Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women.

OBJECTIVES: To describe the effect of multidisciplinary care on survival in women treated for breast cancer. DESIGN: Retrospective, comparative, non-randomised, interventional cohort study. SETTING: NHS hospitals, health boards in the west of Scotland, UK. PARTICIPANTS: 14,358 patients diagnosed with symptomatic invasive breast cancer between 1990 and 2000, residing in health board areas in the west of Scotland. 13,722 (95.6%) patients were eligible (excluding 16 diagnoses of inflammatory cancers and 620 diagnoses of breast cancer at death). INTERVENTION: In 1995, multidisciplinary team working was introduced in hospitals throughout one health board area (Greater Glasgow; intervention area), but not in other health board areas in the west of Scotland (non-intervention area). MAIN OUTCOME MEASURES: Breast cancer specific mortality and all cause mortality. RESULTS: Before the introduction of multidisciplinary care (analysed time period January 1990 to September 1995), breast cancer mortality was 11% higher in the intervention area than in the non-intervention area (hazard ratio adjusted for year of incidence, age at diagnosis, and deprivation, 1.11; 95% confidence interval 1.00 to 1.20). After multidisciplinary care was introduced (time period October 1995 to December 2000), breast cancer mortality was 18% lower in the intervention area than in the non-intervention area (0.82, 0.74 to 0.91). All cause mortality did not differ significantly between populations in the earlier period, but was 11% lower in the intervention area than in the non-interventional area in the later period (0.89, 0.82 to 0.97). Interrupted time series analyses showed a significant improvement in breast cancer survival in the intervention area in 1996, compared with the expected survival in the same year had the pre-intervention trend continued (P=0.004). This improvement was maintained after the intervention was introduced. CONCLUSION: Introduction of multidisciplinary care was associated with improved survival and reduced variation in survival among hospitals. Further analysis of clinical audit data for multidisciplinary care could identify which aspects of care are most associated with survival benefits.

Isolation, characterization, and differentiation of thy1.1-sorted pancreatic adult progenitor cell populations.

We have isolated a novel progenitor cell population from adult rat pancreatic ducts, termed pancreatic-derived progenitor cells (PDPCs). Here, we report the in vitro culture, selection, and characterization of Thy1.1-positive and Thy1.1-negative PDPC subpopulations. These cells exhibit bipotentiality for differentiation into both pancreatic and hepatic cell types. Significantly, they express Pdx-1. Using a serum-free FGF-4-containing differentiation protocol, we have observed a time course of both morphological and gene expression changes indicative of hepatic lineage differentiation for the Thy1.1-positive subpopulation. These cells express albumin and store glycogen, typical features of mature hepatocytes. The Thy1.1-positive subpopulation could also readily be induced to differentiate into a pancreatic lineage with characteristic morphological changes resulting in three-dimensional islet-like structures and the transcriptional expression of insulin and glucagon in addition to Pdx-1. No morphological evidence of islet-like clusters was observed using the Thy1.1-negative population. However, Thy1.1-negative cells grown in pancreatic differentiation medium did show insulin gene transcription. Glucagon was not expressed in the undifferentiated Thy1.1-negative cells, nor was it induced in vitro after differentiation. The detection of Pdx-1 transcriptional expression in both populations indicates their potential as a novel source of non-beta-cell-derived insulin.

[Oncoplastic approach in breast cancer surgery--a new challenge for the future breast surgeon?]. / Onkoplasztikai szemlélet az emlorák sebészetében--új kihívás a jövo emlosebészeinek?

The future challenge of breast surgery, the so-called oncoplastic approach is reviewed in this article. The authors discuss the most frequently applied surgical techniques as well as their indications. Medline and pubmed search was carried out using the following keywords and cross-references: "oncoplastic breast surgery", "breast reconstruction", "breast conserving surgery" and "reduction mammoplasty". Original and review papers published in English language and their references were included. In the literature surprisingly, a large variety of breast oncoplastic surgical procedures has been described. Although reconstructions with local flaps are relatively easy procedures, proper indications for these are critical in order to improve cosmesis after breast conservation. Applications of pedicled flaps are technically more demanding, and only properly trained oncoplastic breast or plastic surgeons are able to provide the possibly best aesthetic outcome after mastectomy or breast conserving surgery. Finally, carrying out free flap reconstructions after mastectomy should be assigned exclusively to plastic surgeons qualified in microsurgical techniques, and not to surgical oncologists. As conclusions oncoplastic approach will be an integral element of the surgical treatment of breast cancer in the future. Breast oncoplastic training is an interdisciplinary task, which combines surgical oncological management of breast cancers with aesthetic/reconstructive breast surgery.

Quantifying tumour-infiltrating lymphocyte subsets: a practical immuno-histochemical method.

BACKGROUND: Efficient histological quantification of tumour-infiltrating T and B lymphocyte (TIL) subsets in archival tissues would greatly facilitate investigations of the role of TIL in human cancer biology. We sought to develop such a method. METHODS: Ten x40 digital images of 4 micro sections of 16 ductal invasive breast carcinomas immunostained for CD3, CD4, CD8, and CD20 were acquired (a total of 640 images). The number of pixels in each image matching a partition of Lab colour space corresponding to immunostained cells were counted using the 'Color range' and 'Histogram' tools in Adobe Photoshop 7. These pixel counts were converted to cell counts per mm(2) using a calibration factor derived from one, two, three or all 10 images of each case/antibody combination. RESULTS: Variations in the number of labelled pixels per immunostained cell made individual calibration for each case/antibody combination necessary. Calibration based on two fields containing the most labelled pixels gave a cell count minimally higher (+5.3%) than the count based on 10-field calibration, with 95% confidence limits -14.7 to +25.3%. As TIL density could vary up to 100-fold between cases, this accuracy and precision are acceptable. CONCLUSION: The methodology described offers sufficient accuracy, precision and efficiency to quantify the density of TIL sub-populations in breast cancer using commonly available software, and could be adapted to batch processing of image files.

A 1-year prospective study of individual variation in distress, and illness perceptions, after treatment for breast cancer.

OBJECTIVE: The primary objective was to conduct a detailed analysis of individual variation in psychological morbidity in the year following surgery for breast cancer. The salience of the patients' "illness perceptions" to morbidity was examined as a secondary objective. METHODS: Psychological morbidity was assessed with the General Health Questionnaire (GHQ-28) in a prospective study of 371 women having surgery for primary breast cancer. Patients also completed the Illness Perception Questionnaire (IPQ), Mental Adjustment to Cancer Scale (MAC) and the Eysenck Personality Scales (EPS). Assessments were made postoperatively and at 3, 6 and 12 months after surgery. RESULTS: Whilst descriptive statistics indicated a general reduction in mean distress over the 12-month follow-up, close analysis showed that a quarter of all patients maintained clinically significant levels of distress throughout the period. Patients with chronically elevated distress were characterised by higher levels of neuroticism, greater symptom awareness, more pain and poorer self-rated general health. In the regression analysis, psychological morbidity across the 1-year follow-up was predicted principally by the immediate postoperative state of distress, IPQ symptom awareness and the perceived time line of the illness, general health and, to a more minor extent, by neuroticism. CONCLUSION: There is marked individual variation in psychological morbidity in the year following breast cancer surgery, which is reliably predicted by the patient's immediate postoperative state of distress, her perception of the impact of the symptoms and the time line of the disease. Subgroups of patients with chronically high distress are characterised by factors including personality and negative perceptions and beliefs about their illness.