An exploration of the concept of directly observed treatment (DOT) for tuberculosis patients: from a uniform to a customised approach

Tuberculosis (TB) management has moved from chaotic systems and low patient adherence with treatment regimens to the directly observed therapy, short course (DOTS) strategy, which has been described as a new paradigm of TB control. Directly observed treatment (DOT) is only one component of the full DOTS strategy. DOT versus self-administered treatment (SAT) has been the subject of extensive debate, particularly about what approach improves treatment adherence. This debate has been complicated by different case-holding rates and cure outcomes in different contexts where DOT is in place. The increasing range of DOT applications in different settings, including the choice of provider, place, target population, and the extent to which DOT is part of a wider approach, has not been sufficiently taken into account. However, the concrete reality of DOT is an important determinant of the overall success or failure of the programme, and has implications in terms of equity and accessibility of care during treatment. This article aims to go beyond the frequently polarised debate of DOT versus SAT and document the diversity of ways in which DOT has been implemented internationally. We also aim to raise key issues for further discussion, including 1) viewing DOT as part of a complex and lengthy set of interventions that are context-specific, 2) incorporating an equity approach that discusses individual patients' needs and the relationship between the patient and provider, and 3) the role of incentives and enablers. It is anticipated that this exchange of opinion and experiences from different parts of the world will be useful for those involved in the policy formulation and practice of TB management.

[Standards, Options and Recommendations for the management of stage I or II primary bronchial cancers treated exclusively with radiotherapy]

CONTEXT

The 'Standards, Options and Recommendations' (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French cancer centres and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.

OBJECTIVES

To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for the management of stage I and II non small cell lung carcinoma treated by radiotherapy alone.

METHODS

Data were identified by searching Medline and personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to independent reviewers, and to the medical committees of the 20 French cancer centres.

RESULTS

The main recommendations for the management of stage I and II non small cell lung carcinoma treated by radiotherapy alone are: 1) The curative external irradiation with a continual course is an alternative to surgery only in the case of medically inoperable tumors or because the patient refuses surgery; 2) The external irradiation of the primary tumor only without the mediastinum could be proposed in peripheral stage IA. In proximal stage IA and IB, external irradiation should be carried out only as part of prospective randomised controlled trials comparing a localised irradiation of the primary tumor with a large irradiation of the mediastinum and the primary tumor. The treated volume must include the macroscopic tumoral volume with or without the microscopic tumoral volume and with a security margin from 1.5 to 2 cm; 3) There is a benefit to delivering a total dose in the primary tumor higher than 60 Gy in so far as the proposed irradiation, taking into account the respiratory function, does not increase the likelihood of severe adverse events due to radiation; and 4) The change in fractionation, the radiochemotherapy combination, the endobronchial brachytherapy with high dose rate alone or with external irradiation could be proposed only as part of prospective controlled trials for tumors classified as stage IB or II.

[Standards, options and recommendations for the management of locally advanced non small cell lung carcinoma]

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.

OBJECTIVES

To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for the management of locally advanced non small cell lung carcinoma.

METHODS

Data were identified by searching Medline and the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to independent reviewers and to the medical committees of the 20 French Cancer Centres.

RESULTS

The main recommendations are: 1) The management of the locally advanced non small cell lung carcinoma has two main goals: firstly to obtain local control of the disease (or to at least delay local progression in order to improve the survival or relapse free survival), and secondly to prevent the development of metastases. 2) There is a consensus that locally advanced non small cell lung carcinoma should be irradiated. External beam radiotherapy should be of optimal quality and delivered at a minimal dose of 60 Gy by standard fractionation. For patients with a poor life expectancy, this can be delivered as a split-course or hypofractionated scheme. 3) Treatment for patients with a performance status of 0-1 should consist of short duration induction chemotherapy (with a least two drugs one of which must be cisplatin), combined sequentially with conventional radiotherapy. 4) Surgery is contraindicated in extensive N3 disease. Combined radio-chemotherapy (adjuvant or neoadjuvant) is not indicated outside clinical trials. Surgery is justified in stage N2 disease as good local control can be achieved. T4-N0 disease should be treated surgically with curative intent.

Validity of earlier positivity of central venous blood cultures in comparison with peripheral blood cultures for diagnosing catheter-related bacteremia in cancer patients

We carried out a prospective study in two French Comprehensive Cancer Centers (95 and 184 beds, respectively) to assess the validity of a test based on the earlier positivity of central venous blood cultures in comparison with peripheral blood cultures for predicting catheter-related bacteremia. The differences between the times to positivity for the 21 patients with clinical catheter-related bacteremia and the differences between the times to positivity for the nine patients with bacteremia due to another source were compared by the median test. The difference between the median values was significant (P = 0.0003). A receiver operating characteristic curve was constructed to determine the optimum threshold of the test, which appeared to be at the cutoff point of >/=+3 h, with 100% specificity and 81% sensitivity. The positive and negative predictive values obtained with this cutoff point confirmed the efficacy of the test for predicting the presence or absence of catheter-related bacteremia in cancer patients. The cutoff point was then used to post-classify the 68 episodes of bacteremia from an unknown source. The characteristics and clinical course of both the positive and negative post-classified episodes did not show that the test was clearly useful for a large number of clinical presentations. We therefore suggest restricting it to febrile neutropenic cancer patients for whom clinical signs of infection are slight or absent and when the test is positive.

Treatment of non-metastatic rhabdomyosarcomas in childhood and adolescence. Results of the second study of the International Society of Paediatric Oncology: MMT84

The second International Society of Paediatric Oncology (SIOP) study for rhabdomyosarcoma (MMT84) had several goals. The two principal aims were: (1) to improve the survival of children with rhabdomyosarcoma; and (2) to reduce the late effects from therapy by restricting the indications for surgery and/or radiotherapy after good response to initial chemotherapy. A further aim was to investigate the role of high-dose chemotherapy in young patients with parameningeal primary tumours. 186 previously untreated eligible patients entered the study. Patients with completely resected primary tumour received three courses of IVA (ifosfamide, vincristine and actinomycin D). Patients with incompletely resected tumour received six to 10 courses of IVA according to stage. Patients achieving complete remission with chemotherapy alone did not usually receive radiotherapy or undergo extensive surgery, but patients remaining in partial remission received local therapy with surgery and/or radiotherapy. Only patients over 5 years of age with parameningeal disease and patients over 12 years with tumours at any site were given systematic irradiation. Complete remission was achieved in 91% (170/186) of all patients. With a median follow-up of 8 years, the 5-year overall survival was 68% (+/- 3% standard error of the mean (SEM) and the 5-year event-free survival 53% (+/- 4% SEM). These results show an improvement over previous SIOP study (RMS75) in which survival was 52% and event-free survival was 47%. Among the 54 patients who exhibited isolated local relapse, 35% (19/54) survived in further remission longer than 2 years after retreatment, including local therapy (surgery +/- radiotherapy). Analysis of the overall burden of therapy received by all surviving children (including primary treatment and treatment for relapse if required) showed that 24% (28/116) were treated by limited surgery followed by three courses of IVA, 29% (34/116) were treated by chemotherapy alone (after initial biopsy) and 13% (15/116) received chemotherapy plus conservative local treatment (limited surgery or radiotherapy for residual disease). Only 34% (39/116) received intensive local therapy defined as radical wide field radiotherapy or radical surgery or both. Compared with the results obtained in the previous SIOP study, treatment in MMT84 was based on response to initial chemotherapy and, despite an overall reduction of the use of local therapy, significantly improved survival for patients with non-metastatic disease. This trial, also for the first time, provides evidence that retreatment after local relapse can achieve long-term second remissions.

Evaluation of the monoclonal antibody antithyroperoxidase MoAb47 in the diagnostic decision of cold thyroid nodules by fine-needle aspiration

Fine needle aspiration (FNA) of cold thyroid nodules has become the first line diagnostic decision for electing which patients need surgery. In order to improve FNA accuracy, the monoclonal antithyroperoxidase (TPO) antibody (MoAb47) was tested. A total of 554 patients were included in this study and among them, 208 were referred to surgery. The results of FNA compared to the final histological diagnosis revealed a sensitivity and a specificity of 94 and 55% respectively, while the sensitivity and specificity of TPO immunodetection on the same cases reached 98 and 83% respectively. By combining the two methods, the 3 false-negative of FNA and 60% of suspicious cytology corresponding to histological benign lesions were correctly identified by immunocytochemistry. With better results than FNA alone, TPO immunodetection with MoAb47 represents a useful adjunct to conventional cytology for selecting patients for surgery.

[Anatomo-clinical prognostic factors of papillary carcinoma of the thyroid. Multivariate analysis: report of a series of 52 cases]

A retrospective study about 52 cases of papillary thyroid carcinomas was carried out with emphasis on histopathological features. The mean follow up period was 10 years. The survival curves were estimated using the Kaplan-Meier method and compared using the log rank test. The multivariate analysis was performed using the Cox's regression model. In univariate analysis, age, Tp (histopathological extension of the tumor), histological differentiation, VAN score (Vascular invasion nuclear Atypia tumor Necrosis) of Akslen and the LeuM1 expression were significant prognostic factors. In multivariate analysis, the Tp and histological differentiation were associated with high risks of poor outcome.

Simultaneous high-dose external irradiation and daily cisplatin in unresectable, non-metastatic adenocarcinoma of the pancreas: a phase I-II study

BACKGROUND AND PURPOSE

Clinical trials have demonstrated that high dose radiation therapy and daily cisplatin (CDDP) could increase local control and survival in carcinoma from various sites. The present phase I-II study has combined high dose radiation therapy and daily CDDP at escalating dosages.

METHODS

From August 1994 to December 1995, 23 patients with non-resectable carcinoma of the pancreas were enrolled in a phase I-II multicentric, pilot study to test the toxicity and the effectiveness of high dose radiotherapy and daily cisplatin (CDDP) at escalating dosages. A dose of 6 mg/sqm/day of CDDP was selected for the phase II step since no grade IV toxicity occurred in any patient in the phase I step.

RESULTS

Toxicity was considered fairly acceptable. At the time of analysis, the 23 patients who entered the study had clear evidence of evolutive disease either locally or distantly in the liver. It is suggested that high dose radiotherapy (60 Gy continuously) and daily CDDP have little effect on local control of the tumor and survival, and only a moderate effect on pain.

CONCLUSIONS

In unresectable, apparently non-metastatic cancers of the pancreas, there is an urgent need for new agents or new combinations of agents to be tested.