Clinical outcomes of ethnic minority women in MA.17: a trial of letrozole after 5 years of tamoxifen in postmenopausal women with early stage breast cancer

BACKGROUND

Aromatase inhibitors are widely employed in the adjuvant treatment of early stage breast cancer. The impact of aromatase inhibitors has not been established in ethnic minority women.

PATIENTS AND METHODS

The purpose of this study was to evaluate the impact of letrozole on minority women in MA.17, a placebo-controlled trial of letrozole following 5 years of tamoxifen in postmenopausal women with early stage breast cancer. Retrospective comparison of disease-free survival (DFS), side effects, and mean changes in quality of life (QOL) scores from baseline between Caucasian and minority women was performed.

RESULTS

Minority (n = 352) and Caucasian (n = 4708) women were analyzed. There was no difference between these groups in DFS (91.6% versus 92.4% respectively for 4 year DFS). Letrozole, compared with placebo, significantly improved DFS for Caucasians (HR = 0.55; P < 0.0001) but not for minorities (HR = 1.39; P = 0.53). Among women who received letrozole, minorities had a significantly lower incidence of hot flashes (49% versus 58%; P = 0.02), fatigue (29% versus 39%; P = 0.005), and arthritis (2% versus 7%; P = 0.006) compared with Caucasians. Mean change in QOL scores for minority women who received letrozole demonstrated improved mental health at the 6-month assessment (P = 0.02) and less bodily pain at the 12-month assessment (P = 0.046).

CONCLUSION

Letrozole improved DFS in Caucasians but a definite benefit in minority women has not yet been demonstrated. Minority women tolerated letrozole better than Caucasians in terms of toxicity. These results need confirmation in other trials of aromatase inhibitors.

Cross-border referral for early breast cancer: an analysis of radiation fractionation patterns

Because of increasing waiting times for adjuvant radiation in the province of Ontario, patients from one Canadian centre were referred to two centres in the United States. This situation provided an opportunity to compare radiation practices.We performed a retrospective review of radiation prescribed to patients following breast-conserving surgery for invasive breast cancer. Patients with positive margins, 4 or more positive lymph nodes, recurrent disease, or large tumours (>5 cm) were excluded. For comparison, we reviewed a random sample of similar patients treated at the Canadian centre during the same period. A total of 120 referred and 217 non-referred patients were eligible for comparison. The analysis included 98 pairs of patients (N = 196), fully matched on age, nodal status, T stage, grade, and estrogen receptor (er) status.Mean patient age was 60.7 years. The median total dose and number of fractions differed between centres [6040 cGy in 32 fractions (United States) vs. 4250 cGy in 16 fractions (Canadian), both p < 0.001). Boost was used more often in the United States (97% vs. 9%, p < 0.001). Variation in prescribing patterns was seen. In the United States, seven different schedules for whole-breast irradiation were used; at the Canadian centre, two schedules were prescribed. Predicted radiobiologic effects of these schedules were calculated to be similar.Differences in fractionation patterns were observed between and within U.S. and Canadian centres. Such variability is likely to affect patient convenience and resource utilization. Although patient selection, referring surgeon, and change in policies may account for some of the observed differences, further research is necessary to better understand the causes.

A comparison of patient and physician attributes that promote patient involvement in treatment decision making in the oncology consultation

6098

Background: Cancer patients have indicted a desire to be more involved in treatment decision making (TDM). However, little is known about the attributes of patients, physicians and their interaction that promotes patient involvement in TDM in the oncology consultation. This study compared attributes generated by patients and physicians that make it easier for patients to be involved in TDM. Methods: Semi-structured interviews were undertaken with 19 patients with cancer (lung, breast, prostate, GI) and 21 medical and radiation oncologists at a regional cancer centre. Participants were asked to identify attributes of physicians, patients and their interaction that promotes patient involvement in TDM. Interview transcripts were independently coded by 2 analysts using decision rules to identify specific attributes. Attributes identified by each analyst were compared and a high level of agreement was found. The analysts then independently compared the physician and patient generated lists and identified common vs unique items. There was a high level of agreement on which attributes were common to both lists versus unique. Results: Oncologists identified 173 physician, 59 patient and 9 interaction items. Patients identified 50 physician, 42 patient and 11 interaction items. Patients and physicians identified 17 common physician items, 29 common patients items and 1 common interaction item. Physicians identified 138 more attributes than patients, most of which were physician related. Common patient attributes centred on information seeking (eg prepare for the consultation by reading, be aware of all treatment options and question the options). Common physician attributes focused on specific communication behaviors (eg, make eye contact, tailor information to patient needs, be direct with patients, ensure patient understands information). The common interaction item was to keep the discussion informal. Conclusions: Patients and physicians appear to have different ideas about what is important to promote patient involvement in TDM. Many of the attributes identified can be easily incorporated into current practice. There is a need to develop and evaluate communication skills training to promote patient involvement in TDM.

No significant financial relationships to disclose.

Agreement between physicians and patients about what constitutes shared decision making

6065

Background: Involving patients in making decisions about their own care is increasingly desirable for patients with serious illness. Shared decision making is one such model, the attributes of which have been well defined (Charles et al., Soc Sci Med,1997,1999). However, it is unclear whether physicians and patients agree on what constitutes a SDM interaction. Methods: Semi-structured interviews were undertaken with 21 medical and radiation oncologists and 14 cancer patients attending a regional cancer centre. Participants were asked what they thought it meant for the patient and physician to share in DM. Responses were compared to the theoretical constructs of SDM defined by Charles et al: information exchange (flow, direction, type, amount), deliberation, and who makes the decision. Two analysts independently reviewed the interviews for patient and physician definitions of SDM and compared these with the Charles et al. model of SDM using explicit classification decision rules. There were few discrepancies between analysts and agreement was reached in all cases. Results: 71% of physicians and 29% of patients described a two-way flow and direction of information exchange as necessary for SDM. Only 24% of physicians and 21% of patients described the exchange of both medical and personal information. All participants indicated that more than the minimum legally required amount of information was needed. 67% of physicians and 36% of patients described both patient and physician involvement in deliberation about treatment as a component of SDM. 48% of physicians and 21% of patients identified both patients and physicians are involved in deciding what treatment to implement in a shared approach. Overall, none of the participant definitions identified all the components of the SDM model. Physicians in their definitions, identified more components than did patients. Conclusions: Physicians appear to have a stronger understanding of the elements involved in SDM. These differences may lead to different expectations about patient involvement in DM. Physicians have a responsibility for ensuring that patients are invited to contribute to all components of SDM in the oncology consultation.

No significant financial relationships to disclose.

Understanding decision supports (DS) for women with breast cancer eligible for clinical trials (CT)

10534

Background: CTs are vital to the development of treatments for patients with cancer, but a low proportion of patients participate in trials, resulting in decreased access to new options. Methods: The study purpose was to explore DS for CT participation decision-making with women diagnosed with breast cancer who were offered a CT. 31 women took part in 6 focus groups - 3 groups of women who consented to a CT, 3 groups who declined a CT. Open-ended questions were asked about specific DS and ideas for new ones. Information rich cases were selected for the sample. Data analyses were conducted by 2 independent coders using a line-by-line, open coding process. Reliability was checked by a 3rd coder. Data was organized with template and editing approaches. Results were compared by group type (declined/consented to CT). Results: Common themes emerged from both group types: too much information is given at the first oncology consult; patients prefer to get CT information from the cancer centre, after their surgery, but prior to their oncology consult; no strong preference about who acts as a DS—family doctor, surgeon, other—as long as good relationship exists; oncologist (to lesser degree surgeon) is seen as most informed about their case; preference for oncologist vs trials nurse to describe CT concept, answer questions, direct them to other information sources; patients doubt family doctors or surgeons have detailed knowledge of CTs, know specific trial data; patients want to feel prepared, know what may happen before they come to oncologist - consult process, CT may be option - to avoid surprise; helpful to know that there is time to make CT decision; other patients are a good source of DS and information. Conclusions: Patients had strong preference to receive information about CTs prior to their consultation with an oncologist; this timing was seen as helpful for decision-making about a CT by both group types.

No significant financial relationships to disclose.

NCIC CTG MA.17: Tolerability of letrozole among ethnic minority women

6018

Background: Disease free survival was significantly improved in women receiving letrozole after standard adjuvant tamoxifen in the MA.17 trial. Based on the results of MA.17 and of other trials of aromatase inhibitors in early stage breast cancer, chronic aromatase inhibitor therapy, in postmenopausal women free of breast cancer recurrence, is now being widely employed. We analyzed the toxicity of letrozole according to ethnic status among women enrolled in MA.17. Methods: The chi-square test was used for comparison of rates of side effects between the two groups, Caucasian vs. ethnic minority (defined as all non-Caucasians). In a subset of women, quality of life (QOL) was assessed by the SF-36 Health Survey. Mean change scores in QOL from baseline were compared between groups for summary measures and domains using the Wilcoxon test. Results: 352 minority women and 4,708 Caucasians were enrolled in MA.17, of which 183 minority women and 2,339 Caucasians were randomized to receive letrozole. Caucasians were older than minority women and had a slightly longer duration of treatment with prior tamoxifen. Tumor size and nodal status were not significantly different between the two groups. In women who received letrozole, minority women had significantly lower incidence of hot flashes (49% vs. 58%; p = 0.02), fatigue (29% vs. 39%; p = 0.005), and arthritis (2% vs. 7%; p = 0.006) compared with Caucasians. Mean QOL change scores of SF-36 domains for women who received letrozole were not different but minority women had better mental health at 6 month assessment (p = 0.02) and worse bodily pain at 12 month assessment (p = 0.046). Conclusions: Minority women tolerated letrozole considerably better than Caucasians in the MA.17 trial. These preliminary findings suggest that minority women respond differently to letrozole in terms of toxicity. Recent demonstration of genotypic variations in the aromatase gene in different ethnic groups plus likely pharmacogenomic differences suggests that further research is needed to clarify the clinical outcomes of aromatase inhibition in women of diverse ethnicities. Future research strategies should focus on examining in vivo genotype-phenotype correlations to determine the effects of genetic variation on response to anticancer therapy and on toxicities and end-organ effects.

[Table: see text]

The difference between study recommendations, stated policy, and actual practice in a clinical trial

BACKGROUND

We determined whether physicians involved in a clinical trial adhere to the study recommendations or the stated policy of their treatment centre with respect to the administration of boost radiation after breast conserving surgery.

PATIENTS AND METHODS

Boost radiation treatment policy was determined by survey at 25 oncology centres involved in a randomised trial of breast or breast plus nodal radiation in Canada. Actual practice was compared with stated policy and study recommendations.

RESULTS

Among 248 subjects, 201 (81%) were treated according to stated policy [kappa=0.40, 95% confidence intervals (CI) 0.27-0.52; P<0.0001], indicating only a fair to moderate agreement between stated and actual practice, while 232 (94%) were treated according to study recommendations (kappa=0.59, 95% CI 0.40-0.77; P<0.0001), indicating moderate to near substantial agreement between study recommendations and actual practice (P=0.88 for z-test of difference). In a multivariate analysis, subjects who had invasive disease at a resection margin were more likely to get a boost than those with margins clear of invasive tumour by 2 mm [odds ratio (OR) 49, 95% CI 7.6-322; P<0.0001].

CONCLUSIONS

Physicians appear compliant with study recommendations for a non-randomised manoeuvre in a clinical trial, possibly at the expense of compliance with stated local policy. Clinical trial protocols should incorporate standard practice.

Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology

OBJECTIVE

To determine indications for the use of postmastectomy radiotherapy (PMRT) for patients with invasive breast cancer with involved axillary lymph nodes or locally advanced disease who receive systemic therapy. These guidelines are intended for use in the care of patients outside of clinical trials.

POTENTIAL INTERVENTION

The benefits and risks of PMRT in such patients, as well as subgroups of these patients, were considered. The details of the PMRT technique were also evaluated.

OUTCOMES

The outcomes considered included freedom from local-regional recurrence, survival (disease-free and overall), and long-term toxicity.

EVIDENCE

An expert multidisciplinary panel reviewed pertinent information from the published literature through July 2000; certain investigators were contacted for more recent and, in some cases, unpublished information. A computerized search was performed of MEDLINE data; directed searches based on the bibliographies of primary articles were also performed.

VALUES

Levels of evidence and guideline grades were assigned by the Panel using standard criteria. A "recommendation" was made when level I or II evidence was available and there was consensus as to its meaning. A "suggestion" was made based on level III, IV, or V evidence and there was consensus as to its meaning. Areas of clinical importance were pointed out where guidelines could not be formulated due to insufficient evidence or lack of consensus.

RECOMMENDATIONS

The recommendations, suggestions, and expert opinions of the Panel are described in this article.

VALIDATION

Seven outside reviewers, the American Society of Clinical Oncology (ASCO) Health Services Research Committee members, and the ASCO Board of Directors reviewed this document.

Cancer care workers in Ontario: prevalence of burnout, job stress and job satisfaction

BACKGROUND

Cancer Care Ontario's Systemic Therapy Task Force recently reviewed the medical oncology system in the province. There has been growing concern about anecdotal reports of burnout, high levels of stress and staff leaving or decreasing their work hours. However, no research has systematically determined whether there is evidence to support or refute these reports. To this end, a confidential survey was undertaken.

METHODS

A questionnaire was mailed to all 1016 personnel of the major providers of medical oncology services in Ontario. The questionnaire consisted of the Maslach Burnout Inventory, the 12-item General Health Questionnaire, a questionnaire to determine job satisfaction and stress, and questions to obtain demographic characteristics and to measure the staff's consideration of alternative work situations.

RESULTS

The overall response rate was 70.9% (681 of 961 eligible subjects): by group it was 63.3% (131/207) for physicians, 80.9% (314/388) for allied health professionals and 64.5% (236/366) for support staff. The prevalence of emotional exhaustion were significantly higher among the physicians (53.3%) than among the allied health professionals (37.1%) and the support staff (30.5%) (p < or = 0.003); the same was true for feelings of depersonalization (22.1% v. 4.3% and 5.5% respectively) (p < or = 0.003). Feelings of low personal accomplishment were significantly higher among physicians (48.4%) and allied health professionals (54.0%) than among support staff (31.4%) (p < or = 0.002). About one-third of the respondents in each group reported that they have considered leaving for a job outside the cancer care system. Significantly more physicians (42.6%) than allied health professionals (7.6%) or support staff (4.5%) stated that they have considered leaving for a job outside the province.

INTERPRETATION

The findings support the concern that medical oncology personnel are experiencing burnout and high levels of stress and that large numbers are considering leaving or decreasing their work hours. This is an important finding for the cancer care system, where highly trained and experienced health care workers are already in short supply.

The effects of radiation therapy on quality of life of women with breast carcinoma: results of a randomized trial. Ontario Clinical Oncology Group

BACKGROUND

The purpose of this study was to evaluate the effect of breast irradiation on quality of life, including cosmetic outcome, for patients enrolled in a clinical trial.

METHODS

Between 1984 and 1989, a randomized trial was conducted in Ontario, Canada, in which women with lymph node negative breast carcinoma who had undergone lumpectomy and axillary lymph node dissection were randomized to either breast irradiation or no further treatment. A modified version of the Breast Cancer Chemotherapy Questionnaire (BCQ) was administered to women at baseline, 1 month (4 weeks), and 2 months (8 weeks) after randomization. Irritation of the skin of the breast, breast pain, and appearance of the breast to the patient were also assessed every 3 months for the first 2 years of the study.

RESULTS

Of 837 patients, 416 were randomly allocated to radiation therapy and 421 to no further treatment. The mean change in quality of life from baseline to 2 months was -0.05 for the radiation group and +0.30 for the control group. The difference between groups was statistically significant (P = 0.0001). Longer term radiation therapy increased the proportion of patients who were troubled by irritation of the skin of the breast and breast pain. Radiation therapy did not increase the proportion of patients at 2 years who were troubled by the appearance of the treated breast; 4.8% in irradiated and nonirradiated patients (P = 0.62).

CONCLUSIONS

Breast irradiation therapy had an effect on quality of life during treatment. After treatment, irradiated patients reported increased breast symptoms compared with controls. However, no difference was detected between groups at 2 years in the rates of skin irritation, breast pain, and being upset by the appearance of the breast.

Does locoregional radiation therapy improve survival in breast cancer? A meta-analysis

PURPOSE

Recent randomized trials in women with node-positive breast cancer who received systemic treatment report that locoregional radiation therapy improves survival. Previous trials failed to detect a difference in survival that results from its use. A systematic review of randomized trials that examine the effectiveness of locoregional radiation therapy in patients treated by definitive surgery and adjuvant systemic therapy was conducted.

METHODS

Randomized trials published between 1967 and 1999 were identified through MEDLINE database, CancerLit database, and reference lists of relevant articles. Relevant data was abstracted. The results of randomized trials were pooled using meta-analyses to estimate the effect of treatment on any recurrence, locoregional recurrence, and mortality.

RESULTS

Eighteen trials that involved a total of 6,367 patients were identified. Most trials included both pre- and postmenopausal women with node-positive breast cancer treated with modified radical mastectomy. The type of systemic therapy received, sites irradiated, techniques used, and doses of radiation delivered varied between trials. Data on toxicity were infrequently reported. Radiation was shown to reduce the risk of any recurrence (odds ratio, 0.69; 95% confidence interval [CI], 0.58 to 0.83), local recurrence (odds ratio, 0.25; 95% CI, 0.19 to 0.34), and mortality (odds ratio, 0.83; 95% CI, 0.74 to 0.94).

CONCLUSION

Locoregional radiation after surgery in patients treated with systemic therapy reduced mortality. Several questions remain on how these results should be translated into current-day clinical practice.

Direct identification and quantitation of prednisone in the presence of overlapping hydrocortisone by liquid chromatography with electrospray and atmospheric-pressure chemical-ionisation mass spectrometry

The paper describes the application of liquid chromatography interfaced to a triple quadrupole mass spectrometer utilising the multiple reaction monitoring (MRM) mode. The technique was shown to provide detection limits lower than 0.01% for the analysis of prednisone in the presence of hydrocortisone. Prednisone was mixed in concentrations from 0.500 to 0.0005 ppm (corresponding to 1% to 0.001% of the hydrocortisone concentration). These solutions were assayed using MRM observing the product ion transitions of 359.2-->147.1 and 359.2-->171.2 and was shown to be capable of detecting co-eluting impurities at concentrations of less than 0.001% of the major component. The assay of prednisone was shown to be linear over the range 0.500-0.0005 ppm with a correlation coefficient of 0.999 and a precision of 6.9% at the concentration of 0.005 ppm. The analysis was carried out using both atmospheric pressure chemical ionisation (APCI) and electrospray ionisation (ESI) as an interface. However, for these compounds APCI provided significantly more sensitive data compared to ESI.

Offering a choice between two adjuvant chemotherapy regimens: a pilot study to develop a decision aid for women with breast cancer

BACKGROUND

The primary objective of this study was to develop a decision aid which would encourage and assist patients to become involved in treatment decision making, and help clinicians to objectively educate patients about the benefits and risks of adjuvant chemotherapy for breast cancer. A secondary objective was to investigate the factors influencing this treatment decision-making process for women when choosing between adriamycin and cyclophosphamide (AC) versus cyclophosphamide, methotrexate and 5-fluorouracil (CMF) chemotherapy.

METHODS

An educational visual instrument called a Decision Board was developed consisting of written and graphical material. The Decision Board displays general information about chemotherapy and detailed information about each chemotherapy regimen, including the schedule and side effects, and was presented to patients with a scripted standardized oral explanation. The instrument was evaluated in 46 premenopausal women newly diagnosed with node-positive breast cancer. Following presentation of the board, the patients were given a take home version to review and asked to return 1-2 weeks later with a decision. During the second visit each patient was asked to complete a questionnaire regarding demographics, learning and comprehension, treatment preference, and factors influencing their decision.

RESULTS

Recall of information was acceptable (> or = 80%). The Decision Board was found helpful by all, but the level of difficulty with decision making was variable. Out of 46 women, 23 women chose AC, 21 chose CMF, and two chose no treatment. The major factors affecting treatment preference were related to the impact on quality of life, the length of therapy, and the side effects, in particular, vomiting and alopecia.

CONCLUSIONS

The Decision Board appears to be a valuable educational tool that enables patients to become well-informed and directly involved in their treatment decisions.

Evaluation of a patient file folder to improve the dissemination of written information materials for cancer patients

BACKGROUND

Many cancer centers make available to patients written information material to supplement verbal information provided by clinicians. Randomized trials have demonstrated that providing such information can increase patient knowledge and satisfaction. However, little data are available regarding effective means of dissemination of such materials. The purpose of this study was to determine whether providing patients with a personal file folder after their first clinic appointment would improve the dissemination of written information materials and increase patient satisfaction.

METHODS

A before/after study was performed. Consecutive patients with newly diagnosed cancer attending the Hamilton Regional Cancer Centre were selected randomly and interviewed by telephone within 1-2 weeks of the first clinic appointment regarding the number of information pamphlets received, patient satisfaction, and general preference for written information materials. The preintervention evaluation (T1) occurred over a 4-month period followed by the introduction of the personal file folder into the clinical practice. Six weeks after its introduction, the postintervention (T2) evaluation took place over the ensuing 4 months.

RESULTS

A total of 300 patients completed the evaluation (150 each in T1 and T2). Responding patients in the two time periods were comparable with respect to background demographic variables. The mean number of information pamphlets received by patients increased with the introduction of the personal file folder from 2.4+/-2.0 standard deviations (SD) in T1 to 3.6+/-2.5 SD in T2 (P=0.0001). The percentage of patients planned for treatment who received treatment-related information increased from 36% (42 of 116 patients) in T1 to 65% (68 of 105 patients) in T2 (P=0.002). Mean patient satisfaction increased from 3.3+/-1.1 SD to 3.8+/-1.0 SD over the 2 time periods (P=0.0001). The majority of patients (87%) believed it was important to receive written information materials.

CONCLUSIONS

The patient file folder increased the dissemination of written information materials and currently is being incorporated into routine practice.

Surgical management of early stage invasive breast cancer (stage I and II). Provincial Breast Disease Site Group

GUIDELINE QUESTION

What is the optimal surgical management of early stage invasive breast cancer (stage I and II)? More specifically, what is the relative efficacy (and safety) of breast conservation therapy (lumpectomy with axillary dissection) compared with modified radical mastectomy?

OBJECTIVE

To make recommendations about surgical management and techniques in the treatment of early stage invasive breast disease (stage I and II).

OUTCOMES

Survival, local recurrence (for lumpectomy patients) and quality of life are the primary outcomes of interest.

PERSPECTIVE (VALUES)

Evidence was selected and reviewed by 6 members of the Ontario Cancer Treatment Practice Guidelines Initiative, Disease Site Group for Breast Cancer (Breast DSG). Earlier drafts of this evidence-based recommendation have been reviewed, discussed and approved by the Breast DSG, which comprises surgeons, medical oncologists, radiation oncologists, epidemiologists, a pathologist and a medical sociologist. There was no consumer participation in the development of this guideline.

QUALITY OF EVIDENCE

There are 7 randomized controlled trials (RCTs) comparing breast conservation therapy with mastectomy in women with early stage breast cancer.

BENEFITS

In 6 RCTs, no statistically significant differences were detected in survival rate between the mastectomy and conservative therapy (lumpectomy) groups. In 1 RCT, a statistically significant differences was detected in favour of the mastectomy arm; however, this was an early trial with substantial methodologic weaknesses.

HARMS

None.

PRACTICE GUIDELINE

Women with early stage invasive breast cancer (stage I and II) who are candidates for breast conservation therapy (see discussion of technical factors) should be offered the choice of either breast conservation therapy (excision of tumour with clear margins and axillary dissection) or modified radical mastectomy. The choice is an individual one for the patient, and thus she should be fully informed of the options, including the risks and benefits of each procedure. She should be informed that breast irradiation is part of the procedure for breast conservation therapy. In addition, she should be aware of the potential need for further surgery if the margins are positive. For further information about the use of radiotherapy in the management of early stage breast cancer, please refer to the Ontario Cancer Treatment Practice Guidelines Initiative's practice guideline Breast Irradiation in Women with Early Stage Invasive Breast Cancer Following Breast Conserving Surgery.

The supportive care needs of newly diagnosed cancer patients attending a regional cancer center

BACKGROUND

The objective of this study was to examine the physical and emotional health status, self-perceived problems, and needs of newly diagnosed cancer patients to determine and plan supportive care strategies.

METHODS

A cross-sectional survey of newly diagnosed cancer patients attending a regional cancer center during a 6-month period was performed. Patients with breast, colorectal, head and neck, lung, and prostate carcinoma as well as nonmelanoma of the skin were selected randomly. Patients were interviewed prior to their first appointment at the clinic. Physical health status was assessed using the Symptom Distress Scale, psychologic health status was assessed with the General Health Questionnaire (GHQ), day-to-day functioning with the Rapid Disability Scale, and social support with the modified Sarason's Social Support Scale. Perceived needs were assessed in a number of ways, including identification of patients' specific social concerns and informational needs, and by asking them to list their current problems or concerns.

RESULTS

Of 156 eligible patients, 134 completed the interview. One hundred and twenty-nine patients (96%) reported current symptoms that included fatigue (66%), worried outlook (61%), difficulty sleeping (48%), and pain (42%). Forty-four patients (33%) were identified as psychologically distressed with a GHQ score of > or = 6. One hundred and fourteen patients (85%) had informational needs, 89 (66%) indicated > or = 1 social concerns, and 55 (41%) reported a need for assistance with day-to-day living.

CONCLUSIONS

Patients with newly diagnosed cancer commonly report symptoms related to fatigue, pain, and psychologic distress. Other frequently reported issues relate to the need for information and social concerns regarding the patients' ability to take care of their home and maintain family and other relationships. Awareness of these issues is important for planning supportive care interventions for newly diagnosed cancer patients.

Breast irradiation in women with early stage invasive breast cancer following breast conservation surgery. Provincial Breast Disease Site Group

GUIDELINE QUESTIONS

1) Should breast irradiation be given to women with early stage invasive breast cancer (stage I and II) following breast conservation surgery (lumpectomy with clear resection margins and axillary dissection)? 2) Is there an optimal schedule for breast irradiation? 3) What is a reasonable interval between definitive surgery and the start of breast irradiation? 4) Are there patients who can be spared breast irradiation after lumpectomy?

OBJECTIVE

To make recommendations about the use of breast irradiation in women with early stage invasive breast cancer following breast conservation surgery.

OUTCOMES

Local control is the primary endpoint of interest. Survival, quality of life (addressed through the adverse effects of radiotherapy) and cosmesis are also considered.

PERSPECTIVE (VALUES)

Evidence was selected and reviewed by 6 members of the Breast Disease Site Group (Breast DSG) of the Ontario Cancer Treatment Practice Guidelines Initiative. Earlier drafts of the evidence-based recommendation were reviewed, discussed and approved by the Breast DSG, which comprises medical oncologists, radiation oncologists, surgeons, epidemiologists, pathologists and a medical sociologist. There was no participation by a community representative in the development of this guideline.

QUALITY OF EVIDENCE

There are 5 randomized controlled trials (RCTs) and 1 meta-analysis comparing breast irradiation with no breast irradiation following breast conservation surgery; 6 randomized trials comparing breast conservation surgery plus breast irradiation with mastectomy are also included, as well as several retrospective studies.

BENEFITS

All of the 5 RCTs showed a significant decrease in local recurrence rates among patients receiving radiotherapy. In the 4 trials with a median follow-up of 5 years or longer, the relative risk reduction with breast irradiation ranged from 69% to 88%. The absolute differences ranged from 16% (p < 0.001) to 25% (p < 0.001). Despite the effect on local recurrence, no difference in survival was detected in any of the 5 trials. Most of the patients with local recurrence in these trials underwent mastectomy.

HARMS

Major adverse effects of breast irradiation occur very infrequently.

PRACTICE GUIDELINE

Women with early stage invasive breast cancer (stage I and II) who have undergone breast conservation surgery should be offered postoperative breast irradiation. The optimal fractionation schedule for breast irradiation has not been established, and the role of boost irradiation is unclear. Outside of a clinical trial, 2 commonly used fractionation schedules are suggested: 50 Gy in 25 fractions to the whole breast, or 40 Gy in 16 fractions to the whole breast with a local boost to the primary site of 12.5 Gy in 5 fractions. Shorter schedules (e.g., 40 or 44 Gy in 16 fractions) have also been used routinely in some centres. The enrollment of patients in ongoing clinical trials is encouraged. Women who have undergone breast conservation surgery should receive local breast irradiation as soon as possible after wound healing. A safe interval between surgery and the start of radiotherapy is unknown, but it is reasonable to start breast irradiation within 12 weeks after definitive surgery. For women who are candidates for chemotherapy, the optimal sequencing of chemotherapy and breast irradiation is unknown. It is reasonable to start radiotherapy after the completion of chemotherapy, or concurrently if anthracycline-containing regimens are not used. For further information, please refer to Ontario Cancer Treatment Practice Guidelines Initiative's practice guideline "Surgical Management of Early Stage Invasive Breast Cancer (stage I and II)."

Patients' preferences for therapy in advanced epithelial ovarian cancer: development, testing, and application of a bedside decision instrument

The objective of this study was to determine a patient's preference for treatment in the poor prognostic situation of advanced epithelial ovarian cancer. A standardized method of information transfer was developed and pretested for feasibility, acceptability, comprehension, interobserver reliability, and validity. The Decision Board (DB) describes to the patient who has completed surgery for suboptimally debulked ovarian cancer two treatment options, their potential side effects, and possible outcomes. The psychometric properties of the DB were determined in 37 volunteers without cancer and 11 women following first-line chemotherapy for ovarian cancer. The Board was then administered to 12 patients with stage IIIc and IV ovarian cancer at the point of deciding future chemotherapy. The feasibility of presenting poor prognostic information, patient comprehension in an emotionally charged situation, and her treatment choice were determined. Observation of patient-physician interviews revealed that survival information is not usually discussed on the initial consultation. Using the DB, it was feasible to provide survival information to 98% of the healthy women. Comprehension was high, with 96% of the questions being correctly answered. Interobserver reliability was high (kappa = 1.00). The construct that hypothesized that understanding information is a determinant of choice was verified, as 95.2% of women had predictable shifts in expressed preference. The strength of preference in healthy women was statistically significantly higher for Plan B (paclitaxel-cisplatin) than for Plan A (cisplatin-cyclophosphamide) (P < 0.001). The method of presenting survival information (median survival versus percentage survival at 3.5 years) influenced choice (P < 0.04). At the point of decision making, 33% of patients with advanced ovarian cancer chose Plan A and 67% chose Plan B. All volunteers and patients stated that they wanted to be fully informed of the choices of therapy for their disease and to be involved in treatment decisions. The DB is a reliable and valid method for sharing information about advanced ovarian cancer with patients. At the point of deciding first-line chemotherapy in this poor prognostic situation, patients still value survival more highly than the quality of life during chemotherapy.

A randomised trial of two information packages distributed to new cancer patients before their initial appointment at a regional cancer centre

The purpose of this study was to evaluate the extent to which a new patient information package (NPIP) or a mini version of the same package (mini-NPIP) reduces emotional distress and meets the informational needs of patients arriving at a tertiary cancer centre for the first time. A comprehensive package, NPIP, consisting of procedural information regarding cancer centre location, description of the health care team, treatment services, research, educational activities, accommodation and community services provided at the centre; and a condensed version of the same package, mini-NPIP, were developed. Consecutive patients with newly diagnosed breast, gynaecological, lung and prostate cancer, referred to the centre for the first time were prerandomised to receive NPIP, mini-NPIP or no information package. Patients randomised to NPIP or mini-NPIP were mailed the information package at least one week before their first appointment. On arrival at the centre, patients were administered the Brief Symptom Inventory (BSI) which measures psychological distress, and interviewed regarding preferences for information and acceptability of the information packages. Of 465 randomised patients, 161 were excluded post-randomisation and 304 completed the entire interview: 100 were randomised to the NPIP, 102 to the mini-NPIP and 102 to the control group. Emotional distress as measured by the BSI was similar for all groups (P = 0.98). Most patients preferred to receive the information (98%), receive it before the first appointment (84%) and by mail (79%). These preferences were more evident for those given the information packages. The majority of patients found the information packages easy to understand (88%) and useful (89%), and no differences were detected between packages. The cost of production and dissemination of NPIP was more than double the cost for mini-NPIP: $ 8.93 vs $ 3.98 (Canadian dollars) per patient. For patients presenting to a cancer centre for the first time, packages of procedural information do not appear to reduce psychological distress, but are preferred by patients. Given the cost of producing NPIP, mini-NPIP is the preferred approach.

Breast irradiation postlumpectomy: development and evaluation of a decision instrument

PURPOSE

To develop an instrument to help clinicians inform patients about the benefits and risks of breast irradiation following lumpectomy and to help an informed patient decide whether she prefers this treatment.

METHODS

A Decision Board consisting of written material and visual aids was developed. It provides the patient with detailed information about her choices (breast irradiation or not), outcomes (breast recurrence and survival), probability of those outcomes, and quality of life associated with treatment and outcome. We studied the decision-making process in 82 consecutive node-negative lumpectomy patients who were seen in consultation by a radiation oncologist and oncology nurse. The Decision Board was used in the last 30 patients in the cohort.

RESULTS

Patient comprehension following the consultation without the Decision Board was greater than 65% for all questions addressed, except for poor understanding of the lack of survival benefit associated with breast irradiation (12% of patients answered correctly) and that it could not be repeated (15% of patients answered correctly). Comprehension following the consultation with the Decision Board was similar, but understanding regarding the repetition of radiation (83%) was improved. Only 70% of patients in the no-Decision Board group felt they were offered a choice. This was increased to 97% in the Decision-Board group. Overall, 95% of patients chose breast irradiation, and this did not differ between groups. Patients reported several reasons for choosing breast irradiation, all of equal importance.

CONCLUSION

The Decision Board facilitated shared decision making in node-negative lumpectomy patients who chose breast irradiation, but it did not affect a patient's choice to select breast irradiation.

Surgical management of cecal diverticulitis

Ninety surgical cases of cecal diverticulitis at the University of Hawaii hospitals were reviewed from 1980 to 1991. Seventy-eight percent of the study group were of Asian descent, with a mean age of 41.7 years. Right lower quadrant pain and tenderness were the only constant findings, occurring in 86 and 87 of the 90 patients, respectively. The most common preoperative diagnosis was acute appendicitis, occurring in 73% of patients. A right colectomy or cecectomy was performed in 49 patients, an appendectomy in 29, and a diverticulectomy in 10. Seventeen complications occurred, only 1 of which was in the appendectomy group. Follow-up of up to 10 years was successful in 27 of 29 appendectomy patients, only 4 of whom had recurrent pain. There were no instances of a missed cecal carcinoma. We concluded that in those patients in whom carcinoma can be ruled out and in whom there is no evidence of abscess formation, appendectomy combined with postoperative antibiotics is a safe and effective method for the treatment of cecal diverticulitis.