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.

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.

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.

Veno-occlusive disease of the liver following chemotherapy with mitomycin C and doxorubicin.

A 54-year-old woman with metastatic breast cancer developed veno-occlusive disease of the liver following chemotherapy with mitomycin C and doxorubicin. The dose of mitomycin C received by this patient was much lower than that previously described to cause this complication. As both these drugs are used widely physicians should be aware of this complication.