An analysis of factors determining the use of breast conserving surgery for treating early-stage breast cancer.

To determine the trend of breast conserving surgery (BCS) in West Virginia and to identify patient, hospital and surgeon factors associated with use of BCS, we conducted a study of all cases of Stage I and II invasive breast cancer treated surgically in West Virginia from 1991 through 1995 (N = 2411). These records were obtained from the State Cancer Registry. Multiple logistic regression was used to generate odds ratios (or) and 95% confidence intervals (CI) to determine factors associated with BCS. Our results showed the rate of BCS increased from 25% in 1991 to 37% in 1994 and 33% in 1995, with an overall rate of 33%. Multiple logistic regression identified the following factors associated with BCS: tumor size less than 1 cm (or = 1.47, 95% C1 = 1.4, 1.5), hospital bed size > 300 beds (or = 1.3, 95% C1 = 1.05-1.6) and a surgeon who had graduated from medical school since 1981 (or = 1.2, 95% C1 = 1.0, 1.36). We conclude the rate of BCS in West Virginia still remains low and that the women least likely to have BCS were women with tumors > 2 cm treated at small hospitals by older physicians.

Competencies and concerns in end-of-life care for medical students and residents.

A palliative medicine comfort-confidence survey developed by Weisman et al was utilized to assess self-reported competence and comfort with four end-of-life dimensions and determine future educational preferences. The survey was completed by 3rd and 4th year medical students (M3 and 4) and residents PGY 1-5. Self-reported competence increased with level of training. All trainees indicated the least comfort with 1) discussing home-hospice referrals; 2) conducting a family conference; 3) discussing the change from curative to comfort care; and 4) discontinuing i.v. hydration in a dying patient not taking oral nourishment. When withdrawing parenteral antibiotics from a non-decisional dementia patient with sepsis at the request of his legal guardian, M3 and 4 expressed a greater concern for violating medical practice standards while PGY4 and 5 showed a greater concern for the violation of personal religious or ethical beliefs. Pain management, pain assessment, hospice care and end-of-life communication where the most requested topics for future education.

The STAR (Study of Tamoxifen and Raloxifene) trial in West Virginia.

Female breast cancer is a major medical problem with significant public health ramifications. In 1999, more than 170,000 women were diagnosed with breast cancer in the U.S. and more than 40,000 died from this disease. The STAR trial will determine if raloxifene (Evista) is either more or less effective than tamoxifen (Nolvadex in reducing the incidence of invasive breast cancer in postmenopausal women who are at increased risk for the disease. A secondary goal is to compare raloxifene and tamoxifen with regard to their side effects. Approximately 22,000 postmenopausal women, 35 years of age or older, who are at increased risk for developing breast cancer will be randomly assigned in this double-blind trial to receive either 20 mg of tamoxifen plus a placebo or 60 mg of raloxifene plus a placebo, for five years. A substudy to evaluate the effect of raloxifene and tamoxifen therapy on study participants' quality-of-life will also be conducted.

Breast cancer risks and prevention: implications of the Breast Cancer Prevention Trial results.

Breast cancer is a major health concern for women in the U.S. Several factors determine a woman's risk for developing breast cancer including age, genetics, hormonal exposure and others. It is possible to estimate a woman's risk for developing breast cancer by using a statistical model known as the Gail model. Using this model, the Breast Cancer Prevention Trial (BCPT) found that women at high risk for breast cancer could have their incidence of breast cancer reduced by 49% by taking tamoxifen. The serious side effects of tamoxifen therapy were almost exclusively seen in women over age 50. Women under 50 with a high risk of breast cancer are, therefore, most likely to benefit from taking tamoxifen for five years. Thus, a benefit-to-risk estimate should be made for each woman before advising her to take tamoxifen. A new trial (Study of Tamoxifen And Raloxifene, STAR) will compare tamoxifen with raloxifene for their effectiveness in reducing breast cancer and for side effects. West Virginia women participated in the BCPT and will be able to participate in the STAR trial through centers in Morgantown and Charleston.

Acute profound thrombocytopenia following C7E3 Fab (Abciximab) therapy: case reports, review of the literature and implications for therapy.

Platelets play a crucial role in the ischemic complications of percutaneous coronary procedures. The recent availability of C7E3 Fab (Abxiximab or ReoProtrade mark), a chimeric monoclonal antibody Fab fragment directed against the platelet glycoprotein IIb/IIIa receptor, has reduced abrupt closure and other adverse events and lessened the need for revascularization procedures. As the use for this drug has increased, rare cases of severe thrombocytopenia have been revealed. From August 1995 to June 1997, 452 patients at Charleston Area Medical Center who underwent percutaneous coronary revascularization procedures and were treated with abciximab were evaluated for the development of severe thrombocytopenia (i.e., platelet count less than 20,000 within 48 hr of treatment). A review of published reports of severe thrombocytopenia was also reviewed. A review of published reports of abciximab-induced severe thrombocytopenia, as well as our three cases, reveals that: 1) the incidence is less than 0.7%; 2) the nadir platelet count (range 1, 000-16,000) was noted within 2-31 hr after abciximab infusion; 3) the platelet count increases to greater than 100,000 within 12 days in all patients; 4) bleeding episodes were treated with platelet transfusion with an improvement in platelet count within 24 hr in all patients in whom they were given; and 5) in the one patient treated with gamma globulin alone, no significant rise in platelet count was noted. Acute severe thrombocytopenia can occur after ReoProtrade mark administration. Its development is not predictable and may occur within 2 hr of administration. Thrombocytopenia, therefore, requires consideration in every patient treated with this drug. It appears prudent to obtain a platelet count 2 hr after initiating ReoProtrade mark. If thrombocytopenia develops, then the drug can be stopped in a timely manner and platelet transfusion can be given.

Surveillance testing in patients with primary malignant melanoma.

There are, at this time, no fully published prospective randomized studies of follow-up strategies for patients with primary malignant melanoma. However, four recent retrospective studies indicated that greater than 90% of melanoma recurrences were detected by history and/or physical examination, and that detection of recurrent melanoma by blood tests, chest X-ray, or CT scan rarely led to long-term survival. Based on the results of the above studies, recommendations for follow-up as developed by the National Institute of Health Consensus Panel on Early Melanoma can be considered. These include: 1) history and physical examination (including total body skin examination) at regular intervals; 2) the consideration of initial screening for first degree family members of patients with melanoma; and 3) on-going education for patients to recognize the signs of local and regional recurrences.

Conventional dose melphalan is inactive in metastatic melanoma: results of an Eastern Cooperative Oncology Group Study (E1687).

Despite reports that i.v. melphalan is active in the settings of conditioning regimens utilizing high-dose chemotherapy for autologous bone marrow transplantation and in isolated limb perfusion for the treatment of malignant melanoma, its activity at conventional doses has never been defined in this disease. We conducted a phase II study of conventional-dose i.v. melphalan (30 mg/m2) in 17 patients with metastatic melanoma. All patients were previously untreated with chemotherapy with performance status 0, 1 or 2. Forty-seven cycles were given with a median of two cycles. One patient was not evaluable due to early death. There were no responses in the 16 patients, resulting in a 0% response rate (95% confidence interval = 0-17%). We conclude that conventional-dose melphalan by i.v. administration has no appreciable activity in patients with metastatic malignant melanoma.

The treatment of breast cancer in the elderly: a community hospital experience.

The physician's dilemma in choosing the optimal management for breast cancer in the elderly arises from long-held beliefs that elderly patients 1) have a limited life expectancy from comorbid conditions other than breast cancer and 2) do not tolerate standard treatment. To determine if these beliefs were indeed reflective of the clinical behavior of breast cancer in the elderly, we reviewed the hospital and tumor registry records of 182 women age 70 years and older who received treatment for locoregional invasive breast cancer (Stage I and II) at CAMC between 1977 and 1987. The median time interval between diagnosis and last contact or death was 82 months. Actuarial survival was calculated on the basis of this interval Statistical Analysis System (SAS). Eighty-five percent of patients underwent mastectomy and 15% had breast conservation surgery. There was only one postoperative death. Forty-eight (26%) of 182 patients received systemic adjuvant therapy. The breast cancer-specific survival rate of all patients in this study was 84% at five years and 71% at 10 years. The 5-year and 10-year breast cancer specific survivals were 94% and 86% for stage I patients respectively and for stage II patients the five-year and 10-year survivals were 74% and 56% respectively. Our results indicate that the majority of elderly women with breast cancer can tolerate standard surgical therapy and survive disease-free for many years.

Attitudes about cancer pain: a survey of 727 health care professionals in West Virginia.

To assess the attitudes of health care professionals in West Virginia about cancer pain, we utilized an 11-item questionnaire developed by DeWiessman and T.L. Dahl. We administered this questionnaire to 727 health care professionals and chi-square tests were used to assess correlations between attitudes on cancer pain and demographic characteristics (e.g. age, family history of cancer, sex, etc.). The majority of respondents believed that greater than 60% of cancer patients experience pain and that most patients were undermedicated with respect to pain. Age and having a family member with cancer were the major factors affecting attitudes. Respondents less than 46 years old compared to those 46 or older, were more likely to believe that most cancer patients were undermedicated; that addiction to narcotics is rare; and that the patient is the best judge of cancer pain intensity. Respondents with a family member with cancer were less likely to be concerned about addiction if a family member is given morphine. We conclude that educational efforts should be directed at altering attitudes regarding cancer pain in individuals age 46 years or older and those without a family history of cancer.

Surveillance testing in patients with early stage breast cancer: a review.

The optimal breast cancer surveillance testing program for early-stage breast cancer patients has not yet been defined. The results of three surveys evaluating patterns of follow-up have indicated that most physicians practice some level of routine surveillance testing (history, physical examination, and yearly mammogram), but there is extreme variation in follow-up practices from physician to physician, especially in the use of blood tests, bone scan, and chest X-ray. The results of numerous retrospective studies and two large randomized prospective studies have indicated that: 1) most recurrences are detected by the history and physical exam; and 2) intensive surveillance testing of asymptomatic patients does not improve overall survival. Several studies on the psychosocial impact of follow-up testing have indicated that: 1) patients desire frequent follow-up visits; 2) patients undervalue the clinical exam and overestimate the value of laboratory and X-ray studies in detecting recurrences.

Survival in patients with invasive breast cancers less than one centimeter.

This article describes our study of the long-term outcomes for 115 women with minimally invasive breast cancer (i.e. < 1 cm) who were treated at Charleston Area Medical Center from 1973-1988. Our goals in initiating this study were to find out whether or not minimally invasive breast cancer (MIBC) is curable by local modalities and if there are subgroups with MIBC that have a lower survival rate. We conclude that the curability of MIBC is quite high with effective locoregional treatment. However, even in patient with such small tumors, 20% will recur. Additional markers are needed to differentiate high and low-risk patients in order to select who might benefit from adjuvant systemic therapy.

Diffuse malignant pleural mesotheslioma at CAMC: a retrospective study of 50 patients.

The cases of 50 patients who were treated for pleural diffuse malignant mesothelioma at Charleston Area Medical Center from 1966-1992 were reviewed retrospectively. Diagnosis was most often made by thoracoscopy or exploratory thoracotomy; pleural cytology was rarely contributory. The delay in diagnosis was often long (median time, 2.5 months; range 1-12 months). The median survival was only 6 months. Six clinical variables were analyzed for prognostic significance. Multivariate analysis showed that stage of disease, age, histology, and smoking history were the most important prognostic factors. Previous asbestos exposure was found in 74% of the patients. There was no cure of mesothelioma, and we did not find any significant differences in survival among groups of patients subjected to the different therapeutic measures. If new active therapies are identified, it would be useful to compare them to a best supportive care arm in order to demonstrate the value of any new therapeutic approach.

Long-term trends in cancer mortality rates for West Virginia.

Using data on death certificates, we examined age-adjusted cancer mortality rates for West Virginia men and women from 1980-1994. The leading causes of cancer deaths among men in the state in 1994 were cancers of the lung, prostate, colon, and pancreas, and non-Hodgkin's lymphoma. Among West Virginia women in 1994, cancer deaths were most often due to cancers of the lung, breast, colon, pancreas, and ovary. Based on polynomial regression analyses, many of the leading cancer mortality rates significantly increased during 1980-1994. The most striking increase was a 76% rise in lung cancer mortality among West Virginia women. These mortality data underscore the continuing need for tobacco control and other cancer control practices. Even though barriers to medical care challenge the state's health care professionals, the burden of cancer in West Virginia can be reduced by prevention, early detection, and appropriate treatment.

A review of the treatment and survival rates of 138 patients with glioblastoma multiforme.

This article reviews the cases of 138 patients at the Charleston Area Medical Center who were treated for glioblastoma multiforme (astrocytoma Grade IV) between 1966-1987. Data was obtained from the hospital's tumor registry, inpatient/outpatient records, pathology reports, as well as radiotherapy records. The median survival rate for all patients was 7 months (range 1-36 months). The median survival of the patients who underwent complete resection and received radiotherapy was 12 months, while the median survival rate was four months for patients who had complete resection but did not undergo radiotherapy. In addition, the median survival of the patients who underwent incomplete resection with radiotherapy was 10 months compared to a survival rate of 3 months of those who did not undergo radiotherapy after incomplete resection. Radiotherapy was the most significant predictor of survival with age being the major factor. Despite the clinical advancements made in the past 10-15 years, no impact has yet been achieved on the natural history of glioblastoma multiforme.

Assessment of knowledge, attitudes, and behaviors relative to cervical cancer and the Pap smear among adolescent girls in West Virginia.

BACKGROUND AND METHODS: Questionnaires assessing knowledge of, attitudes toward, and behaviors relative to cervical cancer and its prevention were administered to 279 tenth-grade girls. RESULTS: Eighty-four percent had heard of cervical cancer, and 83% had heard of the Pap smear. Sexual intercourse with multiple partners and cigarette smoking were risk factors identified by 65% and 40% of these students, respectively. Forty-eight percent reported being sexually active. This group, compared with those not sexually active, was more likely to 1) identify the Pap test as a test involving a vaginal examination, 2) use tobacco products, and 3) be exposed to tobacco smoke. The most common barriers to obtaining a Pap test reported by those sexually active were embarrassment (64%), pain/discomfort (57%), fear of cancer (27%), fear of parents discovering sexual activity (25%), and cost (13%). CONCLUSIONS: Based on the information obtained in this study, the authors recommend changes in school health programs that target adolescent girls: 1) risk factors and behavior should receive more emphasis, and 2) the pelvic examination and Pap test should be described in sufficient detail to address the issues of embarrassment, pain, and discomfort.

Late solitary cerebral metastasis from renal cell carcinoma: a case report and review of the literature.

Metastatic disease to the brain occurs in 5%-10% of cases of renal cell carcinoma (RCC). Solitary involvement of the brain is less common with a reported incidence of 0.6%-2.5% in large autopsy series. In a review of the literature, only five cases of solitary brain metastasis from RCC with a latency period greater than 10 years have been documented. In this article, we report the case of an 86-year-old white female who developed a brain metastasis 15 years after nephrectomy. As a result of our experience with this patient and a review of the literature, we conclude that in patients with a history of RCC, metastatic lesions from the primary tumor must remain in the differential when evaluating any subsequent brain lesion, as metastases may appear well over a decade after nephrectomy.

A comparison of colon cancer cases at the Charleston Area Medical Center with the National Cancer Data Base report.

This article reviews the pattern of care and outcome of colon cancer cases seen at Charleston Area Medical Center (CAMC) between 1985 and 1991, and compares these statistics to the most current National Cancer Data Bank (NCDB) study. CAMC's statistics paralleled those of the NCDB study in several ways including the fact that both studies indicated that there appeared to be stability in the age and gender distribution of colon cancer between 1985 and 1991, and there was a continued trend of proximal migration of colon cancers. Both the CAMC and NCDB studies also indicated that AJCC staging was used increasingly as the standard of cancer diagnosis, and that multimodal therapy (e.g., chemotherapy) was increasingly available to patients at greatest risk for recurrence after surgery (stage III patients). However, the CAMC study indicated that compared to the NCDB, there was a greater incidence of colon cancer in females, and that a greater percentage of stage III patients received adjuvant therapy in 1990 (35.9% and 70% in the NCDB and CAMC studies respectively).

The West Virginia Cancer Registry: historical development and preliminary results.

This article is designed to provide the medical community with an overview of the West Virginia Cancer Registry (WVCR), a population-based registry, which was established in 1993 with both federal and state funding. The WVCR is managed through the Bureau for Public Health's Division of Surveillance and Disease Control in the Office of Epidemiology and Health Promotion, and all data is confidential. The staff of the WVCR consists of a director, a cancer data supervisor, two abstractors, a secretary, and a voluntary, 13-member Cancer Advisory Committee. The initial findings of the WVCR have shown that for each 100,000 West Virginia women, 90.1 were discovered with invasive breast cancer in 1992, an increase from 86.8 in 1991. The invasive cervical cancer rate increased from 10.8 to 12.9 during this same time period. In addition, the age-adjusted death rate for cervical cancer rose from 3.6 cases per 100,000 women in 1991 to 3.8 in 1992. However, the age-adjusted death rate for breast cancer fell to 24.7 per 100,000 women in 1992, compared to 25.5 in 1991.

The management of menopausal symptoms in women with breast cancer.

The symptomatic postmenopausal woman with breast cancer presents the clinician with a difficult task with respect to hormone replacement therapy (HRT). All of the published meta-analyses have been consistent in showing that there is a slightly increased risk of developing breast cancer in those patients using postmenopausal estrogens for greater than 10 years. However, there have been no published placebo-controlled clinical trials on the effects of HRT in women with a history of breast cancer. Quality of life must be balanced against the theoretical risk of tumor promotion. Assessment of osteoporotic and cardiac risk factors (i.e., smoking, hypertension, family history, hyperlipidemia) should influence the decision. Valid alternatives to estrogen replacement include low-dose progesterones such as Bellergal or vitamin E for hot flashes, and biphosphonates, calcium, anabolic steroids, and calcitonin for osteoporosis.