Factors affecting baseline quality of life in two international adjuvant breast cancer trials. International Breast Cancer Study Group (IBCSG)

Quality of life (QL) is used to assess treatments in clinical trials but may be influenced by other factors. We analysed the impact of biomedical, sociodemographic and cultural factors on baseline QL indicators in two International Breast Cancer Study Group trials. Patients with stage II breast cancer were randomized within 6 weeks of primary surgery to various adjuvant treatments. They were asked to assess five indicators of QL at baseline. QL forms were available for 1231 (83%) of the 1475 premenopausal and 989 (82%) of the 1212 post-menopausal patients, who were from nine countries and spoke seven languages. Culture (defined as language/country groups) had a statistically significant impact on baseline QL measures. Premenopausal patients with poor prognostic factors showed a tendency to report worse QL, with oestrogen receptor status as an independent predictor for mood (P = 0.0005). Older post-menopausal patients reported better emotional wellbeing (P = 0.002), mood (P = 0.002), and less effort to cope (P = 0.0009) compared with younger post-menopausal patients. Co-morbidity, type of surgery, treatment assignment and sociodemographic factors showed a statistically significant impact in post-menopausal patients only. Cultural and biomedical factors influenced baseline QL and should be considered when evaluating the impact of treatment on QL in international breast cancer clinical trials.

EMS1 gene expression in primary breast cancer: relationship to cyclin D1 and oestrogen receptor expression and patient survival

The EMS1 and CCND1 genes at chromosome 11q13 are amplified in about 15% of primary breast cancers but appear to confer different phenotypes in ER positive and ER negative tumours. Since there are no published data on EMS1 expression in large series of breast cancers we examined the relationship of EMS1 expression with EMS1 gene copy number and expression of mRNAs for cyclin D1 and ER. In a subset of 129 patients, where matched tumour RNA and DNA was available, EMS1 mRNA overexpression was associated predominantly with gene amplification (P = 0.0061), whereas cyclin D1 mRNA overexpression was not (P = 0.3142). In a more extensive series of 351 breast cancers, there was no correlation between cyclin D1 and EMS1 expression in the EMS1 and cyclin D1 overexpressors (P = 0.3503). Although an association between EMS1 mRNA expression and ER positivity was evident (P = 0.0232), when the samples were divided into quartiles of EMS1 or cyclin D1 mRNA expression, the increase in the proportion of ER positive tumours in the ascending EMS1 mRNA quartiles was not statistically significant (P = 0.0951). In marked contrast there was a significant stepwise increase in ER positivity in ascending quartiles of cyclin D1 mRNA (P = 0.030). A potential explanation for this difference was provided by the observation that in ER positive breast cancer cells oestradiol treatment resulted in increased cyclin D1 gene expression but was without effect on EMS1. The relationship between EMS1 expression and clinical outcome was examined in a subset of 234 patients with median follow-up of 74 months. High EMS1 expression was associated with age > 50 years (P = 0.0001), postmenopausal status (P = 0.0008), lymph node negativity (P = 0.019) and an apparent trend for worse prognosis in the ER negative subgroup. These data demonstrate that overexpression of EMS1 mRNA is largely due to EMS1 gene amplification, is independent of cyclin D1 and ER expression and, in contrast to cyclin D1, is not regulated by oestrogen. Independent overexpression of these genes may confer different phenotypes and disease outcomes in breast cancer as has been inferred from recent studies of EMS1 and CCND1 gene amplification.

Is day care equivalent to inpatient care for active rheumatoid arthritis? Randomised controlled clinical and economic evaluation

OBJECTIVE

To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis.

DESIGN

Randomised controlled clinical trial with integrated cost minimisation economic evaluation.

SETTING

Rheumatic diseases unit at a teaching hospital between 1994 and 1996.

SUBJECTS

118 consecutive patients with active rheumatoid arthritis randomised to receive either day care or inpatient care.

MAIN OUTCOME MEASURES

Clinical assessments recorded on admission, discharge, and follow up at 12 months comprised: the health assessment questionnaire, Ritchie articular index, erythrocyte sedimentation rate, hospital anxiety and depression scale, and Steinbrocker functional class. Resource estimates were of the direct and indirect costs relating to treatment for rheumatoid arthritis. Secondary outcome measures (health utility) were ascertained by time trade off and with the quality of well being scale.

RESULTS

Both groups had improvement in scores on the health assessment questionnaire and Ritchie index and erythrocyte sedimentation rate after hospital treatment (P < 0.0001) but clinical outcome did not differ significantly between the groups either at discharge or follow up. The mean hospital cost per patient for day care, 798 Pounds (95% confidence interval 705 Pounds to 888 Pounds), was lower than for inpatient care, 1253 Pounds (1155 Pounds to 1370 Pounds), but this difference was offset by higher community, travel, and readmission costs. The difference in total cost per patient between day care and inpatient care was small (1789 Pounds (1539 Pounds to 2027 Pounds) v 2021 Pounds (1834 Pounds to 2230 Pounds)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (374 Pounds; 639 Pounds to 109 Pounds).

CONCLUSIONS

Day care and inpatient care for patients with uncomplicated active rheumatoid arthritis have equivalent clinical outcome with a small difference in overall resource cost in favour of day care. The choice of management strategy may depend increasingly on convenience, satisfaction, or more comprehensive health measures reflecting the preferences of patients, providers, and service commissioners.

Resource use and costs of elective surgery for asymptomatic abdominal aortic aneurysm

OBJECTIVES

To determine the hospital costs of elective abdominal aortic aneurysm repair.

DESIGN

Observational study of resource use.

MATERIALS

Forty-six elective aneurysm surgery patients in a hospital; 116 vascular surgeons participating in the U.K. Small Aneurysm Trial.

METHODS

Data on resource use and associated costs were obtained in 1993 for 46 patients who had undergone elective surgery in a teaching hospital. Comparability of resource use with other hospitals in the U.K. was obtained from data on surgical patients in the U.K. Small Aneurysm Trial, and by questionnaire on use of resources sent to surgeons participating in the trial.

RESULTS

The total cost of an elective aneurysm repair calculated from patient data in the teaching hospital was Pounds 4592. One-third of costs were due to stay in a standard surgical ward, and 20% were attributable to the operation. Overall, the use of resources in U.K. hospitals was comparable to that for the teaching hospital. Based on the surgeons' estimates, however, considerable variation existed for typical elective aneurysm patients, with costs ranging from Pounds 2173 to Pounds 7024.

CONCLUSIONS

In the U.K. the average cost of an elective aneurysm repair in 1993 was around Pounds 4600, which was equivalent to around Pounds 5000 (US$8000) in 1996. This estimate is sufficiently reliable to be used in cost effectiveness analyses.

Service provision for people with schizophrenia. I. Clinical and economic perspective

BACKGROUND

The aim of this study was to provide information on patients current service use which could inform future decisions on service planning and resource allocation.

METHOD

Individuals with a diagnosis of schizophrenia, who had received in-patient care in the previous five years, were identified from the Lothian Case Register. Information was obtained from 193 subjects. Patients' service use over a six-month period was examined. The costs incurred in service provision were determined.

RESULTS

Patients differed markedly in their use of services. This was not found to be related to their mental state. Average care costs were high. In-patient care accounted for most of the overall expenditure.

CONCLUSIONS

There is considerable variation in the services used by patients with schizophrenia and in the costs incurred in service provision. When planning services it is therefore important that detailed information on the patient population is available if resources are to be allocated cost-effectively.

The control of breast cancer: the role of tamoxifen

The worldwide burden of breast cancer, already substantial, is increasing in both developed and developing countries. By the year 2000, there will be close to one million new diagnoses and over 400,000 deaths per year. Control measures must be directed toward primary prevention, early diagnosis, and effective therapy. Tamoxifen is an effective treatment for early and advanced disease, it has few side effects, it has a low cost, and it is easy to administer. In early breast cancer tamoxifen produces a 25% reduction in relapse rates and a 17% reduction in mortality rates. This benefit is greater for women with estrogen receptor-positive tumors and with therapy duration longer than 2 years. It is also effective in premenopausal and postmenopausal women, including those over 70 years of age. It reduces the risk of new contralateral cancers, and it is being evaluated as a preventative agent in women at high risk for breast cancer. Tamoxifen has a particularly valuable role in developing countries in which the incidence of breast cancer is increasing as the average age of the population increases and in which control is substantially more difficult with mass mammography screening.

The incidence of breast cancer: the global burden, public health considerations

The incidence of breast cancer continues to increase and will reach close to one million new patients annually by the year 2000. The highest age-specific rates occur in developed regions, but more than 50% of cases occur in developing regions. Effective control requires prevention, early diagnosis, and access to effective treatments. Tamoxifen is an important treatment agent and may have a preventative role. Tamoxifen reduces relapse by approximately 25% and deaths by approximately 17%. Tamoxifen has an important role in reducing local recurrence, in reducing the risk of new contralateral breast cancer, and in the treatment of patients with advanced disease. Current trends are largely due to earlier diagnosis, mammographic screening in developed countries, a decrease in deaths in both the United States and the United Kingdom, and an increasing proportion of deaths in developing countries. The total direct medical costs of breast cancer is more than $7 billion per year worldwide. New cost-effective control strategies are required worldwide.

Impact of adjuvant therapy on quality of life in women with node-positive operable breast cancer. International Breast Cancer Study Group

BACKGROUND

Adjuvant therapy for early breast cancer is effective but may be toxic. Our aim was to investigate the impact of the presence, timing, and duration of adjuvant chemotherapy on patients' perceptions of their quality of life (QL).

METHODS

International Breast Cancer Study Group trial VI assessed adjuvant chemotherapy in 1475 premenopausal and perimenopausal patients, and trial VII assessed adjuvant tamoxifen or chemoendocrine therapy in 1212 postmenopausal patients with node-positive breast cancer. Patients were asked to complete a QL questionnaire-single-item linear analogue self-assessment scales measured physical wellbeing, mood, appetite, and perceived adjustment/coping. QL was assessed in this way at the beginning of treatment, 2 months after the start of treatment, every 3 months, and at 1 and 6 months after recurrence.

FINDINGS

Baseline QL scores decreased as the number of involved axillary nodes increased (for example, mean mood score: 66.1 for women with one positive node, 66.4 for two to four positive nodes, 61.3 for five to nine positive nodes, and 59.1 for ten or more positive nodes; p = 0.008 for trends), and were lower in patients with oestrogen-receptor-negative than in patients with oestrogen-receptor-positive tumours (61.4 vs 66.3, p = 0.0009). All treatment groups showed substantial improvement in QL scores during adjuvant therapy. Patterns of QL scores reflected presence, duration, and timing of cytotoxic treatment. Longer initial cytotoxic therapy delayed improvement in QL scores. Later cytotoxic therapy had transient adverse effects. Anticipation of future therapy also affected QL scores.

INTERPRETATION

Overall, chemotherapy had a measurable adverse effect on QL, but this effect was transient and minor compared with patients' adaptation/coping after diagnosis and surgery. This finding should encourage patients and doctors to choose appropriate adjuvant therapy with less concern for initial toxicity.

The effect of adjuvant prednisone combined with CMF on patterns of relapse and occurrence of second malignancies in patients with breast cancer. International (Ludwig) Breast Cancer Study Group

BACKGROUND

The addition of low-dose prednisone (p) to the adjuvant regimen of cyclophosphamide, methotrexate, 5-fluorouracil (CMF) allowed patients to receive a larger dose of cytotoxics when compared with those on CMF alone. However, disease-free survival and overall survival were similar for the two groups. To test the hypothesis that low-dose prednisone might influence the efficacy of the cytotoxic regimen used, the toxicity profiles of the two treatment regimens and the patterns of treatment failure (relapse, second malignancy, or death) were examined.

PATIENTS AND METHODS

491 premenopausal and perimenopausal patients with one to three positive axillary lymph nodes included in International (Ludwig) Breast Cancer Study Group (IBCSG) trial I from 1978 to 1981 and randomized to receive CMF or CMFp were analyzed for differences in long-term outcome and toxic events. The 250 patients assigned to CMF and prednisone received on the average 12% more cytotoxic drugs than those who received CMF alone.

RESULTS

The 13-year DFS for the CMFp group was 49% as compared to 52% for CMF alone, and the respective OS percents were 59% and 65%. Several toxic effects such as leukopenia, alopecia, mucositis and induced amenorrhea were reported at a similar incidence in the two treatment groups. Using cumulative incidence methodology for competing risks, we detected a statistically significant increase in first relapse in the skeleton for the CMFp group at 13 years follow-up with a relative risk (RR) of 2.06 [95% confidence interval (CI), 1.23 to 3.46; P = 0.004]. Patients with larger tumors in the CMFp regimen were especially subject to this increase with a RR for failure in the skeleton of 3.32 (95% CI, 1.57 to 7.02; P = 0.0005). CMFp-treated patients also had a larger proportion of second malignancies (not breast cancer), with RR of 3.34 (95% CI, 0.91 to 12.31; P = 0.09).

CONCLUSIONS

Low-dose continuous prednisone added to adjuvant CMF chemotherapy enabled the use of higher doses of cytotoxics. This increased dose had no beneficial effect on treatment outcome, but was associated with an increased risk for bone relapses and a small, not statistically significant increased incidence of second malignancies. The effects of steroids, which are widely used as antiemetics (oral or pulse injection) together with cytotoxics, should be investigated to identify their influence upon treatment outcome.

Laparoscopic exploration of intra- and extrahepatic bile ducts and T-tube drainage

Laparoscopic cholecystectomy (LC) has rapidly become the procedure of choice for the management of patients with gall-bladder stones. This contrasts with patients who have common bile duct and intrahepatic duct stones who still usually need an open operation. On the basis of experience of a number of LC by one surgeon and animal experiments, we have completed laparoscopic exploration of both intra- and extrahepatic ducts and T-tube drainage of 57 patients with intra- and extrahepatic bile duct calculi over 13 months during 1992-1993 with satisfactory results. The average operating time was 150 min, with a range of 100 to 220 min. Most patients were mobile and on oral fluids within 24 h postoperative. Average hospital stay was 4 days. Retained stones were found via T-tube cholangiography in four patients (7%) and for each patient these were removed by fibre-optic choledochoscope 2 weeks postoperatively. Laparoscopic exploration of intra- and extrahepatic bile ducts is achievable by experienced surgeons and may be particularly helpful for patients who are not a good operative risk.

A randomised study to compare the effect of the luteinising hormone releasing hormone (LHRH) analogue goserelin with or without tamoxifen in pre- and perimenopausal patients with advanced breast cancer

The use of goserelin with or without tamoxifen was investigated in a randomised multicentre study involving 318 pre- and perimenopausal advanced breast cancer patients. With a median follow-up of 93 weeks, 31% of goserelin-treated patients had objective responses (UICC criteria) compared with 38% of goserelin plus tamoxifen-treated patients (P = 0.24). There was a modest benefit in favour of combination therapy in time to progression (P = 0.03) but not in survival (P = 0.25). Median follow-up for survival was 117.5 weeks. Median times for disease progression and survival were 23 and 127 weeks in the goserelin alone group and 28 and 140 weeks in the combination group, respectively. In 115 patients with skeletal metastases only, significant differences in favour of combination therapy were seen in response rate, time to progression and survival. Both treatments were well tolerated and no additional safety issues were associated with combination therapy.

Surgery of early breast cancer

Randomized clinical trials evaluating local treatments for early breast cancer have provided new data on the long-term morbidity and cause-specific mortality associated with radiotherapy combined with different types of mastectomy. The difficulty surgeons have in determining optimal integration of surgery and radiotherapy for breast preservation is demonstrated by the wide variation of radiotherapy schedules, lack of interpretable data to justify a radiotherapy "boost," and data from a randomized trial suggesting that radiotherapy applied only to the excision site might be sufficient. The use of cytology aspirates for tumor grading, the prognostic importance of vascular invasion, and new tumor markers and cancer cells in bone marrow at diagnosis are all reported. New data came from attempts to identify an axillary sentinel node at surgery for breast cancer. Studies of connective tissue disorders in women with silicone implants failed to find evidence of increased risk, but 3-year follow-ups confirmed that surgeons who preferred mastectomy are more likely to have anxious, depressed patients.

Towards an optimal teaching programme for supportive care

The changes occurring in medical education have led to important principles being identified that are relevant to teaching in supportive care. Many of these principles are already an integral part of the Newcastle, NSW, Medical Faculty undergraduate course and are being applied to the teaching of oncology and supportive care. The same principles can be applied to curriculum development and implementation in other settings. A curriculum is proposed that builds on a general background of oncology knowledge. Factual knowledge is limited to the precarious clinical problems requiring optimal supportive care, the priority oncology syndromes, palliative care and principles of psychosocial and behavioural science interventions. The curriculum also includes critical reasoning, special skills including counselling, communication, self-directed learning, team management, health-service resources and structure, and relevant management skills. To implement the curriculum, consideration must be given to teaching methods (teaching in context and in small groups, problem-based learning and problem solving). The needs of students, quality of the teachers, when and where the teaching and learning will occur and methods of assessment should also be considered to ensure the curriculum can be used optimally.

Surgery of early breast cancer

Randomized trials of treatment have evaluated the role of radiotherapy after breast-preserving surgery for both in situ and invasive cancer. These trials provide treatment guidelines and identified "show biz" questions relating to both therapy and biology. A trial of systemic treatment of premenopausal women with node-positive disease provided compelling reasons to always determine estrogen receptor status before determining adjuvant systemic treatment. Additional data on pathology, needle biopsy, and surgical techniques provide important information for surgeons. New data on breast cancer biology in young women and data suggesting that mastectomy rates are still higher than necessary provide issues on which surgeons can reflect. Evidence that supports marrow biopsy for staging at the time of surgery is important for surgeons. Psychosocial data are partly reassuring in that mastectomy patients, if they choose the procedure themselves, may not be worse off. Finally, a sobering report of the devastating effects of late diagnosis came from Nigeria.

Prognostic value of quality-of-life scores during chemotherapy for advanced breast cancer. Australian New Zealand Breast Cancer Trials Group

PURPOSE

We observed that quality-of-life (QL) scores, collected to evaluate treatment in a randomized trial in advanced breast cancer, predicted survival duration. This report explores the prognostic associations between QL and survival in more detail.

PATIENTS AND METHODS

In a randomized clinical trial comparing intermittent and continuous therapy policies for patients with advanced breast cancer, QL was measured by linear analog self-assessment (LASA) and the Quality-of-Life Index (QLI). Baseline scores and subsequent changes were included in statistical models of survival duration, with and without other prognostic factors.

RESULTS

Physician assessment of QLI and patient LASA scores for physical well-being (PWB), mood, nausea and vomiting, appetite, and overall QL (but not pain) at the commencement of treatment were significant predictors of subsequent survival. Scores for PWB and QLI were independent of other prognostic factors. Changes in scores were also prognostically important. Both baseline and change in scores for PWB, mood, pain, and QLI after the first three treatment cycles, but before an arbitrary 180-day time point, were significantly predictive of survival beyond that time. Both QLI and PWB were prognostically independent of tumor response. Although QL improvement was correlated with tumor response, continuous therapy yielded significantly better QL scores, even in nonresponders.

CONCLUSION

These findings support the validity of the simple QL measures used in the trial. They are compatible with the simple explanation that patients perceive disease progression before it is clinically evident, but also with a causal relationship between QL and survival duration.

The cosleeping habits of military children

Cosleeping is a topic frequently of concern to parents; however, little objective evidence exists to support the historical prohibition against children sleeping in the same bed with their parents. Surveys from the parents of 86 children in the clinics of pediatrics and child psychiatry were analyzed to describe patterns of cosleeping in a group of military dependents aged 2 to 13 years. Shown is a significant increase in cosleeping with father absence and that cosleeping is less frequent in the psychiatric subpopulation.

Promotion of attendance for mammographic screening through general practice: a randomised trial of two strategies

OBJECTIVE

To compare the effectiveness of two strategies--patient education and practitioner recommendation--in encouraging women to attend for mammographic screening.

DESIGN

The study was a prospective randomised controlled trial. Women aged between 40 and 70 years attending a general practitioner participated in the study. Consenting, eligible women were randomly allocated to one of the two strategy groups.

SETTING

The study was conducted in private general practice in Newcastle, New South Wales.

PARTICIPANTS

The general practitioners who took part in the study were a non-random sample of practitioners: 20 were approached, two declined to participate, and five failed to begin recruitment, leaving 13 practitioners who took part in the study. A total of 302 women aged 40-69 were recorded as attending the surgeries during recruitment sessions. Twenty women did not consent to the study and 73 were ineligible. Thirty-four women were not given the intervention because the general practitioner forgot or did not have time. There were 92 women in the simple recommendation group and 83 women in the patient education group.

INTERVENTIONS

An intensive patient education approach based on health belief principles was compared with a simple recommendation by the general practitioner that the woman have a mammogram.

MAIN OUTCOME MEASURE

Attendance rates were calculated from screening service attendance records.

RESULTS

No significant difference in attendance rates was observed between the two groups, 82% of the simple recommendation group and 91% of the patient education group attended for screening.

CONCLUSIONS

These results suggest that mammographic screening can be effectively promoted in general practice without extensive patient education.

Long-term effects of adjuvant chemotherapy in breast cancer

Late effects of adjuvant chemotherapy (ACT) may include second malignant neoplasms (SMN), cardiotoxicity and ovarian suppression. Effects on the biology of residual tumour may be important in protocol design. Studies of SMN need large and reliable data sets. The leukaemia risk with current ACT is likely to be less than a five-fold increase. Leukaemia is predominantly a result of alkylating agents and peaks before 10 years. Solid SMN result also from radiotherapy and this risk continues after 10 years. Cardiotoxicity can be caused by anthracyclines but should not be a problem with current ACT regimens. It can be reduced by careful monitoring and by the cardioprotector ICRF-187. Amenorrhoea is a crude marker of ovarian suppression which may explain conflicting data on its relationship to outcome after ACT. Ovarian suppression following ACT is more likely and more permanent in older premenopausal women, but only explains a part of the ACT effects on outcome. Effects of early ACT on residual tumour are important for planning retreatments and combined modality protocols.

Surgery for early breast cancer

Optimal surgery for breast cancer demands effectiveness in local disease control, minimal physical and psychosocial morbidity, and efficient use of resources for assessment, diagnosis, treatment, and follow-up. These issues are addressed below with particular emphasis on the biologic relevance of tumor recurrence for planning local treatment, the management of subclinical radiographic abnormalities, the degree of importance of the timing of surgery in the menstrual cycle, and the value of axillary dissection.