A survey of physician attitudes and practices concerning cost-effectiveness in patient care.

OBJECTIVE: To identify physicians' views regarding cost-containment and cost-effectiveness and their attitudes and experience using cost-effectiveness in clinical decision making. DESIGN: A close-ended 30-item written survey. SUBJECTS: 1,000 randomly selected physicians whose practices currently encompass direct patient care and who work in the California counties of Sacramento, Yolo, Placer, Nevada, and El Dorado. OUTCOME MEASURES: Physician attitudes about the role of cost and cost-effectiveness in treatment decisions, perceived barriers to cost-effective medical practice, and response of physicians and patients if there are conflicts about treatment that physicians consider either not indicated or not cost-effective. RESULTS: Most physicians regard cost-effectiveness as an appropriate component of clinical decisions and think that only the treating physician and patient should decide what is cost-worthy. However, physicians are divided on whether they have a duty to offer medical interventions with remote chances of benefit regardless of cost, and they vary considerably in their interactions with patients when cost-effectiveness is an issue. CONCLUSION: Although physicians in the Sacramento region accept cost-effectiveness as important and appropriate in clinical practice, there is little uniformity in how cost-effectiveness decisions are implemented.

The inhibitory effect of caffeine on hormone-induced rat breast cancer.

Studies have associated coffee and/or caffeine with human fibrocystic breast disease. Two animal studies have implicated caffeine as a promoter in rat mammary cancer. The current investigation examines the effect of two caffeine doses in ACI rats with and without diethylstilbestrol (DES). Without DES, cancer did not develop in any of the rats receiving either of the two caffeine dosages. With DES, increasing caffeine dosage lengthened the time to first cancer, decreased the number of rats that developed cancers, and decreased the number of cancers overall. The presence or amount of caffeine did not cause detectable histologic differences in the breast cancers. The presence or amount of caffeine did not influence animal weight or mortality, although the rats without DES weighed more and survived better into old age. The presence or amount of caffeine did not influence pituitary weights and prolactin levels, although values of the DES groups were three times higher than the values for the group without DES (P less than 0.05). In conclusion, chronic caffeine ingestion inhibits rat breast cancer, neither by interfering with the high prolactin levels--a necessary step in murine tumor development--nor by causing hypocaloric intake.

The role of gender and other factors in the prognosis of young patients with colorectal cancer.

Fifty patients from a socioeconomically disadvantaged population who were diagnosed when younger than 40 with colorectal cancer between 1968 and 1978 were analyzed. These patients had an increased survival compared with their older counterparts aged 40 years and older who were diagnosed during the same time. The young women had significantly better survival than the young men. Advanced stages, distribution of primary sites, and precancerous conditions were not major factors. The fact that the younger patients' cancers had a higher incidence of extracellular mucin production may have been counterbalanced by their receiving more extensive treatment. At the same time, cultural and social factors related to gender may have more to do with better survival than do factors evaluated in previous studies. In fact, because of the pervasive lack of male/female analysis, it is not known whether the survival difference due to gender found in this report is a universal tendency in young populations.

Can survival in pancreatic adenocarcinoma be predicted by primary size or stage?

Evaluation of diagnosis and treatment modalities in pancreas cancer is hampered by the lack of a suitable staging system. The current staging protocol of the American Joint Committee is arranged as follows: intrapancreatic disease (stage I), localized invasion (stage II), positive regional lymph nodes (stage III), and distant metastases (stage IV). Primary size is not taken into account and may represent an important determinant of survival, as it does in other malignancies. Primary size as a criterion of operability may assume increasing importance, given the demonstrated accuracy of sonography and computed tomography. Chart review was undertaken of the 119 consecutive patients with pancreas cancer presenting at Grady Hospital between 1976 and 1981. Ninety-one per cent were histologically confirmed. The presence or absence of metastases continues to be the most important factor predicting survival (P less than 0.001). It was demonstrated, however, that patients with primary lesions less than 5 cm lived significantly longer than those with primaries greater than or equal to 5 cm (P less than 0.02). Using the currently recommended American Joint Committee protocol, there was no difference in survival curves among stages, I, II, and III. The median survival times were 7.5 months, 5 months, and 5 months, respectively. Between combined stages I, II, and III and stage IV (median survival, 1.0 month), there was a significant difference (P less than 0.001) in survival.(ABSTRACT TRUNCATED AT 250 WORDS)