The clinical effectiveness and cost-effectiveness of computed tomography screening for lung cancer: systematic reviews

OBJECTIVES

The aim of this review is to examine the clinical and cost-effectiveness of screening for lung cancer using computed tomography (CT) to assist policy making and to clarify research needs.

DATA SOURCES

Electronic databases and Internet resources.

REVIEW METHODS

A systematic review was undertaken and selected studies were assessed using the checklists and methods described in NHS Centre for Reviews and Dissemination (CRD) Report 4. Separate narrative summaries were performed for clinical effectiveness and cost-effectiveness. Cost-effectiveness analysis resulting in a cost per quality-adjusted life-year was not feasible, therefore the main elements of such an appraisal were summarised and the key issues relating to the existing evidence base were discussed.

RESULTS

Twelve studies of CT screening for lung cancer were identified, including two randomised controlled trials (RCTs) and ten studies of screening without comparator groups. The quality of reporting of these studies was variable, but the overall quality was adequate. The two RCTs were of short duration (1 year) and therefore there was currently no evidence that screening improves survival or reduces mortality. The proportion of people with abnormal CT findings varied widely between studies (5-51%). The prevalence of lung cancer detected was between 0.4% and 3.2% (number need to screen to detect one lung cancer = 31-249). Incidence rates of lung cancer were lower (0.1-1% per year). Detection of stage I and resectable tumours was high, 100% in some studies. Adverse events, as a result of investigation or surgery, or the screening process per se were poorly reported. Incidental findings of other abnormalities requiring medical follow-up were reported to be as high as 49%. Six full economic evaluations of population CT screening programmes for lung cancer were included in the review. The magnitude of cost-effectiveness ratios reported varied widely. None was set in the UK and generalisation was complicated by wide variation in the data used in different countries and a paucity of UK data for comparison. All six made the fundamental assumption that screening with CT for lung cancer reduced mortality. At the current time, there is no evidence to support that assumption. In the absence of evidence of health gains from screening for lung cancer, in terms of either quantity or quality of life, and faced with a range of uncertainties, from the frequency of abnormal screening findings within a population to the natural history of screening detected lung cancers, it is not feasible at the current time to develop accurately and meaningfully an economic argument for CT screening for lung cancer in the UK. For subgroups, in particular certain occupational groups, there is evidence of increased risk of lung cancer, but the role of screening has not been demonstrated by the current studies.

CONCLUSIONS

The accepted National Screening Committee criteria are not currently met, with no RCTs, no evidence to support clinical effectiveness and no evidence of cost-effectiveness. RCTs are needed to examine the effect of CT screening on mortality, either with whole-population screening or for particular subgroups; to determine the rate of positive screening and detected lung cancers. Research is also needed to understand better the natural history and epidemiology of screening-detected lung cancers, particularly small, well-differentiated adenocarcinomas; as well as the impacts on quality of life. Increased collection is needed of UK health service data regarding resource use and safety data for lung cancer management and services. Research is also needed into the feasibility and logistics of tracing people who have in the past worked in industry where there was exposure to lung carcinogens.

Electrically stimulated resistance training in SCI individuals increases muscle fatigue resistance but not femoral artery size or blood flow

STUDY DESIGN

Longitudinal.

OBJECTIVES

The purpose of this study was to evaluate the effect of lower extremity resistance training on quadriceps fatigability, femoral artery diameter, and femoral artery blood flow.

SETTING

Academic Institution.

METHODS

Five male chronic spinal cord injury (SCI) individuals (American Spinal Injury Association (ASIA): A complete; C5-T10; 36+/-5 years old) completed 18 weeks of home-based neuromuscular electrical stimulation (NMES) resistance training. Subjects trained the quadriceps muscle group twice a week with four sets of 10 dynamic knee extensions against resistance while in a seated position. All measurements were made before training and after 8, 12, and 18 weeks of training. Ultrasound was used to measure femoral artery diameter and blood flow. Blood flow was measured before and after 5 and 10 min of distal cuff occlusion, and during a 4-min isometric electrical stimulation fatigue protocol.

RESULTS

Training resulted in significant increases in weight lifted and muscle mass, as well as a 60% reduction in muscle fatigue (P = 0.001). However, femoral arterial diameter did not increase. The range was 0.44+/-0.03 to 0.46+/-0.05 cm over the four time points (P = 0.70). Resting, reactive hyperemic, and exercise blood flow did not appear to change with training.

CONCLUSION

NMES resistance training improved muscle size and fatigue despite an absence of response in the supplying vasculature. These results suggest that the decreases in arterial caliber and blood flow seen with SCI are not tightly linked to muscle mass and fatigue resistance. In addition, muscle fatigue in SCI patients can be improved without increases in arterial diameter or blood flow capacity.

Single cell PCR amplification of microsatellites flanking the COL7A1 gene and suitability for preimplantation genetic diagnosis of Hallopeau–Siemens recessive dystrophic epidermolysis bullosa

BACKGROUND

Hallopeau-Siemens recessive dystrophic epidermolysis bullosa (HS-RDEB) is a severe inherited blistering skin disorder caused by mutations in the anchoring fibril type VII collagen gene, COL7A1. There is currently no effective treatment but DNA-based prenatal testing in families at risk of recurrence is possible, mostly involving chorionic villus sampling at 10-11 weeks' gestation.

OBJECTIVES

An alternative method, for avoiding recurrence of HS-RDEB, is preimplantation genetic diagnosis (PGD). This involves DNA analysis of single blastomeres extracted from late cleavage stage embryos following in vitro fertilisation.

METHODS

To establish PGD for HS-RDEB, we designed and optimised a sensitive single cell semi-duplex polymerase chain reaction (PCR) assay for two highly polymorphic dinucleotide repeat microsatellite markers, D3S1581 (telomeric) and D3S1289 (centromeric), close to the COL7A1 gene.

RESULTS

We demonstrated high PCR efficiency, low allele drop out rates and no contamination in testing this assay on 50 single buccal cells of known heterozygous genotype and 13 research blastomeres from donated embryos.

CONCLUSIONS

This semi-duplex PCR method provides robust, reproducible and informative amplification results for single cells. Moreover, this test has now been approved for clinical application by the UK Human Fertilisation and Embryology Authority (HFEA). As such, the development of PGD for HS-RDEB broadens the range of prenatal testing options and personal choice for couples at reproductive risk of this severe genetic skin disease.

Molecular epidemiology of rabies viruses in Europe

Several different strains of classical rabies virus co-circulate in Europe. In order to investigate the roles of the host species and topography on the molecular epidemiology of these viruses, a 400 bp region of the nucleoprotein gene was sequenced and compared with more than 500 European virus isolates. Viruses from 21 European countries were represented including some unique panels of archived isolates from the former Republic of Yugoslavia, Estonia, the Czech Republic, Poland and Austria. Phylogenetic analysis of 198 unique sequences demonstrated numerous groups of viruses clustered at both geographical and host-species levels.

Survival in patients with class III idiopathic pulmonary arterial hypertension treated with first line oral bosentan compared with an historical cohort of patients started on intravenous epoprostenol

BACKGROUND

The oral dual endothelin receptor antagonist bosentan improves exercise capacity and delays clinical worsening in patients with pulmonary arterial hypertension, but its use could delay starting intravenous epoprostenol, a life saving treatment.

METHODS

Survival in patients with functional class III idiopathic pulmonary arterial hypertension (PAH) treated with bosentan in clinical trials was compared with historical data from similar patients treated with epoprostenol in the clinic. Statistical methods were used to adjust for possible underlying differences between the two groups.

RESULTS

Baseline factors for the 139 patients treated with bosentan and the 346 treated with epoprostenol suggested that the epoprostenol cohort had more severe disease-that is, a lower cardiac index (2.01 v 2.39 l/min/m2) and higher pressures and resistance. Kaplan-Meier survival estimates after 1 and 2 years were 97% and 91%, respectively, in the bosentan cohort and 91% and 84% in the epoprostenol cohort. Cox regression analyses adjusting for differences in baseline factors showed a greater probability of death in the epoprostenol cohort (hazard ratio 2.2 (95% confidence interval 1.2 to 4.0) in the model adjusted for haemodynamics). Alternative regression analyses and analyses to adjust for different data collection dates gave consistently similar results. When matched cohorts of 83 patients each were selected, survival estimates were similar. In the bosentan cohort 87% and 75% of patients followed for 1 and 2 years, respectively, remained on monotherapy.

CONCLUSIONS

No evidence was found to suggest that initial treatment with oral bosentan, followed by or with the addition of other treatment if needed, adversely affected the long term outcome compared with initial intravenous epoprostenol in patients with class III idiopathic PAH.

Information and support needs of callers to the Cancer Helpline, The Cancer Council Victoria

The broad aims of the present evaluation were, firstly, to describe the information and support needs of callers to a Cancer Helpline and, secondly, to describe the response of the service to these needs. A further aim was to use these results to develop strategies to improve the service. Anonymous caller information collected over a 6-year period was analysed. The setting of the study was the Cancer Helpline service operated by the Cancer Council Victoria within the state of Victoria, Australia. The caller profile was similar to that described in the literature, with the majority of callers being women, younger than the general cancer population and enquiring most commonly about breast cancer. Patients and their relatives called to obtain information about cancer diagnosis, treatment and management and to obtain psychological and emotional support. Callers received emotional support, were supplied with verbal and written information and were referred to a variety of support services. Some population groups are underrepresented in the data. Changes to the Helpline and other services over the 6-year period are described. The pattern of callers to the Cancer Helpline appears similar to that described in the USA and Europe. Many issues and challenges are common. The paper discusses additional strategies for meeting the information and support needs of those affected by cancer and describes current and suggested research areas.

Comprehensive care for haemophilia around the world

Comprehensive haemophilia care has been defined as the continuing supervision of all medical and psychosocial factors affecting the person with haemophilia family. Services offered by haemophilia treatment centres (HTCs) adopting the comprehensive care model include establishing prophylaxis and other treatment protocols, development of psychosocial, education and research programme, maintenance of a patient registry, genetic and reference diagnostic services and orchestration and management of a wide variety of multidisciplinary interventions. Most centres practising this model of care are based in developed countries and can meet costs for plentiful treatment products through government or insurance-company funding. Not all the programmes are dependent on the level of product supply, however, and many have been supported in countries with emerging economies as part of national healthcare systems, particularly in relation to blood management. In this paper we present perspectives from different areas of the world on how to adopt, adapt and achieve economically appropriate models of comprehensive care.

Survival with first-line bosentan in patients with primary pulmonary hypertension

Primary pulmonary hypertension (PPH) is a progressive disease with high mortality. Administration of i.v. epoprostenol has demonstrated improved exercise tolerance, haemodynamics, and survival. The orally active, dual endothelin receptor antagonist bosentan improves exercise endurance, haemodynamics, and functional class over the short term. To determine the effect of first-line bosentan therapy on survival, this study followed 169 patients with PPH treated with bosentan in two placebo-controlled trials and their extensions. Data on survival and alternative treatments were collected from September 1999 (start of the first placebo-controlled study) to December 31, 2002. Observed survival up to 36 months was reported as Kaplan-Meier estimates and compared with predicted survival as determined for each patient by the National Institutes of Health Registry formula. Kaplan-Meier survival estimates were 96% at 12 months and 89% at 24 months. In contrast, predicted survival was 69% and 57%, respectively. In addition, at the end of 12 and 24 months, 85% and 70% of patients, respectively, remained alive and on bosentan monotherapy. Factors that predicted a worse outcome included World Health Organization Functional Class IV and 6-min walk distance below the median (358 m) at baseline. First-line bosentan therapy was found to improve survival in patients with advanced primary pulmonary hypertension.

Autologous stem cell transplantation in the treatment of systemic sclerosis: report from the EBMT/EULAR Registry

OBJECTIVE

To analyse the durability of the responses after haematopoietic stem cell transplantation (HSCT) for severe systemic sclerosis (SSc) and determine whether the high transplant related mortality (TRM) improved with experience. This EBMT/EULAR report describes the longer outcome of patients originally described in addition to newly recruited cases.

METHODS

Only patients with SSc, treated by HSCT in European phase I-II studies from 1996 up to 2002, with more than 6 months of follow up were included. Transplant regimens were according to the international consensus statements. Repeated evaluations analysed complete, partial, or non-response and the probability of disease progression and survival after HSCT (Kaplan-Meier).

RESULTS

Given as median (range). Among 57 patients aged 40 (9.1-68.7) years the skin scores improved at 6 (n = 37 patients), 12 (n = 30), 24 (n = 19), and 36 (n = 10) months after HSCT (p<0.005). After 22.9 (4.5-81.1) months, partial (n = 32) or complete response (n = 14) was seen in 92% and non-response in 8% (n = 4) of 50 observed cases. 35% of the patients with initial partial (n = 13/32) or complete response (n = 3/14) relapsed within 10 (2.2-48.7) months after HSCT. The TRM was 8.7% (n = 5/57). Deaths related to progression accounted for 14% (n = 8/57) of the 23% (n = 13/57) total mortality rate. At 5 years, progression probability was 48% (95% CI 28 to 68) and the projected survival was 72% (95% CI 59 to 75).

CONCLUSION

This EBMT/EULAR report showed that response in two thirds of the patients after HSCT was durable with an acceptable TRM. Based on these results prospective, randomised trials are proceeding.

An audit of neonatal respiratory morbidity following elective caesarean section at term

Studies have suggested that a reduction in neonatal respiratory morbidity may be achieved by delaying elective caesarean section until 39 weeks gestation. In 1997 staff at the Glasgow Royal Maternity Hospital were concerned at the level of neonatal respiratory morbidity following elective caesarean section.

AIMS

To determine the extent of neonatal respiratory morbidity following elective caesarean section at term. Then to present the findings, make recommendations and perform a repeat analysis.

METHODS

A retrospective analysis of all elective caesarean sections at term between October 1996 and October 1997 was performed. Labour ward, operating theatre and SCBU records were examined, followed by maternal and infant case note review. The gestational age at the time of caesarean section and any neonatal respiratory morbidity was recorded. The results were subsequently presented at a perinatal morbidity meeting and a recommendation made to delay elective sections until 39 weeks gestation. The audit was repeated between June 1999 and June 2000.

RESULTS

The first cycle of the audit showed significantly lower rates of neonatal admissions with advancing gestation (p < 0.001). There was also a reduction in the number of infants requiring oxygen (p = 0.001), the number of infants requiring intensive care admission (p = 0.001) and ventilation (p = 0.003) with advancing gestation. In the second cycle of the audit there was a significant decrease in the number of elective caesarean sections performed prior to 39 weeks gestation (51% vs. 26%) (p < 0.0001). There were fewer neonatal admissions with respiratory morbidity between the two phases of the audit (26/292 vs. 18/327) (RR = 0.62, 95% CI 0.34-1.1). There was also a reduction in the number of infants requiring oxygen (RR = 0.5, 95% CI 0.23-1.06) the number of infants requiring intensive care admission (RR = 0.45, 95% CI 0.15-1.29) and the number of infants requiring ventilation (RR = 0.38, 95% CI 0.1-1.47).

CONCLUSION

A reduction in neonatal respiratory morbidity can be achieved by delaying elective caesarean section until 39 weeks gestation.

The WFH Haemophilia Centre Twinning Programme: 10 years of growth, 1993-2003

The World Federation of Haemophilia (WFH) Twinning Programme celebrates its tenth anniversary this year. Twinning is one of several international WFH programmes designed to improve haemophilia care at a global level. There are two types of twinning, and the haemophilia treatment centre twinning programme should be distinguished from the WFH haemophilia organization twinning involving national member organizations. The WFH Haemophilia Treatment Centre Twinning Programme helps emerging haemophilia treatment centres develop partnerships with well-established and experienced centres. Twinning can improve diagnosis and clinical care through coaching, training and transfer of expertise, ultimately leading to improved quality of life for patients. Twinning can also enhance the profile and recognition of treatment centres in emerging countries, which can be valuable in raising awareness among politicians and the media. Examples of activities include consultation on the management of specific cases, clinical and laboratory training, donation of equipment and publications as well as research projects. The centre twinning programme also benefits centres in developed countries by giving them the opportunity to gain exposure to clinical problems no longer encountered in their own countries, as well as experience of new cultures. Currently, a total of 23 treatment centres around the world are linked through the twinning programme and applications for new partnerships are welcome. Twinning links are not permanent, but are reviewed on an annual basis and typically remain in place for periods of 3-5 years. Limited financial support from WFH is available to twinned centres in the form of money for an initial assessment visit, as well as regular annual grants to established partners and the possibility of applying for additional funding to support specific projects. In addition, continuing support and advice are available from the WFH regional programme officers.

Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton

Osteoradionecrosis (ORN) of the craniomaxillofacial skeleton is a serious and debilitating complication that can occur following radiation therapy in the head and neck. Patients require effective treatment, which eradicates diseased tissue and restores function with minimal additional morbidity in a single stage, a requirement fulfilled in many cases by free tissue transfer. In a 6-year period from 1994 to 1999, 21 patients with ORN were treated by wide resection and free-flap reconstruction. The median interval between radiation therapy and ORN was 4 years (range: 1-33 years). The median radiation dose was 6000cGy. The affected areas were the mandible (15 patients), the temporal bone (three patients), the maxilla (one patient), the cervical vertebrae (one patient) and the frontal bone (one patient). Clinical symptoms included pain, ulceration, a persistent draining fistula, exposure of bone or hardware, and pathological fracture or non-union of bone. Six patients had had previous unsuccessful attempts at conservative surgical resection. Ten patients had preoperative hyperbaric oxygen (HBO) therapy. A number of different flaps were used for reconstruction in these patients. These included free fibula flaps (13 patients), iliac crest flaps (two patients), scapula flaps (three patients) and rectus abdominis flaps (three patients). All patients achieved relief from their presenting symptoms and primary bone or wound healing. One flap (4.8%) was lost. This was successfully reconstructed in a subsequent procedure. There were three flap re-explorations, two for arterial thrombosis and one for venous thrombosis. Conservative measures, such as limited debridement and HBO therapy, may be effective in preventing the progression of ORN. However, they fail to eradicate established ORN, which requires radical surgical resection followed by functional reconstruction with well-vascularised tissue.

The Living with Cancer Education Programme. I. Development of an Australian education and support programme for cancer patients and their family and friends

After a diagnosis of cancer, patients and their families and friends experience a significant need for information about the illness, treatment and prognosis, as well as support. Structured education and support group-based programmes play a major role in meeting these needs. Following a needs assessment in 1985, the Anti-Cancer Council of Victoria (ACCV), Australia, initiated development of the Living With Cancer Education Programme (LWCEP), a structured 8-week group programme providing education and support for people with cancer and their families and friends. This paper provides an historical overview of the LWCEP, as well as an outline of the programme aims, structure, content and delivery. Recent developments and future directions are also discussed. These include adaptation of the programme for individuals with advanced or recurrent cancer, modification of the programme structure and revision of the evaluation methodology.

The Living with Cancer Education Programme. II. Evaluation of an Australian education and support programme for cancer patients and their family and friends

A diagnosis of cancer can have major adverse physical, psychosocial and economic consequences for both the individual diagnosed with cancer and their family and friends. The provision of adequate information and support to individuals affected by cancer plays a key role in facilitating better adjustment and coping. Psychoeducational group programmes are an effective way of meeting this need. This paper reports on the results of an evaluation of an Australian education and support programme for individuals with cancer and their family and friends - the Living with Cancer Education Programme (LWCEP). Data are presented based on the evaluation of 152 programmes involving 1460 participants conducted between 1994 and 2000. Participant responses related to changes in self, general coping abilities and satisfaction with the programme are reported. Results showed high satisfaction with the programme and significant improvement in coping abilities, knowledge and communication and relationships with significant others and health professionals among both groups of participants. These findings highlight several important issues for professionals involved in the psychosocial care of cancer patients and their family and friends.

Use of electrolysis as an adjunct to liver resection

BACKGROUND

Patients with hepatic metastases are potentially curable if all the diseased tissue can be resected. Unfortunately, only 10-20 per cent of patients are suitable for curative resection. Electrolysis is a novel non-thermal method of tissue ablation. When used in conjunction with surgery it may increase the number of resectable liver tumours with curative treatment.

METHODS

All patients had been deemed inoperable using currently accepted criteria. Nine patients with hepatic deposits from colorectal carcinoma underwent combined surgical resection and electrolytic ablation of metastases.

RESULTS

The treatment was associated with minimal morbidity. Within the electrolytically treated area seven patients had no radiological evidence of recurrence at a median follow-up of 9 (range 6-43) months; local recurrence was detected in two patients. Six of the nine patients had metastases elsewhere in the liver with four having extrahepatic metastases. Three patients remain tumour free. Three patients died. The median survival was 17 (range 9-24) months from the time of treatment.

DISCUSSION

Electrolysis with resection may confer a disease-free and overall survival benefit. The small size of this initial study precludes statistical analysis, but preliminary results are encouraging.

Dysregulation of transforming growth factor beta signaling in scleroderma: overexpression of endoglin in cutaneous scleroderma fibroblasts

OBJECTIVE

As an initial approach to understanding the basis of the systemic sclerosis (SSc; scleroderma) phenotype, we sought to identify genes in the transforming growth factor beta (TGF beta) signaling pathway that are up-regulated in lesional SSc fibroblasts relative to their normal counterparts.

METHODS

We used gene chip, differential display, fluorescence-activated cell sorter, and overexpression analyses to assess the potential role of TGF beta signaling components in fibrosis. Fibroblasts were obtained by punch biopsy from patients with diffuse cutaneous SSc of 2-14 months' duration (mean 8 months) and from age- and sex-matched healthy control subjects.

RESULTS

Unexpectedly, we found that fibroblasts from SSc patients showed elevated expression of the endothelial cell-enriched TGF beta receptor endoglin. Endoglin is a member of the nonsignaling high-affinity TGF beta receptor type III family. The expression of endoglin increased with progression of disease. Transfection of endoglin in fibroblasts suppressed the TGF beta-mediated induction of connective tissue growth factor promoter activity.

CONCLUSION

SSc is characterized by overproduction of matrix; that is, genes that are targets of TGF beta signaling in normal fibroblasts. Our findings suggest that lesional SSc fibroblasts may overexpress endoglin as a negative feedback mechanism in an attempt to block further induction of profibrotic genes by TGF beta.