Communication about high-cost drugs in oncology--the patient view.

BACKGROUND: Many anticancer drugs are only available to Australian patients at a significant cost in the time preceding approval for government subsidy. Studies indicate that many oncologists find it difficult to discuss high-cost drugs (HCDs) with patients whom they believe are unable to afford treatment, thereby limiting treatment choices. We sought to identify the information needs and communication preferences of women with breast cancer regarding HCDs. PATIENTS AND METHODS: An e-mail invitation was sent to 317 members of Breast Cancer Network Australia. Forty-seven subjects participated in telephone interviews on the basis of a structured questionnaire regarding personal experience with HCD discussions and information preferences. RESULTS: Participants considered an out-of-pocket cost of $50/week to be a HCD. Only 28% had previously discussed HCD treatment with their oncologist; however, 96% of participants wanted to discuss an expensive drug as an option, even if they were unlikely able to afford it. CONCLUSIONS: Women with breast cancer have a strong desire to be active participants in their cancer treatment and wish to be fully informed of potential treatment options, including HCDs. Nondisclosure of information, including HCDs, can result in patient dissatisfaction.

Mineral fibre analysis and routes of exposure to asbestos in the development of mesothelioma in an English region.

OBJECTIVES: To compare the concentrations of inorganic fibres in the lungs in cases of mesothelioma and controls: to determine whether concentrations of retained asbestos fibres differ with the different exposures identified from interview; and to investigate the existence of a cut off point in concentrations of asbestos fibres that indicates occupational exposure. METHODS: Case-control study; 147 confirmed cases of mesothelioma and 122 controls identified from deaths occurring in four districts of Yorkshire between 1979 and 1991. Surviving relatives were interviewed to determine lifetime exposure history to asbestos. Mineral fibre analysis was carried out on lung tissue from postmortem examinations. RESULTS: Odds on high concentrations of retained asbestos fibres were greater in cases than controls. After excluding subjects with occupational and paraoccupational exposure, the odds on high concentrations were still greater in cases than controls, but only significantly so for amphiboles. There was only a weak relation between probability of occupational exposure to asbestos and concentrations of retained asbestos fibres, and no significant difference in fibre concentrations was found between subjects who had been exposed to asbestos through different routes: these comparisons were only based on small groups. There was considerable overlap in concentrations of retained asbestos fibres between cases and controls with and without histories of occupational exposure. CONCLUSIONS: The study has confirmed previous results of higher concentrations of asbestos fibres in cases than controls, and has shown that this is still found in subjects with little evidence of occupational and para-occupational exposure. The overlap in concentrations of retained asbestos for different groups of subjects did not suggest a clear cut of value.

Routes of asbestos exposure and the development of mesothelioma in an English region.

OBJECTIVES: To investigate the contribution of exposure to asbestos through different routes in the development of mesothelioma. METHODS: Case-control study. 185 confirmed cases of mesothelioma and 160 controls were identified, when death had occurred between 1979 and 1991 in four health districts in Yorkshire. The surviving relatives were interviewed to ascertain lifetime exposure to asbestos. Adjusted odds ratios (ORs) of exposure to asbestos (through occupational, paraoccupational, and residential routes) were calculated for cases and were compared with controls. RESULTS: Likely or possible occupational exposure to asbestos was more common in cases than in controls (OR 5.6, 95% confidence interval (95% CI) 3.1 to 10.1). After excluding those with likely or possible occupational exposure, likely or possible paraoccupational exposure was more common in cases than controls (OR 5.8, 95% CI 1.8 to 19.2). Only six cases of mesothelioma were identified as being solely exposed to asbestos through their residence, compared with nine controls. The OR for residential exposure to asbestos varied between 1.5 and 6.6, depending on which potential industrial sources were included, but the 95% CIs were so wide that slightly reduced or greatly increased odds comparing cases with controls could not be excluded. CONCLUSION: Study results support previous evidence that occupational and paraoccupational exposure to asbestos is associated with developing mesothelioma. Despite a rigorous search, purely residential exposure seemed to account for only 3% of identified cases. No firm conclusion can be drawn about the risks from residential exposure alone, as many of the study subjects could also have been occupationally or paraoccupationally exposed to asbestos.

Primary hepatocellular carcinoma presenting as fulminant hepatic failure in a young woman.

A 29 year old Caucasian female, with no history of chronic liver disease, presented with fulminant hepatic failure, the cause of which was not established until post-mortem when it was found that she had a rare form of hepatocellular carcinoma. To our knowledge, this is the only detailed report of hepatocellular carcinoma presenting in this manner.

Secretory IgA: immune defence pattern in ankylosing spondylitis and klebsiella.

Saliva secretory IgA (sIgA), secretory component (SC); serum immunoglobulins (IgG, IgA, IgM), complement (C3, C4), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were performed in 32 patients with ankylosing spondylitis and 29 normal controls. They were investigated for carriage in the faeces of Klebsiella spp. on 3 occasions over the previous months. Throat swabs and urine were cultured at the same time as immunological estimations were done. 24-hour urine sIgA specimens were studied in 13 patients and 12 normal controls. Significantly raised mean values of saliva sIgA and serum IgG, IgA, C3, and C4 were found in patients with raised values of serum ESR and CRP levels when correlated with controls. Raised values of sIgA in saliva, which is an important factor of the local immune defence mechanism of mucosal surfaces, suggests the presence of an antigenic stimulus from the gastrointestinal system in ankylosing spondylitis during activity of disease.

Degenerative lesions of the accessory plantar ligaments.

Degeneration and disintegration of the accessory plantar ligaments occur in the absence of local inflammatory disease. The gross and histological changes are described. These lesions are associated with metatarsalgia, deformities of the metatarsophalangeal joints and the development of the convex anterior metatarsal arch. The connection between these three is explained.

IgE lambda paraproteinaemia associated with a pleomorphic lymphoproliferative disorder.

A new case of IgE lambda paraproteinaemia is described in which the immunoproliferative disorder was lympho-plasmacytoid, rather than myelomatous in type. The patient, an 81-year-old woman, lacked both organomegaly and bone lesions. The peripheral white blood count was 30 X 10(9)/l (43% lymphocytes and 37% lymphoplasmacytoid cells) and the bone marrow was heavily infiltrated with mononuclear cells with 50% lymphocytes and 50% lymphoplasmacytoid cells). Detailed immunological marker analysis of both peripheral blood and marrow showed an increased population of morphologically normal T cells, together with neoplastic population of B cells. The neoplastic cells were shown to re-express surface immunoglobulin after stripping with anti-E anti-serum, and to synthesis Ig in radio-incorporation experiments. The immunological characteristics of the neoplastic cells are considered in relation to B-cell maturation and it is shown that the immunological phenotype was of the intermediate type to be expected in association with a lympho-plasmacytoid proliferation.

Intracranial venous thrombosis in the first trimester of pregnancy.

We describe a fatal case of intracranial venous thrombosis occurring in early pregnancy. Such thrombosis usually occurs in late pregnancy or the puerperium but rarely during the first trimester of pregnancy. Computerized axial tomography suggested massive cerebral venous infarction. Necropsy findings showed not only cerebral venous thrombosis but also extensive pelvic and iliac vein thromboses. The relationship of cerebral venous thrombosis and pregnancy is discussed and the literature reviewed.