software. Data from the studies were extracted, methodological quality appraisal conducted, and a narrative synthesis conducted. RESULTS: Of the 72 papers identified, 36 studies were included. In descending order of frequency of need, psychological needs were identified in 26/36, physical needs 18/36, interpersonal/intimacy needs 19/36, health system/information needs 11/36, cognitive needs 9/36, social needs 7/36, and of equal frequencies counts of 4/36 for family, practical, and patient-clinician information needs. Only one study explored spiritual needs and no daily living needs were identified. CONCLUSIONS: The experience of needs varied in terms of frequency and distress which were commonly influenced by the age of the individual across the cancer care continuum persisting after 1-year post-treatment. IMPLICATIONS FOR CANCER SURVIVORS: When caring for individuals affected by testicular cancer, clinicians are encouraged to take a holistic lens to cancer care, particularly to explore issue or concerns that young men affected by testicular cancer might be embarrassed or reticent to discuss.

Identifying the supportive care needs of men and women affected by chemotherapy-induced alopecia? A systematic review.

PURPOSE: To systematically evaluate evidence regarding the unmet supportive care needs of men and women affected by chemotherapy-induced alopecia (CIA) to inform clinical practice guidelines. METHODS: We performed a review of CINAHL, MEDLINE, PsychINFO, Scopus, the Cochrane Library (CCRT and CDSR) controlled trial databases and clinicaltrials.gov from January 1990 to June 2019 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Twenty-seven publications were selected for inclusion in this analysis. RESULTS: Included reports used qualitative (ten) and quantitative (17) studies. Across these studies men and women reported the major impact that CIA had on their psychological well-being, quality of life and body image. Hair loss had a negative impact irrespective of gender, which resulted in feelings of vulnerability and visibility of being a "cancer patient". Men and women described negative feelings, often similar, related to CIA with a range of unmet supportive care needs. CONCLUSIONS: Some patients are not well-prepared for alopecia due to a lack of information and resources to reduce the psychological burden associated with CIA. Hair loss will affect each patient and their family differently, therefore, intervention and support must be tailored at an individual level of need to optimise psychological and physical well-being and recovery. IMPLICATIONS FOR CANCER SURVIVORS: People affected by CIA may experience a range of unmet supportive care needs, and oncology doctors and nurses are urged to use these findings in their everyday consultations to ensure effective, person-centred care and timely intervention to minimise the sequalae associated with CIA.

Clinical characteristics and outcomes of bilateral breast cancer in an Australian cohort.

PURPOSE: Uncertainty remains about the impact of bilateral breast cancer. Characteristics and outcomes of unilateral and bilateral breast cancer were compared within an Australian multi-institutional cohort. METHODS: Demographic, tumour and treatment characteristics were compared among unilateral (n = 2336) and bilateral cases (52 synchronous, 35 metachronous) using descriptive analyses. Disease-specific outcomes were investigated using Cox regression modelling to adjust for prognostic and treatment factors. RESULTS: Factors associated with increased risk of bilateral breast cancer included lobular histology (p = 0.046), family history (p = 0.025) and metropolitan residence (p = 0.006). Mastectomy was more common for bilateral cases (p = 0.001) while radiotherapy was less common (p = 0.015). Index metachronous cases were less likely to receive hormonal therapy (p = 0.001). Five-year survivals for metachronous, synchronous and unilateral cases were 79%, 88% and 94%, respectively. Poorer outcomes remained after adjusting for prognostic factors [HR = 2.26, 1.21-4.21]. CONCLUSION: Our results confirm international findings indicating worse outcomes from bilateral compared with unilateral breast cancer.

A systematic review of the effectiveness of magnetic resonance imaging (MRI) as an addition to mammography and ultrasound in screening young women at high risk of breast cancer.

Breast magnetic resonance imaging (MRI) has been proposed as an additional screening test for young women at high risk of breast cancer in whom mammography alone has poor sensitivity. We conducted a systematic review to assess the effectiveness of adding MRI to mammography with or without breast ultrasound and clinical breast examination (CBE) in screening this population. We found consistent evidence in 5 studies that adding MRI provides a highly sensitive screening strategy (sensitivity range: 93-100%) compared to mammography alone (25-59%) or mammography plus ultrasound+/-CBE (49-67%). Meta-analysis of the three studies that compared MRI plus mammography versus mammography alone showed the sensitivity of MRI plus mammography as 94% (95%CI 86-98%) and the incremental sensitivity of MRI as 58% (95%CI 47-70%). Incremental sensitivity of MRI was lower when added to mammography plus ultrasound (44%, 95%CI 27-61%) or to the combination of mammography, ultrasound plus CBE (31-33%). Estimates of screening specificity with MRI were less consistent but suggested a 3-5-fold higher risk of patient recall for investigation of false positive results. No studies assessed as to whether adding MRI reduces patient mortality, interval or advanced breast cancer rates, and we did not find strong evidence that MRI leads to the detection of earlier stage disease. Conclusions about the effectiveness of MRI therefore depend on assumptions about the benefits of early detection from trials of mammographic screening in older average risk populations. The extent to which high risk younger women receive the same benefits from early detection and treatment of MRI-detected cancers has not yet been established.

Knowledge of treatment intent among patients with advanced cancer: a longitudinal study.

Increasingly, patients with cancer wish to be more fully informed about their disease, treatment and prognosis, and to participate in decision making. The objective of this study was to assess knowledge of diagnosis and goals of treatment among patients with advanced cancer, and also to assess whether this knowledge changed over time. A cohort of 181 subjects with advanced cancer receiving palliative therapies were interviewed at entry and again 12 weeks later. Knowledge of disease diagnosis, treatment intent, and the main sources of information were determined. Twenty per cent of subjects considered their illness to be non-life threatening, and 46% correctly perceived treatment intent as non-curative; 29% believed the intent of treatment was cure. Subjects resident in rural areas were more likely to misunderstand the goal of their treatment. Treatment modality was significantly associated with knowledge of treatment intent, and subjects in the last 6 months of life had clearer understanding that treatment intent was non-curative. Many patients with advanced cancer do not understand the goals of treatment. Excessive optimism may lead to impaired decision making. Further empirical research into information transfer and predictors of accurate patient understanding would assist clinicians in their discussions of prognosis and potential treatment outcomes with patients.

Implementing clinical practice guidelines: a community-based audit of breast cancer treatment. Australian Capital Territory and South Eastern New South Wales Breast Cancer Treatment Group.

OBJECTIVE: To improve breast cancer management by facilitating implementation of treatment guidelines. DESIGN: A prospective, longitudinal study (developed by clinicians and consumers) of all patients with newly diagnosed breast cancer. Four locally agreed breast cancer management guidelines were established (based on 1995 National Health and Medical Research Council guidelines) as practice indicators. SETTING: Breast cancer treatment facilities and medical practices in the Australian Capital Territory and South Eastern New South Wales, May 1997 to July 1998. MAIN OUTCOME MEASURES: Actual treatment received by patients for primary breast cancer during the study period. RESULTS: During the 14 months of the study, 19 clinicians registered 221 new patients with a proven diagnosis of breast cancer. Of 191 women with localised invasive breast cancer, 112 (59%) had tumours 2 cm or less in diameter. Axillary surgery in 173 (91%) of these women showed 107 (56%) had no axillary lymph node involvement. Of 87 women treated with breast-conserving surgery for locally invasive cancer, 85 (98%) also received postoperative radiotherapy. Some form of systemic adjuvant therapy was indicated in 99 women (axillary nodes positive or tumours > 2 cm diameter) and this treatment was received by 95 (96%). All 27 women aged under 50 years with node-positive disease received adjuvant chemotherapy. CONCLUSIONS: Enhancing uptake of breast cancer management guidelines is feasible at a regional level with an audit program and broad support among clinicians and consumers.

Concurrent validity of the modified Edmonton Symptom Assessment System with the Rotterdam Symptom Checklist and the Brief Pain Inventory.

As part of a longitudinal prospective study we sought a self-completed instrument of symptom assessment suitable for a population of cancer patients who were receiving palliative therapy. The modified Edmonton Symptom Assessment System (ESAS) is such an instrument, but it required validation for this population. This study represents a validation of the modified ESAS with the Rotterdam Symptom Checklist and the Brief Pain Inventory--two instruments widely used in patients receiving palliative therapy for cancer. We conclude that the modified ESAS is a valid, self-administered instrument to assess symptoms for patients from differing palliative care settings.

MDR1 and MRP expression in chronic B-cell lymphoproliferative disorders.

The role of the MDR1 and MRP genes in drug resistance in patients with chronic lymphocytic leukaemia (CLL)/non-Hodgkin's lymphoma (NHL) is unclear. We hypothesized that any relationship between levels of expression and exposure to P-glycoprotein (P-gp) transportable drugs may become evident by using a measure of gene expression that combined the number of positive cells and the degree of positivity. 68 CLL/NHL patients were analysed using flow cytometry with MDR1 and MRP specific antibodies and were divided into subgroups, untreated (n = 31). treated with non P-gp transportable drugs (n = 26), those treated with low total doses of P-gp transportable drugs (n = 6) and patients treated with high total doses of P-gp transportable drugs (n = 5). The group exposed to high doses of P-gp transportable drugs had higher levels of MDR1 expression when compared to all other groups (P<0.05, ANOVA). A positive correlation between the level of MDR1 expression and the cumulative dose of P-gp transportable drugs was demonstrated (P=0.02). MRP expression was higher in those patients exposed to high doses of P-gp transportable drugs when compared to all other groups (P<0.05. ANOVA), although only a trend towards a linear dose correlation effect could be established (P=0.08). We concluded that MDR1 and MRP are involved in drug resistance but only in patients treated with P-gp transportable drugs.

Stereotactic and ultrasound core needle breast biopsy performed by surgeons.

BACKGROUND: The authors evaluated outcomes and treatment costs of stereotactic core needle biopsy (SCNB) and ultrasound core needle biopsy (UCNB), and needle localization biopsy (NLB) in managing patients with mammographic abnormalities presenting to the surgeon. METHODS: Data for all patients with mammographic lesions who underwent SCNB or UCNB since their introduction at this institution were prospectively collected over 17 months. Mean inclusive costs of the three procedures were accumulated and compared. RESULTS: Stereotactic core needle biopsy was performed for 342 lesions in 319 women, for a malignancy rate of 19%; UCNB was performed for 157 lesions in 144 patients, yielding a malignancy rate of 17%. With a mean follow-up of 13.5 months, 1 patient with in situ carcinoma was diagnosed late. Absolute cost savings for the period studied was $721,963. CONCLUSIONS: Minimally invasive breast biopsy procedures can safely and reliably be performed by surgeons in clinical practice with increased patient convenience and decreased costs.

Surgical management of breast cancer in Australian women in 1993: analysis of Medicare statistics.

OBJECTIVE: To examine patterns of surgical management of breast cancer among Australian women. DESIGN: Retrospective survey of Medicare records (a national dataset of all services rendered on a "fee-for-service" basis for which a Medicare benefit has been paid). PATIENTS: All Australian women (4683) who underwent surgery consistent with being for breast cancer in 1993 and for which Medicare benefits were paid. MAIN OUTCOME MEASURES: Proportions of women undergoing different forms of mastectomy, breast-conserving surgery and axillary surgery by patient age and State and region (urban or rural) of residence. RESULTS: Modified radical mastectomy was the most common surgery, performed in 2097 of the 4683 women (44.8%), while 1868 (39.9%) had breast-conserving surgery. Frequency of breast conservation decreased significantly with age and varied significantly between States and region of residence. It ranged from 34% in Western Australia to 49% in South Australia and the Northern Territory, and from 34% among rural women to 42% among urban women. Axillary surgery was recorded for 83% of all women studied. CONCLUSIONS: There was substantial geographical variation in patterns of surgical management for breast cancer. The tendency for rural women to undergo mastectomy rather than breast-conserving surgery may reflect the relative lack of access to postoperative radiotherapy. We are unable to explain the variation between States.

Lymphangitis carcinomatosa complicating primary malignant peritoneal mesothelioma.

A patient with malignant peritoneal mesothelioma and a diffuse pulmonary infiltrate is described. Computed tomographic scanning suggested lymphangitis carcinomatosa. This was confirmed on transbronchial biopsy to be due to metastatic mesothelioma.

An open multicentre study of tropisetron for cisplatin-induced nausea and vomiting.

OBJECTIVES: (i) To assess the efficacy and tolerability of tropisetron when used for acute and delayed cisplatin-induced emesis. (ii) To investigate whether dexamethasone added to tropisetron improves the control of emesis for patients who do not achieve a complete response to tropisetron alone. (iii) To assess sex of the patient and alcohol intake as prognostic factors for nausea and vomiting. DESIGN: A prospective open label phase II trial over one or two cycles of chemotherapy. Data collection was based on observed response and patients' self-reporting. SETTING: Twenty Australian tertiary care hospitals in 1994. PATIENTS: 102 male and female patients from 18 to 75 years with histologically confirmed malignancy receiving their first chemotherapy containing > or = 50 mg/m2 cisplatin. INTERVENTION: In Cycle 1 tropisetron 5 mg was given intravenously before chemotherapy on Day 1, then 5 mg orally before breakfast on Days 2 to 6. In Cycle 2, dexamethasone 20 mg intravenously on Day 1, then 8 mg orally on Days 2 to 6 could be added to tropisetron if a complete antiemetic response had not been achieved in Cycle 1. MAIN OUTCOME MEASURES: Number of vomiting episodes and severity of nausea for 6 days after chemotherapy; severity of side effects; patient satisfaction with chemotherapy treatment; oestradiol levels in women; and past alcohol consumption in men and women. RESULTS: (i) The complete response rate (CR) for acute emesis in Cycle 1 was 64% (95% confidence interval [CI], 54%-72%), with 84% (95% CI, 76%-90%) having < or = 2 vomits. The CR for delayed emesis was 24% (95% CI, 17%-32%). The CR for acute nausea was 56% (95% CI, 47%-66%), with 97% (95% CI, 91%-99%) having < or = 2 nausea episodes. The CR for delayed nausea was 21% (95% CI, 14%-30%). Seventy-one patients received Cycle 2. The main side effects were headache (20 patients) and constipation (16 patients). The control of acute emesis was rated as "good" or "very good" by 68% of investigators; 85% rated the tolerability of treatment as "good" or "very good". Treatment was rated as "very satisfactory" or "satisfactory" by 52% of patients. (ii) The CR for acute emesis with dexamethasone added was 78% (95% CI, 64%-88%). (iii) Women with lower oestradiol levels had better control of emesis, although this difference was not statistically significant. Chronic alcohol intake and binge drinking were strongly associated with a complete acute antiemetic response. CONCLUSIONS: Tropisetron was effective for acute cisplatin-induced emesis; adding dexamethasone enhanced this response. Both single and combined therapy had less effect on delayed emesis. The impact of alcohol on control of emesis is a chronic rather than acute phenomenon which requires prospective testing.

Hickman catheters: left-sided insertion, male gender, and obesity are associated with an increased risk of complications.

BACKGROUND: Semipermanent tunnelled silicone rubber Hickman catheters are widely used to provide durable central venous access for patients with cancer or haematological disease. AIMS: To document the frequency and severity of Hickman catheter related adverse events and to identify predisposing factors. METHODS: A retrospective review was undertaken of 153 sequential Hickman catheters inserted into patients receiving treatment for cancer or haematological disease. All Hickman catheters were inserted percutaneously in a radiology department under local anaesthesia and fluoroscopic control. The exact position of the catheter tip was determined by reviewing post-insertion radiographs. RESULTS: The median duration of catheter use was 55 days (range one-650). Complications led to the removal of 32% of catheters. Exit site infection complicated 22% of catheters, septicaemia 7%, migration or dislodgment 7%, and venous thrombosis 8%. Complications were more common in male patients (exit site infection and catheter loss), in patients with acute leukaemia (septicaemia) and in obese patients (catheter migration). Left sided catheters caused more venous thrombosis and were more likely to malfunction or block. Left sided catheters required removal more frequently than right sided catheters. Termination of the Hickman catheter within the high superior vena cava (SVC) resulted in loss of function earlier when compared to termination with the low SVC or right atrium (RA). CONCLUSIONS: Right-sided Hickman catheters terminating in the low SVC/RA offer the best chance of durable function. The use of subcutaneously tunnelled catheters in obese patients poses unique problems with catheter migration. Vigilance in the placement and care of Hickman catheters remains essential.

A case report of disseminated blastomycosis and adult respiratory distress syndrome.

Blastomycosis is a fungal disease endemic to the midwestern and southeastern United States. This is a case report of a 29-year-old woman who presented with weight loss, fever, fatigue, and pneumonia. She developed disseminated blastomycosis, adult respiratory distress syndrome (ARDS), and ulcerative skin lesions, requiring mechanical ventilation, amphotericin B, and multiple surgeries. Blastomycosis is endemic to a large portion of the United States. Family physicians should consider fungal infection in the differential diagnosis of an unresolving pneumonia.

Enhancement of tumor growth and vascular density by transfection of vascular endothelial cell growth factor into MCF-7 human breast carcinoma cells.

BACKGROUND: Vascular endothelial growth factor (VEGF) is a secreted endothelial-specific growth factor that is angiogenic in vivo. It is commonly expressed in a range of carcinomas. PURPOSE: The study was designed to investigate the effect of constitutive expression of VEGF on tumor formation by estrogen-dependent human MCF-7 breast carcinoma cells. METHODS: A full-length complementary DNA encoding the shortest isoform of VEGF (VEGF121) was stably transfected into MCF-7 cells. Transfected clones were screened for VEGF121 messenger RNA (mRNA) expression by ribonuclease protection analysis and for secretion of VEGF121 protein by Western blot analysis. Secretion of biologically active VEGF121 by transfectants was confirmed by 1) a competitive radioreceptor-binding assay, 2) stimulation of the growth of microvascular endothelial cells in vitro, and 3) potent angiogenic activity in the rabbit corneal assay. Tumor models were then established by subcutaneously implanting wild-type or VEGF121-transfected MCF-7 cells, together with either mouse BALB/3T3 clone A31 fibroblasts or human MDA-435S breast carcinoma cells, into ovariectomized nude mice either with or without a separately implanted slow-release estrogen pellet. Tumor vascularity was quantitatively assessed by capillary vessel counting after staining with the pan-endothelial marker CD31. RESULTS: Stable VEGF121-overexpressing MCF-7 cells were isolated and designated V12 cells. When implanted into the rabbit cornea, V12 cells elicited a strong directional outgrowth of capillaries. The growth rate of V12 cells in vitro was indistinguishable from that of MCF-7 wild-type cells. V12 cells formed faster growing tumors than did wild-type cells (P < .01) when xenografted subcutaneously into nude mice with either 3T3 fibroblasts or MDA-435S cells. Tumors formed from V12 cells were more vascular (P < .01) and showed a heterogeneous distribution of vessels when compared with the homogeneous distribution seen in tumors formed from wild-type cells. VEGF121 overexpression had no effect on hormone dependence or tamoxifen sensitivity of tumor formation by MCF-7 cells in mice. No macroscopic evidence for metastasis from subcutaneous implants was obtained. CONCLUSIONS: VEGF121 expression by breast carcinoma cells confers a growth advantage in vivo but not in vitro. Tumors formed by V12 transfectants were more vascular than those formed by wild-type MCF-7 cells, and we surmise that the growth advantage arises from increased tumor vascularization induced by VEGF121. IMPLICATIONS: Tumor formation by V12 cells could provide a useful model for the assessment of anti-angiogenic drugs.

Clinical prognostic significance of tumour angiogenesis.

BACKGROUND: The importance of tumour angiogenesis in the process of tumour growth and metastasis has recently gained wide acceptance. This has lead to intense investigation into the biology of tumour angiogenesis and its clinical significance. An understanding of angiogenesis may allow therapeutic modulation in order to interrupt the progression from tumourigenesis to metastatic disease and control growth of distant metastases. DESIGN: A review was undertaken of studies relating clinical outcome to the assessment of tumour angiogenesis in patients with cancer. RESULTS: Studies have been recently reported in a variety of tumours, particularly early breast cancer and melanoma. Quantitative pathology, using microvessel counting, has been the main method applied. However assessment of angiogenic growth factors may provide an alternative. In early breast cancer many studies have shown a worse prognosis for those patients with highly vascular tumours. The prognostic influence of tumour angiogenesis is independent of conventional prognostic indicators. Similar, although more varied results, have been obtained in studies of melanoma and other tumour types. CONCLUSION: Tumour angiogenesis, as assessed with quantitative pathology, is an important prognostic indicator in early breast cancer and possibly in other tumour types. Further confirmatory studies are required before this indicator is routinely used to guide treatment selection. Assessment of tumour angiogenesis will be increasingly important in the investigation of new therapies aimed at inhibiting angiogenesis or targeting tumour vasculature.

Transient diabetes insipidus following electrical burns in two patients.

We report on two healthy white men who sustained high-voltage electrical burns and were transferred to our regional burn center for specialized care. Within 24 hours of admission, both patients developed clinical signs and laboratory evidence of diabetes insipidus. With appropriate treatment, no sequelae occurred and their endocrinopathy spontaneously resolved. Diabetes insipidus following traumatic events is not uncommon; however, it has never been reported following an electrical injury.