Early Integration of Palliative Care in Oncology Practice: Results of the Italian Association of Medical Oncology (AIOM) Survey.

BACKGROUND: Early integration of palliative care in oncology practice ("simultaneous care", SC) has been shown to provide better care resulting in improved quality-of-life and also survival. We evaluated the opinions of Italian Association of Medical Oncology (AIOM) members. PATIENTS AND METHODS: A 37-item questionnaire was delivered to 1119 AIOM members. Main areas covered were: social, ethical, relational aspects of disease and communication, training, research, organizational and management models in SC. Three open questions explored the definition of Quality of Life, Medical Oncologist and Palliative Care. RESULTS: Four hundred and forty-nine (40.1%) medical oncologists returned the questionnaires. Forty-nine percent stated they address non-curability when giving a diagnosis of metastatic tumor, and 43% give the information only to patients who clearly ask for it. Fifty-five percent say the main formative activity in palliative medicine came from attending meetings and 90% agree that specific palliative care training should be part of the core curriculum in oncology. Twenty-two percent stated they consulted guidelines for symptom management, 45% relied upon personal experience and 26% make a referral to a palliative care specialist. Seventy-four percent were in favor of more research in palliative medicine. An integration between Units of Oncology and Palliative Care Services early in the course of advanced disease was advocated by 86%. Diverse and multifaceted definitions were given for the concepts of Quality of Life, Palliative Care and Medical Oncologist. CONCLUSION: SC is felt as an important task, as well as training of medical oncologists in symptom management and research in this field.

Colon cancer.

Colon cancer is one of the leading tumours in the world and it is considered among the big killers, together with lung, prostate and breast cancer. In the recent years very important advances occurred in the field of treatment of this frequent disease: adjuvant chemotherapy was demonstrated to be effective, chiefly in stage III patients, and surgery was optimized in order to achieve the best results with a low morbidity. Several new target-oriented drugs are under evaluation and some of them (cetuximab and bevacizumab) have already exhibited a good activity/efficacy, mainly in combination with chemotherapy. The development of updated recommendations for the best management of these patients is crucial in order to obtain the best results, not only in clinical research but also in every-day practice. This report summarizes the most important achievements in this field and provides the readers useful suggestions for their professional practice.

Colorectal cancer treatment in elderly patients: an update on recent clinical studies.

Colorectal cancer (CRC) is one of the most common cancers in the Western world, with > 500,000 new cases diagnosed each year. One of the strongest risk factors for colon cancer is age. Physicians and their older patients commonly face the dilemma of whether to give/receive systemic chemotherapy for CRC. Evidence supports similar survival benefits with adjuvant and palliative chemotherapy in elderly patients compared with younger age groups. Data on treatment- related side effects did not reveal a different toxicity profile for elderly patients. The safety and efficacy of systemic chemotherapy in fit older patients were proven, and this group of patients could be enrolled in clinical trials. Conversely, frail older patients are more likely to suffer adverse outcomes when faced with stressors and might not benefit from chemotherapy. Despite a growing body of data, a great deal of work is still needed to establish optimal strategies to care for patients diagnosed with cancer later in life. There is a paucity of reports published in the literature because of the difficulty in routinely collecting such data. We report an overview of recent studies (clinical trials, pooled analysis, and population studies) to provide more information and to identify new and better treatment options.

Transcervical endometrial resection in women with menorrhagia: long-term follow-up.

OBJECTIVE: Hysteroscopic endometrial resection is an innovative and conservative surgical technique considered, very often, as an alternative to hysterectomy. The aim of the study was to evaluate long-term efficacy of endometrial resection performed in women with menorrhagia. STUDY DESIGN: Retrospective study of 111 premenopausal women with menorrhagia, unresponsive to medical treatment, who underwent endometrial resection by resectohysteroscope (electrocautery technique supplied with a fundus rollerball electrode, with corneal areas, and with a 90 degrees loop for intrauterine walls and used with glycine 1% as distending fluid) between 1994 and 1999. RESULTS: Long-term follow-up questionnaires were completed in 106 cases, while 5 cases dropped-out (4.5%). The mean-age at menopause in our subjects was 52.8 years (17.6+/-18.4 months after operation). After 53.2+/-16.4 months, 82 patients (77.4%) showed a normal menstrual pattern or amenorrhea, while failure was recorded in 24 patients (22.6%) and 12/24 patients underwent hysterectomy. Percentage of success in the older population (>49 years) (94%) was significantly higher than in the younger population (70%). The histologic finding of only fibrosis (41.7%) correlated with failure of the technique. CONCLUSION: Our data suggest that endometrial resection by resectohysteroscope is an innovative and conservative but not exclusive surgical technique in selected younger women, while in older women endometrial resection nearly always resolves long-term menorrhagia.

Role of hysteroscopy with endometrial biopsy to rule out endometrial cancer in postmenopausal women with abnormal uterine bleeding.

OBJECTIVE: To compare the diagnostic accuracy of ultrasonographic endometrial thickness and outpatient hysteroscopy, to establish the most appropriate exam for the diagnosis of endometrial cancer in postmenopausal women with abnormal uterine bleeding (AUB). The secondary aim was to develop a multivariable approach considering clinical history as an added value for these diagnostic procedures. METHODS: This prospective study was conducted on 220 consecutive postmenopausal patients with AUB, who underwent ultrasonographic evaluation of endometrial thickness, outpatient hysteroscopy and endometrial biopsy. Evaluation of sensitivity, specificity, positive and negative predictive value was performed. Receiver operator characteristic curve (ROC) was calculated to assess the global performance of ultrasonographic measurement of endometrial thickness and diagnostic hysteroscopy as tests for detecting endometrial cancer and atrophy. RESULTS: Histological findings for <4 mm level revealed that atrophy was present in 48 (65%) and in 2 cases (2.7%) endometrial cancer was found; for > or = 4 mm values polyps and myomas were present in 86 (59%) and there were 11 (7.5%) endometrial cancer. Sensibility and specificity for trans-vaginal ultrasound, with a cut-off value > or = 4 mm, was 55.6% and 49.7% while positive predictive value was 83.3% and negative predictive value 98.1% (ROC curve 0.597). Hysteroscopy revealed sensitivity 100%, specificity 49.6%, positive predictive value 81.3% and negative predictive value 100% (ROC curve 0.993). CONCLUSIONS: In conclusion, endometrial thickness <4 mm can miss malignancies but trans-vaginal ultrasound remains the first line diagnostic procedure in postmenopausal women without AUB, because it is not invasive and has high sensitivity for detecting endometrial cancer and other endometrial disease; according to our experience, outpatient hysteroscopy with biopsy is mandatory in all postmenopausal women with AUB.

Hysteroscopic metroplasty under laparoscopic guidance in infertile women with septate uteri: follow-up of reproductive outcome.

OBJECTIVE: To evaluate the effectiveness of hysteroscopic metroplasty under laparoscopic guidance in the treatment of infertile women with a diagnosis of septate uterus and the impact of this surgical procedure on reproductive outcome. STUDY DESIGN: From January 1996 to December 2000, 36 women referred to our endoscopy center underwent hysteroscopic metroplasty. Follow-up covered the incidence of pregnancy, term pregnancies and mode of delivery. RESULTS: The mean age of the patients was 31.9 +/- 3.9 years (range, 23-39). One patient (3%) dropped out during follow-up. There were no intraoperative or postoperative complications. The mean interval from metroplasty to conception was 11.3 +/- 9.2 months (range, 2.0-35.5). Twenty of 35 (57%) women had a history of > or = 1 spontaneous abortions, and 18 of the 20 (90%) achieved pregnancy, with 15 of 18 (83%) term deliveries (10 vaginal deliveries and 5 cesarean sections). Fifteen of 35 patients (43%) were nulliparous, and 8 of 15 (53.3%) had term deliveries (1 cesarean section). CONCLUSION: Hysteroscopic metroplasty under laparoscopic guidance is safe, allows spontaneous delivery and short-term pregnancy planning, is particularly successful in infertile women with a history of > or = 1 spontaneous abortions.

Carbon dioxide versus normal saline in outpatient hysteroscopy.

BACKGROUND: The aim of this prospective randomized study was to measure patients' discomfort after hysteroscopy with CO(2) or normal saline. METHODS: A total of 415 patients was randomized to two groups according to distension medium (CO(2), n = 201; normal saline, n = 214). The nature of randomization was to alternate distension media on a weekly basis. After hysteroscopy, women were asked to rate the pain experienced on a 100-mm visual analogue scale (0 = no pain; 100 = worst imaginable pain). Pain scores were expressed as mean +/- SD (0-40 = minimal; 41-70 = moderate; 71-100 = severe). Data were analysed using Student's t-test. RESULTS: Irrespective of the distension medium used, pelvic discomfort was worse in nulliparous women (pain score 39.0 +/- 26.5) than in multiparous women (30.4 +/- 25.9) (P < 0.05), especially if they were premenopausal. For all patients and both distension media, pelvic discomfort was generally minimal but higher in patients who had undergone hysteroscopy with normal saline (P < 0.05). CONCLUSIONS: CO(2) and normal saline were comparable with regard to patient discomfort, but in terms of the high frequency of abnormal uterine bleeding, normal saline may be the most appropriate distension medium for outpatient hysteroscopy.

A new technique of hysteroscopic myomectomy with enucleation in toto.

STUDY OBJECTIVE: To determine the safety and effectiveness of a new technique for hysteroscopic resection of uterine submucous myomas with high intramural involvement (G2 type, European Society of Hysteroscopy classification). DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: University hospital. PATIENTS: Forty-four women. INTERVENTION: Hysteroscopic myoma enucleation in toto. MEASUREMENTS AND MAIN RESULTS: With a hysteroresectoscope and Collins electrode, an elliptic incision of endometrial mucosa that covers the myoma is made at the level of its reflection on the uterine wall until the cleavage zone of the myoma is reached. Connecting bridges between myoma and surrounding muscle fibers are resected. This allows nearly complete protrusion of the myoma into the uterine cavity, facilitating complete myomectomy by slicing. The procedure was performed in 41 (93.1%) of 44 women. Of these, 38 (92.6%) had myomas between 2 and 4 cm in diameter and 3 (7.4%) had myomas exceeding 4 cm. Mean operating time was 27 minutes (range 10-45 min). CONCLUSION: This technique is efficient and allows complete resection of submucous myomas with large intramural component by favoring intracavitary protrusion of that part.