Regional variation in breast cancer treatment in the Netherlands and the role of external peer review: a cohort study comprising 63,516 women

Background Treatment variation is an important issue in health care provision. An external peer review programme for multidisciplinary cancer care was introduced in 1994 in the Netherlands to improve the multidisciplinary organisation of cancer care in hospitals. So far the clinical impact of external quality assessment programmes such as external peer review and accreditation remains unclear. Our objective was to examine the degree of variation in treatment patterns and the possible effect of external peer review for multidisciplinary cancer care for breast cancer patients. Methods Patients with breast cancer were included from 23 hospitals from two ‘intervention regions’ with the longest experience with the programme and 7 hospitals that never participated (control group). Data on tumour and treatment characteristics were retrieved from the Netherlands Cancer Registry. Treatment modalities investigated were: the completeness of breast conserving therapy, introduction of the sentinel node biopsy, radiotherapy after breast conserving surgery for ductal carcinoma in situ (DCIS), adjuvant radiotherapy for locally advanced breast cancer (T3/M0 or any T,N2-3/M0), adjuvant chemotherapy for early stage breast cancer (T1-2/N+/M0) and neo-adjuvant chemotherapy for T4/M0 breast cancer. Hospitals from the two intervention regions were dichotomised based on their implementation proportion (IP) of recommendations from the final reports of each peer review (high IP vs. low IP). This was regarded as a measure of how well a hospital participated in the programme. Results 63,516 female breast cancer patients were included (1990-2010). Variation in treatment patterns was observed between the intervention regions and control group. Multidisciplinary treatment patterns were not consistently better for patients from hospitals with a high IP. Conclusions There is no relationship between the external peer review programme for multidisciplinary cancer care and multidisciplinary treatment patterns for breast cancer patients. Regional factors seem to exert a stronger effect on treatment patterns than hospital participation in external peer revie

Angiosarcomatous transdifferentiation of metastatic melanoma

Melanoma is known to show considerable variation in its histopathological presentation. In exceptional cases, heterologous or divergent differentiation (metaplastic melanoma) can be observed. We report a case of a 69-year-old man who was diagnosed with nodular melanoma on the right upper leg. One year later, the patient presented with an inguinal lymph node metastasis and a lymph node dissection was carried out. In two out of five positive lymph nodes, an angiosarcomatous component was found next to a conventional melanoma component. Shortly after, the patient developed two in-transit metastases in which again an angiosarcomatous component was seen. The vascular component stained positive for ERG and CD31 and negative for melanocytic markers (Mart-1, S100, SOX-10), while the conventional melanoma had an opposite staining pattern. Molecular analysis on both components showed an identical mutation in the NRAS gene, which in our opinion proves the divergent differentiation. To the best of our knowledge, this is the first case report describing angiosarcomatous transdifferentiation of melanoma

The impact of organisational external peer review on colorectal cancer treatment and survival in the Netherlands

Background: Organisational external peer review was introduced in 1994 in the Netherlands to improve multidisciplinary cancer care. We examined the clinical impact of this programme on colorectal cancer care. Methods: Patients with primary colorectal cancer were included from 23 participating hospitals and 7 controls. Hospitals from the intervention group were dichotomised by their implementation proportion (IP) of the recommendations from each peer review (high IP vs low IP). Outcome measures were the introduction of new multidisciplinary therapies and survival. Results: In total, 45 705 patients were included (1990-2010). Patients from intervention hospitals more frequently received adjuvant chemotherapy for stage III colon cancer. T2-3/M0 rectal cancer patients from hospitals with a high IP had a higher chance of receiving preoperative radiotherapy (OR 1.31, 95% CI 1.11-1.55) compared with the controls and low IP group (OR 0.75, 95% CI 0.63-0.88). There were no differences in the use of preoperative chemoradiation for T4/M0 rectal cancer. Survival was slightly higher in colon cancer patients from intervention hospitals but unrelated to the phase of the programme in which the hospital was at the time of diagnosis. Conclusions: Some positive effects of external peer review on cancer care were found, but the results need to be interpreted cautiously due to the ambiguity of the outcomes and possible confounding factors

OECD/MCCI 2-D Core Concrete Interaction (CCI) tests : final report February 28, 2006.

Although extensive research has been conducted over the last several years in the areas of Core-Concrete Interaction (CCI) and debris coolability, two important issues warrant further investigation. The first issue concerns the effectiveness of water in terminating a CCI by flooding the interacting masses from above, thereby quenching the molten core debris and rendering it permanently coolable. This safety issue was investigated in the EPRI-sponsored Melt Attack and Coolability Experiments (MACE) program. The approach was to conduct large scale, integral-type reactor materials experiments with core melt masses ranging up to two metric tons. These experiments provided unique, and for the most part repeatable, indications of heat transfer mechanism(s) that could provide long term debris cooling. However, the results did not demonstrate definitively that a melt would always be completely quenched. This was due to the fact that the crust anchored to the test section sidewalls in every test, which led to melt/crust separation, even at the largest test section lateral span of 1.20 m. This decoupling is not expected for a typical reactor cavity, which has a span of 5-6 m. Even though the crust may mechanically bond to the reactor cavity walls, the weight of the coolant and the crust itself is expected to periodically fracture the crust and restore contact with the melt. Although crust fracturing does not ensure that coolability will be achieved, it nonetheless provides a pathway for water to recontact the underlying melt, thereby allowing other debris cooling mechanisms to proceed. A related task of the current program, which is not addressed in this particular report, is to measure crust strength to check the hypothesis that a corium crust would not be strong enough to sustain melt/crust separation in a plant accident. The second important issue concerns long-term, two-dimensional concrete ablation by a prototypic core oxide melt. As discussed by Foit the existing reactor material database for dry cavity conditions is solely one-dimensional. Although the MACE Scoping Test was carried out with a two-dimensional concrete cavity, the interaction was flooded soon after ablation was initiated to investigate debris coolability. Moreover, due to the scoping nature of this test, the apparatus was minimally instrumented and therefore the results are of limited value from the code validation viewpoint. Aside from the MACE program, the COTELS test series also investigated 2-D CCI under flooded cavity conditions. However, the input power density for these tests was quite high relative to the prototypic case. Finally, the BETA test series provided valuable data on 2-D core concrete interaction under dry cavity conditions, but these tests focused on investigating the interaction of the metallic (steel) phase with concrete. Due to these limitations, there is significant uncertainty in the partition of energy dissipated for the ablation of concrete in the lateral and axial directions under dry cavity conditions for the case of a core oxide melt. Accurate knowledge of this 'power split' is important in the evaluation of the consequences of an ex-vessel severe accident; e.g., lateral erosion can undermine containment structures, while axial erosion can penetrate the basemat, leading to ground contamination and/or possible containment bypass. As a result of this uncertainty, there are still substantial differences among computer codes in the prediction of 2-D cavity erosion behavior under both wet and dry cavity conditions. In light of the above issues, the OECD-sponsored Melt Coolability and Concrete Interaction (MCCI) program was initiated at Argonne National Laboratory. The project conducted reactor materials experiments and associated analysis to achieve the following technical objectives: (1) resolve the ex-vessel debris coolability issue through a program that focused on providing both confirmatory evidence and test data for the coolability mechanisms identified in MACE integral effects tests, and (2) address remaining uncertainties related to long-term 2-D core-concrete interactions under both wet and dry cavity conditions. Data from the various tests conducted as part of the program are being used to develop and validate models and codes that are used to extrapolate the experimental findings to plant conditions. Achievement of these technical objectives will demonstrate the efficacy of severe accident management guidelines for existing plants, and provide the technical basis for better containment designs of future plants. The project completed three large scale CCI experiments to address the second technical objective defined above

OECD MCCI project final report, February 28, 2006.

Although extensive research has been conducted over the last several years in the areas of Core-Concrete Interaction (CCI) and debris coolability, two important issues warrant further investigation. The first issue concerns the effectiveness of water in terminating a CCI by flooding the interacting masses from above, thereby quenching the molten core debris and rendering it permanently coolable. This safety issue was investigated in the Melt Attack and Coolability Experiments (MACE) program. The approach was to conduct large scale, integral-type reactor materials experiments with core melt masses ranging up to two metric tons. These experiments provided unique, and for the most part repeatable, indications of heat transfer mechanism(s) that could provide long term debris cooling. However, the results did not demonstrate definitively that a melt would always be completely quenched. This was due to the fact that the crust anchored to the test section sidewalls in every test, which led to melt/crust separation, even at the largest test section lateral span of 1.20 m. This decoupling is not expected for a typical reactor cavity, which has a span of 5-6 m. Even though the crust may mechanically bond to the reactor cavity walls, the weight of the coolant and the crust itself is expected to periodically fracture the crust and restore contact with the melt. The fractured crust will provide a pathway for water to recontact the underlying melt, thereby allowing other debris cooling mechanisms to proceed and contribute to terminating the core-concrete interaction. Thus, one of the key aims of the current program was to measure crust strength to check the hypothesis that a corium crust would not be strong enough to sustain melt/crust separation in a plant accident. The second important issue concerns long-term, two-dimensional concrete ablation by a prototypic core oxide melt. As discussed by Foit, the existing reactor material database for dry cavity conditions is solely one-dimensional. Although the MACE Scoping Test was carried out with a two-dimensional concrete cavity, the interaction was flooded soon after ablation was initiated to investigate debris coolability. Moreover, due to the scoping nature of this test, the apparatus was minimally instrumented and therefore the results are of limited value from the code validation viewpoint. Aside from the MACE program, the COTELS test series also investigated 2-D CCI under flooded cavity conditions. However, the input power density for these tests was quite high relative to the prototypic case. Finally, the BETA test series provided valuable data on 2-D core concrete interaction under dry cavity conditions, but these tests focused on investigating the interaction of the metallic (steel) phase with concrete. Due to these limitations, there is significant uncertainty in the partitioning of energy dissipated for the ablation of concrete in the lateral and axial directions under dry cavity conditions for the case of a core oxide melt. Accurate knowledge of this 'power split' is important in the evaluation of the consequences of an ex-vessel severe accident; e.g., lateral erosion can undermine containment structures, while axial erosion can penetrate the basemat, leading to ground contamination and/or possible containment bypass. As a result of this uncertainty, there are still substantial differences among computer codes in the prediction of 2-D cavity erosion behavior under both wet and dry cavity conditions. Thus, a second key aim of the current program was to provide the necessary data to help resolve these modeling differences. In light of the above issues, the OECD-sponsored Melt Coolability and Concrete Interaction (MCCI) program was initiated at Argonne National Laboratory. The project conducted reactor materials experiments and associated analysis to achieve the following technical objectives: (1) resolve the ex-vessel debris coolability issue through a program that focused on providing both confirmatory evidence and test data for the coolability mechanisms identified in previous integral effects tests, and (2) address remaining uncertainties related to long-term 2-D core-concrete interaction under both wet and dry cavity conditions. Data from the various tests conducted as part of the program is used to develop and validate models and codes that eventually form the basis for extrapolating the experimental findings to plant conditions. Achievement of these technical objectives will demonstrate the efficacy of severe accident management guidelines for existing plants, and provide the technical basis for better containment designs of future plants. The project completed a total of eleven reactor material tests to investigate melt coolability and 2-D core-concrete interaction mechanisms under both wet and dry cavity conditions

Psychosocial function of Dutch children with cancer and their caregivers during different phases of the COVID-19 pandemic

We compared psychosocial functioning of children with cancer and their caregivers in several phases of the coronavirus disease 2019 (COVID-19) pandemic to before COVID-19. One or more questionnaires on health-related quality of life (HRQoL) or fatigue of children or distress of their caregivers was available from 1644 families. In children with cancer, HRQoL was stable throughout the COVID-19 pandemic. Fatigue was slightly lower and sleep somewhat better during the pandemic than before. Caregiver distress was lower in the first pandemic phase, but increased to pre-COVID-19 levels in later phases, indicating that the length and consequences of the pandemic may be weighing on them

Capturing human intelligence for modelling cognitive-based clinical decision support agents

The success of intelligent agents in clinical care depends on the degree to which they represent and work with human decision makers. This is particularly important in the domain of clinical risk assessment where such agents either conduct the task of risk evaluation or support human clinicians with the task. This paper provides insights into how to understand and capture the cognitive processes used by clinicians when collecting the most important data about a person’s risks. It attempts to create some theoretical foundations for developing clinically justifiable and reliable decision support systems for initial risk screening. The idea is to direct an assessor to the most informative next question depending on what has already been asked using a mixture of probabilities and heuristics. The method was tested on anonymous mental health data collected by the GRiST risk and safety tool (www.egrist.org)

What drives centralisation in cancer care?

Background: To improve quality of care, centralisation of cancer services in high-volume centres has been stimulated. Studies linking specialisation and high (surgical) volumes to better outcomes already appeared in the 1990’s. However, actual centralisation was a difficult process in many countries. In this study, factors influencing the centralisation of cancer services in the Netherlands were determined. Material and methods: Centralisation patterns were studied for three types of cancer that are known to benefit from high surgical caseloads: oesophagus-, pancreas- and bladder cancer. The Netherlands Cancer Registry provided data on tumour and treatment characteristics from 2000–2013 for respectively 8037, 4747 and 6362 patients receiving surgery. By plotting timelines of centralisation of cancer surgery, relations with the appearance of (inter)national scientific evidence, actions of medical specialist societies, specific regulation and other important factors on the degree of centralisation were ascertained. Results: For oesophagus and pancreas cancer, a gradual increase in centralisation of surgery is seen from 2005 and 2006 onwards following (inter)national scientific evidence. Centralisation steps for bladder cancer surgery can be seen in 2010 and 2013 anticipating on the publication of norms by the professional society. The most influential stimulus seems to have been regulations on minimum volumes. Conclusion: Scientific evidence on the relationship between volume and outcome lead to the start of centralisation of surgical cancer care in the Netherlands. Once a body of evidence has been established on organisational change that influences professional practice, in addition some form of regulation is needed to ensure widespread implementation

Topical Report: Natural Convection Shutdown Heat Removal Test Facility (NSTF) Evaluation for Generating Additional Reactor Cavity Cooling System (RCCS) data.

As part of the Department of Energy (DOE) Generation IV roadmapping activity, the Very High Temperature gas cooled Reactor (VHTR) has been selected as the principal concept for hydrogen production and other process-heat applications such as district heating and potable water production. On this basis, the DOE has selected the VHTR for additional R&D with the ultimate goal of demonstrating emission-free electricity and hydrogen production with this advanced reactor concept. One of the key passive safety features of the VHTR is the potential for decay heat removal by natural circulation of air in a Reactor Cavity Cooling System (RCCS). The air-cooled RCCS concept is notably similar to the Reactor Vessel Auxiliary Cooling System (RVACS) that was developed for the General Electric PRISM sodium-cooled fast reactor. As part of the DOE R&D program that supported the development of this fast reactor concept, the Natural Convection Shutdown Heat Removal Test Facility (NSTF) was developed at ANL to provide proof-of-concept data for the RVACS under prototypic natural convection flow, temperature, and heat flux conditions. Due to the similarity between RVACS and the RCCS, current VHTR R&D plans call for the utilization of the NSTF to provide RCCS model development and validation data, in addition to supporting design validation and optimization activities. Both air-cooled and water-cooled RCCS designs are to be included. In support of this effort, ANL has been tasked with the development of an engineering plan for mechanical and instrumentation modifications to NSTF to ensure that sufficiently detailed temperature, heat flux, velocity and turbulence profiles are obtained to adequately qualify the codes under the expected range of air-cooled RCCS flow conditions. Next year, similar work will be carried out for the alternative option of a water-cooled RCCS design. Analysis activities carried out in support of this experiment planning task have shown that: (a) in the RCCS, strong 3-D effects result in large heat flux, temperature, and heat transfer variations around the tube wall; (b) there is a large difference in the heat transfer coefficient predicted by turbulence models and heat transfer correlations, and this underscores the need of experimental work to validate the thermal performance of the RCCS; and (c) tests at the NSTF would embody all important fluid flow and heat transfer phenomena in the RCCS, in addition to covering the entire parameter ranges that characterize these phenomena. Additional supporting scaling study results are available in Reference 2. The purpose of this work is to develop a high-level engineering plan for mechanical and instrumentation modifications to NSTF in order to meet the following two technical objectives: (1) provide CFD and system-level code development and validation data for the RCCS under prototypic (full-scale) natural convection flow conditions, and (2) support RCCS design validation and optimization. As background for this work, the report begins by providing a summary of the original NSTF design and operational capabilities. Since the facility has not been actively utilized since the early 1990's, the next step is to assess the current facility status. With this background material in place, the data needs and requirements for the facility are then defined on the basis of supporting analysis activities. With the requirements for the facility established, appropriate mechanical and instrumentation modifications to NSTF are then developed in order to meet the overall project objectives. A cost and schedule for modifying the facility to satisfy the RCCS data needs is then provided