1128

Occasional Survey MEDICAL CARE OF CHILDHOOD LEUKÆMIA * MARK MCCARTHY &dag er; Department of Community Health, London School of Hygiene and Tropical Medicine

The medical care given to a populationbased sample of children with leukæmia was reviewed between two to three years after diagnosis. Just over half the children had been treated at local hospitals, and the others referred to centres specialising in treatment of leukæmia. Local hospitals could be divided according to the therapeutic regimen used: the survival of children given optimal regimens at local hospitals was equivalent to that of two of the three special centres. Assessment of social, psychological, satisfaction or cost outcomes showed no difference between the groups. It is concluded that a regional policy for childhood leukæmia should be concerned to improve treatment regimens at local hospitals rather than attempt to concentrate care at a few centres.

Summary

INTRODUCTION

IN the 1971 annual report of the Central Health Services Council the standing subcommittee on cancer made suggestions for the organisation of cancer services and research, which have since been developed into four pilot regional cancer organisations in England.1 The Department of Health had already recognised that patients with certain rare tumours such as choriocarcinoma, or malignant conditions requiring special facilities such as childhood leukasmia, needed to be gathered together in hospitals where the patient could benefit from a concentration of experience and equipment.

This policy was based on two sources of evidence 2 Between 1953 and 1957, when steroids and a few cytotoxic drugs were known to be valuable in the treatment of childhood leuksemia, there had been no improvement in survival in the Manchester region; however, survival was doubled after a policy of centralisation of care was introduced during 1958-59.3 In 1971 the M.R.C. Working Party on Leukaemia in Childhood compared the survival of a study group of 220 children diagnosed during 1963-67 treated wholly from the time of diagnosis by physicians who were members of the working-party, with survival of 1025 children treated partly or wholly by other physicians.4 Children with acute lymphatic leuksemia (A.L.L.) in the study group had roughly double the median survival-time of comparable children treated elsewhere. No difference in survival, however, could be demonstrated for other acute leuksemias. The working-party felt that the improvement in survival in the study group was *

Based on an London.

M.SC.

(social medicine) thesis, University of

t Present address: North Hammersmith Health District (Teaching), Hammersmith Hospital, London W12 0HS.

much to the details of the therapeutic to the availability of special facilities and skills. For example, in one of the centres there was no significant difference in survival between patients treated in accordance with M.R.C. trial protocols and those treated in other ways. The working-party concluded that " children with leukaemia should be referred, where this is feasible, to the centre specialising in the treatment of the disease ". However, advances in therapy, notably cyclical multiple chemotherapy and prophylactic cranial irradiation,have changed patterns of survival since the mid-1960s. A study was, therefore, undertaken to determine whether the treatment regimen or the site of treatment is now the greater determinant of survival.

due, not regimens,

so

as

METHODS

Within the four metropolitan hospital regions in SouthEast England live more than 14 million people, and patients frequently cross the regional boundaries for specialist treatment. From the cancer registers of the four regions all 75 children aged 0-14 with leukaemia who had first been treated in hospital between April 1 and Dec. 31, 1971, were identified. Only children resident in the regions and treated within the National Health Service were included. The name of the notifying consultant was provided by the registries. Each consultant was contacted by letter, and his permission sought to include the child in the study. The consultant was also asked to supply the name of the child’s general practitioner, who was also asked for permission for his patient to be included in- the study. When agreement of both doctors had been obtained, a letter was sent to the child’s mother explaining the purpose of the study, and requesting her participation. A final group of 64 children was obtained. Of the 11 remaining patients 5 were not contacted and 3 declined and in 3 cases their G.P. or consultant declined. The interviews with parents used an open-ended questionary, which had been previously tried on other parents, followed by the " present state examination ", a standardised clinical psychiatric schedule. All the interviews were conducted by one person, and undertaken at the parents’ home in all but one instance. The child’s G.P. and district-hospital physician were seen on the same day, where possible, and details of treatment and general policy towards the care of childhood leuksemia were discussed. For all the 75 children, access was provided to the case-notes, from which an assessment of the therapeutic regimen was made. The fieldwork was done between December,1973, and March, 1974, making a length of follow-up of between two and three years. Four London hospitals were designated " special centres ": one, with many referrals, was a children’s hospital, one was an undergraduate teaching hospital, and two were postgraduate teaching hospitals (one treating relatively few children, and none within the group attended there for primary treatment). The three special centres giving primary treatment to 36 of the children will be identified as s.c.1, s.c.2, and s.c.3. The other 39 children were given primary treatment at district general hospitals (D.G.H.), including seven undergraduate teaching hospitals not specialising in the care of leukaemia. The 22 D.G.H.1group of children were given induction and cyclic maintenance and 5 of them were participating in an M.R.C. trial for treatment of acute lymphatic leukaemia. The 17 D.G.H.2 children include those given non-cyclic or minimal therapy. The two groups of children given primary treatment at special centres and district hospitals were not significantly different in composition for diagnosis, sex, age, or parents’

1129 TABLE II-STATE OF THE CHILD AT FOLLOW-UP

The 11 children whose parents were not also similar to the other 64 for these characteristics, but they differed significantly in that all the children had died.

social class. interviewed

were

RESULTS

Process The figure shows that most children were referred their district hospital by their G.P. The 10 referred directly to special centres included 4 referred to a special centre acting as a local hospital, 1 referred without specific diagnosis, and 5 in whom the diagnosis was known or suspected after a blood-count. Of the 64 children seen initially at a district hospital, 26 were referred to a special centre for primary treatment. Only 1 child,each at two of the special centres was subsequently treated by care shared with their local hospital from the beginning of treatment. The remaining 39 children were given primary treatment wholly by their district hospital. 2 of these were subsequently referred for further care at special centres —1because of a relapse, and 1 because of an unusual A few other children neurological complication.

to

* Includes 1 child lost

follow-up by emigration.

of 25-35 months. 29 children (38%) were still alive, although only 15 of these remained in primary remission (table n). Children with A.L.L. fared best at s.c.1; the second and third special centres treated few patients, but their results seem better than those for the district hospitals giving equivalent treatment (D.G.H.1) ; and the second group of hospitals (D.G.H.2) (providing non-cyclic or minimal treatment) The effect of radiotherapy is a have poor results. confounding variable, since it was only in 1971 that cranial irradiation began to be used as prophylactic treatment in England. 14 children at special centres and 7 at district hospitals received prophylactic irradiation, although for a proportion of these it was given at a late stage rather than shortly after first induction of remission. Another 8 children at special centres and 6 at district hospitals received radiotherapy for treatment of relapse, including leukaemic meningitis. It is not clear how much radiotherapy has influenced the results, but, since a greater proportion of children in the s.c. group received prophylactic irradiation, it is likely to have been a factor in their better survival.

follow-up

referred by district hospitals to a special centre for a single confirmatory outpatient attendance at different stages in their illness, but are included in the D.G.H. group. 40 consultants were interviewed and asked about current policies for management of childhood leuk-

were

TABLE I-DISTRICT HOSPITAL CONSULTANTS’ CURRENT POLICIES FOR MANAGEMENT IN 1973-74 COMPARED WITH ACTION IN 1971

Other Outcomes The social effects of treatment in this study are reported in greater detail elsewhere 8 No significant differences were found in the effects when comparison was made by site of treatment. In particular, travelling to special centres was not mentioned as a problem by most parents, despite considerable distances for

replies are compared with practice in i. Only 3 consultants who had previously given primary treatment wished currently to refer completely to special centres, while 23 still wished to give primary treatment at their own hospital. Most

æmia.

to

The

1971 in table

children; travelling was accepted as necessary prevailing view of the superiority of special-centre care. On the other hand, the parents of children treated at district hospitals often emphasised the benefits of local care, especially the minimal disrup-

some

within their

of these consultants had made arrangements for pro-

phylactic irradiation to be given to more recently diagnosed children with leukaemia, either by a radiotherapy department within the district hospital or in conjunction with a regional unit. Information about current optimal regimens came through contact withi special centres by letter, telephone, and meetings, and several district hospitals had been included in multicentre trials since 1971. Many consultants wouldl mention to the parents that their child could be referred to a centre, but pointed out that, where the: treatment provided was equivalent to the speciali centres, parents often preferred local care because off accessibility. .

Medical Outcome The state of the child at Dec. 31, 1973, was thee point taken for analysis of survival, representing a

tion of routine. Ten items of satisfaction derived from the questionary were scaled 0, 1, or 2, and then summed. The components include resentment at delay in diagnosis or referral, care on the ward, waiting-times in outpatients, and communication of information. No clear differences were found between the groups. 61 mothers’ present psychiatric states were assessed. Although clear associations were found with the state of the child, no significant differences could be disaccording to the site of treatment. Similarly, an estimate of the cost of treatment, which included inpatient days and outpatient attendances, social costs of travelling, loss of wages, and other additional costs to parents, revealed no differences in costs between two sites of treatment.

cerned

1130 DISCUSSION

Medical outcome varied between special centres, and district general hospitals giving equivalent treatment regimens had results, especially in maintaining first remissions, of a similar order to two of the three special centres. These outcomes, as might be expected, were better than those for district hospitals giving nonstandard treatment, but they were poorer than those of a special centre with a large experience of this illness in children. On the other hand, the outcome measures of social effects, satisfaction, mother’s psychiatric state, and cost showed no significant differences between the groups. It was clear, however, from the interviews with consultants at district hospitals that many clinicians intend to continue to treat childhood leukaemia locally. They consider that the treatment of leukaemia is moving towards a semiroutine regimen, especially for A.L.L., and that these regimens can be as adequately given in a district-hospital setting as in a special centre, provided there is a continuing interest on the part of the paediatrician or haematologist. With extended can survival, paediatricians gain experience for a number of children with leukaemia attending regularly as outpatients, and keep contact with special centres for particular information about drugs, transfusions, complications, and so on. For 2 children treatment was deliberately minimal because of the wishes of the mother (1 baby had Down’s syndrome), but in D.G.H.2 there remain several children for whom the therapeutic regimen was not optimal. To maintain a high standard of care for all children with leukaemia in a given population, clinicians at district hospitals will need either to give treatment

according

to

currently accepted regimens

refer their patients to a special centre. Such a policy could be promoted if, on an area or regional basis, clinicians agreed to adopt one or other course of action for every newly diagnosed child. If simple details of each child and treatment were transmitted to a coordinating centre, it would be possible to monitor the efficacy of regimens or to identify deficiencies in facilities or skills. Moreover, cooperative research could be programmes developed, perhaps with a physician periodically visiting district hospitals to make clinical assessments and discuss advances in Such a policy might be particularly management. suitable for implementation by a regional cancer or to

organisation. I thank Dr J. J. A. Reid and Mr A. G. McDonald for their advice and assistance and the Department of Health and Social Security for a bursary. REFERENCES 1. Central Health Services Council. Annual Report; appendix III. H.M. Stationery Office, 1971. 2. Taykor, N. R. W. Hlth Trends, 1972, 2, 59. 3. Steward, J. K. Br. med. J. 1966, i, 767. 4. Medical Research Council Working Party on Leukæmia in Childhood. ibid. 1971, iv, 7. 5. Pinkel, D. Treatment of Acute Lymphocytic Leukæmia. Leukæmia Research Fund, London, 1973. 6. Spiers, A. S. D. Lancet, 1972, ii, 473. 7. Wing, J. K., Cooper, J. E., Sartorius, N. The Measurement and Classification of Psychiatric Symptoms. London, 1974. 8. McCarthy, M. J. Soc. Sci. Med. (in the press).

Public Health

EFFECT OF A VACCINATION PROGRAMME ON THE DISTRIBUTION OF RUBELLA ANTIBODIES IN WOMEN OF CHILDBEARING AGE M. H. HAMBLING

Virology Department, Public Health Laboratory, Bridle Path, York Road, Leeds LS15 7TR Results of routine rubella

hæmagglutination-inhibiting antibody tests on 39,005 serum samples showed that 9·5% of women of childbearing age in the Leeds region were seronegative, and a further 9·2% had low antibody titres of 1/8 or 1/16. Since routine rubella vaccination of schoolgirls began in 1970 the frequency of seronegative women in the fifteen to nineteen year ageClinical rubella was group has fallen by 5·7%. confirmed serologically in 140 women, 58 of whom were pregnant. 30 of these pregnancies were termi2 resulted in spontaneous abortions, and 26 nated, proceeded to term. One infant had congenital rubella. Summary

INTRODUCTION

ALTHOUGH rubella is usually a mild illness with few serious complications, an infection during pregnancy, especially early pregnancy, may result in a malformed infant with congenital rubella. This hazard has stimulated the advances in diagnostic laboratory techniques and the production of rubella vaccines. Congenital rubella can be prevented by eliminating rubella from the community, or by producing immunity in women of childbearing age. Since 1970 in the U.K. rubella vaccination has been offered to schoolgirls between their eleventh and fourteenth birthdays. In 1972 the vaccination programme was extended and vaccine was available upon request for selected patients2: women of childbearing age who were seronegative; women in the post-partum period who were seronegative during pregnancy; and seronegative women at special risk either of acquiring rubella or of transmitting it to others. This policy should ultimately produce immunity in the great majority of women of childbearing age; however, until this stage of immunity is reached termination of pregnancy in proven cases of rubella during early pregnancy must be considered.

As four years have now elapsed since schoolgirls first offered vaccination, increasing numbers of these vaccinees are beginning to attend antenatal clinics. If the vaccination programme is successful the frequency of seronegative antenatal patients should be falling. In the Leeds region serological tests for rubella were carried out between January, 1971, and January, 1975, on antenatal patients, pregnant patients in contact with rubella, patients in whom rubella-like illnesses developed, and patients at special risk. Prowere

gress in

parison

forthcoming years may be with these results.

gauged by

com-

Medical care of childhood leukaemia.

1128 Occasional Survey MEDICAL CARE OF CHILDHOOD LEUKÆMIA * MARK MCCARTHY &dag er; Department of Community Health, London School of Hygiene and...
428KB Sizes 0 Downloads 0 Views