National survey on prophylactic cranial irradiation: differences in practice patterns between medical and radiation oncologists

PURPOSE

Prophylactic cranial irradiation (PCI) in the treatment of small cell lung cancer (SCLC) patients remains controversial in the oncology community because of its potential for long-term toxicity and unproven survival benefit in randomized trials. A national survey of 9176 oncologists was conducted to characterize the use of PCI with regard to physician demographics, patient characteristics, and oncologists' beliefs.

METHODS

Data was collected via a questionnaire letter survey. Biographical data, treatment patterns, and clinical impressions were analyzed by the generalized linear model and generalized estimating equations method.

RESULTS

There were 1231 responders overall (13.4% of those surveyed), including 628 (51%) radiation oncologists (RO), 587 (48%) medical oncologists (MO), 8 (0.6%) surgical oncologists, and 8 (0.6%) from other oncology subspecialties. Of respondents, 74% overall recommend PCI in limited-stage patients, including 65% of MO and 82% RO (p = 0.001). Of responders who recommend PCI in limited-stage patients, 67% do so only after complete response to initial therapy. Only 30% of respondents recommend PCI for extensive-stage SCLC patients (p = 0.001), and 94% of these recommend PCI only when those patients have a complete response after initial therapy. Interestingly, 38% of responding MO feel that PCI improves survival of limited-stage patients, but only 11% believe PCI improves quality of life. Of the RO, 48% believe PCI improves survival in limited-stage SCLC, and 36% feel PCI improves quality of life (p < 0.05 and p < 0.01, respectively). MO responders believe PCI causes late neurological sequelae more often than do RO responders (95% vs. 84%, p < 0.05), with impaired memory (37%), chronic fatigue (19%), and loss of motivation (13%) as most commonly seen side effects. Only 1.5% overall, however, routinely obtain neuropsychiatric testing in PCI patients, and 42% overall never obtain them.

CONCLUSION

Results confirm that oncologic subspecialists have statistically significant differences in opinion regarding the use of PCI. However, these differences may not translate into large differences in clinical practice. Most oncologists continue to recommend PCI in limited-stage SCLC patients, despite many believing PCI may not provide a survival advantage nor improve quality of life.

[The state of and ways to improve diagnostic efficacy in the main forms of malignant neoplasms]

The state of diagnosis of malignant tumors in Ukraine concerning the indexes of opportunity, activity, accuracy was analysed. Complex of measures for an early detection of oncologic patients in all ranks of medical-sanitary aid to population was proposed.

Physicians' legal defensiveness and knowledge of medical law: comparing Denmark and the USA

The impact of legal factors on medical treatment decisions for dying patients has been studied in the USA for years. However, it is unknown how legal factors may affect similar medical decisions in other countries. This exploratory study compared responses between two populations of physicians, from Denmark (n = 62) and the USA (n = 301), who regularly treat terminally ill patients in tertiary care medical centers. We investigated whether Danish and US physicians differed significantly in their attitudes about the influence of law on treatment decisions for terminally ill patients. The Danish physicians demonstrated significantly better knowledge of medical law relevant to end-of-life treatment than did US physicians. The Danish sample also reported significantly lower levels of legal defensiveness than the US sample. These findings are consistent with our previous research showing that, among US physicians, legal defensiveness and knowledge of medical law are inversely related.

The current status of surgical staging of ovarian serous borderline tumors

BACKGROUND

The purpose of the current study was to evaluate the current practice of surgical staging of ovarian serous borderline tumors.

METHODS

Women with a diagnosis of ovarian serous borderline tumors whose pathology slides were sent to the M. D. Anderson Cancer Center for second-opinion diagnostic consultation between 1990-1996 were identified. The original pathology reports and M. D. Anderson Cancer Center consultation reports of 255 cases were reviewed for the frequencies of frozen-section analyses and staging biopsies, biopsy results, the specialty of the surgeon, and hospital type.

RESULTS

The majority (78%) of ovarian borderline tumors primarily were encountered and staged by general obstetrician-gynecologists. Overall, 66% of patients had at least 1 staging biopsy performed. Approximately 12% of subjects underwent complete surgical staging, defined as having biopsy samples taken from pelvic and abdominal peritoneum, omentum, and retroperitoneal lymph nodes. Gynecologic oncologists performed complete staging in 50% of cases, obstetrician-gynecologists performed complete staging in 9% of cases, and general surgeons performed complete staging in 0% cases. The overall frequency of a positive staging biopsy was 37%. Approximately 47% (80 of 169) of patients who underwent biopsies were upstaged as a result of positive biopsies, - with 41% (70 of 169) having extrapelvic spread.

CONCLUSIONS

Currently, surgical staging for women with ovarian serous borderline tumors remains inadequate, although a significant proportion of patients who undergo staging are noted to have extrapelvic spread.

[Microbial analysis of clinical material taken from patients at the Oncology Center, Maria Skłodowkda-Curie Institute in Warsaw in 1997]

An analysis was carried out of the microbiological investigations of clinical material samples obtained from the patients of two oncology centres belonging to the Warsaw Oncology Centre. Microorganisms cultured from urine, blood, catheters, smears of wounds and other materials were analysed. From 4839 clinical material samples from the Ursynów centre 1755 bacterial strains were isolated. From 423 samples from the centre in Wawelska Street 171 strains were obtained. In infections of patients from the centres the number of Gram-positive cocci was twice that of Gram-negative rods. In the investigated clinical material S. aureus was the most frequently isolated Gram-positive coccus, while E. coli was the most frequent species among Gram-negative bacteria. In the infections of oncological patients a considerable frequency was noted of yeast-like fungi, especially C. albicans. Particularly disquieting was the increasing number of isolates of C. glabrata and C. krusei strains resistant to fluconazole.

[Information for patients with cancer of the colon: results of a survey of gastroenterologists, surgeons, and oncologists of the North region]

This regional survey was aimed to detect hypothetical variations in attitudes among truth telling in colon cancer by an anonymous questionnaire sent to the 290 gastroenterologists, surgeons and oncologists of the Northern France area. The answers were assessed as always (A), often (O), rarely and never. Diagnosis was revealed to the patient (whether or not he asked the question) or to his spouse in 83%, 40% and 93% of the cases, respectively. The diagnosis of diffuse metastasis was revealed (A + O) to the patient or to his spouse in 23% and 95% of the cases, respectively. Only 3% of the physicians told (A + O) the patient that his condition was incurable while this aspect was A + O revealed to the patient's spouse in 34% of the cases. Most of the time, the diagnosis of colon cancer was revealed by oncologists rather than by surgeons or gastroenterologists. Conversely the full truth was more commonly told to the family by surgeons and gastroenterologists than by oncologists. We found variation in attitudes towards truth telling in colon cancer which depend on the physician's specialty. It seems to us that the magnitude of the full truth told to the patient or his family in Northern France area, is somewhat intermediate between the attitude of doctors in Northern Europe and in Latin Mediterranean or Eastern Europe countries.

A survey of consultants treating upper aerodigestive tract cancer in the UK

A study was undertaken to determine the current service provision for the treatment of upper aerodigestive tract (UAT) cancers in the UK. A postal questionnaire was sent to all consultant members of relevant specialist societies, with 1041 (74%) responding. Treatment of UAT cancer is widely dispersed with over 900 consultants from five major disciplines treating, on average, less than 10 cases per year. There were few regional or provider differences in the facilities and services available and in processes used for assessing patients. There is little systematic collection of data for audit or research and some consultants do not record stage. The involvement of other disciplines in the assessment process, use of joint clinics, counselling, specialist nursing and therapy services appears to be low. There is a need for rationalisation of head and neck cancer services; for more systematic collection of data for audit and research and for improvements in the use of joint clinics and support services.

Attitudes of oncologists, family doctors, medical students and lawyers to euthanasia

The purpose of this survey was to define attitudes and opinions of two types of physicians, medical students and lawyers in the area of euthanasia and related issues and problems. A questionnaire was used as the source of data. There were four groups of test persons: oncologists, home care physicians (family doctors), third-year medical students and lawyers. The questionnaire included 22 questions, 4 of which concerned general characteristics of tested persons (including religious belief), while 18 referred to the problems of euthanasia. The total number of tested persons was 123, 55 men and 68 women with a median age of 38 +/- 11 years ( +/- SD). There were 30 test persons in the group of oncologists, 31 in the group of family doctors, 31 in the group of third-year students, and 31 in the group of lawyers. Between 97% and 100% of individuals gave scored responses to most items. More than half of the individuals (57%) were against euthanasia, and 61% are against the legalization of euthanasia. The views of doctors and medical students were similar (2/3 against) and significantly different from the view of lawyers (2/3 for, P < 0.01). The legalization of euthanasia is favored by 61% of lawyers, in contrast to 43%, 30% and 23% of oncologists, family doctors and medical students, respectively. Overall, 31% sais they would apply euthanasia if they were asked for it, and 36% that would if it had been legalized. Lawyers are twice as willing to perform euthanasia as students or physicians. The least ready to apply euthanasia are physicians working as oncologists (only 1 in 5). Compared with oncologists, one-third of home-care physicians would perform euthanasia anyway, whether legalized or not. Most of the test persons were of the opinion that euthanasia should be performed in the case of children born with a severe anomaly. None of the tested groups considered invalidity or being a burden to the family important reasons for the termination of somebody's life. Approximately 40% of responders believed that the decision for euthanasia should be made by the patient alone. Only lawyers were of the opinion that the misuse of euthanasia could be controlled. Our study shows that it is probably more important to determine factors associated with behavior pertaining to euthanasia in physicians working closely with suffering patients. Reducing suffering and launching a hospice movement and palliative care services might be the most appropriate way to deal with the problem of euthanasia.

[Radiosurgical activity in France. Surveys of the French Society of Oncologic Radiotherapy (SFRO)]

The total record of 3,407 radiosurgical treatments performed from 1986 to 1996 is described per center and per diagnosis. Treatment of arteriovenous malformation (AVM) remains the principal indication (approximately 40%) before treatment of metastasis (approximately 20%). Annual incidence of radiosurgery for AVM can be estimated to 5 per million inhabitants per year in France. First therapeutic results of AVM series are described.

[The goals and possibilities of drug therapy in mastopathies (results of a questionnaire addressed to oncologists in various regions of Russia)]

The results of a questionnaire-based investigation involving 126 oncologists who treat mastopathy are presented. The study failed to establish any significant decrease in breast cancer morbidity as a result of treating mastopathy by medication. It was found that the whole problem of treatment and follow-up of dibraodenoma mammae needs to be re-considered.

Information needs research in the era of the digital medical library

The rapid adoption of Internet-accessible information resources by the clinical community, has resulted in an exponential growth in the variety and type of clinical information resources along with an increasing diversity of information technologies to deliver clinical information. To date, little formal work has been done to investigate the significance of new information technologies such as Internet-based digital libraries and multimedia record systems on clinical information need or information seeking behavior. In the work described in this paper, we highlight some results from our recent multimethod research design and investigation of the information-seeking behavior of Pittsburgh area medical oncologists to argue for the use of a multimethod research design as an essential component of any investigation of clinical information need and information-seeking behavior in the era of the digital medical library.

Attitudes of Canadian oncology practitioners toward psychosocial interventions in clinical and research settings in women with breast cancer

The aim of this study was to survey Canadian oncology practitioners' attitudes toward psychosocial concerns and issues in women with breast cancer. Surveys were mailed to 351 medical, radiation and surgical oncologists and 375 oncology nurses. Standard questionnaires assessed attitudes towards psychosocial issues in women with primary and metastatic breast cancer and evaluated the practitioners' willingness to refer women to psychosocial intervention trials in the presence and absence of competing drug trials. Responses were obtained from 74% of those surveyed. Respondents reported being aware of the common occurrence of psychosocial problems in women with metastatic breast cancer, however, physicians were less likely than nurses to offer these women psychosocial support on a prophylactic basis (p < 0.0001) and they expressed greater concern than nurses about scientific validity of (p = 0.0003), and potential psychological damage from (p = 0.005), psychosocial support groups. Nurses were more likely than physicians to favour a study investigating group psychosocial support over competing drug studies (p < or = 0.003) in the metastatic setting. Physicians were less likely than nurses to deal with weight problems prophylactically in women with primary breast cancer (p = 0.0009) and they expressed greater concern over scientific validity of psychosocial interventions addressing weight than nurses (p = 0.0008); nurses were more concerned about excessive expectations of patients regarding potential benefits of such interventions (p < 0.0001). Regardless, nurses were more likely than physicians to favour a psychosocial intervention study focused on weight management over drug studies in pre- (p = 0.0006) and postmenopausal women (p = 0.05) with primary breast cancer. Canadian oncology practitioners are aware of the common occurrence of psychosocial distress in women with breast cancer. Physicians and nurses assigned differing priorities to psychosocial interventions in both clinical and research situations.

[The project Better Cancer Care in Buskerud]

A project called Better cancer care in Buskerud was started in 1991 in the county of Buskerud, in Norway. The main objective was to improve the out-patient services for cancer patients at the central hospital. In this article we describe the activities at the out-patient clinic during the period 1991-1993. The clinic was staffed by two oncologists and two cancer nurses. A total of 8060 consultations were held with patients during the period. Breast cancer patients comprised the largest group (30%), followed by patients with gastrointestinal cancer (24%) or malignant lymphoma (13%). The hospital's Department of Surgery was particularly relieved to hand over the administration of chemotherapy. The number of patients who received radiotherapy at the nearest cancer centre did not increase, however, during the period. We conclude that the project in Buskerud was a success, and that most of the objectives were achieved.

A preliminary survey of oncologists' perceptions of quality of life information

Quality of life (QOL) of cancer patients has become the focus of increasing research in oncology, and a frequently measured endpoint in clinical trials. Very little attention has been paid to the perspective of physicians on quality of life information, and its role in clinical decision-making. This report describes the findings of research focused on exploring the perspectives of physicians about quality of life information that is available for cancer patients. On the basis of qualitative data gathered through in-depth interviews with 60 oncologists in the first phase of this project, we have developed a self-administered questionnaire (MD-QOL survey) designed to assess oncologists' views on QOL. This survey was administered to an international group of gynecologic oncologists. The objectives of this study were to assess the face validity of the initial items in the MD-QOL, to expand the pool of items, and to assess the feasibility of utilizing a self-administered questionnaire to assess physicians' perspectives on QOL information. Twenty-eight oncologists responded to the questionnaire. The majority of respondents felt that QOL can be measured and that it should be measured from the patient's own perspective. Half of the physicians felt that currently available QOL information is useful in clinical practice. Ninety-three percent of respondents felt that the greatest benefit of QOL information is 'being able to treat the whole patient'. Forty one percent of respondents felt that length of survival is more important to patients than quality of life. However, only 7% of the respondents felt that the primary job of physicians is to save lives, and that QOL should not be a predominant concern for physicians. The inclusion of QOL in randomized trials was perceived as encouraging both patient and physician participation. The results of this survey are being used to further explore these critical issues.

Surveillance in the management of the cancer patient with special reference to breast and colon cancer

Senior surgeons of the Society of Surgical Oncology were surveyed concerning their followup practices for patients with colon and breast cancer and compared them with the recommendations in the current literature. Intensive followup is not indicated for patients with breast cancer patients and all surgeons agree by using physical examination and mammograms predominantly. Colon cancer followup was variable and the literature indicates a small survival advantage for intensive followup.

What changes in the organisation of cancer services will improve the outcome for women with ovarian cancer?

OBJECTIVE

To examine the influence of operator specialty, volume of work and referral to an oncologist on the survival of women with ovarian cancer.

DESIGN

Population-based retrospective cohort study, using hospital records and Cancer Registry data.

SETTING

The North Western Region, UK.

POPULATION

Six hundred and ninety-one women undergoing laparotomy for histologically confirmed ovarian malignancy during 1991 to 1992.

METHODS

Univariate and multivariate survival analyses.

MAIN OUTCOME MEASURES

Univariate survival estimates. Relative risks, derived from Cox's proportional hazards model, describing the effect on survival of surgeons vs gynaecologists as baseline, high volume vs low volume operators and referral vs nonreferral to an oncologist.

RESULTS

After adjusting for woman and disease-related prognostic factors, operation by a surgeon was shown to have an adverse impact on survival (RR = 1.58, 95% CI 1.19 to 2.10). Regardless of how a high volume operator was defined (in terms of the number of laparotomies performed), no survival advantage over low volume operators could be demonstrated. Women referred to an oncologist had significantly better survival than women not referred (RR = 0.54, 95% CI 0.43 to 0.68).

CONCLUSIONS

All women undergoing surgery for ovarian cancer should have access to a gynaecological opinion and postoperatively should be referred for a nonsurgical oncological opinion.

Assessing research productivity in an oncology research institute: the role of the documentation center

An evaluation method used to assess the quality of research productivity and to provide priorities for budget allocation purposes is presented. This method, developed by a working group of the National Institute for Research on Cancer (IST), Genoa, Italy, is based on the partitioning of categories of the Science Citation Index and Journal Citation Reports (SCI-JCR) into deciles, which normalizes journal impact factors in order to gauge the quality of the productivity. A second parameter related to the number of staff of each institute department co-authoring a given paper has been introduced in order to guide departmental budget allocations. The information scientists of the IST Documentation Center who participated in the working group played a pivotal role in developing the computerized database of publications, providing and analyzing data, supplying and evaluating literature on the topic, and placing international bibliographic databases at the working group's disposal.

Surgical audit: do numbers provide good training?

There has been a growing realisation that good resource planning requires effective measurement of surgical workload by good surgical audit. This paper examines the general surgical workload at the Army's tertiary referral centre, utilising the ratio of operative workload expressed as Intermediate Equivalents to total Service Equivalent Value of a Surgical team. A suggested format to enable inclusion of specialist non-surgical therapies is proposed. The limitations of "number crunching" when assessing the value of higher surgical training are discussed.

Physician-assisted suicide and euthanasia in Washington State. Patient requests and physician responses

OBJECTIVES

To estimate how often physicians receive requests for physician-assisted suicide and euthanasia and to describe a case series of patient requests for physician-assisted suicide and euthanasia, including physician responses to these requests.

DESIGN

A mailed, anonymous two-part questionnaire.

PARTICIPANTS

A total of 828 physicians returned questionnaires sent to 1453 potential respondents, for a response rate of 57%. Questionnaires were mailed to random sample (25%) of primary care physicians and all physicians in selected medical subspecialties in Washington State.

MAIN OUTCOME MEASURES

The frequency of explicit patient requests for physician-assisted suicide and euthanasia reported by physicians and individual case descriptions of patient characteristics, physician perceptions of patient concerns, and physician responses to patient requests.

RESULTS

In the past year, 12% of responding physicians received one or more explicit requests for physician-assisted suicide, and 4% received one or more requests for euthanasia. These physicians provided 207 cases descriptions. The diagnoses most often associated with requests were cancer, neurological disease, and the acquired immunodeficiency syndrome (AIDS). The patient concerns most often perceived by physicians were worries about loss of control, being a burden, being dependent on others for personal care, and loss of dignity. Physicians provided assistance more often to patients with physical symptoms. Physicians infrequently sought advice from colleagues. Of 156 patients who requested physician-assisted suicide, 38 (24%) received prescriptions, and 21 of these died as a result. Of 58 patients who requested euthanasia, 14 (24%) received parenteral medication and died.

CONCLUSIONS

Patient request for physician-assisted suicide and euthanasia are not rare. As perceived by physicians, the most common patient concerns at the time these requests are made are nonphysical. Physicians occasionally provide these practices, even though they are currently illegal in Washington State. Physicians do not consult colleagues often about these requests. These findings raise the question of how to ensure quality in the evaluation of patient requests for physician-assisted death.