Promotion of breast cancer screening in communities: a research agenda

This paper used the National Cancer Institute of Canada (NCIC) cancer control framework to review research on participation in breast cancer screening programs and identify areas for further study. Cancer Lit, MEDLINE, CINAHL, Sociofile, Health and the Public Affairs Information Service databases were searched for literature published from 1990 to 1995. Information was also obtained from provincial breast cancer screening programs and Health Canada. Interventions designed to promote participation in screening programs have not been effective. Involvement of the target community, however, increased success and sustainability. Barriers to initial participation within screening programs include alternative sources of screening and the lack of funds to screen all eligible women. Studies show that participation decreases with successive screening rounds. The priorities for study are development of: a theoretical framework for recruitment strategies, a method to capture all Canadian screening results including those performed through provincial health insurance plans and a mechanism to deliver screening to all eligible Canadian women.

The effect of non-polar liquids and non-ionic detergents on the ultrastructure and assembly of rat tail tendon collagen fibrils in vitro

Non-ionic detergents or emulsions of non-polar liquids when added to solutions of rat tail tendon collagen (RTTC) or to the dispersed fibrils produced similar conspicuous ultrastructural modifications in the form of a D-periodic lesion between bands c2 and d in the 'gap region' of the fibril close to the start of the overlap region. The size and extent of the lesion in some fibrils indicates that at least some of the collagen molecules rupture. In an attempt to detect peptide fragments produced in this way we ran SDS-PAGE gels of collagen fibrils treated with the non-ionic detergent Triton X-100. These contained two peptides (44 and 32 kDa) not seen in controls. The lesions are thought to result from interactions between the hydrophobic part of non-polar liquids or detergents with an anomalous part of the fibril's D-period. The anomalous region has a high concentration of hydrophobic and alanyl residues but exceptionally few charged and hydroxyproline ones. We suggest that the anomalous region may play a part in storing and dissipating strain energy and permitting cross-link formation. Similar collagen-lipid interactions may occur under pathological conditions.

The Iowa Articulation Story. Collaboration works

Historically, Iowa has had a majority of diploma and associate degree nursing graduates. Although educational mobility for registered nurses to obtain baccalaureate nursing degrees was available in Iowa before 1991, direct nursing education articulation did not exist. The impetus for developing a statewide nursing articulation plan to facilitate the entry of registered nurses to baccalaureate nursing programs was the result of a recommendation from the Iowa Board of Nursing's 1988 Statewide Plan for Nursing. The Iowa Articulation Plan for Nursing Education: RN to Baccalaureate, implemented in 1991, resulted from collaboration among nurse educators from all levels of nursing and nursing service representatives. The plan consists of four separate options and can be adapted for use in other parts of the country. The Iowa articulation story describes the process used and outcomes achieved when nurses collaborate to advance nursing education.

Posterior dislocation of the shoulder with ipsilateral humeral shaft fracture: a very rare injury

A third case of a posterior dislocation of the shoulder with ipsilateral humeral shaft fracture is described. It is recommended that this difficult management problem requires internal fixation of the humeral shaft fracture to allow control of the shoulder.

Estrogen replacement in surgical stage I and II endometrial cancer survivors

OBJECTIVE

Our purpose was to evaluate our experience with estrogen replacement in women with a history of early-stage endometrial cancer and to determine whether it increased the risk for recurrence or death.

STUDY DESIGN

A retrospective review was performed of 123 women with surgical stage I and II endometrial adenocarcinoma treated between 1984 and 1994; 62 had received estrogen replacement therapy after cancer therapy. Sixty-one women received no estrogen. Variables analyzed included age parity, surgical stage, grade, depth of myometrial invasion, presence of intercurrent illnesses, duration of follow-up, and duration of estrogen replacement, if applicable. Outcome variables assessed included recurrence rate, time to recurrence, and disease-free interval.

RESULTS

The estrogen replacement therapy group had earlier stage disease (p = 0.04) and less severe depth of invasion (p = 0.003); however, the total number of deaths in each group was not significantly different. The disease-free survival in the estrogen replacement therapy group did not differ significantly compared with those not receiving estrogen replacement therapy. The data are suggestive of improved disease-free survival in the estrogen replacement therapy group, which may be related to differences in age, stage, grade, and depth of invasion. The overall recurrence rate was 6.5%, with an overall death rate of 1.6%.

CONCLUSIONS

There is no evidence to suggest that estrogen decreased the disease-free interval or increased the risk for recurrence in early-stage disease.

Enzymic control of collagen fibril shape

The shape of collagen fibrils growing in vitro in a cell-free enzyme/substrate system is shown to be dependent on the enzyme/substrate (E/S) ratio. Long fibrils with tapered ends were generated by exposing pCcollagen (procollagen from which the N-propeptides had been removed) to procollagen C-proteinase (which acts by cleaving the C-propeptides from the pCcollagen, converting it to insoluble fibril-forming collagen). Tip shape profiles, established quantitatively by scanning transmission electron microscopy, depended critically on the C-proteinase/pCcollagen ratio. The finest tips occurred at low ratios, the coarsest at high ratios. All fibrils had molecules oriented with amino termini closest to the pointed ends, i.e. N,N-bipolar fibrils in which molecules change orientation abruptly at one location along the fibril. Fibrils had maximal diameter at this molecular switch region. Shape asymmetric fibrils occurred at low E/S ratios, near-shape symmetric fibrils occurred at high ratios. Fibrils generated at low E/S ratios bore the closest resemblance to those formed in vivo except that the central shaft regions of fibrils formed in vitro showed no tendency to be limited to a uniform diameter.

Combined fine-needle aspiration, physical examination and mammography in the diagnosis of palpable breast masses: their relation to outcome for women with primary breast cancer

OBJECTIVE

To examine the combined and individual predictive values of fine-needle aspiration (FNA), physical examination (PE) of the breast and mammography (the "triple test") in diagnosing breast cancer in relation to the results of open surgical biopsy.

DESIGN

A study of the records of patients who received both FNA and open surgical biopsy for the same palpable breast lump. The results of diagnostic assessment and open surgical biopsy were categorized as positive or negative. Concordance (percentage of tests found to be correct at biopsy), sensitivity, specificity (percentage of patients without breast cancer for whom the diagnostic test was negative) and positive predictive value (percentage of patients with a positive test found to have breast cancer) were determined for the triple test for each diagnostic modality. In addition, prognostic variables (tumour size, node positivity, estrogen and progesterone receptor status) and outcomes were assessed in patients with a diagnosis of breast cancer.

SETTING

A university-affiliated general hospital with a special focus on women's health.

PATIENTS

Of 290 patients who had both FNA and open surgical biopsy, 191 underwent all three diagnostic procedures.

MAIN OUTCOME MEASURES

The diagnostic accuracy of FNA, PE and mammography to permit preoperative definitive therapy or to allow observation without mandating open surgical biopsy.

RESULTS

In 81 patients all three diagnostic modalities were in agreement for a diagnosis of either benign or malignant disease; the concordance for the triple test was 98.8% specificity was 100% and sensitivity was 95.5%. Nodal status, tumour size and outcome were similar whether or not the triple test was positive, but, interestingly, when the triple-test results were positive, estrogen (p < 0.05) and progesterone (p < 0.03) receptor values were more likely to be negative.

CONCLUSIONS

When all three diagnostic modalities were in agreement for a diagnosis of malignant disease, the combination of FNA, PE and mammography had excellent concordance with the results of open surgical biopsy, and in this situation definitive treatment may be carried out. If all three modalities are in agreement for a diagnosis of benign disease, a period of close observation with repetition of FNA may be safely entertained. Lack of concordance of the three diagnostic modalities mandates biopsy. Triple-test positively does not predict a worse outcome.

Factors associated with local breast cancer recurrence after lumpectomy alone

BACKGROUND

The purpose was to determine the rate of local breast relapse in patients with breast cancer uniformly treated with partial mastectomy but without postoperative radiotherapy and without systemic adjuvant therapy. We also systematically examined the factors associated with local recurrence to determine whether a low-risk subgroup existed.

METHODS

A retrospective review of a prospectively followed (median, 8 years) cohort of 293 patients was performed. The end-point was ipsilateral local breast cancer recurrence. The patient's age, tumor size, nodal status, estrogen and progesterone receptor status, histology, and tumor and nuclear grade were studied, as were the presence and amount of carcinoma in situ and the presence of tumor emboli using univariate Kaplan-Meier and Cox step-wise multivariate analyses.

RESULTS

The overall local relapse rate was 26% (77 recurrences). Univariate factors significantly associated with decreased local relapse included older age, negative nodes, small tumor size, positive estrogen receptor status, and absence of tumor emboli. Significant multivariate variables were age, nodal status, estrogen receptor status, absence of comedo carcinoma in situ, and tumor emboli. A low-risk subgroup of 66 patients was defined with a 6% 10-year local recurrence rate.

CONCLUSION

Important patient and tumor variables associated with local breast cancer relapse after breast-conserving surgery can define a low-risk subgroup.

Collagen fibril formation

Collagen is most abundant in animal tissues as very long fibrils with a characteristic axial periodic structure. The fibrils provide the major biomechanical scaffold for cell attachment and anchorage of macromolecules, allowing the shape and form of tissues to be defined and maintained. How the fibrils are formed from their monomeric precursors is the primary concern of this review. Collagen fibril formation is basically a self-assembly process (i.e. one which is to a large extent determined by the intrinsic properties of the collagen molecules themselves) but it is also sensitive to cell-mediated regulation, particularly in young or healing tissues. Recent attention has been focused on "early fibrils' or "fibril segments' of approximately 10 microns in length which appear to be intermediates in the formation of mature fibrils that can grow to be hundreds of micrometers in length. Data from several laboratories indicate that these early fibrils can be unipolar (with all molecules pointing in the same direction) or bipolar (in which the orientation of collagen molecules reverses at a single location along the fibril). The occurrence of such early fibrils has major implications for tissue morphogenesis and repair. In this article we review the current understanding of the origin of unipolar and bipolar fibrils, and how mature fibrils are assembled from early fibrils. We include preliminary evidence from invertebrates which suggests that the principles for bipolar fibril assembly were established at least 500 million years ago.

Clinical behavior of untreated axillary nodes after local treatment for primary breast cancer

BACKGROUND

The purpose of this study was to examine the rate of axillary failure in patients with primary breast cancer treated without axillary dissection or radiation and to determine what factors may be associated with axillary failure.

METHODS

We studied 112 patients with invasive breast cancer treated for primary disease with breast-conserving surgery without axillary dissection or radiation to the breast or axilla, accrued between 1977 and 1986. Data for these patients were prospectively gathered for a research database and reviewed retrospectively to determine axillary failure. The effects of age, tumor size, estrogen receptor (ER) status, progesterone receptor (PgR) status, histologic grade, nuclear grade, and tumor emboli on time to axillary failure were examined.

RESULTS

The median follow-up was 9.6 years. There were 26 axillary recurrences, resulting in a 10-year actuarial nodal control rate of 72%. Patients with nodal failure proceeded to axillary dissection with minimal morbidity. In both univariate and multivariate analyses, only tumor size was significantly associated with axillary failure (p = 0.04 and p = 0.06, respectively).

CONCLUSIONS

This study demonstrates a significant effect of tumor size on axillary failure and a reasonable rate of local control in small tumors. Further research should examine the utility of axillary dissection in women with small breast cancers.

The Henrietta Banting Breast Centre database: a model for clinical research utilizing a hospital-based inception cohort

The cohort study design has been used successfully in clinical cancer research. Cohorts, however, are valuable only if they produce results which are valid and generalizable. Some hospital-based inception cohorts satisfy both these requirements and may thus be useful research tools. The development of one such hospital-based cohort, the Henrietta Banting Breast Centre database, is described. This cohort is composed of 1097 women diagnosed with primary breast cancer at Women's College Hospital, Toronto, from January 1977 through December 1986. Details of diagnostic procedures, pathology, treatment, dates and sites of recurrence, and date of death are available on 96% of women. By comparison with published series and with the Ontario Cancer Registry, we have demonstrated validity and generalizability. A major advantage is the ready availability of paraffin tissue blocks on virtually all cases, facilitating analyses of the prognostic importance of specific biologic variables and immunocytochemical hormone assays. Other completed studies and future uses of the cohort are described.

Correlation of C-myc and HER-2/neu amplification and expression with histopathologic variables in uterine corpus cancer

OBJECTIVE

Initial studies of protooncogenes in uterine corpus cancer have focused on a single aspect of the gene in question (deoxyribonucleic acid, ribonucleic acid, protein) or have studied a small number of patients. Therefore we evaluated c-myc and HER-2/neu gene amplification and ribonucleic acid overexpression in such malignancies and correlated these molecular changes with known pathologic risk factors.

STUDY DESIGN

Quantitative Southern blot analysis for oncogene deoxyribonucleic acid was used to examine 37 tumors from patients with primary untreated uterine corpus cancer referred to the City of Hope National Medical Center. Six normal endometrial specimens were controls. Seventeen tumors were also examined by Northern blotting to assess increased ribonucleic expression.

RESULTS

Histologic types included adenocarcinoma (n = 30), papillary serous adenocarcinoma (n = 2), adenosquamous carcinoma (n = 2), mixed mullerian sarcoma (n = 2), and leiomyosarcoma (n = 1). Carcinomas were stage I (n = 10), II (n = 18), or III (n = 6). Twenty-three had myometrial invasion of less than one third, six one third to two thirds, and eight deeper invasion (greater than two thirds). According to the criteria of the International Federation of Gynecology and Obstetrics stage was as follows: I (n = 22), II (n = 3), III (n = 7), and IV (n = 5). Ten (27%) and four (11%) tumors showed gene amplification of c-myc and HER-2/neu, respectively. Six demonstrated overexpression of either the c-myc or HER-2/neu gene. HER-2/neu gene amplification was associated more closely with overexpression. Stepwise logistic analysis demonstrated c-myc amplification to be associated with higher grade (p = 0.01).

CONCLUSION

In this referral population, c-myc activation is more common than HER-2/neu activation in uterine corpus cancer and is associated with tumors of higher grade.

Vertebrate (chick) collagen fibrils formed in vivo can exhibit a reversal in molecular polarity

A reversal in molecular polarity can occur in vertebrate collagen fibrils. This has been demonstrated using a method for isolating, from chick embryo tendon, entire collagen fibrils 2 to 14 microns in length and suitable for electron-optical examination. A polarity reversal is present in some, but not all, of these fibrils. Such fibrils have two N-ends. The transition region, occupying several D-periods in which the reversal occurs, is not restricted to a central location in a fibril. Analysis of the fibril banding pattern through the transition region shows that the relative axial alignment of antiparallel molecules brings oppositely-directed C-telopeptides into axial register. This could allow antiparallel molecules to be covalently linked via polymeric cross-links involving these C-telopeptides.

Characteristics of local recurrence following lumpectomy for breast cancer

We report the clinical characteristics and treatment of local breast relapse in our breast cancer patients who were initially managed with breast conservation surgery (lumpectomy) alone. A retrospective study was conducted of 366 patients who were treated since 1977. The clinical, pathological, and treatment data regarding the primary tumor and the recurrences (91) were reviewed. The actuarial rate of local breast relapse in this group was 31% at 10 years. Breast relapse was significantly less in those patients 65 years old or greater. Acceptable treatment of the breast relapse included total mastectomy or repeat lumpectomy plus radiotherapy. Most relapses were small and occurred in the same area as the original tumor and had similar histology and estrogen and progesterone receptor values. About one-third of patients will have isolated relapses after conservation surgery alone, but in the older age group, isolated breast relapse occurs less frequently. The recurrences are usually surgically resectable, and acceptable results can be achieved with salvage surgery.

Word meaningfulness and event-related potentials during phrase processing

Evoked Potentials (EP) were recorded to visual presentation of words in phrases. Three EP components, P250, N400, P560, and their dependence on the role that each word plays in the phrase were studied. Subjects were requested to perform a congruity/incongruity task after the presentation of short phrases of two-types that differed in the position of meaningful keywords. We show how these keywords contribute substantially to N400 and possibly to P560 but do not reliably affect P250.

The standardization of estrogen receptors

Tumour estrogen receptor (ER) status may determine the medical treatment of a patient with breast cancer; yet inter-laboratory results can vary markedly, particularly when absolute cut-offs in fmol/mg cytosol protein are used. The use of standardized log units is proposed to permit greater inter-laboratory comparability. We have assessed the biochemical ER values using the dextran-coated charcoal method with three data sets, two quality control (QC) sets for Ontario laboratories and a data set with values for 184 primary breast cancer patients seen at Women's College Hospital (WCH) between 1985 and 1986. The distributions for all the raw data were skewed toward the lower end of the range; a log transformation improved the symmetry of the distributions. There was marked inter-laboratory variation in the QC data, and standardized log units greatly reduced this variability. The WCH data had similar differentiation by tumour size and nodal status with both the raw data and standardized log units. However, standardized log units provided more consistent evidence of an association between ER and immunohistochemical ERICA. The standardized log units provide quantitative receptor values suitable for multi-centre research, for future work with clinical outcomes, and for the daily management of patients.

Effect of administration route and estrogen manipulation on endometrial uptake of Photofrin porfimer sodium

OBJECTIVE

Our purpose was to evaluate the influence of the route of drug administration and target tissue vascularity on the distribution of a photosensitizer, Photofrin porfimer sodium, in the uterus.

STUDY DESIGN

The study was divided in two phases. In phase I 80 mature female rats were hormonally suppressed and then stimulated with estrogen. They were randomized to receive intravenous, intraperitoneal, or intrauterine Photofrin and killed 3, 6, 24, or 48 hours later. Drug distribution and levels were then determined. In phase II 40 female rats were randomized to receive hormonal stimulation, suppression, both, or neither. All received intrauterine Photofrin and were killed 24 hours later. Statistical analysis was performed with the unpaired t test and the two-way analysis of variance.

RESULTS

Intrauterine administration was determined to be the simplest and most effective method of delivery because it provided for optimal uptake and distribution (p = 0.05) within the uterus, at lower doses.

CONCLUSIONS

Selective localization of photosensitizer within the target tissue suggests that highly selective photodynamic destruction of endometrial tissue can be achieved. Furthermore, the combination of intrauterine administration of photosensitizer with estrogen adjuvant may minimize the most debilitating side effect of Photofrin, cutaneous phototoxicity.

Evidence for bimodal distribution of breast carcinoma ER and PgR values quantitated by enzyme immunoassay

Breast carcinoma oestrogen receptor (ER) and progesterone receptor (PgR) values obtained by radioligand binding assays have commonly been observed to have approximate log-normal distributions. We examined the distribution of log-transformed receptor values obtained by enzyme immunoassay for 5468 primary breast carcinomas in five Ontario laboratories. In each laboratory, it was found that the frequency histograms for the log transformed receptor values were not unimodal, and generally were suggestive of bimodality. This was not affected by stratification by age or inferred menopausal status (< or = 49, > or = 50 years), and could not be explained by kit characteristics. However, the low point in the distribution varied from 5 to 63 fmol/mg cytosol protein, depending on the receptor, patient age and laboratory. The tendency towards biomodality was more distinct for ER than for PgR. It remains to be determined whether the low points on the frequency histograms have clinical relevance for discriminating between hormone-sensitive and hormone-insensitive tumours.

The structured oral self-directed learning evaluation: one method of evaluating the clinical reasoning skills of occupational therapy and physiotherapy students

The Structured Oral Self-directed Learning Examination (SOSLE) is used to evaluate the clinical reasoning skills of occupational therapy (OT) and physiotherapy (PT) students. It is an oral examination which evaluates a student's problem-solving ability, self-directed learning skills, knowledge level and self-assessment ability. The three parts of the examination are conducted over a 24-hour period. Validation of this instrument was carried out in two groups of OT and PT undergraduate students over two consecutive years (Year 1--n = 20) (Year 2--n = 18). Inter-rater reliability correlations varied from 0.61 to 0.78 the first year to 0.85 to 0.99 in the second year. The results obtained from the SOSLE were also compared to written and tutorial marks obtained in the same course. Pearson Correlation Coefficients (PCC) among mean SOSLE and two written paper scores ranged from 0.0-0.05 (Year 1) to 0.0-0.1 (Year 2). The PCC among the mean SOSLE and tutorial performance scores were 0.57 (Year 1) and 0.0 (Year 2). The results show that good agreement between raters can be reached using this evaluation method. However, the poor correlations between the SOSLE and the other methods of evaluation may show that different skills are being evaluated. Further validity testing needs to be carried out to confirm that this tool is measuring process oriented skills.

Surgical treatment of unexpected invasive cervical cancer found at total hysterectomy

OBJECTIVE

To determine the proper management of patients found to have invasive cancer of the cervix on pathologic examination of a uterus removed for benign indications.

METHODS

We report 18 patients undergoing hysterectomy who were found to have cervical cancer with invasion deeper than 3 mm and/or lymph-vascular space involvement. None had gross residual tumor following simple hysterectomy. All patients underwent a second operation. Seventeen women underwent a radical parametrectomy, upper vaginectomy, and pelvic lymphadenectomy; one had pelvic and periaortic lymphadenectomy alone because of bilateral grossly positive obturator nodes.

RESULTS

Median follow-up was 72 months. One of the 15 women without residual disease or nodal involvement at second operation had pelvic recurrence 66 months after therapy. Three patients with disease identified at radical surgery underwent tailored postoperative pelvic radiation, and two of these had pelvic recurrence. The overall actuarial 5-year survival for the 18 patients was 89%. Operative morbidity was comparable to that of patients undergoing primary radical hysterectomy.

CONCLUSION

This study confirms that patients with unexpected invasive cervical cancer found at total hysterectomy can undergo radical re-operation with low morbidity and excellent cure rates.