Biomarkers of systemic inflammation provide additional prognostic stratification in cancers of unknown primary.

BACKGROUND: Biomarkers of systemic inflammation have been shown to predict outcomes in patients with cancer of unknown primary (CUP). We sought to validate these findings in patients with confirmed CUP (cCUP) and explore their role alongside existing clinicopathological prognostic categories. PATIENTS AND METHODS: CUP oncologist from across the United Kingdom were invited to include patients with cCUP referred to their local CUP multidisciplinary team. Patient demographics, clinical, pathological and outcome data were recorded and analysed. RESULTS: Data were available for 548 patients from four CUP services. 23% (n = 124) of patients met clinicopathological criteria for favourable-risk cCUP. On multivariate analysis c-reactive protein (CRP) (p < 0.001) and the Scottish Inflammatory Prognostic Score (SIPS: combining albumin and neutrophil count) (p < 0.001) were independently predictive of survival. CRP and SIPS effectively stratified survival in patients with both favourable-risk and poor-risk cCUP based on clinicopathological features. CONCLUSIONS: Biomarkers of systemic inflammation are reliable prognostic factors in patients with cCUP, regardless of clinicopathological subgroup. We recommend that CRP or SIPS are incorporated into routine clinical assessments of patients with cCUP as a tool to aid investigation and/or treatment decision-making across all groups. Established clinicopathological factors can then be used to inform management pathways and specific systemic anticancer therapy selection.

Characterisation and outcomes of patients referred to a regional cancer of unknown primary team: a 10-year analysis.

BACKGROUND: In the United Kingdom, national guidance published in 2010 recommended the establishment of specialist teams to improve clinical pathways for patients presenting with malignancies of undefined primary origin (MUO) and cancer of unknown primary (CUP). This study sought to define outcomes of patients referred to a regional MUO/CUP service. METHODS: Data were collected prospectively on all patients (n = 1225) referred to a regional CUP team over a 10-year period. Patient demographics, clinical, pathological and outcome data were recorded and analysed. RESULTS: Confirmed CUP (cCUP) was diagnosed in 25% of patients. A primary metastatic cancer was identified in 36%, 5% were diagnosed with provisional CUP (pCUP), 27% retained the diagnosis of MUO and in 8% a non-cancer diagnosis was made. Median survival was low in all patients with a final malignant diagnosis: primary identified 9.0 months, cCUP 4.0 months, pCUP 1.5 months and MUO 1.5 months. CONCLUSIONS: Patients presenting with MUO have poor outcomes irrespective of the final diagnosis. These patients need a patient-centred, streamlined, rapid diagnostic pathway. There are clear benefits to primary and secondary care teams having access to a dedicated, multidisciplinary MUO/CUP service, with clinical nurse specialists supporting the patients, to help facilitate this pathway and ensure early oncology review.

Late effects and quality of life after chemo-radiation for the treatment of anal cancer.

PURPOSE: The aim of this study was to evaluate the late effects and quality of life of patients following chemo-radiation treatment for anal cancer. METHODS: All surviving anal cancer patients treated within NHS Lothian between 1990 and 2007 were invited to participate. Data were collected using the EORTC QLQ-C30, the EORTC QLQ-CR38 and the Memorial Sloan-Kettering Cancer Centre Bowel Function Instrument (MSKCC). RESULTS: Overall response rate was 46% (n = 42); mean age 54.7 years and with a median time interval of 63.8 months between treatment and completion of the questionnaires. Thirty-five percent of the participants were 'rarely' or 'never' able to wait 15 min to get to the toilet; 50% were 'rarely' or 'never' able to control the passage of gas; 35% limited the types of solid foods they eat; 22% had leakage of stool during the day; 39% required to use a protective pad and 29% altered their daily activities because of bowel function 'always' or 'most of the time'. Seventeen percent of patients reported financial difficulties ('quite a bit' and 'very much'). Both men and women reported high symptomology for sexual problems with a median score of 83.3 (50.0. 100.0). CONCLUSION: This study has shown that in a sub-set of patients treated with chemo-radiation for anal cancer, persistent treatment related issues are reported at a medium time interval of 5.3 years. Further work is now required to understand the impact of symptoms on day-to-day life and the challenges that people face in managing these inter-related and complex problems.

Long term effect of surgery and radiotherapy for colorectal cancer on defecatory function and quality of life.

PURPOSE: Survival from rectal cancer has improved substantially. Understanding the consequences of treatment is important to optimise patient support and minimise impact on daily life. We aimed to define the long-term prevalence of pelvic dysfunction following curative rectal cancer surgery (+/- radiotherapy) within the context of overall quality of life. METHODS: We evaluated bowel, urinary and sexual function and quality of life using three validated questionnaires in patients treated for rectal cancer. This group was compared to patients undergoing abdominal surgery without pelvic dissection for colon cancer during the same time period. RESULTS: The response rate was 57% (381/667) with a median time interval of 4.4 years. A subset of rectal patients documented persistent problems with faecal leakage (16%); requiring to alter daily activities (18%); always needing to wear a protective pad (17%); rarely or never emptying their bowels fully (31%); difficulty controlling the passage of gas (32%) and requiring to modify diet (30%). Altered bowel function was found to impact on overall quality of life. Men reported increased erectile function difficulties. Pre-operative radiotherapy was associated with increased defecation problems as was low level of anastomosis (≤6 cm). CONCLUSION: In keeping with emergent evidence, this study has quantified the extent of late adverse effects with a sub-set of rectal cancer patients reporting persistent bowel function problems. The implications are now to consider current follow-up services and to 'trial' new models of comprehensive assessment and interventions in patients who are 'at risk' of experiencing late adverse effects of treatment.

Implementation and evaluation of a pilot education programme in colorectal cancer management for nurses in Scotland.

This paper describes the results of an evaluation of a nursing education programme for nurses caring for patients with colorectal cancer. A sample of 67 registered nurses from 6 location sites within the 3 Regional Cancer Networks in Scotland were recruited to the pilot. The programme was adapted from an evidence-based education manual for nurses in the management of colorectal cancer developed by the European Oncology Nursing Society as part of a Nursing in Colorectal Cancer Initiative (NICCI) [Hawthorn, J., Redmond, K., 1999. A Guide to Colorectal Cancer. AstraZeneca Oncology, UK]. The format for evaluating the programme was based on the TELER method of treatment evaluation [Le Roux, A.A., 1995. TELER: the concept. Physiotherapy 79 (11), 755-758] that had previously been developed along side the training manual [Grocott, P., Richardson, A., Ambaum, B., Kearney, N., Redmond, K, 2001a. Nursing in colorectal cancer initiative--the audit phase. Part 1. Development of the audit tool. European Journal of Oncology Nursing 5 (2), 100-111; Grocott, P., Richardson, A., Ambaum, B., Kearney, N., Redmond, K., 2001b. Nursing in colorectal cancer initiative: the audit phase. Part 2. Content validity of the audit tool and implications of the standards set for clinical practice. European Journal of Oncology Nursing 5 (3), 165-173] for cytotoxic chemotherapy to provide the NICCI Audit Tool (Le Roux, 2003). This model was developed further in the current study to include the domains of: Disease, Diagnosis and Staging, Treatment, Nursing Issues and General Issues. Data were analysed descriptively and are discussed. Overall the results from this study demonstrate a statistically significant improvement in disease-related knowledge (p=<0.001) and in the best practice statements for nursing issues (p=<0.001) and general issues (including attitudes) (p=0.023) that were maintained at four months post completion of the course.

Carcinoembryonic antigen (CEA) testing in colorectal cancer follow up: what do patients think?

The carcinoembryonic antigen (CEA) blood test is included in most colorectal cancer follow up protocols, despite little clear evidence for its cost-effectiveness and survival benefit. In this study, patients' views were sought on the use of the CEA blood test in their follow up. Strong associations were found between the age of a patient's children and their concern about cancer recurrence and between concern about recurrence and anxiety about CEA test results (p<0.0001). Many patients expressed a desire for prognostic information, however uncertain or poor. Patients' views should be sought when designing colorectal cancer follow up protocols to ensure their needs are adequately addressed.

Developing and piloting a nurse-led model of follow-up in the multidisciplinary management of colorectal cancer.

One of the main challenges of colorectal cancer follow-up is the detection of early disease in order to influence survival and improve outcome. Yet, the benefits of follow-up are not only related to survival. It is well documented that patients can experience an array of problems following colorectal cancer surgery which impact upon quality of life, therefore symptom management plays an important part in the overall spectrum of follow-up care. In addition, there is emerging evidence to suggest that clinical nurse specialists are well placed in the multidisciplinary team to co-ordinate such follow-up programmes. This paper reports on a pilot study designed to assess the feasibility of a follow-up programme led by nurse specialists for patients with colorectal cancer. Key outcome areas were adherence to an agreed follow-protocol, quality of life, patient and clinician satisfaction and a cost-analysis of the new model. The study was conducted over one year with 60 patients. This redesign resulted in a smoother pathway of follow-up care, improved quality of life and acceptance to both patients and clinicians alike. The introduction of a nurse-led follow-up model is expected to demonstrate cost savings over a 3 year rolling follow-up programme.

Assessing fatigue and self-care strategies in patients receiving radiotherapy for non-small cell lung cancer.

Lung cancer represents a major public health problem worldwide (ISD 2000) with approximately 80% of patients presenting with locally advanced or metastatic disease. Treatment is essentially palliative; therefore, symptom management is important. This paper describes the findings from a prospective study of fatigue in newly diagnosed patients with non-small cell lung cancer. Fifty-three patients undergoing radical or high-dose palliative radiotherapy for Stage I, II and III disease were recruited to the study. Patients completed a structured health diary throughout radiotherapy and for up to 1 month post-treatment. Tape-recorded interviews were conducted with a sub-sample (n=11) to explore the nature of fatigue. Complete data sets were available on 46 patients. Consistent with current literature, the study findings demonstrated the progressive nature of this symptom throughout treatment; however, the levels of distress reported and interference with daily living were not found to be as overwhelming in this group of patients as the literature thus far suggests.