The impact of improving outcomes guidance on surgical management of vulval squamous cell cancer in southwest England (1997-2002)

OBJECTIVE

The objective of this study was to assess the impact of reorganisation of gynaecological services in southwest England following adoption of regionally agreed evidence-based guidelines and publication of the National Improving Outcomes Guidance in 1999.

DESIGN

Prospective audit with cross-checking against histological reports.

SETTING

All 19 acute hospitals in the four Cancer Networks of southwest England.

SAMPLE

All subjects with squamous or verrucous vulval cancer diagnosed between 1997 and 2002.

METHOD

A one-page minimum data set proforma agreed by the South West Gynaecology Tumour Panel was completed by surgeons after treatment of each patient, and was sent to South West Cancer Intelligence Service for entry, collation and analysis. Data are presented for the years 1997 to 2002 inclusive, and comparisons were made between each of the three 2-year cohorts.

MAIN OUTCOME MEASURES

These are standards derived from the guidance.

RESULTS

There were 436 squamous or verrucous vulval cancers registered. Recording of staging was missing in 20% of subjects. The percentage of subjects operated upon by lead gynaecological cancer surgeons increased from 78% in cohort 1 to 93% in cohort 3 (P < 0.001). There is a trend towards more conservative operations, which have lower co-morbidity. High activity surgeons achieved better rates of tumour-free skin margins, but even these were adequate only in 49% of operations. Lymphadenectomy rates did not follow guidance.

CONCLUSION

Centralisation of care of this rare cancer should continue, but specialists need to increase their efforts to ensure adequate skin margins and lymphadenectomy rates while balancing morbidity and the likelihood of recurrence in both fit and frail patients.

Stage III and IV ovarian cancer in the South West of England: five-year outcome analysis for cases treated in 1998

This study evaluates the 5-year outcome data for the management of advanced ovarian cancer in the South West of England. Anonymized data for 361 stage III and IV ovarian cancers registered between January 1, 1998, and December 31, 1998, were obtained from the central gynecological tumor database. The following data were identified: age at diagnosis, FIGO stage, American Society of Anesthesiologists (ASA) grade, tumor differentiation, treating network and surgeon, amount of residual disease after debulking surgery, current life status, and date of death if applicable. Survival analysis was performed using Kaplan-Meier crude survival for univariate analysis, and multivariate analysis was performed by Cox regression. In our data the 5-year survival for patients with stage III was 16% and with stage IV was 10%. Survival analysis demonstrated that patients in whom the disease was debulked to less than 1 cm were more likely to be alive 5 years after diagnosis than those with a 2-cm residuum (P < 0.0001). There was no significant survival difference for those patients operated on by subspecialist surgeons despite these surgeons being twice as likely to achieve optimal debulking. Therefore, there must be other variables influencing survival apart from cytoreductive surgery. While there is near-complete data collection about ovarian cancer surgery, our database on chemotherapy is incomplete. This is clearly crucial for a complete view of cancer care in our region.

Consistency in regional trends of aggressiveness in cancer care near the end of life for elderly Americans, 1991–2000

6004

Background: We have previously developed and reported on performance measures assessing the aggressiveness of cancer treatment near the end of life for selected cancers during 1993–96. Methods: We compared the care delivered in the 77 Health Care Service Areas (HCSAs) monitored by the Surveillance, Epidemiology, and End Results (SEER) program to all Medicare-eligible patients aged 65 and over who died of cancer (any diagnosis) between 1991 and 2000. We used hierarchical regression models to estimate regional variation in both levels and trends of each indicator. We then ranked each region according to the model-estimated rate of each indicator and computed the correlation among relative ranks of each region over the ten-year study period. Results: 215,488 patients met eligibility criteria. Within this broader and more recent sample we confirmed previous observations of steadily and significantly increasing use of chemotherapy within 2 weeks of death, emergency room visits, and intensive care unit admissions in the last month of life, and, among those admitted to hospice, an increasing proportion of late admissions within 3 days of death. There was significant regional variation in all measures, but the relative rankings of health care service areas from one year to the next were stable, with correlations of ranks ranging from .91–.98 from 1991–1992, and .66–.84 over the 5-year span from 1991–1995. Because of significant regional variation in trends, we found only moderate correlations ranging from .40–.61 over the entire decade. Conclusions: Cancer treatment near the end of life continued to become increasingly aggressive over the 1990s, however, there was significant regional variation in trends. The stability of regional practice patterns supports the reliability of these measures for quality surveillance purposes.

[Table: see text]

No significant financial relationships to disclose.

Stage III and IV ovarian cancer in the South West of England: five-year outcome analysis for cases treated in 1998

This study evaluates the 5-year outcome data for the management of advanced ovarian cancer in the South West of England. Anonymized data for 361 stage III and IV ovarian cancers registered between January 1, 1998, and December 31, 1998, were obtained from the central gynecological tumor database. The following data were identified: age at diagnosis, FIGO stage, American Society of Anesthesiologists (ASA) grade, tumor differentiation, treating network and surgeon, amount of residual disease after debulking surgery, current life status, and date of death if applicable. Survival analysis was performed using Kaplan–Meier crude survival for univariate analysis, and multivariate analysis was performed by Cox regression. In our data the 5-year survival for patients with stage III was 16% and with stage IV was 10%. Survival analysis demonstrated that patients in whom the disease was debulked to less than 1 cm were more likely to be alive 5 years after diagnosis than those with a 2-cm residuum (P < 0.0001). There was no significant survival difference for those patients operated on by subspecialist surgeons despite these surgeons being twice as likely to achieve optimal debulking. Therefore, there must be other variables influencing survival apart from cytoreductive surgery. While there is near-complete data collection about ovarian cancer surgery, our database on chemotherapy is incomplete. This is clearly crucial for a complete view of cancer care in our region.

Measurement of the phase diagram of DNA unzipping in the temperature-force plane

We separate double stranded lambda phage DNA by applying a fixed force at a constant temperature ranging from 15 to 50 degrees C, and measure the minimum force required to separate the two strands. The measurements also offer information on the free energy of double stranded DNA (dsDNA) at temperatures where dsDNA does not thermally denature in the absence of force. While parts of the phase diagram can be explained using existing models and free energy parameters, others deviate significantly. Possible reasons for the deviations between theory and experiment are considered.

Factors influencing treatment recommendations in early-stage Hodgkin’s disease: a survey of physicians

BACKGROUND

The aim of this study was to explore variation in practice patterns and identify factors associated with physicians' treatment decisions for early-stage Hodgkin's disease.

METHODS

We conducted a one-time mail survey of oncologists randomly selected from directories of national oncology societies (n = 207) and Hodgkin's disease experts (n = 147). The survey included questions on (i) physician factors, (ii) preferred treatment choices for six case scenarios of early-stage Hodgkin's disease that varied by patient factors, and (iii) thresholds for changing treatment recommendations.

RESULTS

The response rate was 50%. For non-bulky Hodgkin's disease, 69% of respondents chose combined modality therapy (CMT). On multivariate analysis, physician factors that independently predicted for choice of CMT included a high Hodgkin's disease case load (P = 0.02) and a high percentage of patients enrolled in clinical trials (P = 0.05). Radiation oncologists had a lower threshold for adding radiation therapy (P = 0.02). More experience with second malignancy cases and longer time in practice were associated with a higher threshold for adding radiation therapy (P = 0.04 and P = 0.008, respectively). In stratified analyses, treatment decisions of non-experts were significantly influenced by physician factors, but not by patient factors. Conversely, choices of Hodgkin's disease experts were insensitive to all physician factors, but experts were significantly more likely to select chemotherapy alone in young women and CMT in older patients.

CONCLUSIONS

Our results indicate that physician factors including practice type and experience may in part explain variation in practice pattern for Hodgkin's disease therapy. Hodgkin's disease experts are more likely to tailor therapy according to individual patient factors.

The management of women with apparent early ovarian cancer in the south-west region of England

This study investigated the management of women with apparent early ovarian cancer in the South West region of England. This was retrospective review of prospectively collected data supplement by case note review. All women registered with stage 1 ovarian cancer in the 2 years from January 1997 to December 1998 were identified from the database of the Regional Cancer Organisation (RCO). Data on staging and subsequent management were obtained from the RCO database. Additional information was collected from the patients' casenotes. We considered the accuracy of staging, consideration of fertility-sparing surgery, evidence of multidisciplinary approach to management, appropriateness of oncological referral and adjuvant therapy. Of 222 cases of stage 1 ovarian cancer identified from the RCO database, 168 casenotes were available for inspection. Eighty-seven cases were confirmed as FIGO stage 1 but the substage was amended in 21 cases. There were insufficient data available in 75 cases to confirm the stage assigned. Six cases were re-staged to FIGO stage 3a. Fertility-sparing surgery was considered in four of 10 nulliparous patients of reproductive age. Thirty-nine patients with disease more advanced than FIGO stage 1b were not referred for onco1 logical opinion. Even after Calmine-Hine guidelines are implemented, women with early ovarian cancer may still be treated in general hospitals. There is an urgent need to provide clear local guidelines for the management of these patients.

The surgical management of women with ovarian cancer in the south west of England

The surgical management of epithelial ovarian cancer in the South West of England was studied in the two years 1997-1998 in order to determine the factors that influence the outcome of surgery and to provide a baseline from which to assess the effect of centralisation of cancer services. All hospitals in the South West region of England participating in the Regional Cancer Organisation's longitudinal study of outcomes in gynaecological malignancies are included. Six hundred and eighty-two patients with epithelial ovarian cancer were registered with the RCO in the two-year study period. Five hundred and ninety-five women were offered primary cytoreductive surgery of which 438 were said to be optimally cytoreduced. Applying multivariate models to analyse the outcome of surgery, older patients (OR = 0.82 per 5-year increase in age, P = 0.0003), patients treated in hospitals managing fewer than ten cases of ovarian cancer per year (OR = 1.92, P = 0.02) and patients with FIGO stage 3 (OR = 0.02, P < 0.0001) or 4 (OR = 0.002, P < 0.0001) disease were less likely to be optimally cytoreduced. Gynaecological oncologists were 2.06 times more likely to attain optimal cytoreduction when compared to general gynaecologists and this was statistically significant (P = 0.01). The results from this study support the argument that limiting surgery for ovarian malignancy to specialised surgeons improves the extent of cytoreductive surgery.

A prospective regional audit of surgical management of endometrial cancer in the South and West of England

The results of a prospective audit of surgical management of endometrial cancer in the South and West of England is presented. A minimum data set was defined and information collected prospectively. There was limited tertiary referral to a gynaecological oncologist. The role of centralisation of endometrial cancer care has been questioned, as surgery has traditionally been simple in patients perceived to be at increased risk of more radical surgery. However, this audit demonstrates that standards of even this simple care within the region are often inadequate, with only one-third of patients having basic staging procedures performed fully. This has important implications for patients management, future interpretation of outcome data and clinical governance in endometrial cancer care.

Utilization, patient satisfaction, and cost implications of acupuncture, massage, and naturopathic medicine offered as covered health benefits: a comparison of two delivery models

CONTEXT

Increasing numbers of health plans in the United States offer complementary and alternative medicine (CAM) benefits despite limited information.

OBJECTIVE

To determine the utilization rates and costs associated with providing CAM services in 2 benefit designs, and to determine the satisfaction of patients in both plans.

DESIGN

Two health plans were identified: a traditional indemnity plan offered through a defined preferred provider organization (PPO) of CAM providers and a health maintenance organization (HMO). Costs and utilization rates for CAM services were compared during a 1-year period of coverage beginning November 1, 1996.

SETTING AND PARTICIPANTS

1091 patients in both plans who used CAM services during the month of May 1997 in Washington state.

RESULTS

Only 1% of all patients covered for CAM accessed these services during the study period. A significantly higher percentage of patients in the PPO plan (1.2%) used CAM services compared to the HMO plan (0.6%) (P < .001). However, the average total cost of annual CAM services (plan benefit + user contribution) was similar ($347 in the HMO and $376 in the PPO), and the price per member per month was nearly identical ($0.20 in the HMO and $0.19 in the PPO). Most users perceived these services as helpful.

CONCLUSIONS

Utilization of CAM services and per member per month costs were lower than expected given the high interest in CAM services reported in consumer surveys. The high level of satisfaction with CAM services and self-reported decrease in the use of pain medications suggests the need for prospective studies examining the effect of CAM treatments.

A randomized controlled trial of the effect of increased intravenous hydration on the course of labor in nulliparous women

OBJECTIVE

One variable that has the potential to affect the course of labor but has not been evaluated previously is the adequacy of maternal hydration. Typical orders provide for 125 mL of intravenous fluids per hour in patients taking limited oral fluids. Many such patients are clinically dehydrated. Physiologists have shown that increased fluids improve skeletal muscle performance in prolonged exercise. This study was designed to determine whether increased intravenous fluids affect the progress of labor.

STUDY DESIGN

Nulliparous women with uncomplicated singleton gestations at term, in spontaneous active labor with dilatation between 2 and 5 cm, and with a cephalic presentation were included. Patients who gave consent were randomly selected to receive either 125 mL or 250 mL of intravenous fluids per hour.

RESULTS

One hundred ninety-five patients were randomly selected, 94 to the 125-mL group and 101 to the 250-mL group. Prerandomization variables were well matched between the 2 groups. The mean volume of total intravenous fluids was significantly greater in the 250-mL group (2008 mL vs 2487 mL; P =.002), as was the mean hourly rate (152 mL/h in the 125-mL group vs 254 mL/h in the 250-mL group; P =.001). The frequency of labor lasting >12 hours was statistically higher in the 125-mL group (20/78 [26%] vs 12/91 [13%]; P =.047). In addition, there was a trend favoring longer mean duration of the first stage and total duration of labor in patients delivered vaginally in the 125-mL group, by 70 and 68 minutes, respectively (P =.06). There was a trend toward a lower frequency of oxytocin administration for inadequate labor progress in the higher fluid rate group (61 [65%] in the 125-mL group vs 51 [49%] in the 250-mL group; P =.06). Cesarean deliveries were more frequent in the 125-mL group (n = 16) than in the 250-mL group (n = 10) but did not reach statistical significance.

CONCLUSION

This study presents the novel finding that increasing fluid administration for nulliparous women in labor above rates commonly used is associated with a lower frequency of prolonged labor and possibly less need for oxytocin. Thus inadequate hydration in labor may be a factor contributing to dysfunctional labor and possibly cesarean delivery. Consideration of this factor in clinical management and in future studies considering variables that affect labor is warranted.

Costs and cost-effectiveness of colorectal cancer prevention and therapy

For cancer, the evaluation of new prevention and therapeutic strategies has traditionally focused almost exclusively on safety and efficacy. However, comparison of the costs and cost-effectiveness of medical interventions is increasingly being recognized as an important goal. Cancer care is a prime target for scrutiny because US cancer treatment consumes over $40 billion per year or approximately 12% of total health care expenditures. Colorectal cancer (CRC) treatment costs over $6.5 billion per year and, among malignancies, is second only to breast cancer at $6.6 billion per year. Nonetheless, there are relatively few published studies addressing the economic consequences of CRC. This review describes the strengths and limitations of the major types of health economic analyses, as well as the existing literature on the costs and cost-effectiveness of CRC prevention and treatment. Although standard approaches to both CRC screening and treatment appear cost-effective when compared with no intervention, the relative cost-effectiveness of different screening, treatment, and posttherapeutic surveillance strategies remains uncertain. As databases and information systems able to integrate comprehensive cost and treatment data grow in availability and sophistication, it should become easier to compare the impact of various approaches in terms of both traditional and economic outcomes. Over the next few years, the results of the first clinical trials that prospectively assess economic end points in CRC are anticipated; the experience resulting from these efforts should stimulate and enhance future studies.

Outcomes assessment in the NCCN: 1998 update. National Comprehensive Cancer Network

The assessment of outcomes is a major priority of the National Comprehensive Cancer Network (NCCN). To date, the NCCN's outcomes program has (1) made a systematic inventory of member institutions' existing data sources; (2) begun a collaborative project with the National Cancer Data Bank to compare specific surgical patterns of care in NCCN institutions with national norms; and (3) begun the creation of a prospective outcomes database within the NCCN. As the first step in the database initiative, five NCCN institutions participated in a pilot project in one disease, breast cancer, aimed at developing and testing techniques of data collection, aggregation, and analysis. Six more sites were added to the pilot program in 1998. As of September 1998, data on over 1,000 unique cases had been submitted to the database, with the number of additional cases expected to triple or quadruple within the ensuing 12 months. Future plans call for (1) further expansion of the breast cancer database, both in terms of the number of institutions participating and the scope of data being collected; (2) the addition of a second disease, non-Hodgkin's lymphoma, to the database; and (3) the establishment of partnerships with other organizations for whom the database might provide useful information, such as insurers, pharmaceutical and biotechnology firms, and regulatory and accrediting bodies.

Do mite avoidance measures affect mite and cat airborne allergens?

BACKGROUND

Effective mite allergen avoidance measures are presumed to reduce airborne allergens yet the quantity in the air is rarely measured.

OBJECTIVE

To monitor airborne allergen during a placebo-controlled mite allergen avoidance study.

METHODS

Bedrooms of 56 atopic asthmatic children were randomly allocated to hot washing and encasing covers + acaricide (active regime) or placebo treatment. Dust was collected from the mattress, bedding and carpets; airborne allergen was measured using Casella samplers and dust settling in open Petri dishes. Der p 1, Der p 2 and Fel d 1 were measured.

RESULTS

After 24 weeks of mite allergen avoidance the Casella air-samplers collected Der p 1 less frequently in active than placebo-treated bedrooms (0 vs. 29%, P<0.05) and Petri dishes in the active group collected less than baseline (0.2 vs. 0.6 ng/day P<0.05). Homes without cats had less cat allergen than cat-owning homes and when actively treated for 24 weeks showed a greater reduction (P = 0.03) in mattress cat allergen than the placebo group.

CONCLUSION

Encasing covers and hot washing of bed linen reduced mite aeroallergen (and mattress cat allergen in the absence of cats). This could mean dual benefits to a patient sensitive to both mite and cat.

Fatal and non-fatal injuries from vessels under air pressure in construction

Using a surveillance system that captures data on construction workers treated in an urban emergency department, we identified a series of injuries caused by vessels and tools under air pressure. We describe those six cases, as well as similar cases found in the Census of Fatal Occupational Injuries; we also review data from the National Surveillance for Traumatic Occupational Fatalities database and data from the Bureau of Labor Statistics. Among the injuries and deaths for which we had good case descriptions, the majority would have been prevented by adherence to existing Occupational Safety and Health Administration standards in the construction industry.