Saving for hospital care costs in Singapore: are there lessons for Australia? [corrected]

Australian political leaders and policy analysts have increasingly sought to learn from Singapore, a nation which, despite its small size and lack of natural resources, has enjoyed rapid economic growth. Of particular interest to Australian policymakers has been Singapore's compulsory superannuation system, which has provided high levels of domestic savings and high levels of home ownership; it has also incorporated a scheme to enable Singaporeans to save for the costs of health care. In this article, Singapore's Medisave policy is described within its broader socioeconomic context. Saving for health care costs has been a largely neglected option in recent policy debate about reforming funding arrangements for hospital care in Australia. The potential for a formalised scheme for medical savings in Australia, subsidised by taxation concessions, is explored in terms of its socioeconomic policy implications, its congruence with Australian values, and the logistical ramifications of such a scheme.

Preoperative evaluation of abnormal mammographic findings to avoid unnecessary breast biopsies

OBJECTIVE

To prospectively evaluate a program of additional mammographic views, interval follow-up, and stereotactic biopsy in the management of abnormalities detected on mammograms.

METHODS

From June 1988 to September 1991, 267 consecutive women who were referred for surgical consultation because of an abnormal mammographic finding were evaluated. Mammographic abnormalities were assessed as benign or as requiring interval follow-up, stereotactic biopsy, open surgical biopsy, or additional views. Women having additional mammographic views were reassigned to the preceding groups. The mean follow-up for women who did not have a biopsy was 37 months.

RESULTS

Only 129 (48%) of the women who were sent for surgical consultation underwent open biopsy, and 46 (36%) of the biopsy specimens revealed carcinoma. Forty-one (89%) of the cancers were ductal carcinoma in situ or stage I lesions. Of the 117 women who were assigned to follow-up, six (5%) subsequently required biopsy and two cancers were identified.

CONCLUSION

Rigorous mammographic evaluation and the use of stereotactic biopsy for selected lesions can prevent breast biopsy for low-suspicion mammographic abnormalities while still allowing the detection of early-stage breast cancer.

Breast disease in elderly women

Breast cancer incidence and mortality increase with advancing age. In spite of this, screening for breast cancer by physical examination and mammography is underutilized in older women compared with their younger counterparts. Studies suggest that even for elderly women with mild to moderate co-existing illnesses, the use of screening mammography reduces breast cancer mortality. The local therapy of breast cancer is well tolerated by the majority of elderly women. Mastectomy has a 30-day operative mortality of less than 1% in women older than age 65 and provides excellent local control. However, mastectomy has no survival advantage over lumpectomy and radiotherapy. If breast preservation is undertaken, radiotherapy is an important part of the treatment. Local failure in the breast in the absence of radiotherapy usually occurs in the first 4 postoperative years and is likely to become a problem during the patient's lifetime. Radiation to the breast is well tolerated, and the incidence of complications does not appear to be age related. Many older women are anxious to preserve their breasts and should be offered this treatment option. In the older woman with severe co-morbid conditions in whom the risk of operative morbidity and mortality is high, tamoxifen, 20 mg daily, may be used as an alternative to surgical therapy. Complete and partial response rates of 50% to 80% are reported with tamoxifen therapy, and this often results in control of local disease during the patient's lifetime. However, this should not be considered standard therapy for the otherwise healthy older woman. The majority of older women benefit from tamoxifen therapy postoperatively, and cytotoxic chemotherapy, when indicated, can be delivered with acceptable toxicity. The failure to use adjuvant therapy when indicated is one of the most frequently identified problems in the management of breast cancer in the elderly. Breast cancer in older women carries a significant mortality, even in spite of the presence of concurrent diseases. In a number of studies, old age is noted to be a negative prognostic factor. Whether this is due to the biology of the disease or the undertreatment of older women is unclear, but it is evident that breast cancer in the elderly should not be considered an indolent disease. Breast cancer therapy should be determined by a woman's physiologic age and psychological needs rather than her chronologic age.

OA-rehab: designing a personalized exercise program for people with osteoarthritis

We describe the design of a multi-media performance support system (PSS) based on the documented benefits of a personalized exercise program for people with arthritis, on the known value of self-efficacy and stages of change, and on principles of learning theory. The poster will show examples of incorporating motivational and cognitive principles into a PSS.

Identification and management of the woman at increased risk for breast cancer development

Multiple factors which increase a women's breast cancer risk have been identified. These range from conditions such as lobular carcinoma in situ which increase risk to relatively high levels, to reproductive factors such as nulliparity which are associated with only a small increase in risk. When determining an individual's risk, all her potential breast cancer risk factors must be considered. In order for risk information to be meaningful to a woman, risk must be expressed as absolute risk over a defined time interval since there is no uniform agreement on what risk level is high enough to require intervention. At present, careful follow-up or prophylactic mastectomy are the management options available for the woman at increased risk. The efficacy of follow-up including breast self exam, physician exams, and screening mammography for early detection of cancer in a high risk population is unknown. Prophylactic mastectomy, while highly effective, does not provide complete protection from breast cancer and is more radical than the surgery done for established cancer in many cases. Which of these options is chosen by an individual woman is dependent on how much risk she is willing to assume.

Molecular mechanisms of resistance to tamoxifen therapy in breast cancer

Clinical data suggest that the use of adjuvant tamoxifen citrate (Nolvadex) for a minimum of 5 years, and possibly indefinitely, will result in maximal antitumor benefit. There is concern that long-term tamoxifen maintenance therapy may result in the induction of drug resistance. This article reviews the potential molecular mechanisms of resistance to tamoxifen and explores the possibility of tamoxifen-stimulated tumor growth.

An appraisal of strategies to reduce the incidence of breast cancer

The current focus of breast cancer research is to develop a novel strategy to prevent the disease. In this review a potential model of breast cancer development is proposed based upon the results of laboratory models of the induction of mammary carcinogenesis. It is clear that susceptibility to initiation occurs in young female animals, and a preventive strategy is more effective the sooner it is started after initiation occurs. In humans we do not know the timing or the nature of the carcinogenic insult, but epidemiologic studies suggest that the process is long and initiation is most likely to occur in young adults. Hormones are the key to promotion of the carcinogenic process and it would appear that strategically the earlier an intervention is applied after initiation the better will be the general effect on the population. Hormonal contraception could prevent breast cancer if the appropriate formulation was chosen and used by all young women. This inhibitory strategy might protect women without the need to preselect based on risk factors. Breast cancer prevention would be a side effect of the contraceptive method. Alternatively, tamoxifen, an antiestrogen, is known to prevent mammary carcinogenesis in animals and prevent the appearance of second primary breast cancers in women. This well tested therapeutic agent is currently being evaluated in clinical trials of selected high-risk women aged 35 and above. Finally, retinoids have shown promise as agents in the laboratory to prevent cell replication and inhibit mammary tumorigenesis. A trial of retinoids to prevent second primary tumors in node negative breast cancer patients is currently underway in Italy. The review discusses the relative merits and concerns about these prevention strategies and proposes additional studies to be undertaken.

Risk factors and the prevention of breast cancer with tamoxifen

Oestrogen is intimately involved in the growth and development of breast cancer. Tamoxifen, a non-steroidal anti-oestrogen, not only is an effective adjuvant therapy for node positive and node negative disease, but also has several attractive pharmacological features that have enhanced interest in testing it as a preventive drug for breast cancer in high risk women. Tamoxifen is known to prevent contralateral breast cancer, but it also has significant oestrogenicity for reducing circulating cholesterol and preventing bone loss in the lumbar spine of postmenopausal women. Several clinical trials have been initiated around the world; however, there has been increasing concern about the safety of tamoxifen. Nevertheless, current reports indicate that there is little risk of developing endometrial and liver cancer, although further clinical studies must be planned. Concerns about retinal and thromboembolic problems remain anecdotal, and again additional research is essential. The prevention trials with tamoxifen are necessary to establish the worth and feasibility of a pharmacological intervention. If tamoxifen is found to be of value to prevent breast cancer in a broad population, then the future ability to predict breast cancer through molecular markers will provide the physician for the first time with a therapeutic option to treat the targeted patient.

Pre-cancerous breast lesions: implications for breast cancer prevention trials

The relationship between benign breast disease and breast cancer has become the focus of increased clinical attention as breast cancer prevention becomes a clinical reality. In this setting an understanding of the magnitude of the increase in risk conferred by the various types of benign breast disease assumes increasing importance. When benign breast disease is considered as an aggregate, estimates of the relative risk of breast cancer development range from 0.8 to 4.5. This article describes the risk associated with proliferative and non-proliferative benign breast disease, as well as the rationale for considering lobular carcinoma in situ and ductal carcinoma in situ (in some cases) as risk factors for breast carcinoma rather than actual malignant lesions. Mathematical models can provide a more precise estimate of breast cancer risk, but these efforts may be confounded by the lack of uniformity in the pathologic definition of borderline benign breast lesions. The breast cancer prevention trials offer a unique opportunity to improve our database on the natural history of high risk benign breast lesions, while attempting to reduce the 44,000 deaths occurring annually from breast cancer.

Small bowel obstruction in patients with a prior history of cancer

To assess the efficacy of operative and nonoperative therapy of small bowel obstruction (SBO) in patients with a previous diagnosis of cancer, a review of 54 cases was carried out. The 32 men and 22 women had a mean age of 58 years. At presentation with SBO, 26 patients (48%) had known recurrent cancer. Forty patients were initially treated nonoperatively; 11 (28%) had resolution of their SBO after a mean of 7 days of nasogastric suction. Five of 11 patients developed recurrent SBO prior to death. Thirty-seven patients underwent laparotomy, 14 on the day of admission and 23 after failure of nasogastric suction. Twenty-five of 37 (68%) had obstruction due to recurrent carcinoma. Small bowel obstruction due to recurrent cancer occurred earlier (21 +/- 5 months) than SBO from benign causes (61 +/- 18 months; p < 0.01). Mean survival for patients with malignant obstruction (5 +/- 1 month) was significantly shorter than for those with benign obstruction (50 +/- 10 months; p < 0.001). The 30-day and in-hospital mortality rates for the 25 surgically treated patients with malignant SBO were 24% and 28%, respectively; in 9 of 25 (36%), the obstruction failed to fully resolve. The only factor predictive of in-hospital mortality was obstruction secondary to cancer (p < 0.05). The median posthospital survival for surgically treated patients with malignant SBO was only 2.5 months. We conclude that: (1) patients should be given an initial trial of nonoperative therapy; (2) patients with no known recurrence or a long interval to the development of SBO should be aggressively treated with early surgery if nonoperative treatment fails; and (3) for patients with known abdominal recurrence in whom nonoperative therapy fails, the results of surgical palliation are grim. Innovative approaches are needed to maximize palliation while also limiting morbidity and mortality.

Isolation of coordinately regulated genes that are expressed in discrete stages of B-cell development

We have utilized subtractive hybridization to isolate 16 distinct cDNA sequences representing genes expressed in pre-B-cell lines but not myeloma cell or fibroblast lines. These sequences represent RNA transcripts that vary in abundance in pre-B-cell lines from 0.001% to 0.05%. Five of these sequences were not related to any known genes. One was related to but distinct from known myosin regulatory light chain genes and another encoded a protein with lectin domains. Three represented previously identified genes encoding carbonic anhydrase type II, thymosin, and CD2; these genes were not previously known to be specifically expressed in early stages of B-cell development. Other isolated genes corresponded to pre-B-cell-specific or pre-B-cell/B cell-specific genes recently described by others. The isolated cDNA sequences may be divided into two general categories--those representing genes expressed only in the pre-B-cell stage of B-cell development and those expressed in both the pre-B-cell and B-cell stages. The in vivo expression patterns of the identified genes suggest that some function specifically in lymphocytes while others may have roles in additional lineages.

Chloroquine as a hyperthermia potentiator

The antimalarial agent chloroquine (CQ) inhibits DNA and RNA polymerase and interferes with lysosomal function. We sought to determine if these properties make chloroquine effective as a hyperthermia sensitizer. B16F10 melanoma cells were treated for 180 min at 37 or 41 degrees C with 0.005 mM CQ, 0.01 mM CQ, 0.05 mM CQ, or 0.1 mM CQ and colony formation evaluated at 7 days. CQ was cytotoxic at 37 or 41 degrees C in a dose-dependent fashion. A significant increase in cytotoxicity was seen with 0.5 and 0.1 mM CQ at 41 degrees C compared to 37 degrees C (P less than 0.01). The influence of treatment time on CQ cytotoxicity was examined by treating cells with 0.05 mM CQ at 37 or 41 degrees C for 30-min intervals from 30 to 180 min. Increasing length of exposure to CQ increased cytotoxicity at both 37 and 41 degrees C. For each interval studied treatment at 41 degrees C significantly decreased colony formation compared to treatment at 37 degrees C (P less than 0.01). Complete cell kill was achieved after 180 min of 41 degrees C treatment compared to 80% cell kill at 37 degrees C. We conclude that in this model CQ is an effective potentiator of hyperthermia.

Diffuse cystic angiomatosis of the breast

Vascular tumors of the breast are extremely rare, and the majority are malignant. In this report, the presentation of a diffuse, benign, cystic, vascular tumor that histologically was angiomatosis of the breast is described. The clinical presentation, magnetic resonance imaging (MRI) appearance, and histologic features of this rare lesion are reviewed. This case is of particular interest because the tumor recurred during pregnancy and underwent massive enlargement despite negative hormone receptor values. Angiomatosis is prone to local recurrence, so complete excision with histologically negative margins is the treatment of choice.

Patient compliance with aggressive multimodal therapy in locally advanced breast cancer

This study of compliance was performed to determine whether a medically indigent population with breast carcinoma that has been neglected is an appropriate group for inclusion in an aggressive combined treatment program. After incisional biopsy, 28 locally advanced breast cancer (LABC) patients received two cycles of cytoxan, Adriamycin, 5-Fluorouracil, and tamoxifen (CAFT) followed by a simple mastectomy and level I axillary dissection. After surgery, patients received four additional cycles of CAFT alternating with three cycles of 15 Gy to the chest wall and regional lymphatics. Compliance was defined as overall compliance, the percentage of patients completing the protocol as described; and appointment compliance, the ratio between treatments or appointments attended versus those scheduled. Overall compliance was 75% (21 of 28 patients). The total number of appointments scheduled was 1054 (mean, 37 +/- 2), and the total attended was 965 (mean, 34 +/- 3), giving an appointment compliance rate of 91.7%. Compliance did not vary significantly with age, marital status, nationality, the presence of complications, or delay to diagnosis. Compliance did decrease significantly with time. There was 100% overall compliance at 2 months, 82% at 6 months, and 75% at 1 year. We conclude that although our patients had neglected their disease and were medically indigent, they were highly motivated patients once in therapy. This suggests that complex treatment regimens are feasible as well as effective for the treatment of LABC.

Verapamil enhances antitumor activity without increasing myeloid toxicity

The effectiveness of chemotherapy is limited by drugs' resistance and toxicity to normal host cells. Verapamil increases the cytotoxicity of the Vinca alkaloids and doxorubicin hydrochloride (Adriamycin) in tissue culture. In this experiment the effect of verapamil (VER) on the cytotoxicity of vincristine sulfate (VCR) and 5-fluorouracil (5-FU) was studied with the use of an intravenous lung colonization model. After receiving 5 X 10(4) B16 F10 cells intravenously, mice were randomized into six groups and treated with intraperitoneal injections of saline solution, VER, VCR, VCR plus VER, 5-FU, or 5-FU plus VER. In the first experiment, mice were killed on day 22 and lung colonies counted. In subsequent experiments, animals were monitored until death. The addition of VER to VCR significantly decreased pulmonary tumor formation (14 versus 47 colonies; p = 0.05). This was associated with an increase in mean survival from 40.4 to 53.7 days (p = 0.05). Although the addition of VER to 5-FU also decreased pulmonary tumor colony formation (26 versus 73 colonies; p = 0.001), there was no significant prolongation of survival with this treatment. A quantitative clonal culture of granulocyte-macrophage progenitor cells (GM-CFC) was used to assess the effect of VER on bone marrow toxicity. The addition of 5 mumol VER to 5-FU (5 X 10(-3) to 5 X 10(-7) mol/L) or VCR (5 X 10(-5) to 5 X 10(-9) mol/L) did not significantly reduce GM-CFC growth compared with treatment with either drug alone. In vivo marrow toxicity assessed 18 hours after a single drug injection was also not increased by the addition of VER to VCR or 5-FU. In this model, VER enhances the oncolytic effect of both VCR and 5-FU without a concomitant increase in toxicity to normal host marrow progenitor cells.

Multimodal therapy for locally advanced breast cancer

Thirty-one women with stage III breast cancer were prospectively treated with two cycles of cyclophosphamide (Cytoxan), doxorubicin hydrochloride (Adriamycin), fluorouracil, and tamoxifen citrate followed by a simple mastectomy with level I axillary dissection. Postoperatively, four additional cycles of the combination chemotherapy alternating with three cycles of 1500 rad (15 Gy) to the chest wall and lymphatics were given. Seventy-seven percent of patients had a greater than 50% reduction in tumor size after the initial chemotherapy. No tumor size progressed during therapy, and a single patient remained inoperable. Pathologic findings revealed nine patients with only microscopic residual tumor. Nuclear vacuolization was present in 42.8% of tumor cells after chemotherapy vs 14.2% of cells before chemotherapy. The mean follow-up for the groups is 24.3 months. To date, nine patients have had recurrence with only one isolated local recurrence. This therapy is effective in reducing primary tumor size and allows a limited mastectomy to be done with minimal morbidity.