Medical practice on Tristan da Cunha--the remotest island community in the world.

Midway between Africa and South America, on the edge of the 'roaring 40s' (37°S 12°W) is an archipelago of five tiny volcanic islands. Tristan, a British Overseas Territory, is the largest--seven miles across and rising 7,000 feet above sea level. There is no airport, no air access except for an occasional ship's helicopter and no sheltered anchorage. The nearest port is over 1,700 miles away--a week or more by ship and the tiny harbour requires constant repair due to the impact of the relentless South Atlantic. Ship-to-shore travel is hazardous as passengers (and medevacs) are transferred sitting in a box hoisted by crane to a raft or rigid inflatable boat. Tristan has traditionally had a resident 'ships surgeon' or 'island doctor'; although these terms may not have changed, the training and experience to fill these roles have. The island needs a general physician with experience of primary care or a general practitioner with experience of secondary care. Additional training is required in surgical and gynaecological emergencies. The two authors between them had appropriate experience in general medicine, general practice, resuscitation and critical care and to be able to worry together is a better prospect than worrying alone--so a joint appointment for six months seemed sensible and was found to be effective.

Palliative care for patients with gastrointestinal cancer dying under surgical care: a case for acute palliative care units?

BACKGROUND AND AIMS: Patients with advanced gastrointestinal cancer may present late to hospital services and die under surgical care. The aim of this study was to examine end of life care in patients dying of gastrointestinal cancer in Scottish hospital surgical wards. METHODS: The Scottish Audit of Surgical Mortality prospectively peer reviews all inpatient deaths under the care of a consultant surgeon. Patients who died with gastrointestinal cancer under surgical care from 1994 to 2006 were evaluated for operative interventions, adverse events, and palliative care provision. Data was compared with inpatient data from the Information Statistics Division of NHS Scotland. RESULTS: A total of 8019 patients died with gastrointestinal cancer on a surgical ward over 12 years. For 4350 (54%), no operation or endoscopy was performed during the final admission and adverse events were identified in only 86 (2%) of these patients, most commonly due to a complication of an interventional procedures. Specialist palliative care was provided to 57% of patients and was not influenced by cancer site. CONCLUSION: A substantial proportion of patients die with gastrointestinal cancer on general surgical wards without operative or endoscopic intervention and may receive better end of life care in an acute palliative care setting.

Short-stay, specialist beds in a UK teaching hospital as a model to integrate palliative care into the acute hospital culture.

Hospital patients should have access to effective palliative care. In our study, three short-stay beds were re-allocated to specialist palliative care as part of a pilot programme. This paper describes the first 100 admissions of patients with inadequately controlled symptoms or distress. Median pain and distress scores were both seven out of a maximum of 10 (interquartile ranges [IQR] 4-10 and 1-10 respectively), reducing to 3.5 (IQR 1-5) and 0 (0-5) after 48 hours. Median length of stay was five days (IQR 3-10); 77% of patients were discharged: 32% to home, 26% to a hospice or community hospital, 19% to their original ward for treatment and 23% died in the unit. A unit education programme introduced as part of the study attracted 600 staff members. Pain and distress were rapidly improved by brief, intense palliative care in a small onsite facility. The pilot programme also influenced the understanding of palliative care in the hospital, demonstrating what it offered patients, family and staff. It demonstrated effective, concurrent working alongside an active disease-management approach, and encouraged collaborative discussions about the goals of care.

Perceptions of anxiety in lung cancer patients and their support network.

INTRODUCTION: Lung cancer is a disease of high symptom burden, major psychosocial impact and poor prognosis. Although diagnosis is individual, each patient operates within a social context. Patient perception of family's or friends' concern may affirm the presence of support or may drive personal anxiety. Perceived worry may impact on freedom to discuss illness or symptoms within the support network. The validated palliative outcome scale quantifies physical and psychosocial needs. It also evaluates anxiety felt and anxiety perceived in the support network. This study examined lung cancer patients' symptoms, performance status, their supportive care needs and their perception of family's/friends' anxiety. GOALS OF WORK: The aim of this study was to evaluate lung cancer patients' anxiety, physical symptoms, performance status and their perception of anxiety within their support network. PATIENTS AND METHODS: The study was a prospective observational evaluation of 170 lung cancer out-patients using an adapted palliative outcome scale questionnaire. Comparison was made between patients perceiving high anxiety within their support network and those who perceiving low anxiety. MAIN RESULTS: Perceived familial and self-rated personal anxiety both increased as function declined (p < 0.001; p = 0.001). Increased perceived worry was associated with increased physical symptoms [dyspnoea (p < 0.001), cough (p = 0.001), haemoptysis (p = 0.009)], low self-esteem (p = 0.004) and feeling lack of worth (p = 0.035). Perception of increased worry did not influence whether patients felt able to share their feelings (p = 0.362). CONCLUSIONS: As physical function declines and symptoms increase, patients are more worried themselves and perceive increased anxiety within their support network. However, this circle of anxiety did not impair the perception that feelings could be shared within the support network.

Suspected malignant cord compression - improving time to diagnosis via a 'hotline': a prospective audit.

The aim of the study was to achieve earlier diagnosis of malignant cord compression (MCC) using urgent magnetic resonance imaging (MRI) for selected patients. A comparison was carried out of the current prospective audit of 100 patients referred by a general practitioner or a consultant over 32 months with both a previous national Clinical Research and Audit Group (CRAG) prospective audit (324 cases of MCC) and an earlier retrospective audit of 104 patients referred with suspected MCC. A telephone hotline rapid-referral process for patients with known malignancy and new symptoms (severe nerve root pain +/- severe back pain) was designed. Patients were considered for urgent MRI after discussion with a senior clinician responsible for the hotline. Appropriate referrals were discussed with radiology and oncology ensuring timely MRI reporting and intervention. The main outcome measures are as follows: time from referral to diagnosis; time from the onset of symptoms to diagnosis; and mobility at diagnosis. A total of 50 patients (52%) of those scanned had either MCC (44) or malignant nerve root compression (6) compared with the earlier rate of 23 out of 104 patients (22%). Ten out of 44 MCC patients (23%) were paralysed at diagnosis, compared with 149 out of 324 (46%) in the CRAG audit. Time from reporting pain to diagnosis was 32 days compared with 89 days in the CRAG audit. Median time from referral to diagnosis was 1 day, again considerably shorter than the CRAG audit time of 15 days (interquartile (IQ) range: 3-66). In patients at risk of MCC, fast-track referral with rapid access to MRI reduces time between symptom onset and diagnosis, improves mobility at diagnosis and reduces the number of negative MRI scans.

What happens to people after malignant cord compression? Survival, function, quality of life, emotional well-being and place of care 1 month after diagnosis.

AIMS: To present further findings from the Scottish Cord Compression Study, in which the diagnosis, management and outcome of 319 patients with a definitive diagnosis of malignant cord compression (MCC) were examined. MATERIALS AND METHODS: In total, 256 (80%) patients in the study consented to be interviewed shortly after diagnosis and at follow-up interviews. One hundred and twenty-eight patients were interviewed 1 month after diagnosis (40% of the total; 57% [128/224] of patients alive 1 month after diagnosis; 68% [128/188] of patients who also consented to follow-up). Survival data of the whole MCC population and data from interviewing 128 patients 1 month after diagnosis are presented. RESULTS: The median survival of all patients was 59 days (95% confidence interval [CI] 43-75 days). The median Karnofsky performance status was 50 (interquartile range 40-60), indicating a need for considerable nursing and medical care, and was poorest for patients with lung cancer (median 40; interquartile range 30-60). The place of care was dependent on mobility at diagnosis; patients walking at diagnosis were more likely to be at home, whereas patient requiring assistance or who were unable to walk were more likely to be in institutional care (P = 0.019). Mobility and bladder function were determined by mobility and bladder function at diagnosis (P < 0.001). Of those unable to walk at diagnosis, 7% regained full mobility. Of those catheterised at presentation, 28% regained full bladder function. Forty-seven per cent (56/120, 95% CI 40-54) of patients interviewed were in pain despite oncological treatment and 18% (22/ 120; 95% CI 8-19) reported the pain as severe (visual analogue scale > 7). The median quality-of-life (Schedule for Evaluation of Individualised Quality of Life) score was 72/100, and was higher in patients with a better performance status (P = 0.026). A minority of patients (8%) screened positive for anxiety and depression using the Hospital Anxiety and Depression scale. CONCLUSIONS: Notwithstanding the difficulties in following up this group of patients, this paper reports valuable findings detailing the experience of patients with MCC 1 month after diagnosis and treatment.

Listen to the patient: quality of life of patients with recently diagnosed malignant cord compression in relation to their disability.

Quality of life (QOL) was determined using the shortened version of the Schedule for the Evaluation of Individual Quality of Life (SEIQoL-Dw), in 180 patients, shortly after a diagnosis of malignant cord compression. The median SEIQoL score was 66 (maximum 100). Twenty-five per cent of patients had a score >83. SEIQoL correlated with KPS (P<0.004) but the range of scores for each level of performance was very wide. Although there was an association between SEIQoL and ability to walk, the difference was small and not significant. SEIQoL was adversely affected by emotional distress as measured using HAD (P<0.01), although few patients were identified as being severely depressed. The findings are a reminder that QOL as determined by the patient may not coincide with health professionals' opinions.

Don't wait for a sensory level--listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression.

AIM: To report details concerning symptoms (especially pain) preceding the development of malignant cord compression (MCC); delays between onset/reporting of symptoms and confirmed diagnosis of MCC; accuracy of investigations carried out. METHODS: A prospective observational study examined the diagnosis, management and outcome of 319 patients diagnosed with MCC at three Scottish cancer centres between January 1998-April 1999. The process was considered from the perspectives of the patient, the GP and the hospital doctor. RESULTS: At diagnosis, most patients (82%) were either unable to walk or only able to do so with help. Pain was reported by nearly all patients interviewed (94%) and had been present for approximately 3 months (median=90 days). It was severe in 84% of cases, with the distribution and characteristics of nerve root pain in 79%. The site of pain did not correspond to the site of compression. Where reported, weakness and/or sensory problems had been noticed by the patient for some time before diagnosis (median intervals 20 and 12 days, respectively). Most patients reported early symptoms to their General Practitioner (GP) and diagnosis was established, following referral and investigation, approximately 2 months (median=66 days) later. CONCLUSION: Patients who develop spinal metastases are at risk of irreversible spinal cord damage. Weakness and sensory abnormalities are reported late and identified even later, despite patients having reported pain for a considerable time. Patients with cancer who describe severe back or spinal nerve root pain need urgent assessment on the basis of their symptoms, as signs may occur too late. Plain films and bone scans requested for patients in this audit predicted accurately the level of compression in only 21% and 19% of cases, respectively. The only accurate investigation to establish the presence and site of a compressive lesion is magnetic resonance imaging (MRI). A referral guideline based on suspicious symptoms in addition to suspicious signs is suggested.

The knowledge and attitudes of surgical staff towards the use of opioids in cancer pain management: can the Hospital Palliative Care Team make a difference?

The principles of cancer pain management are well established, but evidence suggests that these are not incorporated into daily practice and patients are still in pain. Deficiencies in knowledge and inappropriate attitudes towards the use of opioids may partially explain why the management of cancer pain is still such a widespread problem. This study assessed the knowledge and attitudes of 135 nursing and medical staff working in a surgical unit, before and after working with a newly established Hospital Palliative Care Team. The baseline survey highlighted the existence of a number of myths and misconceptions in relation to opioid use. Results of the follow-up survey indicated that the knowledge and attitudes of doctors and nurses had improved after working with the team, but that this probably occurred as a result of good working relationships and case discussions rather than through formal teaching. The study provided a useful method of identifying deficiencies in knowledge and attitude among staff, and helped to raise awareness of the problem of cancer pain management. Our challenge now is to work with staff to ensure that positive changes in knowledge and attitudes are translated into the everyday practice of hospital nurses and doctors caring for patients with cancer.

Identification of long-term survivors in primary breast cancer by dynamic modelling of tumour response.

Although clinical response to primary chemotherapy in stage II and III breast cancer is associated with a survival advantage, it is the degree of pathological response in the breast and ipsilateral axilla that best identifies patients with a good long-term outcome. A mathematical model of the initial response of 39 locally advanced tumours to anthracycline-based primary chemotherapy has been previously shown to predict subsequent clinical tumour size. This model allows for the possibility of primary resistant disease, the presence of which should therefore be associated with a worse outcome. This study reports the application of this model to an additional five patients with locally advanced breast cancer, as well as to 63 patients with operable breast cancer, and confirms the biological reality of the model parameters for these 100 breast cancers treated with primary anthracycline-based chemotherapy. The tumours that responded to chemotherapy had higher cell-kill (P < 0.0005), lower resistance (P < 0.0001) and slower tumour regrowth (P < 0.002). Furthermore, ER-negative tumours had higher cell-kill (P < 0.05), as compared with ER-positive tumours. All patients with a pathological complete response had zero resistance according to the model. Furthermore, the long-term implication of chemo-resistant disease was demonstrated by survival analysis of these two groups of patients. At a median follow-up of 3.7 years, there was a statistically significantly worse survival for the 37 patients with locally advanced breast cancer identified by the model to have more than 8% primary resistant tumour (P < 0.003). The specificity of this putative prognostic indicator was confirmed in the 63 patients presenting with operable disease where, at a median follow-up of 7.7 years, those women with a resistant fraction of greater than 8% had a significantly worse survival (P < 0.05). Application of this model to patients treated with neoadjuvant chemotherapy may allow earlier identification of clinically significant resistance and permit intervention with alternative non-cross-resistant therapies such as taxoids.

Primary systemic therapy for operable breast cancer--10-year survival data after chemotherapy and hormone therapy.

Between 1984 and 1990, 94 women presenting to the Edinburgh Breast Unit with operable breast cancer of 4 cm or greater in diameter (T2, T3, N0, N1, M0) were given preoperative systemic therapy. Initially, all women received hormone therapy, with CHOP (cyclophosphamide 1 g m(-2), doxorubicin 50 mg m(-2), vincristine 1.4 mg m(-2) to a maximum of 2 mg and prednisolone 40 mg per day orally for 5 days) chemotherapy being administered to those who failed to respond by 3 months. After April 1987, first-line hormone therapy was only offered to women with oestrogen receptor (ER)-moderate/-rich (> 20 fmol mg(-1) protein) tumours, and CHOP was reserved for those women whose tumours failed to respond to hormone therapy and for those with ER-negative/-poor tumours. Response data have been published previously (Anderson et al, 1991). After a median follow-up of 7.5 years, there is no difference in survival between those women given initial hormone therapy and those given chemotherapy, with neither group having yet reached its median survival. The two key factors that predicted for a poor survival were the number of involved axillary nodes after preoperative systemic therapy (P < 0.00001) and a lack of response to preoperative therapy (P < 0.05). These data suggest that many women with ER-moderate/-rich tumours will have a good prognosis after preoperative hormone therapy alone. However, it is possible to identify, by their post-systemic therapy axillary node status, a group of women who still have an appalling prognosis after preoperative chemotherapy or hormone therapy.

Does the oestrogen receptor concentration of a breast cancer change during systemic therapy?

The effect of systemic therapy on tumour oestrogen receptor (ER) concentration has been studied in 88 patients with large, operable, primary tumours (total 89) of the breast. In 26 patients, tumour was not available for study on one occasion (usually post-treatment). Forty-five patients were treated initially by endocrine therapy but, of these, 13 who had failed to respond went on to receive chemotherapy also. Seventeen patients with low concentrations of ER (less than 20 fmol mg-1 protein) were treated directly by chemotherapy. Patients underwent an incisional biopsy for confirmation of diagnosis and determination of pre-treatment ER by radioligand binding assay, followed by systemic therapy for 3 months (or 6 months for both endocrine and cytotoxic therapies). Response was assessed clinically and mammographically before mastectomy. ER concentration was then determined in the post-treatment tumour specimen. No significant change in ER concentration was seen in any treatment group except when the patients had received tamoxifen; there, receptor concentration fell to very low levels, presumably due to interference with the assay. There was no relationship between tumour response to systemic treatment and change in ER concentration. It is concluded that changes in ER concentration are unlikely to play a major role in the early response of breast tumours to systemic therapy.

Response to endocrine manipulation and oestrogen receptor concentration in large operable primary breast cancer.

Forty-three patients with large (greater than or equal to 4 cm) but operable carcinoma of the breast have been treated by endocrine manipulation before definitive local surgery. This has allowed the study of the relationship between response to therapy and pretreatment oestrogen receptor (ER) concentration, as measured by a dextran-coated charcoal adsorption method. Premenopausal patients (17) were treated by surgical (4) or medical (13) oophorectomy. Post-menopausal patients (26) received either tamoxifen (10) or an aromatase inhibitor (16). Response was assessed from statistical analysis of the changes in tumour size. On completion of 12 weeks of endocrine therapy, there was significant regression of tumour size in 18 of the 43 patients. All 18 patients had tumours with ER concentrations of greater than or equal to 20 fmol mg-1 cytosol protein. Conversely all patients except one progressing on treatment had tumours with ER concentrations of less than 20 fmol mg-1 cytosol protein. This relationship applied for both premenopausal and post-menopausal patients. The overall response rate of patients with tumours of ER concentration greater than or equal to 20 fmol mg-1 cytosol protein was 60%.

The cytochemical detection of oestrogen receptors in fine needle aspirates of breast cancer; correlation with biochemical assay and prediction of response to endocrine therapy.

A total of 98 breast aspirates from patients with breast cancer have been fixed and stained for oestrogen receptors using the Abbott ERICA kit. In a preliminary series of 41 aspirates, cytochemical staining index (% cells staining x mean intensity) related to the receptor concentration determined biochemically on a subsequent biopsy with a correlation coefficient of +0.65. In a second series of 56 aspirates examined after lysis and cytocentrifugation, the correlation coefficient was +0.73. For 14 patients, the response of the primary tumour to endocrine therapy was assessed objectively by serial clinical and mammographic measurements (Forrest et al., 1986) and was found to relate strongly to the cytochemical staining of the initial aspirate. The potential and limitations of this technique are discussed.

DNA analysis of breast tumour fine needle aspirates using flow cytometry.

Cellular DNA was analysed by flow cytometry in fine needles aspirates (FNA) from both benign and malignant breast lesions in order to determine the feasibility of flow cytometric analysis. In 22 of 26 (84%) benign and 69 of 74 (93%) malignant aspirates, sufficient cells were present to produce good quality DNA histograms. DNA in all 22 benign lesions was diploid. In contrast, of the 69 cancers with sufficient cells for analysis, 40.6% had a diploid DNA content alone, whilst 59.4% had an additional DNA aneuploid line. These results indicate that the majority of FNAs provide sufficient material for flow cytometric analysis of DNA profiles. Such aspirates taken in a sequential manner may also prove to be an ideal method of studying tumour response to therapy.

Role of fine needle aspiration cytology in breast cancer screening.

In a six year period up to the end of December 1985 fine needle aspiration cytology specimens of the breast were obtained from 562 apparently healthy women invited to participate in a breast cancer screening programme. Of these, 397 had a biopsy and 173 cancers were confirmed histologically. For the diagnosis of cancer, the procedure was less successful than in symptomatic cases. The main factors influencing success were the aspirator, the small size of many cancers, and the occult nature of the lesions seen only on mammography. Retrospective analysis of the figures shows that combining the results of FNA cytology in a triple assessment with physical and mammographical findings for restricted selection means that the number of benign biopsy specimens could be reduced considerably.