Biochemical failure as a determinant of distant metastasis and death in prostate cancer treated with radiotherapy

PURPOSE: Biochemical failure (BF), defined by a rising prostate-specific antigen (PSA) profile, is an early surrogate of treatment failure. However, little evidence is available to show that BF is associated with death for patents with prostate cancer treated with radiotherapy. We examined the relationship between BF and death from prostate cancer. METHODS AND MATERIALS: A total of 942 patients were treated between 1987 and 1998 with external beam radiotherapy who had sufficient PSA determinations in follow-up for the analyses described. The median radiation dose was 72 Gy, median PSA was 9.9 ng/mL, and median follow-up was 73 months. The American Society for Therapeutic Radiology and Oncology consensus definition was used to define BF. Kaplan-Meier calculations were from the start of radiotherapy. Cox proportional hazards regression multivariate analyses were used to investigate the association of BF (time-dependent variable) and other factors to distant metastasis (DM), cause-specific death (CSD), and overall death (OD). The year of treatment was included in some of the multivariate analyses to correct for potential unknown factors that may have occurred during the years of the study, such as stage migration. RESULTS: BF was observed in 316 patients (34%), and 66 (7%) experienced DM, 32 (3%) died of prostate cancer, and 230 (24%) died overall during the study period. The Kaplan-Meier 5-year rate estimates from the start of treatment for BF, DM, CSD, and OD were 38%, 6%, 3%, and 13%, respectively. All patients with DM had BF. In multivariate analyses, BF was associated with DM and CSD, but not OD. The inclusion of the year of treatment did not alter these relationships. CONCLUSION: BF, as a time-dependent covariate, was the strongest determinant of DM and was also very significantly related to CSD. The inclusion of the year of treatment had little effect on these associations. Longer follow-up is needed to determine conclusively the relationship of BF to OD.     

Chronic nonmalignant pain and violent behavior

Research suggests that violence has entered the medical setting to a remarkable degree, causing medical professionals to be at the highest risk for becoming the victims of assaults and violent acts. This article reviews general theories of aggression and research on these theories, and uses them to assess risk factors in patients with chronic pain. There are data to suggest that pain may increase the risk of aggressiveness in some patients. However, it may decrease the risk in others paradoxically. The research available underscores the need for evaluating patients with pain for the risk of violent or aggressive behavior; specific recommendations are made in this regard.     

Tympanometry in newborn infants--1 kHz norms

With the rapid implementation of universal newborn hearing screening (UNHS) programs, a test of middle-ear function for infants is urgently needed. Recent evidence suggests that 1 kHz tympanometry may be effective. Normative data are presented for newborn intensive care unit (NICU) graduates tested at a mean age of 3.9 weeks (Study 1) and full-term infants tested at 2-4 weeks (Study 2) who passed an otoacoustic emissions (OAE) screen. Nearly all infants tested had single-peaked tympanograms. The norms are evaluated for a group of full-term infants who were screened with OAE (Study 3) and two groups of infants (NICU patients and well babies) who were not screened by OAE (Study 4). The 5th percentile for static admittance for NICU and full-term babies was identical, allowing a sinngle pass-fail criterion. Using that criterion, well babies who passed an OAE screen (Study 3) yielded a 91% pass rate. Those who passed the OAE screen had substantially higher 1 kHz static admittance than those who failed, suggesting a strong relationship between middle-ear transmission characteristics and OAE responses. The pass rate was lower for newborn well babies and NICU graduates who were not screened by OAE (Study 4).     

Morphine and alternative opioids in cancer pain: the EAPC recommendations

An expert working group of the European Association for Palliative Care has revised and updated its guidelines on the use of morphine in the management of cancer pain. The revised recommendations presented here give guidance on the use of morphine and the alternative strong opioid analgesics which have been introduced in many parts of the world in recent years. Practical strategies for dealing with difficult situations are described presenting a consensus view where supporting evidence is lacking. The strength of the evidence on which each recommendation is based is indicated.     

Sarcoidosis presenting as an enlarging solitary pulmonary nodule

Sarcoidosis is generally not considered in the differential diagnosis of solitary pulmonary nodules. We recently encountered a case in which preoperative awareness of this presentation of sarcoidosis allowed a limited pulmonary resection with resultant lower morbidity and potential preservation of lung function to be performed. Although rare, sarcoidosis should be considered in the differential diagnosis of solitary pulmonary nodules.     

筛查和诊断糖尿病的新观点

美国约有30％的糖尿病患者（约620万人）被漏诊。超过25％的新诊断糖尿病患者已经患有糖尿病视网膜病变或出现微量白蛋白尿，这意味着患者在2型糖尿病发病和确诊之间被“忽视”了7年。有时发现在糖尿病前期，即空腹血糖（FPG）略有偏高（IFG，空腹血糖受损）或口服葡萄糖耐量试验（OGTT）略有偏高，甚至已存在微血管和大血管并发症。     

Results of the 1988-1989 Patterns of Care Study process survey for Hodgkin's disease

PURPOSE: To document national standards of care for patients receiving radiotherapy as part of curative treatment for Hodgkin's disease. MATERIALS AND METHODS: A national survey was conducted of 61 institutions treating 275 patients with Stages I-III Hodgkin's disease and representing six facility type strata. Pretreatment evaluation, radiotherapy treatment parameters, and use of combined modality therapy were assessed. RESULTS: Ann Arbor stage for the 275 patients was as follows: IA, 69 (25%); IB, 7 (3%); IIA, 123 (45%); IIB, 36 (13%); IIIA 23 (8%), IIIB, 14 (5%); unknown, 3 (1%). Pretreatment evaluation included complete blood count for 93%, sedimentation rate in 29%, chest CT in 88%, abdominal CT scan in 87%, and bone marrow biopsy in 81%. Lymphangiograms were obtained in 50% of cases; laparotomy was performed in 46%. The yield of positive findings in the spleen at laparotomy was 6.5 % overall. Facility differences with respect to staging were seen only for the use of gallium scans, which were more commonly used in academic centers (44% vs. 15-23% elsewhere, p<0.001). Radiotherapy was delivered with a linear accelerator in 94% of cases. Treatment simulation was performed for 94% and individualized blocks constructed for 95% overall; however, freestanding facilities had a lower rate of performance of these procedures (78% vs. 98-99% for simulation and 88% vs. 96-99% for customized blocking, p<0.001). The mean supradiaphragmatic dose was 36.74 Gy and the mean subdiaphragmatic dose was 33.81 Gy. Planned combined modality therapy was given in 36% of patients. The use of combined modality therapy by stage was as follows: IA, 11%; IB, 43%; IIA, 30%; IIB, 68%; IIIA, 57%; IIIB, 100%. Chemotherapy was completed prior to radiation in 80% of cases and generally consisted of ABVD (32%), an alternating regimen (25%), or MOPP (22%). Among Stage I/II patients, use of chemotherapy was associated with reduced radiation doses (mean supradiaphragmatic dose 34.53 Gy vs. 38.43 Gy and mean subdiaphragmatic dose 31.27 Gy vs. 34.51 Gy), and reduced volumes of treatment (87% vs. 28% treated to one side of the diaphragm only). Laparotomy was not associated with decreased supra- or subdiaphragmatic radiation doses or decreased volumes of treatment. CONCLUSIONS: With the exception of gallium scans, pretreatment evaluation is relatively uniform across facility strata. Increased understanding of prognostic factors in Hodgkin's disease and greater use of planned combined modality therapy for higher risk patients appears to have contributed to a decreased use of and low yield of positive findings for laparotomy. Laparotomy was not associated with reduced radiation volumes or doses. Freestanding radiation facilities had a lower rate than other facility types for the performance of treatment simulation and customized patient blocking.     

Is there a role for short-term hormone use in the treatment of nonmetastatic prostate cancer?

We reviewed our institution's experience treating patients with prostate cancer with 3-dimensional conformal radiation therapy (3DCRT) and short-term adjuvant hormonal therapy to determine biochemical no evidence of disease (bNED) and clinical outcome compared with patients treated with 3DCRT alone. Between 4/1/89 and 11/30/94, 558 patients with clinically localized prostate cancer received treatment at Fox Chase Cancer Center (Philadelphia, Pa.); 484 patients were treated with 3DCRT alone (Group I); 74 patients were treated with 3DCRT and hormones (Group II). Five-year actuarial rates of bNED control, distant metastasis-free survival (DMFS), cause-specific survival (CSS), and overall survival (OS) were calculated for pretreatment PSA, Gleason score, T stage, use of hormones, treatment field size, age, and dose. A matched case/control analysis was performed to further evaluate the effect of hormones on treatment with 3DCRT. Median follow-up was 47 months (range: 2-97 months). The 5-year actuarial rates of bNED control, DMFS, CSS, and OS were 66%, 93%, 98%, and 86%, respectively, for Group I patients and 68%, 93%, 98%, and 89%, respectively, for Group II patients. Multivariate analysis demonstrated that hormone use was an independent predictor of bNED control only. A significant difference in bNED control was observed between Group I and II (43% vs. 71%) using the matched case/control analysis (P = 0.02). A trend towards significance was observed for different rates of DMFS between Group I and II (79% vs. 94%, P = 0.09). Patients with clinically localized prostate cancer with poor prognostic features (pretreatment PSA > or = 10 ng/ml, Gleason score > or = 7, and/or T2c or greater palpation stage) show improved rates of bNED control and a trend towards improved DMFS when treated with 3DCRT and short-term adjuvant hormones compared with 3DCRT alone. Long-term observation will be necessary to see if improvements in bNED control will translate into improvements in overall survival.     

A rural/urban comparison of the roles of the general practitioner in colorectal cancer management

Objective: To identify and compare the roles of urban, rural and remote general practitioners (GPs) in colorectal cancer (CRC) management. Design: Semistructured interviews exploring GP views of their role in CRC management. Setting: Urban, rural and remote general practices in north Queensland. Participants: Fifteen GPs in urban, rural and remote practice. Main outcome measures: Self‐reported roles in the management of CRC patients and factors influencing these roles. Results: All GPs, regardless of location of practice, played a role in diagnosis, referral, postoperative care, psychosocial counselling, follow up and palliative care. Involvement in treatment of CRC patients was only performed by remote GPs. In general, rural and remote GPs played greater roles in care coordination, clinical and psychosocial care. Rural and remote GPs were more heavily involved throughout the entire illness progression when compared with their urban counterparts. Conclusions: The results of this study indicate that rural and remote GPs in north Queensland play a greater role than urban GPs in the management of CRC. In order to maintain and enhance the roles of rural and remote GPs in CRC care, appropriate guidelines and remuneration should be provided. Palliative care support might also be useful to rural and remote GPs.