Cost-Effectiveness of Inotuzumab Ozogamicin Compared to Standard of Care Chemotherapy for Treating Relapsed or Refractory Acute Lymphoblastic Leukaemia Patients in Norway and Sweden

OBJECTIVE

The aim was to estimate the cost-effectiveness of inotuzumab ozogamicin (InO) versus standard of care chemotherapy (SoC) for adults with relapsed or refractory B cell acute lymphoblastic leukaemia (R/R ALL) in Sweden and Norway, and compare this to evaluations made by the health technology assessment (HTA) authorities Tandvårds- och läkemedelsförmånsverket (TLV) and the Norwegian Medicines Agency (NoMA).

MATERIALS AND METHODS

A partitioned survival model was developed to determine incremental cost-effectiveness ratios (ICERs) for InO versus SoC. Parametric survival models were fit to overall survival and progression-free survival Kaplan-Meier data from the INO-VATE ALL phase III trial. Two base cases were run using (1) Swedish and (2) Norwegian inputs (costs and discount rates). Core clinical inputs and utilities did not differ between countries. Analyses were then conducted to reflect the preferred assumptions of TLV and NoMA. Univariate and multivariate sensitivity analyses were performed.

RESULTS

The base case deterministic ICERs for InO versus SoC were €16,219/quality-adjusted life years (QALY) in Sweden (probabilistic €19,415) and €44,405/QALY in Norway (probabilistic €47,305). The ICERs using our model but applying the preferred assumptions of TLV or NoMA were €74,061/QALY (probabilistic €77,484) and €59,391/QALY (probabilistic €63,632), respectively. Differences between our base cases and the ICERs with TLV and NoMA settings were mainly explained by the exclusion of productivity costs and use of pooled post-haematopoietic stem-cell transplant (post-HSCT) survival in Sweden and use of higher HSCT costs in Norway. All ICERs remained below the approximated willingness-to-pay thresholds. The probability of InO being cost-effective ranged from 77 to 99% versus SoC.

CONCLUSIONS

InO can likely be considered cost-effective versus SoC under our and the HTA-preferred settings.

European consensus statement on essential colposcopy

This European consensus statement on essential colposcopy provides standards for the general colposcopist seeing women referred for colposcopy with an abnormal cervical screening test (including cytology and HPV tests) or with a clinically suspicious cervix. The article gives guidance regarding the aims and conduct of colposcopy. Recommendations are provided on colposcopy technique, the management of common colposcopy issues, treatment and follow-up of after treatment of CIN or early stage cervical. Colposcopists should make an informed decision on the management of each individual that is referred and organize appropriate follow-up. Cervical cancer is still a major health issue and the quality of care can only improve if there is a structured guidance for women with an abnormal smear or suspicious cervix.

Incidence of lichen sclerosus and subsequent causes of death: a nationwide Finnish register study

OBJECTIVE

To assess the incidence of lichen sclerosus (LS) in women and the all-cause and cause-specific mortality of women with LS.

DESIGN

Population-based descriptive study.

SETTING

Finland.

POPULATION

All Finnish women, including 7790 women diagnosed with LS during the period 1969-2012.

METHODS

Information gathered from the Finnish Hospital Discharge Register on women with LS was combined with dates and causes of death from Statistics Finland and the Finnish Cancer Registry. Population statistics are from Statistics Finland.

MAIN OUTCOME MEASURES

Crude and age-adjusted incidence rates of LS and standardised mortality ratios (SMRs).

RESULTS

The incidence rate of LS adjusted for age (European Standard Population) increased from 14 per 100 000 woman-years in 2003 to 22 per 100 000 woman-years in 2010-2012. The age-specific incidence rate was highest in postmenopausal women (24-53 per 100 000) but was also elevated in girls aged 5-9 years (seven per 100 000). The all-cause mortality of women with LS was lower than in the general female population (SMR 0.84, 95% CI 0.78-0.90), mostly as a result of decreased mortality from circulatory diseases (SMR 0.80, 95% CI 0.72-0.89) and dementia and Alzheimer's disease (SMR 0.75, 95% CI 0.62-0.88). The cancer mortality equalled that of the population, but the vulvar cancer mortality was increased (SMR 28.1, 95% CI 19.3-39.4).

CONCLUSIONS

Lichen sclerosus is a common disease of elderly women. The overall mortality is decreased whereas the mortality as a result of vulvar cancer is increased.

TWEETABLE ABSTRACT

The likelihood of getting LS by age 80 years is 1.6%. The mortality of women with LS is reduced compared with that of the population.

Patterns of African and Asian admixture in the Afrikaner population of South Africa

BACKGROUND

The Afrikaner population of South Africa is the descendants of European colonists who started to colonize the Cape of Good Hope in the 1600s. In the early days of the colony, mixed unions between European males and non-European females gave rise to admixed children who later became incorporated into either the Afrikaner or the Coloured populations of South Africa. Differences in ancestry, social class, culture, sex ratio and geographic structure led to distinct and characteristic admixture patterns in the Afrikaner and Coloured populations. The Afrikaner population has a predominant European composition, whereas the Coloured population has more diverse ancestries. Genealogical records previously estimated the contribution of non-Europeans into the Afrikaners to be between 5.5 and 7.2%.

RESULTS

To investigate the genetic ancestry of the Afrikaner population today (11-13 generations after initial colonization), we genotyped approximately five million genome-wide markers in 77 Afrikaner individuals and compared their genotypes to populations across the world to determine parental source populations and admixture proportions. We found that the majority of Afrikaner ancestry (average 95.3%) came from European populations (specifically northwestern European populations), but that almost all Afrikaners had admixture from non-Europeans. The non-European admixture originated mostly from people who were brought to South Africa as slaves and, to a lesser extent, from local Khoe-San groups. Furthermore, despite a potentially small founding population, there is no sign of a recent bottleneck in the Afrikaner compared to other European populations. Admixture amongst diverse groups from Europe and elsewhere during early colonial times might have counterbalanced the effects of a small founding population.

CONCLUSIONS

While Afrikaners have an ancestry predominantly from northwestern Europe, non-European admixture signals are ubiquitous in the Afrikaner population. Interesting patterns and similarities could be observed between genealogical predictions and our genetic inferences. Afrikaners today have comparable inbreeding levels to current-day European populations.

BedMachine v3: Complete Bed Topography and Ocean Bathymetry Mapping of Greenland From Multibeam Echo Sounding Combined With Mass Conservation

Greenland's bed topography is a primary control on ice flow, grounding line migration, calving dynamics, and subglacial drainage. Moreover, fjord bathymetry regulates the penetration of warm Atlantic water (AW) that rapidly melts and undercuts Greenland's marine-terminating glaciers. Here we present a new compilation of Greenland bed topography that assimilates seafloor bathymetry and ice thickness data through a mass conservation approach. A new 150 m horizontal resolution bed topography/bathymetric map of Greenland is constructed with seamless transitions at the ice/ocean interface, yielding major improvements over previous data sets, particularly in the marine-terminating sectors of northwest and southeast Greenland. Our map reveals that the total sea level potential of the Greenland ice sheet is 7.42 ± 0.05 m, which is 7 cm greater than previous estimates. Furthermore, it explains recent calving front response of numerous outlet glaciers and reveals new pathways by which AW can access glaciers with marine-based basins, thereby highlighting sectors of Greenland that are most vulnerable to future oceanic forcing.

The mitogenome of a 35,000-year-old Homo sapiens from Europe supports a Palaeolithic back-migration to Africa

After the dispersal of modern humans (Homo sapiens) Out of Africa, hominins with a similar morphology to that of present-day humans initiated the gradual demographic expansion into Eurasia. The mitogenome (33-fold coverage) of the Peştera Muierii 1 individual (PM1) from Romania (35 ky cal BP) we present in this article corresponds fully to Homo sapiens, whilst exhibiting a mosaic of morphological features related to both modern humans and Neandertals. We have identified the PM1 mitogenome as a basal haplogroup U6*, not previously found in any ancient or present-day humans. The derived U6 haplotypes are predominantly found in present-day North-Western African populations. Concomitantly, those found in Europe have been attributed to recent gene-flow from North Africa. The presence of the basal haplogroup U6* in South East Europe (Romania) at 35 ky BP confirms a Eurasian origin of the U6 mitochondrial lineage. Consequently, we propose that the PM1 lineage is an offshoot to South East Europe that can be traced to the Early Upper Paleolithic back migration from Western Asia to North Africa, during which the U6 lineage diversified, until the emergence of the present-day U6 African lineages.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries

OBJECTIVE

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).

METHODS

In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.

MAIN OUTCOME MEASURES

Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.

RESULTS

A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.

CONCLUSION

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

TWEETABLE ABSTRACT

An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries

OBJECTIVE

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).

METHODS

In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.

MAIN OUTCOME MEASURES

Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.

RESULTS

A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.

CONCLUSION

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

TWEETABLE ABSTRACT

An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Determining obstetric patient safety indicators: the differences in neonatal outcome measures between different-sized delivery units

OBJECTIVE

To study the differences in neonatal outcome and treatment measures in Finnish obstetric units.

DESIGN

A registry study with Medical Birth Register data.

SETTING AND POPULATION

All births (n = 2 94 726) in Finland from 2006 to 2010 with a focus on term, singleton non-university deliveries.

METHODS

All 34 delivery units were grouped into small (below 1000), mid-sized (1000-2999) and large (3000 or more) units, and the adverse outcome rates in neonates were compared using logistic regression.

MAIN OUTCOME MEASURES

Early neonatal deaths, stillbirths, Apgar scores, arterial cord pH, Erb's paralysis, respirator treatment, the proportion of post-term deliveries (gestational age beyond 42 weeks) and the proportion of newborns still hospitalised 7 days after delivery.

RESULTS

From an analysis of term, singleton non-university deliveries, the early neonatal mortality was significantly higher in the small relative to the mid-sized delivery units [odds ratio (OR), 2.07; 95% confidence interval (CI), 1.19-3.60]. The rate of Erb's paralysis was lowest in the large units (OR, 0.65; 95% CI, 0.50-0.84). The use of a respirator was more than two-fold more common in large relative to mid-sized units (OR, 2.38; 95% CI, 2.00-2.83). The proportion of post-term deliveries was highest in the large units (OR, 1.36; 95% CI, 1.31-1.42), where a significantly higher percentage of post-term newborns were still hospitalised after 7 days (OR, 1.50; 95% CI, 1.19-1.89).

CONCLUSIONS

There are significant differences in several neonatal indicators dependent on the hospital size. An international consensus is needed on which indicators should be used.

Inferring population size changes with sequence and SNP data: lessons from human bottlenecks

Reconstructing historical variation of population size from sequence and single-nucleotide polymorphism (SNP) data is valuable for understanding the evolutionary history of species. Changes in the population size of humans have been thoroughly investigated, and we review different methodologies of demographic reconstruction, specifically focusing on human bottlenecks. In addition to the classical approaches based on the site-frequency spectrum (SFS) or based on linkage disequilibrium, we also review more recent approaches that utilize atypical shared genomic fragments, such as identical by descent or homozygous segments between or within individuals. Compared with methods based on the SFS, these methods are well suited for detecting recent bottlenecks. In general, all these various methods suffer from bias and dependencies on confounding factors such as population structure or poor specification of the mutational and recombination processes, which can affect the demographic reconstruction. With the exception of SFS-based methods, the effects of confounding factors on the inference methods remain poorly investigated. We conclude that an important step when investigating population size changes rests on validating the demographic model by investigating to what extent the fitted demographic model can reproduce the main features of the polymorphism data.

Treatment and overall survival in renal cell carcinoma: a Swedish population-based study (2000-2008)

BACKGROUND

This retrospective register study assessed overall survival (OS) and influential factors on OS in Swedish renal cell carcinoma (RCC) patients.

METHODS

Using three merged national health registers, Cox proportional-hazards analysis was conducted and, in three models, it was used to assess the impact of cytokine (interferon-α and tyrosine kinase inhibitor (TKI; sunitinib or sorafenib) treatment on OS in metastatic (m)RCC.

RESULTS

From 2000 to 2008, 8009 patients were diagnosed with RCC and 2753 with mRCC (2002-2008). Median OS in RCC patients diagnosed from 2006 to 2008 compared with 2000-2005 was not reached vs 47.9 months (P<0.001), and in mRCC patients diagnosed from 2006 to 2008 compared with 2002-2005, was 12.4 vs 9.6 months, respectively (P=0.004). Factors associated with significantly improved OS in RCC were female gender, lower age, and previous nephrectomy, and, in mRCC female gender, previous nephrectomy, and any TKI prescription (Model 1: median-adjusted OS, 19.4 months (TKI patients) vs 9.7 months (non-TKI patients); hazard ratio, 0.621; P<0.001).

CONCLUSION

OS was improved in Swedish patients diagnosed with RCC and mRCC in the period 2006-2008 compared with 2000-2005 (RCC) and 2002-2005 (mRCC). Although multifactorial in origin, results suggest that increased nephrectomy rates and the use of TKIs contributed to the improvement seen in mRCC patients.

Colposcopy referral rate can be reduced by high-risk human papillomavirus triage in the management of recurrent atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion cytology in Finland

The aim of this study was to establish whether a combination of high-risk human papillomavirus (hrHPV) testing and cervical cytology could reduce colposcopy referral among women with atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion cytology. We randomized 598 women in the Helsinki area, Finland into three study groups. Different strategies of hrHPV testing, cytology and colposcopy with biopsy were used; subsequent hrHPV test results and cytological findings were compared with histology. The rates of hrHPV positivity and CIN2+ were compared. In total, 62.5% of all samples were hrHPV-positive. Altogether 45 (12.7%) CIN2 or worse (CIN2+) lesions were found in study groups A and B. Among hrHPV-positive women the rate of CIN2+ was 19.0% (n = 43), in contrast with 1.6% (n = 2) among hrHPV-negative women (relative risk = 12.2, 95% confidence interval [CI] 3.6-81.1, P < 0.001). Among all hrHPV-negative women whose cytological findings were normal or ASCUS, dysplastic lesions were uncommon (n = 4/119, 3.4%), and all were CIN1. If these women had not been referred to colposcopy, the number of colposcopies would have been reduced by 33.6%. We conclude that hrHPV testing combined with repeat cervical cytology had a high negative predictive value in patients with recurrent low-grade cervical cytology. This could reduce the referral rate to colposcopy without jeopardizing patient safety.

What is a 'secure base' when death is approaching? A study applying attachment theory to adult patients' and family members' experiences of palliative home care

OBJECTIVE

Attachment theory has received much interest lately in relation to how adults cope with stress and severe illness. The aim of this study was using the experiences of patients and family members to explore palliative home care as a 'secure base' (a central concept within the theory).

METHODS

Twelve patients and 14 family members were interviewed during ongoing palliative home care. The interviews were analysed with deductive qualitative content analysis.

RESULTS

Informants expressed the relevance of sensing security during palliative home care because death and dying were threats that contributed to vulnerability. Palliative home care could foster a feeling of security and provide a secure base. This was facilitated when informants had trust in staff (e.g. due to availability and competence in providing symptom relief), felt recognised as individuals and welcomed to contact the team in times of needs. Being comfortable, informed and having an everyday life also contributed to a perception of palliative home care as a secure base. Family members stressed the importance of being relieved from responsibilities that were too heavy. The underlying meanings of experiencing palliative home care as a secure base involved gaining a sense of control and of inner peace, perceiving that despite a demanding and changed life situation, one could continue partially being oneself and having something to hope for, even if this no longer concerned cure for the ill person.

CONCLUSIONS

Important aspects of palliative home care as providing a secure base were identified and these have implications for clinical practice.

Using population mixtures to optimize the utility of genomic databases: linkage disequilibrium and association study design in India

When performing association studies in populations that have not been the focus of large-scale investigations of haplotype variation, it is often helpful to rely on genomic databases in other populations for study design and analysis - such as in the selection of tag SNPs and in the imputation of missing genotypes. One way of improving the use of these databases is to rely on a mixture of database samples that is similar to the population of interest, rather than using the single most similar database sample. We demonstrate the effectiveness of the mixture approach in the application of African, European, and East Asian HapMap samples for tag SNP selection in populations from India, a genetically intermediate region underrepresented in genomic studies of haplotype variation.

The evolutionary history of the common chloroplast genome of Arabidopsis thaliana and A. suecica

The evolutionary history of the common chloroplast (cp) genome of the allotetraploid Arabidopsis suecica and its maternal parent A. thaliana was investigated by sequencing 50 fragments of cpDNA, resulting in 98 polymorphic sites. The variation in the A. suecica sample was small, in contrast to that of the A. thaliana sample. The time to the most recent common ancestor (T(MRCA)) of the A. suecica cp genome alone was estimated to be about one 37th of the T(MRCA) of both the A. thaliana and A. suecica cp genomes. This corresponds to A. suecica having a MRCA between 10 000 and 50 000 years ago, suggesting that the entire species originated during, or before, this period of time, although the estimates are sensitive to assumptions made about population size and mutation rate. The data was also consistent with the hypothesis of A. suecica being of single origin. Isolation-by-distance and population structure in A. thaliana depended upon the geographical scale analysed; isolation-by-distance was found to be weak on the global scale but locally pronounced. Within the genealogical cp tree of A. thaliana, there were indications that the root of the A. suecica species is located among accessions of A. thaliana that come primarily from central Europe. Selective neutrality of the cp genome could not be rejected, despite the fact that it contains several completely linked protein-coding genes.

Enhanced ice sheet growth in Eurasia owing to adjacent ice-dammed lakes

Large proglacial lakes cool regional summer climate because of their large heat capacity, and have been shown to modify precipitation through mesoscale atmospheric feedbacks, as in the case of Lake Agassiz. Several large ice-dammed lakes, with a combined area twice that of the Caspian Sea, were formed in northern Eurasia about 90,000 years ago, during the last glacial period when an ice sheet centred over the Barents and Kara seas blocked the large northbound Russian rivers. Here we present high-resolution simulations with an atmospheric general circulation model that explicitly simulates the surface mass balance of the ice sheet. We show that the main influence of the Eurasian proglacial lakes was a significant reduction of ice sheet melting at the southern margin of the Barents-Kara ice sheet through strong regional summer cooling over large parts of Russia. In our simulations, the summer melt reduction clearly outweighs lake-induced decreases in moisture and hence snowfall, such as has been reported earlier for Lake Agassiz. We conclude that the summer cooling mechanism from proglacial lakes accelerated ice sheet growth and delayed ice sheet decay in Eurasia and probably also in North America.

Chloroplast DNA indicates a single origin of the allotetraploid Arabidopsis suecica

DNA sequencing was performed on up to 12 chloroplast DNA regions [giving a total of 4288 base pairs (bp) in length] from the allopolyploid Arabidopsis suecica (48 accessions) and its two parental species, A. thaliana (25 accessions) and A. arenosa (seven accessions). Arabidopsis suecica was identical to A. thaliana at all 93 sites where A. thaliana and A. arenosa differed, thus showing that A. thaliana is the maternal parent of A. suecica. Under the assumption that A. thaliana and A. arenosa separated 5 million years ago, we estimated a substitution rate of 2.9 x 10(-9) per site per year in noncoding single copy sequence. Within A. thaliana we found 12 substitution (single bp) and eight insertion/deletion (indel) polymorphisms, separating the 25 accessions into 15 haplotypes. Eight of the A. thaliana accessions from central Sweden formed one cluster, which was separated from a cluster consisting of central European and extreme southern Swedish accessions. This latter cluster also included the A. suecica accessions, which were all identical except for one 5 bp indel. We interpret this low level of variation as a strong indication that A. suecica effectively has a single origin, which we dated at 20 000 years ago or more.

Ice shelves in the Pleistocene Arctic Ocean inferred from glaciogenic deep-sea bedforms

It has been proposed that during Pleistocene glaciations, an ice cap of 1 kilometre or greater thickness covered the Arctic Ocean. This notion contrasts with the prevailing view that the Arctic Ocean was covered only by perennial sea ice with scattered icebergs. Detailed mapping of the ocean floor is the best means to resolve this issue. Although sea-floor imagery has been used to reconstruct the glacial history of the Antarctic shelf, little data have been collected in the Arctic Ocean because of operational constraints. The use of a geophysical mapping system during the submarine SCICEX expedition in 1999 provided the opportunity to perform such an investigation over a large portion of the Arctic Ocean. Here we analyse backscatter images and sub-bottom profiler records obtained during this expedition from depths as great as 1 kilometre. These records show multiple bedforms indicative of glacial scouring and moulding of sea floor, combined with large-scale erosion of submarine ridge crests. These distinct glaciogenic features demonstrate that immense, Antarctic-type ice shelves up to 1 kilometre thick and hundreds of kilometres long existed in the Arctic Ocean during Pleistocene glaciations.

Fentanyl patches for the treatment of pain in dying cancer patients

It has been claimed that fentanyl patches are less suitable for elderly patients and for patients who are terminally ill and dying. In a retrospective survey of 205 cancer patients who died within the hospital-based home care in Norrköping, Sweden between January 1997 and June 1998 we identified 34 patients who had used fentanyl patches. 30 patients were possible to evaluate for the analgesic efficacy of transdermal fentanyl. 18 out of 30 patients were treated with fentanyl until time of death. The estimated efficacy was good or moderate in 93% and 88%, respectively, of patients younger or older than 65 years of age.

[Midazolam (Dormicum) in terminal anxiety and agitation. The last choice alternative in palliative care]

Although midazolam has been proposed for the treatment of a variety of conditions such as anxiety, dyspnoea, hiccups and status epilepticus, terminal agitation is the only condition where its use is based on a reasonably large number of published clinical studies. A causal approach is generally recommended. Whenever possible, the aetiological condition (pain, fever, constipation, etc.) should be corrected. Such general measures as ensuring a peaceful, familiar environment, and the use of a night light, fluid therapy to counteract dehydration, and antipyretics for fever are beneficial. When symptomatic treatment is needed, drugs with little anticholinergic effect are to be recommended. The use of benzodiazepines as single drug treatment may exacerbate the condition. Haloperidol or risperidone (which has fewer side effects) are recommended. If the agitation is marked, a common strategy is to add lorazepam. Chlormethiazole is an alternative. Subcutaneous midazolam should be reserved for refractory cases. Attention should be paid to dosage, reduced doses being given to the elderly, patients on opioid medication, and patients with impaired liver or renal function. Overdosage may induce deep sedation, and result in carbon dioxide retention and subsequently heart failure and pulmonary oedema which may be fatal.

[Nausea is a common symptom in palliative care. Choice of treatment is based on the cause]

Nausea is a common and distressing condition often regarded solely as a symptom. In many cases, however, there is a clear cause, and causal treatment is to be preferred if it is at all possible. In terminal cases, where causal treatment is not always possible, symptomatic pharmaceutical treatment combined with good care and appropriate diet is preferable.

A randomised placebo controlled study with ondansetron in patients undergoing fractionated radiotherapy

BACKGROUND

There are few randomised studies comparing anti-emetic drugs for the prevention of nausea and vomiting in patients treated with fractionated radiotherapy. The aim of the study was to compare the anti-emetic efficacy of 8 mg dose ondansetron twice a day with placebo.

MATERIALS AND METHODS

One hundred eleven patients who were to commence a course of 10 or more daily fractionated radiotherapy including the abdomen were included in the study. The patients recorded daily emesis, nausea and bowel habit and graded weekly symptoms of nausea, vomiting, diarrhoea and lack of appetite. The EORTC C30 questionnaire was completed.

RESULTS

67% of patients given ondansetron had complete control of emesis compared with 45% of patients with placebo (P < 0.05). The number of emetic episodes recorded on the worst day was 1.4 for the ondansetron group and 3.1 for the placebo group (P < 0.01). Patients given ondansetron had fewer days with emesis and nausea compared with placebo (P < 0.05). The mean sum score of patients weekly grading of symptoms showed that the ondansetron group had less inconvenience than the placebo group (P < 0.05). This difference persisted during the first three weeks, but not thereafter. Similarly, some quality of life measures showed significant differences in favour of the ondansetron group. More patients (n = 13) withdrew due to lack of efficacy in the placebo group compared with patients (n = 8) in the ondansetron group.

CONCLUSIONS

The present study illustrates that prophylactic anti-emetic administration of ondansetron is effective in preventing nausea and vomiting in patients undergoing fractionated radiotherapy of the abdomen.

Treatment of Hodgkin's disease: the Swedish National Care Programme experience

Since 1985 a Swedish National Care Programme has provided tailored principles for the diagnosis, staging, treatment and follow-up of patients with Hodgkin's disease (HD). This report gives the rationale behind the recommendations and presents treatment results for 648 patients diagnosed between 1985 and 1989 after a median follow-up of 70 months. Two hundred and twenty-nine (35%) patients were over 60 years of age. Treatment results for patients below 60 years of age in early and intermediate stages were favourable, provided the recommendations were followed. In advanced stages, the outcome was inferior in patients with CS IIB bulky disease and stage IVB. The prognosis of elderly patients remains poor, although it is too early to evaluate any impact of revisions made in 1989. The tailored principles, which usually entail less staging and/or treatment than is generally the case in the early and intermediate stages, produced favourable results when applied to an unselected group of patients with HD. Only minor changes were made in the recommendations during the 1994 revision.

Samarium-153-EDTMP in bone metastases

Thirty-five patients with painful bone metastases arising from a variety of tumor types underwent a clinical trial in which 153Sm-EDTMP was injected as a single intravenous dose. The injection ranged in amount from 330 MBq to 1110 MBq of 153Sm-EDTMP. Pain relief usually occurred within one week after administration. The duration of pain relief lasted from 2 to 17 weeks. A detectable degree of pain palliation was experienced by 80% of the treated patients; 54% reported substantial or complete pain relief. Due to the small number of patients, no clear-cut dose-related response was detectable. Moderate myelosuppression was observed in one patient (WHO grade III). The metastatic lesion-to-normal bone ratios remained constant (varying from 1.5 to 4.8) for at least 5 days post-injection. 153Sm cleared very rapidly from the blood. Less than 1% of the injected dose remained in circulation at 4 hours post-injection. No local accumulation of the tracer could be detected outside the skeleton. Urinary excretion was quite complete at 6 hours post-injection. The biodistributions of 153Sm-EDTMP and 99mTc-DPD are very similar in metastatic and normal bone; thus, bone scanning can be used for patient selection and followup. According to our results, it seems that higher doses of 153Sm-EDTMP can be given safely and without any irreversible myelosuppression.

Treatment of early and intermediate stages of supradiaphragmatic Hodgkin's disease: the Swedish National Care Programme experience. Swedish Lymphoma Study Group

PURPOSE

Since 1985 a Swedish National Care Programme has provided tailored principles for the staging, treatment and follow-up of patients with Hodgkin's disease (HD). This report presents treatment results for all patients below 60 years of age who were diagnosed with early and intermediate stages, between 1985 and 1989.

PATIENTS AND TREATMENT

During that period, 210 patients with supradiaphragmatic HD in clinical (CS) and pathological (PS) stages IA+IIA, PS IB+IIB, and PS III1 A were diagnosed in five Health Care Regions in Sweden. In patients with CS IA, staging laparotomy was not recommended provided that the radiological assessment of the abdomen was adequate, whereas this procedure was recommended in stages CS IB, IIA and IIB in order to minimize treatment. In the absence of bulky mediastinal disease, patients with CS+PS IA and PS IIA were treated with mantle (occasionally mini-mantle) irradiation alone, while patients with bulky disease, as well as those with stages PS IB+IIB+III1 A, were treated with one cycle of MOPP/ABVD prior to mantle (PS III1 A sub-total nodal) irradiation. Full chemotherapy followed by radiotherapy to initial sites with bulky disease was recommended for patients with CS IIA who did not undergo laparotomy.

RESULTS

After a median follow-up in excess of five years, treatment results are 'favourable' for all stages, provided the recommendations were followed. In patients with CS+PS IA treated according to the recommendations, recurrence rates were 14% (9/65) with all but one patient (64/65, 98%) remaining in continuous first or second remission. These figures were worse in patients treated inadequately (9/26 [35%] and 22/26 [85%], respectively). In PS IIA, adequately-treated patients had a recurrence rate of 13% (7/52) whereas 5/7 (71%) of those with bulky disease who received only mantle irradiation developed recurrences. Similar patterns also emerged in patients with CS IIA, PS IB+IIB and PS III1 A.

CONCLUSIONS

The tailored principles, which usually entail less staging and/or treatment than is generally the case, produced favourable results when applied to an entirely unselected group of patients with early and intermediate stages of HD.

Carboplatin and etoposide in extensive small cell lung cancer

The combination of carboplatin and etoposide was evaluated in 61 previously untreated patients with extensive small cell lung cancer. Treatment was given at four-week intervals with 450 mg/m2 of carboplatin intravenously (i.v.) on day 1 and etoposide 100 mg/m2 i.v. on days 1-3. The response was complete in 5 (9%) and partial in 28 (50%) of the 56 evaluable patients (overall response rate 59%). The median time to progression after response as well as the median survival time in all evaluable patients was 4.6 months. WHO grade 3 and 4 leukopenia and thrombocytopenia occurred in 8% and 11% of the courses respectively. Two treatment-related deaths were registered. The combination of carboplatin and etoposide used in the present study produced acceptable response rate and toxicity, but duration of response and median survival were shorter than expected from earlier studies.

A phase II study of metastatic melanoma treated with a combination of interferon alfa 2b, dacarbazine and nimustine

52 patients with metastatic melanoma have been treated with a combination of recombinant interferon-alfa-2b, dacarbazine and nimustine. The objective response rate was 23% with 9 complete responses (CR) and 3 partial responses (PR). The mean duration of the response was 18+ months for CR (6-31+ months) and 7 months for PR patients (4-10 months). The mean survivals were 24+ months (8-38 months) and 7 months (4-12 months), respectively. The mean duration of the response for patients with stable disease was 10+ months (2-48+ months) and the mean survival 17+ months (3-48+ months), while the patients with progressive disease died within 12 months (mean 4 months). The best responding sites were the lymph node, the lung and the subcutaneous metastases. Myelosuppression was the main adverse effect of the therapy. WHO grade 3-4 toxicity was seen in 27 patients leading to delay and reduced dosage of therapy; in 4 patients treatment was discontinued, 8 patients had no side effects. Combination therapy with interferon and dacarbazine and nimustine for metastatic melanoma offers no advantage over interferon and dacarbazine.

Vincristine, doxorubicin and cyclophosphamide with and without etoposide in limited small cell lung cancer

A total of 80 patients with limited disease of small cell lung cancer were randomized to receive either vincristine 1 mg/m2 (max. 2 mg), doxorubicin 50 mg/m2 and cyclophosphamide 750 mg/m2 (VAC) i.v. on day 1, or the same drugs and etoposide 80 mg/m2 i.v. daily for 3 days (VACE) every 3 weeks for nine courses. Chest irradiation was given in both regimens after the second course. The response rate was 84% for VAC (41% complete responses) and 75% for VACE (46% complete responses). The median survival time was 10 months with VAC regimen, and 14 months with VACE (difference statistically not significant). The median duration of remission was 8 months with VAC and 14 months with VACE (p = 0.03), and the median survival for complete or partial responders was 12 months and 20 months respectively (p = 0.006). Myelosuppression was significantly greater in the VACE group, and there was one treatment related death in the group receiving VACE. In this study the addition of etoposide to VAC improved the duration of response, but did not lead to longer survival of patients with limited disease of small cell lung cancer.

Mammographic and palpation findings in the irradiated spared breast

Between 1983 and 1987, 22 women underwent breast-preserving treatment for T1 (n = 19) or T2 (n = 3) cancer. Axillary surgery was performed in 17 patients and axillary node "sampling" in one patient, while 4 patients had no axillary surgery. Radiotherapy was begun no later than six weeks after operation. The patients had the first post-treatment follow-up examination at 1 month to 41 months after irradiation. Six of the patients had more than one follow-up examination. According to the length of the follow-up period, there were two different groups of patients. Fourteen patients had the first follow-up examination at 1 month to 10 months after completion of radiation treatment. Eleven breasts (79%) had solid consistency as well as radiological edema. Six of the breasts had signs of severe edema seen during the first 6 months. At the second or third examination, if made after 10 months, the signs of edema decreased or disappeared. Eight patients examined for the first time at 12 to 41 months after radiation treatment had no radiological signs of breast edema and only 3 of the breasts were solid. The present results suggest that post-treatment mammograms are not useful during the first 6 months after irradiation and that the value of palpation is limited to at least 10 months; in selected patients these periods can be considerably longer.

Inoperable non-small cell lung cancer: radiation with or without chemotherapy

We report a randomized multicentre study of split-course radiotherapy (RT), with or without combination chemotherapy (CT), in 238 patients with inoperable non-small cell lung cancer (NSCLC), previously untreated, confined to one hemithorax and the mediastinal nodes. In both treatment groups RT consisted of 55 Gy in 20 F given over 7 weeks with a 3-week rest interval. CT consisted of the 3-drug regimen CAP: C = cyclophosphamide 400 mg/m2, A = adriamycin 40 mg/m2, P = cisplatin 40 mg/m2; 2 cycles of CAP given before RT, one during the rest interval and six after RT. Seventy per cent in the RT arm and 67% in the RT-CT arm had epidermoid carcinoma. No significant difference was apparent between the RT and the RT-CT arms with respect to objective response rates (CR + PR) (44 and 49%, respectively), median duration of response (278 and 320 days), local failure (31 and 20%), distant progression (23 and 20%) or median survival (311 and 322 days). The survival figures showed an almost significant (P = 0.05) therapeutic advantage of the combined regimen with stage IIIM0 disease. Progressive disease was the cause of death in 92% and 88%. We conclude that chemotherapy did not contribute significantly to either local control or survival as compared to radiotherapy alone.

Misonidazole combined with radiotherapy in the treatment of non-small cell lung cancer. A randomized double-blind trial

Forty-one patients with inoperable non-small cell lung cancer were randomized to receive irradiation therapy 45 Gy in ten fractions over eight weeks, plus either placebo or misonidazole 1.2 g/m2 orally on treatment day. The irradiated area was the primary tumour. Twenty-one patients received misonidazole and 20 received placebo. Minimal observation time for the study was 36 months. No clear difference was observed in the pattern of relapse between the groups. 43% of the patients in the misonidazole group attained a complete response (CR) or partial response (PR) as compared with 65% in the placebo group. Median survival time was twelve months in the misonidazole group and 14 months in the placebo group.

The effect of surgery, radiation therapy, and combined radiation therapy and chemotherapy on immunocompetence in patients with lung carcinoma

The immunologic status of 59 patients with lung carcinoma was determined by analysis of peripheral venous blood samples. The following tests were performed: total leucocyte and lymphocyte counts, the number of acid alpha-naphthyl acetate esterase (ANAE) positive cells (T-cells), and phytohaemagglutinin (PHA) and tuberculin (PPD) transformation tests. The patients were divided into three treatment groups: a surgery group (S), a radiation therapy group (R), and a combined cytostatic and radiation therapy group (C). A follow-up was carried out 4 to 6 months after treatment. The therapeutic measures, resection, irradiation, and chemotherapy, produced a decrease in the total leucocyte and lymphocyte counts, in the number of T-cells, and in the leucocyte transformation response to PPD. In the surgically treated group the decrease was transient. In the groups treated with radiation therapy and combined cytostatic and radiation therapy the values remained low throughout the follow-up. The lymphocyte response to PHA was not altered in any of the groups during initial treatment or follow-up. The results did not suggest a correlation between the immunologic parameters used and the stage and histologic type of lung cancer. The tests were of no clinical value in the determination of the individual prognosis.