The impact of mode of presentation on distress in patients with early stage breast cancer.

AIMS: We set out to determine whether a difference exists between levels of psychological distress in women diagnosed with breast cancer through routine screening versus those who presented symptomatically. METHODS: We assessed levels of distress in comparable numbers of patients with screen-detected and non-screen-detected female breast cancer patients being treated with curative intent, using the Hospital Anxiety and Distress Scale (HADS) (total n = 93). RESULTS: In both cohorts, 50.5% scored above threshold for anxiety, depression, or both. Being aged over 60 was associated with concomitant positive anxiety and depression screening in both cohorts. Financial stress was associated with positive depression scores. No statistically significant difference was found between HADS scores for screen-detected versus self-detected patients. CONCLUSION: Over 50% of patients with screen-detected or symptomatic breast cancer experience high levels of distress. Consideration should be made for the routine use of distress screening in this population.

Anti-Ri antibody associated small cell lung carcinoma.

BACKGROUND: Anti-neuronal antibody Anti-Ri may be positive in patients with paraneoplastic syndrome associated with certain cancer subtypes. Anti-Ri positivity has been associated with breast, gynaecological and small cell lung cancers. CASE REPORT: A 69 year-old female presented with a sudden decline in cognition requiring hospital admission. She had an extensive medical history including a significant smoking history and bipolar affective disorder for which she was prescribed lithium. Her cognitive decline was initially attributed to diabetes insipidus secondary to lithium therapy. She made a slow but gradual recovery with treatment. Additional investigations revealed positive Anti-Ri antibody. An occult malignancy screen identified enlarged aorto-pulmonary lymph nodes of indeterminate significance. Following discussion at the regional cardiothoracic multidisciplinary team meeting, three monthly surveillance scans were performed. At month 6 an increase in thoracic adenopathy was seen however endobronchial ultrasound guided biopsy failed to identify malignant cells. Further progression with new supraclavicular adenopathy was seen on repeat imaging 6 months later. A fine need aspirate of an enlarged supraclavicular lymph node was diagnostic for small cell lung cancer, staged as TxN3M0 on positron emission tomography. The patient went on to receive sequential chemo-radiotherapy with a truncated course of carboplatin and etoposide and 50 Gy/25 fractions of thoracic radiotherapy. DISCUSSION: This case suggests that a positive Anti-Ri antibody may predate the development of clinical or radiological evidence of malignancy. If Anti-Ri positivity is identified, strong consideration should be given to screening for malignancy and regular surveillance. This approach may lead to earlier diagnosis and a better outcome for these patients.

The association of pre-treatment neutrophil to lymphocyte ratio with overall survival in patients with glioblastoma multiforme.

Neutrophil-lymphocyte ratio (NLR) is a marker of systemic inflammatory response and its elevation has recently been shown to be a poor prognostic factor in many malignancies including colon, prostate and bladder cancer. The primary aim of this study was to assess the prognostic impact of NLR in a clinically annotated cohort of patients with glioblastoma multiforme (GBM). We hypothesised that elevated NLR would be associated with worse prognosis. Between 2004 and 2009, 137 patients had surgery for GBM and were assessed for consideration of adjuvant therapy at our institution. Of these, 84 patients with an evaluable pre-corticosteroid full blood count result were identified and included in the final analysis. Median overall survival was 9.3 months (range 0.7-82.1). On univariate analysis, age >65 years, gender, ECOG performance status ≥2, frontal tumour, extent of surgical resection, completion of adjuvant chemoradiation protocol and NLR > 4 were significantly correlated with overall survival. Patients with NLR > 4, had a worse median overall survival at 7.5 months versus 11.2 months in patients with NLR ≤ 4 (hazard ratio 1.6, 95 % CI 1.00-2.52, p = 0.048). On multivariate analysis NLR > 4 remained an independent prognostic indicator for poor outcome. These data are an important reminder of the potential relevance of host immunity in GBM. In our cohort, NLR > 4 conferred a worse prognosis independent of other well established prognostic factors. If validated in other cohorts NLR may prove to be a useful addition in predicting prognosis in GBM patients. The demonstration that host immunity plays a role in GBM biology suggests that investigation of emerging therapies which modulate host immune response are warranted in this disease.