Patient preferences for chemoradiation-related side effects

e20604

Background: Patients (pts) undergoing chemoradiation (CRT) face intense treatment (tx) schedules and adverse tx- related side-effects (SEs). We conducted this study to determine whether pts’ preferences (PREFs) for CRT-related SEs changed over tx duration. Methods: We used the visual analog scale (VAS) and modified time trade-off (TTO) to assess PREFs of newly diagnosed pts with gynecologic (GYN) and gastrointestinal (GI) cancers scheduled to receive CRT. Pts evaluated 16 SE health state scenarios during interviews conducted at 3 points in time: T1=prior to starting CRT; T2=2–3 weeks after starting CRT; and T3=4–6 weeks after completing CRT. Using the VAS, pts ranked SEs on a scale of 0=worst to 100=best. The TTO asked pts whether they would accept a hypothetical tx for a specified time with the SE in question or a tx for a shorter length of time that involved a worse SE profile. PREF scores were converted to 0.0=least preferred to 1.0=most preferred. Mann-Whitney and Kruskal-Wallis tests were used to analyze data. P- values were adjusted for multiple comparisons. Results: PREFs were collected from 93 pts (GYN=43; GI=50). 46/93 pts were female (3 women were GI pts). Median age was 53.7 yrs. Pts received a median of 5 chemo cycles (31/50 GI and all GYN pts received platinum) and 5.4 wks of external beam radiation. Median time between T1-T2 was 2.6 wks and T2-T3 was 9.1 wks. TTO PREFs were stable over time regardless of disease group or tx regimen. VAS scores for 7 SEs worsened significantly after initiation of CRT and remained low despite completion of CRT ( table ). Pts gave low baseline PREF scores for diarrhea, fatigue, and loss of appetite; these did not change significantly over time. Conclusions: Pts receiving CRT were willing to accept tx of longer duration with less severe SEs instead of shorter tx with more severe SEs. Relative to other SEs, pts rated GI-associated SEs lower after initiation of CRT. Ratings remained low 4–6 weeks after tx completion. Further studies are needed to determine whether pts’ experiences with and perceptions of SEs influence tx compliance.

[Table: see text]

[Table: see text]

A phase I trial of liposomal doxorubicin (D), bevacizumab (A), and temsirolimus (T) in advanced malignancy

e13508

Background: Liposomal doxorubicin (D) and bevacizumab (A) are active drugs in multiple malignancies. Unfortunately, resistance mechanisms have been described for each that limit their efficacy following repeated exposure. These include aberrant activation of alternate signaling pathways, such as PI3K/AKT/mTOR and upregulation of hypoxia inducible factor (HIF-1α). We therefore added temsirolimus (T), an agent known to inhibit mTOR and to downregulate HIF-1α, to the combination of D and A. The objectives of this trial were to assess the safety of this combination, obtain preliminary efficacy data and to identify biologic correlates for treatment response. Methods: D, A and T were administered intravenously on a 21 day cycle. D, A and T were given day 1, and T was administered alone weeks 2 and 3. A standard 3+3 trial design was used for dose escalation; 6 dose levels are planned. Patient serum and biopsies were also collected pre- and post-treatment for batched analysis to assess biologic response correlates. Results: 6/12 treated patients are evaluable (remaining patients have not yet completed 1st restaging). 5 patients are male; median age (all patients) 53, range 12 to 59. Median number of prior treatments = 5, range 2 - 8. At first restaging, 2/2 patients with endometrial cancer were found to have ≥ 25% decrease in tumor size (RECIST), and one patient with colorectal carcinoma had a 15% decrease. 1 patient had stable disease. One of the patients with endometrial cancer and extensive intra-abdominal disease who showed rapid tumor regression (≥ 25% decrease at 2 months) developed an entero-colonic fistula, and chose hospice care. Grade 2 stomatitis and fatigue (CTCAEv3)have also been seen. The current doses being used are 20mg/m2 of D and 5mg/m2 of A every 21 days, and 25mg of T every 7 days (dose level 3). Conclusions: Preliminary data indicate that the combination of D, A and T has anti-tumor activity and is well tolerated at the doses used. Patients with intra-abdominal disease who experience rapid tumor regression may be at risk for fistula formation. Biomarker analysis for modulation of the mTOR signal (via PI3K mutations or other aberrations) and the HIF-1α pathway is ongoing.

No significant financial relationships to disclose.

Complementary and alternative medicine: What do oncology healthcare providers think?

e20614

Background: The use of complementary and alternative medicine (CAM) is growing as the oncology patient (pt) population increases. The purpose of this study was to assess current CAM practice patterns of oncology healthcare providers. Methods: We distributed a 20-page anonymous survey to all physicians (), mid-level practitioners, clinical pharmacists, and dietitians at a comprehensive cancer center. The survey examined factors influencing a provider's inquiry towards pt CAM use, as well as current perception and use of 15 different CAM modalities, such as meditation, acupuncture, chiropractic, and herbal therapy. Descriptive statistics, chi-square, and Student's t-test were used for analysis. Results: 671/1,601 (42%) surveys were returned with s comprising 50% of the responses. 83% of respondents believed CAM has a role in cancer care. Over 70% indicated that massage, meditation/prayer, relaxation techniques, and acupuncture have potential uses, primarily to relieve symptoms not controlled by conventional therapy (tx) (47%) and as psycho-social-spiritual support (47%). Respondents estimated 28% of pts utilize CAM; 25% of respondents and 19% of pts initiated CAM discussions during pt visits. Those in medicine-based fields were more likely to discuss pt CAM use compared to surgical specialities (30% vs. 19%, p<0.01), but there was no significant difference in comfort level to discuss CAM modalities. s were less likely to discuss CAM use compared to all other providers (21% vs. 31%, p<0.01). s were also less comfortable discussing herbs (37% vs. 51%, p<0.01), massage (73% vs. 82%, p<0.05), meditation/prayer (71% vs. 82%, p<0.05), and relaxation tx (67% vs. 77%, p<0.01) compared to all other providers but more comfortable discussing acupuncture (63% vs. 55%, p<0.05). Respondents cited lack of knowledge in CAM as the primary reason for not discussing CAM with pts. Conclusions: Past studies estimate that >50% of patients use at least one form of CAM. Our study suggests that oncology providers critically underestimate the number of patients incorporating CAM into their treatment. Improving provider education on CAM therapies is essential to improve patient-physician communication regarding potential risks and benefits of CAM with traditional cancer therapies.

No significant financial relationships to disclose.

Ethnic differences in socioeconomic status, diagnosis, treatment, and survival among older women with epithelial ovarian cancer

The purpose of the study was to determine the ethnic disparities in socioeconomic status (SES) and in receiving definitive surgical treatment and adjuvant chemotherapy and to examine if these differences contribute to ethnic disparities in survival. We studied a population-based cohort of 5131 women diagnosed with epithelial ovarian cancer at age >or=65 between 1992 and 1999, identified from the Surveillance, Epidemiology and End Results-Medicare linked databases with up to 11 years of follow-up. The percentage of women diagnosed with epithelial ovarian cancer at advanced stage (stage III or IV) was 71.6% in Caucasians and 69.7% in African-Americans. Of these 4264 with stage IC-IV disease who are recommended for chemotherapy, fewer African-Americans received chemotherapy compared to Caucasians (50.2% versus 64.7%, P < 0.001). The risk of all-cause mortality in African-Americans was not significantly different from Caucasians (hazard ratio [HR] = 1.00, 95% CI = 0.88-1.13) after controlling for patient demographics, tumor characteristics, and comorbidity. The HR remained not significant in African-Americans compared to Caucasians after additionally adjusting for treatments (0.93, 0.82-1.06) or SES (0.94, 0.82-1.08) or both (0.88, 0.77-1.01). Women who underwent cancer-directed surgery and received adjuvant chemotherapy were 50% less likely to die than those who did not. The survival benefits from these therapies were similar in Caucasian and African-American women with ovarian cancer. There was no significant difference in survival between African-American and Caucasian women with ovarian cancer after adjusting for tumor characteristics, treatment, and sociodemographic factors. Although adjuvant chemotherapy was effective in prolonging survival, substantial numbers of women with ovarian cancer still did not receive chemotherapy.

Survival in advanced-stage ovarian cancer patients with non-Ashkenazi Jewish BRCA mutations

5514

Background: Previous studies have shown a survival advantage in ovarian cancer patients with Ashkenazi-Jewish BRCA founder mutations compared to sporadic ovarian cancer patients. The purpose of this study is to determine if this association exists in ovarian cancer patients with non- Ashkenazi Jewish (non-AJ) BRCA1 or BRCA2 mutations. Methods: Patients with stage III or IV ovarian, fallopian tube, or primary peritoneal cancer and a BRCA1 or BRCA2 mutation, seen for genetic testing between January 1996 and October 2006, were identified from the institutional and genetics databases. Medical records were reviewed for clinical factors including response to initial chemotherapy. Response is defined as no clinical evidence of disease with normalization of serum CA-125 and no radiographic evidence of disease or a negative second-look surgery. Patients with sporadic ovarian cancer, without a family history of breast or ovarian cancer, were compared to similar cases, matched by age, stage, and year of diagnosis. Progression-free and overall survival were calculated by the method of Kaplan-Meier. Chi-square tests and univariate logistic regression were also used in the data analysis. Results: Thirty-nine advanced-stage ovarian cancer patients with non-AJ BRCA mutations and 47 matched, advanced-stage sporadic ovarian cancer patients have been analyzed. Compared to patients with sporadic ovarian cancer, non-AJ BRCA mutation carriers had a longer progression-free survival (PFS, 32.4 mos. vs. 22.1 mos., p = 0.0303) and overall survival (OS, 101.4 mos. vs. 51.3 mos., p < 0.001). Similarly, 72% of the non-AJ BRCA mutation carriers had a complete response to initial treatment, compared to 45% of the sporadic ovarian cancer patients (p = 0.01). The odds of complete response to initial treatment were 3.2 times greater in the non-AJ BRCA group than in the sporadic group (OR 3.2; 95% CI 1.27 - 8.15). Conclusions: This study demonstrates a significant survival advantage in advanced-stage ovarian cancer patients with non-AJ BRCA mutations when compared to similar patients with sporadic ovarian cancer. Response to initial treatment appears to impact this improved survival.

No significant financial relationships to disclose.

Impact of BRCA 1/2 testing: Body image, sexual functioning, and quality of life (QOL)

1525

Background: Management strategies for women at high risk of breast and ovarian cancer (OVCA) may affect sensitive QOL issues. Methods: As part of a larger study, 540 women who underwent testing for BRCA 1/2 prior to July 2005 were sent follow- up surveys, including FACT-Endocrine Symptom subscale (FACT-ES), Sexual Activity Questionnaire (SAQ), and a modified Body Image Scale. Chi-square, Mann-Whitney and Kruskal-Wallis tests were used to analyze the data. Results: To date, 309 patients (pts) have responded. Pts with previous oophorectomies were excluded (n=68). The final analysis included 241 pts categorized into 4 groups: Group 1=no breast CA, no prophylactic (proph) surgery (n=39); Group 2=no breast CA, + proph surgery (either proph oophorectomy (PO), proph mastectomy (PM), or PO+PM) (n=20); Group 3= + breast CA, no PO or PM (n=90); and Group 4= + breast CA, + proph surgery (n=92). Median age at time of survey = 50 yrs. Median age at time of PO = 46 yrs. Of 65 BRCA + pts, 36 chose PO, while 32/176 BRCA- pts chose PO (p<.001). 155 pts reported being sexually active at time of survey. Women with PO (n=68) had more endocrine symptoms by the FACT-ES vs pts who chose screening (n=173) (p=.005). Women in Group 2 reported more endocrine symptoms compared to all other women (p=.02). The same trend was noted for sexually active women only (p=.06). There were no differences in activity or pleasure measured by the SAQ between women with PO vs screening; pts with PO reported higher levels of pain/discomfort (p=.04). Women in Group 1 reported the lowest level of pain/discomfort (p=.004) and highest level of pleasure. Higher levels of discomfort and less sexual activity were reported by women with breast CA vs those without breast CA (p<.001; p=.05). Women in Group 3 had the most negative body image while Group 2 had the most positive (p=.03). Women who chose screening reported a more negative body image vs women with PO (p=.01). Pts with breast CA had more negative body image scores than women without breast CA (p=.06). Conclusions: Choice of management strategy and personal hx of breast CA appear to influence sexual functioning, endocrine symptoms and body image in women at high risk of breast and OVCA. Baseline assessment of these factors and continued dialogue are critical aspects of comprehensive care for these women.

No significant financial relationships to disclose.

Management strategies for women at high risk for breast and ovarian cancer: Are women satisfied?

1524

Background: Women at high risk for breast and ovarian cancer have two major management options to reduce their risk of ovarian cancer, periodic screening (PS) or prophylactic oophorectomy (PO). Little is known regarding patient satisfaction levels with choice of risk reduction strategy. Our objective was to determine levels of patient satisfaction with PO versus PS and to identify factors which may influence satisfaction. Methods: As part of a larger study, women who received BRCA1/2 testing before July 2005 were sent a follow-up patient questionnaire packet. We are reporting on the Cancer Worry Scale and Satisfaction With Decision (SWD) scale (range of possible scores, 6–30). The lowest 10th percentile of the SWD score (21) was used to define low satisfaction. Chi-square, t-Test and Mann-Whitney tests were used for statistical analyses. Results: A total of 540 surveys were mailed and 309 responses were received (57%). We excluded 127 patients due to history of an oophorectomy for benign or malignant indications or incomplete SWD scale. The median age of respondents was 48.2. 60/182 women (33%) had BRCA mutations and 64/182 (35.2%) underwent PO. The overall satisfaction rate among respondents was high (median score 29, range 14–30). Median SWD score was significantly higher in patients in the PO group compared to the PS group (30.0 vs. 26.5, p<.001). Patients with BRCA mutations had higher median SWD scores, regardless of management type (30.0 vs. 28.0, p=.013). Low satisfaction scores were associated with the perception that the decision between PO and PS was difficult to make (p=.001). Patients who expressed ongoing difficulty in their decision-making also had lower satisfaction scores (p=.016). Satisfaction was unrelated to demographics, clinical factors, or concerns of cancer risk. Conclusions: In our study, the majority of women at high risk for breast and ovarian cancer were satisfied with their choice of risk reduction strategy. In particular, women who chose PO had higher levels of overall satisfaction. Difficulty with decision-making was associated with lower satisfaction levels. Improved education and support of these women through the decision-making process may enhance overall levels of satisfaction with risk reduction strategy.

No significant financial relationships to disclose.

Neoadjuvant chemotherapy for low-grade serous carcinoma of the ovary

5571

Background: Neoadjuvant chemotherapy (NACT) has been associated with significant tumor reduction prior to interval debulking surgery, enabling optimal cytoreduction in up to 50% of patients with high-grade ovarian carcinomas deemed initially unresectable. Since low-grade serous carcinoma (LGSC) appears to be relatively less chemosensitive, we sought to evaluate the outcomes of women with ovarian LGSC treated with platinum-based NACT. Methods: Using institutional databases, we identified 18 women with low-grade serous carcinomas of the ovary who were treated with neoadjuvant platinum-based chemotherapy between 1978 and 2003. Patient demographic and clinical variables were abstracted from the medical records. Progression-free survival (PFS) and overall survival (OS) were estimated using the method of Kaplan-Meier. Results: The median age at diagnosis was 44 years (range, 21 to 81 years). NACT was given for extensive or non-resectable disease in 16 patients (89%) and for unknown reasons in 2 patients (11%). Ten patients (42%) underwent exploratory laparotomy with biopsy only prior to beginning chemotherapy. A median of 6 cycles of chemotherapy was given (range, 2 to 16) and included the following regimens: platinum/taxane (n=12 patients); platinum/cyclophosphamide (n=3 patients); and platinum/leuprolide acetate (n=3 patients). Of the 13 patients who had CA-125 levels available, 8 (62%) had a ≥50% reduction between pre- and post-NACT levels. However, response, determined by radiographic survey at completion of NACT, demonstrated one patient (6%) with a complete response, no patients (0%) with a partial response, and 16 patients (89%) with stable disease. One patient (6%) was not evaluable. Fifteen patients (83%) underwent interval cytoreductive surgery, which was optimal in 8 cases (53%), suboptimal in 4 cases (27%) and unknown in 3 cases (20%). Median PFS and OS for all patients were 18.6 and 56.1 months, respectively. Conclusions: A low response rate to platinum-based NACT was observed among women with LGSC of the ovary. These findings suggest that LGSC is not as responsive to conventional chemotherapy as high-grade serous carcinoma. Prospective clinical trials, focusing specifically on LGSC, are needed to make meaningful advances for this group of patients.

No significant financial relationships to disclose.

Thoracotomy for the management of recurrent vaginal leiomyosarcoma

Vaginal leiomyosarcoma is a rare malignancy for which little data exists to guide treatment decisions. We describe a patient diagnosed with primary vaginal leiomyosarcoma who underwent hysterectomy and upper vaginectomy followed by whole pelvic radiation. Approximately 3 months after her initial treatment, she presented with an isolated pulmonary recurrence, which resolved after 12 cycles of chemotherapy. Nineteen months later, a second recurrence was found at the same site. This metastasis was resected and she has remained without evidence of further disease for more than 24 months. Similar to patients diagnosed with uterine sarcomas, resection of pulmonary metastases may offer women with recurrent vaginal leiomyosarcoma improved survival with good quality of life. Thoracotomy should be considered for women diagnosed with pulmonary recurrences of this disease.

Spirituality, quality of life, and locus of control in a palliative care setting

18529

Background: A patient’s spirituality/religious beliefs have a profound role on how one copes with disease & on quality of life (QOL). Perceptions of control play an important role in coping not only with stressful experiences, but also in health outcomes. Therefore, the primary objective was to determine whether patients’ spirituality/ religiosity correlates with quality of life and locus of control. Methods: As part of a pilot study, pts presenting for initial outpatient evaluation in the Department of Symptom Control & Palliative Care were enrolled and completed self-report measures: Functional Assessment of Chronic Illness Therapy-General (FACT-G), FACT-Spiritual Well-Being Scale (FACT-Sp), Duke University Religion Index (DUREL), Locus of Control (LOC), Herth Hope Scale (HHS), Predestination (PDQ), and Hospital Anxiety & Depression Scale (HADS). LOC contained 3 subscales: perceived occurrence of chance, dependence on powerful others, and internal control. Pearson correlation coefficients were calculated to explore the relationship between measures. The Mann-Whitney t-test was used to compare patient scores. Results: One hundred patients (48 men & 52 women) completed the surveys & 90% reported a Christian affiliation. QOL was positively correlated with FACT-Sp (p ≤ 0.001, r = .614) and the DUREL which measures both external/internal religiosity (p ≤ .01, r = .291). Interestingly, there was no gender difference in spirituality as measured by FACT-Sp; however, by the DUREL women engaged more frequently in private religious activity when compared with men (p < 0.001). Men had more perceived internal control with less emphasis on the occurrence of chance events or dependence on powerful others on LOC (p = 0.07), as well as a positive correlation with controlling of one’s own fate as measured by the PDQ (p = 0.1). Conclusions: As oncologists committed to providing comprehensive care, we need to be receptive to the spiritual needs of our patients since it augments their QOL and to empower them to have a sense of control. Future studies need to further define these complex relationships and to recognize possible gender differences.

No significant financial relationships to disclose.

Preferences for cancer prevention strategies (CPS) in women with hereditary nonpolyposis colectal cancer (HNPCC)

1018

Background: Women with HNPCC have 40–60% lifetime risk of endometrial and colon cancer (CA) and 10–12% risk of ovarian CA. Because CPS have significant QOL implications, understanding how women evaluate CPS and personal risks of CA may facilitate physician and pt communication for medical decision making in this group of pts. Methods: Using the visual analog scale (VAS) and standard gamble (SG), women with HNPCC or with a family history (FHx) that fulfilled Amsterdam II criteria were asked to: 1) score CPS from 0.0=worst to 1.0=best; and 2) state the % personal risk of CA they would need to have in order to undergo each CPS. CPS included oral contraceptives ± COX-2 inhibitors (OC ± COX2); endometrial biopsy/transvaginal ultrasound/CA125 ± colonoscopy (Bx/US ± CSPY); pre- and post-menopausal total abdominal hysterectomy/oophorectomy ± subtotal colectomy (TAH/BSO ± COL). Results: To date, 32 women have enrolled (median age=38.4 yrs). Bx/US + CSPY was rated most favorably (0.95) followed by OC, Bx/US, and CSPY(.90). Pre-menopausal TAH/BSO, COL, and TAH/BSO+ COL had the least favorable ratings (0.50, 0.30, and 0.25, respectively). Women accepted non-surgical CPS if their personal risk of CA was at least 30%; pre- and post-menopausal TAH/BSO if the personal risk of CA was at least 73% and 50%, respectively. Women accepted COL and TAH/BSO + COL if their risks of CA were at least 78% and 80%, respectively. Women without FHx of HNPCC-gynecologic (GYN) CA would participate in all CPS more readily than women with FHx of HNPCC-GYN CA. Specifically, to accept COX2, women without FHx of HNPCC-GYN CA would do to if their personal CA risk was at least 10% compared to a 30% risk for women in the 2nd group (p=.04). For the 2 groups, risks for Bx/US, pre-menopausal TAH/BSO, post-menopausal TAH/BSO, TAH/BSO + COL and COL were 20% vs 30% (p=.06), 40% vs 80% (p=.03), 30% vs 55% (p=.02), 65% vs 80% (p=.06), and 80% vs 100% (p=.01), respectively. Conclusions: Our data indicate that women without FHx of HNPCC-GYN CA are more willing to undergo chemoprevention, screening and prophylactic surgery for HNPCC CA compared to women with a FHx of HNPCC-GYN CA. This may be due to the perception of a more favorable clinical outcome associated with endometrial CA, the more common of the HNPCC-GYN CA.

No significant financial relationships to disclose.

Analysis of 96 patients with advanced ovarian carcinoma treated with high-dose chemotherapy and autologous stem cell transplantation

The purpose of this study was to identify characteristics significant to survival and progression-free survival in patients with advanced ovarian cancer receiving high-dose chemotherapy. In all, 96 patients received autologous stem cell transplantation. Regimens included paclitaxel with carboplatin (PC), topotecan, melphalan, cyclophosphamide (TMC) and cyclophosphamide, BCNU, thiotepa (CBT). At the time of transplantation, 43% of patients were in clinical CR, 34% were in clinical PR, 18% had progressive disease and 5% had stable disease. There were no treatment-related deaths. The 6-year survival by Kaplan-Meier was 38%. For patients who received transplantation for remission consolidation, the 6-year survival was 53% with a PFS of 29%. On univariate analysis, the CBT regimen, clear cell histology and disease status other than CR prior to treatment were statistically significant adverse prognostic factors. This analysis has demonstrated that patients in clinical remission are most likely to benefit from autologous transplantation, with the exception of patients with clear cell histology. The TMC combination appeared to be superior to the PC and CBT combinations. Comparative studies of different consolidation approaches will be necessary to determine if autologous transplantation is the preferred treatment for this patient population.

Approaches for end-of-life care in the field of gynecologic oncology: an exploratory study

We sought to explore the Society of Gynecologic Oncologists (SGO) members' opinions and decisions about end-of-life issues and incurable conditions. A survey was mailed to members of the SGO. Their responses were recorded on a Likert scale and entered into a database. The survey explored opinions, experiences, and decisions in managing terminally ill gynecologic oncology patients. Of 900 surveys, 327 were returned (response rate, 36%). Seventy-three percent were men, 89% were white, and 72% were of Christian denomination. Respondents believed that 97% of patients who are dying realize that they are dying but stated only 40% of these patients initiate conversations about end-of-life issues. In contrast, 92% of respondents stated that they initiate end-of-life discussions with patients. Ninety-two percent of respondents thought that the patients should be allowed to make end-of-life choices independently after the facts are given to them. However, 44% thought that it is important to influence the way information is presented, and 54% believe that the gynecologic oncologist (GO) controls the outcome of end-of-life discussions. Although the physicians' sex, race, religion, and age did not correlate with their treatment decisions, religion did correlate with less fear of death (P = 0.011) and less discomfort when talking with patients about death (P = 0.005). Fifty-four percent of respondents believed that the GO controls the outcome of end-of-life discussions, and 40% believe that their actions prolong the process of dying. Expanding our understanding of what motivates GOs to recommend continued treatment over palliation is important for preserving informed patient-motivated end-of-life decisions.

Approaches for end-of-life care in the field of gynecologic oncology: an exploratory study

We sought to explore the Society of Gynecologic Oncologists (SGO) members' opinions and decisions about end-of-life issues and incurable conditions. A survey was mailed to members of the SGO. Their responses were recorded on a Likert scale and entered into a database. The survey explored opinions, experiences, and decisions in managing terminally ill gynecologic oncology patients. Of 900 surveys, 327 were returned (response rate, 36%). Seventy-three percent were men, 89% were white, and 72% were of Christian denomination. Respondents believed that 97% of patients who are dying realize that they are dying but stated only 40% of these patients initiate conversations about end-of-life issues. In contrast, 92% of respondents stated that they initiate end-of-life discussions with patients. Ninety-two percent of respondents thought that the patients should be allowed to make end-of-life choices independently after the facts are given to them. However, 44% thought that it is important to influence the way information is presented, and 54% believe that the gynecologic oncologist (GO) controls the outcome of end-of-life discussions. Although the physicians' sex, race, religion, and age did not correlate with their treatment decisions, religion did correlate with less fear of death (P = 0.011) and less discomfort when talking with patients about death (P = 0.005). Fifty-four percent of respondents believed that the GO controls the outcome of end-of-life discussions, and 40% believe that their actions prolong the process of dying. Expanding our understanding of what motivates GOs to recommend continued treatment over palliation is important for preserving informed patient-motivated end-of-life decisions.

Cost-effectiveness analysis of diagnosis and management of cervical squamous intraepithelial lesions

OBJECTIVE

To compare five strategies for the diagnosis and treatment of cervical squamous intraepithelial lesions (SILs), including those that incorporate colposcopy and a new technology, fluorescence spectroscopy.

METHODS

On the basis of a health care perspective, we performed a cost-effectiveness analysis using a decision-analytic model for the diagnosis and management of SILs. We compared the five strategies based on the expected costs and number of cases that were treated appropriately, missed, treated inappropriately, and appropriately not treated in a hypothetical cohort of 100 patients referred after an abnormal Papanicolaou smear. Data on prevalence and operating characteristics were derived from the medical literature. Costs were adjusted from hospital charge data.

RESULTS

A see-and-treat strategy based on fluorescence spectroscopy was the least expensive but least effective strategy, costing $160,479 to detect 31.55 cases of cervical precancer accurately in 100 patients. The most expensive strategy was colposcopically directed biopsy, at $311,808 to find 45.78 cases; however, when both tests were used in a see-and-treat modality, slightly more cases were found (46.05) at a lower cost ($285,133). Other strategies were dominated in the base case. The incremental cost-effectiveness of the joint strategy compared with the spectroscopy-only strategy was $8596 per case of cervical precancer detected. Sensitivity analysis showed that the analysis was sensitive to the cost of the new technology of fluorescence spectroscopy.

CONCLUSION

Fluorescence spectroscopy should be considered an important innovation in the diagnosis of SILs as demonstrated by its efficacy and economic advantages.

Eating disorders among selected female student populations at UCLA

Seven hundred sixteen female UCLA students--drawn from Primary Care Clinic, Women's Health Clinic, sorority, athletic team, dance major, and undergraduate psychology class populations--completed questionnaires regarding eating disorders symptoms and attitudes compatible with the diagnostic criteria published by the American Psychiatric Association in the Diagnostic and Statistical Manual, (3rd ed., DSM-III), the Eating Disorders Inventory, and related information. The purpose of the study was to determine the prevalence of eating disorders and eating disorder-related symptoms in particular subgroups for targeting intervention and prevention programs. Although between 7.5% and 46% of subgroup populations reported the presence of individual eating disorder-related symptoms, the prevalence of active eating disorders for the group as a whole at the time of the survey was 2.1%, with the prevalence of disorders at any time during life 4.8%, using DSM-III diagnosis. The Eating Disorders Inventory scores for the group as a whole were comparable with norms reported by other researchers in the literature. Primary Care Clinic attenders and dance majors reported the highest rates of symptoms and disorders, while athletes reported the lowest rates.