- Email: [email protected]
INCREASE IN HIGH-GRADE LYMPHOMAS IN YOUNG MEN
857 TABLE I-AGE DISTRIBUTION OF NHL PATIENTS BY HISTOLOGICAL
Occasional
REVIEW GRADE
Survey
INCREASE IN HIGH-GRADE LYMPHOMAS IN YOUNG MEN RUSSELL K. BRYNES CATHERINE CHASE BORING NICOLE CAUSEY WING C. CHAN MARION R. NADEL HELEN R. GREGORY RAYMOND S. GREENBERG
Departments of Community Health, Pathology and Laboratory Medicine, and Biometry, Emory University School of Medicine, Atlanta, Georgia, and the Chronic Disease Division, Center for Environmental Health, Centers for Disease Control, Atlanta, Georgia, USA The relative
frequencies of non-Hodgkin’s lymphoma (NHL) subtypes and primary sites of presentation in young men before and during the acquired immunodeficiency syndrome epidemic were studied. Diagnostic pathological specimens were reviewed and classified according to the Working Formulation grades for cases of NHL in men aged 20-49 years identified through a population-based cancer registry. 76% of the lymphomas diagnosed in 1981-82 were intermediate or high grade, compared with 29% of those diagnosed in 1976-77. This increase was still significant when men aged 20-39 years and 40-49 years were grouped separately, and for married men. The proportion of extranodal lymphomas diagnosed in men aged 20-39 years also rose significantly from the early to the later period. Summary
INTRODUCTION
acquired immunodeficiency syndrome (AIDS) is severe opportunistic Ziegler et al described highly aggressive non-Hodgkin’s lymphomas (NHL) in 90 homosexual men and concluded that this malignancy was also a serious manifestation of the AIDS-related complex of diseases.’ 62% of the tumours in this patient series were classified as high-grade subtypes of NHL with the nonHodgkin’s Lymphoma Pathologic Classification Project Working Formulation scheme.2Most of the patients presented with extranodal-site involvement. Reference to the frequency of similar malignancies in the general population is lacking. The present study examined the relative frequencies of various lymphoma subtypes and primary sites of presentation in young men before and during the AIDS epidemic to see if concurrent changes were occurring in a male population not at recognisable risk of THE
characterised by susceptibility to infections and/or Kaposi’s sarcoma.
AIDS. METHODS
Patients with NHL were identified through the Atlanta Cancer Surveillance Center, which is a population-based cancer registry affiliated with the Surveillance, Epidemiology, and End Results (SEER) programme of the National Cancer Institute.3Case ascertainment is believed to be complete for all biopsied tumours, since pathology reports at all area hospitals and private pathology laboratories are reviewed by registry abstractors. All NHL diagnosed in male residents of the 5-county Atlanta metropolitan area during the years 1976-77 and 1981-82 were identified. The 1976-77 interval represented a recent but pre-AIDS period, and the 1981-82 interval a period during the emergence of the AIDS epidemic. The histopathological review was limited to males aged
20-49 years at diagnosis. This age range was chosen because at least 90% of all the AIDS cases reported to the Centers for Disease Control fall into this age-group. Registry records, including presenting symptoms and pertinent history, and pathology reports were reviewed to identify any evidence of AIDS-associated risk factors or immunodeficiency disease before diagnosis. Information about sexual orientation was not generally recorded, so marital status was used to indicate sexual
preference. Original diagnostic slides and pathology reports for tissue specimens were requested from area pathologists for each of the 67 patients identified from the registry. Slides were relabelled with coded identifiers and submitted for review. Coded histological sections were independently reviewed by 2 haematopathologists (R. K. B. and W. C. C.). They were unaware of the previous histological diagnosis, time of diagnosis, or age or marital status of the patient. Differences between reviewers’ diagnoses were reconciled by means of re-examination of the sections and discussion.4,s Diagnoses were expressed according to the Working Formulation for non-Hodgkin’s lymphomas and classified as low grade, intermediate grade, or high grade. Low grade includes small lymphocytic lymphomas; follicular, small cleaved-cell lymphomas; and follicular, mixed, small cleaved and large-cell lymphomas. Intermediate grade includes follicular, large-cell lymphomas; diffuse, small cleaved-cell lymphomas; diffuse, mixed small-cell and large-cell lymphomas; and diffuse large-cell lymphomas. High includes immunoblastic grade large-cell, lymphomas; lymphoblastic lymphomas; and small non-cleaved-cell (Burkitt’s)
lymphomas. Differences in distributions of histological grades between the 2 periods were evaluated with contingency tables and a chi-square test.6The proportions of tumours presenting in extranodal sites were examined for each period. In addition results were analysed by age, marital status, and
race.
RESULTS
1
Diagnostic slides were available for 64 of 67 patients (96%). excluded because the specimen was unsuitable for
case was
(diagnosed in 1981); slides from 1 could not be (1976); and 1 pathologist declined to submit slides (1982). 7 cases were excluded on review by the haematopathologists as not representing NHL. 1 was reclassified as Hodgkin’s disease, 1 as a histiocytic tumour of the gastrointestinal tract, 1 as a chloroma, and 4 as non-haematopoietic tumours. All 7 exclusions were diagnosed in the 1976-77 period. There was no disagreement between the 2 reviewers reassessment
found
any of these. Of the other 57 cases 13 were diagnosed in 1976, 11 in 1977, 18 in 1981, and 15 in 1982. 44 patients were white, 10 were black, 2 Hispanic, and 1 an Asian Indian. The age distribution of the reviewed patients is given in table I. Independent histopathological review by the haematopathologists showed within-grade agreement in 51 cases (89%). Differences were resolved as described above for the other 6. The distribution of review diagnoses by time of initial diagnosis is shown in table II. 76% of the lymphomas diagnosed in 1981-82 were intermediate or high grade, on
858 TABLE II-REVIEW DIAGNOSIS OF NON-HODGKIN’S LYMPHOMA BY HISTOLOGICAL SUBTYPES AND PERIOD OF DIAGNOSIS
indicate that any other patients presented with opportunistic infections or other indications of underlying immunodeficiency disease. DISCUSSION
compared with only (p =0-002) (table III).
29% of those
diagnosed
in 1976-77
used to represent sexual orientation for the 42 men who were married at the time of analysis. Among the diagnosis proportion of intermediate-grade and highgrade lymphomas rose significantly from the earlier (25%) to the later period (73%) (X2=110, 2 df, p 0 -004). 7 men were single at diagnosis and 8 were recorded as separated or divorced. These categories were not analysed either separately or in combination, since the numbers were too small. The distributions of review diagnoses were analysed by age at diagnosis. 28 men were aged 20-39 at diagnosis and 29 were aged 40-49. Both age-groups showed significant increases in intermediate-grade and high-grade lymphomas in the 1981-82 period (X2 =7-10, p=0-03 for the younger age-group and X= 7 -02, p 0’ 03 for the older age-group). When analysis was stratified by racial group a significant increase in the proportions of intermediate-grade and highgrade tumours for the 1981-82 period was observed among whites =9-25, p=0’01, n=44). Of the 13 non-white patients 11 had intermediate-grade or high-grade lymphomas; these were considered too few for analysis. Analysis of all patients by primary site of the tumour showed a non-significant increase in the proportion of extranodal lymphomas from 13% in 1976-77 to 30% in 1981-82 (p=0-ll). The difference was significant in the younger age-group, which showed no extranodal lymphomas in 1976-77 and 6 extranodal tumours (35%) in 1981-82 Marital
status was
=
=
(X2=4’94, p=0’03). 2 of the men in this study were thought to have AIDSrelated lymphomas at diagnosis (in 1982). Both were single. 1 had an intermediate-grade lymphoma of the brain and the other had a high-grade lymphoma of the colon. None of the other patients was known to be a haemophiliac, a user of intravenous drugs, or of Haitian origin. Records did not TABLE III-DISTRIBUTION OF NON-HODGKIN’S LYMPHOMA
The increase in the relative frequency of intermediategrade and high-grade lymphomas from the early to the later period was not anticipated at the start of this study. The occurrence of AIDS in the Atlanta area is uncommon (39 cases up to April 23, 1984). None of the men in this study except the 2 AIDS patients was known to be immunodeficient. There appears to be a general increase in intermediate-grade and high-grade NHL in young men that cannot be attributed entirely to the AIDS epidemic. The suggestion of a larger number of lymphomas presenting in extranodal sites during the more recent period (1981-82) is consistent with the increase in higher-grade since tumours, intermediate-grade and high-grade lymphomas are more likely to present at extranodal sites.7
Since the total number of NHL in young
men
in this
population increased between the 1976-77 and 1981-82 periods, age-specific incidence rates were calculated with population estimates developed from the 1970 and 1980 United States census counts for the 5-county metropolitan Atlanta area. On the basis of review diagnoses, annual incidence rates for men aged 20-49 years were 3.4per 100 000 for the 1976-77 period and 4-0 per 100 000 for the 1981-82 period. The sample is too small to determine whether this is a real increase. Miller et al reported a significant increase in the relative frequency of diagnosis of NHL among all lymph-node biopsy samples in 7 New York City hospitals from 1977 to 1981. However, this increase was primarily in men over the age of 44. Analysis of the original diagnoses by Working Formulation grade did not show the secular increases in higher-grade lymphomas found on review. Other reviews of pathological specimens have found considerable differences between original and review diagnoses of NHL, and this reflects the difficulty of morphological subclassification of these tumours, particularly the diffuse-histology types.9,1O For this reason data from population-based tumour registries alone may not be reliable for evaluation of a secular change in NHL subtypes. Incidence data, based on community diagnoses, on the occurrence of different histological subtypes of NHL are available through the SEER programme." However, reference data from reviewed pathological material since the onset of the AIDS epidemic have not been available. This study focused on a population-based series of incident cases in young
men.
The results indicate
an
increase in the relative
frequency of more aggressive NHL during the study period. Larger samples from other populations, including women and persons in older age groups, should be evaluated determine whether this trend persists and if it is unique young men.
to
to
HISTOLOGICAL SUBTYPES BY WORKING FORMULATION GRADE IN
2RECENT PERIODS*
This study was supported in part by contract 200-80-0556 from the Centers for Disease Control and contract NO1-CN-61027 from the National Cancer Institute. We thank the pathologists of the Atlanta area hospitals for providing histological specimens, Dr Margaret A. Child and Ms Susan E. Thomas for assistance in initiating the study, Dr Matthew M. Zack for reviewing the manuscript, John P. Whitaker for help in processing the data, and Ms Vickie Thomas for manuscript preparation.
Correspondence should be addressed to R. S. G., Atlanta Cancer Surveillance Center, Emory University School of Medicine, 246 Sycamore Street, Suite 100 Decatur, Georgia 30030, USA.
X’ = 12. 34,2 df,
p =0- 002. *Males
aged 20-49
yr.
859 TABLE I-COSTS OF OUT-OF-HOURS SERVICE IN
1979, 1982, AND 1984
(AT 1984 PRICES)
Hospital Practice A COMPARISON OF ALTERNATIVE ARRANGEMENTS FOR AN OUT-OF-HOURS CHEMICAL PATHOLOGY SERVICE IAN R. GUNN D. BRIAN MORGAN SHERRY FAYE GILLIAN CLEGG ANDREW M. GRANT
Department of Chemical Pathology, Leeds University, The Old Medical School, Leeds LS2 9JT
*Equipment depreciation: the blood gas equipment would have been purchased for the main laboratory if it had not been bought for the acute laboratory. The other equipment is written off over 5 years. tThe on-call payment was ;E4.55 in 1979 and )E8.33 in 1984, the stand-by payment was f3.00 in 1979 and f6.96 in 1984. Figures include travelling expenses.
Summary
Until
1979, the out-of-hours chemical
pathology service was the conventional oncall service in which the medical laboratory scientific officers (MLSOs) carried out analyses at the direct request of clinical staff. In 1980, during an industrial dispute, junior ward doctors were trained to use three simple instruments which are maintained by the chemical pathology department. In January, 1981, when the dispute was settled, the doctors continued to use these instruments. Analyses they could not make were done by the MLSO on call, but only after the requests were monitored by a chemical pathologist or biochemist. The result was an 80% reduction in the number of calls. When the monitoring was withdrawn in 1983, there was some increase in the number of MLSO calls, but this was still 35% less than that with the conventional system despite a 4-fold increase in the total number of analyses done out of hours between 1979 and 1984. Surveys in 1984 and in early 1985 revealed that most doctors preferred using the instruments to asking an MLSO to make the analysis. INTRODUCTION -
THE demand for chemical pathology measurements working hours has increased dramatically in recent years, particularly in large general hospitals. There are at least three reasons for this increase. (a) Clinicians expect an easily available chemical pathology service. The laboratories have encouraged this expectation for the day-time service; the clinicians now expect it at night as well. (b) The practice of "screening" patients by making routine measurements is accepted during normal working hours and has increasing impact on what clinicians request and expect out of hours. (c) Large general hospitals contain an increasing number of special-care units such as intensive-care units, coronary-care units, and neonatal units. Many of the ill patients in these units require regular biochemical monitoring through each 24 hours, 7 days a week.
outside normal
1. 2.
3
4.
Ziegler JL, Beckstead JA, Volberding PA, et al. Non-Hodgkin’s lymphoma in 90 homosexual men. N Engl J Med 1984; 311: 565-70. The Non-Hodgkin’s Lymphoma Classification Project. National Cancer Institute sponsored study of classifications of non-Hodgkin’s lymphomas. Summary and description of a working formulation for clinical usage. Cancer 1982; 49: 2112-35. Young JL Jr, Percy CL, Asire AJ, eds. SEER program: Incidence and mortality data: 1973-77. National Cancer Institute Monograph 57. Washington DC: US Government Printing Office, 1981. Coppleson LW, Factor RM, Strum SB, Rappaport H. Observer disagreement in classification and histology of Hodgkin’s disease. J Natl Cancer Inst 1970; 85: 731-40.
5. Kim
TH, Hargreaves HK, Brynes RK, et al. Pre-treatment testicular biopsy in childhood acute lymphocytic leukaemia. Lancet 1981; i: 657-58. 6. Fleiss JL. Statistical methods for rates and proportions. New York: John Wiley and
Sons, 1981.
For equipment maintenance. Based on 1112 h 5 days a week at mid-point on the scale ofa basic MLSO salary. Weekend maintenance is included in on-call payments.
Despite the increase in demand for these out-of-hours they continue to be provided largely by an "on-call system" which was designed to deal with the occasional measurement required urgently outside normal working services
hours. We describe here two other arrangements which have been introduced at the Leeds General Infirmary (LGI) during the past 5 years and compare them with the previous conventional out-of-hours on-call service. CHANGES IN THE SERVICE
Until 1979 the service, as in other large general hospitals, provided by medical laboratory scientific officers (MLSOs) on a voluntary basis. An MLSO was on call at home for each out-of-hours period ( 151/z h on week days and 20 h on each Saturday and Sunday). The doctor contacted the MLSOs directly and it was the doctor’s threshold of need which determined the workload. Up to 45 min could elapse between first contact with the MLSO and the result reaching the doctor. Each block of continuous work taking less than 2 h was a call for the purpose was
of payment. In late 1979, in the LGI, there was an average of 14 calls in each on-call period, and the cost, including travelling expenses, was about f50 000 at 1984 prices (table I). A busy night must have significantly affected the performance of the MLSO next day. In 1979, the consultants responsible for some of the specialcare units in the LGI decided to submit applications for analytical equipment which could be sited in these units and used by their clinical and nursing staff. The major reason for this application was that the out-ofhours service, with no resident staff on call, could provide neither the frequency nor the speed of response which the clinicians needed.
RA, Ross ME, DeLellis RA. Primary extranodal lymphoma: Response to therapy and factors influencing prognosis. Cancer 1978; 42: 406-16. Miller B, Stansfield SK, Zack MM, et al. The syndrome of unexplained generalized lymphadenopathy in young men in New York City Is it related to the Acquired Immune Deficiency Syndrome? JAMA 1984; 251: 242-46. Ezdinli EZ, Costello W, Wassner R, et al. Eastern Cooperative Oncology Group experience with the Rappaport classification on non-Hodgkin’s lymphomas. Cancer
7. Rudders 8.
9.
1979; 43: 544-50 10. Whitcomb CC, Cousar JB, Flint A, et al. Subcategories of histiocytic lymphoma. Association with survival and reproducibility of classification. The Southeastern Cancer Study Group experience Cancer 1981; 48: 2464-74. 11. Percy C, O’Conor G, Ries LG, Jaffe ES. Non-Hodgkin’s lymphomas. Application of the International Classification of Diseases for Oncology (ICD-O) to the Working Formulation Cancer 1984; 54: 1435-38.
Occasional
REVIEW GRADE
Survey
INCREASE IN HIGH-GRADE LYMPHOMAS IN YOUNG MEN RUSSELL K. BRYNES CATHERINE CHASE BORING NICOLE CAUSEY WING C. CHAN MARION R. NADEL HELEN R. GREGORY RAYMOND S. GREENBERG
Departments of Community Health, Pathology and Laboratory Medicine, and Biometry, Emory University School of Medicine, Atlanta, Georgia, and the Chronic Disease Division, Center for Environmental Health, Centers for Disease Control, Atlanta, Georgia, USA The relative
frequencies of non-Hodgkin’s lymphoma (NHL) subtypes and primary sites of presentation in young men before and during the acquired immunodeficiency syndrome epidemic were studied. Diagnostic pathological specimens were reviewed and classified according to the Working Formulation grades for cases of NHL in men aged 20-49 years identified through a population-based cancer registry. 76% of the lymphomas diagnosed in 1981-82 were intermediate or high grade, compared with 29% of those diagnosed in 1976-77. This increase was still significant when men aged 20-39 years and 40-49 years were grouped separately, and for married men. The proportion of extranodal lymphomas diagnosed in men aged 20-39 years also rose significantly from the early to the later period. Summary
INTRODUCTION
acquired immunodeficiency syndrome (AIDS) is severe opportunistic Ziegler et al described highly aggressive non-Hodgkin’s lymphomas (NHL) in 90 homosexual men and concluded that this malignancy was also a serious manifestation of the AIDS-related complex of diseases.’ 62% of the tumours in this patient series were classified as high-grade subtypes of NHL with the nonHodgkin’s Lymphoma Pathologic Classification Project Working Formulation scheme.2Most of the patients presented with extranodal-site involvement. Reference to the frequency of similar malignancies in the general population is lacking. The present study examined the relative frequencies of various lymphoma subtypes and primary sites of presentation in young men before and during the AIDS epidemic to see if concurrent changes were occurring in a male population not at recognisable risk of THE
characterised by susceptibility to infections and/or Kaposi’s sarcoma.
AIDS. METHODS
Patients with NHL were identified through the Atlanta Cancer Surveillance Center, which is a population-based cancer registry affiliated with the Surveillance, Epidemiology, and End Results (SEER) programme of the National Cancer Institute.3Case ascertainment is believed to be complete for all biopsied tumours, since pathology reports at all area hospitals and private pathology laboratories are reviewed by registry abstractors. All NHL diagnosed in male residents of the 5-county Atlanta metropolitan area during the years 1976-77 and 1981-82 were identified. The 1976-77 interval represented a recent but pre-AIDS period, and the 1981-82 interval a period during the emergence of the AIDS epidemic. The histopathological review was limited to males aged
20-49 years at diagnosis. This age range was chosen because at least 90% of all the AIDS cases reported to the Centers for Disease Control fall into this age-group. Registry records, including presenting symptoms and pertinent history, and pathology reports were reviewed to identify any evidence of AIDS-associated risk factors or immunodeficiency disease before diagnosis. Information about sexual orientation was not generally recorded, so marital status was used to indicate sexual
preference. Original diagnostic slides and pathology reports for tissue specimens were requested from area pathologists for each of the 67 patients identified from the registry. Slides were relabelled with coded identifiers and submitted for review. Coded histological sections were independently reviewed by 2 haematopathologists (R. K. B. and W. C. C.). They were unaware of the previous histological diagnosis, time of diagnosis, or age or marital status of the patient. Differences between reviewers’ diagnoses were reconciled by means of re-examination of the sections and discussion.4,s Diagnoses were expressed according to the Working Formulation for non-Hodgkin’s lymphomas and classified as low grade, intermediate grade, or high grade. Low grade includes small lymphocytic lymphomas; follicular, small cleaved-cell lymphomas; and follicular, mixed, small cleaved and large-cell lymphomas. Intermediate grade includes follicular, large-cell lymphomas; diffuse, small cleaved-cell lymphomas; diffuse, mixed small-cell and large-cell lymphomas; and diffuse large-cell lymphomas. High includes immunoblastic grade large-cell, lymphomas; lymphoblastic lymphomas; and small non-cleaved-cell (Burkitt’s)
lymphomas. Differences in distributions of histological grades between the 2 periods were evaluated with contingency tables and a chi-square test.6The proportions of tumours presenting in extranodal sites were examined for each period. In addition results were analysed by age, marital status, and
race.
RESULTS
1
Diagnostic slides were available for 64 of 67 patients (96%). excluded because the specimen was unsuitable for
case was
(diagnosed in 1981); slides from 1 could not be (1976); and 1 pathologist declined to submit slides (1982). 7 cases were excluded on review by the haematopathologists as not representing NHL. 1 was reclassified as Hodgkin’s disease, 1 as a histiocytic tumour of the gastrointestinal tract, 1 as a chloroma, and 4 as non-haematopoietic tumours. All 7 exclusions were diagnosed in the 1976-77 period. There was no disagreement between the 2 reviewers reassessment
found
any of these. Of the other 57 cases 13 were diagnosed in 1976, 11 in 1977, 18 in 1981, and 15 in 1982. 44 patients were white, 10 were black, 2 Hispanic, and 1 an Asian Indian. The age distribution of the reviewed patients is given in table I. Independent histopathological review by the haematopathologists showed within-grade agreement in 51 cases (89%). Differences were resolved as described above for the other 6. The distribution of review diagnoses by time of initial diagnosis is shown in table II. 76% of the lymphomas diagnosed in 1981-82 were intermediate or high grade, on
858 TABLE II-REVIEW DIAGNOSIS OF NON-HODGKIN’S LYMPHOMA BY HISTOLOGICAL SUBTYPES AND PERIOD OF DIAGNOSIS
indicate that any other patients presented with opportunistic infections or other indications of underlying immunodeficiency disease. DISCUSSION
compared with only (p =0-002) (table III).
29% of those
diagnosed
in 1976-77
used to represent sexual orientation for the 42 men who were married at the time of analysis. Among the diagnosis proportion of intermediate-grade and highgrade lymphomas rose significantly from the earlier (25%) to the later period (73%) (X2=110, 2 df, p 0 -004). 7 men were single at diagnosis and 8 were recorded as separated or divorced. These categories were not analysed either separately or in combination, since the numbers were too small. The distributions of review diagnoses were analysed by age at diagnosis. 28 men were aged 20-39 at diagnosis and 29 were aged 40-49. Both age-groups showed significant increases in intermediate-grade and high-grade lymphomas in the 1981-82 period (X2 =7-10, p=0-03 for the younger age-group and X= 7 -02, p 0’ 03 for the older age-group). When analysis was stratified by racial group a significant increase in the proportions of intermediate-grade and highgrade tumours for the 1981-82 period was observed among whites =9-25, p=0’01, n=44). Of the 13 non-white patients 11 had intermediate-grade or high-grade lymphomas; these were considered too few for analysis. Analysis of all patients by primary site of the tumour showed a non-significant increase in the proportion of extranodal lymphomas from 13% in 1976-77 to 30% in 1981-82 (p=0-ll). The difference was significant in the younger age-group, which showed no extranodal lymphomas in 1976-77 and 6 extranodal tumours (35%) in 1981-82 Marital
status was
=
=
(X2=4’94, p=0’03). 2 of the men in this study were thought to have AIDSrelated lymphomas at diagnosis (in 1982). Both were single. 1 had an intermediate-grade lymphoma of the brain and the other had a high-grade lymphoma of the colon. None of the other patients was known to be a haemophiliac, a user of intravenous drugs, or of Haitian origin. Records did not TABLE III-DISTRIBUTION OF NON-HODGKIN’S LYMPHOMA
The increase in the relative frequency of intermediategrade and high-grade lymphomas from the early to the later period was not anticipated at the start of this study. The occurrence of AIDS in the Atlanta area is uncommon (39 cases up to April 23, 1984). None of the men in this study except the 2 AIDS patients was known to be immunodeficient. There appears to be a general increase in intermediate-grade and high-grade NHL in young men that cannot be attributed entirely to the AIDS epidemic. The suggestion of a larger number of lymphomas presenting in extranodal sites during the more recent period (1981-82) is consistent with the increase in higher-grade since tumours, intermediate-grade and high-grade lymphomas are more likely to present at extranodal sites.7
Since the total number of NHL in young
men
in this
population increased between the 1976-77 and 1981-82 periods, age-specific incidence rates were calculated with population estimates developed from the 1970 and 1980 United States census counts for the 5-county metropolitan Atlanta area. On the basis of review diagnoses, annual incidence rates for men aged 20-49 years were 3.4per 100 000 for the 1976-77 period and 4-0 per 100 000 for the 1981-82 period. The sample is too small to determine whether this is a real increase. Miller et al reported a significant increase in the relative frequency of diagnosis of NHL among all lymph-node biopsy samples in 7 New York City hospitals from 1977 to 1981. However, this increase was primarily in men over the age of 44. Analysis of the original diagnoses by Working Formulation grade did not show the secular increases in higher-grade lymphomas found on review. Other reviews of pathological specimens have found considerable differences between original and review diagnoses of NHL, and this reflects the difficulty of morphological subclassification of these tumours, particularly the diffuse-histology types.9,1O For this reason data from population-based tumour registries alone may not be reliable for evaluation of a secular change in NHL subtypes. Incidence data, based on community diagnoses, on the occurrence of different histological subtypes of NHL are available through the SEER programme." However, reference data from reviewed pathological material since the onset of the AIDS epidemic have not been available. This study focused on a population-based series of incident cases in young
men.
The results indicate
an
increase in the relative
frequency of more aggressive NHL during the study period. Larger samples from other populations, including women and persons in older age groups, should be evaluated determine whether this trend persists and if it is unique young men.
to
to
HISTOLOGICAL SUBTYPES BY WORKING FORMULATION GRADE IN
2RECENT PERIODS*
This study was supported in part by contract 200-80-0556 from the Centers for Disease Control and contract NO1-CN-61027 from the National Cancer Institute. We thank the pathologists of the Atlanta area hospitals for providing histological specimens, Dr Margaret A. Child and Ms Susan E. Thomas for assistance in initiating the study, Dr Matthew M. Zack for reviewing the manuscript, John P. Whitaker for help in processing the data, and Ms Vickie Thomas for manuscript preparation.
Correspondence should be addressed to R. S. G., Atlanta Cancer Surveillance Center, Emory University School of Medicine, 246 Sycamore Street, Suite 100 Decatur, Georgia 30030, USA.
X’ = 12. 34,2 df,
p =0- 002. *Males
aged 20-49
yr.
859 TABLE I-COSTS OF OUT-OF-HOURS SERVICE IN
1979, 1982, AND 1984
(AT 1984 PRICES)
Hospital Practice A COMPARISON OF ALTERNATIVE ARRANGEMENTS FOR AN OUT-OF-HOURS CHEMICAL PATHOLOGY SERVICE IAN R. GUNN D. BRIAN MORGAN SHERRY FAYE GILLIAN CLEGG ANDREW M. GRANT
Department of Chemical Pathology, Leeds University, The Old Medical School, Leeds LS2 9JT
*Equipment depreciation: the blood gas equipment would have been purchased for the main laboratory if it had not been bought for the acute laboratory. The other equipment is written off over 5 years. tThe on-call payment was ;E4.55 in 1979 and )E8.33 in 1984, the stand-by payment was f3.00 in 1979 and f6.96 in 1984. Figures include travelling expenses.
Summary
Until
1979, the out-of-hours chemical
pathology service was the conventional oncall service in which the medical laboratory scientific officers (MLSOs) carried out analyses at the direct request of clinical staff. In 1980, during an industrial dispute, junior ward doctors were trained to use three simple instruments which are maintained by the chemical pathology department. In January, 1981, when the dispute was settled, the doctors continued to use these instruments. Analyses they could not make were done by the MLSO on call, but only after the requests were monitored by a chemical pathologist or biochemist. The result was an 80% reduction in the number of calls. When the monitoring was withdrawn in 1983, there was some increase in the number of MLSO calls, but this was still 35% less than that with the conventional system despite a 4-fold increase in the total number of analyses done out of hours between 1979 and 1984. Surveys in 1984 and in early 1985 revealed that most doctors preferred using the instruments to asking an MLSO to make the analysis. INTRODUCTION -
THE demand for chemical pathology measurements working hours has increased dramatically in recent years, particularly in large general hospitals. There are at least three reasons for this increase. (a) Clinicians expect an easily available chemical pathology service. The laboratories have encouraged this expectation for the day-time service; the clinicians now expect it at night as well. (b) The practice of "screening" patients by making routine measurements is accepted during normal working hours and has increasing impact on what clinicians request and expect out of hours. (c) Large general hospitals contain an increasing number of special-care units such as intensive-care units, coronary-care units, and neonatal units. Many of the ill patients in these units require regular biochemical monitoring through each 24 hours, 7 days a week.
outside normal
1. 2.
3
4.
Ziegler JL, Beckstead JA, Volberding PA, et al. Non-Hodgkin’s lymphoma in 90 homosexual men. N Engl J Med 1984; 311: 565-70. The Non-Hodgkin’s Lymphoma Classification Project. National Cancer Institute sponsored study of classifications of non-Hodgkin’s lymphomas. Summary and description of a working formulation for clinical usage. Cancer 1982; 49: 2112-35. Young JL Jr, Percy CL, Asire AJ, eds. SEER program: Incidence and mortality data: 1973-77. National Cancer Institute Monograph 57. Washington DC: US Government Printing Office, 1981. Coppleson LW, Factor RM, Strum SB, Rappaport H. Observer disagreement in classification and histology of Hodgkin’s disease. J Natl Cancer Inst 1970; 85: 731-40.
5. Kim
TH, Hargreaves HK, Brynes RK, et al. Pre-treatment testicular biopsy in childhood acute lymphocytic leukaemia. Lancet 1981; i: 657-58. 6. Fleiss JL. Statistical methods for rates and proportions. New York: John Wiley and
Sons, 1981.
For equipment maintenance. Based on 1112 h 5 days a week at mid-point on the scale ofa basic MLSO salary. Weekend maintenance is included in on-call payments.
Despite the increase in demand for these out-of-hours they continue to be provided largely by an "on-call system" which was designed to deal with the occasional measurement required urgently outside normal working services
hours. We describe here two other arrangements which have been introduced at the Leeds General Infirmary (LGI) during the past 5 years and compare them with the previous conventional out-of-hours on-call service. CHANGES IN THE SERVICE
Until 1979 the service, as in other large general hospitals, provided by medical laboratory scientific officers (MLSOs) on a voluntary basis. An MLSO was on call at home for each out-of-hours period ( 151/z h on week days and 20 h on each Saturday and Sunday). The doctor contacted the MLSOs directly and it was the doctor’s threshold of need which determined the workload. Up to 45 min could elapse between first contact with the MLSO and the result reaching the doctor. Each block of continuous work taking less than 2 h was a call for the purpose was
of payment. In late 1979, in the LGI, there was an average of 14 calls in each on-call period, and the cost, including travelling expenses, was about f50 000 at 1984 prices (table I). A busy night must have significantly affected the performance of the MLSO next day. In 1979, the consultants responsible for some of the specialcare units in the LGI decided to submit applications for analytical equipment which could be sited in these units and used by their clinical and nursing staff. The major reason for this application was that the out-ofhours service, with no resident staff on call, could provide neither the frequency nor the speed of response which the clinicians needed.
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1979; 43: 544-50 10. Whitcomb CC, Cousar JB, Flint A, et al. Subcategories of histiocytic lymphoma. Association with survival and reproducibility of classification. The Southeastern Cancer Study Group experience Cancer 1981; 48: 2464-74. 11. Percy C, O’Conor G, Ries LG, Jaffe ES. Non-Hodgkin’s lymphomas. Application of the International Classification of Diseases for Oncology (ICD-O) to the Working Formulation Cancer 1984; 54: 1435-38.