The lack of head-to-head randomised trials and the consequences for patients and national health service: The case of non-small cell lung cancer

INTRODUCTION

To introduce a drug to the market, it's not mandatory for it to be more effective and safer than the current treatment for the same condition. Consequently, head-to-head studies between the two best treatments for the same condition are not required, and this could result in a lack of information for patients, clinicians, and decision-makers. This study aims to evaluate the presence of head-to-head studies among the drugs used for the treatment of non-small cell lung cancer (NSCLC).

METHODS

Taking into account the National Comprehensive Cancer Network (NCCN) guidelines updated to 2022, which list all available treatments for each NSCLC subtype, the search engine Pubmed and the platform clinicaltrials.gov were consulted to find all completed and ongoing head-to-head studies among various treatments for NSCLC.

RESULTS

Among the anti-EGFR (epidermal growth factor receptor) drugs, 7 studies were found, with 6 completed and 5 registrational for drug commercialisation. No completed study to date has compared osimertinib and afatinib. For anti-ALK (anaplastic lymphoma kinase) drugs, 7 studies were found, with 5 completed. Alectinib, brigatinib, and lorlatinib have no completed comparison studies, but all were compared with crizotinib. Among various immunotherapy-based regimens, 5 studies were found, with only 1 completed. Therapeutic regimens based on pembrolizumab, atezolizumab, or the combination of nivolumab/ipilimumab have not been compared in studies published to date.

CONCLUSION

There are few head-to-head studies comparing treatments for NSCLC; there are no such studies between the latest generation of drugs. Consequently, ambiguous areas exist due to the lack of comparative studies among the available evidence, preventing the clinician's choice of the most effective treatment and risking the patient receiving suboptimal therapy. Simultaneously, the price of the drug cannot be determined correctly, relying only on indirect evaluations from different trials. To dispel this uncertainty, it would be desirable to initiate a process that brings together the demands derived from clinical practice and clinical research to provide clinicians and patients with the best possible evidence.

[Clinical trials approved by Aifa for Covid-19: report of the main results to fill the unmet medical need.]

INTRODUCTION

the rapidity with which the Coronavirus epidemic emergency exploded took the scientific community by surprise, unprepared for such an event. The objective of this work is to evaluate, to date, the state of the art of the clinical trials approved by Aifa, analyzing the characteristics of the single completed and published trials and the authorization status for the use of the drugs under study in the treatment of Covid-19.

MATERIALS AND METHODS

The protocols available for each clinical study were extrapolated from the Aifa website relating to the management of clinical trials in Italy during the Covid-19 emergency; the unique EudraCT and Nct codes were extrapolated from these, verifying their publication using the PubMed search engine, the ClinicalTrials.gov platform, the EU Clinical Trials Register portal and the website of the pharmaceutical company identified as the promoter of the study. The characteristics of the individual trials useful for the analysis were extracted from the published papers. Finally, a comparison was made between the studies relating to experimental drugs which were subsequently authorized for the Covid-19 indication and the studies relating to drugs which have not yet been authorized to date.

RESULTS

In total, Aifa approved 94 between March 2020 and March 2022; of these, 22 are not listed on ClinicalTrials.gov; of the 72 trials listed on ClinicalTrials.gov, 31 (43%) were published, for a total of 25 drugs. Of the authorized and published trials, 26 report the "mortality endpoint". The most studied drugs are remdesivir and tocilizumab with 3 studies each, methylprednisone and molnupravir with 2. 14 studies are phase III, of these 12 used a drug as an experimental treatment which was then approved for Covid-19. Of the 41 trials present on ClinicalTrials.gov that have not yet been published, 21 are terminated. The drugs anakinra, remdesivir, molnupravir, regdanvimab, tocilizumab, AZD1222 vaccine have been updated/registered for Covid-19 indication; anakinra, baricitinib, tocilizumab and sarilumab have been included in the list of Law 648/96; remdesivir, canakinumab and ruxolitinib have been entered into compassionate use programmes.

DISCUSSION AND CONCLUSIONS

The methods of early access to therapy have allowed an alternative to patients who are not eligible for the ongoing trials. The challenge that the scientific community has faced has strengthened the culture of evidence-based medicine.

Quality of Care of Colorectal Cancer Patients in General Hospitals: Diffusion and Impact of Management Guidelines

Over the last ten years the Italian National Research Council (C.N.R.) has launched an educational program aimed at favoring the delivery of the most up to date care for cancer patients in community hospitals. Among various tumors for which this effort was undertaken, management guidelines for colorectal cancer were developed in 1978 by a multidisciplinary team of national experts and reported in booklets distributed nationwide under the aegis of the Colorectal Cancer Task Force. In 1988, the C.N.R. funded an evaluation to learn whether: a) the guidelines were widely diffused in the target physician populations; b) their content was accepted by those who received them and, c) practice patterns were consistent with the recommendations in the guidelines. Overall results indicate only a limited effect. Despite clear evidence of a positive self-selection in the physicians’ survey, guidelines were familiar to only 47% of responders. Although acceptance of at least some specific recommendations was good among doctors aware of the guidelines (≥ 60% responders), this finding loses relevance since a not negligible proportion of those not aware of them had the same convictions. Finally, analysis of practice patterns showed serious deficiencies (mostly in terms of thoroughness of operative staging) even in centers where more widespread knowledge of the guidelines should have led to better quality of care. The paper also discusses the comparability of our findings to results of a similar evaluation carried out in the U.S.A. Our results underscore the importance of analyzing the process of diffusion in any assessment of interventions based on knowledge dissemination.

Lung Cancer Care in General Hospitals

Diagnostic procedure, therapeutic care and degree of follow-up delivered to 1692 lung cancer patients over 2 years (1978–79) in 31 Italian hospitals were reviewed. The data show marked deficiencies in the various indicators analysed: staging by standard methods was recorded only in 13% of patients; reliable histocytologic classification in 54% of patients. A group of commonly accepted protocols was adopted as first-line therapy only in 49% of treated cases; 19% of patients were regularly followed according to standard programs, whereas 49% had been dropped without any information in the charts. Better performance, although not satisfactory, was found in hospitals with oncologic facilities and wards compared to centers without « ad hoc » organizations. The discussion focussed on the limits of organizational measures and efforts to determine widespread improvement in care for a disease such as lung cancer for which real therapeutic gains are still hard to achieve.

Trends in Patterns of Care for Breast Cancer in Italy (1979-1987)

We reviewed care delivered to about 2,500 breast cancer patients in general hospitals over the period 1979-1987 using data from three surveys. The most important and consistent failure was in diagnostic timeliness: about one out of four patients was diagnosed six or more months after the first symptom leading to an almost doubled probability of being diagnosed with more advanced disease. Acceptance of treatment recommendations seemed less satisfactory for surgery than for adjuvant treatments. Conservative surgery still appeared to have limited acceptance for patients with small primary tumor (21 and 23% in 1983 and 1987, respectively) although, starting 1983, there was a shift from the Halsted to the Patey type of radical mastectomy. Follow-up was routine in most node-negative patients and adjuvant chemotherapy was already well established treatment for most pre-menopausal node-positive women (64, 79 and 76% in 1979, 1983 and 1987, respectively). Some form of adjuvant treatment in postmenopausal node-positive women was already present In 1983 but became more widespread in 1987 (82%): this being mostly accounted for by the increase in the use of tamoxifen (delivered alone or in combination with chemotherapy to 53% of women). Overall, our results suggest that areas of care more dependent on organization or doctors’ and patients’ education (i.e. diagnostic timeliness and accessibility) are those where deficiencies seen to be least amenable to change in the absence of concerted intervention. Among more narrowly defined clinical issues, there appeared to be some dissonance between the rapid acceptance of adjuvant treatments and the still slow pace of acceptance of less aggressive procedures by surgeons.

Breast Cancer Estrogen and Progesterone Receptors: Associations with Patients' Clinical and Epidemiologic Characteristics

A total of 1095 patients with operable breast cancer and en-rolled in a randomized clinical trial were analysed for estrogen (ER) and progesterone (PgR) receptor content of their primary tumor, and the relationships between steroid receptor status and several epidemiologic characteristics were studied. The proportion of ER+ and median ER levels increased with age: compared to women younger than 40, those aged 66 or more were approximately three times more likely to have an ER+ tumor (OR = 3.0, 95% C.I. = 1.6–5.7). This difference tended to be more marked after comparison between patients with ER > 100 fmol/mg protein and ER- within the same age groups: OR = 7.04, 95 % C.I. = 2.89–17.12. No association emerged between age and PgR. ER status and concentrations were independent of menopausal status after adjustment for age, whereas the proportion of PgR+ and PgR levels were significantly lower in postmenopausal patients of the same age. The distribution of ER and PgR profiles was similar in relation to family history of breast cancer, reproductive events and other selected epidemiologic characteristics of the patients.

Diagnosis and First-Line Treatment of Patients with Lung Cancer in Italian General Hospitals

The quality of diagnostic and therapeutic care was examined in a series of 380 consecutive newly diagnosed cases of primary lung cancer seen in 20 Italian general hospitals between January and June 1987. At diagnosis most patients (78%) had one or more symptoms related to the tumor, and in an additional 9 % symptoms were related to the presence of distant metastases. The median diagnostic time lag between first symptoms and final diagnosis was 50 days with a significantly longer delay in patients first seen by their general practitioner compared with those who sought first care in hospital outpatient departments. The diagnostic process was satisfactorily carried out in fewer than two-thirds of the patients leading to complete ascertainment of disease stage and histology in 58% cases with significantly better performance in more specialized institutions. Analysis of the first-line treatment profile indicated a rather aggressive therapeutic attitude In the case of patients with non-small cell lung cancer – 28% of them had chemotherapy despite the lack of any proof of efficacy in controlled clinical trials – and a failure to identify among the patients with small cell disease those amenable to more aggressive treatment. The lack of progress in the treatment of lung cancer over the last decades seems to have resulted in widely varying practice patterns where a mixture of aggressive and laissez-faire attitudes does not take into account that in the absence of effective therapies a more conservative attitude would at least have some advantage in terms of quality of remaining life for many patients.

Patients’ Assessment of Quality of Care: A Survey of a Group of Breast Cancer Patients in Italy

Patients’ assessment of quality of care was investigated in 825 women with breast cancer treated in a group of specialized and non-specialized institutions in Italy. A 10-page mail questionnaire explored patients’ adjustment to the disease, satisfaction with care, and quality of the information on diagnosis and treatment. Most of the 428 (52 %) responders reported good or acceptable adjustment to the disease (as reflected by acceptable performance in some daily living activities), and favorable judgment about care providers, but many women complained of hospital organizational deficiencies. A contradictory picture emerged regarding the quality of information. Completeness and thoroughness appeared seriously deficient when examined objectively using a series of explicit predefined criteria, but patients’ assessments showed in most cases moderate or high satisfaction. The paper presents these results and discusses pros and cons in the use of patients’ opinions for evaluation of quality of care.

Prevalence study on potential drug–drug interaction in cancer patients in Piacenza hospital’s Onco-Haematology department

Background

Cancer patients can be a human model of potential drug interactions. Usually they receive a large number of different medications, including antineoplastic agents, drugs for comorbid illness and medication for supportive care, however information about these interactions are fragmented and poor.

Objective

We assessed a prospective study to evaluate the prevalence of drug interaction among patients hospitalized in the Onco-Haematology department, Hospital of Piacenza.

Methods

Data on drugs administered for cancer, comorbidities, or supportive care were collected from different computerized prescription software in use in the department; we compared them with a database to focus on the co-administration of drugs. A literature review was performed to identify major potential drug interaction and to classify them by level of severity and by strengths of scientific evidence.

Results

In this study 284 cancer patients were enrolled; patients had taken an average of seven drugs on each day of therapy plus chemotherapeutic agents, we identified 67 potential drug interactions. At least 53 patients had one potential drug interaction. Of all potential drug interactions 63 were classified as moderate severity and only four as major. In 55 cases chemotherapeutic agents were involved in possible interactions with supportive care drugs, meanwhile in 12 cases the potential drug interactions were between supportive care drugs.

Conclusions

In our centre, thanks to a computerized prescription software, integrated with caution alarm in case of possible interaction, we had a lower rate of potential drug interactions than the one from literature. It is possible to improve the software integrating the alarm with the potential drug interactions between chemotherapy agents and supportive care drugs.

Does a drug do better when it is new?

BACKGROUND

When assessing a new, promising therapeutic approach, a clinician's perception of a drug's effectiveness may be shaped by different kinds of phenomena, and among them, a favorable attitude towards new treatments, and as a result a tendency to overestimate their efficacy (wish bias).

MATERIALS AND METHODS

A retrospective study of published randomized clinical trials of doxorubicin-based chemotherapy for advanced breast cancer was carried out. Global (complete plus partial) response rate over time with allowance for type of drug regimen (mono- or polychemotherapy) and prior adjuvant therapies was assessed in the doxorubicin-containing arm using multivariate logistic regression analysis.

RESULTS

Twenty-nine studies published from 1975 to 1999 were retrieved for a total of 2234 women with advanced breast cancer enrolled in the doxorubicin-containing arms. There was a significant decrease in response rate to doxorubicin as first-line treatment over time that resisted adjustment for important differences in therapeutic management [odds ratio for global response = 0.89, 95% confidence interval (CI) 0.81 to 0.99].

CONCLUSIONS

Although only one drug (doxorubicin) in one clinical context (advanced breast cancer) has been analyzed, our findings support the use of double blind methodology whenever possible when assessing subjective endpoints and encourage further studies aimed at defining the clinical relevance of a wish bias in medicine.

Follow-up strategies for women treated for early breast cancer

BACKGROUND

Follow-up examinations are commonly performed after primary treatment for women with breast cancer. They are used to detect recurrences at an early (asymptomatic) stage.

OBJECTIVES

To assess the effectiveness of different policies of follow-up for distant metastases on mortality, morbidity and quality of life in women treated for early breast cancer.

SEARCH STRATEGY

We searched the Breast Cancer Groups specialised register, the Cochrane Controlled Trials Register ( Cochrane Library Issue 4, 1999), MEDLINE (January 1975-September 1999) and EMBASE (1988-September 1999) using "Breast Neoplasms" and "follow-up". References from retrieved articles were also checked, as were the lists of presentations from recent breast cancer meetings.

SELECTION CRITERIA

All randomised controlled trials (RCTs) assessing the effectiveness of different policies of follow-up after primary treatment were reviewed for inclusion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and eligibility for inclusion in the review. Data were pooled in an individual patient data meta-analysis for the two RCTs testing the effectiveness of different follow-up schemes. Subgroup analyses by age, tumour size and lymph node status before primary treatment are also presented.

MAIN RESULTS

Four RCTs involving 3204 women with early breast cancer (clinical stage I, II or III) have been included. Two RCTs involving 2563 women compared follow-up based on clinical visits and mammography with a more intensive scheme including radiological and laboratory tests. After pooling the data, no significant differences in overall survival (hazard ratio 0.96, 95% confidence interval 0.80 to 1.15) or disease-free survival (hazard ratio 0.84, 95% confidence interval 0.71 to 1.00) emerged. No differences in overall survival and disease-free survival emerged in subgroup analyses according to patient age, tumour size and lymph node status before primary treatment. One RCT (296 women) compared follow-up performed by a hospital-based specialist to follow-up performed by general practitioners. No significant differences in time to detection of recurrence and quality of life emerged. One RCT (196 women) compared regularly scheduled follow-up visits to less frequent visits restricted to the time of mammography. No significant differences emerged in interim use of telephone and frequency of GP's consultations.

REVIEWER'S CONCLUSIONS

Follow-up programs based on regular physical examinations and yearly mammography alone appear to be as effective as more intensive approaches based on regular performance of laboratory and instrumental tests in terms of timeliness of recurrence detection, overall survival and quality of life. In one RCT, follow up care performed by general practitioners had comparable effectiveness to that delivered by hospital based specialists in terms of quality of life and time to detection of distant metastases.

Cytotoxic and hormonal treatment for metastatic breast cancer: a systematic review of published randomized trials involving 31,510 women

PURPOSE

A systematic review of randomized clinical trials (RCTs) was undertaken to assess the effectiveness of medical treatment for metastatic breast cancer.

METHODS

RCTs published between 1975 and 1997 have been classified according to 12 therapeutic comparisons: (1) polychemotherapy (PCHT) agents versus single agent; (2) PCHT regimens with anthracycline versus PCHT without anthracycline; (3) other PCHT versus cyclophosphamide, methotrexate, and fluorouracil (CMF); (4) chemotherapy (CHT) with epirubicin versus CHT with doxorubicin; (5) CHT versus same CHT delivered with less intensive schedules; (6) other endocrine therapy (OET) versus tamoxifen; (7) OET plus tamoxifen versus tamoxifen alone; (8) OET versus medroxyprogesterone; (9) OET versus aromatase inhibitors; (10) OET versus megestrol; (11) endocrine therapy (ET) versus same ET at lower doses; and (12) CHT plus ET versus CHT. Tumor response rates, mortality hazards ratio (HR) and frequency of severe side effects were the outcome measures.

RESULTS

A total of 189 eligible trials (31,510 patients) were identified. All provided response rates and 133 (70%) data or survival curves needed for calculation of the HR. In eight of 12 comparisons, statistically significant differences for response emerged (1, 2, 3, 5, 7, 8, 11, 12); all but no. 8 favored the first term of the comparison. Overall survival analysis showed better results of (a) PCHT versus single-agent CHT (HR=0.82; 95% confidence interval [CI], 0.75 to 0.90); (b) CHT with doxorubicin versus CHT with epirubicin (HR=1.13; 95% CI, 1.00 to 1.27); (c) CHT versus the same CHT delivered with less intensive schedules (HR=0.90; 95% CI, 0.83 to 0.97); (d) ET versus the same ET at lower doses (HR=0.86; 95% CI, 0.77 to 0.97). Quality of life was measured in only 2,995 of 31,510 patients (9.5%).

CONCLUSION

Despite some evidence of effectiveness of specific regimens, the relevance of these findings is limited by the modest survival benefit and the lack of evaluation of the quality-of-life impact of these treatments.

EBVD and alternating MOPP/EBVD with or without localized field radiotherapy in advanced or unfavorably presenting Hodgkin's disease

PATIENTS AND METHODS

Ninety-five patients with previously untreated, advanced or unfavorably presenting Hodgkin's disease were recruited in ten centers. Twenty-five patients with stage II-A-bulky disease received four courses of EBVD (epirubicin, bleomycin, vinblastine, dacarbazine) plus involved field radiotherapy (Group 1); 24 patients in stage I-B, II-B and III-A received 6 courses of EBVD (11 of them also received radiotherapy on bulky localizations (Group 2); 46 patients in stage III-AS > or = 3 nodes, III-B and IV received MOPP/EBVD 4 + 4 courses (Group 3).

RESULTS

Eighty patients (84%) achieved CR, eight patients (8%) a PR, five patients did not respond and two progressed during therapy. CRs were achieved by 23/25 patients (92%) in Group 1, 21/24 (87%) in Group 2 and 36/46 (78%) in Group 3. The mean duration of follow-up was 33.3 months (range 5-69). There were three deaths from directly treatment-related causes. Twelve patients suffered chronic toxicity, including six who suffered lung toxicity and two who developed secondary myelodysplasia.

CONCLUSIONS

The results achieved in this co-operative study are similar to those reported by most single-Institution trials and those with adriamycin-containing regimens. Long-term toxicity deserves careful consideration.

Appropriateness of the use of clinical and radiologic examinations and laboratory tests in the follow-up of surgically-treated breast cancer patients. Results of the Working Group on the Clinical Aspects of Follow-up

BACKGROUND

The aim of this working group was to assess the appropriateness of use of radiologic examinations, laboratory tests and periodic check-ups for surgically-treated, disease-free breast cancer patients.

MATERIALS AND METHODS

A total of 252 clinical scenarios (36 for each of the 8 exams considered: clinical examination, mammography, chest roentgenography, hematochemical tests, markers, bone scan, liver echography/abdominal CT scan), each representing a specific surgically treated and disease-free breast cancer patient, were rated by the members of the panel. A 3 point scale was utilized as to whether the test in question was judged inappropriate (1), questionable (2), or appropriate (3) (in the latter case the panel member was also asked for the advised frequency of the exam expressed in months).

RESULTS

After two assessment sessions, consensus among members of the panel was reached on 216 of the 252 scenarios; disagreement remained on only 36 clinical scenarios.

CONCLUSIONS

The panel agreed that only clinical examinations and mammographies should be recommended for routine clinical follow-up of surgically-treated breast cancer patients. Given the current available therapeutic options, these would assure adequate medical care and psychological aid.

[Evaluation of the compliance of thalassemic patients at a structured ambulatory day hospital]

The institution of a self-constructed Ambulatory where both pediatric and adult patient can be assisted with Day-Hospital, gains novelty and new characteristics when four different physicians (Medical, Pediatrician, Hematologist and Psychologist) structured part-time, contribute to functionality with equal participation. Compliance was investigated through a computerized way.

A cooperative study on ProMACE-CytaBOM in aggressive non-Hodgkin's lymphomas

Chemotherapy using cyclophosphamide, doxorubicin, etoposide, cytarabine, bleomycin, vincristine, methotrexate with leucovorin, and prednisone (ProMACE-CytaBOM) for patients with intermediate or high grade non-Hodgkin lymphomas (G, H and K according to the Working Formulation), was tested by the Gruppo Cooperativo Lombardo to confirm the activity of the regimen and to test the feasibility and safety of administering third-generation drug regimen in a cooperative group setting. Among 64 previously untreated patients, aged between 20 and 71 years, 7 had stage IB-IIB, 12 had stage IIIA-B, 45 (67%) had stage IVA-B. There were 44 complete remissions (CRs) (69%) and 14 partial remissions (22%); the difference between patients in stage I-II-III (84% complete remissions) and those in stage IV (62% complete remissions) was statistically significant. The median length of follow up was 20 months (range 1-60 months), with 56% of patients alive at 60 months and 53% of CRs patients free of disease at 60 months. Patients in stage I-II-III have the best survival and disease free survival compared to stage IV, 87% versus 42% and 72% versus 32% respectively (both with high statistical significance). Grade 3-4 (WHO) haematological toxicity was observed in 39% of patients, with 3 septic deaths. Two more patients died with chemotherapy related toxicity (1 stroke and 1 acute renal insufficiency). Administration of ProMACE-CytaBOM is a feasible and safe regimen although it presents moderate toxicity. ProMACE-CytaBOM may represent improved treatment for aggressive lymphomas, in terms of duration of response and survival, but a longer follow up is needed.

The use of a new laser particle sizer and shape analyser to detect and evaluate gelatinous microparticles suspended in reconstituted anthracycline infusion solutions

The anthracyclines are an important group of antitumour drugs: the best known anthracyclines are doxorubicin (Adriamycin) and epirubicin (Pharmorubicin), both of which are very active against a wide range of solid tumours and haematological malignancies. They are marketed as lyophilized formulations that need to be reconstituted for administration with water for injections or sodium chloride injection. With the aim of reducing the risks of contamination during reconstitution (spillage, spray formation, etc.) and of enhancing the rate of dissolution (that is otherwise slow because of the formation of conglomerates and gelatinous masses), a new formulation (rapid dissolution formula, RDF) containing parabens (hydroxybenzoate esters) as anti-aggregants has been developed; the formulation is a freeze-dried product and is characterized by a practically instantaneous and complete reconstitution. A valid estimate of the completeness of dissolution has been objectively achieved by means of an instrument (Galai CIS-1) that acts both as a particle sizer and a shape analyser; the instrument is equipped with a rotating laser system that defines a toroidal-cylindrical space inside the solution in which every moving particle is measured and, at the same time, visualized on a monitor by an electronically driven video microscope. The instrument has been applied with very satisfactory results to the visualization of the reconstitutional behaviour of commercial lots of Adriamycin and Pharmorubicin lyophilized products, reconstituted at a concentration of 2 mg ml-1 with sodium chloride injection.

The role of attitudes, beliefs, and personal characteristics of Italian physicians in the surgical treatment of early breast cancer

The influence of Italian physicians' attitudes, beliefs, and personal characteristics on medical decision making is examined in the case of surgical treatment of early breast cancer. Responses to a mail survey of 657 physicians from different specialties were analyzed comparing doctors recommending a radical procedure (9%) to those preferring a conservative procedure for younger patients only (25%), and those considering conservative surgery the treatment of choice regardless of patients' age (66%). The findings suggest that the likelihood of physicians' preferring a conservative procedure is influenced by their specialty and the extent to which they feel that a patient should have a role in the treatment decision more than by differences in the beliefs of treatment outcomes. Only preferences of the small group indicating radical surgery as the sole admissible treatment can be accounted for by ignorance or distrust of results of recent trials. These findings suggest that other than scientific factors guide many doctors in their decision making; they may help to explain why the diffusion of research results into clinical practice is often disappointingly slow.

[Stage classification of chronic lymphatic leukemia. A retrospective analysis of 263 cases]

We have analyzed 263 consecutive patients with chronic-lymphocytic leukemia. They all have been studied according to five different staging systems respectively proposed by Rai (1975), Binet (1977), Binet again (1981), Baccarini (1982) and Rozman (1984). All these procedures proved to be effective, because they divided our cases in groups with significant differences in survival time. The paper displays features and usefulness of each staging system.

Follow-Up after Mastectomy for Breast Cancer. Observations in 96 Patients

From 1978 to 1982 at the Oncology Unit of the Rho Hospital, we followed 96 women who had been operated for breast cancer. In 22 cases (23%) the first signs of recurrence were changes in the following: physical examination (9), symptoms (7), ESR (3), bone scan (2), alkaline phosphatase (1), chest X-ray (1). An adequate follow-up schedule is based on the following: a) limited examinations causing little disturbance to the patient, easily feasible, sensitive, specific, and of limited cost; b) lead-intervals of various tests set according to the risk of relapse; c) critical periodic review of the series, with constant updating of information in the literature.

Care of cancer patients in thirty-one Italian general hospitals. Methodological aspects and general findings

A large sample of cancer patients was reviewed over a two-year period (1978-1979) in 31 general and community hospitals representing five Italian regions, differing in terms of health care organization. Two thousand four hundred and six patients had breast cancer, 1692 lung cancer, 303 non-Hodgkin's lymphomas, 277 ovarian cancer and 235 Hodgkin's lymphoma. Relevant information was collected from medical records through specific pre-standardized and tested forms. The paper discusses the results obtained with respect to (a) general descriptive data of the population; (b) completeness and reliability of recorded data (e.g. staging, histological classification, therapy); and (c) accuracy and completeness of the follow-up. Consistency of the information obtained on selected items with published series of patients suggests that this methodology is worth a wider testing as a simple, inexpensive tool for routinely monitoring the care of cancer patients and the impact on it of organizational and educational interventions.

Quality of breast-cancer care in Italian general hospitals

The diagnostic and therapeutic care and degree of follow-up delivered to 2406 breast-cancer patients over two years (1978-79) in 31 Italian hospitals are reviewed. Although there was broad agreement about recommended treatment protocols, staging by standard methods was recorded in only 44% of patients, assessment and reporting of side-effects was considered in only 49% of all treated patients, follow-up data at two years were available for only 54% of living patients, and the dropout rate from chemotherapy protocols was 35%. Improvement of these unsatisfactory aspects of care would allow a better appreciation of the real benefit that could be achieved with recommended protocols and would result in a more effective use of health resources.

New broad-spectrum alkylthio cephalosporins

A series of 7-substituted alkyl-thio-acylaminocephalosporins with the following general formula were prepared and tested for in vitro antibacterial activity: (formula: see text). We tried in our research to find any relationship between antibacterial activity and pharmacokinetic properties on the one hand, and chemical structure on the other. The most interesting products were also studied for their in vivo antibacterial activity in experimental acute systemic infections in the mouse.

Snythesis and antiprotozoal activity of nitro derivatives of 2, 2'-biimidazole

We synthesized a series of 2,2'-biimidazoles with different substituents and screened them against Entamoeba histolytica, Trichomonas vaginalis and Giardia muris. A 5-nitro group is necessary for the inclusion of activity and an amino group exercises favourable effect on in vivi activity.