Pregnancy and breast cancer: a population-based study

The incidence of pregnancy-associated breast cancer, i.e. during pregnancy and lactation, and of pregnancy subsequent to a breast-cancer diagnosis will increase as more women choose childbearing at a later age. Few larger series are published on pregnancy-associated breast cancer. In a population-based study, we evaluated the outcome and prognostic factors in 173 breast-cancer patients. One hundred and twenty-two patients had pregnancy-associated breast cancer (20 coincident with pregnancy and 102 during lactation) and 51 patients had pregnancy subsequent to breast cancer. The median follow-up time was 151 months. Histopathological parameters and immunoreactivity for oestrogen and progesterone receptors c-erbB-2 and c-erbB-4 were studied. All three groups had tumours with high histological grade, low frequency of hormone receptors and high expression of c-erbB-2. The pregnancy and lactation groups were near identical with regard to all histopathological parameters and outcome. In the two pregnancy-associated breast-cancer groups, tumours were significantly larger, with more extensive lymph-node involvement. For node-negative tumours the respective 5- and 10-year survival rates were 62% and 50% in the pregnancy group and 60% and 50% in the lactation group. For node-positive tumours, respective 5- and 10-year survival rates were 50% and 34% in the pregnancy group and 50% and 33% in the lactation group. In the subsequent group, overall survival was high in both node-negative and -positive groups, with 5- and 10-year survival rates of 80% and 73% and 86% and 76%, respectively. Tumour size, lymph-node status, histological grade, progesterone receptor, oestrogen receptor and c-erbB-2 were significant prognostic factors in the pregnancy-associated breast-cancer patients.

The prognostic value of p53 and c-erb B-2 immunostaining is overrated for patients with lymph node negative breast carcinoma: a multivariate analysis of prognostic factors in 613 patients with a follow-up of 14-30 years

BACKGROUND

Approximately 30% of breast carcinoma patients with negative lymph nodes die of their disease. Biologic markers such p53 protein and c-erb B-2 have been related to tumor progression, but their prognostic value remains controversial.

METHODS

Two large series of a total of 613 lymph node negative breast carcinoma patients from a single institution were analyzed with respect to tumor size, histologic grade, and immunohistochemical staining for p53, c-erb B-2, estrogen receptor (ER), and progesterone receptor (PgR). Interobserver variation in histologic grading was evaluated by Kappa statistics. The two series had different treatment modalities: 228 patients (SACGS group) were treated surgically with mastectomy and given 1 perioperative chemotherapy course, and 385 patients (HOST group) were treated with mastectomy and ovarian radiation and further randomized to receive postoperative treatment with radiotherapy or no adjuvant treatment. The follow-up ranged from 14-30 years.

RESULTS

Immunoreactivities for p53, c-erb B-2, ER, and PgR did not differ significantly in the two series. p53 immunostaining was present in 187 of 613 tumors (29%), and c-erb B-2 immunoreactivity was present in 58 of the tumors (10%). Three hundred forty-eight tumors (57%) were positive for ER. Kappa statistics value of interobserver variation in the histologic grading of ductal carcinomas was 0.69, which is considered to be a substantial degree of agreement. No significant differences in survival were found when comparing p53, c-erb B-2, ER, and PgR positive and negative cases. However, both recurrence free survival rates and overall survival rates after 10 years were significantly better in the T1N0M0 group compared with the T2N0M0 group (81% vs. 67% [P < 0.0001] and 85% vs. 70% [P < 0.0001]). Ten-year recurrence free survival rates for patients with histologic Grade 1 versus Grades 2-3 (according to Elston and Ellis' modification of the Bloom and Richardson method) tumors were 90% and 70%, respectively (P < 0. 0001), and overall survival rates for the same groups were 94% and 81%, respectively (P=0.0002). After 30 years of follow-up, the overall survival rate for patients with tumors of histologic Grade 1 versus Grades 2-3 were 87% and 68%, respectively, and were 78% and 66%, respectively, for patients with tumors </= 2 mm versus those with tumors > 20-50 mm. Approximately 35% of the patients with tumors of histologic Grades 2-3 and measuring > 20 mm were dead after 10 years of follow-up, contrary to 6% of the patients with tumors of histologic Grade 1 measuring </= 20 mm. A significantly more favorable prognosis also was observed in patients in the HOST group treated with adjuvant radiotherapy.

CONCLUSIONS

Histologic grade and tumor size were found to be major prognostic factors for patients after 30 years of follow-up. c-erb B-2 and p53 immunostaining does not appear have any independent prognostic value. Adjuvant radiotherapy may be of value in the treatment of patients with localized tumors.

The prognostic value of p53 and c-erb B-2 immunostaining is overrated for patients with lymph node negative breast carcinoma: a multivariate analysis of prognostic factors in 613 patients with a follow-up of 14-30 years

BACKGROUND

Approximately 30% of breast carcinoma patients with negative lymph nodes die of their disease. Biologic markers such p53 protein and c-erb B-2 have been related to tumor progression, but their prognostic value remains controversial.

METHODS

Two large series of a total of 613 lymph node negative breast carcinoma patients from a single institution were analyzed with respect to tumor size, histologic grade, and immunohistochemical staining for p53, c-erb B-2, estrogen receptor (ER), and progesterone receptor (PgR). Interobserver variation in histologic grading was evaluated by Kappa statistics. The two series had different treatment modalities: 228 patients (SACGS group) were treated surgically with mastectomy and given 1 perioperative chemotherapy course, and 385 patients (HOST group) were treated with mastectomy and ovarian radiation and further randomized to receive postoperative treatment with radiotherapy or no adjuvant treatment. The follow-up ranged from 14-30 years.

RESULTS

Immunoreactivities for p53, c-erb B-2, ER, and PgR did not differ significantly in the two series. p53 immunostaining was present in 187 of 613 tumors (29%), and c-erb B-2 immunoreactivity was present in 58 of the tumors (10%). Three hundred forty-eight tumors (57%) were positive for ER. Kappa statistics value of interobserver variation in the histologic grading of ductal carcinomas was 0.69, which is considered to be a substantial degree of agreement. No significant differences in survival were found when comparing p53, c-erb B-2, ER, and PgR positive and negative cases. However, both recurrence free survival rates and overall survival rates after 10 years were significantly better in the T1N0M0 group compared with the T2N0M0 group (81% vs. 67% [P < 0.0001] and 85% vs. 70% [P < 0.0001]). Ten-year recurrence free survival rates for patients with histologic Grade 1 versus Grades 2-3 (according to Elston and Ellis' modification of the Bloom and Richardson method) tumors were 90% and 70%, respectively (P < 0. 0001), and overall survival rates for the same groups were 94% and 81%, respectively (P=0.0002). After 30 years of follow-up, the overall survival rate for patients with tumors of histologic Grade 1 versus Grades 2-3 were 87% and 68%, respectively, and were 78% and 66%, respectively, for patients with tumors </= 2 mm versus those with tumors > 20-50 mm. Approximately 35% of the patients with tumors of histologic Grades 2-3 and measuring > 20 mm were dead after 10 years of follow-up, contrary to 6% of the patients with tumors of histologic Grade 1 measuring </= 20 mm. A significantly more favorable prognosis also was observed in patients in the HOST group treated with adjuvant radiotherapy.

CONCLUSIONS

Histologic grade and tumor size were found to be major prognostic factors for patients after 30 years of follow-up. c-erb B-2 and p53 immunostaining does not appear have any independent prognostic value. Adjuvant radiotherapy may be of value in the treatment of patients with localized tumors.

[Cancer and religiosity--a follow up of patients with Hodgkin's disease]

In this study of religiosity among cancer patients and the relationship between religiosity and illness, a questionnaire was sent to 183 survivors of Hodgkin's disease in November 1995, all of them patients treated at the Norwegian Radium Hospital between 1988 and 1994. 107 patients (58%) gave replies to 45 questions relating to religion and belief, view of life, quality of life, and the relationship between religiosity and illness. The patients' attitude to religion differed little from that of the Norwegian population at large. 15% of the patients defined themselves as atheists, 14% as agnostics, 23% believed in God as an impersonal supreme power, and 48% in a personal God. 40 patients (38%) had changed their religious belief, 33 of them becoming more religious. 58% had prayed to God (or a supreme power) for cure. Half of the respondents felt that their religious belief had been a support during their illness. 52 (49%) were not satisfied with the pastoral services during hospitalisation. The study indicates that cancer disease activates religiosity, and that religiosity may help patients cope with their disease.

Elevated levels of p27, p21 and cyclin D1 correlate with positive oestrogen and progesterone receptor status in node-negative breast carcinoma patients

The search for better prognostic indicators and new treatment modalities in node-negative breast carcinoma patients is important. The aim of this study was to determine the immunohistochemical expression of central cell regulator proteins in relation to hormone receptor status, tumour-cell differentiation and prognosis. We investigated the immunoreactivity of p27, p21, cdk4, cyclin D1 and p53 in 77 node-negative breast carcinomas, with long-term follow-up (mean 163 months; range 20-227). Nuclear staining for p27 was seen in 87% of the carcinomas, for cdk4 in 92%, for p21 in 68%, for cyclin D1 in 58% and for p53 in 18%. Oestrogen receptor (ER) and progesterone receptor (PgR) nuclear staining was seen in 69% and 65% of the tumours, respectively. No correlation between the levels of p21 and p53 was observed. p21 overexpression was, however, associated with positive ER status. Elevated levels of p27 and cyclin D1 correlated with positive hormone status (both ER and PgR). We did find a significant correlation between p27 and cyclin D1 and histological grade of the tumours, with extensive positive immunostaining of p27 and cyclin D1 in well-differentiated carcinomas. The only significant prognostic factor in our series was histological grading. Ten-year relapse-free survival was significantly prolonged in patients with histological grade I tumours versus histological grade II and III tumours. Our results suggest that the expression of p27 and cyclin D1 is closely linked to hormone receptor status in breast carcinomas and to tumour differentiation, a finding that may be of importance in the treatment of hormone-dependent tumours.

Late medical sequelae after therapy for supradiaphragmatic Hodgkin's disease

A total of 221 consecutive early stage Hodgkin's disease (HD) patients were given mantle field irradiation only or in combination with chemotherapy in 1971-1991. In 1994 these patients responded to a mailed self-report questionnaire covering items on late medical symptoms. Of 200 patients (91%) who reported that their thyroid function had been tested, 110 patients (55% of those tested) had thyroid hypofunction at follow-up in 1994. Ninety-five patients (86% of patients with biochemical hypothyreosis) had started hormonal substitution. In 1993 and 1994, 101 of these patients who had received mantle field irradiation in 1980-1988 were called in for interview, clinical examination and thyroid function tests. Eighteen patients (18%) had started hormonal substitution treatment earlier, but 58 (70%) of the other 83 patients were found to have biochemical hypothyreosis. Of the 221 patients who completed the questionnaire, 66 patients (30%) reported dyspnoea on exertion for more than 3 years after treatment, 8 patients (4%) reported a history of myocardial infarction, 6 patients (3%) reported pericardial disease and 25 patients (11%) heart valve disease. Increased expenses incurred for dental care were reported by 106 patients (48%), increasing to 55% when Waldeyer's ring had been irradiated. The consequences of late sequelae after mantle field irradiation for future treatment are discussed.

Socio-medical situation for long-term survivors of Hodgkin's disease: a survey of 459 patients treated at one institution

We present the socio-medical situation for 459 adult disease-free long-term survivors of Hodgkin's disease (HD) 3-23 years after first line curative treatment. In 1994, 557 patients were sent a self-report questionnaire relating to their social status and 459 patients (82%) replied. Educational or professional plans were changed due to HD in 142 patients (32%). After 6, 12 and 18 months from start of treatment, 52, 82 and 95% of the patients, respectively, had returned to their job or education. The sum of full-time and part-time employment was in men 78% at diagnosis and 85% at follow-up, and in women 57% at diagnosis and 64% at follow-up. Only 2% of men and 3% of women did not have a job at follow-up in 1994. At diagnosis 2% of the patients were permanently disabled versus 19% at follow-up in 1994. Age > 40 years at diagnosis, increased the total score of psychological distress and fatigue and long-term disablement after first line treatment were predictors for permanent disablement. Transient or permanent sexual problems were reported in 16% and 13%, respectively. MVPP (mustine, vinblastine, procarbazine and prednisone) or LVPP (chlorambucil, vinblastine, procarbazine and prednisone) chemotherapy was responsible for most cases of early menopause in women older than 30 years, and of infertility in both men and women. In summary, most long-term HD survivors had adapted well to their socio-medical situation except a high number of permanently disabled patients. By focusing more on factors predisposing for permanent disablement and early treatment for these, more patients may be helped to return to their job.

Synovial sarcoma. Evaluation of prognosis with emphasis on the study of DNA ploidy and proliferation (PCNA and Ki-67) markers

Controversy still exists regarding the validity of parameters commonly used in the evaluation of prognosis of patients with synovial sarcoma (SS). Forty-nine cases of previously untreated primary SS (23 females and 26 males, ranging in age from 7 to 81, with 31 tumors located in the lower extremity, 8 at the upper extremity and 10 at the trunchus), without regional lymph-node or distant metastases were studied. We investigated the relationship between (flow and image) DNA cytometry, proliferation activity, clinicopathologic parameters, and relapse-free and overall survival of the patients. The prognostic value of gender, age, duration of symptoms, location, compartmentalization, size, adequacy of surgical margins, residual tumor, adjuvant therapy, histologic subtype, extent of necrosis, glandular differentiation, calcification, and extent of hemangiopericytic areas, mitotic rate, amount of mast cells, blood vessel invasion, histologic (UICC and NCI) grades, DNA ploidy, percentage of cells in S and S+G2 phases, PCNA and Ki-67 labeling indices (LI), and TNM (UICC) stage of the tumors, were evaluated by univariate and multivariate (Cox hazard model) analyses. Short duration of symptoms (<12 months), biphasic SS, scarcity of mast cells (<10/10 HPF), high mitotic rate (> or =10/10 HPF), high histologic grade (grade 3), high PCNA-LI (> or =20%), high Ki-67-LI (> or =10%), DNA aneuploidy, and advanced TNM stage (stage III) were features associated with significantly shorter relapse-free and overall 5-year survival rates in the univariate analyses. Scarcity of mast cells, high mitotic rate, or high PCNA-LI were significant predictors of poor survival, in addition to TNM stage in the multivariate analyses. The amount of mast cells was inversely correlated with mitotic rate and PCNA-LI. Scarcity of mast cells, high mitotic rate, or high PCNA-LI are factors associated with poor prognosis, in addition to advanced TNM stage in patients with localized SS.

Ifosfamide and continuous infusion etoposide in advanced adult soft tissue sarcoma. A Scandinavian Sarcoma Group Phase II Study

The purpose of this study was to evaluate tumour response and toxicity to ifosfamide and continuous infusion etoposide in metastatic or locally advanced soft tissue sarcoma, with dose escalations under G-CSF (granulocyte colony-stimulating factor) support. Of 92 eligible patients (median age 51 years), 85% had tumours of high-grade malignancy and 82% had metastatic disease. Chemotherapy, the baseline dose, consisted of etoposide 600 mg/m2 as a 72 h infusion and ifosfamide 1500 mg/ m2/day for 3 days, followed by G-CSF support (VIG regimen). Stepwise 10% dose escalations were performed depending on haematological toxicity. For patients considered operable after induction chemotherapy, surgical resection of all identifiable residual tumour was attempted. Complete and partial response rates were 11% and 31%, for an overall response rate of 42% (95% CI 31-52%). Forty-eight per cent of courses were dose escalated by a median of 20%. Complete responders had significantly higher, and patients with progressive disease had significantly lower, dose levels than other patients. None of 20 patients with liver metastases responded despite high dose levels. Compared to a preceding pilot study, the addition of G-CSF led to significantly higher dose levels, improved schedule adherence and less haematological toxicity, but no apparent increase in response rate. In view of the modest dose of ifosfamide applied in this study, it is possible that the prolonged infusion of etoposide made a significant contribution to the regimen's antitumour activity, although this can only be determined definitively in a randomised study.

Randomized controlled trial of postoperative radiotherapy and short-term time-scheduled 5-fluorouracil against surgery alone in the treatment of Dukes B and C rectal cancer. Norwegian Adjuvant Rectal Cancer Project Group

BACKGROUND

The purpose of the present study was to investigate whether a 1-month regimen of postoperative radiotherapy combined with 5-fluorouracil could reduce the local recurrence rate and improve survival in patients with Dukes B and C rectal cancer.

METHODS

One hundred and forty-four patients were randomized to surgery alone or surgery combined with postoperative radiotherapy (46 Gy) and bolus 5-fluorouracil 30 min before six of the radiotherapy fractions. One hundred and thirty-six patients were eligible.

RESULTS

The adjuvant treatment was well tolerated. After an observation time of 4-8 years, patients in the adjuvant treatment group had a cumulative local recurrence rate of 12 per cent compared with 30 per cent in the group that had surgery only (P = 0.01). The 5-year recurrence-free and overall survival rate was 64 per cent in the adjuvant group compared with 46 per cent (P = 0.01) and 50 per cent (P = 0.05) respectively in the surgery group. The adjusted relative risk of recurrence and death for the adjuvant group was 0.48 (95 per cent confidence interval 0.28-0.82) and 0.56 (0.33-0.94) respectively.

CONCLUSION

The 1-month postoperative combination regimen improved treatment results in patients with Dukes B and C rectal cancer, in terms of local recurrence rate, recurrence-free survival and overall survival, without serious side-effects.

[The project Better Cancer Care in Buskerud]

A project called Better cancer care in Buskerud was started in 1991 in the county of Buskerud, in Norway. The main objective was to improve the out-patient services for cancer patients at the central hospital. In this article we describe the activities at the out-patient clinic during the period 1991-1993. The clinic was staffed by two oncologists and two cancer nurses. A total of 8060 consultations were held with patients during the period. Breast cancer patients comprised the largest group (30%), followed by patients with gastrointestinal cancer (24%) or malignant lymphoma (13%). The hospital's Department of Surgery was particularly relieved to hand over the administration of chemotherapy. The number of patients who received radiotherapy at the nearest cancer centre did not increase, however, during the period. We conclude that the project in Buskerud was a success, and that most of the objectives were achieved.

[Check up of breast cancer stages 1 and 2]

We have studied the efficacy of investigations during follow-up of 430 operable node positive and node negative breast cancer patients. Median follow-up was eight years, and 128 patients had relapsed, 91 with metastatic disease. Eight blood analyses, chest X-ray, limited skeletal X-ray and bone scan examinations were undertaken at regular intervals. Of the patients who had relapsed, 59% had symptoms, 23% were detected by clinical examination and 18% were detected by blood analysis only. X-rays and scintigrams were of little value in proportion to the costs. The combination of three blood analyses was useful. An increase in sedimentation rate (ESR) of more than 10 mm/h, an increase in gamma-glutamyltransferase (GT) of 20 U/l and an increase in alkaline phosphatase (ALP) of 60 U/l or more. By using ESR, gamma-GT, ALP, history and clinical examination, costs could be reduced by 90% while maintaining adequate baseline screening for relapse.

Systemic pneumococcal disease after staging splenectomy for Hodgkin's disease 1969-1980 without pneumococcal vaccine protection: a follow-up study 1994

We surveyed, during 1994, all 325 patients who underwent staging laparotomy with splenectomy for Hodgkin's disease in Norway 1969-80, before pneumococcal vaccine was available in this country. The patients were thus not immunized preoperatively. Of 162 patients (49.8%) who died before 1994, 8 (2.4% of the total study) died from pneumococcal septicaemia and 16 (6.2%) from infections totally. Of 163 patients (50.2%) who were alive in 1994, 158 cooperated and filled in a questionnaire: 22 had been hospitalized for serious infections; 2 with pneumococcal septicaemia, and 6 with pneumonia, although lacking a specified microbiological diagnosis. We observed 325 patients representing 4420 patient-years, 3066 patient-years among survivors and 1354 patient-years among the dead. This resulted in an incidence rate of systemic pneumococcal disease of 226 per 100,000 patient-years, which is a relative risk of 20.5 compared to the general Norwegian population during 1994. Septicaemia for these patients most often had an abrupt clinical start even for relapse-free individuals and occurred from 2 to 17 yr after splenectomy (mean 10 yr). The risk of developing an overwhelming pneumococcal septicaemia with high case-fatality in asplenic patients seems to persist for these patients at about the same level even 15-20 yr after splenectomy. Only 12.7% of the survivors had been given pneumococcal vaccine in the autumn of 1993. Despite the fact that medical journals and media in Norway focused upon the problem of pneumococcal disease in asplenic individuals in the autumn of 1993 and spring of 1994, a substantial proportion of these patients (55.3%) still remained unimmunized when interviewed in the autumn of 1994. None of our systemic pneumococcal disease patients was vaccinated. Our data underline the need for prophylactic immunization with effective vaccines against pneumococcal infection in splenectomized Hodgkin's disease patients.

Psychological distress after cancer cure: a survey of 459 Hodgkin's disease survivors

To assess the levels of psychological distress and identify predictors of anxiety/depression caseness after cancer cure, a national population of 557 Hodgkin's disease (HD) survivors was surveyed. The respondents [204 women, 255 men, mean age 44 years (SD = 12)] returned a mailed questionnaire including The Hospital Anxiety and Depression Scale (HADS). Disease and treatment variables were based on the hospital records. A total of 27% had caseness scores (anxiety, 14.5%; depression, 4%; anxiety and depression, 8.5%). In a multiple logistic regression analysis, anxiety caseness was predicted by low educational status [OR (odds ratio) = 2.07, 95% CI = 1.02-4.22], observational period 7 years or longer (7-10 years: OR = 3.07, 95% CI = 1.26-7.47), combined irradiation and chemotherapy treatment (OR = 2.77, 95% CI = 1.17-6.54) and psychiatric symptoms before HD (OR = 2.55, 95% CI = 1.40-4.65) or during treatment (OR = 3.51, 95% CI = 2.08-5.90). Depression caseness was predicted by age (OR = 1.03, 95% CI = 1.00-1.06) and psychiatric symptoms before HD (OR = 5.1, 95% CI = 2.55-10.31) Anxiety cases are more prevalent than in the general Norwegian population, and were found to be most common 7-10 years after treatment. The most intensive treatment was associated with increased risk for anxiety caseness. The subjects experienced distress during treatment precedes difficulties in long-term adjustment. Focusing on these predictors during treatment and follow-up controls may improve long-term outcome.

Five-year followup of a prospective trial of radical cystectomy and neoadjuvant chemotherapy: Nordic Cystectomy Trial I. The Nordic Cooperative Bladder Cancer Study Group

PURPOSE

Chemotherapy is widely used in patients with locally advanced bladder cancer but until now there has been no conclusive evidence that this therapy improves survival. The Nordic Cooperative Bladder Cancer Study Group conducted a randomized phase III study to assess the possible benefit of neoadjuvant chemotherapy in patients with bladder cancer undergoing radical cystectomy after short-term radiotherapy.

MATERIALS AND METHODS

Our trial included 325 patients with locally advanced stage T1 grade 3 or stages T2 to T4aNXM0 bladder cancer allocated randomly into a chemotherapy or no chemotherapy group (control). The chemotherapy schedule consisted of 2 cycles of 70 mg./m.2 cisplatin and 30 mg./m.2 doxorubicin with a 3-week interval between the cycles.

RESULTS

After 5 years the overall survival rate was 59% in the chemotherapy group and 51% in the control group (p = 0.1). The corresponding cancer specific survival rate was 64 and 54%, respectively. In regard to treatment, no difference was observed for stages T1 and T2 disease, while there was a 15% difference in overall survival for patients with stages T3 to T4a disease (p = 0.03). In a multivariate analysis only chemotherapy and T category emerged as independent prognostic factors. The relative death risk for patients who received chemotherapy was 0.69 (95% confidence interval 0.49 to 0.98) compared to the control group after adjustment for the other tested factors.

CONCLUSIONS

Neoadjuvant chemotherapy seems to improve long-term survival after cystectomy in patients with stages T3 to T4a bladder carcinoma, while no survival benefit was found for stages T1 to T2 disease.

[Prognosis in primary tumors of the central nervous system. A patient material from the Norwegian Radium Hospital 1960-94]

We present the results of a retrospective survey of 1,218 patients treated at the Norwegian Radium Hospital during the years 1980-94 for primary tumours of the central nervous system. Median survival for patients with glioblastoma (n = 492) was 12 months, for patients with anaplastic astrocytoma (n = 83) 25 months, astrocytoma (n = 260) 95 months, oligodendroglioma (n = 85) 74 months, mixed glioma (n = 68) 65 months, and medulloblastoma (n = 53) 109 months. Median survival for patients with brain stem tumours (n = 37) was nine months, while 74% of patients with tumours in the pineal region (n = 38) survived for five years. The histology and localisation of the tumour, as well as age and functional status, are important prognostic factors for survival in patients with primary CNS tumours.

Clinical stage I and II Hodgkin's disease: long-term results of therapy without laparotomy. Experience at one institution

BACKGROUND

We concluded a program in which we administered radiotherapy only to clinical stages I and II Hodgkin's disease patients at standard risk, with the addition of 4 cycles of combination chemotherapy before radiotherapy for high-risk patients.

PATIENTS AND METHODS

From 1980 to 1991, 313 patients with clinical stages I or II Hodgkin's disease underwent treatment in our hospital. Fifty percent of the patients in groups previously identified as being at high risk for relapse received 4 cycles of combination chemotherapy before radiotherapy. The remaining half of the patients received radiotherapy only.

RESULTS

Low- and high-risk patients aged 15-59 years had, respectively, complete remission (CR) rates of 97% and 94%, 5-year survivals of 95% and 91%, and 5-year freedom from relapse (FFR) rates of 78% and 89%. Older low- and high-risk groups had CR rates of 97% and 93%, 5-year survivals of 60% and 56% and 5-year FFR of 77% and 93%, respectively.

CONCLUSION

Here we present our favorable results after treating standard-risk patients with clinical stages I and II Hodgkin's disease with radiotherapy only. With the addition of chemotherapy, the rate of relapse in the high-risk patients was reduced below that of the standard-risk patients. Overall survival was the same for the high- and standard-risk patients.

[Tumor size and histological grading of stage 1 breast cancer. Prognostic and therapeutic significance]

Systemic adjuvant therapy can improve the prognosis for breast cancer patients. In node negative disease most patients have a good prognosis with local therapy only. Therefore, identification of subgroups with higher risk of relapse is warranted in order to avoid overtreatment of a large number of patients. A total of 399 tumours from patients without axillary metastases, operated on in the years 1964-72, were measured preoperatively and graded according to a modified Scharff-Bloom-Richardson scheme. Patients with T2 (UICC) tumours and histologic grade 2 and 3, had a 3.3-fold relative risk of mortality from breast cancer compared with the rest of the patients. These patients should receive adjuvant systemic therapy.

Prognostic factors for glioblastoma multiforme--development of a prognostic index

The prognosis for glioblastoma multiforme is generally poor. However, it can be useful to identify groups of patients with varying prognosis. Based on data from 495 consecutive patients admitted to the Norwegian Radium Hospital during 1980-1994, multivariable methods were used to identify prognostic factors independently associated with length of survival. A prognostic index was derived in 384 randomly selected patients, and tested in 111 other patients. Performance status, dexamethasone dependency, age group, surgery and behavioural changes were prognostic discriminators. On this basis a prognostic index was made and three separate subsets with different survival prognoses could be identified. The prognostic index was then tested among 20% of the patients and shown to predict reliable survival curves. In the subset with the highest index (high risk subset) almost all patients in the main group as well as in the the test group were dead within 18 months.

Skin treatment with bepanthen cream versus no cream during radiotherapy--a randomized controlled trial

In several radiotherapy departments, dexpanthenol cream (Bepanthen 'Roche') has been used extensively to ameliorate acute radiotherapy skin reactions. The evidence base for this practice is obscure as no randomized trials have been performed. In the present clinical prospective study of 86 patients we have compared Bepanthen cream with no topical ointment at all. The cream was applied on randomly selected parts of treatment fields in laryngeal and breast cancer patients, and so each patient acted as his own control. Seven patients were withdrawn from analysis. Scoring of skin reactions in 16 laryngeal and 63 breast cancer patients was performed without knowledge of which area that had been given cream or not. Endpoints were a modified skin reaction grading according to EORTC/RTOG, and itching/pain in treated fields. The study did not indicate any clinically important benefits of using Bepanthen cream for ameliorating radiogenic skin reactions under the conditions applied.

ChlVPP is as effective as alternating ChlVPP/ABOD in advanced stage Hodgkin's disease

The purpose of the study was to evaluate and compare the efficacy and tolerability of two cytostatic regimens-chlorambucil, vinblastine, procarbazine and prednisone (ChlVPP) vs. ChlVPP alternating with doxorubicin, bleomycin, vincristine and dacarbazine (ABOD). One hundred eligible patients with stage IIIA-IVB Hodgkin's disease were randomized to either ChlVPP or ChlVPP alternating with ABOD. The complete response rate (CR) was 80% in both treatment groups. After a median follow-up time of 59 months, 42 (84%) of the patients in the ChlVPP-treated group were in CR compared with 39 (78%) treated with ChlVPP/ABOD. The estimated five-year overall and relapse-free survival rates were 87% and 74%, respectively, for the ChlVPP-treated patients and 76% and 73% for the ChlVPP/ABOD-treated patients. The ChlVPP regimen showed a slightly better subjective tolerance than the ChlVPP/ABOD regimen. The given dose intensity was very close to optimal, and equal for the two regimens.

Clinical research in a hospital--from the lone rider to teamwork

Clinical research of high international standard is very demanding and requires clinical data of high quality, software, hardware and competence in research design and statistical treatment of data. Most busy clinicians have little time allocated for clinical research and this increases the need for a potent infrastructure. This paper describes how the Norwegian Radium Hospital, a specialized cancer hospital, has reorganized the clinical research process. This includes a new department, the Clinical Research Office, which serves the formal framework, a central Diagnosis Registry, clinical databases and multicentre studies. The department assists about 120 users, mainly clinicians. Installation of a network software package with over 10 programs has strongly provided an internal standardization, reduced the costs and saved clinicians a great deal of time. The hospital is building up about 40 diagnosis-specific clinical databases with up to 200 variables registered. These databases are shared by the treatment group and seem to be important tools for quality assurance. We conclude that the clinical research process benefits from a firm infrastructure facilitating teamwork through extensive use of modern information technology. We are now ready for the next phase, which is to work for a better external technical framework for cooperation with other institutions throughout the world.

Survival after curative treatment of muscle-invasive bladder cancer

This retrospective study includes 534 patients who had curatively intended treatment for T2/T3/T4a bladder cancer at the Norwegian Radium Hospital during the period 1980-1990. Total cystectomy preceded by preoperative radiotherapy represented the treatment of choice in 263 patients (CysGr). High-dose radiotherapy was applied in 271 patients in whom total cystectomy could not be performed (RadGr). From 1985 neo-adjuvant cisplatin-based chemotherapy was increasingly used. The 5-year crude survival rate for all patients was 35% with 40% for CysGr and 22% for RadGr. In CysGr the 5-year survival rate was highest (63%) for patients with <pT2 and lowest for pN+ patients (13%). The following independent prognostic parameters were identified for the total group: T category, trial participation, treatment, creatinine, haemoglobin, age and time since initial diagnosis. No significant difference in survival was found when comparing the treatment results obtained before and after 1985. In spite of the introduction of multimodality therapy the treatment results for T2/T3/T4a bladder cancer have remained unchanged. However, subgroups of patients may benefit from this approach allowing bladder conservation in selected cases. More effective adjuvant regimens have to be developed for high-risk patients (pT3b/pN+).

Prognostic variables and results of salvage treatment in Hodgkin's disease

Treatment results and prognostic variables were studied in 549 adult patients with Hodgkin's disease after first-line and salvage treatment. After first-line treatment, 479 out of 549 patients (87%) achieved complete remission (CR). During a mean observation time of 74 months, 99 patients (21%) relapsed. Sixty-nine patients (70% of relapsed patients) achieved a second CR. Variables predicting poor response (< CR) and shortened survival after first-line treatment were advanced disease, B-symptoms and age >60 years. In relapsing patients, age >60 years, relapse within 12 months and non-CR after relapse treatment predicted a poor prognosis, and none of these patients were alive after 10 years. Localized disease at diagnosis and relapse, and relapse later than 24 months predicted a good prognosis with 10-year survival after relapse of 68% and 57%, respectively. Patients with a second relapse had 5-year survival of 28% and 10-year survival of 14%. Based on the prognostic variables at first-line treatment and at relapse, selection of patients to more intensive treatment is discussed.

Systemic relapse of patients with osteogenic sarcoma. Prognostic factors for long term survival

BACKGROUND

A retrospective study of long term outcome after the development of metastases from osteosarcoma was performed, with emphasis on the impact of different treatment strategies and the identification of prognostic factors.

METHODS

From 1975 to 1993, a population-based series of 60 patients with distant metastases (relapse) from high grade, extremity-localized osteosarcoma was treated at The Norwegian Radium Hospital. Six patients relapsed after surgery alone, 28 patients relapsed after primary chemotherapy of low potency, and 26 patients after modern, intensive chemotherapy. Lung metastases were present in 88% of the patients, 52% had bilateral lesions, and the median number of lesions was three (range, 1-25 lesions). Forty-seven percent of patients had complete surgical excision of all identifiable metastatic nodules and 54% of these had additional second line chemotherapy defined as adequate. Adequate chemotherapy included further dose escalations of methotrexate in approximately half of the patients, usually from 8 to 12 g. The rest were exposed to novel agents such as cisplatin, etoposide, and ifosfamide. Of the operated patients, 43% had additional thoracotomies after subsequent relapses.

RESULTS

The projected 5-year survival rate from the first metastatic event was 24% for all patients and 50% for patients who underwent complete metastasectomy. In a multivariate analysis, the factors with independent predictive value for improved overall survival were the presence of a solitary metastasis, the accomplishment of complete metastasectomy, and the administration of adequate salvage chemotherapy.

CONCLUSIONS

Complete metastasectomy is mandatory for long term survival of patients with metastatic osteosarcoma, and repeated lung resections are necessary in nearly half the patients. Second line chemotherapy and following primary treatment with modern intensive chemotherapy protocols may improve survival further.

Adjuvant tamoxifen for pre- and postmenopausal women with estrogen receptor positive, node positive breast cancer: a randomized study

370 patients with operable, axillary node positive breast cancer, were randomized to receive tamoxifen (TAM) 20 mg/day for 2 years or no adjuvant hormone therapy. All patients had estrogen receptor (ER) positive (ER > 10 pmol/g) primary tumours. 350 patients, 93 younger than 50 years of age and 257 patients 50 years or older, were evaluable for the study. After a median follow up of 76 months, significantly (p = 0.0001) fewer loco-regional, but not distant (systemic), relapses have been recorded in the TAM group. Overall survival was also improved, but even though the study was designed to give maximum benefit from TAM statistically significant effect of TAM seemed to be limited to patients 50 years of age and older.

A 10-year experience with splenectomy in patients with malignant non-Hodgkin's lymphoma at the Norwegian Radium Hospital

BACKGROUND

Splenectomy is a major surgical intervention that has many implications for patients with malignant non-Hodgkin's lymphoma. As debated during the last few decades, the therapeutic benefit must outweigh the surgical risk and the loss of cellular immunity. A more liberal attitude toward splenectomy developed during the years 1980-1990 at the Norwegian Radium Hospital, as illustrated by the higher number of operations performed in the last 5 years (21 patients) compared to the first 5 years (14 patients).

METHODS

A 10-year retrospective review of the effects and side effects of splenectomy in 35 patients with malignant non-Hodgkin's lymphoma was performed, based on information obtained from the patient files at the authors' institution.

RESULTS

Clinical Stage IV disease was found in 29 patients (83%), and B symptoms in 15 patients (43%). At diagnosis, 26 patients (74%) had splenomegaly, and 8 patients (23%) had primary splenic lymphoma. The surgical mortality was 2.9%, and the morbidity was 37%. Infection was the most common complication, occurring in seven patients (20%). Pneumococcal vaccination had been performed in 13 patients, and the frequency of septicemia and pneumonia tended to be higher during follow-up in unvaccinated patients (not significant). Blood counts returned to normal during the first postoperative month in 18 of 25 patients (72%) who had cytopenia. After splenectomy, a durable remission was achieved in five patients (14%) who did not receive subsequent treatment.

CONCLUSIONS

Splenectomy has the potential to relieve local symptoms, correct cytopenias, and modify the disease course in patients with malignant non-Hodgkin's lymphomas, even in advanced stages, at the cost of an acceptable operative risk.

[Infrastructure for clinical research in a hospital]

Clinical research in hospitals involves many partners. In Norway, the doctors are allocated little time for clinical research. Furthermore, complicated laws and directives have to be followed. The authors describe the organisation of clinical research and a software collection, including CD-ROM. We conclude that clinical research in large hospitals demands both a strong organisation and extensive use of modern information technology. The problems can be solved at acceptable cost.

Host markers and prognosis in recurrent rectal carcinomas treated with radiotherapy

The value of blood tests as prognostic factors in patients with recurrent rectal carcinomas treated with radiotherapy was studied in one retrospective (n = 114, 1976-1984) and one prospective (n = 100, 1985-1989) group of patients. The retrospective group was used for validation of the results from the prospective group. In univariate survival analyses, 19 of totally 38 variables significantly correlated to the survival. Of 13 significant blood parameters, lactate dehydrogenase (LD), erythrocyte sedimentation rate (ESR), alpha 1-, alpha 2-globulin, fibrinogen, carcinoembryonic antigen (CEA), C-reactive protein (CRP), haptoglobin, granulocytosis and thrombocytosis were the most important ones (p < or = 0.01). In the multivariate analyses (Cox regression) of the prospective group, LD, alpha 1-globulin, diagnosed liver metastases and CEA were found to be significant predictors of survival. A prognostic index was derived from the prospective group including ESR, LD and relapse-free interval. This clearly separated the patients in the retrospective group into one low- and one high-risk group.

Weekly doxorubicin with or without high-dose medroxyprogesterone acetate in hormone-resistant advanced breast cancer. A randomised study. The Norwegian Breast Cancer Group

In a randomised study, 218 patients with advanced breast cancer, resistant to hormone therapy, received either doxorubicin 20 mg every week (Awkly) alone or Awkly combined with high doses (1000 mg daily) of oral medroxyprogesterone acetate (HD-MPA). Of the 210 evaluable patients, the response rates were 26% [95% confidence interval (CI) 18-34%] for Awkly and 38% (95% CI 29-47%) for Awkly + HD-MPA (P = 0.08). There was no significant difference with regard to duration of response. Median survival was 11 months in both groups. Considerable toxicity was seen from HD-MPA, particularly weight gain and fluid retention. The present study provides evidence that, in concordance with preclinical studies and a previous randomised study, interaction between chemotherapy and HD-MPA may exist in breast cancer normally resistant to hormone therapy. For further studies, other gestagens and/or a dose reduction could be investigated.

Prognostic factors in anal carcinoma

This study was performed to examine if commonly recorded parameters are of prognostic importance for patients with squamous cell carcinoma of the anal canal. A total of 77 patients received combined chemoradiotherapy and were followed at regular intervals after treatment. Age, sex, performance status, tumour stage, histopathological differentiation and grade, were not found to be of prognostic importance. Most blood tests did not correlate with prognosis, although elevated serum alkaline phosphatase (ALP) and lactate dehydrogenase (LD) proved to be unfavourable prognostic factors. In the present study serum ALP and LD were the only parameters that significantly correlated with development of distant metastases during follow-up.

[New cancer disease after treatment of Hodgkin's disease]

The risk of a second cancer was assessed in 1,152 patients with Hodgkins disease who were treated at the Norwegian Radium Hospital from 1968-85. 68 patients developed a second cancer more than one year after the diagnosis of Hodgkins disease. These included nine acute non-lymphocytic leukemias, eight non-Hodgkins lymphomas and 51 solid tumours, including 11 lung cancers. The overall relative risk (observed/expected ratios) of developing a second cancer was 1.86. After 18 years the cumulative risk of developing a second cancer was 14.4% +/- 2.9%, of which 11.2% +/- 2.6% referred to solid tumours. The cumulative risk of leukemia appeared to reach a plateau level of 1.5% after 12 years while the risk of non-Hodgkins lymphomas and lung cancer continued to rise with time to 2.1% and 3.3% respectively after 18 years. The risk of developing leukemia increased after treatment with alkylating agents and Procarbazine. The risk of non-Hodgkins lymphoma was not related to any specific type of therapy. Excess lung cancer risk was noted in patients treated with radiotherapy, and the cancers appeared within the treated areas.

[Hodgkin's disease or lymphogranulomatosis. New views on prognosis, complicating conditions and complications after treatment]

Between the years 1968-85, 1,177 patients started treatment for Hodgkins disease at the Norwegian Radium Hospital. In this unselected material from Norway the age distribution was bimodal with the highest incidence between 20-40 years of age. Survival is dependent on age, stage and histology, and was better between the years 1980-85 as compared with the period 1974-79. During the last ten years, treatment has been decentralized in Norway, and all centres cooperate by using the same protocol for staging and treatment. The article summarizes the results of the treatment, and related complications.

Flow cytometric DNA analysis as prognostic factor in human breast carcinoma

Fresh tumour tissue from 198 primary invasive breast carcinomas was analysed by DNA flow cytometry. 108 tumours were non-diploid. A significantly higher proportion of non-diploid tumours was found among node-positive patients, patients with oestrogen receptor negative tumours and among patients with ductal carcinomas. The survival of patients with diploid and non-diploid tumours was not significantly different (p = 0.1). Totally, 145 tumours were analyzed with respect to S-phase fraction (SPF). The distribution of SPF was different in diploid and non-diploid tumours. A low SPF group, defined as the lower SPF quartile (< or = 4.6% in diploid and < or = 8.5% in non-diploid tumours), was associated with highly differentiated tumours and oestrogen receptor positive tumours. Histological grading revealed a highly significant correlation to SPF. 57% of ductal carcinomas grade I (8 out of 14), 30% of ductal carcinomas grade II (20 out of 67) and 5% of ductal carcinomas grade III (2 out of 37) had a low SPF. Patients within the low SPF group had a significantly longer survival than had patients within the high SPF group (p = 0.006). In a multivariate analysis the SPF was found to be an additional prognostic factor next to node status and ER status.

Blood tests and prognosis in bladder carcinomas treated with definitive radiotherapy

The value of some commonly recorded blood tests as prognostic factors in patients with bladder carcinomas treated with definitive radiotherapy has been assessed. This study included 202 consecutive patients (T2, n = 46; T3, n = 82 and T4, n = 74) treated during the period 1980-1987. The median total dose received was 56 Gy [50-67] and the median cumulative radiation effect was 1750 reu (radiation effect unit) (1515-1823). The blood tests examined in survival analyses were erythrocyte sedimentation rate (ESR), hemoglobin (Hb), leucocyte and thrombocyte count, alkaline phosphatase (ALP), gamma-glutamyltransferase (GT), lactate dehydrogenase (LD), creatinine and albumin. In the univariate survival analyses six blood tests were significant prognostic factors (ESR, albumin, creatinine, Hb, ALP and GT). In the multivariate analysis of all 202 patients, the following five variables were significantly associated with shorter survival: T4 tumors, ESR > 30 mm/h, albumin < 35 g/l, LD > 400 U/I and age > 75 years. Our conclusion is that several commonly recorded blood tests are powerful prognostic factors in bladder cancer treated with definitive radiotherapy. These tests can replace other more expensive laboratory investigations used for prognostication.

Expression of CD18 (integrin beta 2 chain) correlates with prognosis in malignant B cell lymphomas

Several studies have shown that cell cycle related parameters including DNA synthesis and activation antigen expression can predict patient survival in lymphoma patients. In this study of 69 malignant B cell lymphomas we have examined the cell surface expression of several cell interaction and activation molecules by flow cytometry. Expression of CD18 (integrin beta 2 chain) was found to correlate strongly with patient survival (median follow up 50 months) even when adjusting for other important prognostic factors (P = 0.0001). The percentage of cells positive for CDw75 proved important both as a single parameter and in the multivariate analysis. Histology, classified as low versus high grade malignancy, bulky versus not bulky disease and high versus low thymidine incorporation, was also found to correlate with prognosis in this study.

Second malignancies after treatment of Hodgkin's disease: the influence of treatment, follow-up time, and age

PURPOSE

In the period 1968 through 1988, The Norwegian Radium Hospital (NRH) treated an unselected population of 1,152 patients with Hodgkin's disease (HD) that comprised more older patients (mean age, 43 years) than most other institutions. We considered it important to evaluate these patients for development of second cancers (SCs).

PATIENTS AND METHODS

The Norwegian Cancer Registry identified previously untreated patients with HD treated at NRH who had developed a SC more than 1 year after diagnosis of HD. The relative risk ratio (RR) (observed/expected cases) and the cumulative risk were calculated.

RESULTS

Sixty-eight patients had developed a SC, including nine acute nonlymphocytic leukemias (ANLLs), eight non-Hodgkin's lymphomas (NHLs), and 51 solid tumors, including 11 lung cancers. The RR of SC and leukemia was 1.86 (95% confidence interval [CI], 1.4 to 2.4) and 24.3 (95% CI, 11.1 to 46.2), respectively. The RR of SC was highest in younger patients (< 41 years, RR = 3.8). No significant association between splenectomy and development of ANLL was found. The influence of treatment and follow-up time on the development of SC agrees with data from other large cancer institutions.

CONCLUSION

(1) The low RR of developing a SC in this study is probably due to the number of older patients included, who have a lower RR of developing a SC due to less aggressive treatment, shorter follow-up time, and higher incidence of cancer in the expected background population. (2) The low RR and cumulative risk of developing ANLL may be due to the limited use of extensive chemotherapy (CT) in our hospital in the earlier years.

Follow-up of breast cancer patients stage I-II: a baseline strategy

In 430 stage I-II breast cancer patients the cost-benefit of investigations during follow-up have been studied. Median follow-up time was 8 years and 128 patients had relapsed, 91 with metastatic disease. High costs of routine chest X-ray, limited skeletal X-ray and bone scan examinations were associated with low incidence of diagnosed relapses not suspected otherwise. In the eight blood analyses examined, increases of more than 10 mm/h in erythrocyte sedimentation rate (ESR), 20 U/l in gamma-glutamyltransferase (GT) or 60 U/l in alkaline phosphatase (ALP) resulted in a combined sensitivity of 55% and specificity of 91% for relapses with distant metastases. Elevation of at least two blood tests gave a combined sensitivity of 31% and a specificity of 98%. The importance of using individual reference values in screening for recurrences is emphasised. Symptomatic relapse or relapse detected at interval visits were not independent prognostic factors. The blood tests ALP, ESR and GT were strong predictors of survival measured from relapse which increase their legitimacy in follow-up. A more frequent follow-up for patients with 4+ involved nodes is proposed: three visits annually the first 5 years vs. two visits annually for the others. We conclude that history, clinical examination, ALP, ESR and GT are sufficient as a baseline screening for relapse in breast cancer patients.

Prognostic factors in malignant gliomas with special reference to intra-arterial chemotherapy

Survival was analyzed in 173 patients with malignant gliomas to study the importance of possible pretreatment prognostic factors. Seventy-nine of these patients received preirradiation intra-arterial chemotherapy with BCNU combined with vincristine intravenously and procarbazine orally; the others received only postoperative whole-brain irradiation. To judge by univariate and multivariate analyses the most important pretreatment prognostic factors were histology, corticosteroid dependency, pretreatment performance status and frontal lobe location of the tumors. Patients with anaplastic astrocytoma, not corticosteroid-dependent, with pretreatment performance status of 0-2 and with a frontal lobe location of the tumor seemed to benefit most from preirradiation chemotherapy.

Combined intra-arterial chemotherapy followed by radiation in astrocytomas

Seventy-five patients harboring astrocytomas received 4 cycles of infra-ophthalmic carotid injections of BCNU, combined with vincristine intravenously and procarbazine orally. All of the patients thereafter, received radiation therapy. The five year survival was 73% for all patients. The age of the patients had no significant impact on survival. The treatment results were compared with the results of 57 patients with astrocytomas who were treated with surgery followed by radiation in the same period. These 57 patients had a 5 year survival of 45% with a five year survival in patients < or = 40 years and patients > 40 years of 70% and 22%, respectively (p < 0.05). In multivariate survival analysis of the BCNU group and radiation group together, treatment group and corticosteroid dependency were the only prognostic factors. No leukoencephalopathy was seen during the treatment or in the follow-up of the patients. We conclude that pre-radiation intra-arterial chemotherapy can be given without significant morbidity and produces an improvement in survival in patients older than 40 years.

Chemotherapy with or without high-dose medroxyprogesterone acetate in oestrogen-receptor-negative advanced breast cancer. Norwegian Breast Cancer Group

In a randomised study 142 patients with advanced oestrogen-receptor-negative breast cancer in the tumour tissue received chemotherapy alone or chemotherapy combined with high doses (1000 mg daily) of oral medroxyprogesterone acetate (HD-MPA). Of the 126 fully evaluable for response, the response rates were 46% for chemotherapy alone and 73% for chemotherapy with HD-MPA (P = 0.005). There was no significant difference with regard to duration of response. Of the 138 patients evaluable for survival and toxicity, survival was shorter in the combined treatment group; median survival of 9 versus 13 months (P less than 0.05). Considerable toxicity was seen from HD-MPA, especially weight gain and fluid retention. The present study provides evidence that in concordance with preclinical studies an interaction between chemotherapy and HD-MPA may exist in breast cancer normally resistant to hormone therapy. The side-effects from MPA were substantial, however, and the survival data are of great concern.

Combined intra-arterial and systemic chemotherapy for recurrent malignant brain tumors

Seventy-nine patients harboring recurrent brain tumors received four cycles of infraophthalmic carotid injections of 160 mg of carmustine. Two milligrams of intravenous vincristine and 50 mg of oral procarbazine was also administered three times daily for 1 week in conjunction with each BCNU treatment. The response rate was 60% with a median survival for patients with astrocytomas, anaplastic astrocytomas, and glioblastomas of 32, 20, and 6.5 months, respectively. The median survival of the responding patients was 20 months, and the survival at 30 months was 45%. The survival in patients not responding to treatment was 5 months, reflecting the natural history of the tumor. There have been no deaths related to the treatment procedure. No incidents of severe or permanent eye complications or leukoencephalopathy were observed. Based on multivariate survival analysis, only patients with a good performance status who are not steroid dependent are candidates for this treatment.

Neuron-specific enolase as a prognostic factor in metastatic malignant melanoma

Serum neuron-specific enolase (NSE) was measured in 63 patients with metastatic malignant melanoma. 20 patients (32%) had elevated serum NSE (> 10 micrograms/l) before the start of treatment. Another 13 patients (21%) developed pathological NSE values during the course of the disease. In many patients, elevated NSE was related to a large tumour burden, and a gradual rise in serum NSE indicated disease progression. Patients with elevated pretreatment NSE had a median survival time of 3 months compared with 12 months for those with normal pretreatment NSE values. NSE thus proved to be a useful prognostic factor in metastatic malignant melanoma.

Blood analyses and survival in symptom- and survey-detected lung cancer patients

Commonly recorded blood analyses as indicators of low- and-high risk patients with lung cancer were studied by comparing symptom- and survey-detected patients. During the period 1976-1985, in 41 of 189 non-small-cell lung cancer patients in Western Norway, lung cancer was detected by chest X-ray survey performed in the preventive tuberculosis screening programme. After adjusting for other variables, including developmental stage, erythrocyte sedimentation rate (ESR) was the only blood analysis which discriminated symptom-detected patients (high ESR) from survey-detected patients (low ESR). Survey-detected patients had a better short-term survival. In multivariate survival analyses leucocyte count, lactate dehydrogenase activity and ESR were significant prognostic factors, in addition to advanced stage and detection due to symptoms. We conclude that common blood analyses such as ESR provide supplementary information concerning low- and high-risk lung cancer patients.

[Taxicabs for patient transport to national hospitals]

The use of taxis to transport patients to and from the Norwegian Radium Hospital has been studied. 36% of the patients travelled by taxi. This frequency gives an estimated 70,000 trips by taxi annually at a cost of NOK 60 million for four national hospitals in Oslo. Since at present most of the patients travel one in a taxi. There seems to be a large potential for reducing costs.

[Use of personal computers for statistical analyses]

We report the range in elapsed time for various statistical analyses and for the same logistic regression analysis in 23 different personal computers (PCs). Without a floating-point coprocessor, the elapsed time increased from ten to 113 minutes in the same PC. Elapsed time ranged from two to 45 minutes from 80486 to 8086 PCs with a floating-point coprocessor. The PC equipment we need strongly depends on the type and frequency of the statistical analyses we are to perform. If a floating-point coprocessor is installed, the 80286/80287 PC family may be fast enough for most users.

Prognostic factors in multiple myeloma in a population-based trial

Prognostic factors have been tested in patients with multiple myeloma treated according to a randomized trial of standard therapy versus 5-drug combination therapy. The following population-based study included 92 patients with a median age of 70 yr. The median survival was 31 months. The Cox regression model was used to search for predictors of survival. The cut-off levels for blood analyses derived in earlier studies tended to select few patients in the high-risk groups, for example only 8% of the patients had hemoglobin (Hb) less than or equal to 7.5 g/dl. Lytic bone lesions in the pelvis or in the long bones, or spontaneous fractures and age greater than 70 yr gave prognostic information in addition to anemia and impaired renal function. The MRC staging system was a better prognostic tool than the Durie & Salmon stages. Palliative treatment regimens which take quality of life into account should be considered carefully in multiple myeloma patients greater than 70 yr.

[Should doctors contribute more to the development of computer-based information systems at hospitals?]

In our X-ray department we have used a commercially available database computer program to design a system for storing information about the X-ray examinations performed. The system runs on a local area network. We have been able to quickly modify the system in the light of feedback from the users. Using modern database programs for personal computers has made it quite easy for doctors to participate directly in the design of information systems for use in hospitals.