Journals Watch - Breast cancer, pain and BMI

Too busy to read the journals? Let Dr Raj Thakkar keep you up to date with all the latest research

Web-based program to assess breast cancer survival Lancet 2009; doi:10.1016/S1470-2045(09)70254-2
Cancer patients often debate whether chemotherapy is likely to confer a survival benefit before they risk the potential side-effects.

Web-based programs can calculate individualised 10-year survival probabilities and 10-year risk of adverse outcome if systemic adjuvant therapy were not used versus therapy. Information including demographics, tumour size, nodal involvement and histology is used.

This study from the Netherlands aimed to assess the accuracy of the web-based program Adjuvant!

The study included patients with invasive breast cancer who were partially treated between 1987 and 1998. Tumour size and axillary node status were known. Patients with distant metastases were excluded and were treated according to standard protocols.

A total of 5,380 patients were included in the study. Ten-year observed overall survival was 69 per cent, and breast cancer specific survival (BCSS) was 78.6 per cent.

The software predicted overall survival to be 69.1 per cent and BCSS at 77.8 per cent. These data were not statistically different to the true values. The calculator overestimated survival by just over 4 per cent in patients younger than 40 years.

The use of computer models and prediction calculators is increasing. If used properly with an awareness of their flaws, they can be incredibly powerful.

Improving care for patients needing costly services N Engl J Med 2009; DOI: 10.1056/NEJMp0907185
The most costly patients to treat tend to be those with multiple chronic diseases. This US article describes how healthcare costs of those with five or more chronic diseases were 17 times higher than for people with no chronic disease.

The paper discussed a number of holistic and supportive care management strategies for people with complex health needs.

Strategies were designed to identify 'expensive' service users, to improve patient's functioning, address psychosocial needs in a coordinated way and reduce spending on expensive medical care.

By using a multidisciplinary approach, risk management, individual needs assessments, family involvement, crisis management planning and admission avoidance planning, medical costs may be reduced significantly.

Investment is needed to fund specialist nurses who can call and visit patients. Evidence suggests at least five patient contacts are needed to reduce the need for hospitalisation.

Cardiac resynchronisation to prevent heart failure events N Engl J Med 2009; 361: 1,329-38
Cardiac failure is increasingly being managed solely in primary care. While many authorities advocate early secondary-care referral to optimise management of these patients, there is pressure from many PCTs to reduce referral rates.

There are a select group of patients who would benefit from referral to secondary care. Some of these patients will require cardiac revascularisation therapy and valve repair. Could patients with minimal symptoms benefit from cardiac resynchronisation therapy (CRT)?

This US study assessed the benefits of CRT with biventricular pacing in patients with mild symptoms, an ejection fraction of less than 30 per cent and a wide QRS complex.

CRT was shown to reduce mortality by a third and heart failure events by 41 per cent.

Intervention in patients with cardiac failure may be considered to reduce mortality and heart failure events even in mildly symptomatic patients.

While NICE recommends treatment for patients with NYHA III-IV, this study may force them to revise their guidance.

Nortriptyline and gabapentin for neuropathic pain Lancet 2009; doi: 10.1016/S0140-6736(09)61081-3
Neuropathic pain is often difficult and unsatisfying to manage. Treatment success is variable and medication side-effects often pose a concern.

This small randomised controlled study aimed to determine the efficacy and tolerability of combining gabapentin and nortriptyline in patients with neuropathic pain.

By using pain scores (0-10), researchers determined pain endured with either drug or combination treatment. The mean pain score was 5.4 (95% CI 5 -5.8) at baseline and dropped to 3.2 (2.5-3.8) with gabapentin, 2.9 (2.4-3.4) for nortriptyline and 2.3 (1.8-2.8) for combination treatment. Despite being a small study, it was adequately powered to show a significant (p=0.001) reduction in pain scores.

This interesting study may help us, or indeed confirm our current practice, when managing patients with difficult to manage pain syndromes.

Varenicline and suicidal behaviour BMJ 2009; 339: b3,805
It is suggested that varenicline can cause mood disorder, but how does the associated suicide risk compare to other smoking cessation therapies?

This UK cohort study involved more than 80,000 people aged between 18 and 95. Almost 11,000 people were prescribed varenicline, the rest were given either nicotine replacement therapy or bupropion.

The researchers concluded that there was no clear evidence of varenicline-associated depression, or fatal or non-fatal self-harm. However, given this is a statistical view, they did comment that a twofold increased risk cannot be ruled out given the 95% confidence interval.

Weight in mid-life in relation to healthy survival after 70 BMJ 2009; 339: b3,796
Obesity remains a major public health concern, with increased risk of cardiovascular disease, diabetes and arthritis.

This US cohort study looked at over 17,000 women who survived until at least 70 to see whether mid-life obesity affected health in later life. It assessed their history of having at least one of 11 chronic diseases or cognitive, medical and physical impairment (usual survival).

Only 9.9 per cent of women were deemed to have met the criteria for healthy survival. BMI was found to be significantly associated with poor health even when corrected for confounding factors. Those who had a BMI of at least 30 were particularly at risk of having 'usual' rather than 'healthy' survival.

Women with a BMI of more than 25 at age 18 who then gained more than 10kg in weight were particularly at risk. The data confirm the importance of obesity care in order to prevent individual morbidity.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review the journals

The quick study

  • Cancer survival probability was accurately predicted using web-based software.
  • Chronic disease management must improve to reduce long-term costs associated with such patients.
  • Cardiac resynchronisation therapy reduced mortality by a third and heart failure events by 41 per cent.
  • Neuropathic pain was significantly reduced in patients taking nortriptyline and gabapentin together.
  • Varenicline showed no association with depression or self-harm.
  • Obesity was shown to reduce the chance of healthy survival in women beyond the age of 70.

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