Discrepancy between second and first opinion in surgical oncological patients.

PURPOSE: To prospectively describe in a population of oncological second opinion patients: (1) the outcome of routine revisions of histopathological and radiological material, (2) the frequency and extent of discrepancy between the second and first opinion and (3) the location of further treatment or follow-up. PATIENTS AND METHODS: In a population of 466 consecutive patients seeking a second opinion at the Surgical Oncology Outpatient Clinic, demographic and clinical patient characteristics were registered prospectively, as were the results of routine revision of histopathological and radiological material and the location of further treatment or follow-up. A classification system was developed to categorize the differences between the second and first opinion. RESULTS: The mean age of the 403 eligible patients was 52 years. Most patients (87%) were women, of whom 83% were diagnosed with breast cancer. Revision of histopathological and radiological material was performed in 80 and 61% of the cases, respectively, and resulted in a major change in treatment or prognosis in 3 and 2% of patients, respectively. In 317 patients (79%), the second opinion could be compared with the first opinion, resulting in an identical advise in 68%, a minor discrepancy in 16% and a major discrepancy in another 16% of patients. For further treatment 78% of patients were referred back to their first specialist. CONCLUSION: One third of patient-initiated second opinion consultations resulted in a discrepancy with the first opinion. Half of these different advise lead to major changes in therapy or prognosis.

Cancer patients seeking a second surgical opinion: results of a study on motives, needs, and expectations.

PURPOSE: To explore the sociodemographic and clinical characteristics of cancer patients seeking a second-opinion consultation and to analyze their second opinion-related motives, needs, and expectations. PATIENTS AND METHODS: In 212 consecutive patients seeking a second opinion at the Surgical Oncology Outpatient Clinic, satisfaction with the first specialist, motivation for the second opinion, need for information, preference for decision participation, and hope for and expectation of a different second opinion were assessed with a questionnaire. RESULTS: The mean age was 53 years. Most patients were women (82%), of whom 76% were diagnosed with breast cancer. Half of the patients (51%) had a low educational level. The majority of patients (62%) only had internal motives for second-opinion seeking associated with the need for reassurance and more certainty, whereas a substantial minority of patients (38%) also had external motives related to negative experiences or unfulfilled needs. The externally motivated patients had a higher anxiety disposition, were less satisfied with their first specialist, preferred a more active role in medical decision making, and more often hoped for and expected a different second opinion. CONCLUSION: Motives for second-opinion consultations differ greatly. Understanding the difference between internal and external motivation is necessary to develop strategies to prevent unnecessary second-opinion seeking. Additional studies are warranted to evaluate the objective and subjective outcomes of second-opinion consultations.

[Second Opinion Consult Clinic for Surgical Oncology in the Daniel den Hoed Clinic: analysis of the first 245 patients]. / De Tweedemeningpolikliniek Chirurgische oncologie in de Daniel den Hoed Kliniek: analyse van de eerste 245 patiënten.

OBJECTIVE: To determine the characteristics and outcome in patients visiting a surgical oncology outpatient clinic for a second opinion. DESIGN: Prospective and descriptive. METHOD: From October 1996 till December 1998, 245 patients visited the Second Opinion Outpatient Clinic of the department of Surgical Oncology of the University Hospital Rotterdam/Daniel den Hoed Cancer Centre, Rotterdam, the Netherlands. The oncological data were recorded. The patient's satisfaction with their first physician and the hospital was scored in a standardized way. Cytological, histological and radiological material was revised and discrepancies with the results from elsewhere were recorded. The results of comparing the first and second opinion were retrospectively categorized as: identical; not identical without consequences for the prognosis but with implications for the quality of life; not identical with implications for the prognosis. RESULTS: The primary tumour was breast cancer in 58% of the patients, 19% had a tumour of the digestive tract, and 23% presented with a variety of malignancies. The main problems for which the second opinion was asked were treatment (69%), diagnosis (17%) and adjuvant treatment (11%). Of all patients 53% was satisfied with the communication with the primary physician, 24% was moderately satisfied and 23% was unsatisfied. Revision of pathological and radiological material was done in 214 and 157 patients, respectively, resulting in 1% and 3% major discrepancies with therapeutical implications. The second opinion was identical to the first opinion in 53% of the patients. In 24% it was different without and in 7% with possible implications for the prognosis. In 16% a comparison of the second with the first opinion was not possible. Seventy-one per cent of the patients were referred to the primary physician, while for 21% further treatment or follow-up was done in the Cancer Centre and 8% chose to be referred to another hospital. Of patients who were satisfied or moderately satisfied with the communication with their primary physician 83% and 79% respectively were referred to the primary physician compared with 31% of those who were unsatisfied.

Quality of life assessment in Hodgkin's disease: a new comprehensive approach. First experiences from the EORTC/GELA and GHSG trials. EORTC Lymphoma Cooperative Group. Groupe D'Etude des Lymphomes de L'Adulte and German Hodgkin Study Group.

Previous reports from available trials have dealt with negative long-term sequelae in Hodgkin's disease (HD) survivors. There is, however, a lack of longitudinal data showing the correlation between outcome and various treatment-related variables and the process of re-adaptation into normal life after the end of treatment. In order to investigate the quality of life (QoL) of patients with HD in different dimensions during active treatment and follow-up and to identify longitudinal patterns of QoL dimensions during re-adaptation to normal life within the EORTC Lymphoma Cooperative Group and Groupe D'Etude des Lymphomes de L'Adulte (EORTC/GELA) and the German Hodgkin Study Group (GHSG), QoL assessment strategies were put into use over the last three to five years. Furthermore, the efforts aimed at obtaining cross-cultural comparisons between the participating countries and study groups (EORTC/GELA and GHSG). Within the randomised EORTC/GELA Trial 'H8' for clinical stage I-II HD which started in September 1993, patients receive a QoL questionnaire for completion at each follow-up visit during the first 10 years after the end of active therapy. The corresponding 'HD8' study of the GHSG employs the assessment of QoL during and after active treatment periods. Within both studies, the EORTC QLQ C30 is used for QoL assessment incorporated in the QLQ-S (quality of life questionnaire for survivors), which additionally addresses the aspects of fatigue/malaise, sexuality, specific side effects, and retrospective evaluation of treatment. In total the QLQ-S includes 45 questions on 14 functional, symptom, and fatigue scales, 15 additional single items, and 3 open questions. In addition to the longitudinal QoL assessment, the GHSG carried out cross-sectional QoL trials with all cured surviving patients from the past HD1-6 studies and a matched normal control sample employing the QLQ-S and the life situation questionnaire (LSQ), an instrument covering objective data from 45 domains of life. To date, within the trials H8 and HD8 over 3000 QoL questionnaires from more than 800 patients from ten countries are available for analysis. Replication of the psychometric properties of the scales revealed satisfactory results using factor analyses and reliability testing across languages for the QLQ-S. A feasibility analysis showed generally a good acceptance of the questionnaire by the patients and physicians. QoL assessment within international multicentre trials in HD proved feasible within the two differently organised study groups of EORTC/GELA and GHSG. The use of subjective QoL data (QLQ-S) together with objective data (LSQ) in a combined cross-sectional and longitudinal trial system will give the most comprehensive insight into the problems of the re-integration process into normal life after cure. This information will provide the basis for the development of remedies/help measures and possible modifications of treatment strategies. The current approach will be further developed in close collaboration between both trial groups, and next steps will include translation of the LSQ into other languages and adaptation to various cultural circumstances.

High-dose therapy followed by bone marrow transplantation for relapsed follicular non-Hodgkin's lymphoma. Dutch HOVON Group.

PURPOSE: To analyze whether, in addition to survival, and disease-free survival progression-free interval after transplantation would be longer than the last progression-free interval before transplantation, supporting the argument that high-dose therapy may change the biologic behavior of the disease. PATIENTS AND METHODS: Patients with a poor-risk relapsed follicular NHL were treated with three cycles of doxorubicin 50 mg/m2 and teniposide 60 mg/m2, followed by etoposide 350 mg/m2, cyclophosphamide 60 mg/kg, and TBI and unpurged BMT. RESULTS: Twelve patients were entered in the study. Ten patients fulfilled the criteria for response and underwent transplantation, two of them with an allograft. Nine of ten patients with transplants achieved a complete remission after BMT. One patient died on day 41 due to veno-occlusive disease. The nine patients with transplants who were evaluable for follow-up had a conversion of remission or response duration after transplantation, their progression-free interval after BMT being superior to the last one before BMT with a median of 1044 + days. Overall survival and disease-free survival in the transplant patients after a median follow-up of 1160 days from BMT is 90%. CONCLUSION: High dose chemotherapy followed by stem cell rescue may change the clinical course in follicular non-Hodgkin's lymphoma patients.

Preliminary results of the EORTC-GPMC controlled clinical trial H7 in early-stage Hodgkin's disease. EORTC Lymphoma Cooperative Group. Groupe Pierre-et-Marie-Curie.

In this phase III trial, 770 patients with clinical stage I-II Hodgkin's disease (HD) have been enrolled since November 1988. Preliminary results are given for the 605 (79%) patients who have completed their initial therapy. Patients were grouped according to 6 pretreatment prognostic characteristics. In the very favourable (VF) group, treatment consisted of mantle field alone. In the favourable (F) group, patients were randomized to either subtotal nodal irradiation (STNI), or 6 cycles of EBVP (epirubicin, bleomycin, vinblastine, prednisone) followed by involved-field irradiation (IF-RT). Unfavourable (U) patients were randomized to either 6 cycles of EBVP plus IF-RT, or to 6 cycles of MOPP/ABV hybrid plus IF-RT. Of the 35 VF patients, none have progressed during radiotherapy. Four patients relapsed and were salvaged. Three-year failure-free survival (FFS) was 82%; overall survival (OS) was 100%. Of the 254 F patients, 130 were treated with STNI and 124 with EBVP plus IF-RT. At 3 years, FFS rates were 81% (1 progression, 14 relapses) and 79% (5 progressions, 8 relapses), respectively. Corresponding OS rates were 99% and 100%. Of the 316 U patients, 160 received EBVP and 156 MOPP/ABV. At 3 years, FFS rates were 72% (18 progressions, 20 relapses) and 88% (7 progressions, 6 relapses), respectively (p < 0.001). Although OS rates were identical (92%), the entry in the U-EBVP arm was stopped in November 1992. We conclude that a treatment strategy based on prognostic factors allows the use of less aggressive treatment in favourable patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Late relapse in early-stage Hodgkin's disease patients enrolled on European Organization for Research and Treatment of Cancer protocols.

PURPOSE: The great majority of relapses after the treatment for early-stage Hodgkin's disease are observed within 4 to 5 years after treatment completion. This study describes the characteristics and outcome of patients who had late relapses, which was defined as relapses that occurred 5 or more years after initial treatment start. PATIENTS AND METHODS: A total of 1,082 adult patients with early clinical stage Hodgkin's disease were enrolled on three consecutive European Organization for Research and Treatment of Cancer (EORTC) protocols (H1, H2, and H5 trials) from 1964 to 1981. Of these, 1,044 patients satisfied the eligibility criteria with a supradiaphragmatic localization, age greater than 15 years, and initial complete remission. Overall, 341 patients (32.6%) relapsed, 304 (29.1%) early and 37 (3.5%) late. For each of these 37 late relapsers, questionnaires were sent to the participating centers and detailed information for 34 relapses was obtained. Cumulative probabilities for developing a late relapse were estimated using the Kaplan and Meier method. Quantification of the relationship between late relapse and several confounding variables was performed using the Cox's proportional hazards model. RESULTS: The 10- and 15-year cumulative probabilities of late relapse in patients who were disease-free at 5 years were 4.8% and 8.3%, respectively. Patients treated on more recent protocols had a higher incidence of late relapse, possibly due to an attempt to tailor therapy to the specific prognostic factors (10-year cumulative probabilities, 4.6%, 2.6%, and 7.5% in trials H1, H2, and H5, respectively). Incidence of late relapses significantly correlated with male sex, B symptoms, mediastinal involvement, and treatment modality. Salvage treatment induced a complete response in 27 patients (79%) and a prolonged complete remission in 24 patients (71%). Twenty years after initial treatment start, similar overall survival rates were observed for late relapsing (72%) and nonrelapsing patients (75%). CONCLUSION: Late relapses of Hodgkin's disease are uncommon, but may be more frequent with recent protocols tailored to specific prognostic factors. If treated, their outcome is favorable. Late relapse is therefore another factor indicating that careful, long-term follow-up is needed for patients with Hodgkin's disease.

The contribution of routine follow-up mammography to an early detection of asynchronous contralateral breast cancer.

The role of routine mammography was assessed in the early detection of asynchronous contralateral breast cancer (ACBC). The breast cancer patient populations of two cities, Nijmegen and Eindhoven, The Netherlands, which were subjected to a well-defined follow-up program, were compared. The program consisted of regular physical examination and annual mammography in Nijmegen and physical examination only in Eindhoven. From 1975 until 1987, 24 ACBC patients were detected within a group of 880 breast cancer patients in Nijmegen (3%) and, from 1971 until 1984, 14 ACBC patients within a group of 411 patients in Eindhoven (3%). In Nijmegen, eight of the 23 evaluable patients (35%) had a contralateral tumor with a histologic size smaller than 10 mm or an in situ carcinoma, compared with one of the 14 of the Eindhoven patients (7%), whereas 18 of the 24 (75%) versus eight of the 14 patients (57%) were node-negative. Thus annual mammography is very likely a contribution in the early detection of contralateral breast cancer as compared with follow-up by regular physical examination only.

Influence of aminoglutethimide on plasma levels of medroxyprogesterone acetate: its correlation with serum cortisol.

Postmenopausal patients with metastatic breast cancer were treated with aminoglutethimide (AG) and high-dose medroxyprogesterone acetate (MPA). Studying the interaction between the two drugs as far as plasma MPA and cortisol levels are concerned we observed a 50% decrease of plasma MPA levels after the addition of AG (P less than 0.005). With large interindividual differences in plasma MPA levels, a significant correlation with serum cortisol levels was found (P less than 0.001). It can be concluded that AG leads to a lowering of plasma MPA levels to such an extent that its adrenal suppressive effect may be diminished or even abrogated. In future trials of MPA with or without AG correlations between plasma MPA levels, serum cortisol levels and treatment response should be taken into account.

Amitriptyline plus fluphenazine to prevent chemotherapy-induced emesis in cancer patients: a double-blind randomized cross-over study.

In a population of 51 ambulant cancer patients treated with doxorubicin-containing chemotherapy we conducted a double-blind cross-over randomized trial, comparing the anti-emetic efficacy of a combination of amitriptyline (25 mg p.o. q 6 hr X 4) and fluphenazine (2.5 mg p.o. q 6 hr X 4) (AF) with that of metoclopramide (20 mg q 6 hr X 4) (M). Thirty-three out of the 51 patients vomited less than six times during treatment with AF as opposed to 26/51 with M. This difference was not significant. However, 55% of patients preferred AF to M, compared to 30% with the reverse preference (P less than 0.1). The main side-effect was drowsiness, which patients reported significantly more frequently when on AF. With both anti-emetic regimens men vomited less frequently than women. The combination of amitriptyline and fluphenazine, though theoretically attractive, did not appear to be an effective anti-emetic regimen in the dose and schedule given.