Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery

Background

Rates of abdominoperineal resection (APR) have been suggested as a solitary surrogate marker for comparing overall hospital quality in rectal cancer surgery. This study investigated the value of this marker by examining the associations between hospital APR rates and other quality indicators.

Methods

Hospital-level correlations between risk-adjusted APR rates for low rectal cancer and six risk-adjusted outcomes and six care processes were performed (such as 30-day mortality, complications, timely treatment). The ability of APR rates to discriminate between hospitals' performance was examined by means of hospital variance results in multilevel regression models and funnel plots.

Results

A linked population-based data set identified 1703 patients diagnosed in 2007 and 2008 who underwent surgery for rectal cancer. Some 15·9 (95 per cent confidence interval (c.i.) 14·2 to 17·6) per cent of these patients had an APR. Among 707 people with low rectal cancer, 38·2 (34·6 to 41·8) per cent underwent APR. Although risk-adjusted hospital rates of APR for low rectal cancer varied by up to 100 per cent, only one hospital (1 per cent) fell outside funnel plot limits and hospital variance in multilevel models was not very large. Lower hospital rates of APR for low rectal cancer did not correlate significantly with better hospital-level outcomes or process measures, except for recording of pathological stage (r = −0·55, P = 0·019). Patients were significantly more likely to undergo APR for low rectal cancer if they attended a non-tertiary metropolitan hospital (adjusted odds ratio 2·14, 95 per cent c.i. 1·11 to 4·15).

Conclusion

APR rates do not appear to be a useful surrogate marker of overall hospital performance in rectal cancer surgery.

The efficacy of HER2-targeted agents in metastatic breast cancer: a meta-analysis

BACKGROUND

The addition of HER2-targeted agents to standard treatment has been shown to improve outcomes for HER2 positive metastatic breast cancer patients. We undertook a meta-analysis to evaluate the efficacy of HER2-targeted therapy in addition to standard treatment in metastatic breast cancer patients.

PATIENTS AND METHODS

Eligible trials were randomised controlled trials (RCTs) comparing the addition of HER2 therapy to standard treatment (hormone or chemotherapy) reporting overall survival (OS), time to progression (TTP), progression-free survival (PFS) and/or response rates.

RESULTS

Eight trials comprising 1848 patients were eligible for inclusion. HER2-targeted agents were trastuzumab and lapatinib and therapeutic partners were taxanes (4 RCTs), anthracyclines (1), capecitabine (2), anastrozole (1) and letrozole (1). The addition of HER2-targeted agents improved OS [hazard ratios (HR) 0.78; 95% confidence interval (CI) 0.67-0.91], TTP (HR 0.56; 95% CI 0.48-0.64), PFS (HR 0.63; 95% CI 0.53-0.74) and overall response rate (relative risk 1.67; 95% CI 1.46-1.90).

CONCLUSIONS

Our meta-analysis confirms the benefit of adding HER2-targeted therapy to standard treatment in HER2 positive metastatic breast cancer. Compared with OS, TTP, PFS and ORR overestimate treatment benefit. Trials in our meta-analysis differed in terms of partner drug or HER2 agents, yet delivered comparable outcomes.

Specific unwillingness to donate eyes: the impact of disfigurement, knowledge and procurement on corneal donation

Although willingness, attitudes and beliefs surrounding solid-organ donation have been extensively investigated, much less is known about corneal donation. Despite evidence that a substantial number of families who agree to multiorgan donation also specifically refuse corneal donation, it is unclear why this occurs and what can be done to increase rates of corneal donation. We conducted a survey of 371 Australian adults regarding their views on corneal donation. Although willingness to donate corneas generally reflected a person's willingness to donate all of one's organs, unwillingness to donate corneas appeared to be due to other factors. Specifically, decisions not to donate appear to be driven by a range of concerns surrounding disfigurement. The survey also provides eye banks with reassurance about the acceptability of whole globe procurement, and recognition that research into blindness is a highly valued part of corneal donation. Finally, the survey identifies that many individuals see benefit in having their family engaged in the decision-making process, suggesting that decisions about donation are more complex than a simple appeal to the autonomy of the deceased.

Oestrogen receptor beta expression in pleomorphic adenomas of the parotid gland

AIMS

Pleomorphic adenomas of the salivary gland have gender and age distributions suggesting that oestrogen has a causal role. However, oestrogen receptor (ER)alpha is expressed at low levels in normal salivary gland tissues and data from salivary gland tumours are conflicting. There is preliminary evidence that the recently described ERbeta may be the major ER in salivary gland tissue. The aim of this study was to determine the nature and extent of ERbeta expression in pleomorphic adenomas of the salivary gland.

METHODS

Pleomorphic adenomas and normal tissues of the parotid gland from 49 patients were tested for ERalpha and ERbeta expression by semiquantitative immunohistochemistry. Associations were sought with patient age and gender.

RESULTS

ERalpha and ERbeta expression was localised mainly to the nuclei of ductal cells in normal tissues and the epithelial components in pleomorphic adenomas. Within each tissue and receptor type there were no associations between ER positivity and patient age or gender. ERbeta was expressed in almost twice as many normal tissues and pleomorphic adenomas as ERalpha. Expression of ERbeta was also significantly higher in tumour compared with normal tissues.

CONCLUSIONS

This is thought to be the first study of ERbeta in pleomorphic adenomas of the salivary gland. Findings support ERbeta as the major ER in salivary glands, and provide evidence that ERbeta may have a role in the development of pleomorphic adenomas of the salivary gland.

Who comes to a workplace health risk assessment?

Workplace health promotion initiatives have proliferated, but there are difficulties in recruiting employees of lower socioeconomic status and at higher risk of disease. A survey of health behaviors and attitudes was administered in 20 worksites and the opportunity to attend a health risk assessment promoted. Those more likely to attend were women, those of higher occupational prestige, and those from a non-English-speaking background. After adjustment for these variables, the only health behavior associated with attendance was smoking status. Perceived risk of lung cancer was significant, even after adjustment for smoking status. Stage of readiness to change health behaviors was associated with attendance, with those in the preparation stage being more likely to attend than those in the precontemplation stage. However, this association was statistically significant only for fruit and vegetable consumption. There was no relation between attendance and support for health promotion, perceived general health, or other perceived risk of disease. These findings suggest that additional risk communication strategies and environmental support are required to involve those with less prestigious occupations.

Factors associated with waiting time for surgery

OBJECTIVE

To explore the factors associated with waiting times for surgery in public hospitals.

SETTING

Three major acute care public hospitals in one Area Health Service.

PARTICIPANTS

691 adult patients entered onto the computerised booking list between 16 and 22 November 1994, and then between 16 January and 12 February 1995, were interviewed prospectively and followed up over a minimum of 18 months. Data were obtained from the Area Health Service's computerised booking system and patient self-report.

RESULTS

Relevant surgical specialty, urgency rating, employment status and health insurance status were significantly associated with waiting time. Age, hospital, sex, country of birth, education, marital status and holding a Health Care Card were not significantly associated with waiting time. Self-reported health status (as measured by the SF-36) was not associated with waiting time for surgery.

CONCLUSIONS

Waiting time for surgery was not simply determined by how urgently patients need surgery, but also by the type of surgery needed and patient's employment and health insurance status. The extent of disability experienced by patients, as measured by the SF-36, was not reflected in waiting times for surgery.