Geographic variation in patient surveillance after colon cancer surgery.

PURPOSE: Considerable variation among surgeons exists in the current practice of patient surveillance after colon cancer treatment. We evaluated whether geographic factors are responsible for this observed variation. METHODS: Profiles of hypothetical patients and a detailed questionnaire based on the profiles were mailed to 2,733 members of two national surgical societies. The influence of the geographic location of the respondents on practice patterns were assessed in two ways. Repeated-measures analysis of variance was used to compare the practice patterns among 19 large metropolitan statistical areas (MSAs) and chi 2 analysis was used to determine whether these patterns differed by MSA population size. RESULTS: Seven of nine commonly used surveillance modalities were ordered significantly more frequently with increasing tumor-node-metastasis (TNM) stage and significantly less frequently with year postsurgery among the 995 respondents with assessable responses, but MSA population size and geographic location of physicians generally had no effect on documented practice variability. The remaining two modalities (bone scan and computed tomography [CT]) were used so infrequently as to preclude meaningful analysis. CONCLUSION: Surveillance after potentially curative colon cancer surgery for otherwise healthy patients is not significantly affected by the geographic location of the surgeon who performs the surveillance testing and only modestly affected by the population size of the MSA in which he/she practices. These data should help in the design of prospective trials of this topic.

A phase II evaluation of pentoxifylline combined with radiation in the treatment of brain metastases.

Pentoxifylline (PTX) has pharmacological properties that suggest potential utility as a radiation sensitizer, and preclinical animal studies have been promising. In a non-randomized phase II trial, we used PTX plus standard-dose external-beam whole-brain radiation treatment (WBRT) in patients with brain metastases. Seventeen patients were entered; 14 received both WBRT and PTX and were considered evaluable. Nine of the 14 completed treatment. Analyzing data on all 14 evaluable patients according to intent to treat, median survival time was 33 days, comparable to published data from historical controls. PTX toxicity was not a common cause of patient dropout, supporting higher PTX doses in future trials.

Cost of patient follow-up after potentially curative lung cancer treatment.

The two objectives of this study were to determine the range of recommended follow-up strategies for patients with lung cancer treated with curative intent and to estimate the cost of such follow-up. Ten articles delineating eight specific follow-up strategies were identified from a Medline search of the literature for 1980 through 1995. An economic analysis was done of the costs associated with the identified strategies. Charge data obtained from the Part B Medicare Annual Data file and the Hospital Outpatient Bill file were used as a proxy for cost. Follow-up intensity varied widely across strategies for 5 years of posttreatment follow-up. Medicare-allowed charges for 5-year follow-up ranged from a low of $946 to a high of $5645. When Medicare-allowed charges were converted to a proxy for actual charges by a conversion ratio of 1.62, the range was $1533 to $9145, a fivefold difference in charges. There was no indication that more intensive, higher-cost strategies increased survival or quality of life. The published literature, including textbooks, holds few answers in this area.

Cost of patient follow-up after potentially curative colorectal cancer treatment.

OBJECTIVE: To estimate the cost of follow-up among colorectal cancer patients treated with curative intent based on the broad spectrum of surveillance strategies suggested in the literature. DESIGN: Economic analysis of the costs associated with 11 separate surveillance strategies. Charge data were obtained from the Part B Medicare Annual Data file and the Hospital Outpatient Bill file. SETTING: Ambulatory care. MAIN OUTCOME MEASURES: Medicare-allowed charges and an actual-charge proxy for 5 years of follow-up after treatment for colorectal cancer patients on a nationwide basis. RESULTS: Medicare-allowed charges varied widely for the 5 years of posttreatment follow-up from a low of $561 to a high of $16,492. When Medicare-allowed charges were converted to a proxy for actual charges using a conversion ratio of 1.62, the range was $910 to $26,717, a 28-fold difference in charges. CONCLUSIONS: Charges vary extensively across follow-up strategies, with no indication that higher-cost strategies increase survival or quality of life.

Outcome of abdominal aortic aneurysm repair in patients with previous spinal cord injury in the Department of Veterans' Affairs hospitals.

A retrospective review was carried out to determine the morbidity and mortality of abdominal aortic aneurysm repair in patients with previous spinal cord injury. A population-based study utilizing computer records on all patients in Department of Veterans' Affairs medical centers from 1987-1991 identified 31 patients with spinal cord injury who underwent subsequent infrarenal abdominal aortic aneurysm repair. Additional information was obtained from individual medical records. Some twenty patients (65%) were paraplegics and 11 (35%) were quadriplegics. Aneurysms were most commonly discovered incidentally during work-up of other conditions. All patients had no symptoms referable to their abdominal aortic aneurysm. In total, 29 patients (94%) underwent elective operations. The complication rate (57%) involved mostly pulmonary, cutaneous or urinary tract morbidity. The 30-day mortality rate was 3% for elective abdominal aortic aneurysm repair. Two patients were operated upon as emergencies for rupture, with one operative death. Long-term follow-up revealed a median survival duration of 5.4 years after aneurysm repair. In conclusion, abdominal aortic aneurysm repair in patients with previous spinal cord injury has a low mortality rate. Postoperative complications are often related to spinal cord injury and are potentially preventable; thus, such injury should not preclude surgical intervention for abdominal aortic aneurysm.

Colorectal cancer in patients with previous spinal cord injury.

BACKGROUND: The optimum management of large-bowel cancer in patients with previous spinal cord injury (SCI) is uncertain. PURPOSE: The aim is to determine the outcome of patients with SCI who are undergoing colectomy or proctectomy for cancer. METHODS: A population-based study of patients receiving care at hospitals in the Department of Veterans Affairs system from 1987 to 1991 was performed. Patients with ICD-9 codes for SCI and colon and rectal cancer were identified. Patients with previous SCI who underwent colectomy or proctectomy for their cancer comprised the study population. Data were compiled from national computerized Veterans Affairs datasets, supplemented by individual operative reports and discharge summaries. RESULTS: Forty-four patients were evaluable. Mean age was 65 (range, 40-80) years, and mean time since SCI was 24 (range, 1-50) years. Mean follow-up was 4.6 years after resection. Distribution of tumors was 39 percent rightsided, 43 percent left-sided, and 18 percent rectal. All 32 patients with colonic tumors underwent resection; 26 of 32 patients (81 percent) had an anastomosis. Seven of eight (88 percent) rectal lesions were treated by abdominoperineal resection. Twenty-six of 44 patients (59 percent) presented with Stage III or IV disease. Twelve of 44 (27 percent) died, 8 of 12 from cancer. Overall 30-day mortality rate was 4.5 percent (2/44). In-hospital morbidity rate (pulmonary, cutaneous, and urinary tract only) was 34 percent. Among those who received postoperative chemotherapy, 80 percent completed treatment. CONCLUSIONS: Patients with previous SCI tolerate resection well. Tumor distribution and stage are similar to those of neurally intact patients. Morbidity is commonly related to pre-existing complications of SCI. Adjuvant therapy is well tolerated.

Post-treatment management options for patients with lung cancer.

OBJECTIVES: The first objective was to identify variations in patient management practice patterns after potentially curative lung cancer surgery. Patient management practice patterns were expected to range from intensive follow-up to no active surveillance. The second objective was to measure whether intensity of follow-up was related to patient outcomes. METHODS: An 18-month retrospective analysis was conducted of 182 patients with low TNM stage (< or = IIIA) lung cancer who were surgically treated with curative intent over the 11-year period from 1982 through 1992 at the St. Louis Department of Veterans Affairs Medical Center. RESULTS: Patients were followed for a mean of 3.3 years, until death or the end of the study. Analyses of diagnostic test and outpatient visit frequency distributions and cluster analyses facilitated the identification of 62 nonintensively followed patients and 120 intensively followed patients. Both groups were comparable at baseline, and there were no significant differences in patient outcomes attributable to intensity of follow-up. Intensively followed patients did, however, live an average of 192 days longer than nonintensively followed patients. CONCLUSIONS: Significant variations in follow-up practice patterns can exist within a single health care facility. In this analysis, variations in test and visit frequency did not result in statistically significant differences in patient outcomes, though the survival difference between groups suggests that some benefit might exist. Only well-designed prospective trials are likely to answer the question of what constitutes optimal follow-up after potentially curative lung cancer treatment.