Ethical, social and economic issues in familial breast cancer: a compilation of views from the E.C. Biomed II Demonstration Project

Demand for clinical services for familial breast cancer is continuing to rise across Europe. Service provision is far from uniform and, in most centres, its evolution has been determined by local conditions, specifically by local research interests, rather than by central planning. However, in a number of countries there is evidence of progress towards co-ordinated development and audit of clinics providing risk assessment, counselling, screening and, in some cases, prophylactic intervention. Much important information should emerge from continued observation and comparative assessment of these developments. In most countries for which relevant data are available, there is a distinct bias towards higher social class among those who avail themselves of clinic facilities (in line with findings from many other health-promotion initiatives). This should be addressed when considering future organisation of clinical services. Molecular genetic studies designed to identify the underlying mutations responsible for familial breast cancer are not generally regarded as part of the clinical service and are funded through research grants (if at all). Economic considerations suggest that there is a case for keeping this policy under review. Familial cancers throw into sharp relief certain ethical and legal issues that have received much recent attention from government advisory bodies, patients' representatives, professional commentators and the popular media. Two are of particular importance; first, the right to gain access to medical records of relatives, in order to provide accurate risk assessment for a given family member, versus the right to privacy in respect of personal medical information and, second, the obligation (or otherwise) to inform family members of their risk status if they have not actively sought that knowledge. The legal position seems to vary from country to country and, in many cases, is unclear. In view of pressures to establish uniform approaches to medical confidentiality across the EC, it is important to evaluate the experience of participants in this Demonstration Programme and to apply the principle of "non-malfeasance" in formulating regulations that should govern future practice in this field. Data on economic aspects of familial breast cancer are remarkably sparse and outdated. As evidence accrues on the influence of screening and intervention programmes on morbidity and mortality, there is a strong case for evaluating the cost-effectiveness of different models of service provision.

Utilisation of prophylactic mastectomy in 10 European centres

Increasingly women at high risk of breast cancer are opting for prophylactic surgery to reduce their risks. Data from 10 European centres that offer a risk counselling and screening service to women at risk show different approaches to the option of preventive surgery, although most centres adhere to a protocol including at least two risk counselling sessions and a psychological assessment. Thus far the combined centres have data on 174 women who have undergone prophylactic mastectomy with in excess of 400 women years of follow up. Operations were carried out on women with lifetime risks of 25-80%, with an average annual expected incidence rate of 1% per women. No breast cancers have occurred in this cohort. Long term follow up on an extended group of women will be necessary to truly address the risk of subsequent breast cancer and the psychological sequelae.

Current policies for surveillance and management in women at risk of breast and ovarian cancer: a survey among 16 European family cancer clinics. European Familial Breast Cancer Collaborative Group

The recent isolation of breast cancer predisposing genes (BRCA1 and BRCA2) allows the identification of carriers within affected families. These carriers have a 50-85% risk of developing breast or ovarian cancer and need careful follow-up. The purpose of this study was to evaluate the management and screening protocols implemented in high risk families at various family cancer clinics in Europe. A questionnaire was mailed to the members of the European Familial Breast Cancer Collaborative Group (n = 30) requesting information on the following issues: indication for surveillance of breasts and ovaries, the recommended protocol, coordination of the screening examination, prophylactic surgery, the specific management of breast cancer in a mutation carrier and the use of oestrogen. 16 centres from nine countries responded. Most centres recommend surveillance of the breasts if the lifetime risk exceeds 15-20%. The surveillance protocol that is generally advised comprises monthly self breast examination, examination by a specialist every 6 months and annual mammography, all starting from an age between 25 and 35 years. Surveillance of the ovaries is recommended in BRCA1 and BRCA2-mutation carriers, in members from breast/ovarian cancer families and in some centres in 'breast cancer only' families with an early onset of breast cancer. The recommended protocol includes gynaecological examination, sonography and estimation of CA-125 at yearly intervals starting from the age 30-35 years. Prophylactic mastectomy is considered for proven mutation carriers in some centres. Most centres consider prophylactic oophorectomy in mutation carriers and some centres also consider it for members of breast/ovarian cancer families. This survey provides insight into the guidelines for surveillance and management of familial breast cancer used at various family cancer clinics in Europe; this insight may contribute to the appropriate management of these high risk women. It should be emphasised that most recommendations are based on experts' opinion rather than on any specific studies.

Computer-assisted three-dimensional reconstruction of head and neck tumors

OBJECTIVE

Because head and neck tumors reside in a complex area, having a three-dimensional (3-D) model of the patient's unique anatomical features may assist in the delineation of pathology. The authors describe a new computer technique of 3-D anatomical reconstruction from two-dimensional computed tomography (CT) and magnetic resonance (MR) data and discuss how it represents a step forward in the continuing evolution of 3-D imaging.

STUDY DESIGN

The authors selected three patients with solitary head and neck tumors and reconstructed their anatomy in a 3-D format for study. The tumors represented locations in the nose and central skull base (patient 1), temporal bone (patient 2), and neck (patient 3).

MATERIALS AND METHODS

MR and CT images from the individual patients were electronically transferred to workstations in the Surgical Planning Laboratory of the authors' institution. Registration (or fusion) was carried out between the MR and CT images. The desired anatomic components underwent segmentation (identification and isolation). Assembly of the segmented images was performed and the resulting structures were integrated to produce a 3-D model.

RESULTS

3-D models of the following were constructed and displayed in an interactive format on high-capacity computer workstations: 1) a skull base sarcoma with extension into the nasopharynx and nose; 2) an acoustic neuroma with internal auditory canal involvement; and 3) a metastatic recurrence of a tongue base squamous cell carcinoma in the posterior triangle of the right side of the neck with extension to the skull base.

CONCLUSION

The authors' Surgical Planning Laboratory has developed a 3-D reconstruction technique that has several new features. The models provided a very good 3-D interactive representation of the tumors and patient anatomy. The need now exists to develop this method of 3-D reconstruction of head and neck tumors for potential applications in treatment, research, and medical education.

PTH-responsive osteoblast nuclear matrix architectural transcription factor binds to the rat type I collagen promoter

In connective tissue, cell structure contributes to type I collagen expression. Differences in osteoblast microarchitecture may account for the two distinct cis elements regulating basal expression, in vivo and in vitro, of the rat type I collagen alpha1(I) polypeptide chain (COL1A1). The COL1A1 promoter conformation may be the penultimate culmination of osteoblast structure. Architectural transcription factors bind to the minor groove of AT-rich DNA and bend it, altering interactions between other trans-acting proteins. Similarly, nuclear matrix (NM) proteins bind to the minor groove of AT-rich matrix-attachment regions, regulating transcription by altering DNA structure. We propose that osteoblast NM architectural transcription factors link cell structure to promoter geometry and COL1A1 transcription. Our objective was to identify potential osteoblast NM architectural transcription factors near the in vitro and in vivo regulatory regions of the rat COL1A1 promoter. Nuclear protein-promoter interactions were analyzed by gel shift analysis and related techniques. NM extracts were derived from rat osteosarcoma cells and from rat bone. The NM protein, NMP4, and a soluble nuclear protein, NP, both bound to two homologous poly(dT) elements within the COL1A1 in vitro regulatory region and proximal to the in vivo regulatory element. These proteins bound within the minor groove and bent the DNA. Parathyroid hormone increased NP/NMP4 binding to both poly(dT) elements and decreased COL1A1 mRNA in the osteosarcoma cells. NP/NMP4-COL1A1 promoter interactions may represent a molecular pathway by which osteoblast structure is coupled to COL1A1 expression.

The role of the external examiner in the assessment of clinical practice

In the first part of this paper we give a brief overview of the development of the different types of clinical assessment used in the UK. Some general problems related to the assessment of clinical practice are outlined. The second part of the paper focuses on the role of the external examiner in the clinical assessment of students. We outline some of the major problems we encountered as internal and external examiners on the same university-based course in which 'I-day' practical assessments were undertaken. We emphasize the particular problems of externally assessing the clinical practice component of the course in this manner and conclude that the continuous assessment model, while not without its own problems, is potentially a more effective approach to student assessment.

The use of behavioural mapping in a study of seclusion

As part of a larger study into the use of seclusion we set out to examine some of the antecedents that led to patients being secluded in one locked psychiatric ward. Behavioural mapping was used to chart the location of incidents that resulted in seclusion. Incidents were observed in several ward areas but most of these occurred in the day room and the dining room. This finding enabled us to question the ward policy of confining patients to these areas to facilitate nursing observation and management. The policy may have contributed to the number of disturbances by limiting personal space for patients. Literature on body buffer zones, crowding and territoriality is used to clarify and interpret the findings.

CD44 expression by leucocytes in rheumatoid arthritis and modulation by specific antibody: implications for lymphocyte adhesion to endothelial cells and synoviocytes in vitro

Anti-CD44 MoAb IM7 induced the loss of CD44 from mouse leucocytes thereby inhibiting leucocyte migration and joint inflammation in murine arthritis. Thus, targeting CD44 with MoAb may have potential for the treatment of patients with inflammatory joint diseases. Expression of CD44 by peripheral blood (PB) and synovial fluid (SF) leucocytes from rheumatoid arthritis (RA) patients was compared and the ability of IM7 to modulate this expression determined. RASF lymphocytes showed increased CD44 expression compared with those in PB indicative of an activated phenotype. As inflammatory SF did not up-regulate CD44 expression on PB lymphocytes, the increased CD44 expression by SF lymphocytes was a result of the selective homing of CD44(high) cells to the synovium rather than an effect of the synovial environment. RASF granulocytes showed reduced CD44 expression compared with those in PB, again indicative of an activated phenotype. However, this reduction could be induced on PB granulocytes following culture with inflammatory SF and was inhibited by anti-TNF-alpha MoAb, implying that soluble factors in inflammatory SF such as TNF-alpha induced granulocyte activation and CD44 loss. IM7 induced the loss of CD44 from lymphocytes (both from PB and SF) and granulocytes in vitro, but was subsequently re-expressed after 24 h culture in the absence of the MoAb. This loss of CD44 was blocked by serine- and metalloprotease inhibitors implying that IM7 induced the proteolytic cleavage of CD44 by a mechanism similar to that reported for the loss of CD44 from PMA-activated granulocytes. Furthermore, IM7-treated CD44(low) lymphocytes showed reduced adherence to both an endothelial cell line and RA synovial fibroblasts in vitro. The unique ability of IM7 to reduce CD44 expression by lymphocytes suggests that it could prevent lymphocyte extravasation and synovial infiltration in RA as previously reported in murine arthritis.

Mutation of Di-leucine residues in the juxtamembrane region alters EGF receptor expression

Di-leucine motifs have been implicated in the internalization or degradation of many membrane proteins. The epidermal growth factor receptor (EGFR) contains two di-leucine residues at 658 (TLRRLLQER) and 679 (NQALLRIL). To determine the role of these di-leucine motifs in regulating EGF receptor expression, activity, or ligand-induced degradation, the di-leucine residues at positions 658 or 679 were mutated to di-alanine residues, and the mutant receptors were stably expressed in CHO cells. The results indicate that mutation of either di-leucine motif generates and promotes cell surface expression of carboxy-truncated EGF receptors (M(r) 120, 140 kDa) that do not undergo EGF-induced autophosphorylation or degradation. In contrast, full-length EGF receptors (170 kDa) containing di-alanine substitutions resemble wild type receptors in that they respond to EGF by autophosphorylation, their tyrosine kinase activity is inhibited by protein kinase C, and they are degraded. The level of autophosphorylation of the 170 kDa mutant receptors and EGF-induced tyrosine phosphorylation of other cellular proteins is lower than that of the wild type receptor, consistent with formation of kinase-inactive heterodimers between the truncated and full-length mutant receptors. These results demonstrate that removal of either of the di-leucines leads to generation of inactivating carboxy-truncated receptors, suggesting that the two di-leucine motifs within the juxtamembrane region of the EGFR are important for ensuring normal receptor expression.

A previously undescribed mutation within the tetramerisation domain of TP53 in a family with Li-Fraumeni syndrome

We report details of a family with classic Li-Fraumeni syndrome in which there is a mutation in codon 344 of the tumour suppressor gene TP53. Codon 344 is a key residue within the tetramerisation domain, and the amino acid substitution of a proline for a leucine is predicted to have profound implications for tetramerisation and potentially DNA binding. This is the first report of a mutation at this residue in either sporadic tumours or in the germline and the first report of a germline mutation within the tetramerisation domain. The family does not appear to be remarkable in the spectrum of tumours, and there is loss of the wild-type allele in a leiomyosarcoma from the proband. A cell line has been established from the tumour of the proband and cytogenetic and molecular studies carried out, providing an extensive analysis in this family.

Role of mitogen-activated protein kinase kinase in regulation of the epidermal growth factor receptor by protein kinase C

The epidermal growth factor receptor (EGFR) is regulated by at least two mechanisms involving protein kinase C (PKC), inhibition of EGF binding and inhibition of EGF-stimulated tyrosine kinase activity. In this study we investigated whether mitogen-activated protein kinase (MAPK) mediates the inhibitory effects of PKC on EGFR binding or kinase activity by pretreating NIH3T3 and Chinese hamster ovary cells expressing the EGFR with PD98059, an inhibitor of MAPK/extracellular signal-regulated kinase kinase (MEK). We also determined whether substitution of cysteine for threonine at residue 669, the site of MAPK phosphorylation of the EGFR, alters the inhibition of kinase activity by PKC. The results indicate that 1) PKC down-regulates EGFR tyrosine kinase activity by an MEK-dependent mechanism presumably involving MAPK; 2) the inhibition by PKC is not a direct result of phosphorylation of the EGFR by PKC or MAPK; 3) activation of MAPK is not sufficient to regulate EGFR kinase activity; and 4) PKC-mediated down-regulation of EGF binding and EGFR kinase activity occur by different mechanisms. These data are consistent with a model for regulation of the EGFR by other receptors whereby their activation of PKC, in conjunction with MAPK, results in the phosphorylation of a protein(s) that modulates EGFR kinase activity.

A study of the official records of seclusion

The official records of seclusion on one locked ward in a city hospital were analysed. In the first instance we examined the frequency of seclusion, the sex and type of the patients secluded over a 4-year period. Following the introduction of a new recording system, a more detailed analysis of all the official records of seclusion over a 2-year period was then carried out (n = 225). The findings are presented here as simple frequency counts and provide a detailed picture of the use of seclusion in this particular area. They include details about the way in which seclusion was used on the ward and the reasons staff provided for secluding patients. The use of official records as research data illustrate how important insights into the daily care of psychiatric patients may be explored in a fruitful manner.

Issues for clinical leaders in nursing development units

This study explores the effect of grants on the clinical leaders of nursing development units (NDUs). A qualitative exploratory study was carried out by The King's Fund Centre using a semi-structured interview schedule. Through the interviews clinical leaders were able to explain how they felt about the responsibility of leading a funded NDU. The information gathered was examined for common themes and categories which revealed the complexity of effects on clinical leaders.

Quality in provision of forensic psychiatric services: room for improvement

Highlights some of the tensions which impede the development of an effective and efficient system of service delivery in forensic psychiatry. Reports on an investigation exploring the quality of care in a relatively small unit providing forensic psychiatric care in a secure setting and the constraints which impede the development of such services. Discusses the findings from the investigation which point to the need for the organizational structure surrounding forensic psychiatric care to be altered so that there are no perverse incentives for purchasers of services and to enable the contracting process, considering both cost and quality issues, to take place on a level playing field.

Staffing levels and seclusion use

In this paper the role of staffing levels as a determinant of seclusion use in one psychiatric hospital is examined. A detailed review of the official records of seclusion over a 2-year period was completed (n = 225). The staffing levels on shifts when seclusions were initiated were compared with similar shifts when seclusions were not used on the same ward. Statistical analysis revealed a highly significant difference between the levels of staffing: Wilcoxon matched pairs signed-ranks test, Z = -5.8675, two-tailed, P = 0.001. This finding suggests that staffing levels play a crucial role in the practice of seclusion. However, the overall staffing level must be considered along with other factors in the makeup of the staff group, including the ratio of female to male staff and the experience level of those staff. These findings have important implications for those involved in the management and practice of seclusion as well as the patients who are secluded.

Somatic mutations in the hMSH2 gene in microsatellite unstable colorectal carcinomas

Microsatellite instability is frequently seen in tumors from patients with hereditary nonpolyposis colorectal cancer (HNPCC). Germline mutations in the mismatch repair gene hMSH2 account for approximately 50% of these cases. Tumors from sporadic cases also exhibit this microsatellite instability phenotype, although at a lower frequency, and very few somatically derived mutations have so far been reported in such tumors. In this study DNA from 23 primary colorectal carcinomas (four familial and 19 sporadic cases) exhibiting microsatellite instability were screened for mutations in the hMSH2 gene using constant denaturant gel electrophoresis (CDGE). Among the sporadic cases, five (26%) were found to have somatically derived mutations. One tumor revealed two different mutations, possibly leading to a homozygous inactivation of the gene. One of the four familial cases was classified as having HNPCC, and a germline as well as a somatic mutation were found in this tumor. These results demonstrate that a considerable proportion of sporadic colorectal cancers with microsatellite instability, have somatic mutations in the hMSH2 gene.

Structure of the human MSH2 locus and analysis of two Muir-Torre kindreds for msh2 mutations

Hereditary nonpolyposis colorectal carcinoma (HNPCC) is a major cancer susceptibility syndrome known to be caused by inheritance of mutations in genes such as hMSH2 and hMLH1, which encode components of a DNA mismatch repair system. The MSH2 genomic locus has been cloned and shown to cover approximately 73 kb of genomic DNA and to contain 16 exons. The sequence of all the intron-exon junctions has been determined and used to develop methods for analyzing each MSH2 exon for mutations. These methods have been used to analyze two large HNPCC kindreds exhibiting features of the Muir-Torre syndrome and demonstrate that cancer susceptibility is due to the inheritance of a frameshift mutation in the MSH2 gene in one family and a nonsense mutation in the MSH2 gene in the other family.