Aftermath of the Rogers decision: assessing the costs

The Massachusetts Supreme Judicial Court's decision in Rogers v. Commissioner is generally regarded as an important right to refuse treatment decision requiring maximum judicial involvement in the treatment of nonconsenting patients. Since courts and legislators in other jurisdictions have looked to Rogers for guidance on right to refuse treatment issues, and since some have adopted it as a model, it is essential for lawmakers to understand the economic realities of the Massachusetts experience and the commitment of resources required by this model. The authors review these realities, suggesting that there are distinct reasons for considering this particular model "cost ineffective" in preserving patients' rights.

Impaired recovery and mutagenic SOS-like responses in ataxia telangiectasia cells

Radiosensitive fibroblasts from patients with ataxia telangiectasia (AT) were studied for their proficiency in two putative eukaryotic SOS-like responses, namely the enhanced reactivation (ER) and enhanced mutagenesis of damaged viruses infecting pre-irradiated versus mock-treated cells. A previous report indicated that, unlike normal human cells, a line of AT fibroblasts (AT5BIVA) could not be induced to express ER of damaged parvovirus H-1, a single-stranded DNA virus, by UV- or X-irradiation. In the present study, AT5BIVA fibroblasts were also distinguished from normal cells by the inability of the former to achieve enhanced mutagenesis of damaged H-1 virus upon cell UV-irradiation. In contrast, dose-response and time-course experiments revealed normal levels of ER of Herpes simplex virus 1, a double-stranded DNA virus, in X- or UV-irradiated AT5BIVA cells. Taken together, these data point to a possible deficiency of AT cells in a conditioned mutagenic process that contributes to a greater extent to the recovery of damaged single-stranded than double-stranded DNA. Such a defect may concern the replication of damaged DNA or the generation of signals promoting the latter process and may be related to the lack of radiation-induced delay that is typical of AT cell DNA synthesis.

Absence of induction of enhanced reactivation of herpes simplex virus in cells from xeroderma pigmentosum patients without skin cancer

The time course of appearance of enhanced reactivation (ER) and enhanced mutagenesis (EM) of herpes simplex virus type 1 were studied in UV-irradiated stationary cultures of xeroderma pigmentosum (XP) fibroblasts. In some of the XP cells EM followed similar kinetics of appearance as ER. Maximal activities occurred when infection was delayed 1 or 2 days after cell treatment. However, in certain XP cells only induction of the EM response was observed, whereas ER was absent. Interestingly, the latter XP cells had been obtained from patients who had not yet developed skin cancer at the time they were described in the literature, whereas the former XP patients had already developed skin tumors. This suggests that the ER response may somehow be involved in the process of oncogenic transformation. Dose-response studies of ER in XP cells from tumor-bearing patients showed that ER is maximally induced with a UV dose of 40 Jm-2 given to the virus. Normal levels of ER were observed in 14 different normal human skin fibroblasts, indicating that the ER- phenotype does not occur in normal cells or at least more rarely than in XP cells.

UVB doses in maintenance psoriasis phototherapy versus solar UVB exposure

A possible increase in the risk of skin cancer in psoriatic patients treated with long-term maintenance UVB phototherapy was assessed by comparing the cumulative doses of UVB with the amount of UVB received from sunlight by normal healthy people. The biologically-effective UVB dose (termed UVB(EE) ) was measured using polysulphone film and worn as a badge by individuals with either an indoor or an outdoor occupation during 4 summer months of 1983 in The Netherlands (52 degrees N). The calculated mean annual UV-B(EE) doses were 5.9 J/cm2 for persons with an indoor occupation and 134 J/cm2 for those with an outdoor occupation. The UVB(EE) doses received by psoriasis patients during an initial course of phototherapy, as well as during maintenance treatment, were also estimated and gave a mean value of 22 J/cm2. Mean annual amounts of solar UVB(EE) exposure were calculated and compared with the administered doses of UVB(EE) during maintenance phototherapy. A dose-response model is described in order to estimate the increased incidence of non-melanoma skin cancer associated with such therapy. The cumulative incidence among patients who received maintenance phototherapy for several decades was calculated to be a factor of 2.5 to 7.5 higher than the incidence among individuals with an outdoor occupation.