How do local authority plans to tackle obesity reflect systems thinking?

AIMS

A whole systems approach to tackling obesity has been recommended by Public Health England for several years. This qualitative study aimed to investigate whether systems thinking is reflected in local authority plans and strategies to tackle obesity, using the leverage points for intervention in a complex system, as a framework.

METHOD

We sought to identify obesity strategies/plans for Southampton and 19 other local authority comparators (based on children's services and Office for National Statistics data). A healthy weight strategy was available for 10 local authorities and a qualitative document analysis was undertaken. The policy actions proposed in the plans were coded against the leverage points for intervention in a complex system and themes were developed to characterise interventions in each category.

RESULTS

A majority of actions included in the plans were categorised as 'Numbers, Constants and Parameters' which reflect downstream measures. However, there were examples of actions that could act on higher leverage points. In addition, some local authority plans included interventions that could act on 10 of the 12 leverage points suggesting incorporation of systems thinking.

CONCLUSIONS

Some local authority plans to tackle obesity do reflect systems thinking when viewed through the lens of the leverage points for intervention in a complex system. Interventions at higher leverage points should be prioritised by public health decision-makers, especially in a climate of competing agendas and limited resources.

Making Every Contact Count with people with MSK conditions: Exploring physiotherapist acceptability

 

There are known risk factors that are associated with the onset and exacerbation of musculoskeletal (MSK) conditions and pain. Physiotherapists are uniquely placed to deliver brief interventions with their patients. Healthy Conversation Skills is the main training component of the Wessex approach to Making Every Contact Count. Despite its potential for promoting MSK health and wellbeing, there is no evidence to support its acceptability within MSK services. This is the first known study to explore the use and perceptions of the Wessex model of MECC HCS within MSK services. A mixed method design was used. Phase one employed an online questionnaire, open to all professionals trained in MECC HCS, consisting of items relating to implementation outcomes. Barriers and facilitators to delivery were explored and mapped to the Theoretical Domains Framework. Phase two invited physiotherapists for a follow-up interview and qualitatively explored their acceptability of delivering MECC HCS to patients with MSK conditions. MECC HCS was found to be highly acceptable, appropriate, and feasible. Physiotherapists reported using their skills at least daily but missed opportunities for delivering MECC HCS were evident. Barriers mapped mostly to ‘Environmental Context and Resources’ on the Theoretical Domains Framework. Qualitative themes developed during phase two were: ‘Recognising the patient as the expert supports change', ‘MECC HCS improves physiotherapy practice', ‘MECC HCS shared problem solving reduces workload', ‘time as a perceived barrier to MECC HCS’ and ‘system-level support needed to sustain MECC HCS'. MECC HCS is a promising brief intervention for supporting people with MSK conditions. Further rollout of this intervention may be beneficial for meeting the goals of the NHS and Public Health England in prevention of MSK conditions and promotion of MSK health. Barriers associated with sustainability must, however, be addressed.

Key messages

• Making Every Contact Count Healthy Conversation Skills is considered a highly acceptable brief intervention for supporting behaviour change in people with musculoskeletal conditions.

• Organisational, system-level barriers to implementation must be addressed in order to increase sustainability and enhance future roll out of the brief intervention.

Meeting the UK Government's prevention agenda: primary care practitioners can be trained in skills to prevent disease and support self-management

Aims:

The NHS Long Term Plan has a prevention focus and ambition to support patients to self-manage disease through improving health behaviours. An essential requirement of self-management is behaviour change, but many practitioners have not been trained in skills to support behaviour change. ‘Healthy Conversation Skills’ (HCS) training was developed at the University of Southampton for this purpose. This article reports on a pilot study that aimed to assess the feasibility of primary care practitioners adopting HCS in their routine practice. It describes their experiences and level of competence post-training.

Methods:

Health Education England (Wessex) commissioned HCS training for 18 primary care practitioners. Fifteen of these practitioners were subsequently observed in their consultations at one or two time points; face-to-face semi-structured, reflective feedback interviews were conducted immediately following the observations. Practitioners’ HCS competence was assessed from the observations and interviews using a previously developed and published coding rubric. The interview data were analysed thematically to understand practitioners’ experiences of using the new skills.

Results:

Practitioners demonstrated competence in embedding the skills into their routine practice following HCS training. They reflected on how patients liked being asked questions, the usefulness of setting SMARTER (Specific, Measured, Action-oriented, Realistic, Timed, Evaluated and Reviewed) goals and the power of listening. They could also identify facilitators of skill use and ways to overcome challenges such as patients with competing priorities and organisational constraints. They found the skills valuable as a way of empowering patients to make changes to manage their own health.

Conclusions:

HCS are acceptable to primary care practitioners, can be readily adopted into their routine consultations and are a helpful strategy for supporting patients to make changes. HCS training has the potential to be a sustainable, scalable and effective way of contributing to the prevention agenda by supporting disease self-management, and hence of addressing today’s epidemic of lifestyle-related conditions.

Improving pregnant women's diet and physical activity behaviours: the emergent role of health identity

Background

Women who gain too much weight in pregnancy are at increased risk of disease and of having children with increased risk. Interventions to improve health behaviours are usually designed for a general population of pregnant women, and trial outcomes show an average impact that does not represent the differences between individuals. To inform the development of future interventions, this study explored the factors that influenced women’s diet and physical activity during pregnancy and aimed to identify the needs of these women with regards to lifestyle support.

Methods

Women who completed a trial of vitamin D supplementation and nurse support in pregnancy were invited to take part in an interview. Seventeen women were interviewed about their lifestyles during pregnancy, the support they had, and the support they wanted. Interview transcripts were coded thematically and analysed to understand the factors that influenced the diets and physical activity levels of these women and their engagement with resources that could provide support.

Results

Women identified barriers to eating well or being physically active, and pregnancy-specific issues like nausea and pain were common. Women’s interest in maintaining a healthy lifestyle and their engagement with lifestyle support was related to the extent to which they self-identified as healthy people. Health-disengaged women were disinterested in talking about their lifestyles while health-focused women did not feel that they needed extra support. Women between these ends of the ‘health identity’ spectrum were interested in improving their health, and were able to identify barriers as well as sources of support.

Conclusions

Lifestyle interventions in pregnancy should be adapted to meet the needs of individuals with different health identities, and encouraging a change in health identity may be one way of supporting sustained change in health behaviours.

Specific Programmed Multiple Development–Thin Layer Chromatography of Furazolidone in Chicken, Turkey, Swine, and Bovine Tissues: Collaborative Study

A specific method for assay of furazolidone at 2 ppb has been developed using programmed multiple development-thin layer chromatography (PMD-TLC) and the conversion of the drug to a fluorescent species which is quantitated by fluorodensitometry on the TLC plate. The method requires only 5 g tissue, specifies an automatic spotter for PMD-TLC, and is capable of measuring <1 ng of drug when the fluorodensitometer is coupled with a computing integrator. This procedure requires an average of 2 man-hours per sample and can be completed in one day. Six laboratories collaboratively studied the method for assay of furazolidone at the 2, 3, and 6 ppb levels in chicken, turkey, swine, and bovine tissues. Tissues were fortified by each laboratory and then processed through extraction, solvent partition, programmed multiple development-thin layer chromatography, and fluorodensitometry. Results showed satisfactory recoveries and accuracy. A statistical comparison of the results demonstrated that 5 of the 6 laboratories obtained similar results. The higher responses from the sixth laboratory appeared to be due to an exceptional vacuum system and the use of silated flasks. The mean drug recovery response for the tissues spiked at 2 ppb from the 5 laboratories was 2.2324 ng ± 20.2% (SD), which at the 99.7% confidence level gives no overlap with control tissue data. The results can be expected to be repeatable within and among laboratories.

The relationship between maternal self-efficacy, compliance and outcome in a trial of vitamin D supplementation in pregnancy

In a randomised controlled trial of vitamin D during pregnancy, we demonstrated that women with lower self-efficacy were more likely to experience practical problems with taking the trial medication and that this was associated with lower compliance and achieved 25(OH)-vitamin D concentrations.

INTRODUCTION

The relationship between self-efficacy (the belief that one can carry out a behaviour), compliance with study protocol and outcome was explored within a randomised, double-blind, placebo-controlled trial of vitamin D supplementation in pregnancy.

METHODS

In the Maternal Vitamin D Osteoporosis Study (MAVIDOS) trial, women with circulating plasma 25(OH)-vitamin D of 25-100 nmol/l in early pregnancy were randomised to either 1000 IU cholecalciferol/day or matched placebo from 14 weeks until delivery. Circulating 25(OH)-vitamin D concentrations were assessed at 14 and 34 weeks' gestation. A sequential sub-sample completed Schwarzer's General Self-Efficacy Scale at 14 and 34 weeks and the Problematic Experiences of Therapy Scale at 34 weeks. Women were interviewed about their experiences of the trial and interview transcripts analysed thematically.

RESULTS

In 203 women, those with higher self-efficacy were less likely to experience practical problems taking the study medication (odds ratio (OR) 0.81 (95 % confidence interval (CI) 0.69-0.95), p = 0.01). Over half reported practical problems associated with poorer compliance with the protocol requiring women to take the medication daily. Compliance in women who experienced practical problems was 94 % compared with 98 % for those with no problems (p < 0.001). Poorer compliance was also associated with lower concentrations of 25(OH)-D in late pregnancy in the treatment group (β = 0.54 nmol/l (95 % CI 0.18-0.89), p = 0.003). Thematic analysis suggested common difficulties were remembering to take the medication every day and swallowing the large capsules.

CONCLUSIONS

These findings suggest that differences in self-efficacy influence trial outcomes. Such information may help clinicians anticipate responses to routine vitamin D supplementation in pregnancy and identify those who may need more support to comply.

TRIAL REGISTRATION

ISRCTN82927713, registered 11/04/2008.

Preconception and pregnancy: opportunities to intervene to improve women's diets and lifestyles

Recently, large-scale trials of behavioural interventions have failed to show improvements in pregnancy outcomes. They have, however, shown that lifestyle support improves maternal diet and physical activity during pregnancy, and can reduce weight gain. This suggests that pregnancy, and possibly the whole periconceptional period, represents a 'teachable moment' for changes in diet and lifestyle, an idea that was made much of in the recent report of the Chief Medical Officer for England. The greatest challenge with all trials of diet and lifestyle interventions is to engage people and to sustain this engagement. With this in mind, we propose a design of intervention that aims simultaneously to engage women through motivational conversations and to offer access to a digital platform that provides structured support for diet and lifestyle change. This intervention design therefore makes best use of learning from the trials described above and from recent advances in digital intervention design.

MDM2 overexpression in benign and malignant lesions of the human breast

MDM2 overexpression has been detected in women with benign or cancerous lesions of the breast. Immunohistochemical methods were used to identify overexpression in 11 of 27 benign cases (41%) and 15 of 22 (68%) cancer cases. MDM2 overexpression correlated well with immunohistochemically detected estrogen receptor (ER), suggesting that expression of these proteins was coordinately regulated. To test this, the MCF-10A human breast cell line, negative for both ER and MDM2 expression, was transfected with a wild-type ER. Following transfection, both ER and MDM2 were strongly expressed in two independent clones. Expression of both was reduced in the presence of increasing concentrations of estradiol (10(-10)-10(-8) M) thus, estrogen may be involved in regulation of MDM2 expression in proliferative breast lesions.

Low levels of food involvement and negative affect reduce the quality of diet in women of lower educational attainment

BACKGROUND

Women of lower educational attainment tend to have poorer quality diets and lower food involvement (an indicator of the priority given to food) than women of higher educational attainment. The present study reports a study of the role of food involvement in the relationship between educational attainment and quality of diet in young women.

METHODS

The first phase uses six focus group discussions (n = 28) to explore the function of food involvement in shaping the food choices of women of lower and higher educational attainment with young children. The second phase is a survey that examines the relationship between educational attainment and quality of diet in women, and explores the role of mediating factors identified by the focus group discussions.

RESULTS

The focus groups suggested that lower food involvement in women of lower educational attainment might be associated with negative affect (i.e. an observable expression of negative emotion), and that this might mean that they did not place a high priority on eating a good quality diet. In support of this hypothesis, the survey of 1010 UK women found that 14% of the effect of educational attainment on food involvement was mediated through the woman's affect (P ≤ 0.001), and that 9% of the effect of educational attainment on quality of diet was mediated through food involvement (P ≤ 0.001).

CONCLUSIONS

Women who leave school with fewer qualifications may have poorer quality diets than women with more qualifications because they tend to have a lower level of food involvement, partly attributed to a more negative affect. Interventions to improve women's mood may benefit their quality of diet.

The effects of diet upon pupal development and cocoon formation by the cat flea (Siphonaptera: Pulicidae)

Cocoon formation by cat flea larvae was directly related to the quantity of eggs or yeast consumed. Larvae consuming either 1-3 eggs or 0.25-1.0 mg of yeast developed as naked pupae or formed incomplete cocoons. Third instar cat flea larvae fed upon naked pupae and pupae within partial cocoons, but complete cocoons protected pupae from cannibalism. First and second instars did not attack pupae. When larvae were provided with a carpet fiber for protection, a greater number of fleas successfully developed to the adult stage.

The effects of flea egg consumption on larval cat flea (Siphonaptera: Pulicidae) development

Cat flea larvae feeding on the feces of adult fleas that were maintained on cats and were provided with frozen flea eggs ad libitum each consumed an average of 21.7 +/- 3.9 eggs and developed rapidly with 100% adult emergence. In contrast, 93.4% of larvae held individually and provided with only flea feces did not survive to the adult stage. Developing larvae consumed eggs in the presence of yeast and rearing diet. In a second experiment, larvae provided with flea feces and eggs and maintained at 55% RH consumed 26.9 +/- 2.7 eggs per larva, compared to larvae maintained at 75% RH that consumed 20.4 +/- 1.9 eggs per larva.

A unique role: the peer mentor on the spinal cord team at G.F. Strong Rehab Centre

The peer mentor is a full time paid staff member of the G. F. Strong Rehab Centre Spinal Cord Program. To qualify for the position, an individual with a high lesion spinal cord injury must live a self-managed life in the community. The peer mentor's role bridges professional, lay, and client perspectives, and is a voice for both clients and staff unlike any other team member. This report focuses on the peer mentor's facilitation of communication between clients and staff and on two initiatives that promote clients' perspectives.

A pilot trial assessing the efficacy of paroxetine hydrochloride (Paxil) in controlling hot flashes in breast cancer survivors

BACKGROUND

Many breast cancer survivors suffer debilitating hot flashes. Estrogen, the drug of choice in perimenopausal women, is generally not recommenced to breast cancer survivors. Nonhormonal treatments are mostly disappointing. Anecdotal reports in our institution suggested that the selective serotonin-reuptake inhibitor, paroxetine hydrochloride, might be efficacious in alleviating hot flashes.

PATIENTS AND METHODS

Thirty women with prior breast cancer who were suffering at least two hot flashes a day entered a single institution pilot trial to evaluate paroxetine's efficacy in reducing the frequency and severity of hot flashes. After completing daily diaries for one week on no therapy, the women received open-label paroxetine, 10 mg daily for one week, followed by four weeks of paroxetine, 20 mg daily. The women completed hot-flash daily diaries throughout the study period, and a health-related symptom-assessment questionnaire and a quality-of-life rating scale in the first and sixth week of the study.

RESULTS

Twenty-seven women completed the six-week study period. The mean reduction of hot flash frequency was 67% (95% confidence interval (95% CI): 56%-79%). The mean reduction in hot flash severity score was 75% (95% CI: 66%-85%). There was a statistically significant improvement in depression, sleep, anxiety, and quality of life scores. Furthermore, 25 (83%) of the study participants chose to continue paroxetine therapy at the end of study. The most common adverse effect was somnolence, resulting in drug discontinuation in two women, and dose reduction in two women. One woman discontinued drug due to anxiety.

CONCLUSIONS

Paroxetine hydrochloride is a promising new treatment for hot flashes in breast cancer survivors, and warrants further evaluation in a double-blind randomized placebo-controlled trial.

Accelerated superfractionated radiotherapy for inflammatory breast carcinoma: complete response predicts outcome and allows for breast conservation

PURPOSE

Chemotherapy and accelerated superfractionated radiotherapy were prospectively applied for inflammatory breast carcinoma with the intent of breast conservation. The efficacy, failure patterns, and patient tolerance utilizing this approach were analyzed.

METHODS AND MATERIALS

Between 1983 and 1996, 52 patients with inflammatory breast carcinoma presented to the Medical College of Virginia Hospitals of VCU and the New England Medical Center. Thirty-eight of these patients were jointly evaluated in multidisciplinary breast clinics and managed according to a defined prospectively applied treatment policy. Patients received induction chemotherapy, accelerated superfractionated radiotherapy, selected use of mastectomy, and concluded with additional chemotherapy. The majority were treated with 1.5 Gy twice daily to field arrangements covering the entire breast and regional lymphatics. An additional 18-21 Gy was then delivered to the breast and clinically involved nodal regions. Total dose to clinically involved areas was 63-66 Gy. Following chemoradiotherapy, patients were evaluated with physical examination, mammogram, and fine needle aspiration x 3. Mastectomy was reserved for those patients with evidence of persistent or progressive disease in the involved breast. All patients received additional chemotherapy.

RESULTS

Median age was 51 years. Median follow-up was 23.9 months (6-86) months. The breast preservation rate at the time of last follow-up was 74%. The treated breast or chest wall as the first site of failure occurred in only 13%, and the ultimate local control rate with the selected use of mastectomy was 74%. Ten patients underwent mastectomy, 2 of which had pathologically negative specimens despite a clinically palpable residual mass. Response to chemotherapy was predictive of treatment outcome. Of the 15 patients achieving a complete response, 87% remain locoregionally controlled without the use of mastectomy. Five-year overall survival for complete responders was 68%. This is in contrast to the 14% 5-year overall survival observed with incomplete responders. The 5-year actuarial disease-free survival and overall survival for the entire patient cohort was 11% and 33%, respectively. All patients tolerated irradiation with limited acute effects, of which all were managed conservatively.

CONCLUSION

Our experience demonstrates that induction chemotherapy, accelerated superfractionated radiotherapy, and the selected use of mastectomy results in excellent locoregional control rates, is well tolerated, and optimizes breast preservation. Based on our present results, we recommend that a patient's response to induction chemotherapy guide the treatment approach used for locoregional disease, such that mastectomy be reserved for incomplete responders and avoided in those achieving a complete response.

Progress in the surgical management of vaginal rhabdomyosarcoma: a 25-year review from the Intergroup Rhabdomyosarcoma Study Group

BACKGROUND/PURPOSE

During its 25 years of experience, the Intergroup Rhabdomyosarcoma Study Group (IRSG) has completed four sequential prospective clinical trials to improve survival and decrease morbidity rates in childhood rhabdomyosarcoma (RMS). Surgical management of vaginal RMS has changed dramatically.

METHODS

The records of 72 patients with localized vaginal RMS were reviewed to assess surgical therapy, chemotherapy, and radiotherapy and their relation to outcome.

RESULTS

Each successive IRSG trial resulted in decreased need for surgical resection (IRS-I, 100%; IRS-II, 70%; IRS-III, 30%; IRS-IV, 13%) and excellent disease-free survival using increasingly effective multiagent chemotherapy.

CONCLUSIONS

Primary chemotherapy after initial biopsy provides excellent tumor control. Local resection may be appropriate, but removal of organs (ie, complete vaginectomy/hysterectomy) has no role except in persistent or recurrent disease. Mature, residual rhabdomyoblasts may be evidence of a chemotherapy response, and further surveillance and biopsy without surgical resection is adequate treatment.

Volunteers as adjunct researchers in a cancer prevention trial: the American Cancer Society Colon Polyp Prevention Study

BACKGROUND

In April 1991, the Virginia Division of the American Cancer Society (ACS) initiated the feasibility phase of the Colon Polyp Prevention Study (CPPS) to determine whether a high fiber supplement would decrease new adenomatous colorectal polyp occurrence. The feasibility phase had two specific objectives: 1) to evaluate accrual and compliance to the designed protocol and 2) to evaluate and demonstrate the effectiveness of volunteers as research assistants. The CPPS is an innovative project in which trained volunteers play a significant role in the research process.

METHODS

In the CPPS, volunteer adjunct researchers (VARs) were trained to perform individual dietary data collection and intervention and other general study monitoring functions. VARs were trained, certified, and monitored in the performance of their assigned tasks by ACS staff and expert consultants.

RESULTS

A total of 119 volunteers were trained as VARs, 74 of whom were certified and matched to a study participant. Between 1991-1995, only six VARs left the study. After active accrual of participants to the study ceased in 1995, 38 VARs (50% of the certified VARs) continued to monitor the active study participants. All VARs were consistently able to conduct the functions for which they were trained.

CONCLUSIONS

In spite of expected volunteer attrition rates, a core of 38 dedicated VARs were matched to 72 participants and demonstrated the ability to perform selected data collecting activities on a consistent and efficient basis. The use of trained volunteers has allowed the CPPS to function in its feasibility phase at personnel cost considerably less than that of other similar cancer prevention trials.

Refsum's disease. A unique case

Refsum's disease, or heredopathia atactica polyneuritiformis, is a peroxisomal disorder leading to the accumulation of phytanic acid throughout the body. It affects sensory and motor neurons and the skeletal system. Peripheral neuropathy, ataxia, blindness, deafness, and skeletal hyperostosis are significant findings used in the diagnosis of the disease.

Chronic vulvar ulceration in an immunocompetent woman due to acyclovir-resistant, thymidine kinase-deficient herpes simplex virus

A 34-year-old healthy woman presented with a 15-month history of persistent, nonhealing vulvar ulcerations due to herpes simplex virus (HSV) type 2. Extensive dermatologic workup and serial skin biopsies failed to reveal an underlying vulvar dermatosis or autoimmune bullous disorder. Virologic studies revealed resistance to acyclovir in vitro due to deficiency in thymidine kinase activity. Serum antibody to human immunodeficiency virus was negative on two occasions, separated by 1 year. Immunologic evaluation showed normal HSV-specific proliferative and CD8 cytotoxic T lymphocyte responses as well as normal NK cell function. Vulvar lesions failed to heal in association with trials of topical trifluorothymidine and oral valacyclovir but resolved completely with the application of 1% foscarnet cream. No recurrence of HSV has been observed in 24 months of follow-up to date.

Thoracic sarcomas in children

OBJECTIVE

This study reviews the experience of the Intergroup Rhabdomyosarcoma Studies (IRS) II and III with thoracic sarcomas.

SUMMARY BACKGROUND DATA

Thoracic sarcomas in children present special problems with histologic diagnosis, total resection of tumor, and local control. Previous studies have shown high rates of local and distant relapse.

METHODS

Data from evaluable patients enrolled in IRS II and IRS III were reviewed. Progression-free and overall survival were estimated by the Kaplan-Meier method and statistical differences were calculated by the log-rank test. The multivariate regression analysis of data was performed using the Cox proportional hazards model.

RESULTS

A total of 84 patients presented with thoracic sarcomas during IRS II (51 patients) and IRS III (33 patients). Of these, 76 were chest wall tumors, 3 were lung tumors, 4 were pleural tumors, and 1 arose from the heart. The average age at diagnosis was 8.5 years (range, 1 month-20.5 years). Thirty-three patients had alveolar histology, 17 had embryonal histology, and 12 had extraosseous Ewing's sarcoma, with indeterminate, undifferentiated, and pleomorphic histologies in the remaining 22 patients. Thirteen patients presented as group I (localized disease completely resected), 18 as group II (microscopic residual or nodal disease), 31 as group III (gross residual disease or biopsy only), and 22 as group IV (distant metastatic disease). Sixty patients (71%) achieved a complete response. Thirty-nine patients had a local relapse, and 22 had a distant relapse. Thirty-five patients (42%) survived with a mean follow-up of 1.8 years (range 0.7-11.7 years); 49 (58%) have died with an average survival of 1.1 years (range 0.3-11.7 years). Four patients (5%) died of infection or treatment complications. Progression-free survival was not significantly associated with histology, site, clinical group, or IRS study. Overall survival was significantly associated with clinical group, size, and local or distant recurrence, but not with histology or IRS study by univariate analysis. In a multivariate analysis, only clinical group and local and distant recurrence showed statistical significance (p < 0.002, < 0.006, and < 0.001, respectively).

CONCLUSIONS

As expected, outcome was better for patients with totally resected or microscopically residual tumor after resection. A higher rate of recurrence in group I versus group II,although not statistically significant, suggests that identification of margin status may be difficult, and these patients may require more intensive efforts for local control. These patients continued to have a high rate of local and distant relapse, and new strategies for preventing these are under development.

Pretreatment TNM staging of childhood rhabdomyosarcoma: a report of the Intergroup Rhabdomyosarcoma Study Group. Children's Cancer Study Group. Pediatric Oncology Group

BACKGROUND

The Intergroup Rhabdomyosarcoma Study Group (IRSG) studies began in 1972 and initially used a clinicopathologic system to place patients into prognostic groups. Because of interest in the development of a pretreatment staging system for assessing the posttreatment outcomes of patients with this disease, potential staging elements were retrospectively evaluated in a subset of 505 patients who participated in IRS-II, an IRSG clinical trial.

METHODS

Using the IRS-II data, a TNM pretreatment staging system was developed and used to stage prospectively the patients who were entering IRS-III, a subsequent treatment protocol of the IRSG. Failure free survival and overall survival were compared by pretreatment stage in IRS-III as a means of evaluating this TNM staging.

RESULTS

The TNM staging system described the tumor (T) in terms of lesion size (< 5 cm or > or = 5 cm) instead of invasiveness, because these two features were not independent of each other. The clinical status of regional lymph nodes (N) was included in the staging system, as was the presence or absence of metastatic disease (M). The latter feature was extremely important, as expected. The anatomic site of the primary tumor also proved to be an important staging element. Classification of patients by tumor size, clinical status of regional lymph nodes, presence or absence of metastatic disease, and location of the primary tumor (at a favorable or unfavorable anatomic site) created four prognostically distinct staging categories that were relatively equal in size. In a prospective evaluation of this staging system with IRS-III patients, the pretreatment staging lost some prognostic impact. The survival of patients with smaller lesions at unfavorable anatomic sites without clinically involved lymph nodes (Stage II) was similar to that of patients with primary tumors at favorable anatomic sites (Stage I).

CONCLUSIONS

A pretreatment TNM staging system for childhood rhabdomyosarcoma, developed with data from IRS-II, was not as predictive of patient outcome when applied prospectively to patients treated in the IRS-III trial. These findings could be due to differences in the management strategy used for IRS-III or the statistical variability in the model-fitting process used to develop the staging system. This demonstrates the need for continual reevaluation of staging systems as patient evaluation and treatment innovations are developed.

The National Cancer Data Base report on gastric cancer

BACKGROUND

Previous Commission on Cancer studies from the National Cancer Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. The most current (1991) data for gastric cancer are described here.

METHODS

Three Calls for Data have yielded a total of 16,992 case reports of gastric cancer for 1985, 1986, and 1991, from hospital cancer registries across the U.S.

RESULTS

Gastric cancer was the 15th most frequent cancer reported to the NCDB. The proportion of all reported cancers that were gastric in the two time intervals studied were essentially the same. In 1991, 20.8% of the cases were reported in minorities. Only 46% of gastric cancer cases were staged by the American Joint Committee on Cancer (AJCC) system in 1985 to 86, compared with 77% in 1991. More advanced stages were reported for younger patients, but less advanced stages were noted in the Asian population. Of all patients reported, 41.4% had no reported cancer-directed surgery, 41.1% had partial or hemigastrectomy, and 6.7% had total gastrectomy. More extensive surgery was associated with patients with Stage III disease than with Stages I and II, as might be expected. Survival after treatment remained poor (5-year relative survival; 43% for Stage I, 37% for Stage II, 18% for Stage III, and 20% for Stage IV).

CONCLUSION

Improvements in treatment will emerge allowing survival to serve as a better guide for the quality of care in the future. In the interim, the frequency of American Joint Committee on Cancer staging in patient charts and the fraction of patients with Stages I and II as opposed to Stages III and IV disease (as a measure of prompt diagnosis) may serve as measure of how quickly these cancers are being diagnosed.

Long-term results of breast conservation therapy for breast cancer

OBJECTIVE

This study was done to determine the long-term outcome of breast conservation therapy (BCT) for patients with early-stage breast cancer during a period of treatment evolution at a single institution.

SUMMARY BACKGROUND DATA

Breast cancer treatment has evolved from extensive surgical extirpation of the breast to treatment options that conserve the breast. Prospective and retrospective studies have confirmed the efficacy of BCT and justify its use for many patients with early breast cancer, but there is no universally accepted consensus as to who benefits from more aggressive application of surgery or radiotherapy in BCT. Prognostic variables for breast cancer and information on factors that contribute to local recurrence help predict BCT results. Continued analysis of BCT still is necessary to improve patient outcome.

METHODS

Eighty-five patients treated with BCT (lumpectomy with adjuvant radiation therapy) at the Medical College of Virginia from 1980 to 1990 were identified. Clinicopathologic parameters and treatment details were analyzed for relationship to development of local recurrence, distant metastasis, and survival. Fisher's exact test was used for comparisons. Actuarial survival curves were plotted. The earlier treatment period (1980-1985) was compared with the later treatment period (1985-1990).

RESULTS

Median follow-up was 5 years. Actuarial overall survival was 83% at 5 years (69% at 10 years), and 5-year distant metastasis-free survival was 79%. The 5-year actuarial local recurrence rate was 6.6% (crude rate 10.6%, 9/85). Young patients (age < 40 years) were found to be at increased risk for local recurrence (24% < 40 years vs. 6% > or = 40 years, p < 0.05). Tumor margins < or = 3 mm were more frequently found, and lumpectomy site radiation boost was used increasingly from 1986 to 1990. Almost half of all local recurrences occurred after 5 years.

CONCLUSIONS

Survival and local recurrence rates were comparable to other series. Young patients were found to be at increased risk for local recurrence. Negative microscopic margins, even when close, can provide low local recurrence rates when adjuvant radiation therapy is administered.

Complications of mastectomy and their relationship to biopsy technique

BACKGROUND

Wound complication rates after mastectomy are associated with several factors, but little information is available correlating biopsy technique with the development of postmastectomy wound complications. Fine-needle aspiration (FNA) biopsy is an accurate method to establish a diagnosis, but it is unknown whether this approach has an impact on complications after mastectomy.

METHODS

Charts of 283 patients undergoing 289 mastectomies were reviewed to investigate any association between biopsy technique and postmastectomy complications.

RESULTS

The diagnosis of breast cancer was made by FNA biopsy in 50%, open biopsy in 49.7%, and core needle biopsy in 0.3%. The overall wound infection rate was 5.3% (14 of 266), but only 1.6% when FNA biopsy was used compared with 6.9% with open biopsy (p = 0.06). Among 43 patients undergoing breast reconstruction concomitantly with mastectomy, the infection rate was 7.1% (0% after FNA, 12% after open biopsy). Neither the development of a postoperative seroma (9.8%) nor skin flap necrosis (5.6%) was influenced by the biopsy technique used.

CONCLUSIONS

These data suggest that wound infections after mastectomy may be reduced when the diagnosis of breast cancer is established by FNA biopsy.

Extremity sarcomas: an analysis of prognostic factors from the Intergroup Rhabdomyosarcoma Study III

PURPOSE

Prognostic factors for extremity sarcomas have been reported previously, after analysis of Intergroup Rhabdomyosarcomas Studies (IRS) I and II. This report reviews the experience of IRS III (1984-1992), in light of these reported factors, and the pretreatment factors used in the staging system currently being evaluated in IRS IV. The results of treatment of extremity sarcomas in IRS III are reported.

METHODS

The charts of all patients entered in IRS III with an extremity-site tumor were reviewed. This group included patients with shoulder girdle and buttock sites. All patients were treated according to IRS III protocols. Survival rates were estimated by the method of Kaplan and Meier, and comparisons among groups of patients were made using a log-rank test. A multivariate analysis was performed to analyze all pretreatment factors that were significant by univariate analysis.

RESULTS

Of the 189 patients entered in IRS III with extremity sites, 88 (47%) had the most common alveolar histology. Fifty-nine patients were in group I at the time of presentation (completely resected disease), 48 in group II (microscopic residual disease), 36 in group III (gross residual disease), and 46 in group IV (metastatic disease). By univariate analysis, the significant prognostic factors affecting survival were clinical group, age at time of diagnosis, tumor size, distant metastases, nodal metastases, and local and distant recurrence. By multivariate analysis of pretreatment factors, age at time of diagnosis, nodal metastases, and distant metastases were significant prognostic factors affecting survival; tumor size approached significance. Both the clinical group system and pretreatment staging system (Lawrence/Gehan) predicted significant differences in survival between groups of patients. The lower survival rate among group II and III node-negative patients with a distal tumor (who, with more extensive surgery, could have been in group I) in comparison to group I patients with a distal lesion, approached significance. In patients without distant metastases, survival was significantly different in those patients that had negative nodes from those in whom nodes were not biopsied.

CONCLUSION

This review confirms that both clinical grouping and the new pretreatment staging system used in IRS IV can predict the likelihood of survival of children with extremity sarcomas. By multivariate analysis of the elements included in the staging system, nodal metastases, distant metastases, and tumor size were useful in predicting survival. In addition, age was a significant predictor. This study confirms previous suggestions that complete excision with gross and microscopically negative margins is preferable in the treatment of children with extremity rhabdomyosarcomas.

Improved survival with preoperative chemotherapy followed by resection uncompromised by tumor response for advanced squamous cell carcinoma of the head and neck

BACKGROUND

A total of 93 patients were treated with one of two preoperative chemotherapy regimens over a 15-year period. The study supports the importance of strict adherence to guidelines for ablative surgery.

METHODS

A single surgeon performed the surgery and evaluated each patient prior to treatment. The extent of the planned operation was documented.

RESULTS

The 5-year absolute survival of 88 patients who completed the protocol was estimated at 55%. The 40 cisplatin/5-fluorouracil-treated patients exhibited a significantly better outcome than the 48 cisplatin/bleomycin-treated patients (76% versus 43%, respectively). Comparison of a subset of 37 patients with a matched group from the standard control arm of the Head and Neck Contracts Program demonstrated a statistically significant improvement in overall survival over standard treatment.

CONCLUSIONS

These data suggest that strict adherence to preoperative chemotherapy planning of ablative uncompromised surgery contribute to improved survival. Selective rather than routine postoperative radiotherapy may be advantageous.

A multicenter, randomized, prospective study of endoscopic laser ablation versus transurethral resection of the prostate

OBJECTIVES

To assess the safety and efficacy of endoscopic laser ablation of the prostate (ELAP), performed with the Urolase fiber and the neodymium:yttrium-aluminum-garnet laser, compared to transurethral resection of the prostate (TURP) in patients with bladder outflow obstruction secondary to benign prostatic hyperplasia (BPH).

METHODS

In this multicenter, prospective, randomized study, a total of 151 patients were treated (ELAP, 76; TURP, 75) of whom 137 completed 1 year follow-up (ELAP, 67; TURP, 70). Safety parameters included measurement of preoperative and 24-hour postoperative sodium, hematocrit, and hemoglobin values and careful monitoring of adverse events. Efficacy was assessed with the American Urological Association symptom score (6), urinary flow rates, and residual urinary volume measurements.

RESULTS

There was 1 death in each group during the study period unrelated to the treatment procedure. There was a clinically significant improvement in all efficacy parameters in both groups. Between group comparisons favored TURP in maximum flow rate, residual urinary volume, and symptom score. ELAP had a better safety profile than TURP in the defined safety parameters of drop in hemoglobin and hematocrit values. In 16% of patients, a blood transfusion was required after TURP compared with no transfusions in the ELAP group. Urinary tract infections and dysuria were more frequent in the ELAP group.

CONCLUSIONS

ELAP performed with the Urolase fiber is a useful alternative therapy to TURP in patients presenting with bladder outflow obstruction secondary to BPH.

Conservative surgical management of vaginal and vulvar pediatric rhabdomyosarcoma: a report from the Intergroup Rhabdomyosarcoma Study III

The current management of pediatric vaginal and vulvar rhabdomyosarcoma (RMS) uses cytoreductive chemotherapy before surgical intervention. During the Intergroup Rhabdomyosarcoma Study (IRS)-III (1984 to 1988), 27 evaluable patients were entered on a preoperative chemotherapy protocol. Among 24 patients with vaginal primaries, 20 had an initial biopsy with gross residual (group III), 3 had resection with positive margins (group IIA) and 1 had metastatic disease (group IV). At subsequent surgery, 7 patients underwent partial or complete vaginectomy and 6 of them had no viable tumor identified in the specimen. Only 1 of these 7 patients underwent a cystectomy, whereas 5 underwent hysterectomy. Seventeen patients in this group have no evidence of disease 66 to 108 months after diagnosis; 2 died of chemotoxicity and 1 of unknown causes after achieving a complete response. Ten of these 17 patients were treated with biopsy and chemotherapy only. Four of these 10 had radiotherapy as well. All group IIA patients have no evidence of disease. The 1 group IV patient had rapidly progressive disease with early death. This primary chemotherapy protocol resulted in less need for operative intervention or irradiation compared with previous experience. There was no local recurrence, and 20 of 24 patients remain continuously relapse-free with no evidence of disease. All 3 patients with vulvar primaries were treated by wide local excision and chemotherapy and have no evidence of disease. Conservative surgical intervention for vaginal RMS with primary chemotherapy and adjunctive radiation when necessary appears to result in excellent disease-free survival.

Conservative management of uterine pediatric rhabdomyosarcoma: a report from the Intergroup Rhabdomyosarcoma Study III and IV pilot

Previous studies have suggested that women with uterine rhabdomyosarcomas (RMS) represent a distinct group of patients who present at an older age, are less responsive to treatment, and have a poorer prognosis than patients with vaginal RMS. During the Intergroup Rhabdomyosarcoma Study (IRS) III and the IRS IV pilot study, 14 patients were registered with uterine primary RMS. Three patients presented with cervical tumors that were completely removed (group 1). Eight patients had initial biopsies with gross residual disease (group 3), and 3 had metastatic disease at presentation (group 4). Of the 5 patients treated with primary chemotherapy or chemotherapy and radiation, 2 had delayed hysterectomy and vaginectomy, 1 had no further surgery, and 2 had exploratory laparotomy with no evidence of disease. There were no relapses or deaths in this group. One patient underwent initial resection of a broad ligament mass, experienced an early (3-week) recurrence of the mass while on chemotherapy, and progressed to developing distant metastases and death. Four patients died of chemotherapy toxicity or sepsis, one after achieving a complete response from chemotherapy and hysterectomy. This primary chemotherapy or chemotherapy and radiotherapy regimen resulted in 8 of 9 (89%) patients (not including those who died of chemotoxicity) surviving between 1.5 and 6 years without evidence of disease. Of the surviving patients, 2 had hysterectomy and vaginectomy, but pathological specimens showed only localized microscopic residual tumor. This report suggests that less vigorous operative resection may be possible in combination with primary chemotherapy when treating uterine rhabdomyosarcomas.(ABSTRACT TRUNCATED AT 250 WORDS)