Direct improvement of quality of life using a tailored quality of life diagnosis and therapy pathway: randomised trial in 200 women with breast cancer

BACKGROUND

Despite thousands of papers, the value of quality of life (QoL) in curing disease remains uncertain. Until now, we lacked tools for the diagnosis and specific treatment of diseased QoL. We approached this problem stepwise by theory building, modelling, an exploratory trial and now a definitive randomised controlled trial (RCT) in breast cancer, whose results we report here.

METHODS

In all, 200 representative Bavarian primary breast cancer patients were recruited by five hospitals and treated by 146 care professionals. Patients were randomised to either (1) a novel care pathway including diagnosis of 'diseased' QoL (any QoL measure below 50 points) using a QoL profile and expert report sent to the patient's coordinating practitioner, who arranged QoL therapy consisting of up to five standardised treatments for specific QoL defects or (2) standard postoperative care adhering to the German national guideline for breast cancer. The primary end point was the proportion of patients in each group with diseased QoL 6 months after surgery. Patients were blinded to their allocated group.

RESULTS

At 0 and 3 months after surgery, diseased QoL was diagnosed in 70% of patients. The QoL pathway reduced rates of diseased QoL to 56% at 6 months, especially in emotion and coping, compared with 71% in controls (P=0.048). Relative risk reduction was 21% (95% confidence interval (CI): 0-37), absolute risk reduction 15% (95% CI: 0.3-29), number needed to treat (NNT)=7 (95% CI: 3-37). When QoL therapy finished after successful treatment, diseased QoL often returned again, indicating good responsiveness of the QoL pathway.

CONCLUSION

A three-component outcome system including clinician-derived objective, patient-reported subjective end points and qualitative analysis of clinical relevance was developed in the last 10 years for cancer as a complex intervention. A separate QoL pathway was implemented for the diagnosis and treatment of diseased QoL and its effectiveness tested in a community-based, pragmatic, definitive RCT. While the pathway was active, it was effective with an NNT of 7.

[Social gradient of PSA screening? 8 years follow up from the cancer registry of the tumor center in Regensburg]

BACKGROUND

Prostate cancer is the most frequent male cancer. In Germany most tumors are detected by PSA testing. Data on the long-term survival of patients with localized early prostate carcinoma are insufficient. We examined the relative survival of the patients with organ-defined prostate cancer (TNM T1-2N0M0, UICC I-II) compared to the standardized age-adjusted rates of the normal male population.

METHODS

Epidemiological and clinical data from 4,124 patients with prostate cancer diagnosed from 1998 to 2007 were extracted from the cancer registry of the tumor center in Regensburg; 2,087 patients suffered from localized early cancer. Kaplan-Meier analysis was used to estimate the overall survival rates in the patient cohorts irrespective of primary cancer therapy. These rates were adjusted for the expected survival rates in a comparable set of individuals from the general population.

RESULTS

Eight years after diagnosis, patients with stage I and II localized prostate cancer had an approximately 10% relative increase in survival compared with the normal male population. This relative increase in survival was already observed 3 years after diagnosis.

CONCLUSION

Patients with stage I-II localized prostate cancer have improved survival compared with the normal male population. This finding cannot be explained solely by the administration of prostate cancer treatments, which do not affect survival until 8-10 years after treatment, suggesting that men who participate in PSA testing may have a better overall health status. Another hypothesis may be a social gradient of PSA testing in Germany.

Expression of the lipid transporters ABCA3 and ABCA1 is diminished in human breast cancer tissue

ATP-binding cassette transporters ABCA3 and ABCA1 are related to a differentiated, lipid-secreting phenotype of type II pneumocytes. Since mammary gland epithelial cells also show pronounced lipid metabolism and secretion, we investigated the expression of these proteins in normal as well as in neoplastic breast tissue. Normal human breast tissue, breast cancer cell lines, and 162 tumor samples of patients with primary unilateral invasive breast cancer were analyzed for ABCA3 and ABCA1 protein expression by immunohistochemistry using tissue microarrays. Strong ABCA3 and ABCA1 expression was found in the inner layer of normal mammary gland epithelium. Concurrent cytoplasmic ABCA3 and ABCA1 immunoreactivity was found in 9 of 11 breast cancer cell lines. ABCA3 and ABCA1 were shown to be differentially expressed in human breast cancer. Loss of ABCA3 staining was significantly associated with positive nodal status and negative progesterone receptor expression. In multivariate analysis, diminished ABCA3 expression proved to be a significant, independent and adverse risk factor for tumor recurrence. ABCA1 expression was associated with positive lymph nodes, but not significantly associated with tumor recurrence or breast cancer-specific survival. ABCA3 and ABCA1 are strongly expressed in normal mammary gland epithelium. Decreased ABCA3 expression in breast cancer seems to be associated with poor prognosis.

Seasonal Patterns of Birth in Patients with Glioblastoma

Seasonal distribution of birth rates was only recently described in patients with high-grade gliomas. We analyzed 501 cases from the database of a Regional Cancer Center in Bavaria to assess annual periodicity in the birth dates of glioma patients. Prior to analysis, the number of births per month was normalized [number of births x 100,000/total number of births in Germany] to obtain birth rates per month. The approximation of the time series data by a one-year cosine model found that the glioblastoma birth rate exhibits a statistically significant annual variation, with the peak rate in January. Vitamin intake, infections, and other as-yet-unknown factors and exposures during pre- and perinatal early life may contribute to the seasonality of birth rate in patients with brain tumors.

[Ten years of epidemiological cancer registration in Bavaria]

For a large territorial state like Bavaria only a decentralised cancer registration structure promises successful results: in the form of regional clinical cancer registries and--using the clinical registration as a base--one population-based registry. After ten years of epidemiological cancer registration in Bavaria it can now be shown that the chosen registration concept has proved itself. Currently the completeness of cancer notifications exceeded the international recommended threshold of 90%. A largely complete data stock is available for the years of diagnosis from 2004 to 2005. The task sharing between clinical and population-based cancer registries avoids double registration of data. Both types of registries are supporting physicians and hospitals with a wide palette of services. Together they enable transparency of cancer occurrence as well as transparency of health care for tumour patients.

Implementing a system of quality-of-life diagnosis and therapy for breast cancer patients: results of an exploratory trial as a prerequisite for a subsequent RCT

A system for quality-of-life diagnosis and therapy (QoL system) was implemented for breast cancer patients. The system fulfilled the criteria for complex interventions (Medical Research Council). Following theory and modeling, this study contains the exploratory trial as a next step before the randomised clinical trial (RCT) answering three questions: (1) Are there differences between implementation sample and general population? (2) Which amount and type of disagreement exist between patient and coordinating practitioners (CPs) in assessed global QoL? (3) Are there empirical reasons for a cutoff of 50 points discriminating between healthy and diseased QoL? Implementation was successful: 74% of CPs worked along the care pathway. However, CPs showed preferences for selecting patients with lower age and UICC prognostic staging. Patients and CPs disagreed considerably in values of global QoL, despite education in QoL assessment by outreach visits, opinion leaders and CME: Zero values of QoL were only expressed by patients. Finally, the cutoff of 50 points was supported by the relationship between QoL in single items and global QoL: no patients with values above 50 dropped global QoL below 50, but values below 50 and especially at 0 points in single items, induced a dramatic fall of global QoL down to below 50. The exploratory trial was important for defining the complex intervention in the definitive RCT: control for age and prognostic stage grading, support for a QoL unit combining patient's and CP's assessment of QoL and support for the 50-point cutoff criterion between healthy and diseased QoL.

Necessity for including quality of life diagnostics and therapy in routine oncological care: Evaluation by methods of clinical guideline implementation

18594

Background: Application of quality of life assessment has become an important topic in oncology. Current approaches, however, have focused on technical issues within single center settings overlooking the requirements of routine care. We report on implementing of structural elements of a quality of life diagnostics and therapy system (QoL system). It was designed as integral part of the health care program for breast cancer patients in a regional tumor center. Methods: The QoL system was implemented by a systematic approach (Med. Care, 39, Suppl.2, 2(2001). Its elements comprised (a) coordinating practitioners (CPs) who functioned as gate keepers for QoL related therapies, (b) experts in the QoL unit who provided QoL reports and specific therapeutic recommendations based on patients’ responses to the EORTC questionnaire, (c) professional health care providers in psychotherapy, pain therapy, social support, physiotherapy/lymph drainage, and fitness (nutrition, sports), (d) clinicians (gynecologists) for patient recruitment and (e) opinion leaders for educational influence on the CPs to keep the QoL system in daily practice. Success of implementation (as indicated by CPs’ QoL-related changes in knowledge, attitude and behavior) was evaluated in a prospective study with breast cancer patients. Results: The QoL system was applicable in all of 170 patients recruited between Dec. 2002-June 2004 (age 34–86yrs, UICC 0–4, breast conserving surgery 67%). From 75 CPs (mostly gynecologists) in the area only 39 fulfilled criteria for the QoL system, 1 refused to participate. 38 CPs showed knowledge about QoL following educational outreach visits. Concerning attitudes and behavior, 64% of CPs found the experts’ reports comprehensible, 56% followed their recommendations, 20% made additional actions. Follow-up 4 months after first QoL measurement revealed improvements in pain, body image and social life (p < .05). Conclusion: The study—in combining doctor’s approach and patient’s demands—showed success using methods of guideline implementation by improving QoL deficits within a routine oncological care. Effectiveness will be analyzed in an ongoing randomized trial.

No significant financial relationships to disclose.

Prognostic relevance of P-cadherin expression in melanocytic skin tumours analysed by high-throughput tissue microarrays

AIM

To investigate whether protein expression or cellular localisation of P-cadherin is associated with clinicopathological characteristics in benign and malignant melanocytic skin tumours.

EXPERIMENTAL DESIGN

P-cadherin expression and the Ki-67 labelling index were analysed immunohistochemically by using tissue microarrays (TMAs). Membranous and cytoplasmic expression was scored semiquantitatively (0 to 2+).

RESULTS

P-cadherin protein expression of any intensity (1+ to 2+) was detected in the membrane in 41.5% (132/318) and in the cytoplasm in 64.2% (204/318) of patients. In general, P-cadherin expression was significantly reduced in malignant melanomas (p<0.001) and melanoma metastases (p<0.001), compared with benign nevi. Additionally, loss of membranous P-cadherin was associated with Clark level (p = 0.011) and tumour thickness (p<0.001). Interestingly, a significantly lower P-cadherin expression was shown by dermal nevi than by compound and junctional nevi (p = 0.005; p = 0.025). In primary melanomas, a Ki-67 labelling index <5% was not associated with P-cadherin protein expression, suggesting that loss of P-cadherin expression was not associated with proliferation. None of the other clinical and histological factors analysed was significantly related to P-cadherin expression. Low cytoplasmic P-cadherin expression was associated with tumour recurrence (p = 0.03) in all the patients who were analysed. After testing various multivariate Cox regression models, loss of cytoplasmic P-cadherin expression remained a highly significant adverse risk factor for tumour recurrence in patients with tumours <2 mm.

CONCLUSIONS

Loss of cytoplasmic P-cadherin expression is common in advanced melanomas and can be a prognostic marker of progression in patients with melanoma, most useful in patients with primary tumours <2 mm in thickness.

[Diagnosis and clinical decision making: a conceptional framework for predictive pathology]

In the clinical pathway of diagnosis and therapy of diseases two decisions are distinguished: diagnostic and therapeutic decision. The former is analysed by decision tables, the latter by decision trees. In both decisions pathology plays a dominant role, especially as a gold standard that is a test to which most people have developed trust. This definition is remarkably soft. An efficient diagnostic prediction depends on a high prevalence of the disease. This is frequently forgotten when tests have a high sensitivity and specificity. The mathematical concept behind this observation is the Bayesian theorem. This is highly important for predictive pathology because it allows to combine attributes with high likelihood ratio simply by multiplication and has been shown to be remarkably stable, e. g. in the differential diagnosis of acute abdominal pain. Pathology should take the leadership in prediction since it has a considerable power as the gold standard of many tests. However, a network is advisable with other basic disciplines.