Cost comparison of adverse event management among breast and ovarian cancer patients treated with poly (ADP-ribose) polymerase inhibitors: analysis based on phase 3 clinical trials

BACKGROUND

The economic impact of adverse events (AEs) for poly (ADP-ribose) polymerase inhibitors (PARPis) in ovarian or breast cancer has not been widely evaluated.

OBJECTIVE

Compare PARPi-related AE management costs from a US payer perspective.

METHODS

The frequency of treatment-related grade 3-4 AEs was obtained from published clinical trials of PARPis for the treatment of advanced ovarian cancer (AOC), platinum-sensitive recurrent ovarian cancer (PSROC), and metastatic breast cancer (MBC). AE management costs per patient (2020 USD) per treatment course were calculated by multiplying the AE unit costs by the frequency of AEs for each arm of each trial. Sensitivity analyses were conducted according to the lower and upper limits of the 95% confidence interval for AE rates and unit costs, respectively. Scenarios were also performed to explore the uncertainty of outcomes.

RESULTS

Total AE management costs in AOC were: $3,904, olaparib; $5,595, olaparib plus bevacizumab; and $12,215, niraparib. In PSROC, total costs were: $3,894, olaparib; $6,001, rucaparib; and $11,492, niraparib, and in MBC: $3,574, olaparib; and $9,489, talazoparib. Hematological toxicities were the key drivers of AE management costs for PARPis.

CONCLUSIONS

The main AEs among PARPis were hematological. Olaparib was associated with lower AE costs compared to other PARPis.

Patient preferences and experiences regarding thrombopoietin-receptor agonists for immune thrombocytopenia in the United Kingdom and Ireland (TRAPeze UK & IE study)

OBJECTIVES

To establish the experiences with and preferences towards existing thrombopoietin-receptor agonist (TPO-RA) treatments of individuals with immune thrombocytopenia (ITP) in the UK and Ireland, based on treatment attributes.

METHODS

Responses from UK and Ireland individuals with ITP were collected in a pan-European online survey (TRAPeze, [Thrombopoietin-Receptor Agonist Patient experience survey]) from 18 September 2020 to 18 February 2021. TRAPeze was a survey of treatment preference regarding TPO-RAs (using a discrete choice experiment design), participant demographics, disease characteristics, treatment history, overall satisfaction with therapy, direct healthcare resource utilization and wider social impact.

RESULTS

The survey was completed by 32 UK respondents. Characteristics with the greatest influence on preference towards TPO-RA treatments were method of administration (odds ratio (OR) 5.6, 95% confidence interval (CI) 3.2-10.1) and drug-food interactions (OR 3.2, 95% CI 1.8-5.7). Particularly, participants were more likely to select an oral tablet over a subcutaneous injection (OR 7.4, 95% CI 3.6-15.1) and a treatment without food restrictions rather than with food restrictions (OR 3.6, 95% CI 1.8-6.8).

CONCLUSION

This is the first study to quantify the preference of individuals with ITP towards TPO-RA treatment attributes and demonstrates preference for orally administered treatments, without drug-food interactions.

Real-world treatment patterns and outcomes in small-cell lung cancer: a systematic literature review

Background

Small-cell lung cancer (SCLC) accounts for 12-15% of lung cancers and is associated with poor survival outcomes and high symptom burden. This study employed a broad, systematic search strategy and timeframe to identify evidence on real-world treatment patterns and outcomes for SCLC outside the USA, including understanding sub-populations such as extensive-stage (ES) or limited-stage (LS) disease.

Methods

Databases (MEDLINE, Embase, and EBM reviews) were searched for journal articles published in the English language between 1 January 2000-1 March 2020 and supplemented by hand searching of conference abstracts and posters presented at conferences between 1 January 2016-1 March 2020 reporting real-world treatment outcomes in patients with SCLC. A targeted clinical guideline review was also completed.

Results

One-hundred studies provided quantitative data; 57 were available as full-text articles, whilst the remaining 43 were presented as abstracts or posters. The majority (80 studies, 80%) of included studies reported treatment in the first-line setting, where platinum-based chemotherapy and chemoradiotherapy was the most commonly used treatment strategy, in line with current treatment guidelines in SCLC. First-line treatments were found to have a high response rate; however, most patients relapsed early. No studies reported treatment or outcomes with immune-oncology therapies. Second-line treatment options were very limited, and primarily consisted of either re-treatment with first-line regimen or topotecan, but the prognosis for these patients remained poor. Outcomes were particularly poor amongst those with ES or relapsed disease vs. LS disease.

Conclusions

SCLC treatment patterns and short survival outcomes have remained constant over the previous 20 years. Due to the search timeframe, none of the studies identified reported on the impact of recently approved immune-oncology therapies in SCLC. Further data is needed on the impact of immunotherapies on treatment patterns and real-world outcomes in SCLC.

A Review of the Important Role of CYP2D6 in Pharmacogenomics

Cytochrome P450 2D6 (CYP2D6) is a critical pharmacogene involved in the metabolism of ~20% of commonly used drugs across a broad spectrum of medical disciplines including psychiatry, pain management, oncology and cardiology. Nevertheless, CYP2D6 is highly polymorphic with single-nucleotide polymorphisms, small insertions/deletions and larger structural variants including multiplications, deletions, tandem arrangements, and hybridisations with non-functional CYP2D7 pseudogenes. The frequency of these variants differs across populations, and they significantly influence the drug-metabolising enzymatic function of CYP2D6. Importantly, altered CYP2D6 function has been associated with both adverse drug reactions and reduced drug efficacy, and there is growing recognition of the clinical and economic burdens associated with suboptimal drug utilisation. To date, pharmacogenomic clinical guidelines for at least 48 CYP2D6-substrate drugs have been developed by prominent pharmacogenomics societies, which contain therapeutic recommendations based on CYP2D6-predicted categories of metaboliser phenotype. Novel algorithms to interpret CYP2D6 function from sequencing data that consider structural variants, and machine learning approaches to characterise the functional impact of novel variants, are being developed. However, CYP2D6 genotyping is yet to be implemented broadly into clinical practice, and so further effort and initiatives are required to overcome the implementation challenges and deliver the potential benefits to the bedside.

Low-dose IL-2 induces CD56bright NK regulation of T cells via NKp44 and NKp46

Low-dose interleukin (IL)-2 has shown clinical benefits in patients with autoimmune and inflammatory diseases. Both regulatory T cells (Tregs ) and natural killer (NK) cells are increased in response to low-dose IL-2 immunotherapy. The role of regulatory T cells in autoimmune diseases has been extensively studied; however, NK cells have not been as thoroughly explored. It has not been well reported whether the increase in NK cells is purely an epiphenomenon or carries actual benefits for patients with autoimmune diseases. We demonstrate that low-dose IL-2 expands the primary human CD56bright NK cells resulting in a contact-dependent cell cycle arrest of effector T cells (Teffs ) via retention of the cycle inhibitor p21. We further show that NK cells respond via IL-2R-β, which has been shown to be significant for immunity by regulating T cell expansion. Moreover, we demonstrate that blocking NK receptors NKp44 and NKp46 but not NKp30 could abrogate the regulation of proliferation associated with low-dose IL-2. The increase in NK cells was also accompanied by an increase in Treg cells, which is dependent on the presence of CD56bright NK cells. These results not only heighten the importance of NK cells in low-dose IL-2 therapy but also identify key human NK targets, which may provide further insights into the therapeutic mechanisms of low-dose IL-2 in autoimmunity.

Phenotypically Silent Bone Morphogenetic Protein Receptor 2 Mutations Predispose Rats to Inflammation-Induced Pulmonary Arterial Hypertension by Enhancing the Risk for Neointimal Transformation

BACKGROUND

Bmpr2 (bone morphogenetic protein receptor 2) mutations are critical risk factors for hereditary pulmonary arterial hypertension (PAH) with approximately 20% of carriers developing disease. There is an unmet medical need to understand how environmental factors, such as inflammation, render Bmpr2 mutants susceptible to PAH. Overexpressing 5-LO (5-lipoxygenase) provokes lung inflammation and transient PAH in Bmpr2^+/- mice. Accordingly, 5-LO and its metabolite, leukotriene B₄, are candidates for the second hit. The purpose of this study was to determine how 5-LO-mediated pulmonary inflammation synergized with phenotypically silent Bmpr2 defects to elicit significant pulmonary vascular disease in rats.

METHODS

Monoallelic Bmpr2 mutant rats were generated and found phenotypically normal for up to 1 year of observation. To evaluate whether a second hit would elicit disease, animals were exposed to 5-LO-expressing adenovirus, monocrotaline, SU5416, SU5416 with chronic hypoxia, or chronic hypoxia alone. Bmpr2-mutant hereditary PAH patient samples were assessed for neointimal 5-LO expression. Pulmonary artery endothelial cells with impaired BMPR2 signaling were exposed to increased 5-LO-mediated inflammation and were assessed for phenotypic and transcriptomic changes.

RESULTS

Lung inflammation, induced by intratracheal delivery of 5-LO-expressing adenovirus, elicited severe PAH with intimal remodeling in Bmpr2^+/- rats but not in their wild-type littermates. Neointimal lesions in the diseased Bmpr2^+/- rats gained endogenous 5-LO expression associated with elevated leukotriene B₄ biosynthesis. Bmpr2-mutant hereditary PAH patients similarly expressed 5-LO in the neointimal cells. In vitro, BMPR2 deficiency, compounded by 5-LO-mediated inflammation, generated apoptosis-resistant and proliferative pulmonary artery endothelial cells with mesenchymal characteristics. These transformed cells expressed nuclear envelope-localized 5-LO consistent with induced leukotriene B₄ production, as well as a transcriptomic signature similar to clinical disease, including upregulated nuclear factor Kappa B subunit (NF-κB), interleukin-6, and transforming growth factor beta (TGF-β) signaling pathways. The reversal of PAH and vasculopathy in Bmpr2 mutants by TGF-β antagonism suggests that TGF-β is critical for neointimal transformation.

CONCLUSIONS

In a new 2-hit model of disease, lung inflammation induced severe PAH pathology in Bmpr2^+/- rats. Endothelial transformation required the activation of canonical and noncanonical TGF-β signaling pathways and was characterized by 5-LO nuclear envelope translocation with enhanced leukotriene B₄ production. This study offers an explanation of how an environmental injury unleashes the destructive potential of an otherwise silent genetic mutation.

In vitro and in vivo evaluation of cephalosporins for the treatment of Lyme disease

Background

Lyme disease accounts for >90% of all vector-borne disease cases in the United States and affect ~300,000 persons annually in North America. Though traditional tetracycline antibiotic therapy is generally prescribed for Lyme disease, still 10%–20% of patients treated with current antibiotic therapy still show lingering symptoms.

Methods

In order to identify new drugs, we have evaluated four cephalosporins as a therapeutic alternative to commonly used antibiotics for the treatment of Lyme disease by using microdilution techniques like minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC). We have determined the MIC and MBC of four drugs for three Borrelia burgdorferi s.s strains namely CA8, JLB31 and NP40. The binding studies were performed using in silico analysis.

Results

The MIC order of the four drugs tested is cefoxitin (1.25 µM/mL) > cefamandole (2.5 µM/mL), > cefuroxime (5 µM/mL) > cefapirin (10 µM/mL). Among the drugs that are tested in this study using in vivo C3H/HeN mouse model, cefoxitin effectively kills B. burgdorferi. The in silico analysis revealed that all four cephalosporins studied binds effectively to B. burgdorferi proteins, SecA subunit penicillin-binding protein (PBP) and Outer surface protein E (OspE).

Conclusion

Based on the data obtained, cefoxitin has shown high efficacy killing B. burgdorferi at concentration of 1.25 µM/mL. In addition to it, cefoxitin cleared B. burgdorferi infection in C3H/HeN mice model at 20 mg/kg.

Comparative study of image contrast in scanning electron microscope and helium ion microscope

Images of Ga⁺ -implanted amorphous silicon layers in a 110 n-type silicon substrate have been collected by a range of detectors in a scanning electron microscope and a helium ion microscope. The effects of the implantation dose and imaging parameters (beam energy, dwell time, etc.) on the image contrast were investigated. We demonstrate a similar relationship for both the helium ion microscope Everhart-Thornley and scanning electron microscope Inlens detectors between the contrast of the images and the Ga⁺ density and imaging parameters. These results also show that dynamic charging effects have a significant impact on the quantification of the helium ion microscope and scanning electron microscope contrast.

Energy band diagram of device-grade silicon nanocrystals

Device grade silicon nanocrystals (NCs) are synthesized using an atmospheric-pressure plasma technique. The Si NCs have a small and well defined size of about 2.3 nm. The synthesis system allows for the direct creation of thin films, enabling a range of measurements to be performed and easy implementation of this material in different devices. The chemical stability of the Si NCs is evaluated, showing relatively long-term durability thanks to hydrogen surface terminations. Optical and electrical characterization techniques, including Kelvin probe, ultraviolet photoemission spectroscopy and Mott-Schottky analysis, are employed to determine the energy band diagram of the Si NCs.

Synthesis of surfactant-free electrostatically stabilized gold nanoparticles by plasma-induced liquid chemistry

Plasma-induced non-equilibrium liquid chemistry is used to synthesize gold nanoparticles (AuNPs) without using any reducing or capping agents. The morphology and optical properties of the synthesized AuNPs are characterized by transmission electron microscopy (TEM) and ultraviolet-visible spectroscopy. Plasma processing parameters affect the particle shape and size and the rate of the AuNP synthesis process. Particles of different shapes (e.g. spherical, triangular, hexagonal, pentagonal, etc) are synthesized in aqueous solutions. In particular, the size of the AuNPs can be tuned from 5 nm to several hundred nanometres by varying the initial gold precursor (HAuCl4) concentration from 2.5 μM to 1 mM. In order to reveal details of the basic plasma-liquid interactions that lead to AuNP synthesis, we have measured the solution pH, conductivity and hydrogen peroxide (H2O2) concentration of the liquid after plasma processing, and conclude that H2O2 plays the role of the reducing agent which converts Au(+3) ions to Au(0) atoms, leading to nucleation growth of the AuNPs.

Mutation analysis of the DBC2 gene in sporadic and familial breast cancer

The expression of the recently identified tumor suppressor gene, DBC2 (Deleted in Breast Cancer 2), is frequently extinguished in breast cancer cells or tissues. Mutation analysis of the essential promoter region, all exons and exon/intron boundaries of the DBC2 gene was performed in 100 sporadic breast cancer cases by PCR-SSCP, and DHPLC, followed by direct sequencing. An additional 17 breast cancer families, who were negative for the BRCA1/2 mutations, were analyzed by direct sequencing. Three novel mutations were observed in the promoter and 5'-untranslated region (UTR) of the gene; a germ-line G>A transition in the promoter at nt -238 from the transcription start site, and two tumor-specific mutations at nt -121C>T and nt +48G>A. No deleterious mutations were detected in the coding sequence of the gene in familial and sporadic breast cancer cases. The sequence variations found within the promoter and 5'-UTR region of the gene warrant expression analysis and screening more tumor samples at this region.

Direct mechanical measurement of geodesic structures in rat mesenchymal stem cells

During numerous biological processes, cell adhesion, cell migration and cell spreading are vital. These basic biological functions are regulated by the interaction of cells with their extracellular environment. To examine the morphology and mechanical changes occurring in mesenchymal stem cells cultured on a mechanically rigid substrate, atomic force microscopy and fluorescence microscopy were employed. Investigations of the cells revealed both linear and geodesic F-actin configurations. No particular cell characteristics or intra-cellular location were implicated in the appearance of the geodesic structures. However, the length of time the cells were cultured on the substrate correlated with the percentage appearance of the geodesic structures. Calculating energy dissipation from cell images acquired by dynamic mode atomic force microscopy, it was observed that the vertices of the geodesic structures had significantly higher energy dissipation compared to the linear F-actin and the glass. This supports work by Lazarides [J. Cell Biol. 68, 202-219 (1976)], who postulated that the vertices of these geodesic structures should have a greater flexibility. Our results also support predictions based on the microfilament tensegrity model. By understanding the basic principles of cell ultrastructure and cell mechanics in relation to different extracellular environments, a better understanding of physiological and pathological process will be elicited.

Alendronate prevents bone loss in patients with acute spinal cord injury: a randomized, double-blind, placebo-controlled study

CONTEXT

Patients who sustain an acute spinal cord injury (SCI) experience rapid dramatic reductions in bone mineral density (BMD), especially marked in sublesional areas and sometimes leading to hypercalcemia and hypercalciuria, as well as increased fracture risk.

OBJECTIVE

In this prospective, double-blind, randomized, placebo-controlled study, we evaluated the hypothesis that oral alendronate administration would preserve BMD when administered soon after acute SCI.

PATIENTS AND INTERVENTION

Thirty-one patients with acute SCI were randomly allocated to receive oral alendronate 70 mg/wk or placebo, within 10 d of acute SCI, for 12 months.

MAIN OUTCOME MEASUREMENTS

At entry and at 3, 6, 12, and 18 months, total body bone density, lumbar and hip BMD, ultrasound of the calcaneus, 24-h urinary calcium, and serum C-telopeptide (betaCTX) were measured.

RESULTS

At study entry, patients in the two groups were well matched for age, gender, severity of neurological deficit, BMD, urinary calcium, and betaCTX. BMD indices declined steadily in the placebo group, and this effect was attenuated significantly by alendronate. After 12 months, there was a 5.3% difference (P<0.001) in total body BMD and a 17.6% difference (P<0.001) in the total hip BMD between the two groups. Alendronate compared with placebo induced significant (P<0.001) reductions in urinary calcium excretion and serum betaCTX. No treatment-related side effects were noted.

CONCLUSIONS

We conclude that alendronate therapy, 70 mg/wk, initiated soon after acute SCI, prevents bone loss and is not associated with side effects.

Gender equality in the work of local research ethics committees in Europe: a study of practice in five countries

BACKGROUND

Funding organisations and research ethics committees (RECs) should play a part in strengthening attention to gender equality in clinical research. In the research policy of European Union (EU), funding measures have been taken to realise this, but such measures are lacking in the EU policy regarding RECs.

OBJECTIVE

To explore how RECs in Austria, Germany, Ireland, The Netherlands and Sweden deal with gender equality issues by asking two questions: (1) Do existing procedures promote representation of women and gender expertise in the committee? (2) How are sex and gender issues dealt with in protocol evaluation?

METHODS

Two RECs were selected from each country. Data were obtained through interviews with key informants and content analysis of relevant documents (regulations, guidelines and review tools in use in 2003).

RESULTS

All countries have rules (mostly informal) to ensure the presence of women on RECs; gender expertise is not required. Drug study protocols are carefully evaluated, sometimes on a formal basis, as regards the inclusion of women of childbearing age. The reason for excluding either one of the sexes or including specific groups of women or making a gender-specific risk-benefit analysis are investigated by some RECs. Such measures are, however, neither defined in the regulations nor integrated in review tools.

CONCLUSIONS

The RECs investigated in five European member states are found to pay limited attention to gender equality in their working methods and, in particular in protocol evaluation. Policy and regulations of EU are needed to strengthen attention to gender equality in the work of RECs.

The involvement of calcium and MAP kinase signaling pathways in the production of radiation-induced bystander effects

Much evidence now exists regarding radiation-induced bystander effects, but the mechanisms involved in the transduction of the signal are still unclear. The mitogen-activated protein kinase (MAPK) pathways have been linked to growth factor-mediated regulation of cellular events such as proliferation, senescence, differentiation and apoptosis. Activation of multiple MAPK pathways such as the ERK, JNK and p38 pathways have been shown to occur after exposure of cells to radiation and a variety of other toxic stresses. Previous studies have shown oxidative stress and calcium signaling to be important in radiation-induced bystander effects. The aim of the present study was to investigate MAPK signaling pathways in bystander cells exposed to irradiated cell conditioned medium (ICCM) and the role of oxidative metabolism and calcium signaling in the induction of bystander responses. Human keratinocytes (HPV-G cell line) were irradiated (0.005-5 Gy) using a cobalt-60 teletherapy unit. The medium was harvested 1 h postirradiation and transferred to recipient HPV-G cells. Phosphorylated forms of p38, JNK and ERK were studied by immunofluorescence 30 min-24 h after exposure to ICCM. Inhibitors of the ERK pathway (PD98059 and U0126), the JNK pathway (SP600125), and the p38 pathway (SB203580) were used to investigate whether bystander-induced cell death could be blocked. Cells were also incubated with ICCM in the presence of superoxide dismutase, catalase, EGTA, verapamil, nifedipine and thapsigargin to investigate whether bystander effects could be inhibited because of the known effects on calcium homeostasis. Activated forms of JNK and ERK proteins were observed after exposure to ICCM. Inhibition of the ERK pathway appeared to increase bystander-induced apoptosis, while inhibition of the JNK pathway appeared to decrease apoptosis. In addition, reactive oxygen species, such as superoxide and hydrogen peroxide, and calcium signaling were found to be important modulators of bystander responses. Further investigations of these signaling pathways may aid in the identification of novel therapeutic targets.

Transfer of communication skills training from workshop to workplace: the impact of clinical supervision

OBJECTIVE

Recent studies have recognised that the communication skills learned in the training environment are not always transferred back into the clinical setting. This paper reports a study which investigated the potential of clinical supervision in enhancing the transfer process.

METHODS

A randomised controlled trial was conducted involving 61 clinical nurse specialists. All attended a 3-day communication skills training workshop. Twenty-nine were then randomised to 4 weeks of clinical supervision, aimed at facilitating transfer of newly acquired skills into practice. Assessments, using real and simulated patients, were carried out before the course, immediately after the supervision period and 3 months later. Interviews were rated objectively using the Medical Interview Aural Rating Scale (MIARS) to assess nurses' ability to use key skills, respond to patient cues and identify patient concerns.

RESULTS

Assessments with simulated patients showed that the training programme was extremely effective in changing competence in all three key areas. However, only those who experienced supervision showed any evidence of transfer. Improvements were found in the supervised groups' use of open questions, negotiation and psychological exploration. Whilst neither group facilitated more disclosure of cues or concerns, those in the experimental group responded more effectively to the cues disclosed, reduced their distancing behaviour and increasing their exploration of cues.

CONCLUSIONS

The study has shown that whilst training enhances skills, without intervention, it may have little effect on clinical practice. The potential role of clinical supervision as one way of enhancing the clinical effectiveness of communication skills training programmes has been demonstrated. PRACTISE IMPLICATIONS: This study raises questions about the effectiveness of training programmes which do not incorporate a transfer element, and provides evidence to support the need for clinical supervision for clinical nurse specialist.

High incidence of skewed X chromosome inactivation in young patients with familial non-BRCA1/BRCA2 breast cancer

BACKGROUND

A higher frequency of skewed X chromosome inactivation has been reported in a consecutive series of young patients with breast cancer compared with controls of a similar age.

OBJECTIVE

To investigate the X inactivation pattern in patients with familial non-BRCA1/BRCA2 breast cancer (n = 272), BRCA1/BRCA2 germline mutations (n = 35), and sporadic breast cancer (n = 292).

METHODS

X inactivation pattern was determined by polymerase chain reaction analysis of the highly polymorphic CAG repeat in the androgen receptor (AR) gene. The X inactivation pattern was classified as skewed when 90% or more of the cells preferentially expressed one X chromosome.

RESULTS

Young patients with familial breast cancer had a significantly higher frequency of skewed X inactivation (11.2%) than young controls (2.7%) (p = 0.001). There was also a strong tendency for middle aged patients with sporadic breast cancer to be more skewed than middle aged controls (13.6% v 4.4%) (p = 0.02). No association between skewed X inactivation and breast cancer was found for the BRCA1/BRCA2 patients .

CONCLUSIONS

Skewed X inactivation may be a risk factor for the development of breast cancer in both sporadic and familial breast cancer and may indicate an effect of X linked genes.

Identifying the concerns of women undergoing chemotherapy

This cross-sectional study aimed to identify key concerns of cancer patients receiving in-patient chemotherapy, determine the prevalence of anxiety and depression, and assess whether ward nurses could identify patients' concerns. Thirty-three women on a chemotherapy ward in the northwest of England who had breast, ovarian, cervical or uterine cancer were interviewed using a Concerns Checklist and the Hospital Anxiety and Depression Scale. Patients expressed an average of 10.3 concerns (range: 2-27). Eighty percent of these were not identified by the nurses, who showed a clear bias towards physical symptoms and treatment-related concerns. The nurses were unable to identify the three main concerns in 70% of patients. Twenty-four percent of patients were found to be probable cases of anxiety and/or depression; there was a moderate correlation between the number of concerns and levels of anxiety and depression. Given the body of evidence that lack of identification of concerns leads to unmet needs, increased psychological distress, dissatisfaction with care and possible complaints, this study has provided clear evidence for the need to address this key area of care, and has highlighted the potential of the Concerns Checklist in busy clinical environments.

Giving feedback to learners in the practice

BACKGROUND

Many general practitioners accept vocational registrars and medical students into their practice. Giving feedback to students on their work performance is an essential component of teaching in general

OBJECTIVE

This article examines the central role of feedback in the teaching of medical students and registrars and provides practical guidelines on how to provide feedback in the setting of a busy general practice, describes some barriers and pitfalls, and provides a registrar's perspective on what learners see as important.

DISCUSSION

For feedback to be effective, it must be given in a supportive environment. Feedback that is specific to the learner performance is highly valued by learners, whereas nonspecific evaluative feedback is less valued. The mentoring relationship between teacher and learner is crucial to giving effective feedback. Learners appreciate a teacher's help identifying any area for improvement, then being given the chance to work out the answers for themselves instead of being told exactly what to do by the more experienced teacher.

Can oncology nurses treat depression? A pilot project

BACKGROUND

Depression is a common problem in all medically ill populations. Reported prevalence rates of major depression in patients with cancer are up to 50%. Cancer patients attending primary care and medical outpatient clinics with comorbid major depressive disorder frequently do not receive effective treatment. More effective ways of identifying and treating patients with both cancer and depression are therefore urgently required.

AIM

The paper reports a study addressing the question of whether oncology nurses can be trained to take on a greater role in the management of major depression in their patients.

METHOD

We developed and piloted an intervention that can be delivered by a specially trained oncology nurse. The intervention is multifaceted and based on a problem-solving model. It requires a widening of the role and expertise of specialist nurses.

DISCUSSION

The challenges this role presents to the nurses are discussed. We suggest that they must have a varied work programme that is not exclusively about managing depression, that they require adequate peer support and are likely to be most effective when working as part of a multidisciplinary psycho-oncology team.

CONCLUSION

We conclude that it is possible to train selected specialist oncology nurses to manage major depression in patients with cancer in the context of an appropriately constituted multidisciplinary team.

Major depression in outpatients attending a regional cancer centre: screening and unmet treatment needs

A screening programme designed to identify cases of Major Depressive Disorder (MDD) in patients attending a Regional Cancer Centre outpatient department was established. It comprised two stages: (1) The Hospital Anxiety and Depression Scale (HADS) self-rating questionnaire administered by a touch-screen computer; (2) we interviewed patients with high scores on the HADS (15 or more total score) over the telephone using the depression section of the Structured Clinical Interview for DSMIV (SCID). A large consecutive sample (5613) of oncology clinic attenders was screened, and practical difficulties in the screening process were identified. The estimated prevalence of major depressive disorder (MDD) in the sample surveyed was approximately 8% (7.8%; 95% confidence intervals 6.9–8.5%). We assessed a consecutive series of 150 patients identified as having MDD to determine how many had received evidence-based treatment for MDD. Only half had discussed their low mood with their general practitioner, only one-third had been prescribed any antidepressant medication, and very few had taken a therapeutic dose for an adequate period. Very few had received psychological treatment or had been referred to mental health services. Most were receiving no potentially effective therapy.

Management of major depression in outpatients attending a cancer centre: a preliminary evaluation of a multicomponent cancer nurse-delivered intervention

A novel nurse-delivered multicomponent intervention for major depressive disorder (MDD) in cancer outpatients was compared with usual care alone in a nonrandomised matched group design (n=30 per group). At the final 6-month outcome, 38.5% (95% CI, 5.4–57%) fewer patients in the intervention group still met the criteria for MDD.

A randomised controlled trial of cytological surveillance versus patient choice between surveillance and colposcopy in managing mildly abnormal cervical smears

OBJECTIVE

To determine whether choice of colposcopy or six month cytological surveillance would be beneficial to women with mildly abnormal smears when compared with the national policy of six months surveillance in terms of psychological morbidity.

DESIGN

A randomised trial based on the Zelen design.

SETTING

A hospital-based research clinic.

POPULATION

Four hundred and seventy-six women who had had a recurrent borderline or mildly dyskaryotic smear on routine cervical screening in primary care.

METHODS

Women were randomised either to six months cytological surveillance or to make a choice between that or colposcopy and were followed up for 1 year.

MAIN OUTCOME MEASURES

The primary outcome measure was caseness (score >or=4) on the General Health Questionnaire at 12 months follow up. Other measures were the Spielberger State and Trait scores, default rates and cytology/colposcopy outcomes.

RESULTS

There was no significant difference between the arms for General Health Questionnaire (GHQ) scores and Spielberger State and Trait at 12 months. There was a significant reduction in psychometric morbidity between baseline and 12 months in both arms. Overall rates of default from the protocol were the same in both arms, but default that led to uncertain ascertainment of cervical pathology was greater in the no-choice arm.

CONCLUSIONS

This trial indicates that having choice did not impact favourably or harmfully on anxiety or feelings of wellbeing. If a patient is anxious, allowing the patient to choose immediate colposcopy may be preferable because it will improve ascertainment of underlying disease in a group who are more likely to default.

Managing the difficult consultation

Patients are more likely to develop psychological problems if their concerns are unresolved and their information needs unmet. However, many health professionals are uncertain how to elicit patients' concerns or tailor information appropriately. These difficulties may also lead to psychological problems for the health professional. Feeling inadequately trained in communication skills has been linked to burnout amongst senior doctors working in cancer. Clinicians find that some consultations are particularly hard to manage; for example, when patients are highly distressed, angry, withdrawn or in denial. Barriers to effective communication are patient-led as well as doctor- or nurse-led but relevant training can help overcome those barriers. The article described one training model that is effective in improving health professionals' skills. Specific strategies are suggested that can help in the more difficult consultations and so enable clinicians to talk to patients about their concerns and worries more freely.

The psychological impact of cancer on patients' partners and other key relatives: a review

Partners and other family members are key supports for cancer patients. Most cope well with the caregiving role, but an important minority become highly distressed or develop an affective disorder. Female carers and those with a history of psychiatric morbidity are more vulnerable, as are those who take a more negative view of the patient's illness and its impact on their lives. Carers are likely to become more distressed and develop psychiatric morbidity as the illness advances and treatment is palliative. Carers are also more at risk when they lack a support network of their own and when there are relationship difficulties with the patient. The review discusses why, given this evidence, carers fail to take advantage of interventions designed to help them and those who participate derive only limited psychological benefits.

A patient-centred approach to defining and assessing interviewing competency

The inclusion of communication skills as a core competency in health care curricula, has led to the need to define adequacy in this area. Developments in the field of interview analysis have meant that robust and objective ways of assessing interview behaviours are now available; however, these systems in themselves do not provide a model for assessing competency. As adequacy in interviewing is contextually driven, this paper discusses the potential of using patient centeredness to address the issue. It suggests two ways in which patient centeredness may be operationally defined, permitting data available from current rating systems, and from a new system shortly to be available, to be used to assess interviewing competency.