Costs and benefits of routine follow-up after curative treatment for endometrial cancer

OBJECTIVE: To examine the costs of routine outpatient follow-up after curative treatment of endometrial cancer, and to determine whether this leads to early detection of recurrence or survival. The impact of specific disease characteristics on survival is examined. DESIGN: Retrospective chart review, and calculation of costs. SETTING: Ottawa Regional Cancer Centre-Civic Division (ORCC-C). PATIENTS: All 432 patients referred to the ORCC-C with endometrial cancer between 1982 and 1991 who received treatment with curative intent and who continued with routine follow-up. RESULTS: Cancer recurred in 50 patients (11.57%). There was no statistically significant difference in overall survival between patients with symptomatic and asymptomatic recurrences, or between those with recurrences detected during routine follow-up visits or in the interval between routine visits. Of 4830 Papanicolaou (Pap) smears performed routinely, cancer was detected in 6 cases. The mean cost of the routine follow-up procedures for each patient with a recurrence was $19,200. CONCLUSION: Intensive follow-up of women with endometrial cancer does not result in improved survival. A prospective randomized study is warranted to evaluate other potential benefits of follow-up, such as improved quality of life or decreased morbidity. There is no economic or clinical justification for the routine use of the Pap smear in the follow-up of patients with endometrial cancer. The potential benefits of routine follow-up in endometrial cancer and other types of cancer with favourable prognoses warrant critical evaluation.     

Report of the Canadian Hypertension Society Consensus Conference: 2. Nonpharmacologic management and prevention of hypertensive disorders in pregnancy

OBJECTIVE: To provide Canadian physicians with comprehensive, evidence-based guidelines for the nonpharmacologic management and prevention of gestational hypertension and pre-existing hypertension during pregnancy. OPTIONS: Lifestyle modifications, dietary or nutrient interventions, plasma volume expansion and use of prostaglandin precursors or inhibitors. OUTCOMES: In gestational hypertension, prevention of complications and death related to either its occurrence (primary or secondary prevention) or its severity (tertiary prevention). In pre-existing hypertension, prevention of superimposed gestational hypertension and intrauterine growth retardation. EVIDENCE: Articles retrieved from the pregnancy and childbirth module of the Cochrane Database of Systematic Reviews; pertinent articles published from 1966 to 1996, retrieved through a MEDLINE search; and review of original randomized trials from 1942 to 1996. If evidence was unavailable, consensus was reached by the members of the consensus panel set up by the Canadian Hypertension Society. VALUES: High priority was given to prevention of adverse maternal and neonatal outcomes in pregnancies with established hypertension and in those at high risk of gestational hypertension through the provision of effective nonpharmacologic management. BENEFITS, HARMS AND COSTS: Reduction in rate of long-term hospital admissions among women with gestational hypertension, with establishment of safe home-care blood pressure monitoring and appropriate rest. Targeting prophylactic interventions in selected high-risk groups may avoid ineffective use in the general population. Cost was not considered. RECOMMENDATION: Nonpharmacologic management should be considered for pregnant women with a systolic blood pressure of 140-150 mm Hg or a diastolic pressure of 90-99 mm Hg, or both, measured in a clinical setting. A short-term hospital stay may be required for diagnosis and for ruling out severe gestational hypertension (preeclampsia). In the latter case, the only effective treatment is delivery. Palliative management, dependent on blood pressure, gestational age and presence of associated maternal and fetal risk factors, includes close supervision, limitation of activities and some bed rest. A normal diet without salt restriction is advised. Promising preventive interventions that may reduce the incidence of gestational hypertension, especially with proteinuria, include calcium supplementation (2 g/d), fish oil supplementation and low-dose acetylsalicylic acid therapy, particularly in women at high risk for early-onset gestational hypertension. Pre-existing hypertension should be managed the same way as before pregnancy. However, additional concerns are the effects on fetal well-being and the worsening of hypertension during the second half of pregnancy. There is, as yet, no treatment that will prevent exacerbation of the condition. VALIDATION: The guidelines share the principles in consensus reports from the US and Australia on the nonpharmacologic management of hypertension in pregnancy.     

Promoting the health of senior citizens

Canada is experiencing a dramatic increase in the number of older people in its population. Adopting strategies that involve physician actions, a societal approach and individual participation may substantially improve the health of senior citizens. This article presents ways to improve the quality of life and reduce the risk of premature death through manoeuvres that can be initiated by physicians in the context of the periodic health examination. The authors highlight the role of evidence in choosing the most appropriate interventions, speculate on areas of future importance and emphasize a societal approach to population health.     

The journal club.

As the body of medical literature continues to expand, physicians must develop the necessary skills to keep up with the vast amount of information available. The journal club provides a forum to allow residents to remain current with the literature while also teaching them the methods to evaluate it critically. Those readers wishing to start a journal club or revive an existing one should begin by designating a leader and defining the conference goals. Emphasizing the importance of this conference in the educational process while allowing it to be structured to optimise resident interest and attendance will help to ensure its success. Periodic evaluation of this conference will allow the organisers to assess the concordance of the resident''s goals with those of the faculty. Formal evaluation will also provide an objective assessment of the knowledge gained by the house-staff through participation in journal club.     

Malakoplakia and colorectal adenocarcinoma.

We report a case of malakoplakia in association with colonic adenocarcinoma. Tumour-associated malakoplakia in the gastrointestinal tract is a rare finding, generally confined to the colon. It may be locally aggressive, with invasion of pericolic tissues, but is always located adjacent to the tumour. This contrasts with the often more diffuse, multifocal distribution of colonic malakoplakia in association with other pathologies.