Addressing the Psychological Needs of the Conservatively Treated Breast Cancer Patient: Discussion Paper

Exploring the challenge of health research priority setting in partnership: reflections on the methodology used by the James Lind Alliance Pressure Ulcer Priority Setting Partnership

PLAIN ENGLISH SUMMARY

The James Lind Alliance (JLA) brings patients, carers and clinicians together in Priority Setting Partnerships (PSPs) to identify and prioritise shared uncertainties about the effects of treatment. The JLA emerged from the evidence-informed healthcare movement to address a concern that the research being carried out on treatment effectiveness is not that of most importance to patients and health professionals. In the JLA PSPs, 'hard' evidence-informed ideals meet 'soft' participatory practices. This article explores the challenges of putting co-production methods into practice by reflecting on the methods used by the JLA Pressure Ulcer PSP (JLAPUP). The JLA principles are transparency, inclusivity and avoiding waste in research. This means paying the same close critical attention to how PSPs are designed and run, as is desired in the health research which the JLA seeks to influence. JLAPUP showed that it was possible to work in partnership in a field where patients are often elderly, immobile, unrepresented and particularly unwell, many of whom are living with more than one long term condition. However, for those unfamiliar with it, 'uncertainty' was a difficult term to get to grips with. Also, it was harder for some people than others to take part and to have their voices heard and understood. In keeping with other PSPs, JLAPUP found that the nature and quality of research into pressure ulcer prevention and treatment did not reflect the priorities of those who took part.

BACKGROUND

Studies identifying a mismatch between the priorities of academics and clinicians and those of people with direct experience of a health condition pose a challenge to the assumption that professional researchers can represent the interests of patients and the public in setting priorities for health research. The James Lind Alliance (JLA) brings patients, carers and clinicians together in Priority Setting Partnerships (PSPs) to identify and prioritise shared uncertainties about the effects of treatment. There is no formal evaluation yet to examine the different approaches used by individual PSPs and the impact these methods have on the quality of the partnership and subsequent outputs. There is no gold standard method for health research topic identification and priority setting and reporting on public involvement in this area is predominantly descriptive rather than evaluative.

METHODS AND FINDINGS

The JLA Pressure Ulcer PSP (JLAPUP) was developed and worked between 2009 and 2013 to identify and prioritise the top 10 'uncertainties', or 'unanswered questions', about the effects of pressure ulcer interventions. JLAPUP identified a mismatch between the nature and quality of RCTs in pressure ulcer prevention and treatment and the kind of research evidence desired by patients or service users, carers and health professionals. Results and methods have been reported fully elsewhere. The consultative and deliberative methods used to establish health research priorities in PSPs are fundamentally interpretive. PSPs are therefore an arena in which 'hard' evidence-informed ideals meet 'soft' participatory practices. This article provides an account of the challenges faced in one particular PSP. We explain the rationale for the approaches taken, difficulties faced and the limitations at each stage, because these aspects are particularly under-reported. The JLAPUP case is used to identify possible areas for evaluation and reporting across PSPs.

CONCLUSION

Engaging people with very different health and life experiences in the complexities of health science based discussions of uncertainty is challenging. This is particularly the case when engaging groups routinely excluded from participating in health research, for example, older people with multiple comorbidities. The JLA principles of transparency, inclusivity and avoiding waste in research require paying close critical attention to PSP methodology, including full evaluation and reporting of PSP processes and outcomes. Assessing the impact of PSPs is contingent on the decision making processes of commissioners and funders.

Concepts of holism in orthodox and alternative medicine

In this essay the nature of holism in orthodox and alternative medicine will be explored and the true meaning of the words will be illustrated with a complicated case history concerning the life or death of a young pregnant mother suffering from a BRCA type breast cancer. Holism in medicine is an open-ended and exquisitely complex understanding of human biology that over time has led to spectacular improvements in the length and quality of life of patients with cancer and that this approach encourages us to consider the transcendental as much as the cell and molecular biology of the human organism. 'Alternative' versions of holism are arid and closed belief systems, locked in a time warp, incapable of making progress yet quick to deny it in the field of scientific medicine.

A comparative study of coping skills and body image: Mastectomized vs. lumpectomized patients with breast carcinoma

BACKGROUND

The diagnosis of breast cancer encompasses not only physical, but also social and psychological implications because of the importance of the breast in a woman's body image, sexuality and motherhood. Women may experience a range of concerns and fears including physical appearance and disfigurement, the uncertainty about recurrence and the fear of death. There are no Indian studies on this subject.

AIM

This study explores the various concerns of mastectomized and lumpectomized (breast conserved) patients, determines the coping mechanisms employed and the resolution of concerns. The levels of anxiety and depression in both groups were also studied.

METHODS

Seventy-five patients with breast carcinoma (50 mastectomized and 25 lumpectomized) were evaluated. The concern and coping checklist of Devlen was used. The severity of anxiety and depression was measured using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Body image or disfigurement was a concern only in the mastectomized group. Concerns were equally resolved between the two groups except for sexual role and performance, wherein the concern was resolved to a lesser extent in the mastectomized group. Coping strategies employed were effective in the resolution of concerns except for sexual role and performance, and recurrence or relapse. No statistically significant difference was found in the depression and anxiety levels of the two groups.

CONCLUSION

Concern regarding sexual role and performance was resolved to a lesser extent in the mastectomized group. Specific psychological intervention is necessary to enhance coping strategies with regard to concerns of body image, and sexual role and performance.

Improving doctor-patient understanding of probability in communicating cancer-screening test findings

Several researchers have questioned the merits of early mammography and prostate-specific-antigen (PSA) screening policies, arguing that these programs have not been proven useful in lowering mortality rates. This controversy highlights the necessity and importance of effectively communicating probability information to patients. Probability information, however, has been plaguing the health care profession--as numerous investigators have shown that it is often difficulty to understand and transmit. These difficulties can be overcome by changing the presentation format from a probabilistic format to a frequency format, thereby enhancing doctors' and patients' ability to solve and understand statistical information. Although I highlight this problematic issue with a discussion of mammography and prostate-specific-antigen screening, the suggested solution is not confined to a single medical procedure, but can be extended to any other medical domains where doctors are faced with the difficult task of providing complex probability data to patients.

An evaluation of the quality of a chemotherapy administration service established by nurses in an oncology day care centre

Traditionally, chemotherapy administration has been a medical role in Hong Kong. In 1998, two chemotherapy nurses took over part of this role within a major oncology day care centre after completing a course in chemotherapy administration and patient care. The aim of this study was to measure and evaluate the quality of care by using a self-developed audit form and the Worthing Chemotherapy Satisfaction Questionnaire (WSCQ). All records of patients who had had i.v. cannulas inserted by nurses over a period of one year were audited for the accuracy of the i.v. cannulation (n=2217). Also, patient satisfaction was assessed in 50 patients. The results showed that the accuracy of i.v. cannulation was kept constantly above 80% from the eighth month of auditing onwards. It was also found that patients preferred the use of a butterfly needle for the administration of chemotherapy. The study revealed that the level of information received regarding treatment (r=0.36, P=0.011) and satisfaction of practical advice on caring for side effects (r=0.35, P=0.012) were determinants of patients' overall satisfaction. Furthermore, anxiety when patients received chemotherapy could also be associated with overall satisfaction (r=-0.27), although the P value was of borderline significance only (P=0.58). In conclusion, the study reflected a high level of quality of care in relation to this element of nurse-led practice.

Experiences of women with a diagnosis of breast cancer: a clinical pathway approach

The study presented in this paper formed the first part of a large survey of breast cancer patients in one health authority in England, UK looking at individual needs expressed by women with a diagnosis of breast cancer. The paper provides an account of the experiences of 12 women with a diagnosis of breast cancer. The women represent a wide age range and different stages of illness. The transcribed accounts of the women were analysed by means of Qualitative Solutions and Research, Non-Numerical Unstructured Data Indexing Searching and Theorising (QSR*NUDIST). The study examined the individual experiences of women with a diagnosis of breast cancer and its aftermath as they passed through different stages related to it. The women's experiences are presented within the conceptual framework of the clinical pathway and their accounts represent their journey along the pathway. Various significant points in this journey are portrayed representing the women's reactions to diagnosis, treatment, femininity and body image, support, family and friends, information and after care.

Fear of cancer recurrence--a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears

Modern treatments for cancer are resulting in cancer patients living longer with the risk of the disease returning at a later stage. Many patients who experience a recurrence blame themselves (Mahon et al., 1990), while those in remission live with the constant fear that the cancer may return. Although fear of recurrence is recognised in the literature, few researchers have focused on this aspect as a precursor to psychological distress. This paper reviews the literature about fear of recurrence and its measurement. Leventhal's Self Regulation Model of Illness is presented to help understand patients' reactions to cancer and fears for the future. The authors propose a formulation for fear of recurrence and examples of interventions that are indicated.

Is it worth the wait? A survey of patients' satisfaction with an oncology outpatient clinic

Increasing numbers of cancer survivors and the tradition of long-term follow-up in the outpatient clinic has resulted in overcrowded oncology clinics and long waiting times. Little is known about patients' perceptions of their clinic attendance. This survey of 252 oncology patients investigated patients' satisfaction with the clinic, anxiety associated with clinic attendance and the strengths and weaknesses of the oncology service. Results demonstrated high levels of satisfaction. Far from being perceived as anxiety-provoking, the clinic was looked upon as a valuable source of reassurance, 92% of patients reporting they were 'always' or 'usually' reassured as a consequence of their visit. Qualitative data showed that clinic staff were the most important source of satisfaction. Waiting was overwhelmingly the worst aspect of the clinic, described by 27% of patients as 'excessively long'. One-fifth of the total sample had attended the clinic for 10 years or more and over a third of this group reported they would be worried at the prospect of being discharged to the care of their general practitioners. Despite disadvantages associated with long waits, the clinic was perceived as providing a valuable source of reassurance which a proportion of patients were clearly reluctant to be without.

When the diagnosis is cancer: patient communication experiences and preferences

BACKGROUND

Discrepancies exist between reported experiences of patients when they have been given a diagnosis of cancer, published guidelines for telling a diagnosis, and patterns of communication patients rate as favorable. Several studies have identified what happened and what is important to cancer patients when told their diagnosis, but no studies have addressed subsequent communications concerning the implications of the diagnosis and treatment choices. This study extended previous research by investigating the experiences and preferences for communication about diagnosis, prognosis, and treatment of patients diagnosed with breast cancer or melanoma.

METHODS

A self-report questionnaire was designed for this study based on previous research and qualitative data generated from focus groups. Patients with breast cancer or melanoma answered questions about their experiences with communication at the time of diagnosis and concerning prognosis, treatment and related issues. Comparisons were made between patient experiences, preferences and published guidelines. Differences between the experiences of breast cancer and melanoma patients were tested and the relationship between communication and subsequent psychological adjustment to cancer was assessed.

RESULTS

Patient preferences for communication during diagnostic consultation were not always consistent with published guidelines. Type of cancer did not significantly affect patient preferences. Psychological adjustment was related to patient ratings of the quality of doctor discussion about treatment options, but not about the diagnosis of cancer and its implications. Patients who wanted more emotional support at the time of diagnosis subsequently experienced poorer psychological adjustment.

CONCLUSIONS

The differences in patient preferences show that a list of prescriptions for how to disclose a cancer diagnosis is too simplistic. Guidelines for clinicians should be derived from patient-based data rather than be limited only to clinical opinion. Guidelines concerning communication at the time of diagnosis also need to address discussions concerning the implications of the diagnosis and making treatment decisions.

The Impacts of Breast Conserving Treatment and Mastectomy on the Quality of Life in Early-stage Breast Cancer Patients

The quality of life (QOL) in 55 early-stage breast cancer patients after surgery was prospectively assessed using a newly developed Japanese QOL questionnaire: The QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs (QOL-ACD). The impacts of breast conserving treatment (BCT) (22 cases) and modified radical mastectomy (MRM) (33 cases) on the QOL in those subjects were compared. The overallQOL scores were evaluated during four periods (before surgery, 0-2, 3-12, and 13-24 months after surgery). The mean scores of the four categories of the QOL-ACD (activity, physical condition, psychological condition, and social relationships) were also compared. The results demonstrated that a significant improvement was observed in the overall QOL scores among the three periods after surgery (0-2, 3-12, and 13-24 months) only in the BCT group (p<0.05). There were no significant differences between the two groups in the overall QOL scores during any of the three periods after surgery, and the mean score of the 'psychological condition' during 0-2 months period in the BCT group was significantly lower than that in the MRM group (p<0.05). These results suggest that BCT does not always improve the patients' QOL more than MRM does, and that the patients receiving BCT require more psychological support than those receiving MRM during the early postoperative period.

Assessment of quality of life in breast cancer

Effective treatment for breast cancer can produce a reasonably good ten-year survival rate in comparison to many other cancer sites. Nevertheless, the potential psychological, sexual and physical dysfunction caused by both the diagnosis and treatments can have a deleterious impact on the quality of a woman's life. The range of possible treatments may have similar outcomes in terms of response and survival, but can produce very different effects on emotional well-being. Therefore, monitoring quality of life in breast cancer should be a mandatory part of follow-up in clinical trials. Data derived from various studies of quality of life can also be used to assist the doctor and patient in decision-making about treatment options. Furthermore, assessment of quality of life can help identify those patients who might profit from psychosocial interventions. In this paper some of the instruments used to assess quality of life in breast cancer will be discussed.

Breast reconstruction at a district general hospital

Breast reconstruction is normally carried out by plastic surgeons, but the advent of permanent tissue expanders places post-mastectomy reconstruction within easy reach of the general surgeon. Nineteen patients underwent breast reconstruction between 1989 and 1991 using a subpectoral silicone-based, double lumen tissue expander. Assessment of results was by: (a) patient completed questionnaire; and (b) third party evaluation of standardized photographs. The mean operating time was 58 min (40-80 min) and mean hospital stay 3 days (2-7 days). Complications included one flap necrosis and one leaking injection port. Outpatient tissue expansion required an average of seven visits (4-11) and was completed in an average of 12 months (7-19). The injection port was subsequently removed under local anaesthetic as a day case. The fully dressed appearance following reconstruction was graded good or excellent by 100% of patients and in over 80% of third-party assessments. Equivalent figures for the appearance when wearing a bra were 93% and 60% and undressed 57% and 47%, respectively. All patients recommended the procedure but 25% found inflation uncomfortable. Subpectoral tissue expansion is a safe, cosmetically acceptable method of breast reconstruction which is associated with a high level of patient satisfaction.

Breast Reconstruction at a District General Hospital

Breast reconstruction is normally carried out by plastic surgeons, but the advent of permanent tissue expanders places post-mastectomy reconstruction within easy reach of the general surgeon. Nineteen patients underwent breast reconstruction between 1989 and 1991 using a subpectoral silicone-based, double lumen tissue expander. Assessment of results was by: ( a) patient completed questionnaire; and ( b) third party evaluation of standardized photographs.

The mean operating time was 58 min (40–80 min) and mean hospital stay 3 days (2–7 days). Complications included one flap necrosis and one leaking injection port. Outpatient tissue expansion required an average of seven visits (4–11) and was completed in an average of 12 months (7–19). The injection port was subsequently removed under local anaesthetic as a day case. The fully dressed appearance following reconstruction was graded good or excellent by 100% of patients and in over 80% of third-party assessments. Equivalent figures for the appearance when wearing a bra were 93% and 60% and undressed 57% and 47%, respectively. All patients recommended the procedure but 25% found inflation uncomfortable.

Subpectoral tissue expansion is a safe, cosmetically acceptable method of breast reconstruction which is associated with a high level of patient satisfaction.

Giving sad and bad news

When bad news is broken insensitively the impact can be distressing for both giver and recipient. For the recipient especially, the effect can be longlasting. Poor training in communication skills leaves most doctors unable to give bad news appropriately. Doctors must realise what impact the news can have on the patient; must overcome fear of being blamed for the message and of a sense of failure for not being able to improve the situation; and must learn how to cope with the recipient's reaction. Doctors should prepare adequately for the meeting, ensure that the patient has understood the message, and see to the patient's immediate needs after the interview. If diagnostic investigations or therapeutic options are being discussed at the same time, giving the patient an audiotape recording of the interview is helpful.

Framing and labelling effects in health descriptions: quality adjusted life years for treatment of breast cancer

At present there is a growing interest in the use of cost-utility analysis (CUA) to a point where it merits serious consideration by health care decision makers. However, there remain a number of theoretical and practical issues to be resolved including the way in which quality of life information is presented and described to subjects. Two potential sources of influence in the construction of the quality adjusted life year (QALY) values elicited for a recent Australian CUA of mammography screening have been investigated. 180 subjects were randomly allocated to nine different presentations of two breast cancer health descriptions to investigate the impact of some framing and labelling effects. No statistically significant differences were found in the valuations placed on these descriptions when framing and labelling effects were taken into account, either as separate framing and labelling factors or as interactions with one another. A significant difference was found in the particular values of descriptions that were written in the third person that differed in terms of whether the word "cancer" was used. The main contribution of these data is to the robustness of the health descriptions used in the cost-utility analysis of mammography screening.

The psychological costs of screening for cancer

The benefits of cancer screening programmes accrue to those who have cancer or identifiable precancerous conditions, and in whom the disease progression is slowed or halted by earlier intervention. The costs accrue to the rest of the population for whom there is no direct benefit to health. Attention has been given to the medical risks of screening procedures and to the economic costs, but there has been very little regard paid to the psychological costs. The aim of this paper is to evaluate the psychological impact of screening. Screening participants who are found to have untreatable disease, or for whom the interventions prove ineffective, have a greater proportion of their life as a cancer patient with all the associated psychological (and perhaps physical) distress, but no increase in their life expectancy. Those who receive false positive results may experience acute psychological distress produced by the prospect of a grave diagnosis before they are found to be free from serious disease. Even the procedure of screening itself, with the disturbance of the invitation, the discomfort of the tests and the wait for the diagnosis, can have a significant impact upon some patients. This paper evaluates the psychological costs which may be involved across the whole screening procedure, from the possible alarm of receiving an invitation to participate in screening, to the trauma of a cancer diagnosis for someone who had been unaware of any symptoms.

The role of a radiographer counsellor in a large centre for cancer treatment: a discussion paper based on an audit of the work of a radiographer counsellor

It is widely accepted that cancer patients have unmet psychosocial needs. There are as yet few guidelines on the appropriate role of a counsellor in centres for cancer treatment. In this study the activities of a radiographer counsellor were audited to try to identify the proportion of patients who would benefit from seeing a counsellor, to estimate the cost of such a service, and to obtain indications of how the effects of counselling could be evaluated. The study suggested that 44% of patients attending for routine radiotherapy have abnormally high levels of anxiety and might benefit from counselling. The Hospital Anxiety and Depression Scale (HADS) is proposed as an objective measure of benefit. Costing and resource allocation are discussed.

A cost utility analysis of mammography screening in Australia

Cost utility analysis is the preferred method of analysis when quality of life instead is an important outcome of the project being appraised. However, there are several methodological issues to be resolved in implementing cost utility analysis, including whether to use generalised measures or direct disease specific outcome assessment, the choice of measurement technique, and the combination of different health states. Screening for breast cancer meets this criterion as mammographic screening has been shown to reduce mortality; and it is said that earlier treatment frequently results in less radical surgery so that women are offered the additional benefit of improved quality of life. Australia, like many other countries, has been debating whether to introduce a national mammographic screening programme. This paper presents the results of a cost utility analysis of breast cancer screening using an approach to measuring outcome, Healthy Year Equivalents, developed within this study to resolve these problems. Descriptions of breast cancer quality of life were developed from surveys of women with breast cancer, health professionals and the published literature. The time trade off technique was then used to derive values for breast cancer treatment outcomes in a survey of women in Sydney, Australia. Respondents included women with breast cancer and women who had not had breast cancer. Testing of (i) the effect of prognosis on the value attached to a health scenario; and (ii) whether the value attached to a health scenario remains constant over time has been reported. The estimate of the net costs of screening are reported. The costs of breast cancer screening include the screening programme itself, the further investigations and the subsequent treatment of breast cancer cases. Breast cancer is treated in the absence of screening, many commentators claim earlier treatment is costly but there is little evidence. Therefore we have investigated current patterns of breast cancer treatment, current use of investigations for women presenting with symptoms and current use of covert mammography screening. The results are extrapolated to obtain estimates of the costs and outcomes presented as cost per healthy year equivalent. This analysis produces important information for the Australian policy debate over mammography. It also contributes to the development of cost utility analysis and the approach developed here can be applied more generally.

Can patients wash during radiotherapy to the breast or chest wall? A randomized controlled trial

A total of 99 patients receiving adjuvant radiotherapy to the breast or chest wall were randomized to one of three washing policies: (1) not washing, (2) washing with water alone, and (3) washing with soap and water. Fifty-three of the patients were treated without the use of bolus, and 46 patients were treated using bolus for 10 to 15 of the 20 treatment fractions. Approximately half of the patients randomized to washing were tattooed. Subjective and objective measurements of acute skin reactions were found to be less in the two groups randomized to washing. There was little difference between the two washing groups. These findings were the same whether or not bolus was used. It is concluded that washing of the skin should be encouraged in patients undergoing radiotherapy associated with low skin doses.

Fatigue syndrome due to localized radiation

For cancer patients, fatigue is a disturbing symptom caused by many factors. Since fatigue is the most common side effect of localized radiation to the breast, this treatment provides a unique opportunity to follow patients prospectively as they develop one type of fatigue. We evaluated the effect of radiation treatment in 15 women with Stage I or II node-negative breast cancer who were otherwise healthy. Fatigue, contrary to our hypothesis, did not increase linearly with cumulative radiation dose over time. It dropped from the first to second week and rose in the third week. The cumulative effects reached a plateau in the fourth week (after an average of 17 fractions), which was maintained during the remaining weeks of treatment. Within 3 wk after treatment, fatigue had diminished. No patient had sustained depressive symptoms. Cardiopulmonary exercise capacity in 5 patients at 6 and 12 wk did not change from just before radiation. Other markers, including reverse triiodothyronine and pulse change with orthostatic stress, did not correlate with subjective fatigue nor cumulative radiation in 15 patients. The curve of the fatigue syndrome during treatment conforms to the adaptation of the organism to a continuing stress and begins to describe a mild fatigue syndrome associated with radiation.

Satisfaction with communication, medical knowledge, and coping style in patients with metastatic cancer

Interviews were conducted with 77 patients aged 19-84, admitted to a medical oncology ward for assessment and modification of treatment. Satisfaction with information provided about tests, symptoms and treatment was assessed, together with satisfaction with care in general, factual knowledge concerning cancer and other medical conditions, and anxiety. Habitual style of coping with stress by information-seeking vs avoidance was measured using the Miller Behavioral Style Scale. Satisfaction levels were generally high. Patients reporting the highest level of satisfaction with information were more avoidant in their coping style than the remainder, and were also less anxious. Factual knowledge about cancer was in contrast greater among patients who were less satisfied with communication. These patterns were not dependent on age or education. It is argued that satisfaction with communication in medical settings is not a simple function of communication skills and the provision of adequately structured information, but that patients' tendencies to cope with stress by seeking out or avoiding information need to be taken into account.

Assessing the quality of life--a study in newly-diagnosed breast cancer patients

Quality of life (QL) assessment is an increasingly important component of clinical research, especially with cancer patients. The literature strongly supports the view that QL should be assessed by the patient rather than the clinician. While clinical parameters such as performance status or toxicity ratings may bear some relationship to QL, they are not a substitute for its measurement. In spite of these observations, clinicians have been reluctant to accept the need for patient-rated measures of QL. In this paper, data from a sample of 109 newly-diagnosed breast cancer patients were used to examine the relationship between expert-rated measures and a patient-rated measure of QL; to determine whether the Cancer Rehabilitation Evaluation System (CARES), an instrument for assessing the rehabilitation needs of cancer patients, is a measure of QL; to explore whether there are any medical, social or demographic variables which the clinician can use to predict how patients assess their QL; and to determine which variables (expert-rated scales, medical, social or demographic variables, or rehabilitation needs) have the most effect on how patients evaluate their QL. In this sample, patient ratings of QL were widely distributed and were only moderately correlated with the expert-rated Karnofsky Performance Status (r = 0.53) and Global Adjustment to Illness Scale (r = 0.59). In addition, there were no significant correlations between important clinical variables (axillary node status, type of surgery, receipt of chemotherapy) and patient-rated QL. Among the clinical variables and instruments studied, the Global CARES score demonstrated the best correlation (r = -0.74) with the patient-rated assessment of QL. A stepwise multiple linear regression procedure was performed with QL as the dependent variable in order to identify which factors accounted for the most variance in patient assessment of QL. The potential predictor variables used in this procedure were chosen from among those that would be available to a clinician. The Global CARES score was the best single predictor of QL, accounting for 55% of the variance, followed by Karnofsky Performance Status, the Medical Interaction and Sexual summary scales of the CARES, and the patient's educational status. Data from the CARES provided additional descriptive information about the type and frequency of rehabilitation problems experienced by these patients in relation to their ratings of QL.(ABSTRACT TRUNCATED AT 400 WORDS)

Best medical practice in practice: measuring efficiency in mammography screening

Breast cancer, screening and mammography have caused considerable debate in several countries. This article explores the concept of best medical practice in the context of mammographic screening for breast cancer. Maximizing the use of technology, ignores the risks intrinsic to technological intervention. To do no harm in modern medical practice means largely doing nothing. Best medical practice, therefore, requires a balancing of benefits and risks so that best practice is that which does more good than harm. At the same time, not all interventions that do more good than harm can be funded out of the current health care budget. Thus, best medical practice is economically efficient practice. From the conceptual notion of what is best medical practice, this article turns to the problem of what that means in practical terms. Can we recognize best medical practice when it occurs? The identification, measurement and valuation of costs and benefits are discussed as a specific case study, in the context of breast cancer screening. Many of the difficulties involved here, particularly on the benefit side, are highlighted, especially in the context of QALYs. Yet, whatever the difficulties involved they have to be seen in the context of otherwise settling for something less i.e. inefficient medical practice.