Abstract P4-03-03: Not presented

This abstract was not presented at the symposium.

Treatment of acute myocardial infarction in the sub-arctic region of Norway. Do we offer an equal quality of care?

Patients, relatives, healthcare workers and administrators are concerned about the quality of care offered. We aimed to explore the treatment of acute myocatrdial infarction (AMI) in Northern Norway, compare it with the national figures, and document whether there is an equal quality of care or not. The retrospective study included data on patients' treatment for AMI. The following sources were employed. The Norwegian Patient Registry, National Quality of Care Database, Norwegian Myocardial Infarction Registry and data from the National Air Ambulance Services of Norway. The period 2012-2014/15 was studied and the variables were: incidence of AMI, gender and age adjusted rates of AMI and revascularization (PCI, CABG) based on patient's place of living (according to hospital catchment area) and 30-day survival rate. The annual incidence of AMI was 9% higher in the northern region. Significant incidence variations (2.7–5.9 AMI/1000 inhabitants) between the hospitals' catchment areas were revealed. The 30-day survival rate varied between 85.1–92.1% between hospitals. The variation in revascularization/AMI rate was 0.72–1.54. Air amublance services' availability varied through the day. In conclusion, significant variations in the AMI rate and an unequal service within the region was revealed.

Lessons learned from the intrinsic subtypes of breast cancer in the quest for precision therapy

BACKGROUND

Wide variability in breast cancer, between patients and within each individual neoplasm, adds confounding complexity to the treatment of the disease. In clinical practice, hormone receptor status has been used to classify breast tumours and to guide treatment. Modern classification systems should take the wide tumour heterogeneity into account to improve patient outcome.

METHODS

This article reviews the identification of the intrinsic molecular subtypes of breast cancer, their prognostic and therapeutic implications, and the impact of tumour heterogeneity on cancer progression and treatment. The possibility of functionally addressing tumour-specific characteristics in in vivo models to inform decisions for precision therapies is also discussed.

RESULTS

Despite the robust breast tumour classification system provided by gene expression profiling, heterogeneity is also evident within these molecular portraits. A complicating factor in breast cancer classification is the process of selective clonality within developing neoplasms. Phenotypically and functionally distinct clones representing the intratumour heterogeneity might confuse molecular classification. Molecular portraits of the heterogeneous primary tumour might not necessarily reflect the subclone of cancer cells that causes the disease to relapse. Studies of reciprocal relationships between cancer cell subpopulations within developing tumours are therefore needed, and are possible only in genetically engineered mouse models or patient-derived xenograft models, in which the treatment-induced selection pressure on individual cell clones can be mimicked.

CONCLUSION

In the future, more refined classifications, based on integration of information at several molecular levels, are required to improve treatment guidelines. Large-scale translational research efforts paved the way for identification of the intrinsic subtypes, and are still fundamental for ensuring future progress in cancer care.

Quality of life (QoL) measurement in economical analysis in cancer

In health economy, the measure of quality of life (QoL) is essential in cost-utility analysis. The most common utility measure is the quality-adjusted-life year (QALY) combining the benefits of survival and QoL during the survival period. Health authorities have to take priority decisions. These should not be founded on differences between choices caused by method chosen. A study on 98 cancer patients (42 Hodgkin's disease, 56 colorectal cancer) was performed to clarify the consistency of three QoL-instruments [EuroQol questionnaire, simple QoL-scale, global QoL-measure (EORTC QLQ-C30)]. The three instruments were significantly correlated (p<0.001). Cost-utility analysis employing one of the three instruments are comparable.

Trastuzumab in adjuvant breast cancer therapy. A model based cost-effectiveness analysis

Trastuzumab has shown activity in early breast cancer patients that overexpress HER2. Significant resources have to be allocated to finance this therapy, underlining the need for cost-effectiveness analysis. A model was set up, societal costs were calculated and the discount rate was 3%. Life expectancy data were based on the literature and prolonged according to qualified guess (10% and 20% absolute improvement in overall survival (OS)). The comparator was the FEC(100) regimen. The median additional health care cost per patient treated was 33,597 euros. The yielding cost per life year gained (LYG) was 15,341 euros with a 20% improved OS and 35,947 euros with 10% improved OS. The corresponding net health care cost per quality adjusted life year (QALY) was 19,176 euros and 44,934 euros. Including all resource use the figures were 8148 euros and 30,290 euros per LYG. Sensitivity analyses documented survival gain, price of trastuzumab, production gain and discount rate to be the major factors influencing cost-effectiveness ratio. Trastuzumab is indicated cost effective in Norway.

Sunitinib, sorafenib, temsirolimus, or bevacizumab in the treatment of metastatic renal cell carcinoma (RCC): A review of health economic evaluations

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Background: Renal cell carcinoma (RCC) is the most prevalent kidney cancer and the 5-year overall survival figure in metastatic disease (mRCC) is about 10%. New targeted drugs (sunitinib, sorafenib, bevacizumab, temsirolimus) have shown activity in the treatment of mRCC, but they are all associated with a significant burden of cost. Methods: To support decision makers in their allocation of resources, cost-effectiveness models are constructed to compare the costs and outcomes of anticancer therapy. The PubMed, ASCO abstracts, Google, and the Igaku Chuo Zasshi databases were searched in November 2008 with key terms: kidney, renal, cancer, cost, sunitinib, sorafenib, temsirolimus, and bevacizumab. Seven studies reporting data on cost-effectiveness were revealed. Three of them were published in full text versions. The countries of application were United Kingdom, Canada, United States, Finland, and Japan. An analytical checklist was applied to the seven economic evaluations. Results: The review reveals figures of cost per LYG or QALY in the range €22,648 to €203,692, depending on line setting and drug focused. The results were limited by short follow up periods and the consequently fact that premature data had to be implemented in the Markov models. When compared, sunitinib has the lowest cost-effectiveness figure. Second-line therapy dose not seem to offer valid incremental cost-effectiveness ratios (ICERs) below accepted cost-effectiveness thresholds. As long as cross-over to the experimental arm is allowed (based on improvement in progression free survival) overall survival data are difficult to interpret and the cost difference between the treatment and the control arm minimised. Conclusions: The review revealed ICERs with a wide range. Sunitinib has the lowest cost-effectiveness figure. Second-line therapy does not look cost-effective.

[Table: see text]

Cetuximab in the treatment of metastatic colorectal cancer: a model-based cost-effectiveness analysis

Cetuximab (Erbitux) has shown activity in patients with metastatic colorectal cancer (mCRC). To evaluate the cost-effectiveness of this drug combined with irinotecan in mCRC, a model-based cost-effectiveness analysis (CEA) was performed. Data on cetuximab obtained from Medline in December 2004 and from the 2004 ASCO-meeting were analyzed for life years gained (LYG) with regard to the use of this monoclonal antibody (MAb). Norwegian prices as of January 2005 were employed. The LYG ranged between 1.7 and 2.0 years. The median cost per patient treated was calculated to 34,256 Euro to 45,764 Euro yielding a cost per LYG in the range between 205,536 Euro and 323,040 Euro. Sensitivity analysis documented price of cetuximab and survival gain to be the major factors influencing the cost-effectiveness ratio. In conclusion, the analysis indicates cetuximab to be a promising, but very expensive antibody.

Trastuzumab in adjuvant breast cancer therapy: A model based cost-effectiveness analysis

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Background: Trastuzumab has shown activity in patients with early breast cancer that overexpress HER2. However, significant resources have to be allocated to finance this therapy, therefore its cost-effectiveness is called for and treatment’s value for money should be calculated. We aimed to evaluate the marginal cost effectiveness of trastuzumab in adjuvant treatment of HER2 positive early breast cancer in a model based cost-effectiveness-analysis (CEA). Methods: A breast cancer treatment model was set up. Societal costs were calculated according to Norwegian prices as in September 2005 and converted to Euros at the rate of 1Euro = 7.81 NOK. Life expectancy data were based on the literature and prolonged according to qualified guess (10% and 20% improved overall survival (OS). The comparator was the present practice, the FEC100 regimen alone. The human capital approach was employed and a sensitivity analysis was added. Results: The median raised cost per patient treated was calculated at Euro16,713 - 35,714. The yielding cost per life year saved was in the range between Euro 5,571 and 32,616, depending on survival gain (10% or 20% improved OS) and discount rate (0% or 3%) employed. The sensitivity analyses documented survival gain, discount rate and price of trastuzumab the major factors influencing cost-effectiveness ratio. Conclusion: The economic evaluation indicates trastuzumab cost effective in adjuvant breast cancer treatment.

No significant financial relationships to disclose.

A monoclonal antibody against HER-2 (trastuzumab) for metastatic breast cancer: a model-based cost-effectiveness analysis

BACKGROUND

The aim of this study was to evaluate the cost-effectiveness of trastuzumab in patients with metastatic breast cancer (MBC) in a model-based cost-effectiveness analysis (CEA). Trastuzumab has shown considerable activity in patients with MBC that overexpress HER2. However, significant resources have been allocated to finance this new therapy. Due to ever increasing pressures on health care budgets, economic evaluations are requested in order to compare health effects with costs.

METHODS

All available data on trastuzumab in MBC presented at the San Antonio breast cancer conference in late 2003 and all data on Medline in December 2003 were analysed for life years (LY) gained and quality of life (QoL) with regard to the use of this new monoclonal antibody. Randomised studies comparing standard chemotherapy, with or without trastuzumab, were focused. The costs were calculated according to Norwegian prices as of January 2003.

RESULTS

The LY gained ranged between 0.3 and 0.7 years. The median cost per patient treated was 44 196 yielding costs per life year saved in the range 63 137-162 417 depending on survival gain and discount rate employed. A sensitivity analysis documented the price of trastuzumab and the survival benefit the two major factors influencing the cost-effectiveness ratio.

CONCLUSION

The economic evaluation indicates that trastuzumab is not cost effective in metastatic breast cancer. Reduced drug costs and/or improved survival may alter the conclusion.

A randomised phase II multicentre trial of irinotecan (CPT-11) using four different schedules in patients with metastatic colorectal cancer

The purpose of this phase II trial was to compare the efficacy, safety and pharmacokinetics of four irinotecan schedules for the treatment of metastatic colorectal cancer. In total, 174 5-fluorouracil pretreated patients were randomised to: arm A (n=41), 350 mg m(-2) irinotecan as a 90-min i.v. infusion q3 weeks; arm B (n=38), 125 mg m(-2) irinotecan as a 90-min i.v. infusion weekly x 4 weeks q6 weeks; arm C (n=46), 250 mg m(-2) irinotecan as a 90-min i.v. infusion q2 weeks; or arm D (n=49), 10 mg m(-2) day(-1) irinotecan as a 14-day continuous infusion q3 weeks. No significant differences in efficacy across the four arms were observed, although a shorter time to treatment failure was noted for arm D (1.7 months; P=0.02). Overall response rates were in the range 5-11%. Secondary end points included median survival (6.4-9.4 months), and time to progression (2.7-3.8 months) and treatment failure (1.7-3.2 months). Similarly, there were no significant differences in the incidence of grade 3-4 toxicities, although the toxicity profile between arms A, B, and C and D did differ. Generally, significantly less haematologic toxicity, alopecia and cholinergic syndrome were observed in arm D; however, there was a trend for increased gastrointestinal toxicity. Irinotecan is an effective and safe second-line treatment for colorectal cancer. The schedules examined yielded equivalent results, indicating that there is no advantage of the prolonged vs short infusion schedules.

A mobile telemedicine unit for emergency and screening purposes: experience from north-west Russia

A mobile telemedicine unit (MTU) was constructed for emergency and screening purposes in north-west Russia. The MTU included facilities for endoscopy, electrocardiography and digital photography. Data transmission was by ordinary telephone line. Between July and December 1999, the MTU was used in 48 incidents, involving 44 patients. The MTU was used to conduct 22 teleradiology examinations and 20 electrocardiograms were transmitted; in 10 cases still images of patients were transmitted and three consultations included tele-electroencephalography. Despite poor-quality analogue telephone lines, the MTU may prove useful in north-west Russia. Following the pilot study, the local Russian health administration stated that the MTU should always be included on emergency trips to the districts.

Injuries and diseases among commercial fishermen in the Northeast Atlantic and Barents Sea. Data from the Royal Norwegian Coast Guard

OBJECTIVES

The working conditions in the Northeast Atlantic may be hazardous, and accidents are frequent. The objective of this study was to clarify the situation as viewed by the Royal Norwegian Coast Guard (RNCG).

METHODS

Consecutive reports on medical assistance given by the three major RNCG vessels from October 1995 and March 2001 were analysed.

RESULTS

There were 117 reports. Men constituted 96%, and 54% were Norwegians. The median age was 38 years. Seriousness was classified as low (46 cases), moderate (43 cases), serious (22 cases) and life threatening [five cases (two died)]. Infection caused 27 visits. Fifty-five cases were due to trauma, and hand injuries constituted 19 cases. Fishermen over 40 years of age were more severely injured ( P<0.04). In 52 cases, the RNCG personnel requested further medical advice. Sixty-one patients were hospitalised and 48 transported by helicopter.

CONCLUSIONS

The RNCG offers an important medical service, but there is frequently a need for consulting medical advisors. Telemedicine should be investigated in this setting.

Ralitrexed (Tomudex) or Nordic-FLv regimen in metastatic colorectal cancer: a randomized phase II study focusing on quality of life, patients' preferences and health economics

Raltitrexed (Tomudex) is proven effective in metastatic colorectal cancer. Between 1998-2000, 25 patients were included in a randomized phase II study comparing raltitrexed (13 patients) and the Nordic FLv regimen (12 patients). 23 patients were evaluable for response. The overall response rate was 2/12 (1 CR, 1 PR) in the raltitrexed arm and 1/11 (1 CR) in the Nordic FLv arm, respectively. There was no difference in overall survival (raltitrexed--14.7 months, Nordic FLv--15.4 months). 23 patients were evaluable for Quality of Life (QoL) analysis. 23/25 and 17/21 questionnaires (EORTC QLQ C-30) were returned at baseline and first evaluation. Raltitrexed tended to be the most toxic regimen, when looking at nausea and vomiting, appetite loss, diarrhea and global QoL. However, most patients (65%) recommended the raltitrexed treatment schedule. The total treatment cost was equal in both arms (about 6,800 EURO/patient) and the hospital/hospital hotel stay costs accounted for more than half of it.

Evaluation of Norwegian cancer hospitals web sites and explorative survey among cancer patients on their use of the internet

BACKGROUND

Hospital homepages should provide comprehensive information on the hospital's services, such as departments and treatments available, prices, waiting time, leisure facilities, and other information important for patients and their relatives. Norway, with its population of approximately 4.3 million, ranks among the top countries globally for its ability to absorb and use technology. It is unclear to what degree Norwegian hospitals and patients use the Internet for information about health services.

OBJECTIVES

This study was undertaken to evaluate the quality of the biggest Norwegian cancer hospitals Web sites and to gather some preliminary data on patients use of the Internet.

METHODS

In January 2001, we analyzed Web sites of 5 of the 7 biggest Norwegian hospitals treating cancer patients using a scoring system. The scoring instrument was based on recommendations developed by the Norwegian Central Information Service for Web sites and reflects the scope and depth of service information offered on hospital Web pages. In addition, 31 cancer patients visiting one hospital-based medical oncologist were surveyed about their use of the Internet.

RESULTS

Of the 7 hospitals, 5 had a Web site. The Web sites differed markedly in quality. Types of information included - and number of Web sites that included each type of information - were, for example: search option, 1; interpreter service, 2; date of last update, 2; postal address, phone number, and e-mail service, 3; information in English, 2. None of the Web sites included information on waiting time or prices. Of the 31 patients surveyed, 12 had personal experience using the Internet and 4 had searched for medical information. The Internet users were significantly younger (mean age 47.8 years, range 28.4-66.8 years) than the nonusers (mean age 61.8 years, range 33.1-90.0 years) (P = 0.007).

CONCLUSIONS

The hospitals Web sites offer cancer patients and relatives useful information, but the Web sites were not impressive.

Molecular cloning of a mammalian nuclear phosphoprotein NUCKS, which serves as a substrate for Cdk1 in vivo

We have isolated and characterized a cDNA encoding a mammalian nuclear phosphoprotein NUCKS, previously designated P1. Molecular analyses of several overlapping and full-length cDNAs from HeLa cells and rat brain revealed a protein with an apparent molecular mass of 27 kDa in both species. The deduced amino-acid sequences are highly conserved between human and rodents, but show no homology with primary structures in protein databases or with translated sequences of cDNAs in cDNA databanks. Although the protein has some features in common with the high mobility group proteins HMGI/Y, attempts to find a putative protein family by database query using both sequence alignment methods and amino-acid composition have failed. Northern blot analyses revealed that human and rat tissues contain three NUCKS transcripts varying in size from 1.5 to 6.5 kb. All human and rat tissues express the gene, but the level of transcripts varies among different tissues. Circular dichroism analysis and secondary structure predictions based on the amino-acid sequence indicate a low level of alpha helical content and substantial amounts of beta turn structures. The protein is phosphorylated in all phases of the cell cycle and exhibits mitosis-specific phosphorylation of threonine residues. Phosphopeptide mapping and back-phosphorylation experiments employing NUCKS from HeLa interphase and metaphase cells show that the protein is phosphorylated by Cdk1 during mitosis of the cell cycle.

Adjuvant cyclophosphamide, methotrexate, fluorouracil (CMF) in breast cancer--is it cost-effective?

Adjuvant chemotherapy (ACT) may expose patients to morbidity, with little gain in outcome. Treatment with CMF (cyclophosphamide, methotrexate, fluorouracil) has been the standard ACT in several countries for decades. In this model, efficacy, tolerability and quality of life data from the English-language literature were incorporated with Norwegian standard ACT practice and cost data in a cost-effectiveness/cost-utility approach. The CMF efficacy was calculated as 2.45 years saved per patient treated. The quality of life was assumed diminished by 0.33 (0-1 scale) for 6 months and the life years gained were valued Q = 0.86. An 85% dose intensity was employed, one British pound ( 1) was calculated as 12 NOK and a 5% discount rate was used. The total cost of adjuvant CMF, including amounts spent on drugs, administration, travelling and production loss, was calculated to 2365- 6253, depending on the method chosen. Money spent on drugs alone constituted 13-34%. The cost per life year saved was measured as 2170- 5737. A cost-utility approach revealed a cost per quality-adjusted life year (QALY) of 2973- 7860. Adjuvant CMF in breast cancer is cost-effective in Norway.

Goserelin (Zoladex) or orchiectomy in metastatic prostate cancer? A quality of life and cost-effectiveness analysis

BACKGROUND

We have today two treatment alternatives (orchiectomy or LHRH-analogue) in metastatic prostate cancer offering the same expectations of survival. This study documents the quality of life (QoL) and cost-effectiveness of these alternatives.

PATIENTS AND METHODS

65 consecutive patients treated at the University Hospital of Tromsø (UHT), Norway, between 1994 and 1999 were registered. At evaluation, 45 patients (LHRH-analogue--15 patients, orchiectomy--30 patients) were alive and included in the QoL-study (EORTC QLQ C-30, QoL 15D). 45 patients were followed-up at the UHT and included in the cost-analysis. Costs were calculated for a 36-month interval and converted to British pounds (1 Pound = 13 NOK). A 5% d.r. was employed.

RESULTS

The mean QoL (15D) was 76.4 (orchiectomy) and 72 (LHRH) (0-100 scale). Constipation, urinating problems, fatigue, pain and loss of sexual functioning were the dominant symptoms. The treatment costs per patient treated were 8,895 Pounds (orchiectomy) and 10,937 Pounds (LHRH-analogue). The crossover in cost was located at 25 months. A sensitivity analysis varying discount rate (0-10%), drug charges (25-50% off) and treatment time (12-18 months) did not alter the conclusion.

CONCLUSION

Orchiectomy is the treatment of choice when life expectancy is more than two years.

Should cancer patients receive a copy of the medical record when visiting an out-patient clinic?

The aim of this study was to clarify the benefit and inconvenience to cancer patients of receiving a copy of the medical record following a visit to the out-patient clinic of the Department of Oncology, University Hospital of Tromsø, Norway. Between January and December 1998, after their attendance at the clinic a printout of the record made after the consultation was mailed to each of 199 patients seen by the same medical oncologist. A 15-item questionnaire was later mailed to 178 survivors in March 1999. The questionnaire had items on the use made of the copy report, side effects it might have occasioned, such as anxiety, worries and fear, and patients' general opinion of this procedure. There were 119 responders (67%), and 93 acknowledged receipt of the record. Most (96%) replied that the report had been beneficial; 78% had shown it to family members or friends; and 27% had shown it to other doctors. Only 9% had taken it with them when travelling. Such side effects as anxiety and worries were mentioned by only a few patients. Some 20% (mostly men) stated that medical terms had caused difficulties. Most patients in the study group (93%) recommended that the study practice should be introduced as standard procedure. Patients who considered receipt of the copy report of little value experienced the highest level of anxiety. In conclusion, cancer patients should be offered a copy of the medical record following an out-patient visit.

Oxaliplatin in colorectal cancer patients living in an arctic or subarctic area: significant cold-triggered dysesthesias and laryngeal reactions

Oxaliplatin combined with 5-fluorouracil (5-FU) and folinic acid (FA) has been proven effective in colorectal cancer. However, side effects such as cold-triggered dysesthesia and laryngo-pharyngeal spasm have been reported. To clarify the side effects of oxaliplatin in a subarctic or arctic setting, a phase II study was performed. In October and November 1999, 8 patients with colorectal cancer were enrolled and treated with oxaliplatin (130 mg/m2 - day 1) and the FLv - Nordic regimen (5-FU 500 mg/m2 and leucovorin 100 mg for 2 days) every 3rd week as second- (6 pts) or third-line (2 pts) therapy. At evaluation in March 2000, 7 patients were alive and 6 PD, 1 SD and 1 PR were obtained. Acute laryngeal reaction was reported by 3 out of 8 patients and cold-triggered dysesthesia by all patients. Six available patients were interviewed by phone. Half of the interviewed patients recommend the therapy to be offered to other patients. In conclusion, oxaliplatin (130 mg/m2) therapy in arctic or subarctic areas during the winter introduces significant cold-triggered symptoms.

Health, life and disability insurance and hereditary risk for breast or colorectal cancer

Fear of insurance discrimination affecting the insurance-seeker and family has been reported as the singlemost important reason why individuals choose not to undergo genetic testing. The eleven health insurers operating on the Norwegian market were mailed a questionnaire asking them to list their insurance products and evaluate two individuals' requests for insurance. The requests were constructed in order to illustrate a high genetic risk for (a) colorectal (HNPCC) and (b) breast cancer (BRCAI/BRCA2), respectively. Nine out of 11 insurers responded. While no restriction was documented concerning risk of BRCA1/BRCA2 and life insurance or disability pension, the premium paid by persons with susceptibility to HNPCC varied between the different insurers from standard to raised premiums. The product 'critical disease' insurance was refused or obtained at normal or raised premiums in both cases, depending on the insurer in question. On examining personal indemnity insurance, we found that the BRCA1/BRCA2-risk individual was offered insurance at the standard premium, whereas HNPCC-risk individuals were offered a standard or raised premium. Only the major Norwegian insurer is in fact diverging in its policies.

Screening for metastatic disease in newly diagnosed breast cancer patients. What is cost-effective?

BACKGROUND

Significant health care resources are today spent on diagnosing and treatment of early breast cancer.

MATERIALS AND METHODS

98 consecutive patients referred to our oncological unit between January 1997 and June 1998 underwent an evaluation programme including thoracic X-ray, liver and bone scan and blood test. When findings suspected for metastatic disease were revealed, further examinations (CT-scan, MRI) were performed.

RESULTS

Whereas the screening programme disclosed four cases (4%) of distant metastasis, several patients had to suffer the psychological distress of false positive results. One in three suspicious thoracic X-rays, two in two liver scans and 18 out of 21 suspected bone scans were concluded false positive in terms of metastatic disease. A screening programme including blood test and thoracic X-ray alone, would have mis-classified one out of 98 patients.

CONCLUSION

This study indicated thoracic X-ray and blood test as being sufficient and 110 Pounds per patient screened could be saved.

Faith among patients with advanced cancer. A pilot study on patients offered "no more than" palliation

Spiritual wellbeing is an important topic in cancer care. Being religious is reported by patients facing dilemmas concerning the quality and meaning of life to be potentially helpful. However, the fear of death may be close to the surface and easily stimulated. The aim of this study was to clarify patients' attitudes to faith. Between February 1998 and February 1999, 20 patients aged 37-74 years and suffering from ten different incurable cancers were enrolled in the study. An interview technique focusing on the topic by way of an open question about faith was employed. The topic was only continued if the patient signalled a clear wish for this. Half the patients had a close relative present during the conversation, and an oncology nurse was present in all cases. Most patients (18, or 90%) intimated that the topic was of interest: 85% responded by saying they believed in God, and 75% reported that they prayed. A quarter (25%) mentioned that they had visited their local Lutheran pastor before their admission to hospital. One patient reported being a Jehovah's Witness and one, a member of the Norwegian Humanistically Ethical Association (HEA). Following the conversation, 4 patients requested a visit from the hospital chaplain, 1 asked for contact with the Salvation Army to be arranged, and 1 wanted to talk to the local leader of HEA. Following the conversation all patients were observed by a nurse, and no raised level of anxiety was reported. Sixteen of the patients died within a median of 18 (1-180) days after the conversation. In conclusion, most patients responded positively to a question about faith. The topic should be addressed in the treatment of patients with advanced disease. However, care must be taken to avoid frightening the patients. Patients' attitudes with regard to what death brings deserve respect.

[Should the community pay for hospitalized patients waiting for transfer to nursing homes?]

Many hospital patients are on waiting lists for transferral to nursing homes. In a retrospective study, all patients (n = 75) hospitalised at the Department of Oncology, University Hospital of Tromsø until their death and all patients (n = 20) transferred to nursing homes from the same department during a 23-month period were registered. The duration of hospitalisation was 1-111 days (median 10 days) for the first group and 1-39 days (median 8 days) for the second group. 23 out of 32 patients (72%) hospitalised more than 14 days were from the city of Tromsø. This city and other municipalities should be required by law to pay the hospital for patients on waiting list for nursing homes. Today, 4 out of 16 major Norwegian hospitals have such arrangements.

Intracavity fractionated balloon brachytherapy in glioblastoma

In order to reduce hospitalisation time for patients receiving postoperative radiotherapy a phase I-II study of intracavity balloon brachytherapy was instituted. An indwelling balloon catheter was implanted during the closing phase of the initial operation. Starting on the second or third postoperative day the catheter was afterloaded with a high dose rate isotope via a remotely controlled afterloading system. The treatment consisted of 10-12 fractions over a period of 5-6 days, with each treatment session requiring approximately 15 minutes. No external beam radiation was given. Forty-four newly diagnosed patients were treated. A total dose of either 60 Gy (33 patients) or 72 Gy (11 patients) was given. The overall median survival was 11.7 months, (range 2.7-50.9). The treatment was well tolerated and none of the applicators were removed prematurely. The total median hospital stay for this group of patients was significantly reduced compared to more conventional protocols. This study indicates that intracavity high dose rate balloon brachytherapy can achieve survival rates equivalent to those of conventional radiotherapy and is both cost and time efficient.

[Euthanasia and cancer]

Euthanasia is clinical practice in several countries world-wide. Cancer patients' attitude in this field was focused through a review of case reports and questionnaire-based studies on Medline (1992-97). A total of nine publications including 459 cancer patients from USA, Canada and Holland were found. The majority of patients had poor performance status and advanced disease. At least one third reported themselves positive to euthanasia. Patients below 50 years of age, having superior performance status and not considering themselves religious, more frequently supported euthanasia. Psychological factors seem to be more significant than physical factors for support of euthanasia. Loss of control, being a burden on one's family and loss of dignity are the psychological factors most frequently reported. A "help to live" approach aimed at avoiding patient requests for help to die will mean that health care workers must allocate more of their time to these patients. Overcrowded hospitals with several patients in corridors and lack of nursing-homebeds do not make this situation easier to handle.

Breast cancer screening by mammography in Norway. Is it cost-effective?

BACKGROUND

Mammography screening is a promising method for improving prognosis in breast cancer.

PATIENTS AND METHODS

In this economic analysis, data from the Norwegian Mammography Project (NMP), the National Health Administration (NMA) and the Norwegian Medical Association (NMA) were employed in a model for cost-effectiveness analysis. According to the annual report of the NMP for 1996, 60,147 women aged 50-69 years had been invited to a two-yearly mammographic screening programme 46,329 (77%) had been screened and 337 (0.7%) breast cancers had been revealed. The use of breast conserving surgery (BCS) was in this study estimated raised by 17% due to screening, the breast cancer mortality decreased by 30% and the number of life years saved per prevented breast cancer death was calculated 15 years.

RESULTS

The cost per woman screened was calculated 75.4 Pounds, the cost per cancer detected 10.365 Pounds and the cost per life year (LY) saved 8.561 Pounds. A raised frequency of BCS, diagnosis and adjuvant chemotherapy brought two years forward, follow-up costs and costs/savings due to prevented breast cancer deaths were all included in the analysis. A sensitivity analysis documented mammography screening cost-effective in Norway when four to nine years are gained per prevented breast cancer death.

CONCLUSION

Mammography screening in Norway looks cost-effective. Time has come to encourage national screening programmes.

Mitoxantrone in malignant pericardial effusion

When occurring, malignant pericardial effusion (MPE) is usually a late phenomenon in most malignancies. Several treatment modalities, including chemotherapy, radiotherapy, pericardial window operation, pericardiotomy, catheter pericardiocentesis and local cytotoxic or sclerotherapy, have been employed. Mitoxantrone is reported as having potential in malignant pleural effusion. Between 1992-97, 5 patients (breast cancer-4 pts, ovarian cancer-1 pt) were admitted to the University Hospital of Tromsø due to a life-threatening MPE. They were all treated with ultrasound-guided pericardiocentesis followed by instillation of mitoxantrone (10 mg). Evaluation at a median follow-up of 59 days (range 28-294 days), 2 patients achieved CR, 1 PR and 2 patients have PD. Two patients are alive 213 and 294 days following therapy. Intrapericardial mitoxantrone instillation is a safe and simple way of handling MPE in malignancies sensitive to mitoxantrone.

Quality of life in colorectal cancer patients treated with doxorubicin and a multi-drug resistance (MDR) modulator (SDZ PSC-833): a pilot study

INTRODUCTION

Next to carcinoma of the bronchus, colorectal cancer (CRC) kills more people than any malignancy. Among the efforts to improve the outcome are studies on multidrug resistance (MDR) modulators combined with doxorubicin.

MATERIAL AND METHODS

Between November 1996 and August 1997, 10 patients were included in a study employing the MDR-modulator SDZ PSC 833 (5 mg/kg qid 3d/3rd w) and adriamycin (35-45 mg/m2/3rd w). Quality of life (QoL) was measured (EORTC QLQ-C30) at baseline and every 3rd week until progression or patient refusal.

RESULTS

SDZ PSC 833 and doxorubicin worsened the global QoL from 68 to 46.6 (0-100 scale) during 6 weeks. There was no improvement in QoL from cycle 1 to 3. The physical, social, nausea/vomiting and dyspnoea subscales were most affected. Mean performance status (WHO) was only slightly reduced.

CONCLUSION

SDZ PSC 833 and doxorubicin did not improve QoL and seemed more toxic than 5-FU containing regimens. If superior data on response and survival are revealed, a cost-utility analysis should be performed.

[Cancer patients' perception of the examination period prior to treatment]

From July 1990 to July 1991 252 cancer patients admitted consecutively to the Department of Oncology, University Hospital of Tromsø, were included in a questionnaire-based study. The aim of the study was to examine the delays involved in the diagnosis and treatment of cancer. The study also focused on the psychological distress related to these periods of delay. A significant correlation between psychological distress and the actual length of delay (weeks) was revealed (p < 0.01). psychological distress was also correlated positively to the degree of depression (p < 0.01). Women found delays more distressing than men (p < 0.01). Patients from the northern areas (Troms and Finnmark counties) considered a cancer unit in Northern Norway to be of greater importance than those living in the southern area (Nordland county).

Prevention of colorectal cancer: a cost-effectiveness approach to a screening model employing sigmoidoscopy

BACKGROUND

Today, only carcinoma of the bronchus kills more people than colorectal cancer (CRC). However, CRC is both preventable and curable. In Norway, projects aiming to detect adenomas and early cancers by the screening of a population aged about 60 years employing sigmoidoscopy have been discussed.

MATERIALS AND METHODS

In this study, a mathematical model was used to estimate the cost-effectiveness of a screening programme for colorectal polyps followed by polypectomy. A once-only sigmoidoscopy at age 60 followed by coloscopy in selected risk groups was suggested. Data from the English-language literature, the National Cancer Registry of Norway, and Statistics Norway were included. Norwegian cost data from the National Health Administration were also used. Costs of screening and those related to earlier diagnosis, and savings on health care and averted loss in production due to prevented CRCs were calculated.

RESULTS

The basic cost per patient invited and screened (70% compliance) in the suggested programme was estimated at 81.7 Pounds and 116.7 Pounds, respectively. When gains due to prevented CRCs were included, the figures became 34.5 Pounds and 49.2 Pounds. The cost per life-year saved was calculated as 2,889 Pounds. This strongly indicates that screening for the early detection and prevention of CRC is one of the most cost-effective programmes in cancer.

CONCLUSIONS

CRC screening according to the suggested programme appears to be cost-effective. Clear evidence that screening can reduce mortality from CRC should convince health-care policy makers that the time has come to encourage screening for colorectal cancer.

A cost-effectiveness approach to the Norwegian follow-up programme in colorectal cancer

BACKGROUND

Today, continued periodic follow-up of patients treated for colorectal cancer (CRC) seems often to be routine because of tradition, rather than its demonstrated value. Recently, the Norwegian Gastrointestinal Cancer Group (NGICG) has recommended a standard surveillance programme in this malignancy. In this protocol patients are suggested followed for four years with CEA monitoring, ultrasound of the liver, chest radiograph and colonoscopy at regular intervals.

MATERIALS AND METHODS

In this study, the cost-effectiveness of this programme was addressed employing Norwegian cost data and data from the Cancer Registry of Norway. Clinical data from the existing English language literature was used in the analysis.

RESULTS

The basic cost of the NGICG recommended programme was 1,232 Pounds per patient. Including extended investigation due to suspected relapse in 45% of cases, the figure raised to 1,943 Pounds per patient. The cost per life year saved was indicated to 9,525 Pounds-16,192 Pounds. The corresponding cost per quality adjusted life year (QALY) was indicated to 11,476 Pounds-19,508 Pounds.

CONCLUSION

We conclude the NGICG recommended follow-up programme in CRC cost-effective. Excluding CEA monitoring may improve the cost-effectiveness.

[Breast cancer treated at the oncologic department, University Hospital in Tromsø 1986-94]

In the period 1986 to 94, 173 women who had had a lumpectomy or a mastectomy were treated with radiotherapy at the University Hospital of Tromsø. The median diagnostic delay was 2.4 months (range 0-98.6 months). Three out of four patients were operated on within two weeks of the diagnosis being made. About two thirds experienced a delay of more than six weeks from the operation to the start of radiotherapy treatment. The five-year overall survival rate in the mastectomy and postoperative radiotherapy group was 67%. Patients with estrogen receptor positive tumours had a better prognosis. Only 5% and 7% of all patients in our region in stages I and II had breast conserving surgery (BCS) during the study period (66 patients). The five-year overall survival rate in the BCS group was 77%. BCS raised the cost per patient by about 3,000 GBP compared to modified radical mastectomy (MRM). The cost per QALY using BCS as against MRM was about 12,000 GBP. We conclude that MRM should not be used instead of BCS merely for economical reasons.

[Follow up after potential curative surgery of colorectal cancer. Guidelines from the Norwegian Gastrointestinal Cancer Group]

In Norway, about 2,800 cases of colorectal cancer are diagnosed every year. Two-thirds of the patients undergo potentially curative surgery and almost half of them develop local or distant metastases. The follow-up of colorectal cancer patients involves four strategies: Educating the patients about the disease, symptoms of relapse, and risk of hereditariness; Early diagnosis of relapse, to make curative re-surgery possible; Diagnosis of metachronous/synchronous cancer(s); Recording the results of current surgical techniques. The Norwegian Gastrointestinal Cancer Group recommend a four-year follow-up programme (every third month for two years and then twice a year) of colorectal cancer patients. It is suggested that patients treated with low anterior resection are followed regularly by means of rectoscopy and local examination (digital or by ultrasound) undertaken by specialist (surgeon or gastroenterologist). The others should be followed up mainly by general practitioners. Carcinoembryonic antigen (CEA)-monitoring is suggested every third month for two years, and then every sixth month. Colonoscopy is recommended at one and four year follow-up. Patients with normal CEA levels prior to surgery should be evaluated by ultrasound of the liver every sixth month for four years.

Lumpectomy or mastectomy? Is breast conserving surgery too expensive?

In the last decade, breast cancer patients have enjoyed an increase in breast conserving surgery (BCS). At present, modified radical mastectomy (MRM) and BCS offers equal expectations of survival. During the last few years, however, a drop in the frequency of BCS has been reported by several authors. Is this new trend due to economic concerns? To clarify the costs of breast cancer therapy (stage I and II), we review the literature and include a cost-utility and a cost-minimisation analysis comparing MRM and BCS. The treatment cost (per patient) of BCS and MRM in Norway was calculated at $9,564 and $5,596, respectively. Employing a quality of life gain in BCS of 0.03 (0-1 scale) and a 5% discount rate, the cost per QALY in BCS compared to MRM was $20,508. In cost-minimising analysis, BCS and mastectomy followed by reconstructive surgery had a cost of $10,748 and $8,538, respectively. This indicates that BCS remains within reasonable cost and should not be displaced by mastectomy on economic grounds.

Adjuvant chemotherapy in Dukes' B and C colorectal cancer has only a minor influence on psychological distress

The object of this cross-sectional study on psychological distress was to reveal such distress among patients treated for colorectal cancer (CRC). Between 1993 and 1996, 95 patients in northern Norway were included in the national study randomising Dukes' B and C CRC patients between adjuvant chemotherapy (ACT: 5-fluorouracil and levamisole) or follow-up following radical surgery. In April 1996, all 82 survivors were mailed the Impact-of-Event Scale (IES), to which 64 patients responded (78%). Less than one-third of the patients reported a moderate to high level of psychological distress. Scores predicting significant stress response syndrome were revealed in 14% of the patients. The mean score on the intrusion and avoidance scales were 6.1 and 7.7, respectively. Such variables as age, sex, tumour location (rectum/colon), Dukes' stage B/C and time of follow up did not significantly influence the scores. Patients receiving ACT reported only a slightly raised level on the intrusion (6.97 vs 5.17) and avoidance (8.48 vs 6.80) scales. This study indicates that ACT in CRC Dukes' B and C is not a stressful happening. All advantages in survival achieved by ACT have to be weighed against the "cost" in terms of physical and psychological side effects. This study indicates the weighting in terms of psychological distress may be minimal.

Quality of life in Dukes' B and C colorectal carcinoma

Adjuvant chemotherapy (ACT) is standard therapy in Dukes' C colorectal carcinoma (CRC) in several countries. Several studies have documented a significant improvement in overall survival, but the clinical efficacy on quality of life (QoL) has been doubted. To clarify this item, we performed a study on QoL in 94 CRC patients diagnosed between 1993-96 and randomised to surgery with or without ACT. 82 'survivors' were mailed the EORTC QLQ C-30. Sixty-two patients (76%) responded. They reported a high level of functioning and a low frequency of symptoms. ACT did not improve global QoL, and tended to cause less pain (p=0.023) and more nausea/vomiting (p=0.065).

Intrapleurally instilled mitoxantrone in metastatic pleural effusions: a phase II study

Thirty cases (breast cancer-20 cases, malignant lymphoma-4 cases, different malignancies-6 cases) of histologically/cytologically verified malignant pleural effusion (MPE) in 29 patients were treated with intrapleurally instilled mitoxantrone (30 mg). The therapy was well tolerated. At evaluation, 25 patients had died of progressive disease. The median survival was 3 months (range 0.3-21.3 months). There were 26 responders (12 complete responses (CR), 14 partial responses (PR)), whereas 4 patients relapsed and 3 of these had an early relapse (within 3 months). Patients achieving PR or CR had a low risk (15%) of treatment failure. Five patients were subjected to a pharmacokinetic evaluation. This demonstrated rapidly declining plasma and pleural exudate levels of mitoxantrone within the first 6 hours. At 24 hours after instillation, mitoxantrone was only detected in circulating mononuclear cells. This study shows that mitoxantrone is efficacious in the treatment of MPE, and may represent a cost-effective alternative.

[Hodgkin disease treated at the Tromsø regional hospital 1985-93. Diagnosis, treatment, prognosis, quality of life and costs of a decentralized treatment]

Between 1985-93, 55 patients were treated for Hodgkin's disease at the University Hospital of Tromsø. The median diagnostic delay was four months and a significant prolonged delay was connected with the lymphocyte predominance subgroup. The ChlVPP regimen was shown to be a risk factor for herpes zoster virus infection. The 5-year overall survival was 90%. The survivors experienced a low frequency of symptoms and a high level of functioning. The females reported a significant superior global quality of life and had a lower psychological distress and fatigue score than the males. The cost of one quality-adjusted life year (QALY) (production gains included and using a 10% discount rate) was estimated to be 1,651 pounds. This makes Hodgkin's disease one of the most cost-effective malignancies to treat.

Adjuvant chemotherapy (5-fluorouracil and levamisole) in Dukes' B and C colorectal carcinoma. A cost-effectiveness analysis

BACKGROUND

Adjuvant chemotherapy (5-fluorouracil, levamisole) is now standard practice in the treatment of Dukes' B and C coloretal carcinoma (CRC), and this has increased the financial burden on health care systems world-wide.

PATIENTS AND METHODS

Between 1993 and 1996, 95 patients in northern Norway were included in a national randomised CRC study, and assigned to surgery plus adjuvant chemotherapy or surgery alone. In April 1996, 94 of the patients were evaluable and 82 were still alive. The total treatment costs (hospital stay, surgery, chemotherapy, administrative and travelling costs) were calculated. A questionnaire was mailed to all survivors for assessment of the quality of their lives (QoL) (EuroQol questionnaire, a simple QoL-scale, global QoL-measure of the EORTC QLQ-C30), and 62 of them (76%) responded.

RESULTS

Adjuvant chemotherapy in Dukes' B and C CRC raised the total treatment costs by 3,369 pounds. The median QoL was 0.83 (0-1 scale) in both arms. Employing a 5% discount rate and an improved survival of adjuvant therapy ranging from 5% to 15%, we calculated the cost of one gained quality-adjusted life-year (QALY) to be between 4,800 pounds and 16,800 pounds.

CONCLUSION

Using a cut-off point level of 20,000 pounds per QALY, adjuvant chemotherapy in CRC appears to be cost-effective only when the improvement in 5-year survival is > or = 5%. Adjuvant chemotherapy does not affect short-term QoL.

Treatment costs in Hodgkin's disease: a cost-utility analysis

The aim of this study was to estimate costs of treatment for Hodgkin's disease (HD) and the outcome in health in terms of quality-adjusted life-years (QALYs), and compare these to a constructed nontreatment alternative. All 55 patients treated for HD at the oncological unit of the University Hospital of Tromsø between 1985 and 1993 were included. The total treatment costs (medication, hospital stay, hospital hotel stay, radiotherapy, travelling, loss in production, i.e. work) were retrospectively estimated for all patients. In December 1994, the 49 survivors were sent a EuroQol questionnaire recording quality of life: 42 responded. The mean quality of life score was 0.78 on a 0-1 scale, and the mean total cost of treatment was pounds 12512. The total treatment costs were significantly higher in patients with advanced clinical stages of the disease (P = 0.0006), B-symptoms (fever, sweats, weight loss) (P = 0.0027) and relapse (P < 0.0001). The costs of one QALY (with production gains included and using a 10% discount rate) were estimated at pounds 1651. When excluding production gains and using a 5% discount rate, the figures became pounds 1327. This makes HD one of the most cost-effective malignancies to treat.