Economic evaluation of a randomized clinical trial of hospital versus telephone follow-up after treatment for breast cancer

BACKGROUND

This was an economic evaluation of hospital versus telephone follow-up by specialist nurses after treatment for breast cancer.

METHODS

A cost minimization analysis was carried out from a National Health Service (NHS) perspective using data from a trial in which 374 women were randomized to telephone or hospital follow-up. Primary analysis compared NHS resource use for routine follow-up over a mean of 24 months. Secondary analyses included patient and carer travel and productivity costs, and NHS and personal social services costs of care in patients with recurrent breast cancer.

RESULTS

Patients who had telephone follow-up had approximately 20 per cent more consultations (634 versus 524). The longer duration of telephone consultations and the frequent use of junior medical staff in hospital clinics resulted in higher routine costs for telephone follow-up (mean difference pound 55 (bias-corrected 95 per cent confidence interval (b.c.i.) pound 29 to pound 77)). There were no significant differences in the costs of treating recurrence, but patients who had hospital-based follow-up had significantly higher travel and productivity costs (mean difference pound 47 (95 per cent b.c.i. pound 40 to pound 55)).

CONCLUSION

Telephone follow-up for breast cancer may reduce the burden on busy hospital clinics but will not necessarily lead to cost or salary savings.

Audit in the management of T3 fixed-cord laryngeal cancer

PURPOSE

To determine results of various treatments for T3 fixed-cord lesions and the subset T3 glottic cancer in Auckland from 1979 to 1995.

PATIENTS AND METHODS

Data were collected retrospectively from a departmental database, and the notes were reviewed. Because of the difficulty in determining the subsite of some fixed-cord lesions, the entire group of T3 fixed-cord lesions was examined, and those tumors that were considered to be definitely arising from the glottis were then analyzed as a specific subset.

RESULTS

Fixed-cord lesions were diagnosed in 75 patients (21 supraglottic, 54 glottic). Primary surgery (total laryngectomy) was performed on 46 patients, primary radical dose radiotherapy was undertaken on 25 patients, and four patients were treated palliatively. For T3 fixed-cord lesions, disease-specific survival for radiotherapy and surgery was 36% and 66%, respectively, and 32% and 67%, respectively, for T3 glottic lesions. For both T3 fixed-cord and T3 glottic lesions, surgery produced significantly better survival than did radiotherapy (<60 Gy; P = .0157). With radiotherapy greater than 60 Gy, cancer of the larynx has been controlled in seven of 13 patients, although only five patients are alive, with a median follow-up of 24 months (range, 12-49 months).

CONCLUSION

Radiotherapy less than 60 Gy produced markedly inferior results to surgery for T3 fixed-cord lesions and T3 glottis in Auckland. Radiotherapy at more than 60 Gy shows promise, but an ongoing audit is essential to ensure that survival is similar to surgery and to that reported by those promoting organ-preservation protocols.

'Watch policy' in patients with suspected stage I testicular seminoma: CT as a sole staging and surveillance technique

A study was undertaken to assess the role of computed tomography (CT) as the sole imaging technique for the staging and surveillance of patients with stage I testicular seminoma. Of the 15 patients studied, five (33%) relapsed. This relapse rate differs from other studies. The reasons for this are discussed.

Hormonal changes in postmenopausal women with breast cancer treated with trilostane and dexamethasone

Postmenopausal women with metastatic breast cancer were treated with trilostane, initially 240 mg daily increasing after 3 days to 480 mg daily and after a further three days to 960 mg daily. After 3 days at this dose dexamethasone 1 mg daily was added and this combination was continued until disease progression occurred. Partial remission was seen in 26% and stabilization of previously progressive disease in a further 13% of the first twenty-three patients studied. During therapy with trilostane alone significant increases in DHEAS, androstenedione, 17-hydroxypregnenolone, progesterone, testosterone and oestradiol were seen. A significant fall in oestrone concentration occurred at the same time. After dexamethasone was added the elevated steroid concentrations fell back to the baseline while oestrone remained depressed below this and testosterone was also significantly lowered. No change was seen in cortisol or ACTH concentration while patients were on trilostane alone but cortisol levels were undetectable after dexamethasone was added though, in most patients, ACTH remained detectable. There was no change in the ratio of delta 5:delta 4 steroids at any stage of therapy but a highly significant increase in the androstenedione: oestrone ratio was seen. We conclude that in long-term use in vivo it is difficult to demonstrate that trilostane inhibits 3 beta-hydroxysteroid dehydrogenase but it may produce inhibition of aromatase.

Trilostane in the treatment of advanced breast cancer

The combination of trilostane 960 mg daily and either dexamethasone 0.5 mg b.d. or hydrocortisone 10 mg b.d. has been used to treat advanced metastatic breast cancer in post-menopausal women. Twenty-three patients had assessable disease and received treatment for a minimum of 8 weeks. Six (26%) showed an objective response and three (13%), stabilisation of previously progressive disease, sustained for at least 3 months. Side-effects were mainly gastrointestinal. Biochemical studies suggest that the mechanism of action may be inhibition of conversion of androstenedione to oestrone.

A double-blind controlled trial of salmon calcitonin in pain due to malignancy

Thirty-two patients with established malignancy and associated pain participated in a randomised double-blind controlled trial. They received salmon calcitonin SC 200 UI or matching placebo 6-hourly for 48 h and were assessed by using a combination of a 20-point visual analogue scale (VAS), a 4-point physician's global pain scale, and ranking of the co-administered analgesics into 20 grades of potency. Twenty-five patients (13 calcitonin, 12 placebo) were evaluated. Seven patients (4 calcitonin, 3 placebo) were excluded either because the initial pain score was less than or equal to 5 on the VAS, or because there were insufficient data (due to death occurring within the first week of the study or, in one patient, blindness preventing completion of the VAS). One week after commencing therapy there was improvement or marked improvement of pain in significantly more patients in the calcitonin group (5/13) than in the placebo group (0/12) (Fisher's exact two-tailed probability test, P = 0.0484). At the end of the second week three patients in the calcitonin group were still showing marked improvement.