Persistence of medical change at implementation of clinical guidelines on medical practice: a controlled study in a cancer network.

PURPOSE: A cancer network of general or private hospitals of a French region was started in 1995 for improving quality of care and rationalizing medical prescriptions. The impact of implementing a clinical practice guidelines (CPG) project assessed conformity with guidelines in medical practice; significant changes were observed within the network, whereas no changes were observed in a control region without cancer network. In the present study, we evaluated the persistence of conformity to guidelines through a new medical audit. PATIENTS AND METHODS: In 1999, the hospitals of the previously compared experimental and control groups accepted to reassess the impact of CPG. A controlled transversal study was performed in the experimental group (cancer network) and in the control group (no regional cancer network). In 1996 (first audit) and in 1999 (present audit), all new patients with colon cancer (177 and 200 in experimental group and 118 and 100 in control group, respectively) and early breast cancer (444 and 381 in experimental group and 172 and 204 in control group, respectively) were selected. RESULTS: In the experimental group, the compliance of medical decisions with CPG was significantly higher in 1999 than in 1996 for colon cancer (73%; 95% CI, 67% to 79% v 56%; 95% CI, 49% to 63%, respectively; P = .003) and similar for the two periods for breast cancer (36%; 95% CI, 31% to 41% v 40%; 95% CI, 35% to 44%, respectively; P = .24). In the control group, compliance was significantly higher in 1999 than in 1996 for colon cancer (67%; 95% CI, 58% to 76% v 38%; 95% CI, 29% to 47%, respectively; P < .001) and identical for the two periods for breast cancer (4%; 95% CI, 1% to 7% v 7%; 95% CI, 3% to 11%, respectively; P = .19). CONCLUSION: The CPG program for cancer management produced persistent changes in medical practice in our cancer network in terms of conformity with CPG.

Class III beta-tubulin expression in tumor cells predicts response and outcome in patients with non-small cell lung cancer receiving paclitaxel.

Both fundamental and clinical studies suggest that class III beta-tubulin expression is associated with resistance to taxanes and constitutes a prognostic factor in several solid tumors. In this study, we assessed the prognostic and predictive value of class III beta-tubulin in tumors of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) treated with paclitaxel-based or other regimens that did not include tubulin-binding agents. Expression of class III beta-tubulin was examined immunohistochemically in 91 tumor samples obtained before treatment from patients with stage III and IV NSCLC, including 47 who received paclitaxel-based regimens and 44 who received regimens without tubulin-binding agents. Response to chemotherapy, progression-free survival, and overall survival were correlated with the expression of class III beta-tubulin protein. The response rate was 37.5% (16 responses among 45 evaluable patients) among patients receiving paclitaxel. Patients whose tumors expressed low levels of class III beta-tubulin isotype had a better response rate, longer progression-free survival, and overall survival (P < 0.001, 0.004, and 0.002, respectively), whereas this variable was not found to be predictive in patients receiving regimens without tubulin-binding agents. A multivariate analysis taking into account sex, age, histology, stage, and class III beta-tubulin confirmed that low-level class III beta-tubulin expression was independently correlated with progression-free survival (P = 0.003) and overall survival (P = 0.003). These findings suggest that the expression levels of class III beta-tubulin in tumor cells is predictive of response to therapy and patient outcome in patients with NSCLC receiving paclitaxel-based chemotherapy but is not a general prognostic factor in this patient population.

Whole-body MRI for metastases screening: a preliminary study using 3D VIBE sequences with automatic subtraction between noncontrast and contrast enhanced images.

OBJECTIVES: To evaluate 3D Volumetric Interpolated Breath-hold Examination (VIBE) whole-body MRI (WB-MRI) acquisition for the metastases staging. METHODS: Thirty-two consecutive patients with solid tumor were examined from head to feet before and after contrast injection. An automatic subtraction occurred between the 2 series of images. WB-MRI was compared with conventional staging techniques (CT, scintigraphy, brain MRI, and whole-body PET in 4 cases). RESULTS: WB-MRI and the reference techniques depicted metastases in 25 patients. WB-MRI depicted more bone lesions in the spine, pelvis, skull, femur, and tibia, whereas scintigraphy detected more rib lesions. WB-MRI depicted 27 cerebral metastases, whereas brain MRI depicted 40 cerebral metastases. WB-MRI depicted a total of 8 hepatic metastases, 8 adrenal lesions, and conventional staging 7 hepatic metastases and 10 adrenal lesions. WB-MRI examination depicted lung metastases in 10 patients, and CT examination in 13 patients. CONCLUSION: The results of this study indicate that WB-MRI is a feasible and promising technique for tumor staging.