Prospective transGEICAM study of the impact of the 21-gene Recurrence Score assay and traditional clinicopathological factors on adjuvant clinical decision making in women with estrogen receptor-positive (ER+) node-negative breast cancer

BACKGROUND

This study examined the impact of the Recurrence Score (RS) in Spanish breast cancer patients and explored the associations between clinicopathological markers and likelihood of change in treatment recommendations.

PATIENTS AND METHODS

Enrollment was offered consecutively to eligible women with estrogen receptor-positive; human epidermal growth factor receptor 2-negative, node-negative breast cancer. Oncologists recorded treatment recommendation and confidence in it before and after knowing the patient's RS.

RESULTS

Treatment recommendation changed in 32% of 107 patients enrolled: in 21% from chemohormonal (CHT) to hormonal therapy (HT) and in 11% from HT to CHT. RS was associated with the likelihood of change from HT to CHT (P < 0.001) and from CHT to HT (P < 0.001). Confidence of oncologists in treatment recommendations increased for 60% of cases. Higher tumor grade (P = 0.007) and a high proliferative index (Ki-67) (P = 0.023) were significantly associated with a greater chance of changing from HT to CHT, while positive progesterone receptor status (P = 0.002) with a greater probability of changing from CHT to HT.

CONCLUSIONS

Results from the first prospective European study are consistent with published experience and use of the RS as proposed in European clinical practice guidelines and provide evidence on how Oncotype DX and clinicopathological factors are complementary and patient selection may be improved.

Oncologists’ perceptions of cancer pain management in Spain: The real and the ideal

AIM

Studies in some countries suggest that cancer pain is often not adequately controlled, but little is known about the situation in Spain. The objective of this study was to identify medical oncologists' perceptions about pain management in their patients.

METHODS

Two-round Delphi survey of 24 medical oncologists from 22 large, geographically diverse hospitals in Spain. Physicians rated each of 150 statements on a Likert scale (1=strongly disagree; 5=strongly agree). The mean, standard deviation and frequency of replies in three agreement categories were calculated for each item. Statements allowing comparison of oncologists' perceptions of how pain is managed in routine clinical practice with how it should be managed were grouped together and analyzed.

RESULTS

The most notable discrepancies between the real and the ideal occurred in the failure to provide written information or to confirm that patients understand what they are told, the lack of comprehensive and systematic evaluation of pain, and the lack of use of non-pharmacological treatments (NPTs) for cancer pain.

CONCLUSIONS

Medical oncologists need to improve their communication skills, providing patients with both written and verbal information about their disease and the plan for pain management. Pain should be evaluated at each patient visit using validated scales, and greater attention should be paid to the possible use of NPTs.

Practical implications of gene-expression-based assays for breast oncologists

Gene-expression profiling has had a considerable impact on our understanding of breast cancer biology, and more recently on clinical care. Two statistical approaches underlie these advancements. Supervised analyses have led to the development of gene-expression signatures designed to predict survival and/or treatment response, which has resulted in the development of new clinical assays. Unsupervised analyses have identified numerous biological signatures including signatures of cell type of origin, signaling pathways, and of cellular proliferation. Included within these biological signatures are the molecular subtypes known as the 'intrinsic' subtypes of breast cancer. This classification has expanded our appreciation of the heterogeneity of breast cancer and has provided a way to sub-classify the disease in a manner that might have clinical utility. In this Review, we discuss the clinical utility of gene-expression-based assays and their technical potential as clinical tools vis-a-vis the performance of breast cancer biomarkers that are the current standard of care.

Cost savings in inpatient oncology through an integrative medicine approach

OBJECTIVES

To evaluate the cost impact of an integrative medicine intervention on an inpatient oncology service.

STUDY DESIGN

This study used nonrandomized, nonequivalent groups. A baseline sample of inpatient oncology patients at Beth Israel Medical Center admitted to the medical oncology unit before implementation of the Urban Zen Initiative were compared with patients admitted after the Urban Zen Initiative was in place.

METHODS

The Urban Zen Initiative incorporated yoga therapy, holistic nursing techniques, and a "healing environment" into routine inpatient oncology care. Length of stay and medication use data were extracted from Beth Israel's decision support electronic database. We compared length of stay, total medication costs, and costs of as-needed medications for both groups: the baseline sample of inpatient oncology patients and patients exposed to the Urban Zen healing environment initiative.

RESULTS

We had complete cost data on 85 patients in our baseline group and 72 in our intervention group. We found no difference in length of stay between the 2 groups. We found a significant decrease in use of antiemetic, anxiolytic, and hypnotic medication costs as well as a decrease in total medication costs in the Urban Zen sample compared with the baseline group.

CONCLUSIONS

An integrative medicine approach including yoga therapy, holistic nursing, and a healing environment in the inpatient setting can decrease use of medications, resulting in substantial cost savings for hospitals in the care of oncology patients.

Implementation and evaluation of an automated patient death notification policy at a tertiary pediatric oncology referral center

BACKGROUND

Not knowing about a child's death can result in poor quality of care coordination among staff and poor quality bereavement care for families. The purpose of this project was to create, implement, and evaluate an automated Patient Death Notification policy and procedure (PDNPP).

MEASURES

Baseline and follow-up surveys of clinical staff.

INTERVENTION

Implementation of a PDNPP that created an automated, systematic process for staff notification of patient deaths.

OUTCOMES

Ninety-six percent of the staff rated the PDNPP as a significant improvement; 91% reported being "very" or "somewhat" satisfied with the PDNPP, whereas only 44% of the staff were satisfied with the process at baseline.

CONCLUSIONS/LESSONS LEARNED

Implementation of an automated PDNPP was feasible and improved staff satisfaction about how they were informed of patient deaths. Staff also reported being notified about patient deaths more quickly, performing their jobs more efficiently, being able to avoid doing something that might upset the deceased patient's family, and being able to better provide support to bereaved families.

Fingertip injuries in children treated in Department of Pediatric Surgery and Oncology in the years 2008-2010

BACKGROUND

Fingertip injuries are the most common hand injuries in children seeking medical advice at trauma care centres. Most cases are treated conservatively and hospitalisation is not necessary. However, surgery under general anaesthesia is often required on account of severity of the injuries and the patients' young age. The aim of the paper is to discuss a series of patients treated in the Department of Paediatric Surgery and Oncology between 2008 and 2010, and present the problems associated with surgical care in fingertip injuries in children.

MATERIAL AND METHODS

A total of 76 children were treated in the Department of Pediatric Surgery and Oncology between 2008 and 2010 because of fingertip injuries. This group is estimated to represent approx. 10% of all patients admitted to the Emergency Unit. Fingertip injuries were treated with situation sutures, V-Y-plasty, suturing back the amputated fingertip and by suturing into thenar skin. Data were extracted from medical files and presented as percentages.

RESULTS

There were 50 boys in the group of 76 children (65.79%). Mean age was 7 years. Most of the patients were children aged 1 to 5 years (36 patients, 47.37%). In 45 children (59%), the right hand was injured. Injury to fingers responsible for the pincer grasp occurred in 29 children (38.16%).

CONCLUSIONS

Fingertip injuries are among the most common injuries in children and preservation of the hand's motor abilities depends on thorough surgical care. Most children with fingertip injuries are treated in Emergency Units and only 10% of patients need surgery under general anaesthesia after hospital admission. A number of surgical techniques can be used in the management of fingertip injuries in children. These techniques represent adaptations of methods used in adults. A model for the evaluation of severity and management of fingertip injuries in children should be established.

[The emotions of oncologists]

Emotions are parts of organizational reality to an ever increasing extent. Importantly, they are not just tools in the hand of healthcare workers to achieve better physician / healthcare professional-to-patient interactions but intrinsic processes and characteristics with psychic, cognitive and somatic actions. For a thorough investigation of the issue, a PANAS-X questionnaire was used to examine the emotions of 187 physicians and other healthcare professionals, all engaged in oncology, in 2009. The research succeeded in exploring the overall emotional state oncology professionals had assumed in relation with their job as well as enabled the authors of this study to draw the respondents' emotional map and assess their fundamental emotional attitudes. Furthermore, the authors managed to identify groups of respondents that had felt more intense positive, and/or less intense negative emotions that are socially accepted than others. They included those of senior experienced oncologists, males, individuals with families, childless individuals, ward workers, and skilled professionals. According to the findings, the range of emotions an oncologist experiences / feels intently during his everyday work is dependent upon a great number of factors.

Increasing accrual in cancer clinical trials with a focus on minority enrollment: The William Beaumont Hospital Community Clinical Oncology Program Experience

BACKGROUND

The authors reviewed changes in accrual to cancer clinical trials over the last 2 decades at their institution with a focus on minority participation after the implementation of a community clinical oncology program (CCOP) and an aggressive, education-orientated minority outreach program (MOP).

METHODS

Data on patient enrollment in clinical trials for the years 1988 to 2010 was obtained from the William Beaumont Hospital (WBH) Cancer Clinical Trials Office. The type and number of cancers diagnosed and treated during the same period were obtained from the WBH tumor registry data. The MOP was initiated in the fall of 2003 with a focus on culture-specific cancer education.

RESULTS

With the development of the CCOP, clinical trials accrual increased significantly by 10-fold (P = .001). The primary service area for the CCOP consistently averaged an 85% to 90% Caucasian population. During the same period, the minority population for the service area remained stable between 8.8% and 10% and did not change significantly. From 1999 to 2004, the WBH tumor registry data demonstrated that minorities represented 8.6% of cancers registered, whereas the average yearly minority enrollment from 2002 to 2004 was 5.4%. After initiation of the MOP, minority accrual doubled to 11% by 2010 with stable minority demographics.

CONCLUSIONS

The current findings support the importance of a CCOP in supporting the accrual of patients to national clinical trials and increasing access to state-of-the art research. These data also strongly support focusing additional energy and educational efforts on targeting minority representation in clinical trials.

A population-based assessment of specialty physician involvement in cancer clinical trials

BACKGROUND

Clinical trials are critical for evaluating new cancer therapies, but few adult patients participate in them. Physicians have an important role in facilitating patient participation in clinical trials. We examined the characteristics of specialty physicians who participate in clinical trials by enrolling or referring patients, the types of trials in which they participate, and factors associated with physicians who report greater involvement in clinical trials.

METHODS

We analyzed data from the Cancer Care Outcomes Research and Surveillance Consortium. The study included 1533 specialty physicians who cared for colorectal and lung cancer patients (496 medical oncologists, 228 radiation oncologists, and 809 surgeons) and completed a survey conducted during 2005-2006 (response rate = 61.0%). Descriptive statistics were used to characterize physicians' personal and practice characteristics, and regression models were used to examine associations between these characteristics and physician participation in clinical trials. All statistical tests were two-sided.

RESULTS

A total of 87.8% of medical oncologists, 66.1% of radiation oncologists, and 35.0% of surgeons reported referring or enrolling one or more patients in clinical trials during the previous 12 months. The mean number of patients referred or enrolled by these physicians was 17.2 (95% confidence interval [CI] = 15.5 to 18.9) for medical oncologists, 9.5 (95% CI = 7.7 to 11.3) for radiation oncologists, and 12.2 (95% CI = 9.8 to 14.6) for surgeons (P < .001). Specialty type, involvement in teaching, and affiliation with a Community Clinical Oncology Program (CCOP) and/or a National Cancer Institute-designated cancer center were associated with physician trial participation and enrolling more patients (all Ps < .05). Two-thirds of physicians with a CCOP or National Cancer Institute-designated cancer center affiliation reported participating in trials.

CONCLUSIONS

Features of specialty physicians' practice environments are associated with their trial participation, but many physicians at CCOPs and cancer centers do not participate.

[Statistical models of longevity, aging and degradation in demography, gerontology and oncology]

Several interesting papers related with the problems of mathematical modelling in connection with a study of aging and longevity have been published recently in "Advances of Gerontology"; see, for example, [1-4, 10, 11]. Following the main idea of these papers we consider here some approaches for construction of statistical models used today in survival analysis and reliability, and which can be used in demography, gerontology and carcinogenesis studies. We expose the so called dynamic regression models, which are well adapted for studies of survival in dynamic environments.

Control chart methods for monitoring surgical performance: a case study from gastro-oesophageal surgery

Graphical methods are becoming increasingly used to monitor adverse outcomes from surgical interventions. However, uptake of such methods has largely been in the area of cardiothoracic surgery or in transplants with relatively little impact made in surgical oncology. A number of the more commonly used graphical methods including the Cumulative Mortality plot, Variable Life-Adjusted Display, Cumulative Sum (CUSUM) and funnel plots will be described. Accounting for heterogeneity in case-mix will be discussed and how ignoring case-mix can have considerable consequences. All methods will be illustrated using data from the Scottish Audit of Gastro-Oesophageal Cancer services (SAGOCS) data set.

Immunisation practices of paediatric oncology and shared care oncology consultants: a United Kingdom survey

BACKGROUND

In March 2002, the Royal College of Paediatrics and Child Health (RCPCH) introduced guidelines for re-immunisation of children after completion of standard-dose chemotherapy and after haematopoietic stem cell transplant (HSCT).

AIMS

To ascertain whether these guidelines form standard unit policy by undertaking a survey of UK paediatric principal treatment centre (PTC) consultants and shared care (SC) consultants.

PROCEDURES

In October 2008, a link to an on-line anonymised survey was sent by e-mail to all UK PTC consultants in Children's Cancer and Leukaemia Group (CCLG) centres and to SC consultants linked to eight of these centres.

RESULTS

Responses were received from 55 PTC consultants (representing all 21 CCLG centres) and 54 SC consultants. In accordance with the RCPCH guidelines, most PTC and SC consultants recommend initiating re-immunisation at 6 months after completion of standard-dose chemotherapy (99/105, 94.3%). Re-immunisation at the recommended time after HSCT for each transplant type was reported by 93-100% of respondents. Pneumococcal conjugate vaccine (PCV) was recommended after chemotherapy by 58.3% (35/60) of respondents and by 51.7% (30/58) after HSCT. There were distinct differences between PTC and SC consultants in their choice of varicella (VZV) post-exposure prophylaxis.

CONCLUSIONS

There is a high level of stated compliance with RCPCH guidelines. Recommendations for PCV after chemotherapy and HSCT were lower than expected. This may reflect the absence of specific guidelines after chemotherapy but not in HSCT patients where guidelines do exist. Variation in VZV post-exposure prophylaxis suggests further studies are required.

Declining death rates reflect progress against cancer

BACKGROUND

The success of the "war on cancer" initiated in 1971 continues to be debated, with trends in cancer mortality variably presented as evidence of progress or failure. We examined temporal trends in death rates from all-cancer and the 19 most common cancers in the United States from 1970-2006.

METHODOLOGY/PRINCIPAL FINDINGS

We analyzed trends in age-standardized death rates (per 100,000) for all cancers combined, the four most common cancers, and 15 other sites from 1970-2006 in the United States using joinpoint regression model. The age-standardized death rate for all-cancers combined in men increased from 249.3 in 1970 to 279.8 in 1990, and then decreased to 221.1 in 2006, yielding a net decline of 21% and 11% from the 1990 and 1970 rates, respectively. Similarly, the all-cancer death rate in women increased from 163.0 in 1970 to 175.3 in 1991 and then decreased to 153.7 in 2006, a net decline of 12% and 6% from the 1991 and 1970 rates, respectively. These decreases since 1990/91 translate to preventing of 561,400 cancer deaths in men and 205,700 deaths in women. The decrease in death rates from all-cancers involved all ages and racial/ethnic groups. Death rates decreased for 15 of the 19 cancer sites, including the four major cancers, with lung, colorectum and prostate cancers in men and breast and colorectum cancers in women.

CONCLUSIONS/SIGNIFICANCE

Progress in reducing cancer death rates is evident whether measured against baseline rates in 1970 or in 1990. The downturn in cancer death rates since 1990 result mostly from reductions in tobacco use, increased screening allowing early detection of several cancers, and modest to large improvements in treatment for specific cancers. Continued and increased investment in cancer prevention and control, access to high quality health care, and research could accelerate this progress.

Referral patterns of Indiana oncologists for colorectal cancer genetic services

We assessed the utilization and referral patterns of Indiana oncologists for colorectal cancer (CRC) genetic services. Surveys were sent to 151 oncologists practicing within the state, with a response rate of 40%. Half of respondents had previously referred patients for CRC genetic services. Those who had not cited reasons, including absence of an appropriate patient, lack of information about genetic services, and uncertainty regarding which patients to refer. Most were interested in materials that would assist in identifying patients for referral. As a result, a booklet was developed and given to participants. This study demonstrates the need for physician education about CRC genetic services.

[Emotional burnout among oncologists]

The burnout syndrome is characteristic of medical profession because doctors are involved with people who are in great trouble; moreover, they are required to engage patients and maintain close psychological interaction with them. An analysis of questionnaires on problems of patient-doctor communication showed that specialized programs of psychological training should be created to help oncological doctors avoid burnout.

Nasopharyngeal carcinoma in Saudi Arabia: clinical presentation and diagnostic delay

Nasopharyngeal carcinoma is commonly advanced at diagnosis. In this study we evaluated the clinical presentation, diagnostic delay and factors affecting delay in nasopharyngeal carcinoma. Data were collected prospectively for 307 newly diagnosed patients, including detailed demographic data, disease history, health care consultations and referral process. Diagnostic delay was classified as patient, professional and overall. Neck lump and nasal obstruction were the commonest presenting symptoms. There was a significant association between delay time of > or = 3 months and advanced stage. Patient's age and otological symptoms were associated with increased overall delay time. Advanced clinical stage at diagnosis was associated with paitents' sociodemographic characteristics.

Contacting bereaved relatives: the views and practices of palliative care and oncology health care professionals

There are few data on the interactions of health care professionals with bereaved relatives. The objective of this study was to explore the current practice of health care professionals in oncology and palliative care in contacting bereaved relatives, and to elicit their views regarding the purpose, the optimal means, the format, timing, and content of these contacts. We conducted 28 in-depth, semi-structured interviews with health care professionals in Australia working in palliative care and oncology. The interviews were audiotaped and transcribed. Further interviews were conducted until no additional themes were raised. The narratives were analyzed using qualitative methodology. Most participants were in favor of contacting bereaved relatives after the death of a patient they had cared for. Some barriers to implementing these contacts were identified, including time constraints, institutional factors, and personal barriers. Contacts ranged from a personal phone call to a standardized letter. Timing of contacts varied from immediately after the death of the patient to several weeks later. Participants used words and phrases in these contacts that ranged from personal and individualized messages to standard phrases. Health care professionals emphasized the importance of contacting bereaved relatives after the death of a patient for whom they had cared. The format and content of current contacts vary widely, and there does not seem to be a gold standard approach. This area has been relatively unexplored and lacks adequate models for health care professionals. This study provides some insight into current practice and hopes to facilitate further discussion of this topic.

Professional burnout among Spanish medical oncologists

INTRODUCTION

Studies on physician burnout in Spain show a significant presence of the syndrome among our professionals. Some studies highlight the speciality of medical oncology as one of the most affected. The objective of this study was to evaluate the incidence of burnout syndrome among the group of medical oncologists affiliated to the Spanish Society of Medical Oncology (SEOM), as well as to assess the weight of sociodemographic variables, background and consequences involved in the process.

MATERIALS AND METHODS

An anonymous protocol was posted to medical oncologist members of the SEOM (n=795). This protocol comprised a scale of sociodemographic variables and three scales of the Medical Professional Burnout Questionnaire. In response we received 200 complete protocols and statistical analyses were conducted with the programme SPSS, version 14.0.

RESULTS

The sample showed high burnout levels in the areas of exhaustion and loss of expectations, with perception of time pressure to conduct work and social deterioration perceived in the profession as the two background elements with the greatest weight to explain the syndrome. The health consequences (physical and emotional) for the phy - sician are clear. Initial results show that conducting research and lecturing tasks could be a protective factor against developing the syndrome.

CONCLUSIONS

The results suggest the importance of developing prevention and intervention lines for medical oncology burnout. In this sense, issues such as work time management and motivational aspects related to research tasks could be worth considering.

[Bibliometry of cancer in Portugal: 1997 to 2006]

INTRODUCTION

the scientific production of Portuguese institutions in the specific field Oncology during a 10 year period (1997-2006) was evaluated. The contribution of national authors to the international scientific production was verified. This enabled to assess and quantify the importance of authors, departments, institutions and scientific investigations.

MATERIAL AND METHODS

Using version 2006 of Web of Science, section Science Citation Index, a database of literature references which enables analysis of citations, and also the Journal Citation Reports (tools produced by ISI Thomson Scientific), a quantitative and qualitative analysis of the Portuguese scientific production on cancer between 1997 to 2006 was performed.

RESULTS

during the studied period, 1.384 articles were published in scientific journals with given impact factor, which obtained a total of 16.484 citations, corresponding to a mean of 11.91 citations per article. Between 1997 and 2006 an increase of 214% was noticed in the national scientific production in the selected field. Ten authors represent 46% of the produced documents. The majority of published articles were performed by Universities, being Oporto University the one with highest contribution. Co-authorship is the rule in the production of articles and Portugal is no exception. Articles with international collaboration where those which obtained the highest citation rate. The Portuguese contribution to the international scientific production in the field of Oncology in the studied period was of 0.21%.

CONCLUSIONS

Bibliometric analysis is a reliable tool to evaluate the development and quality of scientific production. A growing visibility of investigation in this area was observed. This conclusion is based on the increase in the number of articles published in international journals of recognized reputation. National authors publish few articles, but they select high standard journals.

Impact of patient age and comorbidity on surgeon versus oncologist preferences for adjuvant chemotherapy for stage III colon cancer

BACKGROUND

To study surgeons' versus oncologists' preferences for adjuvant chemotherapy for elderly patients with stage III colon cancer, as population studies indicate that such patients are less likely to receive treatment.

STUDY DESIGN

A vignette-based survey was mailed to a nationally representative sample of 1,000 general surgeons and 1,000 oncologists in the United States. Patient age, comorbidity level, and preference were varied across eight vignettes. Physician preference for referral (surgeons) or treatment (oncologists) was measured using a 7-point Likert scale. Mixed-effects linear regression was used to evaluate the results.

RESULTS

One thousand twenty-nine surveys were returned (response rate of 54%). Among surgeons, increasing age and more severe comorbidity resulted in lower likelihood of referral to oncologist: mean difference in preference scores for vignettes describing a 61-year-old versus an 83-year-old patient (adjusted for comorbidity) was 0.77 (p < 0.0001); mean difference in scores between vignettes describing a patient with none versus severe comorbidity, adjusted for age, was 1.94 (p < 0.0001). Among oncologists, patient age and comorbidity interacted significantly (p < 0.0001) to affect oncologists' preferences: both increasing age and more severe comorbidity resulted in decreased preference for recommending adjuvant chemotherapy, but oncologists were more heavily influenced by comorbidity at younger patient age. Patient preference against therapy also affected physicians' recommendations (p < 0.0001), but the magnitude of effect was small relative to age and comorbidity.

CONCLUSION

Patient age and comorbidity level influence both types of physicians' preferences about adjuvant chemotherapy for colon cancer and might explain some of the patterns of care seen for this disease in population-based studies.