Follow-up care for cancer survivors: views of the younger adult

Background:

Since the launch of the National Cancer Survivorship Initiative, there has been a surge of interest surrounding the value and organisation of long-term follow-up care after cancer treatment. We report the views of 309 adult cancer survivors (aged 18–45 years) on provision of follow-up and preferences for care.

Methods:

A total of 207 survivors completed questionnaires before and after routine consultant-led follow-up appointments and 102 were recruited by post. Measures of health status (including late effects, perceived vulnerability to late effects and quality of life), reasons for attending follow-up (clinical and supportive), issues to be discussed at follow-up and preferences for different models of care were assessed.

Results:

In all, 59% of the survivors reported experiencing one or more cancer-related health problems. Survivors rated clinical reasons for attending follow-up more highly than supportive reasons (P<0.001), although nutritional advice and counselling were considered useful (60 and 47%, respectively). Those still receiving scheduled follow-up appointments did not discuss the range of issues intended with ‘late effects'' and ‘fertility'', which were particularly under-discussed. Hospital rather than GP follow-up was more highly rated.

Conclusion:

Survivors value the clinical reassurance currently provided by consultant-led care. However, supportive needs are not systematically addressed. Multi-disciplinary services are recommended to meet supportive needs in addition to clinical care.     

A trial of consent procedures for future research with clinically derived biological samples

Background:

The aims of this study were to determine which consent procedure patients prefer for use of stored tissue for research purposes and what the effects of consent procedures on actual consenting behaviour are.

Methods:

We offered 264 cancer patients three different consent procedures: ‘one-time general consent'' (asked written informed consent), ‘opt-out plus'' (had the opportunity to opt out by a form), or the standard hospital procedure (control group). The two intervention groups received a specific leaflet about research with residual tissue and verbal information. The control group only received a general hospital leaflet including opt-out information, which is the procedure currently in use. Subsequently, all patients received a questionnaire to examine their preferences for consent procedures.

Results:

In all, 99% of patients consented to research with their residual tissue. In the ‘one-time consent'' group 85% sent back their consent form. Patients preferred ‘opt-out plus'' (43%) above ‘one-time consent'' (34%) or ‘opt-out'' (16%), whereas 8% indicated that they did not need to receive information about research with residual tissues or be given the opportunity to make a choice.

Conclusions:

The ‘opt-out plus'' procedure, which places fewer demands on administrative resources than ‘one-time consent'', can also address the information needs of patients.     

Cytology history preceding cervical cancer diagnosis: a regional analysis of 286 cases

Background:

Despite programmed screening in the Netherlands, the decrease in incidence of cervical carcinoma lags behind. We analysed screening results preceding carcinoma cases, timeliness in case of follow-up, and FIGO (International Federation of Gynaecology and Obstetrics) stages as efficiency parameters for screening were taken.

Methods:

We analysed 286 women with cervical cancer between 2005 and 2007 for cytology history preceding carcinoma, hierarchically arranging cytology history (if present) into three groups: ‘screened'', ‘work-up'', and ‘underscreened'' (>6 yrs before diagnosis). For screen- and work-up smears, we analysed timeliness. FIGO stage was measured in relation to cytology history.

Results:

A total of 105 out of 286 (36.7%) women with cervical carcinoma were screened preceding the diagnosis. Delayed time intervals in case of abnormal cytology were 43.5% for borderline/mild dyskaryosis (BMD) and 38.0% for BMD (moderate dyskaryosis or worse; P=0.51). A total of 108 out of 286 (36.4%) women were underscreened, and 73 out of 286 (25.5%) were unscreened. Advanced carcinoma or FIGO stage ⩾2B in screened women was 16.0 vs 48.7% in work-up, underscreened, or unscreened (P<0.001).

Conclusion:

Women with cervical cancer are underscreened and have poor timeliness in case of abnormal cytology. Being un- or underscreened correlates significantly with higher cervical cancer stages, especially in older women (aged ⩾49 years; P<0.001). Improvement of attendancy is needed to meet the standard of quality for screening programmes.     

A telephone survey of cancer awareness among frontline staff: informing training needs

Background:

Studies have shown limited awareness about cancer risk factors among hospital-based staff. Less is known about general cancer awareness among community frontline National Health Service and social care staff.

Methods:

A cross-sectional computer-assisted telephone survey of 4664 frontline community-based health and social care staff in North West England.

Results:

A total of 671 out of 4664 (14.4%) potentially eligible subjects agreed to take part. Over 92% of staff recognised most warning signs, except an unexplained pain (88.8%, n=596), cough or hoarseness (86.9%, n=583) and a sore that does not heal (77.3%, n=519). The bowel cancer-screening programme was recognised by 61.8% (n=415) of staff. Most staff agreed that smoking and passive smoking ‘increased the chance of getting cancer.'' Fewer agreed about getting sunburnt more than once as a child (78.0%, n=523), being overweight (73.5%, n=493), drinking more than one unit of alcohol per day (50.2%, n=337) or doing less than 30 min of moderate physical exercise five times a week (41.1%, n=276).

Conclusion:

Cancer awareness is generally good among frontline staff, but important gaps exist, which might be improved by targeted education and training and through developing clearer messages about cancer risk factors.     

Campaign awareness and oral cancer knowledge in UK resident adult Bangladeshi: a cross-sectional study

Background:

This study reports awareness of the ‘Open up to Mouth Cancer'' campaign materials and oral cancer knowledge among two UK adult Bangladeshi communities, both at high risk for oral cancer.

Methods:

Differences in the outcomes of campaign awareness and knowledge of oral cancer risk factors and early signs were compared between campaign and comparison areas. Home-based interviews were conducted with representative samples from both areas by bilingual interviewers. Data collected included a modified 36-item Humphris Oral Cancer Knowledge Scale and socio-demographic information. The data were collected 4 weeks after the campaign completion and analysed using χ²-tests and binary logistic regressions.

Results:

The response rate was 77%. Both awareness of the campaign materials (29.99% (95% confidence interval (CI) 15.82, 46.99) vs 8.12% (95% CI 6.16, 10.62)) and the mean Humphris Oral Cancer Knowledge Scale scores (13.32 (95% CI 11.06, 15.57) vs 8.27 (95% CI 6.59, 9.94)) were higher in the campaign area. The campaign area sample was significantly more likely to be aware of the materials (odds ratio (OR)=6.03, 95% CI 3.00, 12.1).

Conclusion:

Superior awareness and oral cancer knowledge was identified in the community with access to the campaign materials. Further evaluation to identify long-term campaign impact is required.     

Exposure to animals and increased risk of marginal zone B-cell lymphomas of the ocular adnexae

Background:

Ocular adnexal marginal zone B-cell lymphoma (OAMZL) has been associated with Chlamydophila psittaci, an infection that may be transmitted by carrier animals. However, it is still unclear whether exposure to animals affects the risk of OAMZL in comparison with other lymphoma histotypes. We therefore investigated the role of professional and/or domestic exposures to animals in the occurrence of OAMZL, as compared with other types of lymphoma.

Methods:

A hospital-based case–control study was carried out on 43 consecutive OAMZL patients (cases) and 87 consecutive patients with nodal non-Hodgkin''s lymphomas (NHLs; controls). Multiple logistic regression (MLR) odds ratios (ORs), and 95% confidence intervals (CIs) were used to estimate the association between exposures to animals and OAMZL risk.

Results:

A higher proportion of cases reported a lifetime exposure to household animals (79.1% vs 64.4% among controls), with a non-statistical significant MLR-OR of 2.18 (95% CI: 0.85–5.62). The OAMZL cases more frequently reported a history of occupation in breeding and/or slaughtering than controls (34.9% vs 6.9%), with an overall increased risk of 7.69 (95%CI: 2.65–22.34).

Conclusion:

These results indicate that, compared with nodal NHLs, the risk of OAMZL is markedly increased by contact with animals, particularly by occupational exposures.     

Health behaviour advice to cancer patients: the perspective of social network members

Background:

Survival for many cancers is improved by healthier lifestyles, but giving lifestyle advice to cancer patients may seem insensitive. We investigated attitudes of members of cancer patients'' social networks towards doctors giving lifestyle advice.

Methods:

We identified social network members through a population survey of UK adults (n=2024, age ⩾50) by asking respondents whether anyone close to them had ever had cancer (n=1273). Individuals with a cancer diagnosis themselves (n=222) were termed cancer survivors. Attitudes towards doctors giving advice to cancer patients on physical activity, diet and weight were each assessed with eight items.

Results:

Most social network members (88–93%) and survivors (87–93%) agreed that advice on diet, activity and weight would be ‘beneficial'', ‘helpful'' and ‘encouraging'', and 84–87% thought it was ‘the doctor''s duty'' to provide it. Few network members (10–18%) or survivors (10–24%) believed it was ‘unnecessary'', ‘interfering'', ‘insensitive'' or implied ‘blame''. Adjusted analyses using composite scores showed that attitudes did not differ between the groups.

Conclusion:

Few cancer survivors or members of social networks of individuals with cancer thought lifestyle advice would be insensitive, and most thought it would be beneficial. These results help counter doubts about the acceptability of lifestyle advice in the cancer context.     

Leg length, sitting height and postmenopausal breast cancer risk

Background:

Tallness has consistently been associated with an increased risk of breast cancer. We investigated the association further by decomposing height into leg length and sitting height.

Methods:

From the prospective Danish cohort ‘Diet, Cancer and Health'', 23 864 postmenopausal women enrolled during 1993–1997 were followed for a diagnosis of breast cancer in the Danish Cancer Registry through 2009.

Results:

The incidence rate ratios for breast cancer were 1.11 (95% CI=1.06–1.16) for each 5 cm increase in total height and 1.09 (95% CI=1.01–1.17) and 1.14 (95% CI=1.04–1.25) for each 5 cm increase in leg length and sitting height, respectively. There was no statistical significant difference between the associations for leg length and sitting height (P=0.47).

Conclusion:

Leg length does not seem to be more strongly associated with breast cancer among postmenopausal women than sitting height.     

Predictors of adherence to repeat fecal occult blood test in a population-based colorectal cancer screening program

Background:

Socio-economic, environmental factors and general practitioner (GP) involvement may influence adherence to repeat faecal occult blood testing (FOBT) of organised colorectal cancer (CRC) screening. The aim of the study was to identify predictors of adherence to repeat testing.

Methods:

The populationcomprised people eligible for the third round of a CRC screening programme in a French district (n=118 905). Multilevel logistic regression analysis was performed to identify individual and area-level characteristics associated with ‘compliant participants'' participating in the all three rounds vs ‘occasional participants'' participating in one or two rounds.

Results:

Compared to ‘occasional participants'', ‘compliant participants'' were more likely to participate after receiving a FOBT kit from their GP (odds ratio (OR), 10.7; 95% CI, 10.01–11.5) vs FOBT received at home, and were less likely to live in socio-economically deprived areas (OR, 0.75; 0.70–0.80) and urban areas (OR, 0.94; 0.88–1.00).

Conclusions:

As for a screening round participation, strategies aimed at improving the participation to a screening programme should target GPs and people living in socially deprived areas.     

Toxicity associated with capecitabine plus oxaliplatin in colorectal cancer before and after an institutional policy of capecitabine dose reduction

Background:

Capecitabine plus oxaliplatin (CAPOX) is an established treatment option in colorectal cancer, but can be associated with severe toxicities.

Methods:

Following reporting of severe diarrhoea and dehydration with capecitabine 2000 mg m^–2 per day plus oxaliplatin every 3 weeks (CAPOX 2000) in 2006, we instituted a policy change to reduce capecitabine dose to 1700 mg m^–2 per day (CAPOX 1700). We undertook a retrospective analysis comparing toxicities encountered before and after this dose change.

Results:

Of the 400 patients treated, no significant differences were seen between the CAPOX 2000 and CAPOX 1700 in grades 3 and 4 diarrhoea (21% vs 19% P=0.80), stomatitis (0% vs 1% P=0.50) or grades 2–4 hand foot syndrome (16% vs 11% P=0.18). Grades 3 and 4 neutropenia (9.5% vs 3.5% P=0.03) and all grades hyperbilirubinaemia (60% vs 40% P<0.0001) were significantly reduced with CAPOX 1700. Rates of hospitalisation due to toxicities were not different between two groups (13% vs 11% P=0.53).

Conclusions:

No clinically or statistically significant differences in gastrointestinal toxicities or hospitalisation rate were seen after reducing our routine capecitabine dose from CAPOX 2000 to CAPOX 1700.     

Differentiating benign from malignant solid breast masses: value of shear wave elastography according to lesion stiffness combined with greyscale ultrasound according to BI-RADS classification

Background:

The aim of this study was to assess the performance of shear wave elastography combined with BI-RADS classification of greyscale ultrasound images for benign/malignant differentiation in a large group of patients.

Methods:

One hundred and seventy-five consecutive patients with solid breast masses on routine ultrasonography undergoing percutaneous biopsy had the greyscale findings classified according to the American College of Radiology BI-RADS. The mean elasticity values from four shear wave images were obtained.

Results:

For mean elasticity vs greyscale BI-RADS, the performance results against histology were sensitivity: 95% vs 95%, specificity: 77% vs 69%, Positive Predictive Value (PPV): 88% vs 84%, Negative Predictive Value (NPV): 90% vs 91%, and accuracy: 89% vs 86% (all P>0.05). The results for the combination (positive result from either modality counted as malignant) were sensitivity 100%, specificity 61%, PPV 82%, NPV 100%, and accuracy 86%. The combination of BI-RADS greyscale and shear wave elastography yielded superior sensitivity to BI-RADS alone (P=0.03) or shear wave alone (P=0.03). The NPV was superior in combination compared with either alone (BI-RADS P=0.01 and shear wave P=0.02).

Conclusion:

Together, BI-RADS assessment of greyscale ultrasound images and shear wave ultrasound elastography are extremely sensitive for detection of malignancy.     

A randomised study evaluating the use of pyridoxine to avoid capecitabine dose modifications

Background:

Pyridoxine is frequently used to treat capecitabine-induced hand–foot syndrome (HFS), although the evidence of benefit is lacking. We performed a randomised placebo-controlled trial to determine whether pyridoxine could avoid the need for capecitabine dose modifications and improve outcomes.

Methods:

A total of 106 patients planned for palliative single-agent capecitabine (53 in each arm, 65%/ 35% colorectal/breast cancer) were randomised to receive either concomitant pyridoxine (50 mg po) or matching placebo three times daily.

Results:

Compared with placebo, pyridoxine use was associated with an increased rate of avoiding capecitabine dose modifications (37% vs 23%, relative risk 0.59, 95% CI 0.29, 1.20, P=0.15) and fewer grade 3/4 HFS-related adverse events (9% vs 17%, odds ratio 0.51, 95% CI 0.15–1.6, P=0.26). Use of pyridoxine did not improve response rate or progression-free survival.

Conclusion:

Pyridoxine may reduce the need for capecitabine dose modifications and the incidence of severe HFS, but does not impact on antitumour effect.     

Vaginal self-sampling is a cost-effective way to increase participation in a cervical cancer screening programme: a randomised trial

Background:

Cervical cancer screening coverage remains insufficient in most countries. Our objective was to assess whether in-home vaginal self-sampling with a dry swab for high-risk human papillomavirus (HR-HPV) testing is effective and cost-effective in increasing participation in cervical cancer screening.

Methods:

In March 2012, 6000 unscreened women aged 30–65 years, living in a French region covered by a screening programme, who had not responded to an initial invitation to have a Pap smear were equally randomised to three groups: ‘no intervention'' ‘recall'', women received a letter to have a Pap smear; and ‘self-sampling'', women received a self-sampling kit to return to a centralised virology laboratory for PCR-based HPV testing.

Results:

Participation was higher in the ‘self-sampling'' than in the ‘no intervention'' group (22.5% vs 9.9%, P<0.0001; OR 2.64) and ‘recall'' group (11.7%, P<0.0001; OR 2.20). In the ‘self-sampling'' group, 320 used the self-sampling kit; for 44 of these women with positive HR-HPV test results, 40 had the recommended triage Pap smear. The ICER per extra screened woman was 77.8€ and 63.2€ for the ‘recall'' and ‘self-sampling'' groups, respectively, relative to the ‘no intervention'' group.

Conclusions:

Offering an in-home, return-mail kit for vaginal self-sampling with a dry swab is more effective and cost-effective than a recall letter in increasing participation in cervical cancer screening.     

Birth characteristics and childhood carcinomas

Background:

Carcinomas in children are rare and have not been well studied.

Methods:

We conducted a population-based case–control study and examined associations between birth characteristics and childhood carcinomas diagnosed from 28 days to 14 years during 1980–2004 using pooled data from five states (NY, WA, MN, TX, and CA) that linked their birth and cancer registries. The pooled data set contained 57 966 controls and 475 carcinoma cases, including 159 thyroid and 126 malignant melanoma cases. We used unconditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

Results:

White compared with ‘other'' race was positively associated with melanoma (OR=3.22, 95% CI 1.33–8.33). Older maternal age increased the risk for melanoma (OR_{per 5-year age increase}=1.20, 95% CI 1.00–1.44), whereas paternal age increased the risk for any carcinoma (OR=1.10_{per 5-year age increase}, 95% CI 1.01–1.20) and thyroid carcinoma (OR_{per 5-year age increase}=1.16, 95% CI 1.01–1.33). Gestational age <37 vs 37–42 weeks increased the risk for thyroid carcinoma (OR=1.87, 95% CI 1.07–3.27). Plurality, birth weight, and birth order were not significantly associated with childhood carcinomas.

Conclusion:

This exploratory study indicates that some birth characteristics including older parental age and low gestational age may be related to childhood carcinoma aetiology.     

Antibodies against lytic and latent Kaposi's sarcoma-associated herpes virus antigens and lymphoma in the European EpiLymph case-control study

Background:

Kaposi''s sarcoma-associated herpes virus is associated with primary effusion lymphoma and multicentric Castleman''s disease.

Methods:

Seropositivity to lytic and latent Kaposi''s sarcoma herpes virus (KSHV) antigens were examined in 2083 lymphomas and 2013 controls from six European countries.

Results:

Antibodies against KSHV latent and lytic antigens were detectable in 4.5% and 3.4% of controls, respectively, and 3.6% of cases (P>0.05). The KSHV seropositivity was associated with splenic marginal zone lymphoma (SMZL) (odds ratio (OR)=4.11, 95% confidence interval (CI)=1.57–10.83) and multiple myeloma (OR=0.31, 95% CI=0.11–0.85).

Conclusion:

The KSHV is unlikely to contribute importantly to lymphomagenesis among immunocompetent subjects. However, the observed association with SMZL may underline a chronic antigen mechanism in its aetiology.     

Sensitivity of immunochemical faecal occult blood testing for detecting left- vs right-sided colorectal neoplasia

Background:

Faecal occult blood tests (FOBTs) are used for colorectal cancer (CRC) screening. We aimed to assess the sensitivity of an immunochemical FOBT for detecting advanced colorectal neoplasia in the left vs the right colon and to explore reasons for potential differences in site-specific test performance.

Methods:

We prospectively measured faecal occult blood levels by a quantitative immunochemical FOBT (RIDASCREEN) in 2310 average-risk subjects undergoing screening colonoscopy. We compared diagnostic performance for subjects with left- vs right-sided advanced neoplasia, as well as patient characteristics and adenoma characteristics that have been suggested to impact faecal haemoglobin levels.

Results:

Sensitivities for subjects with left- vs right-sided advanced neoplasia were 33% (95% confidence interval (CI), 26–41%) and 20% (CI, 11–31%) (P=0.04) at a specificity of 95% (overall sensitivity: 29%) and the areas under the receiver-operating characteristics curve were 0.71 (CI, 0.69–0.72) and 0.60 (CI, 0.58–0.63), respectively. Pedunculated shape was strikingly more common in participants with left- vs right-sided advanced neoplasia (47% vs 14%). In logistic regression analyses adjusted for site, pedunculated shape was statistically significantly associated with test sensitivity (P=0.04).

Conclusions:

The immunochemical FOBT in our study was more sensitive for detecting subjects with left- vs right-sided advanced colorectal neoplasia. Our findings may stimulate further diagnostic research in the field as well as modelling analyses to estimate the potential effect of site-specific test performance on the effectiveness of annual or biennial FOBT-based screening programmes, in particular with respect to protection from right-sided CRC.     

Prostate involvement during sexually transmitted infections as measured by prostate-specific antigen concentration

Background:

We investigated prostate involvement during sexually transmitted infections by measuring serum prostate-specific antigen (PSA) as a marker of prostate infection, inflammation, and/or cell damage in young, male US military members.

Methods:

We measured PSA before and during infection for 299 chlamydia, 112 gonorrhoea, and 59 non-chlamydial, non-gonococcal urethritis (NCNGU) cases, and 256 controls.

Results:

Chlamydia and gonorrhoea, but not NCNGU, cases were more likely to have a large rise (⩾40%) in PSA than controls (33.6%, 19.1%, and 8.2% vs 8.8%, P<0.0001, 0.021, and 0.92, respectively).

Conclusion:

Chlamydia and gonorrhoea may infect the prostate of some infected men.     

Long-term results of screening with magnetic resonance imaging in women with BRCA mutations

Background:

The addition of breast magnetic resonance imaging (MRI) to screening mammography for women with BRCA mutations significantly increases sensitivity, but there is little data on clinical outcomes. We report screening performance, cancer stage, distant recurrence rate, and breast cancer-specific mortality in our screening study.

Methods:

From 1997 to 2009, 496 women aged 25 to 65 years with a known BRCA1/2 mutation, of whom 380 had no previous cancer history, were enrolled in a prospective screening trial that included annual MRI and mammography.

Results:

In 1847 screening rounds, 57 cancers were identified (53 screen-detected, 1 interval, and 3 incidental at prophylactic mastectomy), of which 37 (65%) were invasive. Sensitivity of MRI vs mammography was 86% vs 19% over the entire study period (P<0.0001), but was 74% vs 35% from 1997 to 2002 (P=0.02) and 94% vs 9% from 2003 to 2009 (P<0.0001), respectively. The relative sensitivities of MRI and mammography did not differ by mutation, age, or invasive vs non-invasive disease. Of the incident cancers, 97% were Stage 0 or 1. Of 28 previously unaffected women diagnosed with invasive cancer, 1 BRCA1 mutation carrier died following relapse of a 3 cm, node-positive breast cancer diagnosed on her first screen at age 48 (annual breast cancer mortality rate=0.5%). Three patients died of other causes. None of the 24 survivors has had a distant recurrence at a median follow-up of 8.4 years since diagnosis.

Conclusion:

Magnetic resonance imaging surveillance of women with BRCA1/2 mutations will detect the majority of breast cancers at a very early stage. The absence of distant recurrences of incident cancers to date is encouraging. However, longer follow-up is needed to confirm the safety of breast surveillance.     

Exploring the use and impact of adjuvant Trastuzumab for HER2-positive breast cancer patients in a large UK cancer network Do the results of international clinical trials translate into a similar benefit for patients in South East Wales?

Background:

Trastuzumab was approved in the United Kingdom for adjuvant treatment of human epidermal growth factor receptor 2 (HER2)+ breast cancer in 2006 at significant economic cost and with limited evidence in smaller T1N0 tumours. The South East Wales Cancer Network covers a population of 1 420 000 and maintains a database of treatments used. We examined this database to ensure the outcome of Trastuzumab use is as expected, especially in patients with T1N0 cancers.

Ethods:

M Case notes of patients with HER2+ disease eligible for adjuvant Trastuzumab over 2005–2008 were reviewed. Disease-free survival (DFS) and overall survival (OS) were calculated with the Kaplan–Meier method using SPSS (version 16.0.01 for Windows, SPSS, Chicago, IL, USA).

Results:

A total of 239 of 338 (70.7%) eligible HER2+ patients received treatment. At 3 years, the DFS of the treated group was 90.3% vs 73.3% and the OS was 98.5% vs 87.6%. In all, 47 of 92 stage I patients received Trastuzumab. Despite a trend towards worse prognostic factors in the treated group the DFS was 100% vs 84.1% and the OS was 100% vs 93.3%.

Conclusion:

Our results are comparable to those from landmark Trastuzumab trials. As evidence continues to emerge that smaller HER2+ cancers may behave aggressively our analysis of stage I tumours adds further support to the use of Trastuzumab in these patients.