Survival with bladder cancer, evaluation of delay in treatment, type of surgeon, and modality of treatment.

Summary The objective of this study was to compare the pre-hospital health care process, clinical characteristics at admission and survival of patients with a digestive tract cancer first admitted to hospital either electively or via the emergency department. The study involved crosssectional analysis of information elicited through personal interview and prospective follow-up. The setting was a 450-bed public teaching hospital primarily serving a low-income area of Barcelona, Catalonia, Spain. Two hundred and forty-eight symptomatic patients were studied, who had cancer of the oesophagus (n = 31), stomach (n = 70), colon (n = 82) and rectum (n = 65). The main outcome measures were stage, type and intention of treatment and time elapsed from admission to surgery; the relative risk of death was calculated using Cox's regression. There were 161 (65%) patients admitted via the emergency department and 87 (35%) electively. The type of physician seen at the first prehospital visit had more often been a general practitioner in the emergency than in the elective group (89% vs 75%, P < 0.01). Emergency patients had seen a lower number of physicians from symptom onset until admission, but two-thirds had made repeated visits to a primary care physician. Emergency patients were less likely to have a localized tumour and a diagnosis of cancer at admission, and surgery as the initial treatment. Median survival was 30 months for elective patients and 8 months for emergency patients (P < 0.001), and the relative risk of death (RR) was 1.83 (95% confidence interval, Cl, 1.32-2.54). After adjustment for strong prognostic factors, emergency patients continued to experience a significant excess risk (RR = 1.58; Cl 1.10-2.27). In conclusion, in digestive tract cancers, admission to hospital via the emergency department is a clinically important marker of a poorer prognosis. Emergency departments can only partly counterbalance deficiencies in the effectiveness of and integration among the different levels of the health system.

Section: Discussionmentioning

confidence: 99%

Emergency admission for cancer: a matter of survival?

Porta

Fernández²,

Belloc³

et al. 1998

“…In studies of colorectal and bladder cancer, however, mortality was similar among patients operated on by consultants and trainee surgeons after allowance was made for disease severity (Phillips et al. 1984;Gulliford et al, 1991).…”

Section: Effects Of Hospital and Protocolmentioning

confidence: 99%

Centralised treatment, entry to trials and survival

Stiller

1994

228

S_.mary A review was carried out of the published literature on survival rates for cancer in relation to patterns of organisation of medical care, specifically treatment at specialist centres or at hospitals treating larger numbers of patients and treatment by protocol, usually within the context of a clinical trial. Centralised referral or entry to trials was frequently associated with a higher survival rate, particularly for the less common cancers, and was never found to be associated with a lower survival rate. Few (Chouillet et al., 1994). Analyses of survival in relation to organisational factors have yet to appear from either of these studies.Finally, for 1984 onwards two electronic databases, Medline and Embase, were searched on the Silver Platter Cancer CD. Tables I-XI contain 32 references included on Cancer CD and already known to the author before searching began. Of these, 14 (44%) could be retrieved by a search of medical subject headings (MESH) containing at least one of the terms survival, outcome, prognosis, mortality and at least one of hospitals, protocols, cancer care facilities, referral, health services. Four additional references not previously known were found in this search, making a total of 18 publications, and these accounted for 2.8% of the total of 649 references so indexed. Extending the search to other fields or by additional keywords increased the total number of references retrieved by a much greater proportion than it did the number of relevant publications found. This is a considerably worse result than that found by Silagy (1993)

“…The recurrence risk is dependent on a number of prognostic factors (Abel, 1988;Lum & Torti, 1991 Society, 1991). In a recent study in the United Kingdom, the 5-year survival in 150 pTa and 85 pTa patients was 80 and 69%, respectively (Gulliford et al, 1991). Flamm and Havelec (1990) (Cutler et al, 1982).…”

Section: Survivalmentioning

confidence: 99%

The clinical epidemiology of superficial bladder cancer

Kiemeney

Witjes²,

Verbeek³

et al. 1993

127

Summary Even though the majority of patients with bladder malignancies initially present with low stage disease, the clinical epidemiology of these so-called superficial bladder tumours is not well known. In this paper, disease characteristics at initial presentation and during follow-up are described in 1,745 primary cases documented prospectively in the Netherlands. The risk of recurrent disease after primary treatment is very high: in 60% of cases, at least one recurrence is diagnosed within 5 years (95% CI: 58-62% Society, 1991). Therefore, the greatest concern in these patients is not to reduce mortality but to lower and postpone the number of recurrences (which are very common in superficial TCC) and thereby to prevent progression to invasive disease (and document) at least four random quadrant biopsies in macroscopically normal-looking urothelium (left and right lateral wall, trigone and dome) at the time of resection of the tumour(s). The therapy to be applied was transurethral resection of the tumour (TUR) in all patients. Urologists were advised to consider adjuvant intravesical instillations with chemotherapy or BCG vaccine in the case of multiple tumours. In pTI grade 3 patients more aggressive therapy, such as radical surgery or external or interstitial radiotherapy, would have to be considered. To detect recurrences, cystoscopy and urine cytology were used every 3 months in the first year after treatment. From the second year onwards, this check-up was performed every 6 months. Follow-up data concerning disease and life status were collected for each patient once every year.Between 1983 and 1990, 2,805 cases were documented. In 1991, all the data in the documentation project were reviewed using the medical files. After this check, the records of 100 cases were excluded. Of these, 30 had an inverted papilloma (which was considered to be benign), 58 had recurrent instead of primary disease at first registration, five did not have TCC in the bladder but in the upper urinary tract. In the records of seven cases, there were major inconsistences, which could not be corrected with information from the medical files. Of the remaining 2,705 cases, 1,745 (64.5%) had superficial TCC. 'Superficial' is defined as tumour extension limited to the mucosa (pTa) or the lamina propria (pTl) of the bladder wall with or without carcinoma in situ in random biopsies. In urology practice, primary carcinoma in situ (pTis) is considered to be very different from pTa and pTI tumours because of its relatively aggressive clinical behaviour. For that reason, patients with primary pTis (n = 52 in our series) were not evaluated in this study. Survival free of recurrence, survival free of progression and survival itself were measured from the data of histological diagnosis to the date of first recurrence, first evidence of disease progression and the date of death, respectively. Survival curves were based on the life table method, statistical significance being determined by the log rank test. The independence of host and tum...