Surveillance after potentially curative cancer treatment.
Explore the source record for details and available documents.
Costs and Cost Analysis↗
Biomedical subjects
F E Johnson
Publications and source records attributed to F E Johnson.
Lower gastrointestinal bleeding.
BACKGROUND: Lower gastrointestinal bleeding can be a confusing clinical conundrum, the satisfactory evaluation and management of which requires a disciplined and orderly approach. Diagnosis and management has evolved with the development of new technology such as selective mesenteric angiography and colonoscopy. PURPOSE: This study was undertaken to review the available data in the literature and to determine the current optimum method of evaluation and management of lower gastrointestinal hemorrhage most likely to result in a successful outcome. METHODS: Data available on the topic of lower gastrointestinal bleeding in the English literature were obtained via MEDLINE search and were reviewed and analyzed. RESULTS: The colonic origin of lower gastrointestinal hemorrhage in order of decreasing incidence is diverticulosis, inflammatory bowel disease, including ischemic and infectious colitis, colonic neoplasia, benign anorectal disease, and arteriovenous malformations. Approximately 10 to 15 percent of all cases of rectal bleeding are attributable to a cause that is proximal to the ligament of Treitz. Small intestinal sources such as arteriovenous malformations, diverticula, and neoplasia account for between 3 and 5 percent of all cases. Colonoscopy successfully identified an origin in severe hematochezia in 74 to 82 percent of cases. Mesenteric angiography has a sensitivity of 42 to 86 percent. The best method of management depends on whether hemorrhage persists, the severity of continued hemorrhage, the cumulative transfusion requirement, and the specific origin of bleeding. CONCLUSION: Lower gastrointestinal hemorrhage is a complex clinical problem that requires disciplined and sophisticated evaluation for successful management. Diverticulosis is the most common cause. Colonoscopy is the diagnostic procedure of choice both for its accuracy in localization and its therapeutic capability. Selective mesenteric angiography should be reserved for those patients in whom colonoscopy is not practical. Precise identification of the bleeding source is crucial for a successful outcome. Specific directed therapy, such as segmental colonic resection for bleeding diverticulosis, is associated with the highest success rate and the lowest morbidity. A complete review of lower gastrointestinal bleeding is contained herein.
Angiography↗
Outcome of abdominal aortic aneurysm repair in patients with previous spinal cord injury in the Department of Veterans' Affairs hospitals.
A retrospective review was carried out to determine the morbidity and mortality of abdominal aortic aneurysm repair in patients with previous spinal cord injury. A population-based study utilizing computer records on all patients in Department of Veterans' Affairs medical centers from 1987-1991 identified 31 patients with spinal cord injury who underwent subsequent infrarenal abdominal aortic aneurysm repair. Additional information was obtained from individual medical records. Some twenty patients (65%) were paraplegics and 11 (35%) were quadriplegics. Aneurysms were most commonly discovered incidentally during work-up of other conditions. All patients had no symptoms referable to their abdominal aortic aneurysm. In total, 29 patients (94%) underwent elective operations. The complication rate (57%) involved mostly pulmonary, cutaneous or urinary tract morbidity. The 30-day mortality rate was 3% for elective abdominal aortic aneurysm repair. Two patients were operated upon as emergencies for rupture, with one operative death. Long-term follow-up revealed a median survival duration of 5.4 years after aneurysm repair. In conclusion, abdominal aortic aneurysm repair in patients with previous spinal cord injury has a low mortality rate. Postoperative complications are often related to spinal cord injury and are potentially preventable; thus, such injury should not preclude surgical intervention for abdominal aortic aneurysm.
Aged↗
How tumor stage affects surgeons' surveillance strategies after lung cancer surgery.
The factors that influence decision making among surgeons are not well understood. We evaluated how tumor stage in patients subjected to potentially curative surgery for lung cancer affects the self-reported follow-up strategies employed by practicing surgeons. Hypothetical patient profiles and a detailed questionnaire based on these profiles were mailed to the 3,700 members of the Society of Thoracic Surgeons. The effect of TNM stage on the surveillance strategies chosen by the respondents was analyzed. All of the ten most commonly employed surveillance modalities were ordered significantly more frequently with increasing TNM stage, although the differences are small. Only 23% of respondents modified their strategies according to the patient's TNM stage. This effect persisted through 5 years of follow-up. We conclude that most surgeons performing surveillance after potentially curative surgery for otherwise healthy patients with lung cancer use the same follow-up strategy irrespective of TNM stage. These data should help in the design of prospective trials of this topic.
Adult↗
Sociosexual behaviour and paternity in procarbazine-exposed rats with or without regional testicular circulatory isolation.
Male Sprague-Dawley rats were used in two experiments in which a procarbazine bolus (400 mg kg-1 body mass) was administered with or without testicular circulatory isolation in the form of brief clamping of the spermatic cord and gubernaculum during drug administration. Separate tests of aggressiveness, sexual motivation, copulatory performance and paternity over the subsequent 6 weeks were used to assess functional changes resulting from testicular circulatory isolation. Experiment 1 compared intermale aggression and sexual motivation of animals in groups receiving procarbazine plus testicular circulatory isolation lasting 0, 15 or 45 min with that of animals in control groups with no clamp and no drug. Experiment 2 used a 2 x 2 factorial design to evaluate sexual performance and resulting paternity in animals 2 months after testicular circulatory isolation and drug exposure compared with that in control animals. Procarbazine treatment induced minimal disruption of normal interest in a receptive female, copulatory measures (intromissions or ejaculations) and structural integrity of seminal vesicles, bulbospongiosus muscles and ventral prostate glands. Animals exposed to the drug without testicular circulatory isolation were significantly less aggressive than animals in other groups. The most profound influence of procarbazine was on paternity. Males exposed to procarbazine with or without testicular circulatory isolation impregnated notably fewer females than did control males that were not exposed to the drug. There was no evidence of recovery of normal fertility up to 10 weeks after exposure to the drug. In conclusion, the deleterious influence of procarbazine on androgen-sensitive processes appears to be specific to intermale aggression and to fertility. The testicular circulatory isolation technique, for 45 min in particular, softened the impact of the drug on social behaviour, although procarbazine suppressed fecundity even with testicular circulatory isolation.
Animals↗
Effect of chronic oral pentoxifylline administration on murine erythrocyte deformability.
BACKGROUND: Pentoxifylline has been reported to increase radiation sensitivity in vivo. We sought to evaluate whether this effect is mediated by changes in murine erythrocyte flexibility. METHODS: Pentoxifylline was administered via liquid or solid diet to young adult male CF-1 mice for 1-6 weeks. After 1, 3, and 6 weeks of drug administration, plasma levels of pentoxifylline and major derivatives were measured and erythrocyte deformability was assessed by rheoscopy, a technique which permits direct measurement of individual cellular dimensions. RESULTS: Contrary to prior reports, we found no discernible effect of the drug on erythrocyte deformability. CONCLUSIONS: The beneficial effect of pentoxifylline administration on radiation sensitivity in tumor-bearing mice is mediated by other mechanisms.
Administration, Oral↗
Ischemic colitis complicating abdominal aortic aneurysm surgery in the U.S. veteran.
Ischemic colitis (IC) is an infrequent but serious complication of abdominal aortic surgery. Prior reports have generally described small, selected populations. The aim of this paper is to evaluate characteristics of clinically diagnosed IC in a large non-referral-based population. Using national Veterans Affairs (VA) computer data sets, we identified all patients with the diagnostic codes for both prosthetic replacement of aorta for abdominal aortic aneurysm and subsequent vascular insufficiency of the intestine in the entire VA population from 1987 to 1991. Clinical information on these patients was then requested from the VA Medical Centers where they received care. Patients demographics, clinical data regarding both the aortic surgery and IC, and survival data were extracted from patient charts and computer records. Of 4957 patients who underwent surgery of the abdominal aorta for infrarenal abdominal aortic aneurysm, 58 (1.2%) also had the code for subsequent IC. In 49/58 (74%), sufficient chart-derived and computer-derived data were available for analysis. The mean age was 69 (range 57-95); all were males. Bloody diarrhea was the most frequent symptom and colonoscopy the most common means of diagnosis. Mean time to diagnosis of IC was 5.5 days after aortic surgery (range 1-21 days). Aneurysmal rupture or perioperative hypotension were present in 35/49 patients. Bowel resection with fecal diversion was required in 32/49 (65%). The overall mortality was 54% but it was 89% if bowel resection for bowel infarction was required. Only 2/12 (16%) of those who required fecal diversion and survived underwent eventual stoma closure. Among 7 patients who received second-look laparotomy for IC, additional bowel resection was required in 6. No patient had aortic graft infection diagnosed during the index hospitalization. The overall mean hospitalization duration after the diagnosis of IC was 38 days (range 1-164). IC following aortic aneurysm surgery in this national patient population is infrequently diagnosed. Emergency aneurysm operation and perioperative hypotension are common in patients who develop IC. The majority of patients diagnosed receive surgical intervention. Most patients who undergo fecal diversion retain their stomas.
Aged↗
Incidence and treatment of periampullary duodenal cancer in the U.S. veteran patient population.
BACKGROUND: Because fewer than 1000 cases of primary adenocarcinoma of the duodenum have been reported, earlier series are limited by local referral patterns and the long periods of time needed for retrospective reviews. METHODS: This study reports the outcomes of preiampullary duodenal adenocarcinoma treatments in all hospitals of the Department of Veterans Affairs from 1987 through 1991, using computer and tumor registry records. Patients were grouped by their most aggressive treatment (resection > operative bypass > percutaneous biliary intubation) and survival calculated from the date of this procedure. RESULTS: Of 2185 patients with periampullary cancers (1753 pancreatic, 432 other periampullary), 85 were duodenal and thus comprised only 4% of periampullary tumors. Thirty-four duodenal cancers were resected, 44 bypassed, and 7 had biliary intubation, with 30-day mortality rates of 6%, 18%, and 0%, respectively. Mean survival exceeded 1 year in all groups, and resection resulted in a significant increase in mean survival (784 vs. 438 days for nonresection, P = 0.01). The projected 5-year survival rate after resection was 23%. Mean survival after resection of 9 Stage I-II cancers was 668 days, but was similar after 5 resections with nodal or other metastases. Similarly, survival did not correlate with cancer stage in 13 palliated patients. CONCLUSIONS: This large study of patients with duodenal cancer provides a unique perspective of disease prevalence and response to surgical treatment. Prolonged survival is common with any treatment, but the longest survivals were after resection.
Adenocarcinoma↗
Colorectal cancer in patients with previous spinal cord injury.
BACKGROUND: The optimum management of large-bowel cancer in patients with previous spinal cord injury (SCI) is uncertain. PURPOSE: The aim is to determine the outcome of patients with SCI who are undergoing colectomy or proctectomy for cancer. METHODS: A population-based study of patients receiving care at hospitals in the Department of Veterans Affairs system from 1987 to 1991 was performed. Patients with ICD-9 codes for SCI and colon and rectal cancer were identified. Patients with previous SCI who underwent colectomy or proctectomy for their cancer comprised the study population. Data were compiled from national computerized Veterans Affairs datasets, supplemented by individual operative reports and discharge summaries. RESULTS: Forty-four patients were evaluable. Mean age was 65 (range, 40-80) years, and mean time since SCI was 24 (range, 1-50) years. Mean follow-up was 4.6 years after resection. Distribution of tumors was 39 percent rightsided, 43 percent left-sided, and 18 percent rectal. All 32 patients with colonic tumors underwent resection; 26 of 32 patients (81 percent) had an anastomosis. Seven of eight (88 percent) rectal lesions were treated by abdominoperineal resection. Twenty-six of 44 patients (59 percent) presented with Stage III or IV disease. Twelve of 44 (27 percent) died, 8 of 12 from cancer. Overall 30-day mortality rate was 4.5 percent (2/44). In-hospital morbidity rate (pulmonary, cutaneous, and urinary tract only) was 34 percent. Among those who received postoperative chemotherapy, 80 percent completed treatment. CONCLUSIONS: Patients with previous SCI tolerate resection well. Tumor distribution and stage are similar to those of neurally intact patients. Morbidity is commonly related to pre-existing complications of SCI. Adjuvant therapy is well tolerated.
Adult↗
Testicular circulatory isolation: not a cause of immune-mediated testis injury in the rat.
BACKGROUND: Testicular circulatory isolation (TCI), a regional drug exclusion approach designed to prevent chemotherapy-induced male infertility, can reduce testicular drug exposure and preserve fertility. The immunological sequelae of this surgical procedure were investigated. METHODS: Forty Sprague-Dawley rats received unilateral TCI for 45 min and were killed at intervals of up to 43 days later. Testicular histology was evaluated qualitatively using hematoxylin and eosin stain, a direct immunofluorescent technique for detection of antigen-antibody complexes, and an indirect immunofluorescent technique to detect circulating antitestis antibodies. RESULTS: No immune-mediated injury was evident up to 43 days after TCI. CONCLUSION: The current work, taken together with previously published data, indicate that TCI produces no immunological damage in the rat testis. Because TCI is well tolerated in humans, this work also supports the institution of human clinical trials of this technique in men about to receive fertility-threatening chemotherapy.
Animals↗
Cost of patient follow-up after potentially curative lung cancer treatment.
The two objectives of this study were to determine the range of recommended follow-up strategies for patients with lung cancer treated with curative intent and to estimate the cost of such follow-up. Ten articles delineating eight specific follow-up strategies were identified from a Medline search of the literature for 1980 through 1995. An economic analysis was done of the costs associated with the identified strategies. Charge data obtained from the Part B Medicare Annual Data file and the Hospital Outpatient Bill file were used as a proxy for cost. Follow-up intensity varied widely across strategies for 5 years of posttreatment follow-up. Medicare-allowed charges for 5-year follow-up ranged from a low of $946 to a high of $5645. When Medicare-allowed charges were converted to a proxy for actual charges by a conversion ratio of 1.62, the range was $1533 to $9145, a fivefold difference in charges. There was no indication that more intensive, higher-cost strategies increased survival or quality of life. The published literature, including textbooks, holds few answers in this area.
Blood Chemical Analysis↗
Population-based analysis of treatment of pancreatic cancer and Whipple resection: Department of Defense hospitals, 1989-1994.
BACKGROUND: The influence of hospital experience and referral patterns on the operative mortality rate of pancreaticoduodenectomy was studied in a worldwide hospital system. METHODS: We analyzed computerized data on pancreatic cancer patients from U.S. Department of Defense (DOD) hospitals from 1989 to 1994. RESULTS: Six hundred ninety-eight patients had pancreatic cancer, and 130 Whipple operations (105 for pancreatic and 25 for other cancers) were performed with an 8.5% 30-day operative mortality rate. Although most resections were done in teaching hospitals performing more than 1 Whipple procedure per year, their results were not superior to smaller, lower volume nonteaching hospitals. Patients transported for resection were younger than patients undergoing resection at their local DOD hospital but had similar outcomes. The operative mortality rate was higher after unusual resections and with increasing age; the tumor stage had no effect. Unresected patients undergoing combined radiation and chemotherapy had the longest survival times. Radiation therapy was associated with significantly longer survival times in patients without distant metastases, but chemotherapy was associated with a longer survival time when metastases were present. CONCLUSIONS: This mortality rate 8.5% for Whipple resections matches that from other large populations. Equivalent results were obtained in DOD teaching hospitals and smaller, community-type institutions. Because the DOD medical system minimizes financial and logistic barriers to transfer, the even distribution of DOD pancreatectomy mortality suggests that these barriers may favorably influence single institutional outcomes.
Adenocarcinoma↗
How practice patterns in colon cancer patient follow-up are affected by surgeon age.
BACKGROUND: Strategies for the follow-up of colon cancer patients after potentially curative treatment are known to vary widely. The optimal regimen remains unknown. We investigated whether the date of completion of formal surgical training affects choice of surveillance strategy. METHODS: The 1070 members of the Society of Surgical Oncology (SSO) and the 1663 members of the American Society of Colon and Rectal Surgeons (ASCRS) were surveyed using a detailed questionnaire to measure how these surgical experts deal with colon cancer follow-up. Subjects were asked how they use nine specific follow-up modalities during years 1-5 following primary treatment for patients with colon cancer (TNM Stages I-III). Repeated-measures analysis of variance was used to compare practice patterns by TNM stage and year post-surgery, as well as by the year in which the surgeon's formal surgery training was completed. RESULTS: Evaluable responses were received from 349 SSO members (33%) and 646 ASCRS members (39%). Few significant differences in follow-up practices were noted by training period, but follow-up for most of the nine modalities was highly correlated with TNM stage and year post-surgery, as expected. CONCLUSIONS: This analysis indicates that the post-treatment surveillance practice patterns of surgeons caring for patients with colon cancer do not vary substantially with practitioner age. The data provide credible evidence that postgraduate education is effective in homogenizing practitioner behaviour.
Age Factors↗
"Practice makes perfect" is intuitive; the applicability of this axiom to surgical outcomes has been tenuous at best.
Explore the source record for details and available documents.
Humans↗
Geographic variation in patient surveillance after colon cancer surgery.
PURPOSE: Considerable variation among surgeons exists in the current practice of patient surveillance after colon cancer treatment. We evaluated whether geographic factors are responsible for this observed variation. METHODS: Profiles of hypothetical patients and a detailed questionnaire based on the profiles were mailed to 2,733 members of two national surgical societies. The influence of the geographic location of the respondents on practice patterns were assessed in two ways. Repeated-measures analysis of variance was used to compare the practice patterns among 19 large metropolitan statistical areas (MSAs) and chi 2 analysis was used to determine whether these patterns differed by MSA population size. RESULTS: Seven of nine commonly used surveillance modalities were ordered significantly more frequently with increasing tumor-node-metastasis (TNM) stage and significantly less frequently with year postsurgery among the 995 respondents with assessable responses, but MSA population size and geographic location of physicians generally had no effect on documented practice variability. The remaining two modalities (bone scan and computed tomography [CT]) were used so infrequently as to preclude meaningful analysis. CONCLUSION: Surveillance after potentially curative colon cancer surgery for otherwise healthy patients is not significantly affected by the geographic location of the surgeon who performs the surveillance testing and only modestly affected by the population size of the MSA in which he/she practices. These data should help in the design of prospective trials of this topic.
Analysis of Variance↗
Geographic variation in the conduct of patient surveillance after lung cancer surgery.
PURPOSE: Considerable variation among surgeons exists in the current practice of patient surveillance after lung cancer treatment. We evaluated whether geographic factors are responsible for this observed variation. METHODS: Profiles of hypothetical patients suitable for postoperative surveillance and a detailed questionnaire based on the profiles were mailed to the 3,700 members of the Society of Thoracic Surgery (STS). The influence of the geographic location of the respondents on practice patterns was assessed among eight large metropolitan statistical areas (MSAs) with sufficient numbers of respondents, among nine broad geographic areas (United States census regions), and by the population size of the MSA from which the respondents reported. RESULTS: There were 2,009 responses (54% return rate); 768 of those respondents both operate on and provide long-term follow-up care for lung cancer patients. There were sizeable effects of tumor-node-metastasis (TNM) stage and year postsurgery on practice patterns. Respondents from the Los Angeles/Long Beach MSA consistently had the highest frequency of follow-up test usage and those from the Tampa/St Petersburg MSA usually had the lowest. This held true for most testing modalities and was consistent across TNM stages I to III and years 1 to 5 postsurgery. Follow-up strategy was generally most intensive in the largest MSAs (population size, 2.5 to 10 million). The STS respondents from the Pacific US census region generally used the most intensive follow-up strategies and those from the East North Central and Mountain regions often used the least intensive. The differences disclosed in all three analyses were small. CONCLUSION: There is marked variation among STS members in surveillance strategy, and the determinants of testing intensity are complex and interrelated. TNM stage and year postsurgery clearly affect follow-up practice; this analysis provides the first evidence that geographic setting has rather little effect on the surveillance strategies of clinicians.
Continuity of Patient Care↗
Outcomes after detection of metastatic carcinoma of the colon and rectum in a national hospital system.
BACKGROUND: Selected institutions have reported good results with resection for metastatic carcinoma of the colon and rectum, but the number of patients and the expenses required to identify the resectable metastases are unknown. STUDY DESIGN: A retrospective survival analysis was performed using computerized files of the United States Department of Veterans Affairs hospitals from 1988 to 1992, complete through December 1994. Survival was calculated from diagnosis or resection until death. Patients without a death record were assumed to be alive. RESULTS: In all, 22,715 patients underwent colectomy for carcinoma, and 12,150 presented with metastatic carcinoma of the colon and rectum, of which 6,607 had hepatic and 2,659 had pulmonary metastases. Only 2,040 patients with hepatic (and 514 with pulmonary metastases had no prior or other metastatic sites. Of the patients with hepatic metastases, 887 had a computed tomography (CT) scan or liver biopsy, or both, for diagnosis; 133 hepatic and 76 pulmonary resections were done. The projected five-year survival rate after hepatic resection was 26 percent, mean survival was 31 months, and the 30-day mortality rate was 4 percent. After pulmonary resection, results were similar: 36 percent, 38 months, and 3 percent, respectively. The 887 patients with hepatic metastases documented by CT scan or biopsy results has a mean survival of 11 months, and less than 2 percent were alive or unavailable for follow-up examination at analysis. Estimated surveillance costs alone averaged $1.3 million per life saved by resection, or $203,000 per year of added life. CONCLUSIONS: Resection of isolated colorectal metastases produced 70 five-year survivors (hepatic, n=42, pulmonary, n=28) and accounted for 446 additional years of patient life over that expected without resection.
Carcinoma↗