Vinorelbine and infusional 5-fluorouracil in anthracycline and taxane pre-treated metastatic breast cancer.

AIMS: To evaluate the efficacy and toxicity of a combination of intravenous vinorelbine and 5-fluorouracil (5-FU) given by continuous infusion in the treatment of metastatic breast cancer previously treated with anthracyclines and taxanes. MATERIALS AND METHODS: Sixty-one patients with metastatic breast cancer were treated with intravenous vinorelbine 30 mg/m2 on days 1 and 8 of each 21-day cycle together with 5-FU 200 mg/m2/day by continuous infusion. All had previously been treated with an anthracycline and 41% had also been previously treated with a taxane. All had normal haematological, renal and hepatic function and all but three had an Eastern Cooperative Oncology Group performance score of 2 or better. RESULTS: The overall response rate by World Health Organization criteria was 46% (28 patients); excluding nine non-evaluable patients gave a response rate of 54%. In patients who had previously been treated with both an anthracycline and a taxane, a response rate of 50% was observed (12 of 24 patients). Severe toxicity was uncommon, as was toxicity attributable to infusional 5-FU. Myelosuppression was rarely severe, but was common and led to delay or dose reduction in 38% of treatments. Eleven patients (18%) were admitted with fever and/or neutropenia and one patient died. The median received dose intensity was vinorelbine 16 mg/m2/week and 5-FU 143 mg/m2/day. CONCLUSIONS: The combination of vinorelbine and infusional 5-FU is active in metastatic breast cancer, including in patients previously treated with an anthracycline and a taxane. Toxicity is generally manageable, but myelosuppression is significant at this dose regimen. Recommended doses for routine clinical use are 5-FU 200 mg/m2/day and intravenous vinorelbine 30 mg/m2 days 1 and 15 on a 28-day cycle.

A novel coloured latex test for the detection and identification of more than one antigen.

A novel latex agglutination test employing coloured latex particles is described. The latex reagent contains two or more differently coloured latex suspensions, each colour having been coated before mixing with at least one specific antibody, so that two or more antigens can be detected and identified with a single reagent. The antigen is identified by observing the colour of the agglutinated particles against a contrasting change in the colour of the background.

Immunohistological studies of lymphoproliferative lesions in a fatal case of Epstein-Barr virus infection.

A fatal case of infectious mononucleosis occurred in a young adult. Abnormal serological features were noted in his mother, although there was no other family history suggesting an inherited defect of immune response to Epstein-Barr virus (EBV). The cellular infiltrate observed in tissues obtained at necropsy was analysed with a range of specific monoclonal and polyclonal antibodies. Polyclonal plasmacytoid B cell proliferation had occurred in many tissues. These cells were positive for EBV nuclear antigen, but viral particles were not seen on ultrastructural examination, and the virus was not isolated, suggesting a non-permissive infection.

Differentiation of enterococci from other group D streptococci by means of a specific monoclonal antibody.

We report on the specificity of a monoclonal antibody which reacts with autoclaved extracts of four species of enterococci but does not react to the same extent with similar extracts from two non-enterococcal group D streptococci. The monoclonal antibody also reacts specifically with purified lipoteichoic acid from Streptococcus faecalis but not significantly with purified lipoteichoic acid from the non-enterococcal species Streptococcus bovis and Streptococcus equinus. The specific antigen detected with this antibody could correlate with the definition of the enterococcus subgroup of the streptococci which would provide further evidence that this sub-group is taxonomically distinct from the other group D streptococci.

The universal, situational, and personal needs of cancer patients and their main carers.

The importance of psychosocial factors in the cancer journey for both patients and their carers has been recognised in UK health policy. The aim of this paper is to consider--(1) which needs are regarded as important by patients and their carers; (2) which are the unmet needs of patients and their carers. The study focuses on the responses of 233 paired cancer patients and their carers derived from a cross-sectional questionnaire survey in three health authorities in North West England. The majority of patient-carer pairs expressed the importance of having good relationships with health-care professionals and receiving good-quality information. These can be identified as "universal" needs. A minority of patient-carer pairs expressed the importance of other kinds of needs. These items were mainly to do with managing daily life, emotions, and social identity and can be identified as "situational" or "personal" needs. Where there were discrepancies between patients and carers, patients were likely to identify more needs as important. In contrast, carers have more unmet needs, reflecting their comparative neglect. Broadly, "universal" needs are being met, but "situational" and "personal" needs, particularly among carers, are relatively unmet and require greater attention on the part of nurses and primary care professionals.

Informal carers of cancer patients: what are their unmet psychosocial needs?

This paper considers the significant unmet psychosocial needs of the informal carers of cancer patients, drawing on data generated in a 3-year UK study (1997-2000) on the psychosocial needs of cancer patients and their main carers. While the needs of the carers of cancer patients are increasingly being recognised in healthcare policy documents, there is relatively little published literature on these needs. A "significant unmet need" is defined here as a need deemed important by the carer, but which has not been met. A descriptive cross-sectional survey of carers was conducted and the responses of 195 carers relating to 48 psychosocial need items were analysed. A subset of these carers (n = 32) were interviewed. Forty-three per cent of carers had significant unmet needs. They were more likely to be those where the relationship to the patient was not that of a partner or spouse, more likely to have other caring responsibilities, and less likely to have friends or relations to call upon for help. Carers with unmet needs were also more likely to be in poor health themselves or to be caring for a patient who had reached the palliation-only phase in their cancer journey. The majority of carers expressed the importance of needs such as having good relationships with healthcare professionals and receiving honest information, but few expressed dissatisfaction with these aspects of need. Items of significant unmet need clustered around aspects of managing daily life, emotions, and also social identity for a sizeable minority of carers. These are the same areas of significant unmet need that concern patients. However, carers have more of these concerns, reflecting their comparative neglect. The paper also considers how these widespread concerns can be addressed.

Streptococci with dual antigen specificity for Lancefield groups D and G.

Streptococci have been isolated which may be identified in serological tests as belonging to Lancefield group G, but in fact belong to group D. Twenty-two cultures with this property were obtained from four countries; they included Streptococcus bovis and Streptococcus durans as well as Streptococcus faecalis. Selected strains were studied in serological tests and cross-absorption procedures, in which it was found that the group G reaction given by these isolates is due to an epitope with at least partial identity with reference group G antigen. Identification of an enterococcus as a group G streptococcus could lead to erroneous and ineffective chemotherapy. Antibiotic sensitivity testing of streptococcus group G isolates should be a routine procedure, and bile-aesculin and salt-tolerance testing of these isolates would be a wise precaution.

Supportive care and the use of relaxation therapy in a district cancer service.

The development of a cancer support organisation, CancerCare, for North Lancashire and South Lakeland is described. The use of relaxation therapy is described to illustrate the demand for supportive care. Between January 1990 and 1991, 513 patients, 243 relatives and 143 bereaved were referred to five cancer support nurses. One hundred and sixty-two (32%), 29 (12%) and 49 (34%) respectively, used relaxation therapy. The high demand for supportive care suggests that services should be made available in any district health provider unit. Measures of benefit and better definition of services are required before clear recommendations can be made.

Acute renal failure due to gold.

A patient with rheumatoid arthritis is described who developed acute renal failure whilst receiving gold. This occurred despite the normal precautions of patient monitoring before each dose was given. The clinical picture suggests this was a hypersensitivity reaction to chrysotherapy.

Cancer support nurses: a co-ordinating role in cancer care.

Cancer support nurses (CSNs) have a key co-ordinating role in the cancer services in North Lancashire and South Lakeland. The working practices of the three CSNs in North Lancashire are described in detail. There was a total cumulative caseload of 604 patients in September 1996, with 397 referrals in the previous 12-month period. There were 267 deaths during this time. CSNs are an essential element of cancer service provision. A ratio of one CSN to 40,000 population gives a manageable workload, provided there is an infrastructure of supportive care to which patients, carers and bereaved can be referred.

Carcinoma of the lung presenting with a myeloproliferative disorder. A report of two patients.

A myeloproliferative disorder, similar to agonogenic myeloid metaplasia, has been described in patients with cancer. Two patients with carcinoma of the lung are described who presented with such a disorder but in whom there was no evidence of bone marrow fibrosis and in one of whom there was no evidence of bone marrow infiltration by tumor. The possible mechanism of this association is discussed.

Phytohaemagglutinin-induced lymphocyte transformation in patients before and after resection of large intestinal cancer.

Lymphocyte responses to stimulation with phytohaemagglutinin (PHA) have been compared in 20 patients with large intestinal cancer, 10 patients whose large intestinal cancers have been removed, and in 30 age- and sex-matched control individuals. Responses were markedly reduced in the tumour-bearing patients and were unaffected by substituting normal for autologous plasma during incubation. Responses, however, were normal after tumour resection suggesting that the defect in lymphocyte responsiveness is a reversible one and related to the presence of tumour tissue.

Inhibition of leucocyte migration in patients with large intestinal cancer by extracts prepared from large intestinal tumours and from normal colonic mucosa.

The degree of migration inhibition in response to tissue extracts has been examined in leucocyte preparations obtained from patients with large intestinal cancer and from age and sex matched control individuals. A greater degree of migration inhibition was observed in response to a colorectal tumour extract in cells obtained from the cancer patients. Inhibition also tended to be more marked in response to the tumour extract than in response to a normal colonic mucosal extract in these patients. These results suggest that altered cellular immune reactivity is demonstrable by this simple in vitro technique in patients with large intestinal cancer.

Rapid diagnosis of tuberculous meningitis by latex particle agglutination.

A simple latex particle agglutination test for the rapid detection of Mycobacterium tuberculosis plasma membrane antigen in cerebrospinal fluid was evaluated in 18 children with tuberculous meningitis and 134 control children with other disorders. The antigen was detected in all 18 patients with tuberculous meningitis, although an initial sample from 1 patient did not contain detectable antigen before it was concentrated. 133 of 134 control samples gave negative results.

The psychosocial needs of cancer patients: findings from an observational study.

The objectives of this study were to identify the prevalence of psychosocial need, and the contributory factors to need, among cancer patients, using a descriptive cross-sectional questionnaire survey of adult cancer patients. The participants were 1,000 patients from four hospitals in the north west of England with the following characteristics: tumour type (breast, colorectal, lymphoma, lung), being 1 month from a 'critical moment' in the cancer journey (i.e. (i) diagnosis, (ii) end of first treatment, (iii) recurrence, (iv) move from active treatment to palliative care), and aged over 18 years. The main outcome measure was a psychosocial needs inventory comprising seven needs categories (48 need items). A sample of 402 was achieved (40% response rate). Psychosocial needs relating to the need categories 'health professionals', 'information' and 'support networks' are commonly expressed and strongly felt by cancer patients. Needs relating to 'identity', 'emotional and spiritual' issues and 'practical' issues are less commonly expressed but are also strongly felt. Particular needs are related to tumour type, illness 'critical moment', age, gender, health status, socioeconomic and other social factors. This information should increase awareness among cancer care professionals about a range of psychosocial needs and may help them target particular patient groups for particular support interventions.

The significant unmet needs of cancer patients: probing psychosocial concerns.

'Significant unmet needs' are those needs that patients identify as both important and unsatisfied. In this article we ask whether the overall needs of cancer patients are actually being met. We believe that the range of unmet need, and the kinds of patients who are more likely to claim unmet need, should be carefully identified. The needs responses of a series of 295 cancer patients in a cross-sectional survey were analysed. The majority expressed the opinion that information and good relationships with health care professionals were important, and few expressed dissatisfaction with these aspects of need. Similarly, needs items about support from family and friends were largely rated as important and satisfied. For a sizeable minority of patients, items of significant unmet need cluster around aspects of managing daily life, emotions, and social identity. The distribution of significant unmet needs is not random but is more likely to be experienced by patients who are younger, have a long-standing illness or disability, do not own/have use of a car, and/or have no religious faith. Furthermore, significant unmet needs relate to patients' ability to talk freely to a carer about the cancer, the degree to which the cancer interferes with social activities, and whether financial difficulties are experienced. Most of the significant unmet need is beyond the remit of services primarily designed for the treatment of disease. We consider whether multidisciplinary cancer teams can be expected to deal with all aspects of the cancer experience.

Immunological monitoring in a controlled trial of immunotherapy in stage IIB malignant melanoma.

Fifteen patients undergoing surgery for Stage IIb malignant melanoma were randomly allocated either to a group who received a vaccine of BCG mixed with irradiated autologous melanoma cells, or a control group who received no further treatment. All patients were monitored sequentially for immunological competence and tumour-directed immunity, using a wide range of techniques, and the results were compared retrospectively with their clinical course. Three months after surgery, there was a trend towards inhibition of PHA-induced lymphocyte transformation by autologous serum in patients who developed recurrent tumour within 12 months after treatment. Serum from patients who remained tumour-free for 12 months did not inhibit stimulation of autologous lymphocytes by PHA. Apart from this test, no other immunological parameters correlated either with clinical course or with the type of treatment received.

All change: cancer services in transition.

The policy and health service background to this discussion are the radical changes in cancer services currently underway in the wake of the Calman-Hine Report and the wider changes ushered in by the NHS and Community Care Act 1990 (UK). Using the changing face of hospice care as the focus, the authors explore some of the potential issues and dilemmas involved in providing supportive care for cancer patients and their families. Three 'themes', or areas of concern, are highlighted: links between services, changing organizational factors, and increasing 'medical imperialism'. Potential benefits and drawbacks of the changing ethos and organizational structures are discussed. Interview data are used as 'triggers' for the presentation of the authors' own reflections on developments in the hospice and cancer services' arenas. The paper draws on interview data collected in the pilot phase of a 3-year study on the psycho-social needs of cancer patients and their informal carers in north-west England. Twenty-nine interviews were conducted with a range of professionals involved in the provision of cancer services in Lancaster and Kendal. In the spirit of 'gathering thoughts' and facilitating debate, a commentary on developments in the hospice sector is offered rather than any firm conclusion.