The impact of nausea and vomiting upon quality of life measures

The measurement of quality of life in cancer patients has achieved prominence in recent years. This results from recognition of the limitations of available therapies and a clearer view of the goals of treatment in patients whose diseases may not be curable. Many different approaches to the measurement of quality of life have been proposed and these will be reviewed. In a recent survey of available methods, the Medical Research Council's Working Party on Quality of Life Measurement systematically analysed available instruments for measuring quality of life specifically in cancer patients and commented on a number of instruments of general purpose that may be used in oncology. It was concluded that no instrument is entirely satisfactory for all purposes and that available instruments have to be selected carefully for a particular study or a particular aspect of clinical practice. However, among the existing instruments, the Rotterdam Symptom Checklist for a general assessment of many facets of quality of life and the Hospital Anxiety and Depression Scale, for detecting psychosocial morbidity quickly and easily, were useful. In our own studies we have used a multiple linear analogue scale system to measure aspects of quality of life in breast cancer patients and have recently addressed the determinants of overall quality of life. Our studies identify the importance of evaluating the psychometric properties of measurement instruments in quality of life. Reliability and validity and the ability to discriminate changes with time and between clinically distinct groups have to be carefully assessed.(ABSTRACT TRUNCATED AT 250 WORDS)

A method for assessing the quality of life of cancer patients: replication of the factor structure

The psychometric properties of a method of measuring the quality of life of cancer patients based on multiple linear analogue scales have been assessed in a group of 294 patients with breast cancer attending one clinical unit. The method was found to be readily managed by patients although a small number of scales presented difficulties of understanding to patients and difficulties of analysis. The scales distinguished readily between patients of different disease and treatment status. Factor analysis revealed a 5 factor structure which we interpret as relating to physical activities of everyday living, emotional disturbance, alimentary disturbances, appearance and cosmetic problems and a fifth factor which is more difficult to interpret and includes impairment of speech, writing and concentration. We feel the essential factors determining quality of life in cancer patients have been demonstrated in this and our earlier studies and there is now a substantial level of agreement in the factors that have been identified by groups taking quite different approaches. The major factors determining quality of life in cancer patients are now known and should be assessed in clinical research and clinical trials. The method by which they should be assessed is not as yet so clear.

Risk of second brain tumour after conservative surgery and radiotherapy for pituitary adenoma

OBJECTIVE

To assess the risk of second brain tumour in patients with pituitary adenoma treated with conservative surgery and external beam radiotherapy.

DESIGN

Long term follow up of a cohort of patients with pituitary adenoma and comparison of tumour occurrence with population incidence rates.

SETTING

The Royal Marsden Hospital.

SUBJECTS

334 patients with pituitary adenoma treated with conservative surgery and radiotherapy (median dose 45 Gy) and followed up for 3760 person years.

MAIN OUTCOME MEASURES

Second intracranial tumour and systemic malignancy.

RESULTS

Five patients developed a second brain tumour: two had astrocytoma, two meningioma, and one meningeal sarcoma. The cumulative risk of developing a second brain tumour over the first 10 years after treatment was 1.3% (95% confidence interval 0.4% to 3.9%) and over 20 years 1.9% (0.7% to 5.0%). The relative risk of a second brain tumour compared with the incidence in the normal population was 9.38 (3.05 to 21.89). There was no excess risk of any other type of second primary malignancy.

CONCLUSIONS

There is an increased risk of second intracranial tumour in patients with pituitary adenoma treated with surgery and radiotherapy. Although radiation is likely to be the most important factor contributing to the excess risk, further study is required in a cohort of similar patients not receiving radiation.

Adjuvant psychological therapy for patients with cancer: a prospective randomised trial

OBJECTIVE

To determine the effect of adjuvant psychological therapy on the quality of life of patients with cancer.

DESIGN

Prospective randomised controlled trial comparing the quality of life of patients receiving psychological therapy with that of patients receiving no therapy, measured before therapy, at eight weeks, and at four months of follow up.

SETTING

CRC Psychological Medicine Group of Royal Marsden Hospital.

PATIENTS

174 patients aged 18-74 attending hospital with a confirmed diagnosis of malignant disease, a life expectancy of at least 12 months, or scores on various measures of psychological morbidity above previously defined cut off points.

INTERVENTION

Adjuvant psychological therapy, a brief, problem focused, cognitive-behavioural treatment programme specifically designed for the needs of individual cancer patients.

MAIN OUTCOME MEASURES

Hospital anxiety and depression scale, mental adjustment to cancer scale, Rotterdam symptom checklist, psychosocial adjustment to illness scale.

RESULTS

156 (90%) patients completed the eight week trial; follow up data at four months were obtained for 137 patients (79%). At eight weeks, patients receiving therapy had significantly higher scores than control patients on fighting spirit and significantly lower scores on helplessness, anxious preoccupation, and fatalism; anxiety; psychological symptoms; and on orientation towards health care. These differences indicated improvement in each case. At four months, patients receiving therapy had significantly lower scores than controls on anxiety; psychological symptoms; and psychological distress. Clinically, the proportion of severely anxious patients dropped from 46% at baseline to 20% at eight weeks and 20% at four months in the therapy group and from 48% to 41% and to 43% respectively among controls. The proportion of patients with depression was 40% at baseline, 13% at eight weeks, and 18% at four months in the therapy group and 30%, 29%, and 23% respectively in controls.

CONCLUSIONS

Adjuvant psychological therapy produces significant improvement in various measures of psychological distress among cancer patients. The effect of therapy observed at eight weeks persists in some but not all measures at four month follow up.

Mitozantrone and methotrexate chemotherapy with and without mitomycin C in the treatment of advanced breast cancer: a randomised clinical trial

Patients with advanced breast cancer were randomised to 3M (mitozantrone 6.5 mg/m2q 21 days, methotrexate 30 mg/m2q 21 days, mitomycin C 6.5 mg/m2q 42 days) or 2M (as 3M but without mitomycin C). The objective response rates of 30% in 51 evaluable patients receiving 3M and 26% of 54 patients receiving 2M were not significantly different. 4/16 patients not responding to 2M responded to 3M on crossover. Both regimes were well tolerated but there was significantly less haematological toxicity and fewer dose reductions and delays with 2M. We conclude that patients should initially be treated with 2M and that non-responding patients should be crossed to 3M.

Communality of videogame performances with tracking tasks

Performances on three videogames were compared with two different tracking tasks and a third dual tracking task, after stability of performance was achieved by 40 male subjects. The six tasks were performed in succession for three weeks each, and one year separated administration of the tracking tasks from the videogames. Convergence of the cross-correlations among these tasks occurred such that higher correlations were attained for scores obtained late in practice (late/late) of two tasks (even when they were performed a year apart) rather than for scores obtained earlier in training (viz., early/early). High communality between these two types of tasks was observed as indicated by virtual overlap between the videogames and the tracking tasks, even though different control media (joysticks, knobs), control orders (zero/first), and control inputs (displacement/force transducer) were required. Because these tasks apparently index similar abilities, there may be advantages to measuring tracking skills with videogames, which include low cost, wide availability, inherent interest to subjects and motivation, rapid approach to stable levels, and, in many cases greater apparent face validity relative to real world performance requirements.

4-Hydroxyandrostenedione in the prophylaxis of N-methyl-N-nitrosourea induced mammary tumourigenesis

We have examined the role of the aromatase inhibitor 4-hydroxyandrostenedione (4-OHA) in the prevention of mammary tumourigenesis in experiments involving 170 rats. We first demonstrated a prophylactic effect of 4-OHA (50 mg/week) in reducing tumour incidence over a 30 week period compared to controls (P = 0.04). We repeated the experiment to determine optimum dose and duration of therapy. Although 4-OHA again prevented tumour development (P less than 0.0005), there was no difference between the standard (50 mg/week) dose and the higher dose (100 mg/week). Rats were randomised at 30 weeks to either stop or to continue prophylactic therapy; marginal benefit in tumour free survival in continuing therapy was observed (P = 0.03). We conclude that 4-OHA is an effective agent in preventing carcinogen-induced mammary tumours in rats and further studies of the role of oestrogen synthesis inhibitors in the prevention of human mammary tumours may be indicated.

Relationships between emotional control, adjustment to cancer and depression and anxiety in breast cancer patients

The possible relationship between psychological responses among breast cancer patients and disease outcome continues to be an area of controversy and debate. Two parallel findings are reported separately in the literature: first, that emotional control is more common among women with breast cancer than in women with benign breast disease or in healthy controls and second, that a helpless attitude towards the disease is related to a poor prognosis. These previously unrelated psychological responses are examined here in a group of women (N = 359) with early stage breast cancer, who were seen one to three months after diagnosis. The relationships between emotional control, adjustment to cancer and psychological morbidity were examined. Prevalence levels of 16 and 6% were observed for anxiety and depression respectively, which are lower than reported more generally in the literature. The results indicated a highly significant association between scores for the tendency to control emotional reactions and a fatalistic attitude toward cancer. A significant association was observed between anger control and a helpless attitude. Psychological morbidity was also linked to type of adjustment to cancer. The data are interpreted in terms of a process model of psychological responses which suggests that emotional control (an important component of the Type C behaviour pattern) fatalism, helplessness and psychological morbidity are linked.

The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer

An exploratory factor analysis of the HAD was carried out in 568 cancer patients. Two distinct, but correlated, factors emerged which corresponded to the questionnaire's anxiety and depression subscales. The factor structure proved stable when subsamples of the total sample were investigated. The internal consistency of the two subscales was also high. These results provide support for the use of the separate subscales of the HAD in studies of emotional disturbance in cancer patients.

A randomized trial comparing adjuvant fluorouracil, doxorubicin, and mitomycin with no treatment in operable gastric cancer. International Collaborative Cancer Group

Three hundred fifteen patients with operable gastric cancer were randomized to receive fluorouracil, Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), and mitomycin (FAM) or no adjuvant treatment between September 1981 and July 1984. After excluding ineligible patients, 281 patients are included in this analysis. Treatment was moderately well tolerated by the majority of patients, the common side effects being nausea and vomiting (58%) and alopecia (57%). Three possible treatment-related deaths were seen, all due to cardiac failure. At median follow-up of 68 months, 164 patients have died, 73 in the treated arm and 91 in the control arm. There was no significant difference in disease-free or overall survival between the two arms of the study (P = 0.21). There is some evidence that patients with more advanced carcinoma (T3-T4) derived some benefit from treatment (P = 0.04). The interpretation of this finding must take into account that all subgroups were defined retrospectively, and this could, therefore, be a chance finding. We conclude that adjuvant chemotherapy as given in this trial is not indicated as routine treatment in operable gastric cancer, but that further evaluation in stage T3-T4 patients is warranted.

The growth rate of metastatic nonseminomatous germ cell testicular tumours measured by marker production doubling time--II. Prognostic significance in patients treated by chemotherapy

Tumour growth rates have been measured in metastatic non-seminomatous germ cell testicular tumours (NSGCTT) by estimating the rate of rise of tumour marker production (TMP). TMP was calculated for the time between orchidectomy and the start of chemotherapy in a group of 58 patients with metastatic NSGCTT treated with BEP combination chemotherapy (bleomycin, etoposide and cisplatin). Calculation of TMP (iu/l/day) took account of the continuing clearance of marker from the serum. TMP increased with time in 51 patients and this rise generally appeared to be exponential. The rate of this increase was expressed as the marker production doubling time (MPDT) and is a measure of the tumour growth rate. MPDT varied from 0.5 to greater than 80 days (45 cases) for AFP + ve patients and from 1.8 to greater than 80 days (34 cases) for HCG + ve patients. Patients who failed BEP first line therapy had shorter MPDTs than those who responded (AFP P = 0.08, HCG P = 0.003). It was found that patients with a MPDT less than or equal to 4 days were more likely to fail treatment than those who had a MPDT greater than 4 days (AFP P = 0.009, HCG P = 0.005). MPDTs were independent of initial serum marker concentration. Patients with small volume disease had longer MPDTs than patients with large volume disease (AFP P = 0.02, HCG P = 0.04). Rapid tumour growth rate reflected by short MPDT carries a poor prognosis in patients with NSGCTT treated by BEP chemotherapy.

Chemotherapy for malignant melanoma: combinations and high doses produce more responses without survival benefit

In a consecutive series of studies, 164 patients with symptomatic and/or visceral metastatic malignant melanoma were treated with single agent vindesine, high dose melphalan with autologous bone marrow transplantation (AMBT), high dose BCNU with ABMT or the BOLD (bleomycin, vincristine, CCNU and DTIC) combination. The high dose treatments and the combination chemotherapy resulted in significantly higher response rates but no prolongation of survival. Factors associated with longer survival included the absence of visceral metastases, the absence of bulky disease and good performance status. For all treatments, life table estimates of survival at 1 and 2 years were only 10% and 4% respectively.

Effect of human recombinant tumour necrosis factor and rat gamma interferon on nitrosomethylurea-induced mammary tumours

We have used the nitrosomethylurea-induced rat mammary tumour model to study the effects of parenteral administration of human recombinant tumour necrosis factor (rHu-TNF) and rat gamma interferon (IFN-gamma). An inbred strain of tumour bearing female Ludwig/Wistar/Olac rats were randomised to either treatment or control groups. Two independent studies showed that combined treatment with rHu-TNF and rat IFN-gamma induced significant tumour regression over 4 weeks (P = 0.004, P = 0.005 respectively). Treatment with either rHu-TNF or rat IFN-gamma given individually did not affect the overall rate of tumour growth (P = 0.157 and 0.40 respectively) although an initial reduction in tumour size was observed during the first few days after injection. Measurement of circulating oestradiol levels in groups in which maximum tumour regression was observed showed no statistically significant difference when compared to the control group. Similarly, measurement of oestrogen receptor content showed no statistically significant difference between rHu-TNF-gamma or rat-IFN-gamma treatment or combined treatment of rHu-TNF and IFN-gamma with the control group. We conclude from these observations that combined therapy with rHu-TNF and rat IFN-gamma may prove to be useful new forms of treatment for human breast cancer.

The late effects of cis-platinum on renal function

The combination of bleomycin, etoposide and cis-platinum (BEP) is an effective treatment for germ cell tumours. To help define the role of recently developed non-nephrotoxic analogues of cis-platinum we have analysed the long term renal damage caused by this agent. We report on 22 patients studied 8-60 months following BEP chemotherapy. In the 17 cases with no pre-chemotherapy renal impairment there was a fall in mean glomerular filtration rate from 132 ml/min (95% confidence interval 123, 141) pre-chemotherapy to 103 ml/min (95% confidence interval 94, 113) on late follow up. The overall pattern is one of initial fall of glomerular filtration rate during chemotherapy, and no consistent evidence of late recovery or further deterioration; considerable individual variation is observed.

Adjuvant chemotherapy in T3 carcinoma of the bladder. A prospective trial: preliminary report

We report the early results of a multi-centre, randomised prospective trial of neoadjuvant and maintenance chemotherapy with methotrexate (MTX) in 376 patients with advanced (T3) carcinoma of the bladder. In patients under 65 years of age, treatment consisted of radical radiotherapy (64 Gy) or, in some centres, pre-operative radiotherapy (44 Gy) and elective cystectomy. All patients over 65 had radical radiotherapy. MTX was administered to 188 patients. There was no increase in toxicity attributable to the MTX. MTX did not significantly increase the proportion of patients whose tumours responded to radiotherapy; 50% (70/141) responded to radiotherapy and 56% (76/136) to MTX radiotherapy. The development of metastases and survival was also similar in both groups (3-year survival: radiotherapy 37.3%, MTX + radiotherapy 38.6%). We report the logistic difficulties of the administration of prolonged courses of maintenance chemotherapy. Further controlled trials of neo-adjuvant chemotherapy in advanced bladder cancer are required, involving more active regimes.

A quantitative analysis of the spatial relationships of grouped microcalcifications demonstrated on xeromammography in benign and malignant breast disease

The mammograms of 444 patients who had a breast biopsy leading to a definitive histological diagnosis were reviewed. In 21 cases (4.7%) grouped microcalcifications were identified as the only mammographic abnormality. These groups of microcalcifications were analysed to determine whether there was any quantitative difference between benign and malignant lesions with respect to a shape parameter of the group, the spatial frequency of the particles and neighbour-to-neighbour relationships of the particles. This analysis did not reveal any significant difference between the spatial relationships of the grouped microcalcifications found in benign and malignant breast disease.

Gastrointestinal morbidity of adjuvant radiotherapy in stage I malignant teratoma of the testis

Between January 1963 and December 1983, 248 patients with stage I teratoma were managed by the Testicular Tumour Unit of the Royal Marsden Hospital (RMH). Before 1979, these patients were treated with adjuvant irradiation to the abdominal and pelvic lymph nodes (142 patients) to a mid-plane dose of 40 Gy in 20 fractions over 4 weeks. In 1979, a surveillance policy was adopted (106 patients) and relapsing patients treated with chemotherapy. By 2 years post-orchidectomy, seven patients (4.9%) in the irradiated group developed duodenal ulceration compared to none in the surveillance group (p = 0.05). A past medical history of duodenal ulcer was a significant risk factor for ulceration after radiotherapy (p = 0.04) whereas a past history of abdominal surgery was not (p = 0.8). It is concluded that adjuvant radiotherapy for stage I teratoma may increase the risk of peptic ulceration.

Controlled release morphine tablets: a double-blind trial in patients with advanced cancer

Eighteen of 27 patients with pain due to advanced cancer, completed a randomised crossover comparison of 4-hourly aqueous morphine sulphate and twice daily controlled release morphine tablets. There was no difference between the two regimens in analgesic efficacy or adverse effects, but there was an apparent improvement in quality of sleep on the controlled release tablets. After completion of the study, 17 patients continued with the latter medication for periods that ranged from 2 days to 94 weeks (median 6.5 weeks). Controlled release morphine tablets given twice daily provide a simpler and more convenient treatment regimen than a 4-hourly opioid for patients with cancer pain, once they have been stabilised.

Radical neck dissections for squamous carcinomas: pathological findings and their clinical implications with particular reference to transcapsular spread

Two hundred fifty radical neck dissections, undertaken for mucosal squamous carcinomas of the head and neck, were reviewed with reference to pathological findings and their clinical implications. No major differences in descriptive surgical pathology were established between irradiated and non-irradiated resections. In general, irradiated dissections had lower total node counts and somewhat fewer nodal metastases involving a smaller number of different nodal groups. The topography of nodal deposits was similar in irradiated and non-irradiated resections. Palpable keratin granulomas (without intact tumor) were almost confined to irradiated patients. Transcapsular spread of tumor from involved lymph nodes was common: it was demonstrated in 160/188 'positive' dissections (85%) and was subclassified as 'macroscopic' in 90 and 'microscopic' in 70. The incidence and extent of transcapsular spread was similar in irradiated and nonirradiated resections. It was more frequently observed in association with large nodal masses but it was also regularly found with small nodal deposits less than 3 cm in diameter. Statistical analyses showed strong associations (p less than 0.0005) between the presence and/or extent of transcapsular spread and subsequent recurrence in the operated neck and overall survival. The predictive value of other clinical and pathological features vis-a-vis local neck recurrence such as numbers of involved nodal groups was weaker. Macroscopic transcapsulr spread emerges as the major prognostic factor for recurrent disease in the neck (p less than 0.0001). Attention is drawn to the advantages of accurate descriptive categories ('macroscopic', 'microscopic') for this critical prognostic feature.

Substructure of skeletal myosin subfragment 1 revealed by thermal denaturation

The stability of myosin subfragment 1 (S1) to thermal denaturation has been followed by limited tryptic proteolysis. Digestions done during the thermal denaturation show that at temperatures at and above 37 degrees C there is a marked increase in the susceptibility of S1 to tryptic degradation, as evidenced by the loss of all bands corresponding to the normally trypsin-resistant fragments of 50, 27, and 21 kDa of the heavy chain and to the light chain. The enhanced digestion of S1 appears to be due to a general unfolding of all segments of S1, although the 50-kDa segment appears to unfold at a lower temperature than the remainder of the S1 structure. Digestions done after 30-min exposure to higher temperatures or after subsequent cooling to 25 degrees C show marked differences in the susceptibility of the S1 to trypsin. This suggests that, on cooling, a substantial portion of the S1, but not the 50-kDa segment, is capable of refolding to a state corresponding closely to that in the native S1. These data indicate that in terms of thermal denaturation the S1 behaves as though it is comprised of two domains--an unstable 50-kDa domain and a more stable domain comprised of the 27- and 21-kDa segments of the heavy chain interacting with the light chain, as proposed recently by Setton and Muhlrad [Setton, A., & Muhlrad, A. (1984) Arch. Biochem. Biophys. 235, 411-417]. The rates of thermal inactivation of the ATPase of S1 are found to correspond closely to the decay rates for the 50-kDa fragment, suggesting that this segment in S1 is closely associated with the ATPase function of the protein.

Prognostic implications of perineural spread in squamous carcinomas of the head and neck

The occurrence and prognostic implications of perineural spread were examined in 239 patients with mucosal squamous carcinomas of the head and neck. Perineural spread was demonstrated in resections from 64 patients (27%), the majority having primary tumors at one of three sites: buccal cavity, larynx, and pharynx. Perineural spread near nodal metastases was uncommon. There was no evidence that perineural involvement was more commonly associated with large tumors or less differentiated ones. No association was established between perineural spread and coexistent lymph node deposits in the surgical resections. Perineural spread was, however, shown to be a statistically significant prognostic factor for an increased incidence of subsequent locoregional recurrence and for decreased survival.