Telemedicine was introduced for weekly tumour case conferences between Sahlgrenska University Hospital and two district hospitals in Sweden. The accuracy of tele-oncology was determined using simulated telemedicine consultations, in which all the material relating to each case was presented but without the patient in person. The people attending the conference were asked to determine the tumour ('TNM') classification and treatment. The patient was then presented in person, to give the audience the opportunity to ask questions and perform a physical examination. Then a new discussion regarding the tumour classification and the treatment plan took place, and the consensus was recorded. Of the 98 consecutive patients studied in this way, 80 could be evaluated by both techniques. Of these 80, 73 (91%) had the same classification and treatment plan in the telemedicine simulation as in the subsequent face-to-face consultation. In four cases the TNM classification was changed and for three patients the treatment plan was altered. The specialists also had to state their degree of confidence in the tele-oncology decisions. When they recorded uncertainty about their decision, it was generally because they wanted to palpate the tumour. In five of the seven patients with a different outcome, the clinical evaluation was stated to be dubious or not possible. The results show that telemedicine can be used safely for the management of head and neck cancers.
Automated computer system for differential diagnosis and defining the indications for pathogenetic therapy is described, which was used in 2816 patients and was effective in 97% of cases. The system includes computer-regulated Lancet surgical lasers (wavelength 10.6 microns, power 60 W, frequency 0.05-1.0 Hz) and Optodan physiotherapeutic laser (wavelength 0.85 micron, power 4 W, frequency 0.08-3 kHz).
The incidence of basal cell carcinoma is increasing. New aspects of diagnosis and treatment are discussed in this thesis. Interferon can be used for the treatment of BCC. In paper I, 15 patients received 13.5 x 10(6) IU of alfa-2b-interferon intralesionally. Four patients healed completely whereas a 75% reduction was seen in 5 cases. Intralesional alfa-2b-interferon can reduce the number of excisions during Mohs Micrographic Surgery. Topical photodynamic therapy involves the application of ALA on the skin. In tumour cells selectively, formation of the photosensitizer Pp IX occurs. After 4 hours of occlusion of ALA the area is irradiated with light at a wavelength of 630 nm. Tumour cells are selectively destroyed during this procedure. 144/157 SBCC healed in this series and 14/18 Mb Bowen (paper II). The method is only suited for thin BCCs as the result on thicker lesions is poor (2/10 healed). The cosmetic result was generally good or excellent. Another way of utilising the tumour selectivity of Pp IX is for diagnostic purposes. Instead of illuminating with 630 nm, 365, 366 and 405 nm are used to induce a specific fluorescence. In the present paper (III), 50% of facial BCCs with ill-defined borders could be completely visualised and another 23% partly outlined. The technique did not seem to work in 27% of the cases. The critical factor using ALA is probably the relatively poor penetrance through the skin. In paper IV, microdialysis is used for pharmacokinetic studies of ALA for the first time. The concentration of ALA increases rapidly in lesional skin whereas there is virtually no penetration in healthy skin. Also, the blood perfusion in BCCs was investigated by means of laser Doppler Perfusion Imager. The perfusion in skin overlying a BCC was 2.5 fold higher compared to normal skin. For BCCs with ill-defined borders Mohs Micrographic Surgery is generally recommended. Regarding Mohs Micrographic Surgery, Sweden is underserved as only 1% of BCCs are treated with Mohs Micrographic Surgery as opposed to 30% in the US. Consequently, the Swedish cases are probably more severe. The long-term results are reported in paper V. Two hundred and twenty-eight tumours were followed for at least 5 years. The rate of recurrence was 8%. This figure is slightly higher than in international materials but surprisingly low considering the type of tumours.
The survival of patients with bladder cancer has not improved significantly during the past decades in spite of new diagnostic methods and treatment modalities. This observation underlines the need for improved routines to ensure earlier detection of the disease by patients and doctors and thereby start the treatment sooner. The common finding of treatment failures in patients who have shown no sign of local recurrence but have undergone radical cystectomy indicates that subclinical metastases are primarily responsible for the poor outcome in most cases. This indicates that, in addition to radical surgery, effective chemotherapy is needed to counteract the systemic spread of the disease.
Danish healthcare seeks to improve cancer survival through improved diagnostics, rapid treatment and increased focus on cancer prevention and early help-seeking. In neuro-oncology, this has resulted in the Integrated Brain Cancer Pathway (IBCP). The paper explores how the pathway works in the initial phase in a clinical setting with emphasis on pathway criteria.
All patients admitted during the first two-year period to a regional neurology department in Denmark and fulfilling the IBCP inclusion criteria were included. Data regarding onset symptoms, diagnosis and time for diagnostic work-up were obtained and supplemented by a retrospective review of patient records. Sensitivities, specificities and positive predictive values of the inclusion criteria were calculated with magnetic resonance imaging scan of the cerebrum as index of validity.
The strength of the pathway inclusion criteria was determined largely by the number of criteria fulfilled and by the type of predominant symptoms. The criteria identified the majority of patients with symptomatic brain malignancy and were also highly predictive of general structural brain lesions.
The introduction of the pathway is a major step forward in the efforts to optimize brain cancer patients' illness trajectory.
This study was funded by a grant from the Danish Ministry of Health and Interior Affairs 2009 and the Helen Rude Foundation and has been approved by the Danish Data Protection Agency.