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The contribution of drugs to the control of cancer, especially the lymphoid and haematological malignancies and the rarer, solid tumours, has been considerable and their use is increasing. Despite this, however, specialists in cancer chemotherapy are found mainly in regional cancer centres and few have been appointed to district general hospitals in the United Kingdom. Medical oncologists appointed to health districts could do much to improve the quality of care of patients with cancer. This paper outlines the development of a cancer treatment service in the Lancaster and South Cumbria districts since the appointment of a consultant physician with an interest in medical oncology. Case historyA 21 year old labourer was admitted with appendicitis. At laparotomy enlarged lymph nodes were found along the posterior abdominal wall. This was an undifferentiated malignant tumour. Staining for cc fetoprotein gave a negative result but the serum concentration was raised suggesting that the tumour might be of germ cell origin. Staging investigations showed that his disease was confined to the abdominal cavity. He was treated with a five day intravenous regimen using cisplatin, etoposide, and vinblastine, repeated at three week intervals.The toxicity of the treatment was considerable. He suffered severe prostration, nausea, and vomiting with recovery only days before his next course was due. He was persuaded to complete five treatments, at which time he was in complete clinical and biochemical remission. Some months later his disease relapsed. Radiotherapy was given to the posterior abdominal wall over three weeks and this was accompanied by further severe symptoms of toxicity. After a few more weeks he developed abdominal pain, the serum a fetoprotein concentration was raised, and chemotherapy was restarted. Vincristine, doxorubicin (Adriamycin), and cyclophosphamide were given by intravenous injection in three week cycles. Though he tolerated this better than the previous combination, he developed severe anticipatory symptoms and needle phobia, the latter despite the insertion of a permanent atrial catheter. His symptoms improved but this time there was no corresponding fall in the serum a fetoprotein concentration. Treatment was stopped after only four cycles and when his pain returned he was given only symptomatic measures. He died some nine months later, 25 months after his first admission to hospital. PHYSICAL CONSEQUENCES OF THE ILLNESSThis patient's sudden and dramatic illness brought with it considerable discomfort, distress, and inconvenience to him and his family. He lived in a small village some 10 miles from the district general hospital in Lancaster and 80 miles from the regional cancer centre in Manchester. Outpatient attendances or visiting by his family when he was in hospital meant at best a round trip of 20 miles (32 km) and at worst 160 miles (256 km), which was time consuming and expensive. The disruption to family life was extreme. The organisation and planning of simple daily tasks affected not only t...

Psychological problems commonly follow the diagnosis, treatment and progression of cancer (Maguire, 1983). Effective communication between patient and doctor can reduce some of these problems, notably anxiety, but patients still feel the need for emotional support as evidenced by the distressing case histories which appear in the lay press from time to time, the large number of patient-led self-helf groups of which there are about 440 in the UK, the demand for the services of CancerLink and BACUP (15,500 and 18,000 telephone calls respectively in 1990) and the increasing interest in alternative and complementary treatment practices.Cancer services are organised around modalities of treatment and the wider issues of convenience, accessibility and emotional support have not been taken into account. A strong plea has been made for supportive care to be part of any cancer service (Smith, 1990) and it is likely that this view will gain force as patients become more assertive in the new-style health service. In the planning of cancer services it would be useful to know what the likely4emand for supportive care would be.We have described a system of delivering supportive care in a district cancer service (McIllmurray et al., 1986

Cancer support nurses (CSNs) have a key co-ordinating role in the cancer services in North Lancashire and South Lakeland. The working practices of the three CSNs in North Lancashire are described in detail. There was a total cumulative caseload of 604 patients in September 1996, with 397 referrals in the previous 12-month period. There were 267 deaths during this time. CSNs are an essential element of cancer service provision. A ratio of one CSN to 40,000 population gives a manageable workload, provided there is an infrastructure of supportive care to which patients, carers and bereaved can be referred.

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Two postgraduate sculptors from The Royal Academy carried out a 10-week residency at St John's Hospice in Lancaster. Their work is described and an evaluation report is discussed.

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