ESMO expert consensus statements on the screening and management of financial toxicity in patients with cancer.

BACKGROUND: Financial toxicity, defined as both the objective financial burden and subjective financial distress from a cancer diagnosis and its treatment, is a topic of interest in the assessment of the quality of life of patients with cancer and their families. Current evidence implicates financial toxicity in psychosocial, economic and other harms, leading to suboptimal cancer outcomes along the entire trajectory of diagnosis, treatment, supportive care, survivorship and palliation. This paper presents the results of a virtual consensus, based on the evidence base to date, on the screening and management of financial toxicity in patients with and beyond cancer organized by the European Society for Medical Oncology (ESMO) in 2022. METHODS: A Delphi panel of 19 experts from 11 countries was convened taking into account multidisciplinarity, diversity in health system contexts and research relevance. The international panel of experts was divided into four working groups (WGs) to address questions relating to distinct thematic areas: patients with cancer at risk of financial toxicity; management of financial toxicity during the initial phase of treatment at the hospital/ambulatory settings; financial toxicity during the continuing phase and at end of life; and financial risk protection for survivors of cancer, and in cancer recurrence. After comprehensively reviewing the literature, statements were developed by the WGs and then presented to the entire panel for further discussion and amendment, and voting. RESULTS AND DISCUSSION: A total of 25 evidence-informed consensus statements were developed, which answer 13 questions on financial toxicity. They cover evidence summaries, practice recommendations/guiding statements and policy recommendations relevant across health systems. These consensus statements aim to provide a more comprehensive understanding of financial toxicity and guide clinicians globally in mitigating its impact, emphasizing the importance of further research, best practices and guidelines.

Hearing aid compliance in the elderly.

OBJECTIVES: A decreasing but still substantial proportion of elderly persons with hearing aids use them only occasionally. Because the prevalence of age-related hearing loss is increasing, it is important for the hearing rehabilitation process to be effective. The aim of this study was to use a mailed questionnaire to evaluate the rate of hearing aid use and the reasons for minimal use or nonuse. METHODS: Questions about hearing aid use and associated problems were included in a survey of hearing mailed to 4,067 people in age cohorts of 70, 75, 80 and 85 years in an industrialized urban community in Finland. RESULTS: In this sample of 249 hearing aid users, 55.4% used their hearing aid daily, and 27.3% used it > 6 hours a day. The percentage of subjects who never used their hearing aid was 10.7%. Use of hearing aids tended to decline with advancing age. The most common reasons for minimal use were disturbing background noise, acoustic feedback problems, battery cost, and a lack of motivation to use the hearing aid. CONCLUSIONS: Compliance with hearing aid use by the elderly is increasing, but a significant proportion of hearing aids are still used only occasionally or never. We discuss methods to improve compliance in this patient group. Our results may be used to reexamine existing procedures for fitting hearing aids for counseling, which may increase patient compliance with hearing aids, leading to greater benefits from their use.

Thermal comfort and gender: a literature review.

UNLABELLED: This review examines scientific literature on the effect of gender on indoor thermal comfort. Gender differences have been generally considered to be small and insignificant but this review shows that a growing number of studies have found significant differences in thermal comfort between the genders. Clearly more than half of the laboratory and field studies have found that females express more dissatisfaction than males in the same thermal environments. Very few studies have found males to be more dissatisfied than females. A meta-analysis shows that females are more likely than males to express thermal dissatisfaction (ratio: 1.74, 95% confidence interval: 1.61-1.89). However, most studies found no significant difference in neutral temperatures between the genders. Females are more sensitive than males to a deviation from an optimal temperature and express more dissatisfaction, especially in cooler conditions. PRACTICAL IMPLICATIONS: We should no longer neglect the more rigorous requirements that females have for indoor thermal environments. Gender differences indicate that females have, on average, a greater need for individual temperature control and adaptive actions than males. The results of this review suggest that females should primarily be used as subjects when examining indoor thermal comfort requirements, as if females are satisfied it is highly probable that males are also satisfied.

Iron in boreal river catchments: Biogeochemical, ecological and management implications.

Iron (Fe) is an important element in aquatic ecosystems worldwide because it is intimately tied with multiple abiotic and biotic phenomena. Here, we give a survey of manifold influences of Fe, and the key factors affecting it in the boreal catchments and their waters. It includes the perspectives of biogeochemistry, hydrology, ecology, and river basin management. We emphasize views on the dynamics and impacts of different forms of Fe in riverine environments, including organic colloids and particles, as well as inorganic fractions. We also provide perspectives for land use management in boreal catchments and suggest guidelines for decision making and water management. Based on our survey, the main emphases of water protection and management programs should be (i) prevention of Fe mobilization from soil layers by avoiding unnecessary land-use activities and minimizing soil disturbance in high-risk areas; (ii) disconnecting Fe-rich ground water discharge from directly reaching watercourses; and (iii) decreasing transport of Fe to watercourses by applying efficient water pollution control approaches. These approaches may require specific methods that should be given attention depending on catchment conditions in different areas. Finally, we highlight issues requiring additional research on boreal catchments. A key issue is to increase our understanding of the role of Fe in the utilization of DOM in riverine food webs, which are typically highly heterotrophic. More knowledge is needed on the metabolic and behavioral resistance mechanisms that aquatic organisms, such as algae, invertebrates, and fish, have developed to counter the harmful impacts of Fe in rivers with naturally high Fe and DOM concentrations. It is also emphasized that to fulfil the needs presented above, as well as to develop effective methods for decreasing the harmful impacts of Fe in water management, the biogeochemical processes contributing to Fe transport from catchments via rivers to estuaries should be better understood.

Emission of the greenhouse gases nitrous oxide and methane from constructed wetlands in europe.

The potential atmospheric impact of constructed wetlands (CWs) should be examined as there is a worldwide increase in the development of these systems. Fluxes of N(2)O, CH(4), and CO(2) have been measured from CWs in Estonia, Finland, Norway, and Poland during winter and summer in horizontal and vertical subsurface flow (HSSF and VSSF), free surface water (FSW), and overland and groundwater flow (OGF) wetlands. The fluxes of N(2)O-N, CH(4)-C, and CO(2)-C ranged from -2.1 to 1000, -32 to 38 000, and -840 to 93 000 mg m(-2) d(-1), respectively. Emissions of N(2)O and CH(4) were significantly higher during summer than during winter. The VSSF wetlands had the highest fluxes of N(2)O during both summer and winter. Methane emissions were highest from the FSW wetlands during wintertime. In the HSSF wetlands, the emissions of N(2)O and CH(4) were in general highest in the inlet section. The vegetated ponds in the FSW wetlands released more N(2)O than the nonvegetated ponds. The global warming potential (GWP), summarizing the mean N(2)O and CH(4) emissions, ranged from 5700 to 26000 and 830 to 5100 mg CO(2) equivalents m(-2) d(-1) for the four CW types in summer and winter, respectively. The wintertime GWP was 8.5 to 89.5% of the corresponding summertime GWP, which highlights the importance of the cold season in the annual greenhouse gas release from north temperate and boreal CWs. However, due to their generally small area North European CWs were suggested to represent only a minor source for atmospheric N(2)O and CH(4).

Relationship of leukemia risk to radiation dose following cancer of the uterine corpus.

BACKGROUND: Radiotherapy has been linked infrequently to secondary leukemia despite extensive exposure of the active bone marrow to ionizing radiation. Few studies include substantial numbers of elderly patients. PURPOSE: We evaluated women with cancer of the uterine corpus, the majority of whom were treated at older ages, to gain additional information on cancer risk following partial-body radiotherapy and to examine differences in risk between external-beam therapy and brachytherapy. METHODS: A cohort of 110,000 women with invasive cancer of the uterine corpus who survived at least 1 year following their initial cancer was assembled from nine population-based cancer registries. Cancer diagnoses occurred from 1935 through 1985, and most patients were diagnosed during the 1960s and 1970s. Radiation doses were computed to 17 sections of the active bone marrow for 218 women who developed leukemia and for 775 matched control subjects. RESULTS: Radiotherapy did not increase the risk of chronic lymphocytic leukemia (CLL) (relative risk [RR] = 0.90; 95% confidence interval [CI] = 0.4-1.9). However, for all leukemias except CLL, a significant risk was identified (RR = 1.92; 95% CI = 1.3-2.9). Overall, the pattern of risk in relation to dose was erratic and was most consistent with a constant increased risk across the entire dose range. The risk following continuous exposures from brachytherapy at comparatively low doses and low dose rates (RR = 1.80; 95% CI = 1.1-2.8; mean dose = 1.72 Gy) was similar to that after fractionated exposures at much higher doses and higher dose rates from external-beam treatment (RR = 2.29; 95% CI = 1.4-3.7; mean dose = 9.88 Gy), indicating a large difference in the estimated risk per unit dose. Risk did not vary by age at first exposure; increased risks were apparent for irradiated patients aged 65 years or older (RR = 1.77; 95% CI = 0.9-3.5). CONCLUSION: The leukemia risk associated with partial-body radiotherapy for uterine corpus cancer was small; about 14 excess leukemia cases were due to radiation per 10,000 women followed for 10 years. Women aged 65 years or older had a radiation risk comparable with that found in younger women. The relationship of leukemia risk to radiation dose was found to be complex due to the competing processes of cell killing, transformation, and repair. At very high doses delivered at high rates, destruction of cells likely dominates, and the risk per unit dose is low. In the low dose range, where dose was protracted and delivered at relatively low dose rates, the leukemia risk appears lower than that projected from risk estimates derived from the instantaneous whole-body exposures of atomic bomb survivors.

1H MRS studies in the Finnish boron neutron capture therapy project: detection of 10B-carrier, L-p-boronophenylalanine-fructose.

This article summarizes the current status of 1H MRS in detecting and quantifying a boron neutron capture therapy (BNCT) boron carrier, L-p-boronophenylalanine-fructose (BPA-F) in vivo in the Finnish BNCT project. The applicability of 1H MRS to detect BPA-F is evaluated and discussed in a typical situation with a blood containing resection cavity within the gross tumour volume (GTV). 1H MRS is not an ideal method to study BPA concentration in GTV with blood in recent resection cavity. For an optimal identification of BPA signals in the in vivo 1H MR spectrum, both pre- and post-infusion 1H MRS should be performed. The post-infusion spectroscopy studies should be scheduled either prior to or, less optimally, immediately after the BNCT. The pre-BNCT MRS is necessary in order to utilise the MRS results in the actual dose planning.

Effectiveness of screening for colorectal cancer with a faecal occult-blood test, in Finland.

BACKGROUND: Screening for colorectal cancer (CRC) with guaiac-based faecal occult-blood test (FOBT) has been reported to reduce CRC mortality in randomised trials in the 1990s, but not in routine screening, so far. In Finland, a large randomised study on biennial FOB screening for CRC was gradually nested as part of the routine health services from 2004. We evaluate the effectiveness of screening as a public health policy in the largest population so far reported. METHODS: We randomly allocated (1:1) men and women aged 60-69 years to those invited for screening and those not invited (controls), between 2004 and 2012. This resulted in 180 210 subjects in the screening arm and 180 282 in the control arm. In 2012, the programme covered 43% of the target age population in Finland. RESULTS: The median follow-up time was 4.5 years (maximum 8.3 years), with a total of 1.6 million person-years. The CRC incidence rate ratio between the screening and control arm was 1.11 (95% CI 1.01 to 1.23). The mortality rate ratio from CRC between the screening and control arm was 1.04 (0.84 to 1.28), respectively. The CRC mortality risk ratio was 0.88 (0.66 to 1.16) and 1.33 (0.94 to 1.87) in males and females, respectively. CONCLUSIONS: We did not find any effect in a randomised health services study of FOBT screening on CRC mortality. The substantial effect difference between males and females is inconsistent with the evidence from randomised clinical trials and with the recommendations of several international organisations. Even if our findings are still inconclusive, they highlight the importance of randomised evaluation when new health policies are implemented. TRIAL REGISTRATION: 002_2010_august.

Salivary cholesterol of healthy adults in relation to serum cholesterol concentration and oral health.

Salivary lipids are mostly glandular in origin, but some are believed to diffuse directly from serum. This diffusion and the role of salivary lipids in oral health have scarcely been studied. Therefore, the serum and saliva cholesterol concentrations and oral health were analyzed in a group of healthy adults (n = 139; 64 men and 75 women; 34.2 +/- 5.2 yrs). Paraffin-stimulated whole saliva was collected, centrifuged (10,000 x g; 30 min, 4 degrees C), and lyophilized, and the cholesterol and other neutral lipids were extracted, separated by thin-layer chromatography, and quantified. The mean +/- SD (range) of saliva cholesterol concentration was 1.20 +/- 0.75 (0.02-5.46) mumol/L, and the saliva cholesterol level of men (1.36 +/- 0.85 mumol/L) was significantly higher than that of women (1.06 +/- 0.64 mumol/L; p < 0.05). Weak positive correlations between saliva and serum cholesterol concentrations and saliva cholesterol and serum non-high-density lipoprotein cholesterol concentrations were found (r = 0.22, p < 0.05; r = 0.28, p < 0.005, respectively). The saliva cholesterol assay detected subjects with high (> or = 6.5 mmol/L) serum cholesterol values, with sensitivity and specificity values of 100% and 29%, respectively. A positive correlation between the body mass index and the level of saliva cholesterol concentration was also found (r = 0.31 p < 0.01). Oral health, microbial counts, or saliva flow rate revealed no differences in subjects with low and high salivary cholesterol level. We conclude that, in healthy adults, saliva cholesterol concentration reflects serum concentration to some extent and can be used to select individuals with high serum cholesterol levels.

Geographical variation in cancer patient survival in Finland: chance, confounding, or effect of treatment?

STUDY OBJECTIVE: The aim was to determine whether survival of cancer patients in Finland varies with their place of residence, and if so, what proportion of the variation might be due to health services rather than to confounding variables. DESIGN: Patients with breast and prostatic cancer diagnosed in Finland between 1970 and 1981 were classified by place of residence (from 21 hospital districts), and area specific 5 year relative survival rates were estimated. SETTING: This was a population based survey of the whole of Finland. PATIENTS: 16,754 cases of breast cancer and 9483 cases of prostatic cancer were identified. Of these, 0.5% of breast cancers and 4.1% of prostatic cancers were excluded because diagnosis was based only on necropsy findings or because the only information available was from the death certificate. MEASUREMENTS AND MAIN RESULTS: There was a large variation in rates, ranging from 59% to 76% for breast cancer, and from 30% to 65% for prostatic cancer. However, after accounting for age of patient and extent of disease, the standardised differences for prostatic cancer closely followed random distribution, indicating equal results of treatment in different areas. For breast cancer there was more variation than expected by chance and patients resident in any of the university central hospital districts with modern radiotherapy equipment survived better than other patients. CONCLUSIONS: There is little indication that large variations in crude mortality rates from these two cancers in different parts of Finland are due to inequalities of medical care, though a small effect on breast cancer survival which might be care related was shown.

Paternalism and Finnish anti-smoking policy.

Paternalism is one of the most problematic ethical issues in public health promotion. In the article an attempt is made to elucidate the matter by examining the theoretical characteristics of paternalistic attitudes and action on the one hand, and actual Finnish anti-smoking policies on the other. The attitudes adopted by Finnish health authorities toward smoking are strongly paternalistic, i.e. based on the idea that the general public is not to be relied on in assessing the health risks of tobacco use. Surprisingly, however, the actual governmental anti-smoking measures in Finland cannot be truthfully described as overtly constraining. Since paternalism implies restrictions on personal freedom for the individual's own good, many branches of smoking control fall outside its proper scope: for instance, restrictions on smoking in public premises can almost always be justified by referring to the harm inflicted by smokers on the other people. But most of the Finnish governmental anti-smoking measures which can be classified as paternalistic are also justifiable. Some of them concern minors only or mainly minors, and thus can be defended as instances of authorities' parental concern for our children. Some are freedom-restricting but only in a weak sense and are based on the idea of informing people about the dangers of smoking, while leaving the final decision up to them. In the last analysis, there is but one regulation that meets the criteria of wrongful paternalism, and that one, the ban on strong tobacco brands, may not be important enough, in practice, to raise major ethical controversies.

Survival of female breast cancer patients in Finland and in Estonia: stage at diagnosis important determinant of the difference between countries.

The survival experiences of female breast cancer patients diagnosed in 1968-81 in Finland and in Estonia were compared. The series consisted of 18,729 patients in Finland and 4100 in Estonia. The overall estimated 5-year relative survival rate was 67.3% in Finland and 55.9% in Estonia. The stage-adjusted 5-year relative survival rate in Estonia was 63.4% (the Finnish rates used as a standard). Older patients in Finland had much higher survival rates than older patients in Estonia. There was a clear difference in the stage distribution in Estonia between older and younger age groups, with non-localized cases occurring in older age groups. No such difference was noticed in Finland. It seems that the diagnostic lag for older women is longer in Estonia than in Finland. In Estonia older patients seek medical assistance later, or symptoms and signs of younger patients are more effectively studied.

Suction blister device with regulation of temperature: demonstration of histamine release and temperature change in cold urticaria.

A suction blister device with a sensitive thermometer and with a temperature regulator was constructed. Utilizing this device, it was demonstrated that the cold challenge induces an increase in the skin temperature in cold urticaria patients during the cold challenge and a simultaneous release of histamine into the suction blisters. The skin temperature increases faster after the cold challenge period in cold urticaria patients than in normal control persons. This could be explained by vasodilatation and increased circulation in the skin, following the release of histamine in the cold urticaria reaction.

A mechanical apparatus with microprocessor controlled stress profile for cyclic compression of cultured articular cartilage explants.

An apparatus was designed for mechanical compression of cultured articular cartilage explants with acylindrical plain-ended loading head (diameter 2-5 mm) driven by a stepping motor. A load cell under the culture dish was applied for feedback regulation utilizing a microprocessor-based control unit. The operating programs allowed either continuous or cyclic loading, the latter with adjustable loading/resting ratio. The improvements in the present design compared with previously described apparatuses for similar purposes include: (1) the accurately controlled compression by a load cell and a rapid feedback circuit; (2) the wide range of selectable stresses (25 kPa-12.5 MPa) with both continuous and cyclic loading modes; (3) the ability to handle cycles as short as 1 s with 15 ms peak loading phase. Using a 4 s cycle and 0.5 MPa load for 1.5 h resulted in a significantly enhanced incorporation of radiosulphate in cultured bovine articular cartilage explants, suggesting a stimulation of proteoglycan synthesis. Light and scanning electron microscopic examinations revealed a slight depression and superficial alterations in cartilage structure at the impact site following high pressures. We expect that this apparatus will help in revealing how articular cartilage tissue and chondrocytes respond to external mechanical stimuli.

Usher's syndrome type 3 in Finland.

Usher's syndrome, type 3 (USH3) is characterized by progressive hearing loss. Usher's syndrome, type 3 has been supposed to be rare, occurring in 2% to 4% of all patients with Usher's syndrome. In a nationwide study we collected data on 229 patients with Usher's syndrome in Finland. Definite cases of USH3 were found in 30 (13%) of the 229 patients. An additional 61 patients had clinical evidence of earlier progression of their hearing impairment. We suggest that 91 (40%) of the 229 patients with Usher's syndrome represent cases of USH3.

A mineral-related feature of young plaque characteristic to periodontitis-affected adults.

The calcium concentration of 3-day-old total supragingival plaque in periodontitis-affected adults (n = 12) and their age and sex-matched periodontitis-free pairs was compared. The young plaque of the periodontitis-affected adults contained more calcium per protein (P less than 0.025, sign test) than that of the periodontitis-free pairs. The findings of the present study may suggest that high Ca-content of supragingival plaque is connected to the development of adult periodontitis.

Immunohistochemical localization of types I and III collagen and fibronectin in the dentine of carious human teeth.

Reparative dentine formed as a response to caries was mostly type I collagen similar to that of normal dentine. The predentine related to reparative dentine reacted positively with antisera to types I and III collagen and to fibronectin. Normal odontoblasts and their processes reacted positively both with types I and III collagen antibodies. Fibronectin was related to odontoblasts and their processes pericellularly. Odontoblasts appeared not to lose totally their developmental ability to synthesize type III-like molecules after maturation. Pulp fibroblasts reacted positively both with types I and III antibodies as well as antifibronectin. The cell-free and cell-rich zones revealed a dense layer of fibres reacting positively with type III collagen and fibronectin antibodies. The width of these zones were reduced in relation to reparative dentine.

The effect of hormone replacement therapy on salivary calcium concentrations in menopausal women.

Hormone replacement therapy in menopausal women is known to affect the general calcium turnover of the body. No information is available about the effects of hormone therapy on salivary electrolytes and on calcium in particular. A group of 16 healthy peri- and postmenopausal women, all recommended to start hormone replacement therapy, were studied longitudinally for 5 months. Paraffin-stimulated whole saliva was collected at baseline, at 3 and at 5 months after the onset of therapy, and analysed for calcium, sodium and potassium concentrations. In response to hormone replacement therapy, calcium concentration decreased (p = 0.037), that of sodium increased (p = 0.019), while no change was observed in the potassium concentrations during the follow-up period.

Cancer risk among health care personnel in Finland, 1971-1980.

Standardized incidence ratios were calculated for the assessment of cancer risk among Finnish health care personnel in 1971-1980. The overall relative cancer risk among the men was low when compared with that of all economically active men, mainly due to the low relative risk of lung cancer. The cancer risk of female health care personnel was increased when compared with that of all economically active women. The relative risk of breast cancer among registered nurses was high, being twice that of practical nurses, who had an average risk. In contrast, the risk of lymphomas, leukemia, and primary liver carcinoma was low among registered nurses and high among practical nurses. Although specific occupational exposures could not be assessed, the results did not imply any alarming major hazards related to health care work itself.

Hearing levels of patients with otosclerosis 10 years after stapedectomy.

Hearing levels of 174 patients (213 ears operated on) with otosclerosis undergoing stapedectomy were analyzed. All patients had followup of 10 years or more, the mean follow-up period being 13.4 years. Eighty-seven ears (41%) underwent posterior crus stapedectomy, and in the remaining 126 ears (59%) a prosthesis was inserted. Large fenestra technique was used in all cases. In the long run, both air conduction and bone conduction thresholds of ears operated on showed remarkable deterioration from the best values obtained 6 to 12 months postoperatively. Ten years after surgery both air conduction and bone conduction thresholds of ears operated on were significantly worse than those of normal controls. At 10 years, 70 percent of the ears operated on had hearing levels (at 0.5 to 2.0 kHz) of 30 dB or better and 88 percent had 40 dB or better. At the last follow-up examination, in 90% of the patients the better hearing ear had a hearing level of 40 dB or better. In 90% of patients with bilateral otosclerosis who had operations in only one ear, the ear operated on had better hearing function than the opposite ear that had not been operated on.