Audit of public education campaign to encourage earlier detection of malignant melanoma

OBJECTIVES

To evaluate a public campaign to encourage earlier referral and treatment of primary cutaneous malignant melanoma and thus reduce mortality related to melanoma.

DESIGN

Production and distribution of educational material aimed at adults. Update information sent to general practitioners before campaign. Analysis of data on melanoma before and after campaign in June 1985.

SETTING

West of Scotland, population 2.7 million.

MAIN OUTCOME MEASURES

Total numbers of referrals per month to melanoma clinic, numbers of melanomas diagnosed, change in distribution of thickness, and mortality before and after introducing the campaign.

RESULTS

Referrals to the pigmented lesion clinic increased by 278%, from five a week in June-July 1984 to 19 a week in June-July 1985. Twice as many women as men were referred to the clinic (49% of referrals were of women aged under 65). The numbers of newly diagnosed primary cutaneous melanoma were 63 (12/month) in January-May 1985 and 146 (21/month) in June-December 1985, an increase of 131%. The percentage of tumours detected that were less than 1.5 mm thick rose significantly by 16% (95% confidence interval 11% to 19%), from 38% (328) in 1979-84 to 54% (592) in 1985-9. Mortality began to fall in women from 1988.

CONCLUSIONS

The public education campaign succeeded in reducing the absolute number of thick tumours and melanoma related mortality in women.

Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival

OBJECTIVE

To assess the differences among surgeons in postoperative complications, postoperative mortality, and survival in patients undergoing surgery for colorectal cancer.

DESIGN

Prospective study of patients with colorectal cancer managed by one of 13 consultant surgeons, none of whom had a special interest in colorectal surgery.

SETTING

Royal Infirmary, Glasgow.

PATIENTS

645 sequential patients with colorectal cancer presenting over the six years from 1974 to 1979.

MAIN OUTCOME MEASURES

Postoperative complications, postoperative mortality (within 30 days), and survival (up to 10 years); predictive factors for postoperative mortality and survival; and relative hazard rate ratios for individual surgeons.

RESULTS

The proportion of patients undergoing apparently curative resection varied among surgeons from 40% to 76%; overall postoperative mortality varied from 8% to 30%. After curative resection postoperative mortality varied from 0% to 20%, local recurrence from 0% to 21%, and the rate of anastomotic leak from 0% to 25%. Survival at 10 years in patients who underwent curative resection varied from 20% to 63%, two year survival in those who underwent palliative resection varied from 7% to 32%, and median survival in those who underwent palliative diversion varied from one to eight months. The hazard rate ratios among individual surgeons, taking into account the identified risk factors, varied from 0.56 to 2.03, from 0.17 to 1.92, and from 0.57 to 1.50 for curative resection, palliative resection, and palliative diversion, respectively.

CONCLUSION

There were significant variations in patient outcome among surgeons after surgery for colorectal cancer; such differences compromise survival. A considerable improvement in overall survival might be achieved if such surgery were undertaken by surgeons with a special interest in colorectal surgery or surgical oncology.

Long term results of cyclophosphamide, adriamycin and platinum chemotherapy in advanced epithelial ovarian cancer

Between January 1980 and December 1983, 57 consecutive patients with advanced epithelial ovarian cancer (FIGO Stage IIc n = 5; III n = 45; IV n = 7) were treated with 6 cycles of cyclophosphamide 600 mg/m2, adriamycin 30-45 mg/m2 and platinum 50 mg/m2 (CAP) at 3 weekly intervals. Pathological complete remission (CR) was documented in 10 (18%) and 4 with no residual disease after primary cytoreductive surgery were free from progression (FFP). There were 19 partial remissions (PR) giving a 51% overall response rate. The median duration of CR was 33 months from second look surgery. Median survival (MS) for all patients was 22 months. Multivariate analysis indicated that response to chemotherapy was the most important prognostic factor, with MS for CR of 53 months, PR 23 months and stable or progressive disease 11 months (p = 0.001). Most CR (8 of 10) occurred in patients with minimal residual disease (no single lesion greater than 2.0 cm), but extent of disease, though significant in univariate analysis of prognostic factors was not an independent predictor of survival. Six patients (11%) are alive and tumour free with a minimum follow-up of 7 years. All had FIGO Stage III disease at presentation and four had no residual tumour after primary surgery.

Asian osteomalacia is determined by dietary factors when exposure to ultraviolet radiation is restricted: a risk factor model

Twenty-seven previously osteomalacic and 77 normal Asian women participated in a seven-day survey of dietary intake and daylight outdoor exposure. Individual levels of daylight outdoor exposure discriminated poorly between normal and osteomalacic women. The presence of osteomalacia was strongly related to varying degrees of vegetarianism. Lactovegetarianism (no meat, fish or egg consumption) was associated with significantly greater osteomalacic risk than ovolactovegetarianism (no meat or fish consumption). Unlike Asian rickets, high-extraction wheat cereal as chapatti was not a significant risk factor for osteomalacia in Asian women and dietary fibre was a less important risk factor than absent dietary meat, fish or egg. When exposure to ultraviolet radiation is limited, Asian osteomalacia (and Asian rickets) are determined by dietary factors.

Prospective study of colorectal cancer in the west of Scotland: 10-year follow-up

Six hundred and forty-five patients presenting with colorectal cancer over a 6-year period were studied prospectively. At the time of presentation almost half the patients had clinical evidence of local tumour fixity and over one-quarter had distant metastases. The overall resectability rate was 70.8 per cent, apparently curative resection being obtained in 52.5 per cent. Overall operative mortality rate was 13.8 per cent, increasing in the elderly. Approximately 70 per cent of patients undergoing 'curative' resections survived for 2 years, 50 per cent survived for 5 years and 40 per cent survived for 10 years. After palliative resection approximately 10 per cent of patients survived for 5 years; only six of 133 patients (4 per cent) undergoing palliative diversion survived for 2 years. This prospective study confirms the advanced stage of colorectal cancer as it presents to a non-specialist centre. Although the poor outlook is largely a consequence of the advanced nature of the disease, there is evidence to suggest that the results of surgical intervention could be improved.

Estrogen and progesterone receptors in ovarian cancer

To determine whether steroid hormone receptor expression is clinically relevant in ovarian cancer, cytoplasmic and nuclear estrogen (ER) and progesterone (PR) receptor levels have been measured and their concentration calculated by Scatchard analysis. Of 89 samples from patients with non-pretreated epithelial ovarian cancer, 33% were ER-positive, PR-positive (ER+PR+) and 40% ER-negative, PR-negative (ER-PR-); 20% were ER+PR-, and 7% ER-PR+. There was no correlation between receptor status and patient age, menopausal status, or tumor grade, although serous tumors were more likely to be ER+. The incidence of PR+ tumors was highest in early disease and decreased with increasing International Federation of Gynecology and Obstetrics (FIGO) stage. Survival of patients with advanced disease (FIGO Stages IIC, III, or IV) was significantly prolonged by optimal initial cytoreductive surgery (P = 0.002), platinum therapy (P = 0.003), and tumor expression of PR (P = 0.009). On multivariate analysis, PR positivity was still associated with improved survival, although this did not retain statistical significance (P = 0.09).

Changes in the incidence of acute appendicitis in Glasgow Asian and white children between 1971 and 1985

Between 1971 and 1985 there was a significant rise in the annual hospital discharge rate for acute appendicitis in Glasgow Asian boys aged 10-19.9 years. A smaller and statistically insignificant rise occurred in Asian girls of 10-19.9 years; discharge rates for younger Asian boys and girls did not change significantly. In keeping with national trends, discharge rates for acute appendicitis in all Glasgow children fell significantly between 1971-85. The divergent trend in older Asian children may reflect dietary adaptation which is most marked in older Asian boys.

Evaluation of the prognostic factors in gastric cancer: the effect of chemotherapy on survival

This is a retrospective review of 328 consecutive patients with histologically confirmed gastric adenocarcinoma diagnosed in one centre between 1974 and 1984. Of these patients, 128 (39 per cent) had a curative resection, 32 (9.8 per cent) had a palliative resection, 33 (10.0 per cent) had a gastro-enterostomy, 26 (7.9 per cent) had a Celestin tube inserted, 58 (17.7 per cent) had a laparotomy alone, and 51 (15.5 per cent) had no surgical procedure. The 5 year survival was 11 per cent but all long term survivors were patients who had a curative resection. Using multivariate analysis the best predictor of survival after curative resection was the presence or absence of serosal involvement (P = 0.0004). Patients with a long history of presenting symptoms (greater than 6 months) survived longer than those with a short history (P = 0.001). The impact of chemotherapy on the survival of 202 patients with advanced gastric cancer was analysed by multivariate analysis. The median survival of the 50 patients receiving combination chemotherapy was better than that of the 152 who did not (median survivals 160 versus 71 days; P less than 0.001). When deaths occurring within 14 days of diagnosis were excluded, the significance value dropped to P = 0.02. Comparison of the groups treated between 1974 and 1979, when 8 per cent of 92 patients received chemotherapy, with 1980-1984, when 45 per cent of 110 patients received chemotherapy, showed no significant difference in survival.

Mortality in patients of the Glasgow Blood Pressure Clinic

The mortality of 3783 non-malignant hypertensive patients attending the Glasgow Blood Pressure Clinic between 1968 and 1983 and followed for an average of 6.5 years was compared with that in three control groups: the general population of Strathclyde a group of 15 422 subjects aged 45-64 years and screened in Renfrew and Paisley between 1972 and 1976, and a group of hypertensives seen in a blood pressure clinic based on general practice in Renfrew. Average blood pressure for men at entry to the Glasgow Clinic was 181/111 mmHg falling to 158/96 mmHg during treatment. Corresponding values for women were 185/109 mmHg and 161/96 mmHg. Seven hundred and fifty clinic patients (451 males) died during follow-up, the commonest causes of death in both sexes being myocardial infarction and stroke. All-cause age-adjusted mortality (deaths per 1000 patient-years) was 41.4 for men and 22.1 for women. At all ages in both sexes and for all levels of initial blood pressure mortality was less in patients whose blood pressure was reduced most. Without a randomized control group it is not certain that lower mortality in those with well controlled blood pressure was due to treatment, although this is the most likely explanation. Cigarette smoking, a history of myocardial infarction, angina or stroke, retinal arterio-venous nipping, raised blood urea, an abnormal electrocardiogram (ECG) and secondary hypertension were associated with increased risk, but heavy alcohol intake, obesity, haematocrit greater than 45%, hypokalaemia and social class were not. Life table analysis showed that, despite some reduction of mortality by treatment, the relative risk to men and women in the clinic remained two- to five-times that of the general population. The benefits of treatment were not such as to restore normal expectation of life even when blood pressure was well controlled. Excess mortality in the clinic could not be explained by difference of smoking habit or social class. This suggests that there is in the hypertensive patients of the Glasgow Clinic an element of irreducible risk, that treatment may be beneficial in some respects but harmful in others, or that patients at particularly high risk are selectively referred to the clinic.

Adjuvant radiotherapy and chemotherapy in breast cancer

Three hundred and twenty-two women with involvement of axillary lymph nodes following surgery for operable breast cancer were randomized to receive either postoperative radiotherapy, chemotherapy (CMF) or radiotherapy followed by chemotherapy. There was an increase in disease free interval in pre- and postmenopausal patients receiving radiotherapy and chemotherapy regardless of the number of nodes involved. However, there was a trend towards an improvement in disease related survival only in those patients with more than three nodes involved.

Improved control of primary vaginal tumours by combined external-beam and interstitial radiotherapy

In 20 years we have seen only 78 cases of primary vaginal cancer. 61 patients had squamous carcinoma, three had adenocarcinoma, 10 had clear-cell carcinoma, four of which may have been metastatic from carcinoma of the kidney, and four had malignant melanoma. The actuarial 5-year survival of patients with squamous cancer was: Stage I, 68%; Stage II, 34%; Stage III, 29% and Stage IV, 14%. Patients treated by combined external and intracavitary or interstitial radiotherapy had increased local control and superior survival to those treated by interstitial methods alone. The improved tumour control offered by combination treatment may be due to the elimination of small tumour deposits in lymph nodes within the treated volume and the sterilisation of carcinoma in situ in the vagina some distance from obvious tumour.

Effect of natural estrogen on the serum level of follicle-stimulating hormone (FSH), estradiol and estrone in post-menopausal women and its effect on endometrium

Serum FSH, estradiol and estrone levels were assayed in 35 post-menopausal women who received the three commonly available estrogen preparations Premarin, Progynova and Harmogen. The results were compared with the levels during treatment with Dixarit. Hormone levels did not change when Dixarit was used. The levels of estrone and estradiol increased significantly (p less than 0.01) when estrogen preparations were used. There was no abnormality in the endometrium at the end of the treatment period.

Vindesine and cisplatin combination chemotherapy compared with vindesine as a single agent in the management of non-small cell lung cancer: A randomized study

One hundred and five patients with inoperable non-small cell lung cancer were included in a randomized trial comparing the activity of vindesine as a single agent with the combination of vindesine and cisplatin. All patients were previously untreated and the majority (70%) had squamous carcinoma. The overall partial response rates in 88 evaluable patients were 7% for vindesine alone and 33% for the combined regime. There were no complete responders in either arm. The median survival of patients treated with vindesine and cisplatin was 11 months, compared with 4 months in those treated with vindesine alone (P = 0.008). Patients showing a partial or complete response to vindesine and cisplatin survived a median duration of 13 months, compared with 7 months for non-responders (P = 0.03). This survival benefit associated with the combination was particularly apparent for patients with ECOG performance status 0 or 1 (median survival greater than 18 months and 13 months respectively), locoregional disease (median survival 14 months) and squamous cell histology (median survival 13 months). Myelo-suppression was greater with the combination but was not a major treatment problem. Neurotoxicity, which was frequently dose-limiting, was of similar severity in both treatment groups. The results indicate that the combination of vindesine and cisplatin is superior to vindesine alone for remission induction in non-small cell lung cancer and confers a significant survival advantage compared with vindesine alone in patients with favourable prognostic factors.

Pre-operative carcino-embryonic antigen and survival in patients with colorectal cancer

The relationship between pre-operative levels of carcino-embryonic antigen (CEA), resectability of the primary tumour, the extent of tumour spread and subsequent survival was studied in 333 patients with colorectal cancer. Twenty-five per cent of patients undergoing 'curative' resection had elevated CEA levels compared with fifty-six per cent of patients receiving palliative treatment. Twenty-five per cent of patients with Dukes B or C tumours had elevated pre-operative CEA levels compared with seventy per cent of patients with stage D disease. In patients undergoing 'curative' resection there was no correlation between pre-operative CEA levels and subsequent survival. In patients undergoing palliative resection, elevated pre-operative CEA levels were associated with poor survival. Although pre-operative levels of CEA reflect the extent of the underlying disease process, estimations of pre-operative CEA levels are of limited value in predicting patients with a poor prognosis following curative resection for colorectal carcinoma.

Plasma amine and hormone changes in 'post-partum blues'

The relationship between hormone levels, plasma catecholamines, and mood disturbances has been investigated in 44 patients during days 2 to 5 of the immediate post-partum period. Fifty-two per cent of the mothers showed periods of emotional lability although there was no significant correlation between plasma concentrations of FSH, prolactin, oestrone, oestradiol, cortisol, or progesterone and the incidence of post-partum blues. In contrast there was a significant reduction of circulating catecholamines which correlated with mood disturbances. Women who experienced only a single day of post-partum blues had significantly lower levels of noradrenaline and adrenaline on that day compared with preceding or subsequent days.

Local tumour invasion as a prognostic factor in colorectal cancer

A prospective study was carried out of 404 patients with colorectal cancer who were followed up for a mean period of 42 months. Macroscopic extramural tumour invasion was found at laparotomy in 46 patients undergoing apparently curative surgery and the survival rate was significantly reduced in these patients. The site of primary tumour in the colon or rectum did not influence the incidence of local tumour spread, but local invasion was related to the incidence of lymph node metastases and histological grading of the tumour. A staging classification has been proposed based not on lymphatic metastases, but on the extent of local tumour penetration. This modified staging system combines the operative findings with pathological grading of the tumour and emphasizes the prognostic significance of local tumour invasion.

Evaluation of flurbiprofen in detrusor instability

Thirty women with detrusor instability (27 cases idiopathic, and three secondary to multiple sclerosis) completed a double-blind, cross-over trial of the prostaglandin synthetase inhibitor flurbiprofen and a placebo, results being evaluated by questionnaire and cystometry. Frequency, urgency, and urge incontinence were all significantly reduced with flurbiprofen (P less than 0.001, P less than 0.025, and P less than 0.025 respectively), as was the detrusor-pressure rise during bladder filling (P less than 0.01). Side effects, however, occurred in 13 patients while taking flurbiprofen compared with five while taking placebo (P less than 0.025). After the trial 19 patients wished to continue with flurbiprofen. Flurbiprofen is a useful treatment for idiopathic detrusor instability and is well tolerated by most patients.

The mortality of men in the Rhondda Fach, 1950--1970

A more detailed analysis of material from the 20-year follow-up of men in the Rhondda Fach confirms the similarity between the Standardised Mortality Ratios (SMRs) of miners and exminers with radiological categories 0, 1, 2, 3 and A (120.3, 116.5, 119.0, 115.7, and 120.1 respectively) as well as the difference between these SMRs and that of the non-moners (98.7). The specific death rates show a raised SMR for bronchitis and other respiratory diseases excluding pneumoconiosis for all categories including category 0, but little difference between those for category 0 and those for simple pneumoconiosis. The SMRs for ischaemic heart disease and other circulatory diseases for categories A, B and C combined are lower than those for simple pneumoconiosis and category 0 (84.2 and 85.0, compared with 109.8 and 121.8 for simple pneumoconiosis, and 117.5 and 114.6 for category 0). Fortunately the SMR for leukaemia is low. A comparison between the survival rates of men aged 55-64 in Leigh, Lancashire and those in the Rhondda Fach suggests that nonminers in the two areas have similar survival rates while the survival rates for category 0 and simple pneumoconiosis are lower in the Rhondda Fach.

Influenza and ischaemic heart disease--a possible trigger for acute myocardial infarction?

Prompted by a clinical observation of an increase in hospital admissions for acute myocardial infarction during an influenza outbreak, a study was designed to examine the number of deaths from ischaemic heart disease (IHD) at the time of influenza. Deaths from IHD were found to be increased at all ages, and particularly in younger age groups when deaths attributed specifically to acute myocardial infarction are considered. The question of whether influenza could act as a precipitating factor in acute myocardial infarction is discussed, together with a possible mechanism.

The effect of an aldosterone antagonist on the protective action of carbenoxolone on the gastric mucosal barrier

The effect of an aldosterone antagonist on the protective action of carbenoxolone sodium on the gastric mucosal barrier has been studied in three dogs with Heidenhain pouches. The net fluxes of hydrogen ion and sodium ion were measured before, during, and after contact with a 10 mM bile acid solution at pH 2, in pouches which had not been treated with drugs, in pouches treated with carbenoxolone sodium and in pouches treated with both carbenoxolone sodium and the aldosterone antagonist, spironolactone. Hydrogen ion back diffusion from, and sodium ion gain by the untreated pouch was increased by 10 mM bile acid solution. Addition to the pouches of either carbenoxolone sodium alone or carbenoxolone sodium and spironolactone reduced the hydrogen ion back diffusion after exposure to the bile acid solution. The spironolactone did not change the protective effect of carbenoxolone on the gastric mucosal barrier. Carbenoxolone did not change the increased sodium ion diffusion caused by bile.