Pivotal role of families in doctor-patient communication in oncology: a qualitative study of patients, their relatives and cancer clinicians.

Families are a unique source of support for many cancer patients. Most advanced communication skills training for oncologists are patient centred and do not cover interactions with family members. The current study used in-depth qualitative interviews of patients, relatives and cancer clinicians with thematic analysis to explore the role of family members in the communication process. Forty-one participants included 10 cancer patients, 10 relatives ensuring proportionate representation of both gender and primary cancer site and 21 doctors representing both medical and surgical oncology. Nineteen of 20 patients and relatives wanted an "open and honest" discussion with their doctors. All patients, relatives and doctors preferred involvement of the family at most stages of cancer treatment. Five themes were identified in relation to communication with family members. The participants highlighted the "importance of family for physical and psychological care," they emphasised the need to "balance patient autonomy and relatives desire to be protective" using varied "negotiating strategies" that are influenced by "socioeconomic circumstances of both patient and family." The doctor-patient-relative communication process was not static with preferences changing over time. The data suggests that communication skills training of cancer clinicians should incorporate modules on better communication with relatives.

Arginine dependence of tumor cells: targeting a chink in cancer's armor.

Arginine, one among the 20 most common natural amino acids, has a pivotal role in cellular physiology as it is being involved in numerous cellular metabolic and signaling pathways. Dependence on arginine is diverse for both tumor and normal cells. Because of decreased expression of argininosuccinate synthetase and/or ornithine transcarbamoylase, several types of tumor are auxotrophic for arginine. Deprivation of arginine exploits a significant vulnerability of these tumor cells and leads to their rapid demise. Hence, enzyme-mediated arginine depletion is a potential strategy for the selective destruction of tumor cells. Arginase, arginine deiminase and arginine decarboxylase are potential enzymes that may be used for arginine deprivation therapy. These arginine catabolizing enzymes not only reduce tumor growth but also make them susceptible to concomitantly administered anti-cancer therapeutics. Most of these enzymes are currently under clinical investigations and if successful will potentially be advanced as anti-cancer modalities.

Repeating cytology at initial colposcopy does not improve detection of high-grade abnormalities: a retrospective cohort study of 6595 women.

OBJECTIVE: To determine if repeating a smear improves detection of high-grade pre-invasive or invasive disease of the cervix compared with women who do not have a repeat smear at the time of the initial colposcopic assessment for referral of an abnormal smear. DESIGN: Retrospective cohort study. SETTING: All Wales Colposcopy database. POPULATION: The cohort included women referred for colposcopy with an abnormal smear result, who were seen between 1st January 2002 and 31st December 2002. METHOD: The management of the group of women who had a repeat smear was compared with the group who did not have a repeat smear test at their first visit. Confidence interval analysis was used to compare results between the two groups. MAIN OUTCOME MEASURE: The positive predictive value and sensitivity of the repeat smear to predict outcome, compared to the referral smear in cases where a smear was not repeated at the colposcopy clinic. RESULTS: 3505 cases (54.0%) did not have a repeat smear at initial colposcopy, whereas 2990 (46%) did. There was a significantly higher rate of referral for low-grade dyskaryosis in the group who had repeat smear testing. The median time interval from the referral smear to the first colposcopy was 49 days for both groups. The specificity and positive predictive value for high-grade lesions were significantly higher in the repeat smear results. The sensitivity was significantly lower, and a high-grade lesion would have been missed with the repeat smear in 14.0% of all referrals. CONCLUSIONS: Colposcopists appeared more inclined to repeat smears for low-grade referrals. The time interval from the referral smear to colposcopy did not appear to influence this decision. A repeat smear test at the first colposcopy visit will detect less high-grade pre-invasive or invasive disease than the initial referral smear.

Safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles in vaginal hysterectomy: randomised controlled trial.

OBJECTIVE: To assess the safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles during vaginal hysterectomy in comparison with the conventional method of securing the pedicles by suture ligation. DESIGN: Randomised controlled trial. SETTING: Gynaecology Department, Benenden Hospital, Kent. POPULATION: One hundred and sixteen women undergoing vaginal hysterectomy were prospectively randomised to either LigaSure (Group I) or suture ligation (Group II) for securing the pedicles. METHODS: Data of patients were collected prospectively. Statistical analysis was performed using the Mann-Whitney U test, chi(2) and Fisher's exact test as appropriate. MAIN OUTCOME MEASURES: Operating time, operative blood loss and peri-operative complications. RESULTS: The operating time was significantly shorter in the LigaSure group compared with the control group (P < 0.04). There was no statistical significant difference between the two groups in operative blood loss (P= 0.433), but peri-operative haemorrhagic complications were less frequent in the LigaSure group (0%vs 6.8%, P= 0.057). Four patients in the control group required either conversion to laparotomy because of bleeding, return to theatre for immediate post-operative haemorrhage or readmission for vault haematoma, whereas none in the LigaSure group had bleeding from unsecured pedicles. CONCLUSION: The LigaSure vessel sealing system is a safe alternative for securing pedicles in vaginal hysterectomy when compared with conventional suture ligation. Larger studies are required to determine its place in gynaecological surgery.

The inadequate smear: does it matter?

The objective of this study was to quantify the incidence of underlying cervical intraepithelial neoplasia (CIN) among women referred for colposcopy with three consecutive inadequate smears. The design was a retrospective cohort study analysing data from a regional colposcopy database at Cervical Screening Wales. Women who were referred to all the colposcopy clinics in Wales with three consecutive inadequate smears, the third inadequate smear being taken between 1 April 2001 and 31 March 2002 constituted the study population. The results of the fourth smear taken at the colposcopy clinic after three consecutive inadequate smears, the worst biopsy results from any of the subsequent colposcopies and the relationship between the result of the fourth smear taken at colposcopy clinic and any histology result were the main outcome measures. The accuracy of the colposcopic opinion was also examined. Of the 433 women identified as having been referred because of three consecutive inadequate smears, 302 were linked to either a subsequent smear and/or a biopsy result. An adequate smear result was available for 85% of these women when the smear was taken in the colposcopy clinic; 77% were reported as negative and 8% were abnormal. Of the 347 women seen in the colposcopy clinic, high-grade CIN was seen in 3% and low-grade lesion in 8%. The sensitivity and specificity of the fourth inadequate smear test in predicting underlying CIN were 15% and 84% respectively, with a positive predictive value of 8%. The sensitivity and specificity of colposcopy in predicting histological CIN among patients with three inadequate smears was 70% and 49%, respectively, and the positive predictive value was 44%. This study raises the question as to whether three consecutive inadequate smears should be considered as an indication for colposcopy, or merely for a further smear to be taken in circumstances where there is a greater likelihood getting an adequate result.

The value of human papillomavirus testing in the colposcopy clinic.

The aim of the study was to investigate if human papillomavirus (HPV) testing can help in treatment and management decision-making in patients referred to the colposcopy clinic with mildly dyskaryotic or borderline smears. Fifty-five patients referred to the colposcopy clinic in Benenden Hospital with mildly dyskaryotic or borderline smears had HPV testing in addition to colposcopy. Twenty-eight patients had a negative HPV test and normal colposcopy and were discharged back to their general practitioners for cytological surveillance. The most recent smear results of these 28 patients were obtained from their general practitioners to assess if any patient had progressed to a higher-grade smear. Twenty-one (75%) replies were obtained and in 17 (80.9%) patients smear results had regressed to normal. Three continued to have borderline or mildly dyskaryotic smear and one had progressed to moderate dyskaryosis. Our conclusion was that in the presence of normal colposcopic findings in patients with mildly dyskaryotic or borderline smears, negative HPV status justifies referral back to the general practitioner for cytological surveillance, thus reducing workload and cost.

Sacrospinous cervicocolpopexy with uterine conservation for uterovaginal prolapse in elderly women: an evolving concept.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of the performance of sacrospinous cervicocolpopexy with uterine conservation in the treatment of uterovaginal prolapse in women over the age of 60 years. STUDY DESIGN: This was a nonrandomized prospective controlled study. Between February 1996 and January 2001, 109 women above the age of 60 years with a complaint of symptomatic uterovaginal prolapse were treated with either sacrospinous cervicocolpopexy with uterine conservation or vaginal hysterectomy concomitant with sacrospinous colpopexy. Patients were reviewed at 6 weeks and 6 and 12 months after operation and then yearly thereafter. Preoperative patient characteristics, operative, and postoperative events and follow-up results were recorded. RESULTS: During the study period, 61 patients (56%) underwent sacrospinous cervicocolpopexy with uterine conservation (group A), whereas 48 patients (44%) had vaginal hysterectomy performed concomitantly with sacrospinous colpopexy (group B). The mean age for the two groups was comparable (70.1 +/- 6 years vs 69.4 +/- 4.6 years, respectively; P =.8). Group A had significantly less blood loss (P <.01), shorter operating time (P <.01), and fewer complications after surgery (P =.01) compared with group B. After a mean follow-up period of 33 and 34 months, respectively, the two groups had comparable success rates with regard to uterine and upper vaginal support (93.5% and 95.9%, respectively; P =.6). Recurrent cystocoele developed in 11.4% and 10.4% of groups A and B, respectively (P =.9). Within the follow-up period, 3 patients (5%) in group A and 2 patients (4.2%) in group B underwent repeat operation for recurrent uterovaginal or vault prolapse. CONCLUSION: Sacrospinous cervicocolpopexy with uterine conservation is a safe and effective surgical option that could benefit elderly patients with uterovaginal prolapse. It avoids the potential morbidity of vaginal hysterectomy and is associated with a high success rate.

Sexual function after using tension-free vaginal tape for the surgical treatment of genuine stress incontinence.

OBJECTIVE: To determine whether the use of the tension-free vaginal polypropylene tape (TVT) procedure for the treatment of genuine stress incontinence (GSI) affects sexual activity. PATIENTS AND METHODS: Sixty-seven women treated by insertion of a TVT between September 1998 and March 2001 for GSI were sent questionnaires 6-36 months after surgery to determine any urinary symptoms, sexual activity, patient satisfaction and the use of hormone-replacement therapy. RESULTS: The questionnaire was returned by 57 patients (87%); 43 (76%) reported being sexually active and 14 (25%) were not. Of the former, 31 (72%) reported no change in sexual function after surgery and only two reported an improvement; six (14%) reported that sexual function was worse and four did not reply to the questions. The patients reporting that sexual function was worse cited loss of libido as the main reason. No patients complained of dyspareunia. CONCLUSIONS: There was no significant change in sexual function or activity after the TVT procedure and patients can thus be reassured that this operation will not affect their sex life.