Divided care and the Third Way: user involvement in statutory and voluntary sector cancer services.

In health care, as in much of the public sphere, the voluntary sector is playing an increasingly large role in the funding, provision and delivery of services and nowhere is this more apparent than in cancer care. Simultaneously the growth of privatisation, marketisation and consumerism has engendered a rise in the promotion of 'user involvement' in health care. These changes in the organisation and delivery of health care, in part inspired by the 'Third Way' and the promotion of public and citizen participation, are particularly apparent in the British National Health Service. This paper presents initial findings from a three-year study of user involvement in cancer services. Using both case study and survey data, we explore the variation in the definition, aims, usefulness and mechanisms for involving users in the evaluation and development of cancer services across three Health Authorities in South West England. The findings have important implications for understanding shifts in power, autonomy and responsibility between patients, carers, clinicians and health service managers. The absence of any common definition of user involvement or its purpose underlines the limited trust between the different actors in the system and highlights the potentially negative impact of a Third Way health service.

User involvement in UK cancer services: bridging the policy gap.

Recent UK government initiatives aim to increase user involvement in the National Health Service (NHS) in two ways: by encouraging service users to take an active role in making decisions about their own care; and by establishing opportunities for wider public participation in service development. The purpose of this study was to examine how UK cancer service users understand and relate to the concept of user involvement. The data were collected through in-depth interviews, which were analysed for content according to the principles of grounded theory. The results highlight the role of information and communication in effective user involvement. Perhaps more importantly, this study suggests that the concept of user involvement is unclear to many cancer service users. This paper argues the need for increased awareness and understanding of what user involvement is and how it can work.

A critical evaluation of current protocols for the follow-up of women treated for gynecological malignancies: a pilot study.

This retrospective review was undertaken to determine the efficacy of routine follow-up in the detection and management of recurrent cancer. The case notes of all women attending a regional cancer center who were diagnosed with cancer in 1997 were reviewed. Of 81 new cancers followed up for a median of 42 months (range 36-48), 14 have recurred after curative treatment and there were six cases of persistent disease. The median number of clinic visits per patient was 3.5 (range 1-16). Eight recurrences (57.1%) were diagnosed at scheduled outpatient appointments, three (2 l.4%) presented to the general practitioner (GP), and three were seen as emergencies in hospital. Seventeen patients with persistent/recurrent disease have died and three are alive with disease. The median time from initial presentation to disease recurrence was 12 months (range 5-25) and the median time from recurrence to death was 5 months (range 1-20). The longest interval between onset of symptoms and diagnosis of recurrence (4 months) occurred in those presenting at scheduled outpatient clinics. This study demonstrates that the current follow-up protocol is associated with delays in diagnosing recurrence, because symptomatic patients postpone seeking help until their scheduled visit. We have therefore commenced a prospective study evaluating other models of follow-up.

The Young Person's Perspective on Living and Coping with Diabetes.

Adolescence and young adulthood is a time of significant psychological and psychosocial development, and for young people with Type 1 diabetes mellitus it is a time when self-care and metabolic control of diabetes may become compromised. In order to enhance services' efforts to meet the complex needs of young people with diabetes, a qualitative interview study with eight young people (aged 16-22 years) was carried out. Young people identified an inherent vulnerability associated with having diabetes and feared that diabetes would take control and overwhelm them. Through learning to live with diabetes, and learning to manage a relationship with diabetes, the young people had developed sophisticated, interrelated self-protective strategies to manage intrapersonal and interpersonal threats from diabetes.

Chemotherapy in advanced ovarian cancer: four systematic meta-analyses of individual patient data from 37 randomized trials. Advanced Ovarian Cancer Trialists' Group.

The purpose of this systematic study was to provide an up to date and reliable quantitative summary of the relative benefits of various types of chemotherapy (non-platinum vs platinum, single-agent vs combination and carboplatin vs cisplatin) in the treatment of advanced ovarian cancer. Also, to investigate whether well-defined patient subgroups benefit more or less from cisplatin- or carboplatin-based therapy. Meta-analyses were based on updated individual patient data from all available randomized controlled trials (published and unpublished), including 37 trials, 5667 patients and 4664 deaths. The results suggest that platinum-based chemotherapy is better than non-platinum therapy, show a trend in favour of platinum combinations over single-agent platinum, and suggest that cisplatin and carboplatin are equally effective. There is no good evidence that cisplatin is more or less effective than carboplatin in any particular subgroup of patients.

Palliative radiotherapy for lung cancer: two versus five fractions.

The aim of this prospective randomized trial was to compare the symptomatic effects of two different regimens of palliative radiotherapy for lung cancer. Two hundred and sixteen patients needing palliation were randomized to receive either a 17 Gy mid-point dose in two fractions 1 week apart or 22.5 Gy in five daily fractions. Both toxicity and efficacy were evaluated by postal questionnaires. This small study was intended to identify any clinically important differences in toxicity or efficacy between the two regimens. We detected no such difference, although there was a tendency for iatrogenic dysphagia and improvement in chest pain and cough to be more common with the two-fraction regimen. The only symptom that was improved in over 50% of patients for 8 weeks or more was haemoptysis. Haemoptysis and chest pain appeared to be the best indications for treatment. The relief of other symptoms was disappointing in both degree and duration.

Choriocarcinoma presenting as a breast lump.

A case of choriocarcinoma in a previously well 32-year-old woman presenting as a tender breast lump whilst she is breastfeeding.

Tropisetron alone or in combination with dexamethasone for the prevention and treatment of emesis induced by non-cisplatin chemotherapy: a randomized trial.

This study compared the efficacy and tolerability of tropisetron (Navoban, Novaban) alone or in combination with dexamethasone for the treatment of emesis induced by moderately emetogenic non-cisplatin chemotherapy. In total, 126 patients with cancer, who had never received chemotherapy and who required at least two courses of moderately emetogenic non-cisplatin chemotherapy each lasting for a minimum of 5 days, were recruited into the study. Patients were randomized to receive tropisetron, 5 mg o.d., plus either dexamethasone, 12 mg i.v. on day 1 followed by 4 mg orally b.i.d. on days 2-5, or placebo. Greater control of acute and delayed vomiting and nausea was achieved in patients given the tropisetron-dexamethasone combination than in those who received the tropisetron-placebo treatment. The majority of adverse events were mild and could be attributed to the chemotherapeutic regimen used or to the underlying disease. Patients and investigators both rated tropisetron alone or in combination with dexamethasone as a highly effective and well-tolerated antiemetic treatment. The results of this study show that tropisetron, 5 mg o.d., is an effective, well-tolerated and simple to use antiemetic treatment for patients receiving moderately emetogenic non-cisplatin chemotherapy. The addition of dexamethasone increases the efficacy of tropisetron without significantly decreasing its tolerability.

Multicentre cross-over study of aminoglutethimide and trilostane in advanced postmenopausal breast cancer.

Trilostane and aminoglutethimide, both given with a physiological replacement dose of hydrocortisone, were randomly allocated to 112 eligible patients with postmenopausal advanced breast cancer. Following treatment failure on either drug the patient continued with the other, if they were in a suitable clinical condition. Sixty-three patients initially received trilostane, of whom 33 subsequently received aminoglutethimide; 49 patients initially had aminoglutethimide and 14 of these then received trilostane. Both groups of patients were comparable in all respects. There was no difference in the response rate to either drug or in the average time to disease progression for the two drugs. Of the 47 patients who received both drugs, nine (19%) showed a response to both, indicating no cross-resistance. Side effects were seen to both drugs in approximately half the patients; these were mainly gastrointestinal symptoms with trilostane and rashes and drowsiness with aminoglutethimide. There was no evidence of cross-over patient susceptibility to side effects.

Multicentre cross over study of aminoglutethimide and trilostane in advanced postmenopausal breast cancer.

Trilostane and Aminoglutethimide, each given with a physiological replacement dose of hydrocortisone, were randomly allocated to 72 eligible postmenopausal advanced breast cancer patients; following treatment failure on either drug the patient continued with the other drug, if in a suitable clinical condition. Thirty-eight patients initially received Trilostane of whom 19 subsequently received Aminoglutethimide; 34 patients initially had Aminoglutethimide and seven of these then received Trilostane. Both groups of patients were comparable in all respects. There was no difference in the objective response rate to either drug, Trilostane 11/38 = 29%, Aminoglutethimide 12/34 = 35%, nor in the average time to disease progression for the two drugs, Trilostane 64 weeks, Aminoglutethimide 68 weeks. Of the 26 patients who received both drugs, four showed a response to both suggesting no cross resistance. Side effects were seen to both drugs in approximately half of the patients, but were mainly gastro-intestinal with Trilostane and rash and drowsiness with Aminoglutethimide. There was no evidence of cross over patient susceptibility to side effects.

Endometrial resection after radiotherapy for cervical carcinoma.

A patient with persistent chaotic menses during hormone replacement therapy after radiotherapy for cervical cancer was rendered amenorrheic by transcervical endometrial resection.

Intravenous treosulfan versus intravenous treosulfan plus cisplatinum in advanced ovarian carcinoma.

In a prospective, multicentre, randomized trial, the efficacy and tolerance of treosulfan alone was compared with that of treosulfan plus cisplatinum in 135 women with advanced ovarian carcinoma. No statistically significant difference was found between the two treatments in terms of median survival. Combined treatment was associated with significantly greater side-effects and haematological toxicity. Optimal survival with minimal toxicity can be achieved by using treosulfan alone in patients (mainly stages Ic or II) with minimal postoperative residual disease. Patients (likely to be stage III or IV) with greater residual disease should receive treosulfan plus cisplatinum.

Multicenter study of trilostane: a new hormonal agent in advanced postmenopausal breast cancer.

Trilostane, an inhibitor of the production of adrenal estrogens, was administered, together with dexamethasone, to 97 eligible postmenopausal women with advanced breast cancer. Seventy-four patients who had either received trilostane for a minimum of 10 weeks or whose disease had progressed while on trilostane before this period were assessed for tumour response. Eighteen patients (25%) had objective responses (two complete, 16 partial); a further 21 patients had stable disease. The response rate among all 97 patients, including those not treated for a minimum 10-week period, was 19%. Thirty-two of 97 patients reported adverse reactions which were attributed to trilostane and/or dexamethasone. Therapy was stopped for 15 patients, and the dose of trilostane was reduced for ten. Diarrhea was the commonest side effect, being reported in 16 patients, of whom nine stopped treatment. Trilostane, given with a corticosteroid, is an effective alternative hormonal agent acting by adrenal blockade for postmenopausal women with advanced breast cancer.