Assessing risk communication effectiveness: perspectives of agency practitioners.

A study conducted by the Agency for Toxic Substances and Disease Registry (ATSDR), a US public health agency, evaluated ATSDR's risk communication process, specifically the roles and responsibilities, planning, implementation, and coordination of activities in response to illegal indoor spraying of methyl parathion, a hazardous pesticide, in Pascagoula, MS. Interviews of staff members involved in the intervention were conducted and an analysis revealed strengths and areas in need of improvement in the design and implementation of risk communication strategies. Key recommendations included developing a clear strategy for planning and conducting communication activities; determining staff roles and responsibilities for coordination; and developing clear and consistent health messages, a dissemination strategy, and training in the delivery and evaluation of messages, effects, and outcomes.

Malignant melanoma in Cape Town, South Africa.

There is a world-wide increase in the incidence of cutaneous malignant melanoma among white people. Absence of accurate population-based data on the incidence of melanoma in South Africa prompted a study to determine the incidence, anatomical sites and pathological details of melanoma in Cape Town. In a prospective study from 1 January 1990 to 31 December 1995, all the histopathology reports of melanoma presenting in a geographically defined area of Cape Town, were actively retrieved from every pathologist practising in this area. The data evaluated included information on age, sex, ethnic group and location of residence. Details of melanoma comprised body site, Clark level of invasion, Breslow thickness in millimetres and histogenetic type. The histology slides were reviewed by a panel in those cases where the recorded information was ambiguous or incomplete. A final number of 595 reports of primary invasive cutaneous melanomas in white people was analysed. Of these 50.3% were men and 49.7% women. The overall age-standardized incidence rate was 24.4 per 100,000 per annum (27.5 for men and 22.2 for women). There was no change in the incidence rate over the study period. Most melanomas in both sexes (74% of women and 71% of men) were < 1.5 mm Breslow thickness. Results of this study indicate a high incidence rate of melanoma in white South Africans, comparable with that in Australia, which demands urgent preventive health measures.

Treatment of aggressive non-Hodgkin's lymphoma in the elderly.

A nonanthracycline-containing chemotherapeutic combination for the treatment of intermediate and high-grade non-Hodgkin's lymphoma was evaluated. Thirty-four consecutive and previously untreated patients, with a median age of 75 (range 54-86) years, with aggressive lymphoma, received daily etoposide (60 mg/m2 intravenous infusion [IVI]), cytosine arabinoside (50 mg/m2 subcutaneously), and methylprednisolone (60 mg/m2 IVI) on each of 5 consecutive days. Individuals with limited disease (stages I and II) (n = 9) received six, 3-day cycles of the same therapy and involved field radiation (36 Gy in 20 fractions) between the third and fourth courses. Patients with disseminated lymphoma (n = 25) received 10 cycles over 8 months of the same combination, with the addition of methotrexate (200 mg/m2 on days 8 and 15), followed by leucovorin rescue (10 mg/m2 orally every 6 hr for 8 doses). Of the 34 patients, 44% entered complete remission (CR), and 7 died before completing the first cycle of chemotherapy. Fifty-six percent of the patients with limited disease and 40% with disseminated lymphoma (P > 0.05) achieved CR. For all patients, median survival was 14 months (range 3 days- > 54 months), this being 12 and 15 months, respectively. For the entire population of responding patients, median survival has not been reached at a median follow-up of 39 months, while the median CR duration is 21 months. Ten of the 15 responders are alive in unmaintained CR at a median of 41 (range 30-54) months. Myelotoxicity was the major side effect, leading to adjustments in dose and schedule in two-thirds of the patients, although treatment changes did not affect outcome. Of the 15 deaths that occurred in this trial, in 53.3% it was unrelated to lymphoma or its therapy. Four patients that had achieved CR died of cardiovascular events (n = 2) or of progressive second malignancies (n = 2). It is concluded that cytosine arabinoside in combination regimens is effective in selected patients; this is particularly relevant in the elderly.

Subungual melanoma.

Twenty (1.5%) of 1,350 patients with malignant melanoma treated during a 17-year period had their primary lesion in the nail bed. The thumb (5 patients) and big toe (7) were the most commonly involved digits. Mean delay before diagnosis was 1.4 years. Thirteen patients were black and 7 white. Eight patients (40%) were initially misdiagnosed as having traumatic, infective or benign lesions. Four patients presented with recurrent local disease after inappropriate nail excision or inadequate nail biopsy, while 2 patients had regional nodal spread and 2 had systemic metastases. Mean Breslow depth was 5.7 mm. The histogenetic subtypes were acral lentiginous melanoma (12 patients) and nodular melanoma (4 patients); 4 lesions were unclassifiable. All patients underwent amputation of the involved digit and 12 required node dissection (therapeutic in 11, prophylactic in 1). Five patients (25%) are alive (mean 52 months, range 29-99 months); 4 are disease-free and 1 has brain metastases. Overall median survival was 32 months with a 26% 5-year survival rate. Delayed diagnosis and advanced disease at presentation contributed to the poor prognosis in nail bed melanoma.

Delay in the diagnosis of cutaneous malignant melanoma. A prospective study in 250 patients.

The extent and consequence of patient and professional delay in the diagnosis and treatment of 250 consecutive patients with primary cutaneous malignant melanoma was investigated. Mean total delay from the onset of observed change in a melanoma to appropriate therapy was 11.1 months. The major component of delay (9.8 months) was patient related. Seventy-nine (31.6%) patients waited more than 6 months before seeking medical attention. Few patients recognized early melanoma, and 46% responded only to late features (i.e., ulceration or bleeding). Inappropriate professional delay (misdiagnosis or observation without specific action) occurred in 30 consultations (12.4%) and resulted in a further 1.3-month mean delay in treatment. No correlation (r = 0.027) was found between delay in diagnosis and thickness of melanoma for the study population overall. A significant relationship (r = 0.2087; P less than 0.05) was found between longer lag time and advanced disease in 92 patients with nodular melanoma. Asymptomatic melanomas incidentally diagnosed during routine skin surveillance were significantly more favorable (mean depth, 0.89 mm) than symptomatic melanoma (1.76 mm; P less than 0.01). These data suggest that future public education campaigns should emphasize early signs of melanoma and that professional programs should stress routine skin surveillance and prompt referral of suspicious lesions for diagnostic biopsy.

Superior vena cava syndrome caused by an intrathoracic plasmacytoma.

A case of an extramedullary intrathoracic plasmacytoma causing superior vena cava syndrome is described. Review of the literature on intrathoracic plasmacytomas and superior vena cava syndrome revealed that no similar cases have been described to date. The initial presentation, management, and response to treatment are described.

Primary thyroid lymphomas. A clinicopathological study of 8 cases.

Eight elderly women with primary non-Hodgkin's lymphoma were treated with a combination of surgery, chemotherapy and radiation with excellent outcome. Clinically, the patients presented with thyromegaly and did not have lymphadenopathy or hepatosplenomegaly. On histological examination, the lymphomas resembled diffuse follicle-centre cell tumours. All patients showed extension beyond the thyroid capsule and lympho-epithelial lesions; 3 displayed kappa-light-chain restriction and 2 lambda-monoclonality. Thyroid lymphomas fall into the spectrum of mucosa-associated lymphomas, which have a better prognosis than their equivalent nodal-based counterparts.

Malignant melanoma of the external ear.

Twelve patients with primary melanoma of the external ear were treated during a 10-year period. Ten patients were males. Median melanoma depth was 2.1 mm and seven patients had lesions deeper than 2 mm. Eight of 12 lesions were either Clark level IV or V. Six patients had wedge excisions of the primary lesion and all developed recurrent disease (local: three). Six patients underwent wide excision and none developed local recurrence. All patients with primary disease less than 2 mm are alive. Only two of seven patients with lesions deeper than 2 mm have survived. The definitive excision for melanoma of the ear should encompass wide margins despite the cosmetic consequences. Lesser procedures inevitably lead to local recurrence. Melanoma deeper than 2 mm penetration on the ear in our series had a poor prognosis.

Subungual melanoma of the hand.

Thirteen patients with subungual melanoma on the fingers had a mean delay before diagnosis of 1.2 years. Four patients presented with local recurrence after inadequate initial treatment and two presented with systemic metastases. Mean primary subungual melanoma thickness was 6.1 mm. and nine patients had Clark level IV or V disease. All patients underwent digital amputation. Two of seven patients who had localised disease initially are alive at 29 and 44 months. One of four patients who had locally recurrent melanoma is alive at 36 months. Both patients with systemic disease at presentation died. Advanced disease and delayed presentation contributed to the poor prognosis of subungual melanoma in our patients.

Combination chemotherapy for advanced diffuse large cell lymphoma. The adverse effects of bone marrow invasion, gastrointestinal tract involvement or high bulk disease.

Thirty-nine adults with clinical stage III or IV diffuse large cell lymphoma were prospectively randomised to receive etoposide with doxorubicin (Group 1: n = 17), the same schedule of etoposide with carminomycin (Group 2: n = 8), or BACOP (Group 3: n = 14). The complete remission rates were respectively 24%, 25% and 28%, and further good partial remissions were 41%, 25% and 14%. The incidence of adverse prognostic factors was examined with the first two groups combined for comparison to patients receiving BACOP. The low complete remission rates were attributable to bone marrow invasion in 64% (16/25) of patients in groups 1 and 2, and 64% (9/14) in group 3; to extensive gastrointestinal tract involvement in 24% (6/25) of patients in groups 1 and 2, and 36% (5/14) in group 3; and to high bulk disease in 24% (6/25) of patients in groups 1 and 2, and 36% (5/14) in group 3. Actuarially predicted survival has not been reached for group 1, is 12 months for group 2, and 8 months for group 3; these different trends are not statistically significant. The trial was discontinued when it became clear that there was no difference between the two- and five-drug treatment regimens and that unacceptably low remission rates were obtained in patients having a high incidence of these poor prognostic factors, particularly when compared with results being reported in regimens that contain high or intermediate doses of methotrexate.

Recombinant alpha-interferon as salvage therapy in multiple myeloma. A pilot study.

Ten patients with end-stage multiple myeloma refractory to conventional chemotherapy and hemibody irradiation received recombinant alpha-interferon as salvage therapy. The median duration of treatment was 8 weeks. One patient had an objective response and survived 8 months, whereas in the remaining 9 patients the disease progressed and median survival was 11.5 weeks. Side-effects were substantial and included confusion with extreme weakness, resulting in 5 patients refusing further therapy. The low response rate and the morbidity in this pilot study resulted in its discontinuation and the conclusion that recombinant alpha-interferon as single-agent therapy used for salvage in patients with refractory myeloma is of no value.

Massive macroglossia, amyloidosis and myeloma.

A 74 year old man with light-chain myeloma developed amyloidosis with macroglossia after 10 years of therapy with alkylating agents. Over a 2-year period his tongue enlarged to persistently protrude from his mouth, inhibit his speech, interfere with normal swallowing and eventually threaten his airway. As a life-saving procedure the tumorous anterior two-thirds of the tongue was resected, with excellent primary healing. Within two weeks the patient's speech became comprehensible and his ability to eat returned to normal. Although rare in amyloidosis, massive macroglossia may occur and surgical correction is easily achieved.

Prophylactic hyperthermic limb perfusion in stage I melanoma.

Ninety-three patients with stage I primary cutaneous malignant melanoma of the lower limb were treated by wide local excision and hyperthermic isolated regional perfusion with melphalan (L-phenylalanine dihydrochloride) in a prospective non-randomized study between 1976 and 1982. Eighteen patients (19.4%) developed recurrent melanoma. Nine had recurrent regional disease, one with in transit metastases and eight with positive regional nodes. Nine patients developed distant metastases. No patient had locally recurrent disease. This series confirmed the close correlation between tumour microstaging, melanoma recurrence and survival. Seventy-nine per cent of patients were disease-free at 5 years. Males had deeper lesions (mean 4.56 mm) and increased recurrence (33%) than females (mean 3.36 mm and 13%). Superficial spreading melanoma had the most favourable prognosis of the three histological types. Overall survival was 83% (female 86%; males 64%) at 5 years. Significant morbidity occurred in two patients with deep vein thrombosis. Adjuvant therapy using hyperthermic regional perfusion provides improved local and intransit control of limb melanoma.

Sequential half-body irradiation as salvage therapy in chemotherapy-resistant multiple myeloma.

Fifteen patients with a median age of 58 years, having multiple myeloma resistant to conventional combinations of cytotoxic drugs, received sequential half-body irradiation as salvage therapy. Response was obtained in 53% (n = 8: group 1); this was objective in 40% (n = 6), being defined as 50% or greater reduction in paraprotein, clearance of light chains from the urine, or an unequivocal decrease in tumor bulk on an adequate marrow trephine biopsy; a further 13% (n = 2) just failed to meet these criteria but nevertheless had excellent subjective response. Median survival was 24 months. No objective or subjective improvement occurred in 47% (n = 7: group 2); median transient survival was 4 months. Short-term toxicity was limited to transient nausea in 30% (n = 5) and protracted pancytopenia in about one-half of the patients (n = 7), who remain dependent on intermittent RBC transfusions. Morbidity is only moderate, and the response rate of 53% in refractory patients suggests that sequential half-body irradiation has a definite place in managing patients with end-stage disseminated myelomatosis.

A randomized prospective comparison of chemotherapy to total body irradiation as initial treatment for the indolent lymphoproliferative diseases.

One hundred eight consecutive patients with indolent lymphoproliferative diseases were stratified into chronic lymphocytic leukemia (CLL), stage III and IV well-differentiated lymphocytic lymphoma (WDLL), and stage III and IV follicular lymphoma (FL). Within each stratum, patients were prospectively and randomly assigned to receive chemotherapy with chlorambucil and prednisone (CP) or fractionated total body irradiation (TBI). Morbidity from both regimens was negligible. Complete response (CR) was defined as the resolution of organ enlargement and the return of blood count to normal. The CR rate for the entire CP group (n = 54) was 59% and that for the TBI group (n = 54), 52%; median survivals were 53 and 57 months respectively. In the 41 patients with CLL the CR rate for CP (n = 17) was 47% and that for TBI (n = 24), 50%; the median survival for CP was 48 months, and for TBI it was 51 months. In the 21 patients with WDLL the CR rate for CP (n = 15) was 53% and that for TBI (n = 6), 67%; the median survival for CP was 42 months and has not yet been reached for TBI. For the 46 patients with FL the CR rate for CP (n = 22) was 72% and that for TBI (n = 24), 50%; the median survival was 55 months, and for TBI it was 56 months. None of the differences in CR or survival are statistically significant (P greater than .05). In these indolent lymphoproliferative diseases, CP and TBI are equally effective forms of initial treatment irrespective of the end point being defined as CR or survival.

Waldenstrom macroglobulinaemia treated with sequential hemibody irradiation.

A 40-year-old man presented with symptoms of anaemia and blurred vision. Waldenstrom macroglobulinaemia was diagnosed on the basis of plasmacytoid lymphocytes in the peripheral blood, extensive bone marrow involvement, and an IgM kappa monoclone in the plasma of 48 g/liter. Symptoms were immediately reversed by isovolaemic continuous-flow plasmapheresis coupled with red cell transfusion. Specific therapy was undertaken with sequential hemibody irradiation. At two years of follow-up the patient enjoys excellent health, has improved haematopoietic reserve in the bone marrow, and the only therapy required is intermittent plasmapheresis to control symptoms relating to rising viscosity. Thus, systemic irradiation, which is well tolerated and objectively reduces marrow tumour bulk, offers an alternative to chemotherapy in the palliative management of active macroglobulinaemia and may diminish but not prevent the need for intermittent plasmapheresis.