Management of bowel obstruction in advanced and terminal cancer patients

Background: Bowel obstruction is a common and distressing outcomein patients with abdominal or pelvic cancer. Patients and methods: Patients may develop bowel obstructionat any time in their clinical history, with an incidence rangingfrom 5.5% to 42% in ovarian carcinoma and from 10% to 28.4%in colorectal cancer. The causes of the obstruction may be benignpostoperative adhesions, a focal malignant or benign deposit,relapse or diffuse carcinomatosis. The symptoms which are almostalways present are intestinal colic (reported in 72%–76%of patients), abdominal pain due to distension, hepatomegalyor tumor masses (in 92% of patients) and vomiting (68%–100%)of cases. Conclusion: While surgery must remain the primary treatmentfor malignant obstruction, it is now recognised that there isa group of patients with advanced disease or poor general conditionwho are unfit for surgery and require alternative managementto relieve distressing symptoms. A number of treatment optionsare now available for the patient with advanced cancer who developsintestinal obstruction. In this review of the literature, theindications for surgery will be examined, the use of nasogastrictube and percutaneous gastrostomy evaluated and the place ofdrugs for symptom control described. bowel obstruction, advanced and terminal cancer patients     

Canadian National Breast Screening Study: 1. Breast cancer detection and death rates among women aged 40 to 49 years.

OBJECTIVES: To evaluate the efficacy of the combination of annual screening with mammography, physical examination of the breasts and the teaching of breast self-examination in reducing the rate of death from breast cancer among women aged 40 to 49 years on entry. DESIGN: Individually randomized controlled trial. SETTING: Fifteen urban centres in Canada with expertise in the diagnosis and treatment of breast cancer. PARTICIPANTS: Women with no history of breast cancer and no mammography in the previous 12 months were randomly assigned to undergo either annual mammography and physical examination (MP group) or usual care after an initial physical examination (UC group). The 50,430 women enrolled from January 1980 through March 1985 were followed for a mean of 8.5 years. DATA COLLECTION: Derived from the participants by initial and annual self-administered questionnaires, from the screening examinations, from the patients' physicians, from the provincial cancer registries and by record linkage to the Canadian National Mortality Data Base. Expert panels evaluated histologic and death data. MAIN OUTCOME MEASURES: Rates of referral from screening, rates of detection of breast cancer from screening and from community care, nodal status, tumour size, and rates of death from all causes and from breast cancer. RESULTS: Over 90% of the women in each group attended the screening sessions or returned the annual questionnaires, or both, over years 2 to 5. The characteristics of the women in the two groups were similar. Compared with the Canadian population, the participants were more likely to be married, have fewer children, have more education, be in a professional occupation, smoke less and have been born in North America. The rate of screen-detected breast cancer on first examination was 3.89 per 1000 in the MP group and 2.46 per 1000 in the UC group; more node-positive tumours were found in the MP group than in the UC group. During years 2 through 5 the ratios of observed to expected cases of invasive breast cancer were 1.26 in the MP group and 1.02 in the UC group. Of the women with invasive breast cancer through to 7 years, 191 and 157 women in the MP and UC groups respectively had no node involvement, 55 and 43 had one to three nodes involved, 47 and 23 had four or more nodes involved, and 38 and 49 had an unknown nodal status. There were 38 deaths from breast cancer in the MP group and 28 in the UC group. The ratio of the proportions of death from breast cancer in the MP group compared with those in the UC group was 1.36 (95% confidence interval 0.84 to 2.21). The survival rates were similar in the two groups. The highest survival rate occurred among women whose cancer had been detected by mammography alone. CONCLUSION: The study was internally valid, and there was no evidence of randomization bias. Screening with yearly mammography and physical examination of the breasts detected considerably more node-negative, small tumours than usual care, but it had no impact on the rate of death from breast cancer up to 7 years' follow-up from entry.