tbuckley/cabot-search huggingface dataset:
Rethinking Consultants: Specialists in the United States: what lessons?
Authors: J. Roberts
Journal: BMJ (1995)

Several pressures are forcing a rethink of the way that consultants in Britain work. Perhaps the most acute pressures come from the current moves to reduce junior doctors' working hours and the Calman proposals for more structured and shorter specialty training programmes. Together these will mean fewer juniors available to do service work within the NHS and a greater load on the consultants who have to teach them. But patients and purchasers are also demanding that more clinical work should be done by fully trained doctors, not trainees, and the requirements of the new NHS require consultants to take part in auditing, contracting, and managing the service. Last week (11 March, p 673) the BMA council heard consultants' anxieties that the numbers of consultants were not growing in line with the demands of the Calman implementation plan. There is a feeling that something will have to give, and the BMA fears the proliferation of subconsultant grades (staff who are not trainees but do not have full clinical autonomy) to fill the growing gap between the work to be done and doctors available to do it. Also, on 6 April the Central Consultants and Specialists Committee of the BMA is holding a conference to discuss consultants' career development in the face of these changes.

We have commissioned four articles to contribute to this debate about how consultants should organise themselves and their work in future. In the first of these our North American editor, John Roberts, outlines the effect of similar pressures on the way that specialists in the United States organise their work, and how their working practices are changing.

The American specialist and the British consultant travel separate but often parallel roads. Both have recently been buffeted by the same storms: privatisation and competition; demands for account-ability; problems of …
Chemotherapy plus concomitant low-dose fractionated radiotherapy as second-line treatment for recurrent or progressive glioblastoma after temozolomide-based chemoradiation: A pilot study.
Authors: G. R. D'Agostino, B. Diletto, S. Manfrida, A. Mangiola, S. Chiesa, L. De Filippo, V. Frascino, F. Micciche', C. Anile, M. Balducci
Journal: Journal of Clinical Oncology (2011)

2083 Background: Second-line treatment in recurrent or progressive glioblastoma (GBM) has not yet been defined. Since in vitro and preclinical studies demonstrated a hyper-radiosensitivity of human malignant glioma cell lines to low doses fractionated radiotherapy (LD-FRT) and a synergism with chemotherapy, we performed a pilot study to evaluate the feasibility and efficacy of this approach. Methods: Eligibility criteria were: radiological diagnosis of recurrent or progressive GBM, previously treated by surgical resection followed by 3D-CRT (total dose 59,4 Gy) plus concomitant and adjuvant TMZ. Patients with recurrent or progressive disease during adjuvant TMZ received 30 cGy twice a day on days 1-2,8-9,15-16, q42, concurrently with fotemustine (40 mg/m2 on days 1, 8, 15) and cisplatin (30 mg/m2 on days 2, 9, 16), whereas in patients with recurrent/progressive disease occurring more than 6 months after the end of adjuvant TMZ a re-challenge with TMZ (150/200 mg/m2) concurrently with LD-FRT (40 cGy twice a day, over consecutive 5 days, q28) was attempted. Primary endpoints were toxicity (RTOG criteria) and efficacy (RECIST criteria); Progression Free Survival (PFS) and Overall Survival (OS) were also evaluated. Results: From February 2008 to January 2011, 20 patients were enrolled. The median total dose of LD-FRT was 760 cGy (range, 240-1200). The associated chemotherapy was based on cisplatin and fotemustine in 7 patients and on TMZ in 13 patients. Hematologic toxicity was mild, with a G3-4 (leucopenia) observed in 5% of patients; no treatment related death was observed. One out of 20 patients (5%) had a complete response, 1 patient (5%) experienced a partial response (PR), while 5 patients (25%) had a stable disease (SD) lasting at least 8 weeks (Clinical Benefit 35%). The median PFS and OS from relapse were 5 and 7 months, respectively; survival rate at 6 months was 58.7 % with an OS at 1 year of 26.7 %. No differences were observed between the two schedules of chemotherapy. Conclusions: These data suggest that chemotherapy plus LD-FRT as second-line treatment is safe and well tolerated, encouraging the prosecution of the study.
Outcomes following sublobar resection for early-stage non-small cell lung cancer (NSCLC) with or without adjuvant external beam radiation therapy (XRT): A population-based study
Authors: J. Rineer, E. Katsoulakis, D. Schreiber, A. Young, T. Nabhani, P. Han, K. Choi, M. Rotman
Journal: Journal of Clinical Oncology (2008)

7540 Background: Patients undergoing sublobar resection for early stage NSCLC may receive XRT in an effort to improve outcomes despite limited data regarding its efficacy. Methods: Using the Surveillance, Epidemiology and End-Results (SEER) registry we identified patients diagnosed with stage T1–2N0M0 NSCLC between 1988–2003 who were definitively treated with sublobar surgical resection. Patients who refused radiation therapy, received radiation therapy other than XRT, or were coded as unknown regarding radiation treatment were excluded. Kaplan-Meier analysis was performed to compare overall survival (OS) and cause-specific survival (CSS) for patients receiving XRT versus no additional local-regional therapy. Multivariate Cox regression analysis was performed to evaluate the effect of XRT controlling for other covariables. Results: 5,908 eligible patients were identified. 493 received XRT and 5,415 received no additional local-regional treatment. The use of XRT was associated with significantly worse OS and CSS compared with no additional local-regional therapy: 31 and 45 months versus 51 and 98 months, respectively (p<0.001). One, three and five year OS estimates were 78.5%, 43.5%, and 24.5% versus 87.1%, 61.3%, and 43.7%, respectively. On multivariate analysis, the most significant predictor of death was the use of XRT (hazard ratio 1.505, 95% confidence interval 1.318–1.717, p<0.001). Conclusions: The use of adjuvant XRT is associated with a significant decrease in OS and CSS for patients with T1–2N0M0 NSCLC treated with sublobar resection. This may be related to covariables not reported in SEER such as margin status, chemotherapy use, radiation dose and XRT portal. Despite these uncertainties, every effort should be made to avoid combination therapy including XRT in patients not fit for anatomic resection. Alternative treatments such as surgery with wide margins alone, surgery with brachytherapy, or conformal XRT alone should be explored. No significant financial relationships to disclose.
IVR-based cancer symptom assessment: Nurses' expectations and perceived barriers
Authors: D. E. Theobald, D. Butler, J. Coburn, S. Edgerton, W. M. Dugan, C. S. Cleeland
Journal: Journal of Clinical Oncology (2004)

6135 Background: Continuous multi-symptom assessment in cancer care was recommended in a recent NIH consensus statement. We tried pencil-and-paper screening but clinic was slowed, some patients could not complete surveys, paper symptom reports could not be analyzed quickly or charted for provider use, assessments could only be done at visits, symptom trends could not be easily tracked, and creating longitudinal databases was laborious and expensive. We asked nurses to help test an interactive voice response (IVR) system to automate symptom self-reporting using touch-tone telephones to complete the M.D. Anderson Symptom Inventory. Nursing support is critical to its integration into clinic workflows. Method: We first presented the system to 30 oncology nurses via a lecture to assess impressions of its potential value and to identify barriers. Anonymous surveys were collected. The same nurses used the IVR-based symptom in a patient role. Computer-automated calls were generated to their home, work, or cell phone; each nurse placed calls to the IVR. We then asked them to evaluate the IVR system for use in their practices, and to gauge usability by patients. Anonymous responses were gathered and tabulated. Results: Pre-test expectations included better patient care, ease of gathering data, increased patient involvement in care, more honest reporting, and a “we care” message. A frequent pre-test barrier anticipated was elderly patients' inability to use the system. Other barriers were increased staff time to monitor the system, need for interventions for symptoms, and the impersonal nature of the IVR. In post-test findings, after using the IVR themselves, 70% of nurses felt that communication would be improved, and 68% reported that patients who need additional help could be identified. Seventy percent felt the care process would be improved. Some perceived post-test barriers remained: 1) concerns that elderly patients may not understand, and 2) concerns about staff time needed to use the system. Conclusion: Survey responses were sufficiently positive after nurses' experience with the system that further attempts at integrating the process into the clinic workflow are warranted. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Interactive Performance Technologies Interactive Performance Technologies Interactive Performance Technologies
&lt;italic&gt;Brief Communication:&lt;/italic&gt; In Vivo and In Vitro Tests of Inhibitory Effect of Progesterone on Cell-Mediated Immunity in Rats Bearing a Syngeneic Uterine Adenocarcinoma
Authors: S Sekiya, M Kamiyama, H Takamizawa
Journal: JNCI Journal of the National Cancer Institute (1975)

Growth inhibition or stimulation of target adenocarcinoma cells in rats sensitized with spleen cells from syngeneic tumor-bearing rats was significantly suppressed in colony inhibition assays when the spleen cells were treated in vitro with 0.8 mug progesterone or more/ml medium. In addition, when tumor-bearing rats were treated with 1 mg medroxyprogesterone acetate weekly in vivo, the inhibiting action of the spleen cells from rats with regressed tumors was also suppressed. Progesterone thus suppressed immune spleen cells in vivo and in vitro.
Abstract 18387: Compliance With Chronic Coronary Artery Disease Secondary Prevention Guidelines in the USA
Authors: Francisco Lopez-Jimenez, Victoria Zysek, Veronique Roger, Virend Somers, Juliette Liesinger, Henry Ting, Randal Thomas, Ondrej Sochor
Journal: Circulation (2013)

Objectives: To assess compliance with chronic coronary artery disease (CAD) secondary prevention guidelines in the USA, to determine time trends, and to identify potential sociodemographic predictors of low compliance. Design, Setting and Participants: We analyzed the National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2010, representative of non-institutionalized civilian population in the USA. We included people with self-reported previous diagnosis of CAD, angina or myocardial infarction (MI). Primary Outcome: Adherence to secondary prevention guidelines including blood pressure control, lipid control, not smoking, normal body mass index, physical activity at goal, and meeting all 5 outcomes (“all-or-none”). Use of antiplatelet therapy was reported and analyzed from 1999-2004. Secondary Outcome: Use of beta-blocker therapy in people with history of MI; in diabetes (DM), use of ACE-inhibitors or angiotensin receptor blocker, and HgbA1C &lt;7%. Age, gender, race, income, education and insurance status were evaluated as covariates. Analyses were weighed according to Center for Disease Control guidelines. Results: There were 62,160 individuals in the cycle data of which 2,615 comprised the study group, representative of 73,574,548 individuals in the USA. Mean age was 65 yr, 58% men, 79% white. Only 2.8% of people with CAD met all 5 main outcomes. Only blood pressure and LDL control showed significant improvement over time, see Figure. Antiplatelet therapy was reported in 58.2%. Of those with history of MI, only 50.5% were on a beta-blocker and of those with history of DM, 59.4% were using either an ACE-I or an ARB; and 54% had a HgbA1C less than 7%. When adjusting for demographics, no significant differences were found regarding compliance with all 5 main outcomes. Conclusions: Adherence to guidelines for secondary prevention of CAD is suboptimal. There is an immense opportunity for improvement in secondary prevention for CAD in the USA.
BRCA1 status, molecular markers, clinical variables in breast cancer patients with high probability of having an inherited genetic mutation
Authors: A. Musolino, M. A. Bella, M. Michiara, P. Zanelli, N. Naldi, B. Bortesi, M. Capelletti, N. Bandini, R. Camisa, V. Franciosi
Journal: Journal of Clinical Oncology (2004)

9648 Background: to evaluate the clinical features and outcomes of Breast Cancer (BC) patients with genetic susceptibility to this disease and to investigate the contribution of BRCA1 germline mutation to the phenotype of these tumors. Methods: we reviewed clinical and pathological records of 144 women with autosomal dominant inheritance of breast (+/- ovarian) cancer risk. All women underwent full genetic counseling. Of these, 101 selected patients with high probability of having a germ-line mutation were tested for BRCA1 mutation analysis. Exon 11 was screened for BRCA1 mutations using Protein Truncation Test; mutations detected were confirmed by Direct Sequencing. All the other exons were analyzed by DS. Results: the two different risk groups had similar clinical outcomes. Of the 57 patients with completed mutation analysis, 44 (77%) patients had wild type BRCA1, 8 (14%) had variants of unclear significance, 5 (8%) had deleterious mutations in BRCA1. With regard to entry criteria for BRCA1 genetic testing, mutations were detected in 5% (1/20), 2,5% (1/41), 16% (2/12) and 16% (1/6) of women with family history, early onset BC (< 40 years), Breast-Ovarian Cancer (BOC) and early onset plus Bilateral Breast Cancer, respectively. BRCA1 Associated Breast Cancers (BABC) were more likely to have histological grade 3 and high proliferation rate than negative cases (40% v 27%; 60% v 45%). These differences were not statistically significant. BABC were significantly more likely to be estrogen receptor-negative (67% v 16%, P = .04). Though not significant, all valuable tumors with BRCA1 mutations were HER-2/neu negative. In the entire cohort, there were no significant differences between BABC and non-BABC in 5 year relapse free survival (60% v 78%, P = not significant [NS]), 5 year event free survival (60% v 66%, P = NS), or 5 year overall survival. Conclusions: BABC seem to present with adverse molecular and histopathologic features when compared with cases not associated with BRCA1 mutations. However, the prognosis of BABC appears to be similar to that of non associated cancer. No significant financial relationships to disclose.
Safety and efficacy of gefitinib monotherapy for patients (pts) ≥80 years (yrs) with advanced non-small cell lung cancer (NSCLC): A phase II subset analysis
Authors: N. Ebi, H. Semba, S. Tokunaga, K. Takayama, H. Wataya, T. Kuraki, H. Yamamoto, S. Akamine, I. Okamoto, Y. Nakanishi
Journal: Journal of Clinical Oncology (2009)

e19059 Background: Lung cancer is a disease of the elderly with median age at diagnosis of 70 yrs. The very elderly pts (age ≥80 yrs) with advanced NSCLC have not been well studied, even though this proportion is increasing over coming years. There are no data to evaluate the safety and efficacy of gefitinib treatment for pts ≥80 yrs with advanced NSCLC. Methods: We reported the phase II trial of gefitinib monotherapy in chemotherapy-naïve pts of 75 yrs or older with advanced NSCLC (J Thorac Oncol. 2008;3: 1166–1171). We analyzed data for pts ≥80 yrs, comparing with those &lt;80 yrs in our trial. Results: A total of 28 pts were 80 yrs old and over in our trial. Patient characteristics: male/female = 12/16, median age = 82 (range 80–90), ECOG PS 0/1/2=7/13/8, stage IB/IIIA/IV=1/3/24, and adenocarcinoma (Ad)/non-Ad= 22/6. Five pts achieved partial response. The response rate was 18% (CI 95%, 6–39). The disease control rate was 50%. Median survival time was 9 months and 1-year survival rate was 39%. The most frequent adverse events were skin disorders (86%). Nine pts (32%) experienced toxicities ≥grade 3. There were two pts with possible interstitial lung disease including one treatment-related death. Tumor samples from 10 pts were analyzed for EGFR mutation status. EGFR mutations were detected in tumor tissues from 5 pts, of which 3 had partial responses (60%). Table shows the difference between the pts ≥80 yrs and those &lt;80 yrs. Conclusions: Gefitinib monotherapy is effective and relatively well tolerated for pts ≥80 yrs with advanced NSCLC. Gefitinib has potential as a first-line therapeutic option even if elderly pts are more than 80 yrs old. [Table: see text] No significant financial relationships to disclose.
Mental healthcare is biggest NHS worry for the public
Authors: Adrian O’Dowd
Journal: BMJ (2016)

Access to and the quality of mental health services in England are the biggest concerns for the public, indicates research carried out by Healthwatch England.

General practices could do more in this area by offering in-house counselling services and ensuring that practice staff were trained to recognise mental health problems early, it said.

Healthwatch England, the national consumer champion in health and care, released findings of its annual survey of health and care priorities on 31 December.1 It gathered responses from all of its 152 local branches for the survey and …
Cisplatin-etoposide combination in adjuvant therapy for non-small cell lung cancer: A Brazilian experience.
Authors: L. B. França, M. A. Oliveira, I. A. Small, M. Zukin, L. H. de Lima Araujo
Journal: Journal of Clinical Oncology (2011)

e17530 Background: Adjuvant chemotherapy is generally recommended in most patients with resected non–small cell lung cancer (NSCLC), with some restrictions according to tumor stage and size. However, different cisplatin-doublets were used in phase III trials, and the best choice remains unclear. The purpose of this study is to describe the Brazilian National Cancer Institute (INCA) experience with the cisplatin-etoposide (Cis-Vp) combination in this situation, with special interest to survival data. Methods: We retrospectively evaluated the medical charts of patients receiving adjuvant treatment for NSCLC at INCA between 2004 and 2008. The primary outcome was overall survival (OS) and prognostic factors were analyzed using log-rank. Results: Fifty-one patients were included, all treated with Cis-Vp. Median age was 61 years (40-76), and 53% were female. Adenocarcinoma was the most frequently reported histological subtype (57%), while squamous cell carcinoma was detected in 33%. Forty percent of patients were diagnosed with pathologic stage I, 33% with stage II, and 27% with stage III. Lobectomy was the predominant surgical procedure (80%), whereas pneumectomy was performed in 14%, and bilobectomy in 6%. The median number of cycles was 4 (1-4). Fifty-nine percent of patients received 80 mg/m2 of cisplatin and 76% received 300 mg/m2 of etoposide at the first cycle. Eleven patients (22%) were also treated with adjuvant radiation therapy. After 31 months median follow-up, the median OS was 57 months. In the univariate analysis, survival was inferior in advanced stage (III vs. I-II; median 34 vs. 57 months, respectively; p=0.22) and after RT (median 19 vs. 57 months; p<0.001). No difference was detected for OS according to gender (p = 0.70), histology (p = 0.33), or platinum dose (p = 0.13). Conclusions: The outcomes described in our institution are in line with those reported in the early IALT study publication, in which 57% of patients received Cis-Vp. Nevertheless, recent data suggest more consistent results with cisplatin in combination with novel-generation agent vinorelbine, especially after long-term follow-up. These data support the need for long follow-up in the adjuvancy.
Ontario Cancer Research Ethics Board (OCREB): A central research ethics board initiative
Authors: S. F. Dent, R. Saginur, S. Stacey, R. Heslegrave, B. Zanke
Journal: Journal of Clinical Oncology (2004)

6094 Background: Research ethics review of clinical trials is conventionally done at the local institutional level, requiring multiple local research ethics boards (LREB's) to conduct reviews of the same protocol. Centralized ethics review offers potential efficiency, quality and consistency of review for clinical trials, however, it may limit LREB authority. Previous attempts at centralization have been unsuccessful or of limited generalizability (NCI-central institutional review board). We proposed a centralized research ethics board (REB) for multi-centre trials in Ontario. The goal was to create a REB that would reduce the workload of LREB's, increase the quality and uniformity of reviews, and simplify the initiation of multi-centre trials. Methods: With support from the Ontario cancer research network (OCRN) (funded from the Ministry of Economic Development and Trade) meetings were convened in June, 2002 and May, 2003 of representatives (1 REB and 1 clinical investigator) from 10 cancer centres in Ontario, in an attempt to achieve consensus for this concept. The proceedings from these meetings were distilled into a business plan for an Ontario cancer research ethics board (OCREB). OCREB will provide full REB reviews, the results of which will be distributed to LREB's via the OCRN website. LREB's will have the option of conducting a facilitated review which will focus on local concerns and will not require a meeting of the full REB. Secondly, cancer centres and community hospitals are able to use OCREB as their official board of record for multi-centre cancer studies, including all amendments, adverse events, and continuing reviews. An evaluation framework to monitor the effectiveness of OCREB is under development. Results: An Executive Director, a Chair, and a Vice-Chair have been appointed. OCREB members from around the province (including community representation) have been selected and the first meeting was held in December, 2003. Updated information, including the number of clinical trials reviewed and the time to approval will be presented at the meeting. Conclusions: A regional REB was established using a highly consultative approach. No significant financial relationships to disclose.
Adjuvant adriamycin and cisplatin in newly diagnosed, nonmetastatic osteosarcoma of the extremity.
Authors: L J Ettinger, H O Douglass, E R Mindell, L F Sinks, C K Tebbi, D Risseeuw, A I Freeman
Journal: Journal of Clinical Oncology (1986)

Twenty-two patients with newly diagnosed nonmetastatic osteosarcoma of the extremity were treated with an adjuvant chemotherapeutic regimen consisting of Adriamycin (Adria Laboratories, Columbus, Ohio) and cisplatin. Fourteen of the 22 patients remain continuously disease free for 65+ to 113+ months, with a median time on study of 70+ months. The 72-month disease-free survival estimate is 64%. Pulmonary metastases occurred in six patients, an isolated stump recurrence was seen in one patient, and one patient had a local recurrence following a limb-salvage procedure. For those patients in whom pulmonary metastases developed, the onset was late in three of six, and the number of metastases was three or fewer in all patients. Two patients with pulmonary metastases and one with a stump recurrence have apparently been salvaged, thus resulting in a 77% 72-month survival. Toxicity observed in patients treated with this regimen was in keeping with previous reports. This chemotherapeutic regimen is effective in the adjuvant therapy of nonmetastatic osteosarcoma of the extremity. It should be incorporated into other adjuvant protocols in an effort to continue to improve the outcome in patients with osteosarcoma.