Return-to-Work Coordinators' Perceptions of Their Roles Relative to Workers: A Discourse Analysis

PURPOSE

This paper describes how Canadian Return to Work coordinators (RTWC) framed their job roles relative to workers in ways that went beyond the usual professional norms of helping worker recovery.

METHODS

In-depth interviews were conducted with 47 RTWCs across Canada in 2018-2019. We used critical discourse analysis to analyze the way coordinators viewed workers in the complex, multi-stakeholder system of RTW.

RESULTS

We identified four ways that RTWCs positioned themselves relative to workers: as trust builders, experts, detectives and motivators. These roles reflected RTWCs position within the system; however, their discourse also contributed to the construction of a moral hierarchy that valued worker motivation and framed some workers as attempting to exploit the RTW system.

CONCLUSIONS

RTWCs' positions of power in the coordination process warrant further investigation of how they exercise judgement and discretion, particularly when the process depends on their ability to weigh evidence and manage cases in what might be seen as an objective and fair manner.

Abstract GS4-05: Dose escalated simultaneous integrated boost radiotherapy for women treated by breast conservation surgery for early breast cancer: 3-year adverse effects in the IMPORT HIGH trial (CRUK/06/003)

Background

IMPORT HIGH is a randomised, multi-centre phase III trial testing dose escalated simultaneous integrated boost (SIB) against sequential boost each delivered by intensity modulated radiotherapy (IMRT) for early stage breast cancer with higher risk of local relapse. The primary endpoint was initially breast induration at 3 years, requiring 840 patients; accrual was extended (target 2568) with the new primary endpoint of local relapse. We report adverse effects (AE) at 3 years.

Methods

Women age ≥18 after breast conservation surgery for pT1-3 pN0-pN3a M0 invasive carcinoma were eligible. Randomisation was 1:1:1 between 40Gy/15F to whole breast (WB) + 16Gy/8F sequential photon boost to tumour bed (40+16Gy), 36Gy/15F to WB, 40Gy to partial breast + 48Gy (48Gy) or + 53Gy (53Gy) in 15F SIB to tumour bed. AEs were assessed annually by clinicians in all patients and in a planned sub-set (840) of patients by photographs at 3 years and by patients at 6 months, 1 and 3 years. AE scores were dichotomised as none/mild vs marked for photographs and none/mild vs moderate/marked for patients and clinicians. Fisher's exact tests compared groups; principal comparison (protocol-specified) between 53Gy and 48Gy (p<0.01 defined as statistical significance).

Results

2617 women consented between 03/2009 and 09/2015 from 39 UK radiotherapy centres. Median follow-up was 49.1 (IQR 36.8-63.2) months. Median age was 49 (IQR 44-56); 9%, 38% & 53% were tumour grade 1, 2 & 3 respectively; 30% were node positive. 66% received chemotherapy and 73% endocrine therapy. 3-year AE data were available for 2017 clinician assessments, 641 photographs and 842 patient assessments. Proportions of patients with marked AEs were low overall. Rates of moderate/marked AEs at 3 years were broadly similar between the randomised groups; with a suggestion of a slightly increased risk for breast induration in 53Gy compared with control (borderline significance).

AE at 3 years 40+16Gy n(%)48Gy n(%)53Gy n(%)ClinicianBreast induration;N656668654None451 (69)483 (72)445 (68)Mild167 (25)141 (21)146 (22)Moderate32 (5)42 (6)56 (9)Marked6 (1)2 (1)7 (1)P-value 0.57010.0102  0.0443Breast shrinkage;N655669654None442 (68)472 (71)448 (69)Mild167 (26)161 (24)166 (25)Moderate40 (6)33 (5)35 (5)Marked6 (1)3 (1)5 (1)P-value 0.25410.5772  0.6373Breast distortion;N656669654None451 (69)464 (69)442 (68)Mild169 (26)170 (25)170 (26)Moderate33 (5)32 (5)38 (6)Marked3 (1)3 (1)4 (1)P-value 0.90310.4862  0.4113PatientChange in breast appearance;N287264285None38 (13)50 (19)58 (20)Mild164 (57)151 (57)142 (50)Moderate57 (20)45 (17)54 (19)Marked28 (10)18 (7)31 (11)P-value 0.14910.9992  0.1243PhotographChange in breast appearance;N218210213None183 (84)185 (88)177 (83)Mild25 (11)23 (11)32 (15)Marked10 (5)2 (1)4 (2)P-value 0.03610.1732  0.6853148Gy v 40+16Gy; 253Gy v 40+16Gy; 353Gy v 48Gy

Conclusions

These results represent the largest and most mature reported AE outcomes of breast SIB within a clinical trial. At 3 years, rates of moderate/marked AEs were similar between SIB IMRT and WB + sequential boost IMRT delivered over 3 and 4.5 weeks respectively.

Citation Format: Coles CE, Griffin CL, Kirby AM, Haviland JS, Titley JC, Benstead K, Brunt AM, Chan C, Ciurlionis L, Din OS, Donovan EM, Eaton DJ, Harnett AN, Hopwood P, Jefford ML, Jenkins PJ, Lee CE, McCormack M, Sherwin L, Syndikus I, Tsang Y, Twyman NI, Ventikaraman R, Wickers S, Wilcox MH, Bliss JM, Yarnold JR. Dose escalated simultaneous integrated boost radiotherapy for women treated by breast conservation surgery for early breast cancer: 3-year adverse effects in the IMPORT HIGH trial (CRUK/06/003) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS4-05.

Women's Free-text Comments on their Quality of Life: An Exploratory Analysis from the UK Standardisation of Breast Radiotherapy (START) Trials for Early Breast Cancer

Aims

Exploratory analysis of patients' unsolicited written comments in the first 2 years of the Standardisation of Breast Radiotherapy (START) trial quality of life study highlighted a potential effect of non-treatment-related problems on the ratings and interpretation of patient self-reported questionnaires. At 5 years of follow-up all eligible subjects were invited to write comments to further explore these findings.

Materials and methods

Using inductive qualitative methods informed by the exploratory analysis, comments were allocated to relevant themes. Key patient-reported outcome measures (PROMs), clinical and demographic factors were collated for patients who did and did not comment at 5 years and comparisons between the groups explored.

Results

Of 2208 women completing baseline PROMs, 482 proffered comments from 0 to 24 months, forming nine distinct themes, including chronic conditions, life events and psychosocial concerns. At 5 years, 1041/1727 (60.3%) women contributed comments, of whom 500 randomly selected participants formed the sample for analysis. Findings revealed comorbidity, impaired physical functioning and psychosocial problems as key themes, with prevalent adverse effects from local and systemic treatments. Eight new themes emerged at 5 years, including ageing, concerns about future cancer and positive aspects of care. Women commenting were better educated, slightly older and more likely to have had chemotherapy compared with non-commenters. They had significantly worse PROM scores for global health and key quality of life domains relevant to the difficulties they revealed.

Conclusions

Difficult personal circumstances and other health concerns affected many women's PROM ratings at 5 years of follow-up, in addition to ongoing cancer treatment effects. Greater attention to multiple sources of distress and adversity could facilitate personalised care and aid interpretation of PROMs.

Do Patient-reported Outcome Measures Agree with Clinical and Photographic Assessments of Normal Tissue Effects after Breast Radiotherapy? The Experience of the Standardisation of Breast Radiotherapy (START) Trials in Early Breast Cancer

AIMS

In radiotherapy trials, normal tissue effects (NTE) are important end points and it is pertinent to ask whether patient-reported outcome measures (PROMs) could replace clinical and/or photographic assessments. Data from the Standardisation of Breast Radiotherapy (START) trials are examined.

MATERIALS AND METHODS

NTEs in the treated breast were recorded by (i) annual clinical assessments, (ii) photographs at 2 and 5 years, (iii) PROMs at 6 months, 1, 2 and 5 years after radiotherapy. Hazard ratios for the radiotherapy schedules were compared. Measures of agreement of assessments at 2 and 5 years tested concordance.

RESULTS

PROMs were available at 2 and/or 5 years for 1939 women, of whom 1870 had clinical and 1444 had photographic assessments. All methods were sensitive to the dose difference between schedules. Patients reported a higher prevalence for all NTE end points than clinicians or photographs (P < 0.001 for most NTEs). Concordance was generally poor; weighted kappa at 2 years ranged from 0.05 (telangiectasia) to 0.21 (shrinkage and oedema). The percentage agreement was lowest between PROMs and photographic assessments of change in breast appearance (38%).

CONCLUSIONS

All three methods produced similar conclusions for the comparison of trial schedules, despite low concordance between the methods on an individual patient basis. Careful consideration should be given to the different contributions of the measures of NTE in future radiotherapy trials.

Learning from the QUEST multicentre feasibility randomization trials in breast reconstruction after mastectomy

BACKGROUND

Breast reconstruction aims to improve health-related quality of life after mastectomy. However, evidence guiding patients and surgeons in shared decision-making concerning the optimal type or timing of surgery is lacking.

METHODS

QUEST comprised two parallel feasibility phase III randomized multicentre trials to assess the impact of the type and timing of latissimus dorsi breast reconstruction on health-related quality of life when postmastectomy radiotherapy is unlikely (QUEST A) or highly probable (QUEST B). The primary endpoint for the feasibility phase was the proportion of women who accepted randomization, and it would be considered feasible if patient acceptability rates exceeded 25 per cent of women approached. A companion QUEST Perspectives Study (QPS) of patients (both accepting and declining trial participation) and healthcare professionals assessed trial acceptability.

RESULTS

The QUEST trials opened in 15 UK centres. After 18 months of recruitment, 17 patients were randomized to QUEST A and eight to QUEST B, with overall acceptance rates of 19 per cent (17 of 88) and 22 per cent (8 of 36) respectively. The QPS recruited 56 patients and 51 healthcare professionals. Patient preference was the predominant reason for declining trial entry, given by 47 (53 per cent) of the 88 patients approached for QUEST A and 22 (61 per cent) of the 36 approached for QUEST B. Both trials closed to recruitment in December 2012, acknowledging the challenges of achieving satisfactory patient accrual.

CONCLUSION

Despite extensive efforts to overcome recruitment barriers, it was not feasible to reach timely recruitment targets within a feasibility study. Patient preferences for breast reconstruction types and timings were common, rendering patients unwilling to enter the trial.

Comparison of patient reported quality of life and impact of treatment side effects experienced with a taxane-containing regimen and standard anthracycline based chemotherapy for early breast cancer: 6 year results from the UK TACT trial (CRUK/01/001)

BACKGROUND

The TACT trial (CRUK/01/001) compared adjuvant sequential FEC-docetaxel (FEC-D) chemotherapy with standard anthracycline-based chemotherapy of similar duration in women with early breast cancer. Results at a median of 5 years suggested no improvement in disease-free survival with FEC-D. Given differing toxicity profiles of the regimens, the impact on quality of life (QL) was explored.

METHODS

Patients from 44 centres completed standardised QL questionnaires before chemotherapy, after cycles 4 and 8, at 9, 12, 18 and 24 months and at 6 years follow-up. Patient diaries assessed frequency, associated distress and impact on daily activity of 15 treatment related side effects.

FINDINGS

830 patients (415 FEC-D; 415 controls) contributed assessments during 0-24 months; 362 of whom participated again at 6 years. During chemotherapy, FEC-D impaired global health/QL and depression rates and significantly more QL domains than standard regimens. Novel diary card ratings highlighted significantly more distress and interference with daily activities due to FEC-D side effects compared with standard treatment. In both groups, most QL parameters returned to baseline levels by 2 years and were unchanged at 6 years.

INTERPRETATION

Within expected negative effects of chemotherapy on wide ranging QL domains FEC-D patients reported greater toxicity, disruption and distress during treatment with no improvement in disease outcome at 5 years than patients receiving standard anthracycline-based chemotherapy. Findings should inform future patients of relative costs and benefits of adjuvant chemotherapy.

Abstract P2-19-10: Quality of life following mastectomy and breast reconstruction (QUEST): Learning from two feasibility randomized controlled clinical trials

Background: Breast reconstruction (BRR) aims to improve health related quality of life (HRQL) after mastectomy, but with poor evidence to date informing the optimal type or timing of surgery to guide shared-decision making. Systematic reviews show the paucity of randomised trials (RCT) with only two-singe centre RCTs. Although, an RCT has theoretical advantages, there have been concerns that clinicians may not share clinical equipoise regarding recommending types of BRR surgery that is sensitive to patient preferences. The aim of the QUEST trials (CRUK/08/027) was to determine the optimal types of latissimus dorsi (LD) BRR (Trial A) when there is no expectation for post-mastectomy radiotherapy (PMRT), and timings of LDBRR when PMRT is recommended (Trial B), that would benefit HRQL during five years post-operatively. As this was the first attempt at a multi-centre RCT, the main trial was preceded by a feasibility phase to demonstrate that recruitment was achievable and that randomization was acceptable to patients. An embedded qualitative study, the QUEST Perspective Study (QPS) assessed the perceptions of equipoise of patients and health care professionals (HCPs) for the types of surgery.

Methods: QUEST comprised two parallel phase III multicentre feasibility RCTs to assess HRQL impact of the type of LDBRR when PMRT is unlikely (Trial A, LD - implant assisted (LDI) versus extended autologous LD (ALD)). Trial B evaluated optimal timings of LDBRR comparing staged - delayed ALD (skin-preserving sub-pectoral expander implant then ALD) to immediate ALD when PMRT was likely.

Eligible patients comprised mastectomy recommended for invasive breast cancer or DCIS in the context of technical feasibility for ALD and preferred synchronous breast reduction. The primary endpoint was the proportion of eligible women approached who accepted randomisation. QPS explored patients and HCPs’ acceptability of the trial and randomisation using semi-structured telephone interviews and questionnaires.

Results: The QUEST trials opened in May 2011 with 15 UK centres participating. After 18 months of recruitment, 17 patients had been entered in Trial A and 8 in trial B with acceptance rates of 19% (17/88) and 22% (8/36) for trial A and B respectively. Patient preference was the predominant reason for eligible patients approached about the trial not being randomised with 47 of the 88 (53%) for Trial A and 22 of 36 (61%) eligible for Trial B, declining for that reason. Patient acceptance rates for randomisation increased from 19% during the first 6 months to 29% from 7-12 months for Trial A; corresponding figures for Trial B were 11% and 27%. The recruitment challenges and funding cessation caused the Trial Steering Committee to recommend trial closure in December 2012.

Conclusion: Despite the need for clinical evidence, patients retained strong preferences for breast reconstruction type and timing, amidst ‘standardised’ trial processes. Patient acceptance rates did improve during the trial, but it was not possible to meet target recruitment within the constraints of a feasibility trial.

Funding for this NCRN portfolio trial (92581226) was from Cancer Research UK (CRUK) and BUPA Foundation funding for QPS.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-19-10.

The cost-effectiveness of adjuvant chemotherapy for early breast cancer: A comparison of no chemotherapy and first, second, and third generation regimens for patients with differing prognoses

BACKGROUND

The risk of recurrence following surgery in women with early breast cancer varies, depending upon prognostic factors. Adjuvant chemotherapy reduces this risk; however, increasingly effective regimens are associated with higher costs and toxicity profiles, making it likely that different regimens may be cost-effective for women with differing prognoses. To investigate this we performed a cost-effectiveness analysis of four treatment strategies: (1) no chemotherapy, (2) chemotherapy using cyclophosphamide, methotrexate, and fluorouracil (CMF) (a first generation regimen), (3) chemotherapy using Epirubicin-CMF (E-CMF) or fluorouracil, epirubicin, and cyclophosphamide (FEC60) (a second generation regimens), and (4) chemotherapy with FEC60 followed by docetaxel (FEC-D) (a third generation regimen). These adjuvant chemotherapy regimens were used in three large UK-led randomised controlled trials (RCTs).

METHODS

A Markov model was used to simulate the natural progression of early breast cancer and the impact of chemotherapy on modifying this process. The probability of a first recurrent event within the model was estimated for women with different prognostic risk profiles using a parametric regression-based survival model incorporating established prognostic factors. Other probabilities, treatment effects, costs and quality of life weights were estimated primarily using data from the three UK-led RCTs, a meta-analysis of all relevant RCTs, and other published literature. The model predicted the lifetime costs, quality adjusted life years (QALYs) and cost-effectiveness of the four strategies for women with differing prognoses. Sensitivity analyses investigated the impact of uncertain parameters and model assumptions.

FINDINGS

For women with an average to high risk of recurrence (based upon prognostic factors and any other adjuvant therapies received), FEC-D appeared most cost-effective assuming a threshold of £20,000 per QALY for the National Health Service (NHS). For younger low risk women, E-CMF/FEC60 tended to be the optimal strategy and, for some older low risk women, the model suggested a policy of no chemotherapy was cost-effective. For no patient group was CMF chemotherapy the preferred option. Sensitivity analyses demonstrated cost-effectiveness results to be particularly sensitive to the treatment effect estimate for FEC-D and the future price of docetaxel.

INTERPRETATION

To our knowledge, this analysis is the first cost-effectiveness comparison of no chemotherapy, and first, second, and third generation adjuvant chemotherapy regimens for early breast cancer patients with differing prognoses. The results demonstrate the potential for different treatment strategies to be cost-effective for different types of patients. These findings may prove useful for policy makers attempting to formulate cost-effective treatment guidelines in the field of early breast cancer.

Menopausal symptoms and bone health in women undertaking risk reducing bilateral salpingo-oophorectomy: significant bone health issues in those not taking HRT

BACKGROUND

Women at high ovarian cancer risk, especially those with mutations in BRCA1/BRCA2, are encouraged to undergo bilateral risk-reducing salpingo-oophorectomy (BRRSPO) prior to the natural menopause. The decision to use HRT to cover the period of oestrogen deprivation up to 50 years of age is difficult because of balancing the considerations of breast cancer risk, bone and cardiovascular health.

METHODS

We reviewed by questionnaire 289 women after BRRSPO aged ≤48 years because of high ovarian cancer risk; 212 (73%) of women responded.

RESULTS

Previous HRT users (n=67) had significantly worse endocrine symptom scores than 67 current users (P=0.006). A total of 123 (58%) of women had ≥24 months of oestrogen deprivation <50 years with 78 (37%) never taking HRT. Bone density (DXA) evaluations were available on 119 (56%) women: bone loss with a T score of ≤-1.0 was present in 5 out of 31 (16%) women with no period of oestrogen deprivation <50 years compared with 37 out of 78 (47%) of those with ≥24 months of oestrogen deprivation (P=0.03).

INTERPRETATION

Women undergoing BRRSPO <50 years should be counselled concerning the risks/benefits of HRT, taking into consideration the benefits on symptoms, bone health and cardiovascular health, and that the risks of breast cancer from oestrogen-only HRT appear to be relatively small.

Health-related quality of life assessment after breast reconstruction

Background

Health-related quality of life (HRQL) is an important outcome following breast reconstruction. This study evaluated current methods of HRQL assessment in patients undergoing latissimus dorsi breast reconstruction, hypothesizing that early surgical morbidity would be reflected by poorer HRQL scores.

Methods

Patients completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and breast module (QLQ-BR23), the Functional Assessment of Cancer Therapy (FACT) general measure, and breast module and arm subscale (FACT-B + 4), and the Body Image Scale and Hospital Anxiety and Depression Scale (HADS) 3 months after surgery. They also reported additional HRQL problems not included in the questionnaires. HRQL scores were compared between patients with and without early surgical morbidity.

Results

Sixty women completed the questionnaires, of whom 25 (42 per cent) experienced complications. All EORTC and FACT subscale and HADS scores were similar in patients with or without morbidity. Women with complications were twice as likely to report feeling less feminine and dissatisfied with the appearance of their scar than those without problems. Thirty-two women (53 per cent) complained of problems not covered by the questionnaires, most commonly donor-site morbidity.

Conclusion

Existing HRQL instruments are not sufficiently sensitive to detect clinically relevant problems following breast reconstruction.

Modelling the cost-effectiveness of first, second and third generation polychemotherapy regimens in women with early breast cancer who have differing prognoses

Abstract #6106

Purpose: To use individual patient data from three sequential large UK randomised trials to facilitate an integrated comparison of the cost-effectiveness of three generations of chemotherapy plus a no treatment option. The ABC trial compared CMF versus no chemo (1991 patients), NEAT trial Epirubicin-CMF versus CMF (2391 patients) and TACT FEC-Docetaxel vs FEC or epi-CMF (4162 patients)&#x2028; Methods: The model estimates lifetime costs and Quality-Adjusted Life Years (QALYs). Model inputs include transition probabilities which are estimated from a longitudinal observational study using parametric survival models incorporating characteristics such as number of positive lymph nodes, ER status, grade and tumour size that allow analyses to be conducted for women with differing baseline prognoses. The effects of each chemotherapy regimen on preventing recurrence are taken from the above UK trials and are assumed to be additive on the log scale to facilitate previously untested comparisons. Costs and utility decrements associated with chemotherapy, its toxicity, and type of recurrent disease, are informed from the trial data and published literature. A secondary analysis is performed by basing the effects of each chemotherapy regimen on published meta-analyses based on individual level data that include RCTs conducted in a range of multi-national settings.&#x2028; Results: For a woman aged 50 years with 1 positive node, grade 2 tumour size 2cm, ECMF is expected to be the most cost-effective regimen. However, the cost-effectiveness of the chemotherapy options varies between women with different risk factors. On the basis of the results of the TACT trial, 3rd generation chemotherapy is not cost-effective, but including evidence of the relative risk of recurrence from non-UK trials, particularly those with ER- and HER2+ phenotype, may alter this conclusion.&#x2028; Indicative lifetime costs and QALYs for a woman aged 50 years, with 1 positive node, grade 2 tumor size 2cm, with and without ER+ are shown:&#x2028; &#x2028; &#x2028; &#x2028; Conclusions: Evaluating the cost-effectiveness of chemotherapy regimens in women with early breast cancer who have differing prognoses is feasible using an integrative synthesis and model. Thought does, however, need to be given to how best present cost-effectiveness results when there are differing levels of baseline risk.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6106.

The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial

BACKGROUND

The international standard radiotherapy schedule for early breast cancer delivers 50 Gy in 25 fractions of 2.0 Gy over 5 weeks, but there is a long history of non-standard regimens delivering a lower total dose using fewer, larger fractions (hypofractionation). We aimed to test the benefits of radiotherapy schedules using fraction sizes larger than 2.0 Gy in terms of local-regional tumour control, normal tissue responses, quality of life, and economic consequences in women prescribed post-operative radiotherapy.

METHODS

Between 1999 and 2001, 2215 women with early breast cancer (pT1-3a pN0-1 M0) at 23 centres in the UK were randomly assigned after primary surgery to receive 50 Gy in 25 fractions of 2.0 Gy over 5 weeks or 40 Gy in 15 fractions of 2.67 Gy over 3 weeks. Women were eligible for the trial if they were aged over 18 years, did not have an immediate reconstruction, and were available for follow-up. Randomisation method was computer generated and was not blinded. The protocol-specified principal endpoints were local-regional tumour relapse, defined as reappearance of cancer at irradiated sites, late normal tissue effects, and quality of life. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN59368779.

FINDINGS

1105 women were assigned to the 50 Gy group and 1110 to the 40 Gy group. After a median follow up of 6.0 years (IQR 5.0-6.2) the rate of local-regional tumour relapse at 5 years was 2.2% (95% CI 1.3-3.1) in the 40 Gy group and 3.3% (95% CI 2.2 to 4.5) in the 50 Gy group, representing an absolute difference of -0.7% (95% CI -1.7% to 0.9%)--ie, the absolute difference in local-regional relapse could be up to 1.7% better and at most 1% worse after 40 Gy than after 50 Gy. Photographic and patient self-assessments indicated lower rates of late adverse effects after 40 Gy than after 50 Gy.

INTERPRETATION

A radiation schedule delivering 40 Gy in 15 fractions seems to offer rates of local-regional tumour relapse and late adverse effects at least as favourable as the standard schedule of 50 Gy in 25 fractions.

The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial

Background

The international standard radiotherapy schedule for breast cancer treatment delivers a high total dose in 25 small daily doses (fractions). However, a lower total dose delivered in fewer, larger fractions (hypofractionation) is hypothesised to be at least as safe and effective as the standard treatment. We tested two dose levels of a 13-fraction schedule against the standard regimen with the aim of measuring the sensitivity of normal and malignant tissues to fraction size.

Methods

Between 1998 and 2002, 2236 women with early breast cancer (pT1-3a pN0-1 M0) at 17 centres in the UK were randomly assigned after primary surgery to receive 50 Gy in 25 fractions of 2·0 Gy versus 41·6 Gy or 39 Gy in 13 fractions of 3·2 Gy or 3·0 Gy over 5 weeks. Women were eligible if they were aged over 18 years, did not have an immediate surgical reconstruction, and were available for follow-up. Randomisation method was computer generated and was not blinded. The protocol-specified principal endpoints were local-regional tumour relapse, defined as reappearance of cancer at irradiated sites, late normal tissue effects, and quality of life. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN59368779.

Findings

749 women were assigned to the 50 Gy group, 750 to the 41·6 Gy group, and 737 to the 39 Gy group. After a median follow up of 5·1 years (IQR 4·4–6·0) the rate of local-regional tumour relapse at 5 years was 3·6% (95% CI 2·2–5·1) after 50 Gy, 3·5% (95% CI 2·1–4·3) after 41·6 Gy, and 5·2% (95% CI 3·5–6·9) after 39 Gy. The estimated absolute differences in 5-year local-regional relapse rates compared with 50 Gy were 0·2% (95% CI −1·3% to 2·6%) after 41·6 Gy and 0·9% (95% CI −0·8% to 3·7%) after 39 Gy. Photographic and patient self-assessments suggested lower rates of late adverse effects after 39 Gy than with 50 Gy, with an HR for late change in breast appearance (photographic) of 0·69 (95% CI 0·52–0·91, p=0·01). From a planned meta-analysis with the pilot trial, the adjusted estimates of α/β value for tumour control was 4·6 Gy (95% CI 1·1–8·1) and for late change in breast appearance (photographic) was 3·4 Gy (95% CI 2·3–4·5).

Interpretation

The data are consistent with the hypothesis that breast cancer and the dose-limiting normal tissues respond similarly to change in radiotherapy fraction size. 41·6 Gy in 13 fractions was similar to the control regimen of 50 Gy in 25 fractions in terms of local-regional tumour control and late normal tissue effects, a result consistent with the result of START Trial B. A lower total dose in a smaller number of fractions could offer similar rates of tumour control and normal tissue damage as the international standard fractionation schedule of 50 Gy in 25 fractions.

Impact of pre-operative chemotherapy on the quality of life (QL) of patients with resectable non-small cell lung cancer (NSCLC): Experience from the MRC LU22/NVALT/EORTC 08012 multicentre randomised trial

9020

Aim: To evaluate QL during the first 2 years follow-up in patients randomised to receive 3 cycles of platinum-based chemotherapy (CT-S) prior to surgical resection of NSCLC compared to those receiving surgery alone (S). Methods: A total of 519 patients were entered into the LU22 trial from 70 centres in the UK, The Netherlands, Germany and Belgium. All patients were asked to complete the SF-36 QL questionnaire prior to randomisation and at 6 and 12 months then annually to 5 years. The scores from the SF-36 questionnaire were combined into 8 domains and also summarised as physical component summary (PCS) and mental component summary (MCS). The 6,12 and 24 month PCS and MCS scores were analysed using multivariable regression to identify prognostic factors and investigate the difference between the regimens. Results: 82% patients completed QL at baseline, and compliance at 6, 12 and 24 months was 59%, 60% and 67% respectively. Median age was 63 (range 25 to 79 years) and 72% were male. At 6 months patients in the S group reported somewhat better functioning in all domains except general health and mental health, but no differences were seen at 12 or 24 months. The regression analyses indicated that better physical health outcomes (PCS) were predicted by baseline PCS and MCS at all follow-up points (all p<0.05), whereas longer time since surgery predicted better PCS at 6 months (p<0.05), and younger age predicted better PCS at 24 months (p=0.07). For mental health, better MCS was predicted at all time points by baseline MCS (p<0.05). In addition, female gender (p=0.07), and PCS (p<0.05), were predictors at 6 months, and younger age predicted better MCS at 24 months (p<0.01). Treatment regimen had no effect on QL at any time point. At 1 and 2 years more than 50% patients considered their health comparable to others, and 45% were generally optimistic about their future health. Conclusions: Over 2 years follow-up, QL was not adversely affected by pre-operative chemotherapy and there were no significant differences between the regimens. Many patients saw themselves as fit as their contemporaries.

[Table: see text]

Hypofractionation for early breast cancer: First results of the UK standardization of breast radiotherapy (START) trials

LBA518

Background: The START Trials (ST-A and ST-B) test the hypothesis that breast cancer is as sensitive to fraction (Fr) size as late reacting normal tissues, with an a/β value of about 4Gy. Methods: The phase III randomised START Trials tested hypofractionated post-operative RT in women with completely excised invasive breast cancer (T1–3, N0–1, M0). Centres opted for either ST-A or ST-B. ST-A tested 50Gy in 25Fr (5 wks) vs 41.6Gy vs 39Gy, both in 13Fr (5 wks). ST-B tested 50Gy in 25Fr (5 wks) vs 40Gy in 15Fr (3 wks). Stratification was by centre, surgery and boost. The primary endpoint was local-regional (LR) relapse. Late normal tissue effects (NTE) were assessed by breast photographs, clinical examination and quality of life (QL) questionnaires. Survival analysis methods were used to estimate rates of relapse and NTEs, and hazard ratios (HR) (with 95%CI). Smoothed estimates of absolute differences in relapse rates were obtained from the rates in the 50Gy control arms and the HR. Results: 2236 (ST-A) and 2215 (ST-B) patients were recruited from 35 UK centres during 1999–2002. Median follow-up is 5.1 years (ST-A) and 6.0 years (ST-B). There were 93 LR relapses in ST-A (4.1% at 5 years, 3.2- 5.0%), with absolute differences in LR relapse rates at 5 years compared with 50Gy of 0.2% (−1.3%−2.6%) for 41.6Gy and 0.9% (−0.8%−3.7%) for 39Gy. The a/β estimate for tumour control was 5.0Gy (−2.7–12.7). In ST-B, there were 65 LR relapses (2.8% at 5 years, 2.1–3.5%), with an absolute difference in LR relapse rates at 5 years of −0.6% (−1.7%−0.9%) for 40Gy vs 50Gy. In ST-A the rate of mild/marked change in photographic breast appearance was lower in 39Gy vs 50Gy (HR 0.69, 0.52–0.91), and similarly for 40Gy vs 50Gy in ST-B (HR 0.83, 0.66–1.04). The a/β estimate for change in breast appearance was 3.1Gy (1.6–4.6). Rates of induration, telangiectasia and breast oedema were lower in 39Gy (ST-A) and 40Gy (ST-B) compared with the 50Gy arms. QL results were consistent with the clinical findings. Conclusions: The fractionation sensitivity of breast cancer is comparable to that of late reacting normal tissues, confirming the results of a recent pilot trial. These results support the use of hypofractionated RT schedules for early breast cancer.

No significant financial relationships to disclose.

Pre-operative chemotherapy in patients with resectable non-small cell lung cancer (NSCLC): First results of the MRC LU22/NVALT/EORTC 08012 multi-centre randomised trial

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Aims: Although surgery offers the best chance of cure for patients with NSCLC, the overall 5-year survival rate is modest, and improvements are urgently required. This intergroup trial was designed to investigate whether, in patients with operable NSCLC of any stage, neo-adjuvant platinum-based chemotherapy prior to surgery would improve outcomes. Methods: Patients were randomised to receive either surgery alone (S), or 3 cycles of platinum-based chemotherapy prior to surgery (CT-S). Results: 519 patients were randomised (261 S, 258 CT-S) from 70 centres in the UK, the Netherlands, Germany and Belgium. The median age of the patients was 63 years, 72% were male, 59% were PS 0, and 50% had squamous cell histology. The majority were clinical stage I (17% Ia, 45% Ib, 3% IIa, 29% IIb, 7% IIIa), and 12% received mitomycin/vinblastine/cisplatin (MVP), 7% mitomycin/ifosfamide/cisplatin (MIC), 45% vinorelbine/cisplatin, 12% carboplatin/docetaxel, and 25% cisplatin/gemcitabine. The trial showed that neo-adjuvant chemotherapy was feasible (76% of patients received all 3 cycles of chemotherapy), resulted in a good response rate (4% CR, 45% PR, and only 2% PD), appeared to cause down-staging in about 20% of patients, and did not affect the type of surgery performed, the post-operative complication rate, or quality of life. However, there was no evidence of a benefit in terms of progression-free survival (282 events, HR 0.98, 95% CI 0.77,1.23) or overall survival (232 deaths, HR 1.04, 95% CI 0.81, 1.35), and more patients were reported as having brain metastases in the CT-S group (30 CT-S vs 11 S patients). Exploratory analyses showed no evidence that any subgroup of patients benefited from the addition of neo-adjuvant chemotherapy. Conclusions: This intergroup trial, which is the largest trial of neo-adjuvant chemotherapy in patients with resectable NSCLC, indicated that the addition of neo-adjuvant platinum-based chemotherapy did not lead to a benefit in overall survival. However, a 19% survival benefit or a 35% detriment cannot be excluded and this result needs to be considered in the context of all other relevant randomised trials of neo-adjuvant chemotherapy for NSCLC.

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Predictive genetic testing for BRCA1/2 in a UK clinical cohort: three-year follow-up

This prospective multicentre study assesses long-term impact of genetic testing for breast/ovarian cancer predisposition in a clinical cohort. Areas evaluated include risk management, distress and insurance problems 3 years post-testing. Participants are adults unaffected with cancer from families with a known BRCA1/2 mutation. One hundred and ninety-three out of 285 (70% response) participants at nine UK clinical genetics centres completed assessments at 3 years: 80% female; 37% carriers of a BRCA1/2 mutation. In the 3 years, post-genetic testing carriers reported more risk management activities than non-carriers. Fifty-five per cent of female carriers opted for risk reducing surgery; 43% oophorectomy; and 34% mastectomy. Eighty-nine per cent had mammograms compared with 47% non-carriers. Thirty-six per cent non-carriers > or =50 years did not have a mammogram post-test. Twenty-two per cent male carriers had colorectal and 44% prostate screening compared with 5 and 19% non-carriers respectively. Seven per cent carriers and 1% non-carriers developed cancer. Distress levels did not differ in carriers and non-carriers at 3-year follow-up. Forty per cent of female carriers reported difficulties with life and/or health insurance. Given the return to pre-test levels of concern among female non-carriers at 3 years and a substantial minority not engaging in recommended screening, there appears to be a need to help some women understand the meaning of their genetic status.

Feasibility of familial PSA screening: psychosocial issues and screening adherence

This study examined factors that predict psychological morbidity and screening adherence in first-degree relatives (FDRs) taking part in a familial PSA screening study. Prostate cancer patients (index cases - ICs) who gave consent for their FDRs to be contacted for a familial PSA screening study to contact their FDRs were also asked permission to invite these FDRs into a linked psychosocial study. Participants were assessed on measures of psychological morbidity (including the General Health Questionnaire; Cancer Worry Scale; Health Anxiety Questionnaire; Impact of Events Scale); and perceived benefits and barriers, knowledge; perceived risk/susceptibility; family history; and socio-demographics. Of 255 ICs, 155 (61%) consented to their FDRs being contacted. Of 207 FDRs approached, 128 (62%) consented and completed questionnaires. Multivariate logistic regression revealed that health anxiety, perceived risk and subjective stress predicted higher cancer worry (P = 0.05). Measures of psychological morbidity did not predict screening adherence. Only past screening behaviour reliably predicted adherence to familial screening (P = 0.05). First-degree relatives entering the linked familial PSA screening programme do not, in general, have high levels of psychological morbidity. However, a small number of men exhibited psychological distress.

Surgical decisions made by 158 women with hereditary breast cancer aged <50 years

AIM

To establish the uptake of contralateral risk reducing mastectomy in women informed of their risks and options at time of diagnosis of their primary unilateral breast cancer.

METHODS

We have assessed the surgical choices of 70 women diagnosed with breast cancer <50 years as part of a family history surveillance program and fully informed about their contralateral risks and surgical options. We have compared this to women from other surgical clinics who were subsequently found to harbour a pathogenic BRCA1/2 mutation.

RESULTS

Sixty-five percent (13/20) of BRCA1/2 mutation carriers and 59% (n=20/34) of those at the highest level of risk pre-diagnosis (33+% lifetime risk) opted for contra-lateral mastectomy in the study sample. In contrast only 10% (n=9/88) women identified as mutation carriers from other clinics opted for such surgery.

CONCLUSIONS

We would suggest that women with a significant family history and therefore a high contra-lateral breast cancer risk, should have these risks and management options discussed at the time of diagnosis of breast cancer.

Breast cancer patients' experiences on endocrine therapy: monitoring with a checklist for patients on endocrine therapy (C-PET)

Women with hormone responsive breast cancer routinely receive endocrine therapy. There is growing evidence that patients experience significant side effects. Between 1996 and 1998, all patients on endocrine therapy for adjuvant or advanced breast cancer, attending the Edinburgh Breast Unit, were invited to complete a checklist for patients on endocrine therapy. This simple form, designed as a communication aid, was completed by patients before their consultation. 708 patients (age 28-93) completed 1060 forms. These forms were analysed in order to gain a better understanding of the side effects experienced. Most patients were on tamoxifen (n = 524), with 103 on anastrazole and 35 on megestrol acetate. Common symptoms experienced were hot flushes, sweats and weight gain. Symptoms varied according to the patients' ages and the setting in which they received endocrine treatment. Pre-menopausal women were more likely to experience problems with flushes, sweats, weight gain and reduced libido.

Psychosocial impact of breast/ovarian (BRCA1/2) cancer-predictive genetic testing in a UK multi-centre clinical cohort

This multi-centre UK study assesses the impact of predictive testing for breast and ovarian cancer predisposition genes (BRCA1/2) in the clinical context. In the year following predictive testing, 261 adults (59 male) from nine UK genetics centres participated; 91 gene mutation carriers and 170 noncarriers. Self-report questionnaires were completed at baseline (pre-genetic testing) and 1, 4 and 12 months following the genetic test result. Men were assessed for general mental health (by general health questionnaire (GHQ)) and women for general mental health, cancer-related worry, intrusive and avoidant thoughts, perception of risk and risk management behaviour. Main comparisons were between female carriers and noncarriers on all measures and men and women for general mental health. Female noncarriers benefited psychologically, with significant reductions in cancer-related worry following testing (P<0.001). However, younger female carriers (<50 years) showed a rise in cancer-related worry 1 month post-testing (P<0.05). This returned to pre-testing baseline levels 12 months later, but worry remained significantly higher than noncarriers throughout (P<0.01). There were no significant differences in GHQ scores between males and females (both carriers and noncarriers) at any time point. Female carriers engaged in significantly more risk management strategies than noncarriers in the year following testing (e.g. mammograms; 92% carriers vs 30% noncarriers). In the 12 months post-testing, 28% carriers had bilateral risk-reducing mastectomy and 31% oophorectomy. Oophorectomy was confined to older (mean 41 yrs) women who already had children. However, worry about cancer was not assuaged by surgery following genetic testing, and this requires further investigation. In all, 20% of female carriers reported insurance problems. The data show persistent worry in younger female gene carriers and confirm changes in risk management consistent with carrier status. Men were not adversely affected by genetic testing in terms of their general mental health.

A randomised comparison of UK genetic risk counselling services for familial cancer: psychosocial outcomes

The aim of the study was to compare psychosocial outcomes for 50 new clinic attendees, referred for cancer genetic counselling to five UK centres. The centres represented England, Scotland and Wales, and were randomly selected from groups ranked by different levels of clinical activity in cancer genetics practice. Questionnaires assessed demographic data, risk perception, mental health and use of health services pre-consultation and at 1 and 12 months follow-up. Satisfaction was measured for attendees and referring doctors at follow-up. A total of 256 unaffected adults fulfilled the study criteria. The five centres varied widely with respect to service organisation and activity, but all had a greater proportion of unaffected attendees with a breast cancer risk (61–91%) than either a bowel cancer risk (0–33%) or ovarian cancer risk (3–25%). There were no significant differences in the psychosocial data between centres pre-counselling. No significant change over time occurred for any of the centres for risk perception or general psychological distress. There were significant differences between centres in reduction of cancer worry from baseline to 12 months and with the number of women who were recommended to have mammographic surveillance who had not received this. Overall, one-third of women for whom mammography had been recommended had not been screened within 1 year of follow-up. Subsequent attendance at the GP, but not at a hospital, was associated with risk level, but differences between centres could not be analysed. Satisfaction differed significantly between centres for 4 : 14 aspects of service provision and with 3 : 17 items concerning communication; satisfaction was high overall. Over 90% of referring doctors were moderately/very satisfied with the service, but 23% were dissatisfied with waiting times and 19% with access to preventive treatment. Results differed significantly between centres for doctor's satisfaction with the provision of referral criteria and prescribing information. In conclusion, there were relatively few significant differences in psychosocial outcomes between centres, considering the wide variation in service organisation and activity. These significant differences were not consistent across the centres, therefore, differences could not be linked to specific aspects of service provision.

Cancer Genetics Service Provision: A Comparison of Seven European Centres

OBJECTIVE

To conduct a survey in seven European cancer genetics centres to compare service provision, organisation and practices for familial breast and colon cancer consultations and testing. Information was obtained on aspects of services both nationally and locally.

METHODS

A detailed survey questionnaire was adapted collaboratively to obtain the required information. Initial survey data were collected within each centre and interim results were discussed at two European Workshops. Where differences in practice existed, details were clarified to ensure accuracy and adequacy of information. Participating centres were Haifa (Israel), Hannover (Germany), Leiden (The Netherlands), Leuven (Belgium), Manchester (UK), Marseille (France) and Milan (Italy), representing countries with populations ranging from 6.5 to 80 million.

RESULTS

The European countries diverged in regard to the number of cancer genetics centres nationally (from 8 in Belgium to 37 in France), and the average population served by each centre (from 0.59 million in Israel to 3.32 million in Italy). All centres offered free care at the point of access, but referral to specialist care varied according to national health care provision. At a centre level, staff roles varied due to differences in training and health care provision. The annual number of counsellees seen in each participating centre ranged from 200 to over 1,700. Access to breast surveillance or bowel screening varied between countries, again reflecting differences in medical care pathways. These countries converged in regard to the wide availability of professional bodies and published guidelines promoting aspects of service provision. Similarities between centres included provision of a multidisciplinary team, with access to psychological support, albeit with varying degrees of integration. All services were dominated (70-90%) by referrals from families with an increased risk of breast cancer despite wide variation in referral patterns. Collection of pedigree data and risk assessment strategies were broadly similar, and centres used comparable genetic testing protocols. Average consultation times ranged between 45 and 90 min. All centres had access to a laboratory offering DNA testing for breast and bowel cancer-predisposing genes, although testing rates varied, reflecting the stage of service development and the type of population. Israel offered the highest number of genetic tests for breast cancer susceptibility because of the existence of specific founder mutations, in part explaining why the cancer genetics service in Haifa differed most from the other six.

CONCLUSION

Despite considerable differences in service organisation, there were broad similarities in the provision of cancer genetic services in the centres surveyed.

Symptoms of colorectal liver metastases: correlation with CT findings

AIM

To correlate CT appearances of colorectal liver metastases (LM) with pattern and severity of symptoms.

MATERIALS AND METHODS

One hundred and twenty patients with treated primary colorectal carcinoma were prospectively assessed by questionnaire for recent symptoms when attending for CT examination. Thorax, abdomen and pelvic CT scans were prospectively assessed for LM and extrahepatic disease (EHD). The number of LM, percentage liver replaced by LM and distribution of LM were recorded.

RESULTS

Patients' ages ranged from 35 to 89 years (median 60) and 74/120 (62%) were male. Four subgroups were compared: group 1 - LM only (n = 30); 2 - EHD only (n = 22); 3 - both LM and EHD (n = 28); 4 - neither LM/EHD (n = 40). Anorexia was significantly worse in gp2 vs gp4 (P = 0.016) and lower abdominal pain (LAP) was significantly worse in gp2 vs gpl (P = 0.019). General pain was the worse symptom in all groups but notstatistically greater in any group. Patients with more than 10 LM had significantly worse anorexia (P = 0.002). general pain (P < 0.001) and LAP (P = 0.001). There was a trend (P > 0.05) towards worse symptoms with either volume of diseased liver or subcapsular LM.

CONCLUSION

With increasing liver tumour burden there was an increase in symptomatology but extrahepatic abdominal metastatic tumour produced more symptoms than LM alone. Symptoms, particularly pain, therefore are not good predictors of hepatic metastatic disease.

Management options for gynaecomastia and breast pain associated with nonsteroidal antiandrogen therapy : case report series

OBJECTIVE

To present management options for gynaecomastia and mastodynia associated with nonsteroidal antiandrogen therapy, supported by relevant data and case studies.

BACKGROUND

Gynaecomastia (male breast enlargement) and breast pain/ sensitivity (mastodynia or mastalgia) are pharmacologically expected adverse effects of nonsteroidal antiandrogen therapy for prostate cancer. They are caused by proliferation of glandular tissue in response to an increase in the ratio of estrogen to androgen. Gynaecomastia and mastodynia are benign conditions, and many patients choose to tolerate them as acceptable, usually mild or moderate, adverse effects of therapy. Recent data show that nonsteroidal antiandrogen monotherapy significantly reduces disease progression in localised and locally advanced prostate cancer, a finding that may result in wider and more long-term use of this treatment. Therefore, both clinicians and patients may benefit from increased awareness of the options available for the management of gynaecomastia and mastodynia. Management options, data and case studies: Management options for gynaecomastia and mastodynia are illustrated in a schematic flow diagram. Options identified are: (1) risk reduction using pretreatment breast irradiation; (2) stopping antiandrogen therapy; (3) acceptance of gynaecomastia and/or mastodynia in the context of the significant clinical benefit of antiandrogen treatment; (4) prompt treatment (liposuction/breast tissue excision, hormonal manipulation or pain control with irradiation or analgesics); and (5) later treatment (liposuction/breast tissue excision, hormonal manipulation or pain control with irradiation or analgesics). Where available, relevant data are discussed and the options are illustrated by case studies.

CONCLUSIONS

The risk of developing gynaecomastia is lessened by prophylactic breast irradiation. Following the development of gynaecomastia, treatment options include readjustment of the estrogen-to-androgen ratio using antiestrogens, surgery in the form of liposuction or, for more advanced cases, breast tissue excision. Mastodynia may be controlled by post-treatment irradiation or analgesics.

Comparison of survival, palliation, and quality of life with three chemotherapy regimens in metastatic colorectal cancer: a multicentre randomised trial

BACKGROUND

This randomised trial compared three chemotherapy regimens in the first-line treatment of advanced colorectal cancer, in terms of their effect on overall and progression-free survival; other endpoints included toxicity, symptom palliation, and quality of life.

METHODS

905 patients were randomly assigned the de Gramont regimen (n=303; folinic acid 200 mg/m(2), fluorouracil bolus 400 mg/m(2), and infusion 600 mg/m(2) on days 1 and 2, repeated every 14 days), the Lokich regimen (n=301; protracted venous infusion of fluorouracil 300 mg/m(2) daily), or raltitrexed (n=301; 3 mg/m(2) intravenously every 21 days). Analyses were by intention to treat.

FINDINGS

Median follow-up of survivors was 67 weeks. For the de Gramont, Lokich, and raltitrexed groups, respectively, median survival was 294, 302, and 266 days. The hazard ratios for overall survival were 0.88 (95% CI 0.70-1.12, p=0.17) for de Gramont versus Lokich, and 0.99 (0.79-1.25, p=0.94) for de Gramont versus raltitrexed. An increase in treatment-related deaths was seen on raltitrexed (de Gramont one, Lokich two, raltitrexed 18) due to combined gastrointestinal and haematological toxicity. Patients' assessment of quality of life showed that raltitrexed was inferior to the fluorouracil-based regimens, especially in terms of palliation and functioning.

INTERPRETATION

The deGramont and Lokich regimens were similar in terms of survival, quality of life, and response rates. The Lokich regimen was associated with more central line complications and hand-foot syndrome. Raltitrexed showed similar response rates and overall survival to the de Gramont regimen and was easier to administer, but resulted in greater toxicity and inferior quality of life.

A descriptive study of UK cancer genetics services: an emerging clinical response to the new genetics

The objective was to describe NHS cancer genetic counselling services and compare UK regions. The study design was a cross-sectional study over 4 weeks and attendee survey. The setting was 22 of the 24 regional cancer genetics services in the UK NHS. Participants were individuals aged over 18 attending clinics at these services. Outcome measures were staff levels, referral rates, consultation rates, follow-up plans, waiting time. There were only 11 dedicated cancer geneticists across the 22 centres. Referrals were mainly concerned with breast (63%), bowel (18%) and ovarian (12%) cancers. Only 7% of referrals were for men and 3% were for individuals from ethnic minorities. Referral rates varied from 76 to 410 per million per annum across the regions. Median waiting time for an initial appointment was 19 weeks, ranging across regions from 4 to 53 weeks. Individuals at population-level genetic risk accounted for 27% of consultations (range 0%, 58%). Shortfalls in cancer genetics staff and in the provision of genetic testing and cancer surveillance have resulted in large regional variations in access to care. Initiatives to disseminate referral and management guidelines to cancer units and primary care should be adequately resourced so that clinical genetics teams can focus on the genetic testing and management of high-risk families.

An innovative approach to clinical communication in schizophrenia: the approaches to schizophrenia communication checklists

Side effects from antipsychotic medications can have a profound effect on patients' lives and may adversely affect their willingness to comply with treatment. Identification of side effects through improved communication between psychiatrists, other members of the healthcare team, and their patients might increase treatment compliance. The Approaches to Schizophrenia Communication (ASC) Steering Group developed two simple, practical checklists for use in the busy clinical setting. The ASC-Self-Report (ASC-SR) checklist is completed by the patient and comprises a list of the more common or clinically important side effects of antipsychotic treatment. The ASC-Clinic (ASC-C) checklist is completed by both clinician and patient together, being used as the basis for a semi-structured interview. In a multicenter pilot study set up to evaluate the utility of checklists, 86% of patients responding considered the ASC-SR to be useful in communicating their problems to psychiatrists and other members of the healthcare team. All healthcare team respondents found both checklists to be helpful when discussing side effect problems with their patients. Moreover, 41% and 47% of healthcare team respondents reported that the ASC-SR and ASC-C, respectively, had assisted them in identifying side-effect problems not previously acknowledged. Preliminary evaluation of the ASC-SR and ASC-C in this multicenter pilot study suggests that both tools were user-friendly, encouraged communication between patients and healthcare professionals about antipsychotic drug side effects, and could readily integrated into everyday clinical practice.