Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study

BACKGROUND

Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis.

METHODS

The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance.

RESULTS

Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven.

CONCLUSION

A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.

Accuracy of fine needle aspiration in the pre-operative diagnosis of thyroid neoplasia

The aim of this study was to determine the accuracy and clinical utility of fine needle aspiration (FNA) for the preoperative diagnosis of patients presenting with solitary thyroid nodules. Between 1987 and 1991, 317 patients with a thyroid nodule underwent FNA. Surgery was performed on 98 of the patients, and the cytologic findings were correlated with the final histologic diagnoses for these cases. Of the 98 patients operated on, satisfactory aspirates were obtained in 85 patients and classified as either malignant, suspicious for malignancy, or benign. The FNA was correct in predicting malignancy in 29 of 35 nodules (82.9%). With the benign nodules, FNA was correct in 44 of 50 nodules (88%). The overall accuracy of FNA was 85.9%. The accuracy for the combination of FNA and frozen section (FS) was 92.6%. We conclude that both FNA and FS are accurate tests that play a useful role in the pre- and intraoperative diagnostic evaluation of patients presenting with solitary thyroid nodules.

Diagnosis of thyroid nodules by fine needle biopsy: use and abuse

FNB can be as good as you make it, and vice versa. Most worrisome to physicians and patients is the false negative diagnosis. The stringent criterion that I have advised for adequate sampling to exclude cancer can reduce the potential for false negative diagnoses to about 1%. Specific FNB tissue diagnoses provide the best guidelines for management decisions on when to operate and what operation to perform. However, each institution must generate its own FNB statistics. Management of follicular neoplasms requires integration of FNB findings with clinical features that relate to the probability of cancer and the risks thereof as well as the risks of operation. When FNB provides inadequate numbers of benign-appearing cells to exclude malignancy, unless there are compelling clinical features suggesting cancer, it may be suitable to observe as long as the course and subsequent FNBs fail to suggest cancer.

Audit of pleural biopsies: an argument for a pleural biopsy service

We audited 203 consecutive pleural biopsies performed by medical and geriatric firms over a 3-yr period in our hospital (1987-9). For firms without a special respiratory interest only two to three biopsies per yr were performed, compared with 23 per yr for a respiratory team. Twenty percent of biopsies failed to obtain pleural tissue, 50% revealed normal or non-diagnostic pleural changes and 30% provided a diagnosis. For the respiratory team that performed a third (68) of the biopsies the failure rate for obtaining pleura was 9% compared with 27% for other teams. In view of this disparity a pleural biopsy service was offered by the respiratory team during routine bronchoscopy lists. A repeat audit (1990-2) following the introduction of this service revealed that 60% (84) of 141 biopsies were performed by the respiratory team with their failure rate for obtaining pleura being lower at 6% as compared to 16% for the general physicians. Thirty-one percent of biopsies provided a definitive diagnosis, being higher for those performed by the respiratory team (37%) as opposed to 23% for general physicians.

Changes in the investigation and management of primary operable breast cancer in Victoria

OBJECTIVES

To investigate the surgical practice and adjuvant therapies used in the treatment of primary operable breast cancer in Victoria in 1990 and compare them with results of a similar study in 1986.

DESIGN

All 856 cases of primary operable breast cancer registered by the Victorian Cancer Registry between 1 April and 30 September 1990 were identified. Each patient's surgeon was sent a standard questionnaire covering diagnosis, investigations, operative procedures, adjuvant therapies and reasons for certain management choices. Data were collected on 89% of the patients from 176 participating surgeons.

RESULTS

Most patients (82%) were referred to surgeons by general practitioners. Mammographic screening detected 14% of the cancers. The proportion of women receiving breast-conserving operations rose from 22% in 1986 to 42% in 1990. Surgeons operating on more than 20 breast cancers per annum were most likely to perform breast-conserving operations. The most common reasons given for non-conservative operations were the size of the tumour (37%), its central location (25%) and/or patient concern about the risk of recurrence if the breast was to be conserved (22%). Among these patients, reconstruction was done at the time of primary treatment in 13%, subsequently in 2%, and was planned by another 5%. Of all patients, 33% were referred to a radiation oncologist and 24% actually received radiotherapy (similar to 1986). Medical oncologists saw 33% of the patients and 20% of all patients received chemotherapy (similar to 1986), which was given by a medical oncologist in 83% of the cases. Use of endocrine therapy increased from 20% in 1986 to 40% in 1990.

CONCLUSIONS

There has been a strong trend towards more conservative breast surgery in Victoria, with surgeons who are most active in breast cancer surgery most likely to perform breast-conserving operations. Apart from a significant increase in the use of endocrine therapy, use of adjuvant therapies was unchanged from 1986.

[The role of stereotactic radiography in nonpalpable breast lesions. The authors' own experience]

Stereotaxis is a well-known technique allowing fine-needle aspiration cytology and preoperative localization of the nonpalpable breast lesions seen on mammograms, permitting early diagnosis and easy surgical ablation. The authors report on their experience (126 cases) with stereotactic aspiration (85 cases) and preoperative localization (41 cases) of nonpalpable lesions. The technique allowed to hit the lesion in 115/126 cases (91.3%). Cytology showed 24 cases of cancer and 38 benign lesions (3 of them were false negatives); in 8 cases cytology was suspect (7 cancers and 1 sclerosing adenosis) and in 15 inadequate (17.7%). Sensitivity and specificity were confirmed by histology or follow-up (6 months + 6 months); sensitivity was 91.2% and specificity 97.2% (excluding inadequate cases). The 41 needle localizers were useful to detect 37 malignancies. Fifty-one lesions were biopsied: 37 of them were malignant and 14 benign (benign/malignant ratio = 0.38/1).

[The diagnostic value of liver aspiration puncture with echographic control]

OBJECTIVE

To correlate liver fine needle aspiration (FNA) diagnosis with histopathological diagnosis and clinical evolution.

DESIGN

Retrospective analysis of liver FNA validity, evaluating sensitivity, specificity and predictive value of the method in correlation with the clinical evolution and biopsy results.

RESULTS

Malignancy was diagnosed in 46 cases (20 hepatocarcinomas and 26 liver metastases), and benign lesions in 24 patients. Ten additional cases were excluded on the grounds of insufficient material or the impossibility of establishing clinico-histological correlation. There were 6 false-negatives and one false-positive. The overall accuracy of the method was 90% with a sensitivity of 88.2% and specificity of 94%. The positive and negative predictive values of the method were 97.8 and 75%, respectively.

CONCLUSIONS

Liver FNA is efficient in cases of suspected liver tumoration. The technique proved particularly useful in the present series in diagnosing liver metastases, often allowing the establishing of tumor origin.

[Preoperative cytodiagnosis by needle aspiration of follicular thyroid lesions]

In the period 1989-92, 2729 F.N.A.B. were performed: 585 with an histological control were reviewed. The aim of the study was to evaluate the risk of carcinomatous occurrence in the follicular-structured smears and to suggest a new cytodiagnostic classification. Out of 398 follicular-structured smears, 188 were colloid nodules (CN), 38 thyreocytic hyperplasias without nuclear atypia (THWNA), 146 predominantly follicular lesions (PFL), 26 follicular lesions with nuclear pleomorphism (FLWNP). The last one showed a high incidence of neoplasia (69.2%) and carcinoma (46.1%); the second and the third only a difference in the incidence of benign neoplasms (32.9 vs. 15.8%), with almost the same percentage of occurrence of malignancies (2.6 vs. 2.1%). Such results suggest that a six-months dilatory strategy might be useful in simple follicular lesions (THWNA and PFL) whereas a cytological follicular pattern with nuclear pleomorphism requires a surgical treatment for the high risk of carcinomatous occurrence.

Is needle-directed breast biopsy overused?

We undertook this study of needle-localized breast biopsy--a frequently done surgical procedure--to examine current practice patterns and to determine if the technique is overused in any group of patients. From a retrospective review of medical records of all patients who had needle-localized breast biopsy at a teaching hospital between June 1, 1988, and October 31, 1990, we found that a total of 125 were done: 24 biopsy specimens showed malignancy (19%). Mammographic indications for biopsy were microcalcification (n = 62, or 50%), mass or density (n = 60, or 48%) and mass and calcifications (n = 3, or 2%). Indications for biopsy in patients with cancer were microcalcification (14 patients) and mass or density (10 patients). The incidence of malignancy increased with age. In patients younger than 40 years, no biopsy showed malignancy. Only 2 of 30 biopsies done in patients younger than 50 showed cancer (7%). Breast cancer was most frequently discovered in patients in the seventh and eighth decades of life, and this group accounted for 75% of "positive" biopsies. Needle-localized breast biopsy is a useful technique in the early diagnosis of breast cancer. Although indications for the procedure should remain liberal, in women younger than 50, the percentage of biopsies that reveal malignancy is low.

A nationwide survey of liver biopsy--is there a need to increase resources, manpower and training?

A postal questionnaire survey was conducted to establish the pattern of current practice of liver biopsy, to estimate the frequency of adverse events and their possible associations, and to compare respondents' personal preferences with what they offer patients. Three hundred and sixty-four members of the British Society of Gastroenterology (BSG) were questioned. There were 296 returns, of which 278 were appropriate, giving an overall response rate of 81.3%. Over the previous 2 years complications were reported in 80 patients who required blood transfusion, 11 who needed laparotomy (including 1 for pain), 13 with septicemic shock, 29 who had peritonitis, and 1 with a subphrenic collection; 53 had pulmonary complications (hemoptysis, pneumothorax and 1 hemothorax), and there were 19 deaths. The overall complication rate was 5.6 per 1,000, and the mortality rate 5.2 per 10,000. The complication rate gradually decreased with increasing number of biopsies performed until the number reached 20 per month, after which there was a significant increase in complications (chi 2 = 42.98, p < 0.001). Although 50% of the respondents were themselves prepared to have a liver biopsy on a day case basis, only 11% do it routinely on patients, and 72% do not offer it at all (chi 2 = 76.8, p < 0.001). There were no differences in complication and death rates between the above groups, but those who do occasional (< 50%) day case biopsies have a significantly higher complication rate (chi 2 = 24.3, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasound-guided fine-needle biopsy with an automatic full-incision system: the initial experiences and comparison with a conventional biopsy gun]

The purpose of this study was to evaluate the efficacy of a new automatic biopsy device (Autovac, Angiomed, Karlsruhe, Germany) in ultrasound (US) guided biopsies of focal abdominal lesions. 50 consecutive patients with focal abdominal lesions underwent US guided biopsies. In the first 24 patients, needle passes were performed with the Autovac system (outer diameter 0.95 mm) as well as with the Biopty gun (outer diameter 0.9 mm) (Bard Covington, USA). The size and the quality of the histologic and the cytologic material obtained by both systems were evaluated by histopathologists blinded to the system used. Autovac yielded significantly more material (defined as the area of the obtained tissue cores) and a significantly higher quality score than did the Biopty system. 96% of the histologic specimen and 100% of the cytologic smears obtained with Autovac were diagnostic, compared to 70 and 81% with Biopty, respectively. With the exception of a short-time elevation of the blood pressure in one patient, no complications occurred. The results indicate an advantage of the automatic full-cut type system Autovac over the tru-cut type Biopty gun in US-guided biopsies of focal abdominal lesions.

[CT-guided biopsies of the axial skeleton. The approaches and results]

The value of percutaneous CT-guided biopsies of the axial skeleton for establishing a diagnosis is determined from a series of 75 punctures in 74 patients in retrospect. Indications showed benign conditions to prevail over malignant lesions by a ratio of 1.6:1. Biopsy routes turned out to be strongly determined by regional anatomy allowing for a standardised procedure in each area. 64 out of 75 histological diagnoses were confirmed by open surgery (n = 17) or follow-up (n = 58) accounting for an accuracy of 85.3%. In 7 cases no definite diagnosis could be made from the sample and in 4 cases the diagnosis proved false although tissue cores could be obtained in each case. No serious or irreversible complications occurred. CT-guided punctures of the axial skeleton are considered a safe and highly accurate procedure to establish a definite diagnosis unless there is a primary indication for surgery or the need for decompression.

Sonographically guided needle biopsy in peripheral thoracic masses: results in 50 patients

50 patients with thoracic lesions were selected for percutaneous biopsy guided by real-time sonography. The indications were pulmonary, pleural and mediastinal lesions which made contact with the chest wall and sonographically accessible. Included were lesions near vital structures in the mediastinum (n = 3), in the apex of the lung (n = 8), small pulmonary nodules in contact with the chest wall (n = 24), lesions with intervening pleural fluid (n = 2), pleural nodules (n = 9) and masses arising from the chest wall itself (n = 4). A definitive diagnosis was established in 38 of the 45 (84.4%) malignant lesions and in 4 of the 5 (80%) benign lesions. Complications were restricted to one pneumothorax. Sonographically guided biopsy can be carried out as a bedside procedure. Real-time monitoring compensates for respiratory movements. Its role is curbed by intervening air such as in aerated lung, pneumothorax or primarily cavitatory lesions.

[Post-operative examination of 2930 thyroid glands: observations on primary carcinoma. Incidental carcinoma and the preoperative diagnostic assessment of thyroidectomy for cancer]

The histological examinations performed in our Institute in the years 1985-1991 and concerning thyroid diseases pertain to 2930 patients. These were considered clinically benign in 2463 cases and malignant in 467. After histological control, the actually benign cases resulted to be 2335, whereas carcinomas were 588 (495 papillary, 61 follicular, 17 anaplastic, 15 medullary). Six lymphomas and 1 fibrosarcoma have been also observed. A comparison between clinical and morphological diagnosis for thyroids thought to be clinically benign has shown a diagnostic overlapping of 93.8%, with absolute agreement for Basedow's diseases, whereas thyroiditis is the disease most often not diagnosed preoperatively. Incidental carcinomas were 132, with an attendance related directly to the number of samples randomly taken from the surgical specimen. In 538 cases of carcinoma it has been possible to evaluate the intraglandular spread of the tumor: bilateral multifocal cases were 18.4%, with an incidence of latero-cervical metastases (41.4%) nearly twice as that observed in monolateral cases (24.2%). Post-surgical examination of the whole gland in 381 patients treated with a total thyroidectomy for carcinoma has discovered 20 false positive cases: 11 were operated on only according to clinical and instrumental examinations, 2 on the basis of just the cytological results, and 7 on the basis of cytologically positive evidence though refuted by intraoperative frozen sections. In the 381 cases taken into account, intraoperative frozen sections have been done 256 times: the results have been confirmed by the histological post-surgical examination of the whole gland in 94.5% of the cases. No false positive cases did occur. False negative cases were 7, due to inadequate sampling (in the operating room or in the pathology lab). Delayed diagnoses were 4, whereas truly false negative cases have been in all 3 (1.2%). The greater part of our data has been disaggregated in two different periods (1985-1988 and 1989-1991) to point out any change with time in the parameters under observation. The most relevant reflections relating to the time were the following: (1) per cent increase of bilateral multifocal carcinomas (13.9 vs. 21.8%), (2) per cent decrease of latero-cervical metastases in monolateral carcinomas (31.8 vs 17.7%), (3) frank decrease in the median value of incidental carcinomas' diameters (2.2 cm in the first vs. 0.6 cm in the last year), (4) frank decrease of false positive cases among patients operated on without prior cytological or histological verification (6/21 vs. 1/27), (5) remarkable improvement of the rate of correlation between intraoperative frozen section diagnosis and post-surgical histological examination (92.1 vs. 97.4%).(ABSTRACT TRUNCATED AT 400 WORDS)

Thoracic lesions: diagnosis by ultrasound-guided biopsy

We reviewed the results of US-guided fine-needle biopsies of peripheral pulmonary, pleural, mediastinal and chest wall lesions in 200 patients. Sufficient material for cytological analysis was obtained in 95%, 92%, 96% and 100%, respectively. Sensitivity was 88%, 94%, 96%, 100% and specificity 89%, 100% and 100%, respectively. The ratio of false-negative results was 7%. A cutting needle biopsy was additionally performed in 24 patients. All but two of the histological samples (92%) were adequate for diagnostic purposes and a correct diagnosis was established in 86% (19/22) of these. 8 patients (4%) with pleural or pulmonary targets had minor complications (5 pneumothorax, 3 haemoptysis), which did not require treatment. Cutting needle biopsies and biopsy of mediastinal lesions proved safe. Due to the many advantages US may be considered for guidance in peripheral larger-sized pulmonary lesions, particularly those abutting the pleura, and also in pleural, thoracic wall and mediastinal masses.

[The role of needle aspiration biopsy in the diagnosis of parotid masses]

The aim of this work is to assess the list of fine needle aspiration in the diagnosis of lesions of the parotid. Thirty-nine patients suffering from parotid pathology were subjected to cytology examination through fine needle aspiration. Thirty seven patients subjected to surgical operation have a histological comparison. We have proved the validity of the technique considering the sensibility, specificity and the accuracy. We didn't have FN we only had 1 FP that could be a suspect cytology. We had a 100% sensibility, a 75% specificity and 97.29% accuracy.

[Errors and complications in computed tomography-guided biopsies]

The article analyses the results of 104 biopsies which were carried out in 84 patients with different diseases of the organs of thoracic (50) or abdominal (16) cavities, postperitoneal space (32), bones and soft tissues (6). Positive results were obtained in 67 cases, negative--in 26, false-negative--in 11. The specificity was 70.3%, sensitivity--100%, authenticity--64.4%. The authors make a conclusion that the results and authenticity of biopsies depend on such factors as the proper organ to be punctured, character and structure of the affection, its location, volume and spreading, as well as the type of needles to be used.

A rational approach to the use of fine-needle aspiration biopsy in the evaluation of primary and recurrent neoplasms in children

Fine-needle aspiration (FNA) has been recommended as a technique for accurate evaluation and diagnosis of childhood malignancies. Very little data exist regarding the limitations and utility of FNA in children. We reviewed our experience over the past 5 years to assess the clinical use of FNA and its limitations. One hundred seventy-three FNAs were performed in 156 patients who ranged in age from 7 months to 18 years. Sixty-three patients were female and 110 were male. Thirty-seven aspirations were obtained to evaluate new masses in children with previously diagnosed malignancies. FNA allowed diagnosis of the malignancy in 90% of patients with solid tumors, whereas only 9 of 19 patients with lymphomas were diagnosed accurately with FNA. The specificity was 99.7%. Inadequate material was obtained in 13 aspirates. Insufficient material was obtained in 14% of patients who had FNA as their initial diagnostic tool. Four false-negatives were obtained while evaluating children for recurrent disease. There were 16 true-negative biopsies. These data suggest that FNA is an excellent tool for diagnosing both recurrent malignancies as well as previously undiagnosed solid tumors in the pediatric population but is inadequate to diagnose children with suspected undiagnosed lymphomas. Negative studies should be considered nondiagnostic and followed by open biopsies when clinical suspicion of malignancy is high.

Practice and complications of liver biopsy. Results of a nationwide survey in Switzerland

Studies on the complication rate of liver biopsy have hitherto been conducted in referral hospital centers. They are therefore not representative for general practice where liver biopsy is performed by specialists and nonspecialists. In a postal nationwide survey, we approached all gastroenterologists and hospital internists to assess the complication rate and practice (setting, needle type, use of ultrasonography) of percutaneous liver biopsy performed in 1989 in Switzerland for diffuse liver disease. Two hundred eighty questionnaires were mailed and 252 were returned (response rate 90.0%) 165 respondents (65.5%) performed 3501 biopsies while 87 respondents (34.5%) did not practice liver biopsy; 67.7% of biopsies were executed blindly and 32.3% were guided. Eight nonfatal and three fatal complications occurred. Hemorrhage was the most frequent complication (five cases) and was responsible for all three fatal outcomes. The overall complication rate was 0.31%, being distinctly lower in the group of gastroenterologists (0.11%) as compared to the group of internists (0.55%; P = 0.031). The complication rate was 1.68% in the group of internists performing fewer than 12 biopsies per year, while there was no complication in the group of internists performing more than 50 biopsies per year (P = 0.036). Complications were not related to the needle diameter or to the absence of ultrasonography before biopsy. In conclusion, this representative survey in Switzerland shows that the complication rate of liver biopsy is mainly related to the experience and training of the operator.

Radiological findings in bile duct carcinoma

Radiological findings in 58 cases of pathologically proven bile duct carcinoma were analysed retrospectively. 11 patients had peripheral intrahepatic cholangiocarcinoma, 30 either hepatic duct or choledochal carcinoma and 17 carcinoma of the papilla of Vater. The tumour was local abdominally in 41 and spread abdominally in 17 cases. All cases but one were examined by US, 27 by CT, 19 by PTC, 28 by ERCP and 11 by angiography. US showed bile duct obstruction in all the cases in which it was present and CT in 94%. US showed the primary tumour in 63% and CT in 44%, while the figures for showing abdominal spread were 56 and 17% respectively. No tumour mass was found at US in 28% of cases or at CT in 52%. ERCP failed in 3 out of 28 cases, showed a tumour in 24 (86%) and showed ambiguous narrowing of the bile duct in one. PTC showed obstruction or narrowing of the bile duct caused by a tumour in all cases, while angiography detected all the intrahepatic cholangiocarcinomas but was abnormal in only 2 out of 6 cases of extrahepatic bile duct carcinoma.

Evidence that the sensitivity is increased and the inadequacy rate decreased when pathologists take aspirates for cytodiagnosis

The results of the diagnostic accuracy of breast fine needle aspiration specimens taken by the pathologist in a joint surgical clinic are compared with those taken by a surgeon. In the joint clinic the complete sensitivity rose by 15% and the number of missed malignancies fell by half.

Fine needle aspiration of thyroid nodules in a rural setting

PURPOSE

The purpose of this study was to evaluate the applicability of fine needle aspiration biopsy (FNAB) of thyroid nodules in rural practices with smaller patient numbers, to assess the effect of these numbers on the results, and to establish the level of accuracy of the procedure in this setting.

PATIENTS AND METHODS

We retrieved all thyroid FNAB reports identified as being performed by a single practitioner in a referral endocrine practice in Rapid City, South Dakota, between September 30, 1987, and September 30, 1991. Biopsy results are separated by year to establish correlations with the number of biopsies and outcomes. Follow-up pathology reports were obtained for all patients known to have undergone surgery.

RESULTS

A total of 189 FNABs in 165 patients were available for review from a 4-year period. The number of FNABs increased progressively from 28 per year to 65 per year during the 4-year course of the study. The incidence of inadequate specimens decreased inversely from 18% to 6% with the increase in the number of FNABs. The percentage of surgical interventions in which malignancy was found increased from 23% to 50% over the same period. Analysis of the results suggests that accuracy and specificity are comparable to results from larger centers.

CONCLUSIONS

FNAB of thyroid nodules can substantially reduce surgical intervention and increase the yield of malignancy without excessive loss of accuracy even in rural areas with small numbers of patients. Improved results as the number of biopsies increased to 50 or more per year suggest benefits from concentrating biopsies with as few operators as practical.

Comparison of fine-needle aspiration biopsy, Doppler ultrasound, and radionuclide scintigraphy in the diagnosis of acute allograft dysfunction in renal transplant recipients: sensitivity, specificity, and cost analysis

150 episodes of allograft dysfunction in 128 renal transplant recipients, 77 due to acute rejection, 32 secondary to acute-on-chronic rejection, 33 due to either prerenal factors, acute tubular necrosis, or ciclosporin A nephrotoxicity, and 8 secondary to multiple causes, were evaluated by fine-needle aspiration biopsy (FNAB), Doppler ultrasound (DUS), and radionuclide scintigraphy (RS), each performed within a 24-hour period and prior to any specific therapeutic intervention. Tests were interpreted by appropriate specialists in a large transplant center without access to clinical information. The final diagnosis was based primarily upon response to therapeutic maneuvers with histological (core biopsy) confirmation in 123 episodes. RS was the most sensitive (70%) test for the diagnosis of acute rejection during the early posttransplant period, exceeding both FNAB (52%) and DUS (43%). The predictive accuracy of either FNAB, DUS, RS, or core biopsy in the detection of a steroid-responsive component to acute rejection when superimposed upon chronic rejection was low at approximately 50%. When the underlying cause of renal dysfunction was either prerenal, acute tubular necrosis, or ciclosporin A nephrotoxicity, FNAB, DUS, and RS each gave an erroneous diagnosis of acute rejection in about 50% of the episodes. Cost analysis revealed that core biopsy was the most expensive test, but only 9% more than RS, with FNAB the least costly. In conclusion, the lack of ideal sensitivity and specificity combined with the expense of present-day FNAB, DUS, RS, and core biopsy in the diagnosis of a therapeutically reversible component to acute-on-chronic rejection and of FNAB, DUS, and RS in the diagnosis of acute rejection during the early posttransplant period should prompt research into ways to improve their diagnostic yield or alternate modalities.

Urban-rural differences in the management of breast cancer

We conducted a population-based study with medical-record review of breast cancer patients as part of a larger study of an oncology outreach program to improve cancer management for rural patients within their community hospital. This analysis compares the breast cancer care received by the rural population before the oncology outreach program with that of the contiguous urban population. All 1986-87 cases in selected Illinois (United States) counties were identified using the Illinois State Cancer Registry. Data were obtained by hospital record audit and physician survey. Case follow-back was 98 percent complete. Rural cases were evaluated separately when they were diagnosed in an urban facility. State-of-the-art management was defined by the 1986-87 Physician Data Query and included diagnostic evaluation, prognostic evaluation, and stage-specific treatment. A summary variable incorporated whether or not the most appropriate management was offered. Compared with urban cases, rural cases diagnosed in rural hospitals were less likely to have staged tumors and more likely to have node dissections. Rural cases traveling to urban centers were less likely to have limited surgery, hormone therapy, and a biopsy as a first-step surgical procedure, and more likely to have node dissection.