Search

This paper presents the results of a multi-method research project investigating the psychological distress associated with waiting for results of diagnostic investigations in a delayed-results breast clinic. A cohort of 126 women completed standardized psychometric instruments to assess anxiety, mood and coping over 3 days. Semi-structured interviews were conducted with 20 respondents. The findings indicate that waiting sustained but did not exacerbate psychological distress. Peri-diagnostic anxiety, depression, uncertainty and confusion were associated with anxiety levels immediately following triple assessment. Women leaving the clinic with low anxiety retained this composure throughout the peri-diagnostic period. Those in the moderate and high anxiety groups recorded sustained anxiety, depression, uncertainty and confusion, with mean scores comparable to and exceeding those reported by psychiatric out-patients. Coping during the waiting period was typically accomplished by emotion-focused strategies. Qualitative data suggested the delayed-results clinic structure may facilitate psychological preparation for test results.

Objective: Tumour vascularity can be assessed in-vivo using Doppler ultrasound. The purpose of this study was to determine whether Power Doppler imaging (PDI) better differentiates benign from malignant breast masses than conventional Colour Doppler imaging (CDI) on the basis of assessment of tumour vascularity. Methods: One-hundred women with solid breast lumps (51 malignant lesions, 49 benign lesions) were investigated using a Toshiba SSA-270A ultrasound machine with a 5.0 MHz (3.75 MHz Doppler reference frequency) or a 7.5 MHz (5.0 MHz Doppler reference frequency) linear array probe. The vascularity within or at the periphery of the mass was subjectively assessed from the CDI and Power Doppler images by two independent observers. It was assumed that the absence of vascularity indicated benignity and the presence of flow malignancy. Results: CDI showed sensitivities of 62 and 42% and specificities of 62 and 62% using the 5 and 7.5 MHz probes respectively. PDI showed sensitivities of 76 and 51% and specificities of 56 and 48% using the 5 and 7.5 MHz probes respectively. A comparison of images of the 59 lesions investigated with both probes on both CDI and PDI concluded that the 5 MHz (3.75 MHz DRF) probe displayed equal vascularity to the 7.5 MHz (5.0 MHz DRF) probe in 76% of cases and greater vascularity in 24% of cases on CDI, and 68 and 31% of cases respectively on PDI. Conclusion: Power Doppler imaging with a 5 MHz (3.75 MHz DRF) probe increases the sensitivity of Doppler ultrasound to malignant breast tumours but the sensitivity achieved is not high enough to propose it as a screening investigation.

The data on 91 patients (aged 30–78 years) with inoperable locally advanced breast cancer treated by primary chemotherapy and radiation therapy from 1980 to 1995 in the Breast Oncology Unit, Cardiff were analysed. Four chemotherapy regimens were used: 1) doxorubicin 40 mg/m 2 + vincristine 1 mg/m 2 (AV), three cycles; 2) mitozantrone 14 mg/m 2 (MZ), three cycles; 3) cyclophosphamide 600 mg/m 2 , methotrexate 40 mg/m 2 , 5-fluorouracil 600 mg/m 2 (CMF), six cycles; 4) cyclophosphamide 600 mg/m 2 , adriamycin/epirubicin 50 mg/m 2 , 5-fluorouracil 600 mg/m 2 (CAF/CEF), six cycles. The breast and glandular areas were irradiated to 40–50 Gy in 15–25 fraction (+/-5–10 Gy boost in two-to-five fractions. The overall response rate to chemotherapy was 61% (95% confidence interval 51–71%) with 13% CR (6–20%). Thirteen patients underwent mastectomy for operable persistent disease. Ten patients had uncontrolled inoperable local disease after primary therapy; 61 patients have relapsed, 69% due to metastases, (15% synchronous with local relapse), 31% local failure only. The overall 2−, 5− and 10-year survival rates are 54% (42–66%), 28% (16–40%) and 11% (1–21%) respectively. These results confirm that metastasis rather than local failure dictates the poor outcome in these patients and that breast conservation can be achieved.

139 peri- and postmenopausal women with advanced or recurrent breast cancer who had not received prior hormonal therapy were randomised in an open, cross-over study comparing the synthetic progestogen megestrol acetate with tamoxifen. The response rate (CR/PR) to megestrol acetate (25%; 95% confidence interval (CI) 15-35%) was not significantly different from that produced by tamoxifen (33%, CI 22-44%). Time-to-treatment failure was also similar in the two groups. Cross-over treatment was given on progression in 76 cases. Cross-over response (CR/PR) was seen in 3 of 35 patients (9%) receiving megestrol acetate as second-line therapy and in 6 of 41 patients (15%) receiving tamoxifen second-line. There was no significant difference in survival between the groups (P = 0.17) with median survival times of 24 and 32 months for the megestrol acetate and tamoxifen groups, respectively. The toxicity profile of the two drugs was different, although significant toxicity was rare with either agent. Megestrol acetate is an effective treatment for advanced breast cancer in older women when used either as first- or second-line treatment. Cross-over response is seen following both treatments. Given that most patients now receive tamoxifen as adjuvant treatment, megestrol acetate would appear to be one of the logical choices for patients who find the side-effects of tamoxifen unacceptable and for those who relapse on tamoxifen with further hormone therapy being clinically indicated.

To our knowledge, a chronic expanding haematoma has not been reported in a patient who received silicone gel breast prostheses for augmentation and never before at an interval as long as 12 years, as in our case. There have been occasional reports of chronic haematoma as complication of implantation of silicone breast prostheses after mastectomy for cancer, presenting 2.5-8 years later.

The value of follow-up after mastectomy for breast cancer is controversial. One reason is to detect metachronous tumour in the contralateral breast, but the optimum method for achieving this is undecided. The long-term follow-up policy of our unit is annual clinical review combined with biennial mammography. We have assessed the benefit of this policy in the detection of tumours of the contralateral breast. The case notes of 216 patients undergoing mastectomy between 1978 and 1985, under the care of one consultant surgeon (DJTW) were reviewed. Follow-up was complete to December 1997, thus allowing a minimum follow-up of 12 years. The development of a metachronous tumour was recorded as was its method of detection : either clinically, by the patient or the clinician, or by routine mammography. Two-hundred and five patients were available for follow-up of the contralateral breast. Seventeen (8.3%) developed metachronous tumours. Eight were detected by the patient, 4 by the clinician and 5 by routine follow-up mammography. Biennial mammography does not appear to be beneficial in breast cancer follow-up. More work is required to determine the benefits of more frequent mammography, with or without breast self-examination and clinical review within the hospital environment or within primary care.

Audit based on the use of case notes completed in the ordinary course of patient care has not been widely used because of concern about the completeness and adequacy of such records. This paper describes the results of a study carried out to assess whether information contained in case notes was sufficiently reliable to enable clinical effectiveness to be measured. The study examines the extent to which a radiologist and an epidemiologist agree with two experienced clinicians in making retrospective judgements on whether out-of-hours radiological investigations are worthwhile. There was a high measure of agreement; only a relatively small amount of information in the case notes is needed to make valid judgements on clinical performance. The method described here may be applicable to other diagnostic investigations and the results of the study have wide implications for more effective and efficient management of resources within the NHS.

Neoadjuvant chemotherapy is showing promising results in the primary treatment of breast cancer. We have analysed the data on 91 patients (age 30–78 years) representing 15 years of experience firm 1980–1995 in our unit. All patients had advanced tumours, 69% being T4 (46% of these inflammatory), with 76% of tumours more than 5 cm in size and 68% clinically node positive at diagnosis. Four chemotherapy regimens have been used: (1) Ariamycin 40 mg/m2 + Vincristine 1 mg/m3 × 3 cycles. (2) Mitozanstrone 14 mg/m2 × 3 cycles. (3) Cyclophosphemide 500–600 mg/m2, Methotrexate 40–50 mg/m2, 5 Fluorouracil 500–600 mg/m2 (CMF) × 3–6 cycles. (4) Cyclophosphamide 500–600 mg/m2, Adriamycin/Epirubicin 40–50 mg/m2, 5 Fluorcuracil 500–600 mg/m2 (CAF/CEF) × 3–6 cycles. The breast and glandular areas were irradiated with 40–50 Gy in 15–25 fractions ± 5–10 Gy boost in 2–5 fractions. The overall 2, 5 and 10 year actuarial survival rates are 54%, 28% and 11% respectively. Overall response rates to chemotherapy were 61% (14% CR). Response rates were highest [92% (50% CR)] with CAF/CEF based regimens. The addition of radiotherapy increased the response rate to 93% overall, and with CAF/CEF there was a 75% CR rate. The median time to maximum clinical response was 5 months and 9 months on radiological criteria. Sixty-one patients have relapsed, 54% due to metastases, 15% synchronous local and metastatic disease, 31% local failure only. Thirty-one percent of patients had mastectomy, with only 10% of patients having uncontrolled inoperable local disease after therapy.

A prospective study of pre-treatment general immune competence in breast cancer patients has been instituted to determine its relationship to recurrence and its clinical value in predicting prognosis. A 2 yr follow-up has been completed on 198 patients. The tests of immune competence, all completed before treatment was commenced, were total WBC, absolute and percentage lymphocyte counts, serum immunoglobulins (IgG, IgA and IgM), lymphocyte transformation with PHA and delayed cutaneous hypersensitivity responses to tuberculin PPD and dinitrochlorobenzene (DNCB). None of these pre-treatment tests was predictive for recurrence or prognosis when the effects of stage-related immunosuppression were excluded by analysing the results within each clinical stage. Hence for those patients who developed recurrence within 2 yr , pretreatment immunological status gave no additional prognostic information over conventional clinico-pathological data.

Up to fifteen plasma proteins were measured before treatment in 249 women presenting with lumps in the breast. Concentrations showed considerable overlap between the various clinical stages, and were often normal even in metastatic disease. A discriminant function is proposed, based on measurement of C-reactive protein, beta 2-microglobulin, carcinoembryonic antigen and ferritin and calculation of a score for each subject. High-risk scores resulted for all 18 patients with Stage 4 (i.e., metastatic) disease, and the number of Stage 1 patients attaining high scores was consistent with the reported incidence of development of metastases in such a group. Follow-up studies are in progress.