An exploratory study of the use of advance directives by US oncologists.

PURPOSE: This study sought to determine the rate of advance directive completion among US oncologists and factors influencing such a decision. METHODS: We surveyed 7590 members of the American Society of Clinical Oncology using a web-based questionnaire. RESULTS: The response rate was 8.1%. Most respondents (59%) had completed at least 1 document: 9% living will, 9% power of attorney for health care, and 41% both. Respondents who were older, men, married, with children, working in the community setting, radiation oncologists, and practicing general oncology were more likely than their counterparts to have an advance directive. Among those who had one, 95% and 36% had discussed their wishes with their loved ones and health care providers, respectively. Factors including experience at work, spouse, children, family, and religion had the most influence on respondents' decision. The majority of those without an advance directive reported either no reason or lack of time. Those who had them were more likely to report having a comprehensive review of their wishes with those closest to them, being more knowledgeable, having more routine discussions with their patients, and being more comfortable helping their patients complete one. CONCLUSION: Only about half of US oncologists who responded to our survey have completed an advance directive.

Circulating endothelial cells in patients with chronic lymphocytic leukemia.

Angiogenesis is increased in B-cell chronic lymphocytic leukemia (B-CLL). We wanted to quantify and characterize the circulating endothelial cells (CECs) in patients with B-CLL and correlate with plasma angiogenesis-related factors. Using a four-color flow cytometry, we prospectively analyzed the CEC in the whole blood of 20 healthy controls and 20 patients with B-CLL. We quantified (CD45-/CD31+/CD146+) and characterized the CECs according to whether they were apoptotic (annexin stain) or activated (CD106+). We also measured plasma levels of vascular endothelial growth factor (VEGF), fibroblast growth factor-2 (FGF-2), and thrombospondin-1 (TSP-1). Most patients (90%) had Rai stages 0-2 at the time of diagnosis. As a group, B-CLL patients had higher number of CECs (median of 26.5 cells/ml) compared (P = 0.04) to healthy controls (18.5 cells/ml). However, only four (20%) patients had elevated CEC counts, defined as >/=2 SD of the control mean (>/=53 cells/ml). The proportions of apoptotic (P = 0.83) and activated (P = 0.12) CECs were similar in both groups. B-CLL patients had higher FGF-2 (P < 0.001), lower TSP-1 (P = 0.004), and similar VEGF (P = 0.27) plasma levels. The number of CECs was not associated with Rai stage, absolute lymphocyte count, or levels of angiogenesis-related factors. CECs are increased in only a small fraction of B-CLL patients in our cohort with low rates of apoptosis and activation. While no correlation was found between CECs and clinical features, more studies in a larger patient sample size and advanced disease are necessary.

Clinical trial accrual among new cancer patients at a community-based cancer center.

BACKGROUND: To the authors' knowledge, only limited data are available regarding clinical trial accrual patterns and the barriers encountered among newly diagnosed patients seen at community-based cancer centers. METHODS: In the current study, the authors prospectively collected clinical and sociodemographic data from all adult patients seen at a community-based cancer center who had new cancers diagnosed between 2003-2004. Clinical trial enrollment decisions were noted and factors that prevented accrual were identified. RESULTS: There was a total of 1012 new cancer patients. In 587 patients (58%), clinical trials appropriate for the diagnosis and stage of disease were not available. Among those patients for whom trials were available, 19.8% did not meet eligibility criteria, and only 9.9% of patients were enrolled. Although more trials were found to be available for women compared with men (51% vs. 32%; P < 0.01), the accrual rates were equal (11.2% vs. 7.6%; P = 0.24). Elderly patients comprised approximately 59.4% of those patients with available trials, but they were less likely to be enrolled (5.1% vs. 16.8%; P < 0.01). The major barriers to nonparticipation can be grouped into protocol limitations (68.1%), physician triage (16%), and patient decisions (15.9%). The overall accrual rate when all patients were included was 4% (42 of 1012 patients). CONCLUSIONS: At the study institution, participation in clinical trials is reported to be low. The unavailability of appropriate clinical trials represents the most significant barrier. Continuing efforts to encourage physicians and to educate patients remain necessary. If the current study findings are found to be applicable to other community-based cancer centers, making a larger variety of clinical trials available to the community may help to improve the accrual of patients to national cancer clinical trials.