M.H.N. Tattersall

On the receiving end—patient perception of the side-effects of cancer chemotherapy

We conducted a survey to identify and rank side-effects perceived by 99 patients receiving cancer chemotherapy. Non-physical side-effects constituted 54% of the 15 most severe symptoms, and included the thought of coming for treatment, the length of time taken by treatment and having to have a needle. Major physical side-effects were vomiting, nausea and hair loss. Differences in ranking of severity of side-effects were evident when patient groups were divided by sex, age, marital status and domestic situation, as well as by diagnosis, treatment and response. Evaluation of patient perception of the severity of side-effects is an aid to striking the cost benefit balance when deciding whether to use cancer chemotherapy.

On the receiving end—II. Linear analogue self-assessment (LASA) in evaluation of aspects of the quality of life of cancer patients receiving therapy

Linear analogue self-assessment (LASA) scales were used to measure general well-being and specific factors (mood, pain, nausea and vomiting, appetite, breathlessness, physical activity) in patients receiving therapy for malignant melanoma, small cell bronchogenic carcinoma (SCBC) or ovarian cancer. Among the patients with SCBC and melanoma, high correlations were observed between LASA scores for general well-being, mood and appetite. There was a significant relationship between performance status and LASA scores for general well-being, pain and appetite. Among patients with ovarian cancer, there was a significant association between performance status and LASA scores for general well-being, breathlessness and physical activity. Objective response category was related to change in LASA scores for pain. Changes in LASA scores during treatment reflected increased morbidity during radiotherapy in patients also receiving chemotherapy for SCBC. The LASA technique provides a convenient method for the assessment of quality of life in patients receiving cancer therapy, and potentially allows comparison of patient perception of treatment-related morbidities.

Flow cytometric analysis of cellular DNA content as an adjunct to the diagnosis of ovarian tumours of borderline malignancy

Summary Flow cytometric analysis of cellular DNA content was performed on tissue from 44 borderline ovarian tumours (tumours of low malignant potential). Forty‐two tumours (95%) were diploid and associated with both an indolent biological behaviour and good prognosis. Aneuploidy was identified in only 2 tumours (5%), and one of the associated patients died of progressive disease within months of the initial diagnosis. Careful review of the histopathology of these 2 aneuploid tumours revealed areas of invasion in the omental and peritoneal “implants” of each. This study has reinforced the currently advocated separation of so‐called borderline tumours from invasive ovarian carcinomas and the interpretation of the pathological criteria used to categorize such neoplasms. Our results indicate that flow cytometric analysis of cellular DNA content may complement conventional histopathological diagnosis by providing an objective parameter which correlates with biological behaviour and may identify the few genuine borderline ovarian epithelial neoplasms which show clinical progression.

UNDIFFERENTIATED CARCINOMA IN YOUNG MEN: THE ATYPICAL TERATOMA SYNDROME

In 5 young men with apparent undifferentiated carcinoma involving lung, mediastinum, and lymph-nodes subsequent response to treatment, tumour-marker analysis, and histology review suggested a diagnosis of embryonal-cell carcinoma. It is suggested that atypical presentation of extragonadal germ-cell tumours may be common. Because such tumours respond to chemotherapy, accurate diagnosis is essential.

Extraskeletal Ewing's sarcoma: A clinical, morphological and ultrastructural analysis of five cases with a review of the literature

In 1969 it was recognised that tumors with light microscopic appearances indistinguishable from Ewings sarcoma of bone may arise in extraskeletal sites (extraskeletal Ewings sarcoma). Here, we review the available literature and report five new cases. All five received combined modality therapy with combination chemotherapy and radiotherapy to the primary site followed by surgical excision in two. All attained complete remission; after a median follow-up of 26 months, three remain disease-free but two have relapsed and died. Our experience, in accord with previous series, suggests that extraskeletal Ewings sarcoma compared with its bony counterpart tends to occur in older subjects, has a similar incidence in males and females, usually presents with a painless mass and readily responds to combined modality therapy. We detected no light or electron microscopic features to denote a histogenetic origin. However, we suspect extraskeletal Ewings sarcoma may occur more frequently than previously supposed.

THYMIDINE SENSITIVITY OF CULTURED LEUKÆMIC LYMPHOCYTES

Cultured leukaemic lymphocytes from patients with T, null, or pre-B acute lymphoblastic leukaemia are shown to be highly sensitive to growth inhibition by thymidine. Thymidine sensitivity was correlated with reduced activity of the catabolic enzyme thymidine phosphorylase and sustained elevation of the deoxythymidine triphosphate pool after exposure to thymidine. It is suggested that thymidine may have a role in the management of certain acute lymphoblastic leukaemias of lymphomas.

Counting the costs of cancer therapy

The costs of cancer treatment were estimated for five groups of cancer patients: those with operable breast cancer receiving adjuvant chemotherapy and patients with advanced breast cancer, ovarian cancer, germ cell cancer and small cell lung cancer. Cancer treatment costs were substantial but chemotherapy cost was a relatively minor item. Methods of limiting treatment costs are identified as reducing hospital stay, encouraging outpatient administration of chemotherapy and limiting the number of supernumary investigations. The cost of different cancer treatment options should be considered when management decisions are made.

Undergraduate education about cancer: a survey in Australian medical schools

The goals of undergraduate medical education are to provide a core of basic knowledge, and a framework to permit further development of that knowledge. The structure of teaching and experience in cancer medicine should reflect the increasing importance of cancer in the community. Undergraduate teaching of oncology and its scientific bases is currently fragmented, and in some cases may be deficient. Until now, there have few analyses of what is being taught about cancer at different medical schools. We have undertaken a survey of final year medical students or recently qualified doctors in Australia enquiring about their cancer education. The results indicated that substantial differences existed between the medical schools, and we therefore surveyed the teaching faculty in the schools to determine their view of the validity of the questions we used. Together these surveys showed that significant disparities existed between what the faculty felt should be taught and what students had actually experienced.

Chemotherapy of advanced colorectal cancer. A randomized trial of sequential methotrexate and 5-fluorouracil.

Fifty-five patients with advanced colorectal cancer were entered into a randomized controlled clinical trial to evaluate order of administration and sequential methotrexate (MTX) and 5-fluorouracil (5-FU) therapy. Patients were randomized to receive either MTX, 250 mg/m2, followed 1 h later by 5-FU, 600 mg/m2, or 5-FU followed 1 h later by MTX in the same doses. Fifty-four patients were evaluable for response, of whom 15 (28%) achieved objective partial tumor response. There were no significant differences between the two sequences in response rate, time to treatment failure, or survival duration. The results of this study do not indicate a clinically significant difference between the two sequences tested, in which MTX preceded or followed 5-FU by 1 h. Determination of the value of these drugs given sequentially at longer intervals must await appropriate controlled trials.

DOING THE BEST FOR THE CANCER PATIENT

An overview is presented of special dilemmas facing the cancer clinician as a result of changes in the nature of cancer care, such as the trends toward multidisciplinary cancer management and toward involving patients in treatment decisions. The desire to introduce experimental treatments may conflict with the welfare of the patient. Informed consent documents are often barely comprehensible and are frequently geared toward legal considerations. A patient needs a reasonable understanding of treatment goals in order to make decisions regarding quantity and quality of survival. Priorities for allocating limited resources must be evaluated, with careful consideration being given to the diverting of funds from unsuccessful therapies to disease prevention.