Cancer prevention & control : CPC = Prevention & controle en cancerologie : PCC最新文献

Guideline question: Is there a role for the use of gemcitabine in the treatment of patients with locally advanced or metastatic non-small-cell lung cancer (NSCLC)?

Objective: To make recommendations about the use of gemcitabine in the management of medically appropriate patients with stage IIIB-IV NSCLC.

Outcomes: The outcomes of interest were survival, response rate, symptomatic response, response duration and toxicity.

Perspective (values): Evidence was selected and reviewed by 2 members of the Provincial Lung Cancer Disease Site Group (DSG) of the Cancer Care Ontario Practice Guidelines Initiative. The practice guideline report was reviewed by the Provincial Lung Cancer DSG and by the Systemic Treatment Disease Site Group. These committees comprise medical and radiation oncologists, surgeons, pathologists, nurses, a psychologist, a medical sociologist and administrators. One community representative participated in the development of this practice guideline.

Quality of evidence: Five phase II studies of single-agent gemcitabine in advanced NSCLC were reviewed. Four of these are published as full reports. Two randomized phase II studies comparing single-agent gemcitabine with etoposide plus cisplatin were also reviewed. One of these studies is fully published. Seven phase II studies of gemcitabine in combination with cisplatin and I phase II study of gemcitabine in combination with ifosfamide were reviewed. Three randomized controlled trials (RCTs) and 1 randomized phase II study, published in abstract form, compared gemcitabine combination chemotherapy with cisplatin combination chemotherapy. An additional phase II study, published in abstract form, of gemcitabine as salvage therapy in previously treated patients was also included.

Benefits: Four phase II studies of single-agent gemcitabine at a dose of 1000 mg/m2 or more showed a combined response rate of 19% (intention-to-treat analysis; 95% confidence interval [CI] 15% to 24%) or 21% (efficacy analysis; 95% CI 17% to 26%) in advanced NSCLC. Median survival ranged from 7 to 9 months. Improvement from baseline in cough, hemoptysis and dyspnea was comparable to what would be expected with radiation therapy and with standard combination chemotherapy regimens. Improvement from baseline in their performance status was reported in 52% of treated patients. The 2 randomized phase II studies reported equivalent response rates for gemcitabine compared with etoposide plus cisplatin; the response data were pooled, which resulted in a nonsignificant benefit for gemcitabine (common odds ratio [OR] 0.90; 95% CI 0.43 to 1.90; p = 0.78). Gemcitabine has most frequently been combined with cisplatin, yielding a combined response rate of 44% (intention-to-treat; 95% CI 36% to 47%) or 45% (efficacy; 95% CI 39% to 51%) from 7 phase II studies. Median survival times ranged from 10

Objective: To describe the knowledge, practices and perspectives of Canadian family physicians regarding ovarian cancer.

Design: A mailed survey questionnaire was followed by a reminder card, a second mailing of the questionnaire and a final reminder card.

Setting: A national sample of family physicians was drawn randomly from the membership database of the College of Family Physicians of Canada.

Main outcome measures: Knowledge related to ovarian cancer. Practices related to the screening and detection of ovarian cancer. Attitudes towards screening for ovarian cancer. Perceived role in the care of women at risk of, or diagnosed with, ovarian cancer. Perceived educational needs of physicians.

Results: A total of 1079 completed questionnaires were returned, providing a response rate of 56.6%. Although most family physicians were aware of the basic facts about ovarian cancer, there were knowledge limitations related to risk factors, familial ovarian cancer syndromes and symptoms. Practices related to asymptomatic women were found to be mostly in accord with current guidelines and recognized the prevailing lack of evidence for the effectiveness of tests. Areas that were troublesome included the role of screening in high-risk women and knowledge about available tests. Most family physicians indicated that they have an important role to play in the care of women after they have been diagnosed with ovarian cancer. They also expressed a high level of interest in obtaining additional information related to ovarian cancer.

Conclusions: This study clearly shows that there is a need for additional research to assist with the development of evidence-based guidelines for women at increased risk of ovarian cancer and for women at no known risk. Pending more definitive evidence, interim guidelines could provide assistance to physicians currently having to make decisions in a context of massive uncertainty. Canadian family physicians would be interested in and would benefit from continuing medical education (CME) initiatives concerning ovarian cancer.

Medical educators at undergraduate, postgraduate and continuing medical education levels acknowledge that communication is a fundamental medical skill. Responding to patient, professional and governmental advocates, as well as to advances in research on patient-physician communication and its teaching, some medical educators are in the process of starting new communication curricula, while others are working at expanding, integrating and further developing already well-established programs. For most people working in this area, the question is no longer whether to teach and assess communication skills and attitudes but, rather, how to do so most efficiently and effectively. In order to enhance the development of communication curricula at all levels, we first provide a brief look at how communication education has become widely encouraged in many parts of the globe, and we set out the underlying assumptions that frame the teaching and learning of communication in medicine. We then summarize critical components common to many established communication curricula and identify a series of specific strategies for teaching communication skills. We include a chart that describes a sample of the wide variety of resources available to assist in the development and teaching of communication curricula in medicine. Finally, we consider gaps in current communication curricula and suggest the next steps and ideas for moving forwards.

The patient-doctor relationship is central to medicine. From this relationship, duties and obligations are derived; within this relationship, hopes and expectations are set. Communication is essential in this relationship and evidence-based efforts directed at improving it are a key element in improving care. At an even deeper level, critical reflection reveals fundamental values operating within and beneath this discourse that must be addressed if the goals of improving communication are to be achieved in a meaningful way. This is the stuff of the ethics of patient-physician communication. Because these values are so deeply embedded in the speech and actions of physicians, insights are best provided by those who are observers of the discourse rather than by participants. Observations from the history and sociology of physician communication, literary analysis and reflections on the illness experience by women provide important insights into the values and attitudes underlying physician communication, which must be taken into account in the education of physicians if the outcome is to benefit all participants.

Objective: To inform the reader of the objectives of staging classification, and review history of the development of modern staging classifications in cancer.

Design: Review of the literature documenting the development of modern cancer staging systems with the emphasis on the history of the development of the TNM classification by the UICC and the history of the Canadian Committee on Cancer Staging. The underlying principles of the TNM system have been reviewed in the context of modern cancer practice.

Conclusion: In the era of the multidisciplinary approach to cancer management, staging allows precision in documenting disease extent, thereby enhancing the quality of patient care. The recording of cancer stage at diagnosis is necessary to optimise patient care and provides a valuable means for recording patterns of disease presentation and monitoring advances in diagnosis and therapy. The objectives of staging described in the TNM staging system are as valid today as when implemented almost 50 years ago.

The Canadian Council on Health Services Accreditation has a mission to promote excellence in the provision of quality health care and the efficient use of resources in health organizations throughout Canada. The products and services of the CCHSA include national standards, onsite surveys and field education. The present standards of this voluntary, nonprofit national organization recognize the importance of cancer staging as an activity to evaluate the extent of disease in cancer patients and require cancer stage to be recorded. The CCHSA is implementing the next generation of accreditation, the Achieving Improved Measurement (AIM) project, which will lead to improved measurement of quality of health care. These quality-improvement efforts will emphasize the process of recording and reporting the TNM stage in all appropriate new cases of cancer.

All sectors of the cancer control community in Canada agree that cancer staging is useful, and that stage should be assigned to every new case. At present, however, staging is not always recorded in the patient's records and treatment patterns and outcomes are rarely reported in terms of stage. This paper discusses what needs to be done to promote the use of staging in Canada. It is concluded that multifaceted programs of interventional continuing education (CE), tailored to meet the needs of the particular institution, offer the best prospect of success but the necessary organizational structure and information systems have to be put into place in advance. Implementation programs should be based on a thorough evaluation of the particular needs of the institution or community, and should be evaluated carefully in a few institutions before an attempt is made to disseminate them more widely. We recommend a phased approach to implementation which will first target institutions that already have the necessary infrastructure, i.e., provincial cancer centres. Demonstration of the feasibility and value of staging in that setting is seen as a means of promoting the adoption of staging in other institutions.

Objective: 1. To present the steps taken and lessons learned from one cancer centre's efforts to capture tumour stage information in a cancer database. 2. To determine the accuracy of the stage data through a chart audit. 3. To describe the potential uses of stage information in a cancer centre.

Design and setting: This is a retrospective review of an initiative to capture tumour stage information at a regional cancer centre in Ontario.

Data sources: The minutes of the centre's Health Records and Medical Advisory Committees related to staging were reviewed. Data on stage by tumour type was extracted from the centre's Oncology Patient Information System (OPIS). Three hundred and ninety charts were analysed to assess the accuracy of stage information and identify staging errors. Health Information Services workload statistics were reviewed to determine the types and frequency of projects undertaken using stage-related data.

Results: In January 1994, the Ottawa Regional Cancer Centre introduced policies and procedures to capture stage-related information. Standardized staging forms and a physician reminder system encouraged the centre's physicians to record tumour stage within 3 months of new patient registration. Of all qualifying cases in 1994, 92% were staged. A medical audit in 1998 of 390 charts from the 3 previous years of staging data revealed that 71.5% of the charts reviewed had been staged completely. Of the incompletely staged cases, 19% to 57% had TNM recorded, but the stage grouping was not recorded, or the "stage" was the extent of disease at the time of disease progression rather than at initial diagnosis (35% to 71%). Physician-related staging errors occurred in 2% to 5% of cases; data-entry errors occurred in 3% to 6% of cases.

Conclusions: Stage information has enabled the centre to better describe its patient clientele for accreditation purposes and to assist researchers in estimating the number of patients potentially available for prospective and retrospective studies. It is being used to guide targeted educational initiatives to selected populations in the region's catchment area and assists administrators in estimating resource needs. Resistance to the capture of stage information can be overcome with persistence, the development of procedures that facilitate physician compliance, including a reminder system, the development of institutional policies and procedures and by feedback on the uses and availability of stage information.