Radical radiotherapy of inoperable non-small cell lung cancer. Irradiation techniques and tumor characteristics in relation to local control and survival.

The relation between tumor characteristics, irradiation technique, local tumor control and survival was retrospectively studied in 323 patients with non-small cell lung cancer who started radical radiotherapy in 1974-1981. At that time three non-randomized different fractionation schedules were used: 16 x 3.25 Gy, total dose 52 Gy, 3 fractions/week (schedule 1), 11 x 4 Gy, total dose 44 Gy, 2 fractions/week (schedule 2) and 25 x 2 Gy, total dose 50 Gy, 5 fractions/week (schedule 3). The highest survival rates were observed in the patient group treated according to schedule 2. The 2-year survival rate was 30% compared with 18% and 6% in the patients treated according to schedule 1 and 3 respectively. However, this can at least partly be explained by patient selection. A correlation between size of the tumor, target volume and survival was observed: the larger the tumor, the poorer the survival. Pleural effusion showed to be an unfavorable prognostic factor. The prognosis of inoperable lung cancer on the whole remained poor: the 1-year survival rate was 43% and 2-year survival rate 16%. Only 3% of the patients lived at least five years.     

Predictors of quality of life in newly diagnosed melanoma and breast cancer patients.

BACKGROUND: Quality of life (QoL) is a multidimensional construct, and several psychosocial and medical factors can predict a patient's QoL. We investigated the impact of factors in the psychological stress processes on QoL 3 months after diagnosis of melanoma or breast cancer. PATIENTS AND METHODS: In consecutive melanoma and breast cancer patients with localized disease, cancer-specific social support, coping with cancer, personality trait anger expression, non-cancer stress, sociodemographic variables, cancer and treatment variables, and QoL (evaluated as self-reported psychological and physical symptoms, self-perceived QoL, and depression) were assessed with validated quantitative questionnaires. The associations between QoL and the other factors were investigated with multivariate methods. RESULTS: Only a few factors differed between melanoma and breast cancer, in terms of treatment modalities and gender. The amount of received social support was higher among breast cancer patients. The predicting power of psychological stress factors on all the QoL measures was strong, but differed between the treatment groups (surgery only versus adjuvant treatment). Psychosocial factors were the strongest predictors of QoL, not cancer type or treatment. Behavioral Escape-Avoidance coping was associated with worse QoL. However, non-cancer life stresses showed the strongest QoL-decreasing influence. QoL-enhancing factors, including social support, were seen clearly only within the breast cancer patients receiving adjuvant treatment. CONCLUSIONS: QoL of newly diagnosed cancer patients is highly associated with psychosocial factors. Non-cancer life stresses seem to be very important in the QoL of newly diagnosed cancer patients. Adjuvant treatment may comprise supportive psychosocial factors that enhance QoL in cancer.     

Toremifene in the treatment of breast cancer

Although more widespread screening and routine adjuvant therapy has improved the outcome for breast cancer patients in recent years, there remains considerable scope for improving the efficacy, safety and tolerability of adjuvant therapy in the early stage disease and the treatment of advanced disease. Toremifene is a selective estrogen receptor modifier (SERM) that has been widely used for decades in hormone receptor positive breast cancer both in early and late stage disease. Its efficacy has been well established in nine prospective randomized phase III trials compared to tamoxifen involving more than 5500 patients, as well as in several large uncontrolled and non-randomized studies. Although most studies show therapeutic equivalence between the two SERMs, some show an advantage for toremifene. Several meta-analyses have also confirmed that the efficacy of toremifene is at least as good as that of tamoxifen. In terms of safety and tolerability toremifene is broadly similar to tamoxifen although there is some evidence that toremifene is less likely to cause uterine neoplasms, serious vascular events and it has a more positive effect on serum lipids than does tamoxifen. Toremifene is therefore effective and safe in the treatment of breast cancer. It provides not only a useful therapeutic alternative to tamoxifen, but may bring specific benefits.     

Anaemia: a rare but neglected problem among Finnish patients receiving chemotherapy for solid tumours

Goals of the work  

Anaemia is very frequently diagnosed among cancer patients. Use of erythropoietins has proved to be effective in reducing the need of transfusions and enhancing patients' quality of life, but may also have detrimental effects in treating nonanemic asymptomatic patients. We assessed the frequency of anaemia and the frequency with which it was diagnosed and treated in different types of solid tumours treated at outpatient chemotherapy policlinics.     

Influence of Body Mass Index and Smoking on the Long-Term Survival of Patients With Renal Cell Cancer

BackgroundSmoking and obesity are known risk factors for renal cell carcinoma (RCC). We determined the influence of smoking, body mass index (BMI), and symptoms on the survival of patients with RCC.Patients and MethodsIn this retrospective study, the relative overall survival (OS) up to 25 years was calculated among 948 Finnish patients with RCC diagnosed between 1964 and 1997 using a Bayesian univariate analysis and the life-table method.ResultsObese patients had better OS than did normal or underweight patients (median, 5.9 years, 3.4 years, and 12 months, respectively), with lower stage and more asymptomatic tumors at diagnosis and fewer relapses during surveillance. Clinical presentation of the tumor was a stronger prognostic factor than BMI; however, asymptomatic patients with a low BMI had poorer survival compared with normal or overweight patients. There was no difference in tumor stage or presentation at diagnosis between the nonsmokers and smokers; however, the smokers had more relapses with shorter disease-free intervals (DFIs) than did the nonsmokers. The OS was poorer in the smokers (4.2 years compared with 6.6 years in nonsmokers), but no difference was observed in cancer-specific survival (CSS).ConclusionOverweight patients have better survival, with more asymptomatic or local tumors. The clinical presentation was a stronger prognostic factor than BMI. Additionally, survival is poorer in smokers, even if there is no difference in tumor stage or symptoms.     

Factors affecting physicians' decisions to forgo life-sustaining treatments in terminal care

OBJECTIVES: Treatment decisions in ethically complex situations are known to depend on a physician's personal characteristics and medical experience. We sought to study variability in decisions to withdraw or withhold specific life-supporting treatments in terminal care and to evaluate the association between decisions and such background factors. DESIGN: Readiness to withdraw or withhold treatment options was studied using a terminal cancer patient scenario with alternatives. Physicians were asked about their attitudes, life values, experience, and training; sociodemographic data were also collected. SETTING: Finnish physicians, postal survey. SURVEY SAMPLE: Five hundred general practitioners, 300 surgeons, 300 internists, and 82 oncologists. RESULTS: Treatments most often forgone were blood transfusion (82%) and thrombosis prophylaxis (81%). Least willingly abandoned were intravenous (i.v.) hydration (29%) and supplementary oxygen (13%). Female doctors were less likely to discontinue thrombosis prophylaxis (p=0.022) and supplementary oxygen (p<0.001), but more readily x ray (p=0.039) and laboratory (p=0.057) examinations. Young doctors were more likely to continue antibiotics (p=0.025), thrombosis prophylaxis (p=0.006), supplementary oxygen (p=0.004) and laboratory tests (p=0.041). Oncologists comprised the specialty most ready to forgo all studied treatments except antibiotics and blood transfusion. The family's wishes (alternative 1) significantly increased treatment activity. Young and female practitioners and oncologists were most influenced by family appeal. Advance directives (alternative 2) made decisions significantly more reserved and uniform. Different factors in the physician's background were found to predict decisions to withdraw antibiotics or i.v. hydration. CONCLUSION: The considerable variation observed in doctors' decisions to forgo specific life-sustaining treatments (LST) was seen to depend on their personal background factors. Experience, supervision, and postgraduate education seemed to be associated with more reserved treatment decisions. To increase the objectivity of end of life decisions, training, and research are of prime significance in this ethically complex area of medicine.     

Chromosomal gains and losses detected by comparative genomic hybridization and proliferation activity in renal cell carcinoma

OBJECTIVE: The number of DNA losses found using comparative genomic hybridization (CGH) and the proliferation index MIB-1 have been shown to be prognostic factors in renal cell carcinoma (RCC). We evaluated the associations of these two factors with each other and with histopathology and clinical outcome. MATERIAL AND METHODS: In this prospective study, specimens from 20 primary RCCs were investigated using CGH and MIB-1 assay. The associations of the commonest chromosomal aberrations with histopathology, stage and the clinical outcome of the disease were evaluated. RESULTS: CGH detected genetic aberrations in all tumours. Losses of genetic material (85%) were more common than gains (65%). Most common was loss in the short arm of chromosome 3, which was found in 70% of the tumours. Other frequent changes (20%) were losses of 4q, 13q, 18 and Xp, as well as gains of 5q, 7p, 7q (25%) and chromosome 12. The number of deleted chromosomal areas varied from none to six. The MIB-1 index varied from 0 to 39 (median 4.0). The total number of chromosomal aberrations or deletions showed no association with MIB-1 index or nuclear grade. Most grade 1 and 2 tumours showed a low MIB-1 index. All nuclear grade 4 tumours progressed and were associated with short survival. CONCLUSION: CGH gives an overview of DNA changes in RCC and helps to locate targets for more precise genetic evaluation. CGH findings are also helpful for classifying tumours. In this study, genetic aberrations in primary RCCs were not associated with histopathology, proliferation or clinical outcome, which suggests that CGH does not necessarily give any additional information on the prognosis of the disease. MIB-1 index and TNM stage were associated with survival.     

Membranous location of EGFR immunostaining is associated with good prognosis in renal cell carcinoma

Epidermal growth factor receptor (EGFR) is a key factor in tumorigenesis. The association between EGFR expression and prognosis in renal cell carcinoma (RCC) is not clear. In our study of 134 RCCs, the cellular location of immunostaining was evaluated and patients with EGFR-positive tumours with prominent membranous staining had a good prognosis. Their overall survival was significantly longer (P=0.004) than that of patients with either EGFR-negative tumours or with mainly cytoplasmic staining. However, further studies on the different EGFR expression patterns in RCC are needed to clarify their role in the progression of the disease.     

Hormone-resistant metastatic prostate cancer. Comparisons between estramustine phosphate and low-dose epirubicin treatments.

We compared the effect and toxicity of estramustine phosphate and weekly low-dose epirubicin in a prospective randomized trial in 41 patients with metastatic prostate cancer refractory to hormonal manipulation. No significant difference between treatment modalities was seen. Palliation was reached in over 60% of patients. The median survival was 15 months in both groups. Toxicity was mild. Further, we investigated the effect of epirubicin after the failure of preceding estramustine phosphate therapy in additional 20 patients. Pain relief was achieved in 50% of these patients. The median survival was 10 months. Toxicity was acceptable.     

Palliative cancer care in two health centres and one hospice in Finland

This study evaluates palliative treatment of inpatient cancer patients in two health centres and in one hospice in Finland. Apart from outpatient clinics, health centres in Finland also have inpatient wards where patients are treated by GPs. The hospice provides a home-like environment for terminal patients, who are cared for by a specialist in internal medicine. Our patient population comprised 36 health centre patients and 36 hospice patients enrolled in 1998. A structured questionnaire was used containing information on diagnosis, duration of the illness, current medication, daily activities, and socioeconomic background. The nurses assessed their patients' emotional needs. We found that the two groups of patients were similar in terms of gender, marital status and social situation. The hospice patients were significantly younger (P < 0.05) and better educated than the health centre patients (P = 0.001), and their disease had lasted longer (P < 0.05). Upon admission, 12 (33%) of the hospice patients were using opioids, as were 6 patients (17%) in the health centre group. During the treatment period in the hospice the nurses reported more anxiety and depression in their patients (P < 0.05); staff in the health centres were more often unable to report on their patients' feelings. Hospice patients (20/35) were significantly (P < 0.001) more concerned about the wellbeing of their relatives than patients in the health centres (2/35). In the hospice 18 patients (50%) showed significantly (P < 0.001) more spiritual needs than health centre patients (4/34). We conclude that more education is needed to improve the awareness of the multidimensional needs of terminally ill cancer patients in primary health care.