Piloting a novel cancer care pathway: socioeconomic background as a barrier to access

BACKGROUND

The multidisciplinary diagnostic clinic (MDC) model for 'non-specific' symptoms has been piloted in the UK. We aimed to assess the degree to which the MDC pathway was influenced by socioeconomic factors.

METHODS

We collected data for all patients referred to the MDC from 01 January 2017 - 28 March 2019. Indices of multiple deprivation (IMD) scores were matched to patients' postcodes and referring general practitioner (GP) location. Socioeconomic data for MDC patients was compared with all other cancer patients diagnosed in the MDC's base hospital, Airedale General Hospital (AGH), in 2018. Statistical significance was tested using the Mann-Whitney U test and Spearman's rank correlation.

RESULTS

No significant difference was found between MDC pathway and the rest of AGH when comparing social deprivation of patients. There was a moderate negative correlation between the IMD associated with the location of GP premises and the number of referrals; practices in more deprived locations referred fewer patients (p≤0.025).

CONCLUSION

The MDC pathway referral rate seems to be affected by social deprivation in a similar manner to other cancer diagnosis pathways. Our work highlights the importance of engaging GP practices with socially deprived populations as the MDC programme is rolled out across the UK.

Requests from primary care for chest X-ray and CA125 measurements during the COVID-19 emergency: An observational study

During the first 3 months of 2020, as the COVID-19 pandemic developed, it was noticed that requests from primary care for investigations were decreasing, including those that form part of the diagnostic process for cancers. We therefore obtained data on the requests from primary care for chest X-rays (CXRs) and CA125 measurement our hospital received in the first half of 2020 and compared them with 2019. The number of CXRs declined by 93% in April 2020 compared with 2019, with the decline being greater for patient living in outlying areas. Requests from the emergency department also declined. Requests for CA125 measurement similarly fell by 77% from all areas. The requests increased in June, CA125 more than CXR. If this phenomenon is widespread it may have an impact on diagnosis of major conditions, particularly cancers and tuberculosis.

Geographical access to GPs and modes of cancer diagnosis in England: a cross-sectional study

BACKGROUND

Poor geographical access to health services and routes to a cancer diagnosis such as emergency presentations have previously been associated with worse cancer outcomes. However, the extent to which access to GPs determines the route that patients take to obtain a cancer diagnosis is unknown.

METHODS

We used a linked dataset of cancer registry and hospital records of patients with a cancer diagnosis between 2006 and 2010 across eight different cancer sites. Primary outcomes were defined as 'desirable routes to diagnosis' [screen-detected and 2-week wait (TWW) referrals] and 'less desirable routes' [emergency presentations and death certificate only (DCO)]. All other routes (GP referral, inpatient elective and other outpatient) were specified as the reference category. Geographical access was measured as travel time in minutes from patients to their GP, and multinomial logistic regression was used to estimate relative risk ratios (RRR).

RESULTS

Longer travel was associated with increased risk of diagnosis via emergency and DCO, but decreased risk of diagnosis via screening and TWW. Patients travelling over 30 minutes had the highest risk of a DCO diagnosis, which was statistically significant for breast, colorectal, lung, prostate, stomach and ovarian cancers (compared with patients with travel times ≤10 minutes: RRR 5.89, 7.02, 2.30, 4.75, 10.41; P < 0.01 and 3.51, P < 0.05).

DISCUSSION

Poor access to GPs may discourage early engagement with health services, decreasing the likelihood of screening uptake and increasing the likelihood of emergency presentations. Extra effort is needed to promote early diagnosis in more distant patients.

Outcome of elevated CA125 values from primary care following implementation of ovarian cancer guidelines

BACKGROUND

Ovarian cancer presents later in the UK compared to economically similar countries. National guidance suggests measuring CA125 in primary care as a means of bringing patients to specialist attention.

AIM

To investigate the outcome of CA125 values measured in accordance with this policy.

SETTING AND DESIGN

Examination of the laboratory records of female patients from the usual catchment population of one general hospital in whom CA125 was measured from primary care in a calendar year.

METHODS

Those with values >35 u/ml were identified. Electronic records within the hospital were interrogated to identify what further evaluation had been undertaken whether ovarian or primary peritoneal cancer had been diagnosed or what other pathology was identified. We also reviewed the CA125 measurement history of patients diagnosed over 3 years by any route.

RESULTS

One hundred and sixty-four new cases of CA125 ≥35 u/ml were found. Further information was available for 152 of them. Sixteen had ovarian or primary peritoneal cancer and 16 had other cancers. In 50 no cause for the abnormality was found. The remainder had various non-malignant conditions. The specificity for carcinoma of ovary/primary peritoneal carcinoma was 95.4% [95% confidence interval: 94.8-96.0). In a 3-year period, 65 patients were diagnosed with ovarian or primary peritoneal cancer, 5 had values of CA125 between 20 and 35 u/ml shortly before diagnosis.

CONCLUSIONS

The CA125 level is a useful diagnostic test for ovarian cancer which has been embraced by primary care but higher sensitivity for earlier disease will require strategies to improve the specificity.

Geographical disparities in access to cancer management and treatment services in England

This study seeks to examine the extent to which cancer services are geographically located according to cancer incidence, and assess the association with cancer survival. We identified hospital sites serving English PCTs (Primary Care Trusts) with the management and treatment of breast, lung and colorectal cancer. Geographical access was estimated as travel time in minutes from LSOAs (Lower Super Output Areas) to the nearest hospital site and aggregated to PCT level. Correlations between PCT level mean travel times and cancer cases were estimated using Spearman's rank correlation. Associations between PCT level mean travel times and cancer relative survival rates were estimated using linear regression with adjustment for area deprivation and for a PCT level measure of the reported ease of obtaining a doctor's appointment. We found that cancer services tended to be located farther from areas with more cancer cases, and longer average travel times are associated with worse survival after adjustment for age, sex, year and area deprivation. This suggests that geographical access to cancer services remains a concern in England.

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Estimates of the Prevalence of Obesity in Canadian Children

Childhood obesity is becoming a topic of great con cern due to the rising prevalence of this condition in North America. Studies conducted in the United States have indicated that the prevalence of obesity has increased dramatically over the past few decades. The purpose of this study was to estimate the prevalence of obesity in Canadian children between the ages of 5 and 12 years by examining data from two national and two regional surveys The 85th percentiles of each of four anthropometric indices derived from large normative populations were used as diagnostic criteria for obesity. As expected, the resulting prevalences varied according to the criteria used. A significant increase in childhood obesity between the 1981 to 1988 national surveys was observed when the three indices which used skinfolds were applied Weight-for-height percentiles did not indicate an increase in obesity in these samples. Regional samples showed a less than expected prevalence of obesity among the middle-class children and a higher than expected rate among the inner city boys. It can be concluded that there is a need for a defined criteria for identifying obesity in children in order to avoid confusion resulting from the wide variation in estimates of prevalence resulting from different standards and measurements. Using adiposity-based criteria for obesity it was clearly evident that the prevalence of obesity has increased in Canadian children.

Neo-escape: Neoadjuvant extended sequential chemotherapy with adjuvant postoperative treatment for epithelial nonmucinous advanced inoperable peritoneal malignancy

5046

Background: Neo-Escape was designed to exploit fully the modest non-cross resistance of carboplatin (CBDCA) and paclitaxel (ptx) in an extended sequential regimen, with dose-dense ptx, and address feasibility of combining gemcitabine (gem) with either CBDCA or ptx. Methods: A randomised phase II trial in patients (pts) with untreated (FIGO stage 3C/4) inoperable ovarian, fallopian, or primary peritoneal carcinoma to assess feasibility of two regimens of sequential neoadjuvant-then-adjuvant chemotherapy (CT); (a) CBDCA AUC 2.5 and gem 1000mg/m2 repeated days 1 and 8 q 3 wks x 6 cycles, then ptx 175mg/m2 q 2 wks x 6 cycles (CG-P) or (b) CBDCA AUC 6 q 3 wks x 6 cycles, then ptx 175mg/m2 and gem 2000mg/m2 q 2 wks x 6 cycles (C-PG). All pts were considered for delayed 1o debulking surgery after neoadjuvant CT. The 1o feasibility outcome was % pts completing 12 cycles of CT. Using Fleming’s single stage procedure 44 patients on each arm were needed to test null hypothesis of feasibility ≤60% with 5% 1-sided significance level and 90% power. 2o outcomes included safety, PFS and ORR. Pts were stratified by serum albumin, stage and tumor differentiation. Results: 75 pts were recruited Sept 2007 - May 2011 (28 CG-P; 47 C-PG), median age 62 yr (range 21-75). Recruitment to CG-P closed early due to futility. 52% had albumin >35g/L, 68% FIGO stage 3C and 80% poorly differentiated tumors. 64% on CG-P and 55% on C-PG had debulking surgery as planned and a further 4% on CG-P and 13% on C-GP after completion of all CT. For CG-P 35% achieved 0cm, 35% <1cm and 30% ≥ 1cm residuum; for C-GP 34% 0cm, 13% <1cm and 34% ≥1cm, 19% TBC. 14/28 pts on CG-P completed all 12 cycles (feasibility 50%; 95% CI 31-67%); 37/47 pts on C-PG (feasibility 79% (95% CI 64-88). Main reason for early discontinuation was toxicity on CG-P and disease progression on C-PG. Similar proportions of pts on each arm had dose reductions (68%) or delays (86% on CG-P; 89% on C-PG), mainly for toxicity. 82% of pts experienced grade 3/4 toxicity on CG-P; 72% on C-PG. Median PFS for CG-P is 14.3 mths (95% CI 11.6-15.7mths) and 13.0 mths (95% CI 11.5-15.4mths) for C-PG. Conclusions: CG-P was not feasible at these doses using pre-specified criteria, but C-PG is feasible.

Social and geographical factors affecting access to treatment of colorectal cancer: a cancer registry study

OBJECTIVE

Cancer outcomes vary between and within countries with patients from deprived backgrounds known to have inferior survival. The authors set out to explore the effect of deprivation in relation to the accessibility of hospitals offering diagnostic and therapeutic services on stage at presentation and receipt of treatment.

DESIGN

Analysis of a Cancer Registry Database. Data included stage and treatment details from the first 6 months. The socioeconomic status of the immediate area of residence and the travel time from home to hospital was derived from the postcode.

SETTING

Population-based study of patients resident in a large area in the north of England.

PARTICIPANTS

39 619 patients with colorectal cancer diagnosed between 1994 and 2002.

OUTCOMES MEASURED

Stage of diagnosis and receipt of treatment in relation to deprivation and distance from hospital.

RESULTS

Patients in the most deprived quartile were significantly more likely to be diagnosed at stage 4 for rectal cancer (OR 1.516, p<0.05) but less so for colonic cancer. There was a trend for both sites for patients in the most deprived quartile to be less likely to receive chemotherapy for stage 4 disease. Patients with colonic cancer were very significantly less likely to receive any treatment if they came from any but the most affluent area (ORs 0.639, 0.603 and 0.544 in increasingly deprived quartiles), this may have been exacerbated if the hospital was distant from their residence (OR for forth quartile for both travel and deprivation 0.731, not significant). The effect was less for rectal cancer and no effect of distance was seen.

CONCLUSIONS

Residing in a deprived area is associated with tendencies to higher stage at diagnosis and especially in the case of colonic cancer to reduced receipt of treatment. These observations are consistent with other findings and indicate that access to diagnosis requires further investigation.

Geographical access to healthcare in Northern England and post-mortem diagnosis of cancer

BACKGROUND

There is some previous evidence that diagnosis of cancer at death, recorded as registry death certificate only records, is associated with problems of access to care.

METHODS

Records from the Northern and Yorkshire Cancer Registry for patients registered with breast, colorectal, lung, ovarian or prostate cancer between 1994 and 2002 were supplemented with measures of travel time to general practitioner and hospital services, and social deprivation. Logistic regression was used to identify predictors of records where diagnosis was at death.

RESULTS

There was no association between the odds diagnosis at death and access to primary care. For all sites except breast, the highest odds of being a cancer diagnosed at death fell among those living in the highest quartile of hospital travel time, although it was only statistically significant for colorectal and ovary tumours. Those in the most deprived and furthest travel time to hospital quartile were 2.6 times more likely to be a diagnosis at death case compared with those in the most affluent and proximal areas.

CONCLUSIONS

There is some evidence that poorer geographical access to tertiary care, in particular when coupled with social disadvantages, may be associated with increased odds of diagnosis at death.

Effects of cooked temperature on pork tenderness and relationships among muscle physiology and pork quality traits in loins from Landrace and Berkshire swine

The effect of, and associations between, loin muscle morphology and pork quality indicator traits were assessed at three cooked temperatures in loin chops from 38 purebred Berkshire and 52 purebred Landrace swine. Three loin chops from each pig were randomly assigned to cooked temperature treatments of 62, 71, or 79 degrees C and loin tenderness was assessed as Warner-Bratzler shear force (WBSF). Cooked temperature (P<0.001), breed (P<0.001) and breed x cooked temperature (P<0.001) effects influenced loin chop WBSF, whereby WBSF increased as cooked temperature increased. Chops from Landrace pigs had greater WBSF at each cooked temperature compared with chops from Berkshire pigs. Chops from Landrace pigs became less tender with increasing cooked temperature, whereas chops from Berkshire pigs became less tender only when cooked to 79 degrees C. In loins from Landrace pigs, Minolta a* at 62 degrees C (R(2)=0.07), and average muscle fiber diameter at 71 degrees C and 79 degrees C (R(2)=0.07 and 0.24, respectively), contributed to WBSF variation. In contrast, for loins from Berkshire pigs, loin ultimate pH and intramuscular fat percentage accounted for 27% and 30% of the variation in WBSF at 62 degrees C and 71 degrees C, respectively, and loin ultimate pH accounted for 7% of variation in WBSF at 79 degrees C. Results suggest that loins from Berkshire pigs have properties that resist toughening at greater cooked temperatures and that associations between quality measures and loin tenderness differ between Landrace and Berkshire pigs.

Sustained effect of the aromatase inhibitors anastrozole and letrozole on endometrial thickness in patients with endometrial hyperplasia and endometrial carcinoma

OBJECTIVE

To investigate whether there may be a role for aromatase inhibitors (AIs) in the treatment of endometrial hyperplasia (EH) and endometrial adenocarcinoma (EA) in postmenopausal women, a retrospective study on the effect of aromatase inhibitors (anastrozole or letrozole) was conducted for 16 patients who were not amenable to surgical treatment.

MAIN OUTCOME MEASURE

Resolution of endometrial thickening measured by transvaginal ultrasound at 3-month intervals; the response of metastases was assessed by standard oncological criteria.

RESULTS

In all, 16 patients were studied. The BMI of 13 of the 16 patients was known and ranged from 20.7 to 47.7 (mean 34.5) kg/m(2). During treatment with AIs, mean endometrial thickness in the eight patients with EH decreased progressively by 81.7% from 14.7 mm at the start of treatment to 2.7 mm following 36 months of treatment. A greater original mean endometrial thickness of 17 mm was seen in the four patients with localised EA, this fell progressively by 67.1% to 5.6 mm following 36 months of treatment. No responses were seen in four patients with metastatic disease.

CONCLUSION

Our results indicate that treatment of EH with anastrozole or letrozole can reduce endometrial thickness as seen ultrasonically, and that in some cases AI treatment can reduce endometrial thickness in patients with localised EA. We found no evidence to indicate that AI treatment prevents disease progression in patients with metastatic EA. Further investigations will be necessary to validate our findings from this small retrospective study and to compare AI inhibitor treatment with topical progestogen therapy.

Severe sequence-specific toxicity when capecitabine is given after Fluorouracil and leucovorin

PURPOSE

Options for single-agent fluoropyrimidine adjuvant therapy after bowel cancer resection include intravenous fluorouracil with leucovorin (FU/LV) or oral capecitabine. These treatments have similar efficacy but differ in convenience and toxicity. We therefore wished to compare their overall acceptability to patients.

PATIENTS AND METHODS

Patients scheduled for adjuvant single-agent fluoropyrimidine therapy were randomly assigned to receive once-weekly FU/LV (425 mg/m(2) FU, 45 mg LV) for 6 weeks, followed by two 3-week cycles of capecitabine (1,250 mg/m(2) twice daily, days 1 through 14), or the same treatments but in reverse order. After 12 weeks, the patients were asked which treatment they preferred, and received the preferred treatment for an additional 12 weeks. The primary end point was patient preference.

RESULTS

After 40 of the planned 74 patients had been randomly assigned, real-time adverse event monitoring led to early trial closure because of excess sequence-specific toxicity. Eleven of 14 patients (79%) receiving capecitabine as their second treatment experienced grade >/= 3 toxicity. This compared with five of 18 patients (28%) receiving capecitabine as the first treatment, and no patients receiving FU/LV as the first treatment (zero of 16) or the second treatment (zero of 12). Similar imbalances were seen in the proportion of patients requiring interruption of treatment.

CONCLUSION

In chemotherapy-naïve patients, capecitabine produced more toxicity than FU/LV, but at levels in line with previously reported data. However, treatment with capecitabine after FU/LV caused markedly increased toxicity, indicating a sequence-specific interaction. The mechanism has not been determined, but interaction with intracellularly retained folate after FU/LV therapy is a possibility. Oncologists need to be aware of this risk if considering crossing patients over from FU/LV to capecitabine-based regimens.

Travel time to hospital and treatment for breast, colon, rectum, lung, ovary and prostate cancer

The aim was to examine the effect of geographical access to treatment services on cancer treatment patterns. Records for patients in northern England with breast, colon, rectal, lung, ovary and prostate tumours were augmented with estimates of travel time to the nearest hospital providing surgery, chemotherapy or radiotherapy. Using logistic regression to adjust for age, sex, tumour stage, selected tumour pathology characteristics and deprivation of place of residence, the likelihood of receiving radiotherapy was reduced for all sites studied with increasing travel time to the nearest radiotherapy hospital. Lung cancer patients living further from a thoracic surgery hospital were less likely to receive surgery, and both lung cancer and rectal cancer patients were less likely to receive chemotherapy if they lived distant from these services. Services provided in only a few specialised centres, involving longer than average patient journeys, all showed an inverse association between travel time and treatment take-up.

Centralisation of services for the management of ovarian cancer: arguments against

In 2000, the Commissioning Guidance for gynaecological cancer services relied on a subset analysis within a retrospective study to support its requirement that surgery for carcinoma of the ovary be centralised. We have reviewed the literature covering this issue, especially that published in the past 6 years. There is no evidence for an advantage for specialist gynaecological oncologists over general gynaecologists for these women; studies that suggest that one exists fail to separate patients presenting to general surgeons, whose patients are at a clear disadvantage, from those seen by gynaecologists. There is evidence for the need for appropriate surgery in women with less extensive disease where the diagnostic difficulties are greatest. We argue for investment in the diagnosis of ovarian cancer and the provision of services for its medical treatment over a prolonged period.

Travel times to health care and survival from cancers in Northern England

The aim was to assess the effect of geographical accessibility on the stage of cancer at diagnosis and survival. Records of 117,097 cases of breast, colorectal, lung, ovary and prostate cancer diagnosed in Northern England between 1994 and 2002 were supplemented with estimates of travel times to the patients' general practitioners (GPs) and hospitals attended, together with measures of access to public transport. Logistic regression and Cox proportional hazards models were used, adjusting for age, sex, whether the first hospital visited was a cancer centre and deprivation of area of residence. Late stage at diagnosis was associated with increasing travel time to GP for breast and colorectal cancers and risk of death was associated with travel time to GP for prostate cancer. Travel times to hospital and other accessibility measures showed no consistent associations with stage at diagnosis or survival, so travel to GP was the only influential factor.

Epirubicin and cyclophosphamide, methotrexate, and fluorouracil as adjuvant therapy for early breast cancer

BACKGROUND

The National Epirubicin Adjuvant Trial (NEAT) and the BR9601 trial examined the efficacy of anthracyclines in the adjuvant treatment of early breast cancer.

METHODS

In NEAT, we compared four cycles of epirubicin followed by four cycles of cyclophosphamide, methotrexate, and fluorouracil (CMF) with six cycles of CMF alone. In the BR9601 trial, we compared four cycles of epirubicin followed by four cycles of CMF, with eight cycles of CMF alone every 3 weeks. The primary end points were relapse-free and overall survival. The secondary end points were adverse effects, dose intensity, and quality of life.

RESULTS

The two trials included 2391 women with early breast cancer; the median follow-up was 48 months. Relapse-free and overall survival rates were significantly higher in the epirubicin-CMF groups than in the CMF-alone groups (2-year relapse-free survival, 91% vs. 85%; 5-year relapse-free survival, 76% vs. 69%; 2-year overall survival, 95% vs. 92%; 5-year overall survival, 82% vs. 75%; P<0.001 by the log-rank test for all comparisons). Hazard ratios for relapse (or death without relapse) (0.69; 95% confidence interval [CI], 0.58 to 0.82; P<0.001) and death from any cause (0.67; 95% CI, 0.55 to 0.82; P<0.001) favored epirubicin plus CMF over CMF alone. Independent prognostic factors were nodal status, tumor grade, tumor size, and estrogen-receptor status (P<0.001 for all four factors) and the presence or absence of vascular or lymphatic invasion (P=0.01). These factors did not significantly interact with the effect of epirubicin plus CMF. The overall incidence of adverse effects was significantly higher with epirubicin plus CMF than with CMF alone but did not significantly affect the delivered-dose intensity or the quality of life.

CONCLUSIONS

Epirubicin plus CMF is superior to CMF alone as adjuvant treatment for early breast cancer. (ClinicalTrials.gov number, NCT00003577 [ClinicalTrials.gov].).

A visitor with Munchausen's syndrome

The arrival on the hospital ward of a person who was fabricating an illness was an unsettling experience for the medical and nursing staff involved. As the patient was expected only to be present for a short time and claimed to have a proven diagnosis, the approach may have been less rigorous than usual. The article describes the experience of three members of staff with a patient who proved to have Munchausen's syndrome, and their reaction to discovering the truth.

Does the nadir CA125 concentration predict a long-term outcome after chemotherapy for carcinoma of the ovary?

The tumour marker CA125 is an important indicator of the clinical progress of women with carcinoma of the ovary. We have investigated the interval from the nadir CA125 value to progression defined by rising CA125 (time to biochemical progression, TBP), and overall survival of patients treated with chemotherapy for this disease in relation to the nadir CA125 value in patients in whom this was <30 U/ml following chemotherapy. The median TBP in group A (38 patients, nadir </=10 U/ml) was 2436 days, in group B (32 patients, nadir 11-20) 182 days and in group C (nine patients, nadir 21-30) 90 days, (P < 0.001). This was associated with similar differences for overall survival, the median was 2968 days in group A, 537 days in group B and 537 days in group C, (P < 0.001). Variations in the CA125 value even within the normal range carry useful information. This prognostic indicator will be useful in studying the management of patients following response to first-line chemotherapy.

Phase II study of docetaxel in combination with epirubicin and protracted venous infusion 5-fluorouracil (ETF) in patients with recurrent or metastatic breast cancer. A Yorkshire breast cancer research group study

This study was originally designed as a phase I/II study, with a dose escalation of docetaxel in combination with epirubicin 50 mg m⁻² and 5-fluorouracil (5-FU) 200 mg m⁻² day⁻¹. However, as dose escalation was not possible, the study is reported as a phase II study of the combination to assess response and toxicity. A total of 51 patients with locally advanced or metastatic breast cancer were treated on this phase II study, with doses of docetaxel 50 mg m⁻², epirubicin 50 mg m⁻² and infusional 5-FU 200 mg m⁻² day⁻¹ for 21 days. The main toxicity of this combination was neutropenia with 89% of patients having grade 3 and 4 neutropenia, and 39% of patients experiencing febrile neutropenia. Nonhaematological toxicity was mild. The overall response rate in the assessable patients was 64%, with median progression-free survival of 38 weeks, and median survival of 70 weeks. The ETF regimen was found to be toxic, and it was not possible to escalate the dose of docetaxel above the first dose level. This regimen has therefore not been taken any further, but as a development of this a new study is ongoing, combining 3-weekly epirubicin, weekly docetaxel and capecitabine, days 1–14.