Practice patterns of palliative care for the United States 1984-1985

This study reports the national averages for patterns of palliative radiation therapy observed in the United States for patients treated in 1984-1985 and compares those patterns to the pertinent literature. The data were collected in 1984-1985 by the Patterns of Care Study Survey of Palliative Care conducted in 49 institutions selected to provide valid national averages for the practice patterns reported. Data were collected from 784 patient records selected from five "strata" of practice. Demographic data and process data were tabulated and national averages were calculated from the data. Four metastatic sites were selected, weight bearing bones (401), non-weight bearing bones (102), brain metastasis (224), and lung-mediastinum (57). The median patient age was 63 years, equally divided by sex. In 52% of patients this was the first metastasis. Common Karnofsky performance scores ranged from 40 to 80%. Lung, breast, and prostate were the most common primaries. Two-thirds of the patients were treated by linear accelerators, one-third by cobalt. The median number of fractions was 10, median dose 3000 cGy, median fraction size 300 cGy, and median treatment duration 15 days. The goal of treatment was relief of pain (98%) and return of function (30%) for weight bearing bones, for brain metastasis it was preservation of function (68%), pain relief (33%), and relief of compression (25%). All sites showed TDF values that ranged from 33-85, and a TDF of approximately 65 was most common for weight bearing bones and brain metastasis with no consistent pattern of TDF selection for the other sites. Compliance by strata of practice with work-up criteria was excellent with isolated poor compliance seen in several strata.

The structure of radiation oncology practices in the continental United States

The American College of Radiology periodically collects data on radiation oncology facilities with megavoltage equipment. The results of the 1986 survey are summarized, with specific reference to the substantial growth in free-standing facilities.

The outcome of treatment of 313 patients with T-1 (UICC) prostate cancer treated with external beam irradiation

Three hundred and thirteen patients with UICC T-1 N-0 M-0 prostate cancer were treated with external beam irradiation in 1973 and 1974 or in 1978, and their outcome determined 3-10 years after treatment. Survival over the first 5 years was comparable to that expected for a group of age matched normal males (77% vs. 81%), but during the second 5-year interval, there was a decrease in survival below that expected (51% vs 62%), a reflection of death in patients who developed metastasis as a first recurrence (18%). Overall, 72% of patients were free of any recurrence at 5 years and, 88% free of infield recurrence. The development of metastatic recurrence was significantly related to grade; at 5 years 87% of grade I, 79% of grade II and 69% of grade III patients were free of metastasis. There was a trend for increased local recurrence with increasing grade, but it was not statistically significant. There was a dose/response relation for complications, and radiation doses above 6500 cGy are associated with an increase in complication from 6% to 11% (p = .09). Complications requiring hospitalization for evaluation or management occurred in 30 (10%) of 313 patients. There were no deaths from complications and less than 2% of patients required surgical correction of complications. External beam radiation offers the patient with early prostate cancer a favorable opportunity for cure without the morbidity of impotence, incontinence, and occasional death experienced following LND and radical prostatectomy. Lymph node dissection does not seem necessary for most patients with T-1 prostate cancer as the positive yield in those with Grades I and II cancers is less than the complications of the procedure, and extensive involvement can be detected by non-invasive means.

Radiation Therapy Oncology Group (RTOG) studies in head and neck cancer

Since its foundation in 1971, the RTOG has conducted a successful clinical research program in head and neck mucosal squamous cell carcinoma with 22 treatment protocols and one registry study which combined have accumulated data on over 5,500 patients. The RTOG was the first multicenter group to evaluate neoadjuvant chemotherapy before definitive radiation with its methotrexate study. Although the study was negative, RTOG has since conducted five pilot or phase II studies of neoinduction or concurrent chemotherapy with radiation therapy in patients with inoperable tumors. The last study showed that radiation concurrent with cisplatinum was tolerable with a suggestion of increased antitumor effect. In patients with potentially resectable tumors, RTOG has completed a pilot study of combination chemotherapy administered either before or after the surgery with radiotherapy. Based upon its findings, the treatment sequence, surgery-chemotherapy-radiotherapy, was chosen as the experimental arm for a new phase III study. This study was subsequently adopted by the head and neck intergroup mechanism as its study (INT 0034/RTOG 8503). RTOG has investigated the optimal timing of radiotherapy with surgery. The 7303 study established that postoperative radiotherapy achieved significantly better locoregional control but not improved absolute survival. Approximately 30% of the patients on each arm failed to complete both modalities. Even when comparison is restricted to patients who completed both modalities, postoperative radiotherapy still produced the better locoregional control. Efforts to overcome the limitations imposed by tumor hypoxia through use of carbogen (95% O2 and 5% CO2) breathing or the radiosensitizer misonidazole during radiotherapy have been unsuccessful. In a phase I study, RTOG showed that 15 to 18 sessions of sensitized radiation can be safely delivered with the new radiosensitizer SR 2508 in contrast to only six such sessions with misonidazole. This promising radiosensitizer is now being tested in a phase III trial. RTOG has also investigated variations in fraction size, fraction number, and total radiation dose. In the 7102 study, split-course irradiation achieved equivalent antitumor results as compared to continuous daily irradiation but with less social alteration and cost to the patient. In the hyperfraction pilot study 7703, twice a day irradiation with 120 cGys up to 6,000 cGys proved to be tolerable.(ABSTRACT TRUNCATED AT 400 WORDS)

Combined radiation therapy and surgery in the management of advanced head and neck cancer: final report of study 73-03 of the Radiation Therapy Oncology Group

Between March 1973 and June 1979, patients with advanced operable squamous cell carcinoma of the supraglottic larynx or hypopharynx were randomly allocated to receive either preoperative radiation therapy (5,000 rad) or postoperative radiation therapy (6,000 rad). Patients with oral cavity or oropharynx lesions were randomly assigned either preoperative radiation, postoperative radiation, or definitive radiation therapy (6,500-7,000 rad), with surgery reserved for salvage if residual disease was present 6 weeks after completion of irradiation. Three hundred twenty patients were evaluable with a median follow-up of 60 months. Based on results in 277 patients across all four regions combined, locoregional control was significantly better for patients assigned to receive postoperative radiation therapy (65%) compared with those assigned to receive preoperative radiation therapy (48%, P = 0.04). This was due to a higher rate of both persistent and recurrent local and regional disease in the preoperative group. Survival also showed a trend to be better in the postoperative group (38%) compared with the preoperative group (33%, P = 0.10). Rates of severe surgical and radiation therapy complications were similar overall. Forty-three patients were evaluable for each of the three treatment regimens assigned to patients with oral cavity or oropharynx lesions. Due to the small number of patients available for this portion of the trial, the observed differences for overall survival (4-year percentage 33% overall; 30% preoperative, 36% postoperative, 33% definitive radiation therapy) and for locoregional control (45% overall; 43% preoperative, 52% postoperative, 38% definitive radiation therapy) were not statistically significant. The use of definitive radiation therapy with surgical rescue as an ethically justified alternative treatment for these tumors remains a question for further research.

Failure of misonidazole-sensitized radiotherapy to impact upon outcome among stage III-IV squamous cancers of the head and neck

As part of the RTOG research effort in the treatment of advanced, inoperable squamous cancer of the head and neck region, the hypoxic cell sensitizer, misonidazole, was selected for investigation as an adjuvant to definitive irradiation. Based upon a pilot experience (78-02) showing a 67% complete response rate among 36 AJC Stage III-IV patients receiving full-dose irradiation and 6 weekly p.o. doses of misonidazole, a phase III trial was carried out from '79-'83. Three hundred and six patients were entered, 42% of whom had oropharyngeal primaries and with 78% of all cases representing T3 or T4 (inoperable) lesions. Only 16% of the entire series presented with N0 necks. Fractionation was altered among the misonidazole-receiving patients, in contrast to "standard" 5 treatments per week among "control" patients, such that 2 separate treatments were given on each day of p.o. misonidazole administration (2.0 gm/m2/wk X 6 doses, 2.5 Gy in a.m., 2.1 Gy in p.m.). Total tumor doses were identical among the two treatment arms except that a limitation of 40.0 Gy to spinal cord was specified for sensitized radiotherapy vs. 45.0 Gy for "control" patients. Primary tumor clearance was observed to be 55-60%, with minor variations according to tumor stage and site. The local regional control rate among radiotherapy-alone patients was 26% at 2 years compared to 22% (2 years) within the misonidazole-receiving group. Analysis of survival revealed no advantage to the sensitized patients, with 55 +/- 2% surviving 1 year and 22 +/- 1% living 3 years following treatment in both treatment categories. Distant metastases as first site of failure (12-13%) and the local failure among initial complete responders (46%) showed no advantage to the misonidazole group. Although a misonidazole dosage of 2.0 gm/m2/wk X 6 (12 gm/m2 total) is well tolerated, no clinical benefit was demonstrated in this randomized trial. Other nitroimidazole analogs (e.g. SR-2508) are now being investigated.

Purification of bovine protoporphyrinogen oxidase: immunological cross-reactivity and structural relationship to ferrochelatase

Protoporphyrinogen oxidase, the penultimate enzyme in the haem biosynthetic pathway has been purified to apparent homogeneity from bovine liver mitochondria, by a published method (Dailey, H.A. and Fleming, J.E., (1983)), with an additional ion-exchange chromatography step, using a Mono Q column on an FPLC-system. This gave a product with a 68% yield and 870-fold purification. Protoporphyrinogen oxidase (EC 1.3.3.4) has an apparent Mr of 57,000 and the Km for protoporphyrinogen IX was 16.6 microM. Activity of the isolated enzyme was increased by 66% in the presence of oleic acid, and evidence was obtained for a FAD prosthetic group. Ferrochelatase (EC 4.99.1.1) was purified and antibodies were raised in rabbits against ferrochelatase and protoporphyrinogen oxidase, respectively. Anti-protoporphyrinogen oxidase IgG showed marked cross-reactivity with ferrochelatase and anti-ferrochelatase IgG cross-reacted with protoporphyrinogen oxidase. In addition, radiolabelled peptides of both enzymes, generated by chymotrypsin, demonstrated common peptides when analysed by two-dimensional chromatography.

Gestational risk factors for Wilms' tumor: results of a case-control study

Gestational risk factors for Wilms' tumor were investigated in a pair-matched case-control study. Cases who were under 15 years of age at diagnosis during 1970-1983 were identified through the registries of the three main hospitals treating childhood cancer in the greater Philadelphia area. Controls were selected by random digit dialing and were matched to cases on race, birth date, and telephone area code and exchange. Because of a low participation rate among nonwhites, results are reported only for the 88 white matched pairs whose parents were interviewed by telephone. Of the hypothesized risk factors, maternal use of hair-coloring products in the year prior to the index child's birth (odds ratio, 3.6; P = 0.003) and hypertension or fluid retention during pregnancy (odds ratio, 5.0, P = 0.01) were significantly associated with increased risk of Wilms' tumor. Use of hair-coloring products was strongly associated with cases in which Wilms' tumor was diagnosed before 2 years of age (odds ratio, 15; P = 0.001). For two other gestational factors, tea drinking and vaginal infection, the odds ratios were significantly elevated for all cases and the effects were concentrated among the nongenetic cases. Bilateral cases had a significantly higher mean birth weight than did their controls. Older maternal age was significantly associated with the genetic form of Wilms' tumor. Adjustment for possible confounders and consideration of the time interval between the index pregnancy and the interview did not substantially alter the findings.

Medical and drug risk factors associated with neuroblastoma: a case-control study

A matched case-control study of prenatal risk factors for neuroblastoma was conducted, including 104 cases diagnosed over the period 1970-79 in the Greater Delaware Valley. Significantly elevated odds ratios (ORs) were associated with maternal use of a neurally active drug during pregnancy (OR = 2.83), sex hormone exposure 3 months prior to or during pregnancy (OR = 2.25), frequent alcohol consumption during pregnancy (OR = 9.0), and maternal use of diuretic drugs during pregnancy (OR = 5.75). Significantly more case mothers than control mothers reported use of hair coloring products during pregnancy (OR = 3.0). No association was found between cigarette smoking, coffee consumption, or medical irradiation and case-control status.

A ten year follow-up of 682 patients treated for prostate cancer with radiation therapy in the United States

This report extends the follow-up of patients studied in the Patterns of Care Survey of Prostate Cancer treated in the United States between 1973 and 1975 from a maximum of 5 years to a maximum of 10 years. Survival for 60 Stage A patients was the same as expected for their age distribution (83% at 5 years and 62% at 10 years). Survival for 312 Stage B patients was 73% at 5 years and 46% at 10 years and for 296 Stage C patients was 58% at 5 years and 38% at 10 years. Infield recurrence was determined by clinical means, at 5 years 97% of Stage A patients, 86% of Stage B patients, and 74% of Stage C patients were free of local recurrence. At 10 years 97% of Stage A patients, 74% of Stage B patients, and 69% of Stage C patients remained free of local recurrence. Patients with Stage B and C cancer who developed their first failure infield show a long-term survivorship after recurrence of 40% and 20% respectively. This is in contrast to Stage B and C patients who develop a first recurrence at a metastatic site where the rate of progress to death was slower in Stage B patients than for those with Stage C disease (mean survival 32 months versus 19 months), but eventually all are dead by 7 years after recurrence. Complications were infrequent, actuarial analysis shows 93% of patients free of serious complications at 5 years and 89% free at 10 years. There were 14 patients (2%) whose complications required surgical correction and 2 of the 682 patients died of complications.

Antisecretory activity of misoprostol, its racemates, stereoisomers and metabolites in isolated parietal cells

Inhibition of histamine-stimulated acid secretion by misoprostol was compared to its racemates, stereoisomers and metabolites in isolated canine parietal cell preparations. The concentration of misoprostol required to inhibit 50% of maximal histamine-stimulated acid secretion (IC50) was 3.8 +/- 0.3 nM. One racemate of misoprostol was at least 1000 times more potent than the other. Of the four misoprostol stereoisomers, the 11R, 16S isomer exhibited the most potent activity against histamine with an IC50 value of 1.4 +/- 0.1 nM. The acid metabolite of misoprostol was equally potent as misoprostol. In contrast to the acid metabolite, the beta-oxidation metabolites of misoprostol lacked significant activity at 1 microM. The results indicate that: 1) the acid metabolite of misoprostol may play a significant role in the antisecretory activity of misoprostol, and 2) the high degree of stereo-specificity associated with the antisecretory effects indicates that the activity of misoprostol may be receptor mediated.

Protoporphyrinogen oxidase in porphyria variegata. A report of the findings in 7 families

Protoporphyrinogen oxidase (PPO) activity was determined in 7 families with porphyria variegata (PV). Enzyme activity was reduced by 50% in 8 propositi and in 8 out of 16 prepubertal children. These results are in keeping with the concept that PV is inherited as an autosomal dominant disease. Enzyme activity was also reduced in the fathers of 2 of the propositi, who were suspected on family history of carrying the PV trait, but who had no clinical manifestations. Determination of PPO activity provides a reliable means of identifying PV and of identifying offspring who could, at puberty, become PV patients.

Quantitation of the monoclonal plasma cell component in bone marrow from patients with serum paraproteinemia and nondiagnostic marrow morphology

Twenty-one patients with serum monoclonal gammopathy but lacking acceptable morphological evidence of myelomatosis were studied with reference to the degree, if any, of monoclonal plasma cell expansion in aspirated marrow samples, enriched for plasma cells and analysed with respect to light chain distribution. Four of these patients had a biopsy-proven plasmacytoma of bone. Bone marrow aspirated from sites distant to the tumor showed clear evidence of infiltration by monoclonal plasma cells in two of the cases studied; the other two patients had normal results. Of the 17 other cases, 14 showed evidence of a monoclonal plasma cell component qualitatively concordant with the serum paraprotein as one would expect. These cases could be subdivided into those with myeloma (six cases) and those with monoclonal gammopathy of undetermined significance (eight cases) on the basis of conventional biochemical and radiological criteria. Three of the 17 patients, however, did not show evidence of monoclonal plasma cell infiltration, despite the presence of lytic lesions. It is important to recognize this minority group that simulates myeloma but that may well reflect alternative pathology that has not been identified.

Prognostic factors for loco/regional control and metastasis and the impact on survival

For the identification of predictive factors for local (head and neck) control and metastases and impact on survival in squamous cell cancer of the head and neck, we have used data from over 2000 patients from the Patterns of Care Study (PCS) and the Radiation Therapy Oncology Group (RTOG) studies. Complete local response (C.R.) is significantly related to T stage, N stage, general performance status (Karnofsky), and site of primary tumor. There is a strong association between T and N stage. T1N0 tumors showed a C.R. of 99%, whereas, T1N3 had a C.R. of 57%. T4N0 showed a C.R. of 75%, but this went down to 31% in the T4N3 lesions. Glottic tumors showed a C.R. of 96% versus the other sites, which ranged from 81% for the nasopharynx to 59% for the hypopharynx. Patients with a performance status (KPS) of less than 90% showed a C.R. of 60% versus 88% for AKPS 90% or higher. Absence of local recurrence after C.R. is significantly related to T stage, N stage, and the site of primary tumor (glottis versus the rest). The appearance of distant metastases is significantly related only to N stage and primary site. This relationship persists in control of loco/regional tumors. In Stages III & IV in non-glottic head and neck cancer, metastases as the cause of death play an increasingly important role. This can be as high as 30%. The appearance of new malignant tumors and death unrelated to cancer, that is, death related to lifestyle, assumes an important role in patients with advanced head and neck cancer. The number of advanced glottic larynx was too small to examine this question. The use of a surgical procedure in carcinomas of the anterior tongue and floor of the mouth was associated with a smaller percentage of infield recurrences at 2 years, than when radiation therapy alone was used (27% versus 88% p less than .01). The same observation was noted at 3 years in the glottic and supraglottic Stage III & IV tumors (p less than .01).

Patterns of Care Study. Analysis of outcome survey data-anterior two-thirds of tongue and floor of mouth

The Patterns of Care Study, begun in 1973, carried out its second outcome survey from December 1978 through April 1979. The review of patients with epidermoid carcinomas of the anterior two-thirds of tongue and floor of mouth included patients treated between January 1973 and June 1975 so that a minimum follow-up period of 2 years was evaluable. Records of 434 patients from 96 facilities were available for analysis, although not every patient could be evaluated for every variable. Almost three-fourths (320) were treated with radiation alone. In these data, four patient and disease characteristics were strongly related to recurrence rates including stage at presentation, deep ulceration, deep infiltration, and age. Treatment variables significantly affecting recurrence included use of interstitial therapy in Stages I and II, use of surgery in Stages III and IV, and a facility's best equipment.

Carcinoma of the nasopharynx. A 25-year study

Between 1958-1983, 79 patients with a diagnosis of epithelial tumor of the nasopharynx received definitive irradiation at Thomas Jefferson University Hospital. Seventy-two percent of the patients had a Stage IV lesion. The dose to the nasopharynx was over 6,000 cGy in all but four patients. The 5- and 10-year actuarial survivals were 33% and 19% respectively. The 5-year disease-free survival was 33%. Histology had no bearing on survival. Survival was influenced by the stage of primary tumor and nodes. Advanced nodal disease correlated with distant metastasis, being present in 13/15 cases with hematogenous spread.

The need for complex technology in radiation oncology. Correlations of facility characteristics and structure with outcome

The Patterns of Care Study data are used to correlate therapy equipment and practice characteristics with outcome, using Hodgkin's disease, prostate cancer, and cervix cancer as examples. The shift to linear accelerators and higher photon energy is supported, as is the increased use of treatment simulators. Part-time practitioners of radiation therapy and facilities whose only equipment is a less-than-80-cm cobalt unit have poor technical support and exhibit poor staging, poor achievement of minimum tumor dose, and poor patient follow-up as compared to the national average or best-performing strata of practice. These facilities should either upgrade their equipment, technical support, and level of practice or close.

Protoporphyrin accumulation by mitogen stimulated lymphocytes and protoporphyrinogen oxidase activity in patients with porphyria variegata and erythropoietic protoporphyria: evidence for deficiency of protoporphyrinogen oxidase and ferrochelatase in both diseases

In erythropoietic protoporphyria (EPP) and porphyria variegata (PV) excess protoporphyrin is excreted in the stool, suggesting one or more enzyme defects in the terminal steps of the haem biosynthetic pathway. We measured protoporphyrinogen oxidase (PPO), which catalyses the oxidation of protoporphyrinogen to protoporphyrin, in both EPP and PV patients and in the offspring of PV patients. In the same subjects we measured protoporphyrin formation by mitogen stimulated lymphocytes, with delta aminolaevulinic acid (ALA) as substrate and with the addition of chelators or iron, an indirect measure of ferrochelatase activity. PPO activity was reduced by 41% (P less than 0.001) in PV patients and in 50% of their offspring, and by 36% (P less than 0.001) in EPP patients. Protoporphyrin accumulation in stimulated lymphocytes was increased by 1.3-fold (P less than 0.001) in EPP and 1.5-fold (P less than 0.001) in PV patients compared to normal subjects. There was a significant difference in protoporphyrin accumulation between iron deficient and iron replete cells from PV patients as compared to normals but not as marked as for EPP cells treated similarly. Stimulated lymphocytes from prepubertal PV offspring with reduced PPO activity accumulated normal amounts of protoporphyrin. We have interpreted our findings as follows: PPO is significantly reduced in both diseases. Ferrochelatase becomes defective in PV patients after puberty. This could explain why PV is clinically and biochemically manifest only after puberty. As it has been repeatedly shown that ferrochelatase is markedly reduced in EPP, it would appear that both enzymes are deficient in these two porphyrias.

The role of radiation therapy in the management of intracranial meningiomas

Thirty-two patients with the diagnosis of intracranial meningioma were treated with radiation therapy over the past 24 years at the Thomas Jefferson University Hospital. Indications for irradiation included incomplete resection, malignant histology, and progressive or recurrent disease after curative surgery. Patients with malignant histology did poorly, with only 2 of 7 alive. This contrasts with 17 of 25 patients with benign histology who are either alive and well or who have enjoyed a long-term disease-free survival. No difference in ultimate outcome could be found between patients with benign histology irradiated in the immediate postoperative period as opposed to those irradiated at time of progression or recurrence.

Combined preoperative and postoperative radiation for bladder cancer. Results of RTOG/Jefferson Study

Ninety-two patients with bladder cancer have been treated with combined pre- and postoperative radiation in a Radiation Oncology Study Group (RTOG) Phase I-II study and at Thomas Jefferson University Hospital. Patients with invasive bladder cancer were entered into the study and given low-dose preoperative radiation (500 rad) to the whole pelvis, either on the day of or the day before cystectomy. Following surgery, patients were pathologically staged. Patients with stage B1 (T2) (grade 3 or 4), stage B2 and C (T3) tumors were given 4500 rad in 5 weeks postoperative radiation. Follow-up in the study ranges from a minimum of 24 months to 5 years, with a median of 36 months. Incidence of complications was 15% (14/92). The 4-year actuarial survival (Kaplan-Meier) by stage of disease is 68% for stage B1 (T2) (grade 3 or 4), 78% for stage B2, and 57% for stage C. These survival results appear to be better than those obtained with other approaches of adjuvant therapy and/or surgery in comparable histopathologically staged patients.

Is dose/time fractionation important in treating rectal cancer?

In a study to evaluate the effect of increasing dose per fraction on radiation response in rectal cancer, two groups of 29 patients each, matched for extent and size of disease, were evaluated. Group A was treated with conventional dose/fraction (180-200 cGy) X 5 days/week and Group B was treated with 250 cGy/fraction X 4 days/week. Total dose was reduced by 10% in Group B patients to allow comparison of biologically equivalent doses. Two categories of patients were analyzed in each group: patients receiving planned high dose preoperative radiation (4000-4500 cGy); and patients receiving high dose radiation for post-surgical recurrent tumors or locally advanced inoperable tumors (5500-6000 cGy). Tumor regression was markedly better in patients treated with the 250 cGy/fraction. Overall response (greater than 50% regression) was 35% (10/29) in Group A and 62% (18/29) in Group B. Nine of 10 patients in Group B, treated preoperatively, had greater than 50% regression in tumor size, with two patients having no evidence of disease on surgico-pathological evaluation. Six of 10 similar patients in Group A had greater than 50% tumor regression.

Results of adjuvant radiation therapy in cancer of the rectum. Thomas Jefferson University Hospital experience

From 1972 to 1981, 174 patients with cancer of the rectum surgically staged as B2 or C disease, underwent surgical resection of the tumors for cure. Eighty-eight patients received surgery only with no further adjuvant therapy, and the remaining 86 patients were treated with a combination of radiation and surgery. Twenty-nine patients received low-dose preoperative radiation (500 rad in one fraction); 26 patients received postoperative radiation (4500 rad in 5 weeks); and 31 patients received combined low-dose preoperative radiation (500 rad) and postoperative radiation (4500 rad in 5 weeks). This experience was analyzed to determine the patterns of failure and the impact of adjuvant therapy on survival. Patients undergoing surgery alone had a 26% incidence of local failure in the pelvis and a 57% incidence of distant metastasis. Patients receiving low-dose preoperative radiation had a reduction in the rate of distant metastasis (24%), but no effect on local failure (34%). On the other hand, patients receiving postoperative radiation had a reduction in the local failure rate (11%), with no effect on distant metastasis (50%). Patients who received the combined preoperative and postoperative treatment had a reduction in both the local recurrence rate (7%), and the rate of distant metastasis (13%), and these patients also had a substantial improvement in survival over surgery alone. Survival of patients undergoing surgery alone was 34% at 5 years and was not substantially different for patients undergoing low-dose preoperative irradiation (48%), or for patients receiving postoperative irradiation (29%). Survival in patients receiving combined preoperative and postoperative irradiation was substantially better (78%) than the other groups of patients.

Radiotherapy of stage I and II Hodgkin disease with inguinal presentation

Seventeen patients who presented with inguinal adenopathy were found to have stage I or II infradiaphragmatic Hodgkin disease. Sixteen were treated with an inverted-Y field (supplemented by mantle irradiation in 3) and 1 had irradiation of the involved field only. Two patients with stage IIB disease also received MOPP chemotherapy. Fifteen patients currently have no evidence of recurrence; one died of acute myelogenous leukemia 6 years after total nodal irradiation, while another died of cardiopulmonary disease but had no evidence of Hodgkin disease at autopsy. In one patient, progressive peripheral atherosclerosis developed in an irradiated inguinal area, requiring angioplasty. Patient characteristics and results of treatment are analyzed and implications for management presented.

Patterns of care studies: dose-response observations for local control of adenocarcinoma of the prostate

Five hundred seventy-four patients with prostate cancer treated by external beam radiation therapy in the United States in 1973 to 1975 have been analyzed comparing radiation dose with in-field recurrence. Dose-response effects are observed for all cases (p = less than .05) and T-2 and T-3 tumors, but not for T-0, T-1 and T-4 tumors. For doses calculated at the center of the prostate, these observations suggest optimal control is obtained at no more than 6000 rad for T-0 and T-1 tumors; 6000-6500 rad for T-2 tumors; 6500-7000 rad for T-3 tumors; and that greater than 7000 rad is required only for T-4 tumors. The paraprostatic dose calculated at a point 4 cm lateral to the center of the prostate also shows a correlation of dose with infield failure for all cases (p = .01). Observations in individual T states suggest optimal control is obtained at no more than 6000 rad for T-0, T-1 and T-2 tumors, 6500-6999 rad for T-3 and greater than or equal to 7000 rad for T-4. These data suggest that for T-2 and T-3 cancers, extension in the periprostatic region must be treated. A comparison of central dose vs. stage indicates institutional policy rather than cancer volume determines the radiation dose used in treating prostate cancer. A change in institutional policies to treat with optimal doses as indicated by this study would result in an overall increase in local control and a decrease in complications.

The effect of age on the circadian rhythms of 23 liver or brain enzymes from C57BL/6J mice

Mice were standardized to 12 h of light exposure alternating with 12 h of darkness and were fed ad libitum. The mice in the first group were 8 weeks old and in the other 104-116 weeks old. Subgroups of 7 animals from each age group were killed at 6 circadian stages. Enzyme activities of 23 enzymes from liver or brain were measured by an analysis of variance for each age group. All but 1 enzyme from young mice, and all but 9 from older mice showed significant changes over time (p less than 0.01). The data from the 22 enzymes from young mice and the 14 enzymes from old mice were fit to the cosinor regression model to further characterize the rhythm. 15 enzymes from the young and 8 from the aged mice showed a significant regression to a 24-hour cosine curve (p less than 0.01); of the 8, 7 were the same enzymes in both groups. Amplitude changes, where they could be compared from the cosinor data (7 enzymes), were not statistically different. When total variance was compared, 12 enzymes showed unequal variance. Of these, old mice had the larger variance in 9 enzymes. Another difference between the young and the old was changes in mean enzyme activities. 12 enzymes from aged mice had decreased mesors, 2 had increased mesors, and 9 were unchanged. In general, our data suggest that some enzyme activity rhythms were lost, others were altered and a few were not affected by aging. In the case of many enzymes, older mice have a diminished ability to synchronize to the light signals.

The Patterns of Care Outcome Studies: results of the National practice in carcinoma of the larynx

The Patterns of Care Study conducted a survey of patients with glottic and supraglottic carcinomas treated in 1973 and 1974. Patients for this study were randomly selected from all types of treatment facilities, including those with full and part-time therapists and large and small institutions. Detailed evaluation and treatment parameters were recorded for a total of 707 patients. Overall three-year recurrence free survival for glottic carcinoma was: Stage I, 90%; Stage II, 78%; Stage III, 65%; and Stage IV, 23%. For supraglottic carcinoma the rates are: Stage I 78%, Stage II, 60%, Stage III, 34% and Stage IV, 30%. The use of surgery in this study for advanced lesions varied among different departments. For advanced lesions, those treated with combined radiation and surgery had improved survival; this was also related to completeness of work-up and departmental equipment.

The efficacy of random digit dialing in selecting matched controls for a case-control study of pediatric cancer

A study of random digit dialing as a method of control selection was conducted as part of a matched case-control study of risk factors for neuroblastoma. The study was conducted in 1981-1982 in the Greater Delaware Valley region. Participation involved parents submitting to a 2-4-hour telephone interview. Potential control telephone numbers were selected by substituting the last two digits of the case family's telephone number with randomly selected digits. Successive random telephone numbers were called until a family with a child matching the case by year of birth plus or minus three years and race who agreed to participate was identified. A total of 3,245 telephone numbers were dialed to select controls for 101 cases, an average of 32.1 telephone numbers per case. Among 1,908 residential households contacted, 25.5% refused to give information about household characteristics. Of households with known characteristics, 45% had children under 25 years of age and 14.9% had a child eligible for the study. Among 181 households invited to participate, 101 agreed. For 18.6% of all calls, residential respondents were randomly offered $10 as an inducement to participate. This inducement did not significantly influence participation rates among families invited to participate.

In vitro reconstitution of nitrate reductase activity of the Neurospora crassa mutant nit-1: specific incorporation of molybdopterin

The reduced, metal-free pterin of the molybdenum cofactor has been termed molybdopterin. Oxidation of any molybdopterin-containing protein in the presence or absence of iodine yields oxidized molybdopterin derivatives termed Form A and Form B, respectively. Application of these procedures to whole cells and cell extracts has demonstrated the presence of molybdopterin in wild-type Neurospora crassa, and its absence in the cofactor-deficient mutant nit-1. In order to demonstrate that the reconstitution of nitrate reductase activity in nit-1 extracts results from the incorporation of molybdopterin into the apoprotein, active molybdopterin, free of contaminating amino acids or peptides, was isolated from chicken liver sulfite oxidase and used in the reconstitution system. The results show that, during reconstitution, exogenous molybdopterin is specifically incorporated into the nitrate reductase protein, confirming the role of molybdopterin as the organic moiety of the molybdenum cofactor.

Symbolic Notation and Kinematic Equations of Motion of the Twenty-Two Basic Spur Planetary Gear Trains

This paper introduces a symbolic notation for describing two degree-of-freedom spur planetary gear trains with the configuration of two central gears, one carrier or arm, and at least one planet gear. This simple notation is then used to write the kinematic equation of motion for this type of planetary gear train without the need to develop any intermediate equations. It is also shown that, there are exactly 22 basic spur planetary gear trains with this configuration and not 34 as Levai [1] previously found. These 22 planetary gear trains are illustrated along with their symbolic notation and kinematic equation of motion.

Influence of place of treatment on diagnosis, treatment, and survival in three pediatric solid tumors

This study examines differences between cancer centers (CC) and noncancer centers (NCC) in terms of management procedures and outcomes for three pediatric solid tumors: Wilms' tumor (N = 147), rhabdomyosarcoma (N = 87), and medulloblastoma (N = 76). Data were derived for the period 1970-1979 from the population-based Greater Delaware Valley Pediatric Tumor Registry maintained at the Children's Cancer Research Center, which routinely collects data on all childhood neoplasms that occur in a 31-county region. Management measures reviewed included the degree to which important pretreatment evaluations were performed, types of therapy used, and extent of follow-up examinations conducted. Outcome variables were three-year disease-free survival and frequency of deaths related to complications of therapy. Differences in three-year disease-free survival between CC and NCC were noted for medulloblastoma (52% v 24%) and rhabdomyosarcoma (48% v 10%), but not for Wilms' tumor (79% v 68%). Among medulloblastoma patients, differences were detected in the frequency of pretreatment evaluations and in the therapy used. The principal management contrast found in rhabdomyosarcoma was that multiagent chemotherapy was used less often in NCC. Wilms' tumor patients were evaluated and treated similarly in the community versus the CC, except for some contrasts in the surgical approach and the frequency of follow-up for the detection of late complications.

Adjuvant radiation therapy for rectal cancer

Since 1976, 104 patients with rectal cancer have been treated with a new approach of combined pre- and postoperative radiation. All patients were given 500 rad preoperative irradiation on the day of or the day before surgery. Surgery in the majority of patients was an abdominal perineal resection. The disease was then staged pathologically according to Astler-Coller's modification of Duke's staging. Patients with early stage cancer (Stages A and B1) were followed with no further therapy. Patients with poor prognostic characteristics (Stages B2, C1, C2) were given postoperative pelvic irradiation (4500 rad in 5 weeks). Twenty-nine patients were found to have Stage A or B1 cancer and were followed with no further therapy. Of these 29 patients, 1 patient developed recurrence and one has died of metastatic disease. The excellent survival of patients with early tumors indicates that minimizing the role of adjuvant therapy in this group has not been detrimental to their survival. Fifteen were found to have liver metastases at laparotomy and had just a colostomy and palliative therapy. Sixty patients had Stage B2 and C disease. Thirty-one received postoperative irradiation as per protocol. Twenty-nine patients did not receive postoperative irradiation for a variety of reasons. Follow-up ranges from 1 to 7 years in these patients. Of the 29 patients with Stage B2 and C disease who should have but did not receive postoperative radiation, 10 patients (34%) have developed a recurrence in the pelvis, and 5 other patients (17%) have developed metastatic disease. Of 31 patients who received postoperative irradiation, only 2 patients (6%) developed a local recurrence and 4 patients (13%) have developed distant metastases. Survival at 3 years was 80% for patients receiving the combined treatment, as compared to 42% for those not receiving the postoperative part of the treatment protocol.

Quality assurance in radiation therapy: clinical and physical aspects. Consensus of best current management: the starting point for clinical quality assessment

Consensus of best current management developed by a rational and deliberative process can provide the basis for clinical quality assessment. Unfortunately, it is not always possible to arrive at a consensus at all cancer sites, and this generally indicates areas where clinical research is needed. Assessing the quality of care in these situations presents special problems. When it is possible to arrive at consensus in a specific disease, this consensus should detail appropriate pretreatment evaluation and the details of the treatment. Committees of experts for each specific disease site can formulate the consensus and must document their decisions based on information from the current world literature. A carefully thought out and documented consensus can then provide the basis for the development of process based questionnaires in assessing quality. We have observed that individuals formulating consensus of best current management do not strictly follow their own criteria, and that compliance in various strata of practice throughout the United States shows a greater deviation from consensus than anticipated and indeed this deviation crosses all types of practice. It was then necessary to conduct outcome surveys in the same patients to validate the processes of care by showing a correlation of process performance with outcome or indeed to change our concepts of best current management. We recognize from these outcome studies that relatively few processes have direct association with outcome and the majority of our consensus points relate to either good general patient management or items important to individual patients but not to large groups of patients. In addition to validating processes through outcome correlations, we have found that process verification is important. We have observed quite different outcomes for two groups of patients with Hodgkin's disease treated with the same processes (i.e., mantle field technology and adequate radiation dose, etc.). We were unable to identify the reason for an increased failure rate in one group of these patients until we looked at each individual mantle port film from the two groups of patients. We then identified that one facility was not including the Hodgkin's disease in the treatment portal due to poor technical performance. We believe that this program of process verification may be important in evaluating quality for any disease site. Data will be presented that illustrates the above problems.

An on-line interactive interviewing program for epidemiological studies

An on-line interactive verification and entry system (OLIVES) has been developed for conducting telephone interviews in large-scale epidemiological studies. Responses are automatically coded into a computer legible form suitable for analysis. Use of a question stack to control question flow allows on-line response modification, restart from any termination point, and minimal reprogramming in order to change question order. Numerical, coded, and text string data types are permitted. A multilevel hierarchical data structure reflects interview content. The advantages and disadvantages of the on-line approach are discussed. OLIVES is generalizable and is applicable to other on-line or off-line interview situations.

Patterns of care outcome studies: results of the national practice in adenocarcinoma of the prostate

The Patterns of Care Study reviewed the processes and outcome of 682 patients with carcinoma of the prostate treated with radiation therapy from 1973-1976. The study and patient sampling were designed to reflect a valid representation of how prostate cancer is treated by radiation oncologists in the United States. The outcome results represent national benchmarks. The three year actuarial survival was 91% for Stage A, 88% for Stage B, and 76% for Stage C. The three year relapse free survival rate was 85% for Stage A, 77% for Stage B, and 59% for Stage C. The infield recurrence rates were: Stage A--4%, Stage B--9%, and Stage C--20%. Stage, grade, elevated serum acid phosphatase, Karnofsky performance status, previous hormonal therapy, age, and prior transurethral resection were identified by multivariate regression analysis to be important independent prognostic variables. Local control was related to the dose of the primary site, paraprostatic region, and pelvic sidewall. Local control was significantly improved if the facility's best treatment equipment was a linear accelerator. Major complications occurred in 9% of patients with Stage A, 2% of Stage B, and 6% with Stage C disease. Complications were related to dose and treatment technique. The Patterns of Care Process Survey identified that only 60% of patients surveyed had the necessary pretreatment evaluation studies required for best current management of adenocarcinoma of the prostate. Variance occurred within each stratum of facilities sampled. Strict attention to the details of evaluation of therapy will help to enhance the delivery of optimal radiation therapy in the management of patients with carcinoma of the prostate.

"Masked" Ph1 chromosome abnormalities in CML: a report of two unique cases

Two patients with chronic myeloid leukemia (CML) showed previously undescribed variants of a "masked" Ph1 abnormality. The first patient had the karyotype 46,XY, + 21, -9, -22, +mar9,mar18 at presentation in the chronic phase. The dicentric marker 9 was interpreted as representing the usual translocation of 22q11 to 9q34, followed by translocation of the Ph1 chromosome (the deleted 22) to 9p and probable translocation of 9p to the distal long arm of the marker. The patient developed clones containing 2 and 3 copies of the "Ph1-containing" marker 9 concomitant with the metamorphosis of his disease to a more aggressive phase. The second case presented with the karyotype 46,XY,-9,-22,+two D-group markers. A complex rearrangement of chromosomes 9 and 22 is postulated, with interstitial insertion of either 9p or distal 9q into chromosome 22q11. This patient is still in the chronic phase of his disease 9 mo after presentation. The common denominator in these unusual "masked" cases is the 22q11 breakpoint. The paucity of published reports of duplication of 9q + without concurrent duplication of the Ph1 chromosome, supported by the findings in our first case, leads us to conclude that the amplification of genes on the Ph1 chromosome are more important for the evolution of the abnormal stem cell in CML than the chromosome 9 derivative.

Racial variation in incidence of Wilms' tumor: relationship to congenital anomalies

This is a study of the occurrence of Wilms' tumor and associated anomalies in all incident cases in the Greater Delaware Valley by race. The average annual incidence of Wilms' tumor in this population of 2 million children is significantly higher among nonwhites than whites. A significantly larger proportion of black cases has a Wilms' tumor-associated condition including aniridia, genito-urinary anomalies, the Beckwith-Wiedemann Syndrome, and hemihypertrophy. For very young patients, there was a greater tendency for blacks to have bilateral tumors or a tumor-associated anomaly, features characteristic of the hereditary form of Wilms' tumor. The excess risk of Wilms' tumor among blacks may be a result of a higher proportion having a hereditary predisposition or more common exposure to agents capable of inducing germinal mutations.

Patterns of care study: Hodgkin's disease relapse rates and adequacy of portals

The Patterns of Care Study (PCS) has noted differences in stage adjusted relative relapse rates for Hodgkin's disease in four large facilities; the rates vary from 0% to 11% for infield or marginal recurrence (P = 0.003), and from 10% to 39% for any relapse (P = 0.0006) among these facilities. These differences in outcome were not attributable to variation in patient workup, treatment method, or radiation dose. A resurvey of 181 of these records of patients treated with radiation therapy for cure, in which portal films were available for review, indicates that treatment portal films did not encompass the disease adequately in 66 patients. When this occurred, there was a 50% overall relapse rate with 32% recurrence either infield or marginal. Chemotherapy tended to obscure the effect of inadequate technology, and when the 26 patients receiving chemotherapy as part of their initial treatment were excluded, inadequate margins were followed by even higher rates of relapse. For the subgroup of patients treated with radiation therapy alone, inadequate margins were associated with a 54% overall relapse rate, of which 33% were infield or marginal recurrence. When the portal films for patients treated with radiation therapy only were judged to be adequate, the total rate of any relapse was 14%, with 7% infield or marginal recurrence. PCS data indicate there is a critical need for accurate inclusion of Hodgkin's disease in the treatment portals; that marked facility differences exist in this technical process; and that skilled independent observers can reliably identify inaccurate technical performance.