University College Hospital Macmillan Cancer Centre

This paper reports the development and validation of a disease-specific measure of health status and well-being of children with severe cerebral palsy (CP). The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) was constructed from recommendations from caregivers, healthcare providers, and review of other measures. Items spanning six domains are rated on an ordinal scale. Standardized scores (0-100) are reported for each domain and in total. Primary caregivers (n = 77) of 45 males and 32 females between 5 and 18 years of age (mean age 13 y 5 mo [SD 3 y 4 mo]) with CP, categorized by the Gross Motor Function Classification System (GMFCS) level, completed the CPCHILD. Caregivers of children with severe CP (GMFCS Levels IV and V) also completed a second administration of the CPCHILD 2 weeks after the first. The mean CPCHILD score for children with severe CP was 56.2 (SD 15.7; range 24-93). The mean CPCHILD scores for children in GMFCS Levels I to V were 22.0, 38.2, 23.0, 44.5, and 59.3 respectively (p < 0.001). Reliability was tested in 41/52 caregivers who reported no change in health status between the two administrations of the CPCHILD. The intraclass correlation coefficient was 0.94 (95% confidence interval 0.90-0.97). The CPCHILD seems to be a reliable and valid measure of caregivers' perspectives on the health status, functional limitations, and well-being of these children.

Selective dorsal rhizotomy (SDR) is widely used to treat spasticity in children with diplegic cerebral palsy (CP) but has never been shown conclusively to improve functional outcome. The study was designed to measure changes in gross motor function in children 1 year following rhizotomy compared with a control group receiving equivalent physiotherapy (PT) and occupational therapy (OT) with the exception that the rhizotomy group initially underwent a 6-week postoperative in-patient therapy program. Twenty-four children (mean age 58 months) with mild to moderate CP with spastic diplegia were randomly assigned to a therapy-only control group (CG) (N=12) or rhizotomy and therapy group (RG) (N=12). The Gross Motor Function Measure (GMFM) was administered at the baseline, 6-, and 12-month assessments. Extremity tone, range of motion (ROM), biomechanics of the ankle-stretch reflex, isometric contraction, and temporal gait components were also evaluated. GMFM scores in the RG improved by 12.1 percentage points versus 4.4 percentage points in the CG (P<0.02). RG knee and ankle tone was significantly reduced (P<0.005), associated with increased passive ankle ROM (P<0.001), and decreased soleus EMG reflex activity on forced dorsiflexion (P<0.008). Foot-floor contact pattern improved in the RG compared with the CG (P<0.05). In conclusion, SDR combined with PT and OT leads to significantly greater functional motor improvement at 1 year following surgery compared with PT and OT alone. This was achieved in part through reduced knee and ankle tone, increased ankle dorsiflexion ROM, and more normal foot-floor contact during walking.

This paper reports the development and validation of a disease‐specific measure of health status and well‐being of children with severe cerebral palsy (CP). The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) was constructed from recommendations from caregivers, healthcare providers, and review of other measures. Items spanning six domains are rated on an ordinal scale. Standardized scores (0–100) are reported for each domain and in total. Primary caregivers ( n =77) of 45 males and 32 females between 5 and 18 years of age (mean age 13y 5mo [SD 3y 4mo]) with CP, categorized by the Gross Motor Function Classification System (GMFCS) level, completed the CPCHILD. Caregivers of children with severe CP (GMFCS Levels IV and V) also completed a second administration of the CPCHILD 2 weeks after the first. The mean CPCHILD score for children with severe CP was 56.2 (SD 15.7; range 24–93). The mean CPCHILD scores for children in GMFCS Levels I to V were 22.0, 38.2, 23.0, 44.5, and 59.3 respectively ( p &lt; 0.001). Reliability was tested in 41/52 caregivers who reported no change in health status between the two administrations of the CPCHILD. The intraclass correlation coefficient was 0.94 (95% confidence interval 0.90–0.97). The CPCHILD seems to be a reliable and valid measure of caregivers’perspectives on the health status, functional limitations, and well‐being of these children.

The purpose of this study was to establish guidelines for the use of screening electroencephalograms (EEGs) in autism spectrum disorders to identify subclinical epileptiform activity. MEDLINE and EMBASE were searched for relevant articles. The evidence was reviewed using the methodology of the Canadian Task Force on Preventive Health Care. A priori criteria were established for article selection and for grading the quality and strength of the evidence. Seizures are common, occurring in 20 to 30% of patients based on the majority of studies. Epileptiform EEG abnormalities are present in 10.3% to 72.4% of patients and subclinical abnormalities in 6.1% to 31%. Evidence for the effectiveness of anticonvulsants and corticosteroids in reducing seizures and/or autistic symptoms is based primarily on case series and case reports, with only one published randomized trial. There is currently insufficient evidence to recommend for or against the use of screening EEGs in autistic patients. Given the frequency of seizure disorders in this patient population, a high index of clinical suspicion should be maintained for subtle symptoms of seizures.

This paper aims to examine the loss of weight and loss of appetite as 'problems' experienced by patients with advanced cancer and those that care for them. It reports the results of a systematic search of the literature and presents the findings as a narrative review. Research to date has focused upon charting the prevalence and incidence of these symptoms, but little empirical work has been conducted to investigate how patients and carers experience these problems. There is some evidence to suggest that anorexia may be more distressing for those caring for the patient than the person suffering from the symptom itself. Understanding the reason for this anguish requires an appreciation of the meaning of food refusal and constitutes the first step towards informing the development of effective interventions. Such exploratory work is mandatory if health professionals wish to move beyond speculation and deliver interventions that provide meaningful benefits for the cancer patient and their family.

A group of 100 adults and 190 youth who have cerebral palsy (CP), spina bifida (SB), and acquired brain injuries from childhood (ABIc) participated in a multi-method study focused on the transition to adult health care. The results show that 95% of youth and 61% of adults were living with their parents; 23% of the youth and 55% of adults were employed; and 60% of youth and 42% of adults reported "excellent" or "very good" health. The lowest health scores were reported by adults with SB. These findings provide a starting point for examining health issues specific to youth and young adults with CP, SB, and ABIc.

BACKGROUND: On the basis of phase 2 studies, trastuzumab deruxtecan was approved for patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic gastric cancer or gastroesophageal junction adenocarcinoma who had previously received trastuzumab-based therapy. Ramucirumab plus paclitaxel is also a standard second-line treatment option regardless of HER2 status. METHODS: We conducted an international, randomized, phase 3 trial comparing second-line trastuzumab deruxtecan at a dose of 6.4 mg per kilogram of body weight with ramucirumab plus paclitaxel in patients with HER2-positive metastatic gastric cancer or gastroesophageal junction adenocarcinoma confirmed on tumor biopsy conducted after the patient had progression while receiving trastuzumab-based therapy. The primary end point was overall survival. Secondary end points included progression-free survival, confirmed objective response (complete or partial response lasting ≥4 weeks), disease control, duration of response, and safety. RESULTS: Among 494 patients who had undergone randomization, overall survival was significantly longer with trastuzumab deruxtecan than with ramucirumab plus paclitaxel (median, 14.7 vs. 11.4 months; hazard ratio for death, 0.70; 95% confidence interval, 0.55 to 0.90; P = 0.004). Significant results were also seen with regard to progression-free survival (hazard ratio for disease progression or death, 0.74; 95% CI, 0.59 to 0.92) and confirmed objective response (in 44.3% of the patients in the trastuzumab deruxtecan group vs. 29.1% of those in the ramucirumab-paclitaxel group). The incidence of drug-related adverse events of any grade was 93.0% with trastuzumab deruxtecan and 91.4% with ramucirumab plus paclitaxel; the incidence of drug-related adverse events of grade 3 or higher was 50.0% and 54.1%, respectively. Adjudicated drug-related interstitial lung disease or pneumonitis occurred in 13.9% of the patients who received trastuzumab deruxtecan (grade 1 or 2 in 33 patients and grade 3 in 1) and in 1.3% of those who received ramucirumab plus paclitaxel (grade 3 in 2 patients and grade 5 in 1). CONCLUSIONS: Trastuzumab deruxtecan led to significantly longer overall survival than ramucirumab plus paclitaxel among patients with HER2-positive metastatic gastric cancer or gastroesophageal junction adenocarcinoma. Adverse events were common in both groups. Events of interstitial lung disease or pneumonitis with trastuzumab deruxtecan, a known risk, were mainly low-grade. (Funded by Daiichi Sankyo and AstraZeneca; DESTINY-Gastric04 ClinicalTrials.gov number, NCT04704934.).

The cloning of the dystrophin gene has led to major advances in the understanding of the molecular genetic basis of Duchenne, Becker, and other muscular dystrophies associated with mutations in genes encoding members of the dystrophin-associated glycoprotein complex. The recent introduction of pharmaceutical agents such as prednisone has shown great promise in delaying the progression of Duchenne muscular dystrophy but there remains a need to develop more long-term therapeutic interventions. Knowledge of the nature of the dystrophin gene and the glycoprotein complex has led many researchers to think that somatic gene replacement represents the most promising approach to treatment. The potential use of this strategy has been shown in the mdx mouse model of Duchenne muscular dystrophy, where germ line gene transfer of either a full-length or a smaller Becker-type dystrophin minigene prevents necrosis and restores normal muscle function.

The purpose of this evaluation project was to elicit nurses’and families’ experiences about differences and changes for nurses and families and the familynurse relationship when a family systems nursing approach was used to guide practice. Following nurses’ involvement in an educational workshop, the evaluation examined changes in nurses’and families’ experiences over an 8-week period of a child’s hospitalization in a pediatric rehabilitation center. A total of 17 nurses and 13 parents participated in the project. Nurses and parents completed questionnaires and participated in semi-structured interviews and focus groups. Nurses completed journals reflecting on their interactions with families. Data were analyzed using descriptive statistics and content analysis. Findings indicate that a family systems nursing approach had a positive impact on how nurses viewed their nursing practice and their work with families, thereby enhancing family-nurse relationships. Such findings have relevance to clinical nursing practice, professional development, and evaluation research design.

Chromosomal instability (CIN) has been implicated in multidrug resistance and the silencing of the ceramide transporter, CERT, promotes sensitization to diverse cytotoxics. An improved understanding of mechanisms governing multidrug sensitization might provide insight into pathways contributing to the death of CIN cancer cells. Using an integrative functional genomics approach, we find that CERT-specific multidrug sensitization is associated with enhanced autophagosome-lysosome flux, resulting from the expression of LAMP2 following CERT silencing in colorectal and HER2(+) breast cancer cell lines. Live cell microscopy analysis revealed that CERT depletion induces LAMP2-dependent death of polyploid cells following exit from mitosis in the presence of paclitaxel. We find that CERT is relatively over-expressed in HER2(+) breast cancer and CERT protein expression acts as an independent prognostic variable and predictor of outcome in adjuvant chemotherapy-treated patients with primary breast cancer. These data suggest that the induction of LAMP2-dependent autophagic flux through CERT targeting may provide a rational approach to enhance multidrug sensitization and potentiate the death of polyploid cells following paclitaxel exposure to limit the acquisition of CIN and intra-tumour heterogeneity.

The Pediatric Pain Questionnaire and relevant medical records were used to investigate the frequency, intensity, location, and duration of pain experienced by children with spina bifida and to examine the concordance between child self-report and parent proxy report of pain. There were 68 children with spina bifida (30 males, 38 females) between the ages of 8 and 19 years (mean age 12y 8m). Fifty-nine children (87%) were diagnosed with myelomeningocele, six (9%) with lipomyelomeningocele, and three (4%) with lipomeningocele (4%). Forty-nine children (72%) had shunted hydrocephalus. Twenty-six children (38%) ambulated full-time. Fifty-six per cent of children reported experiencing pain once a week or more often. For these children, pain occurred most frequently in the head, back, abdomen, neck, shoulders, legs, and hands. Of the 49 children with shunted hydrocephalus, 43 (88%) reported headaches; 15 of 19 children (79%) without hydrocephalus reported headaches. Children who reported more intense pain also reported more frequent pain and more pain locations. Parents were most reliable at reporting locations of their children's severe pain. Parents of younger children significantly underestimated their children's current pain and worst pain in the past 7 days. Lesion level and ambulatory status were not associated with any of the pain variables. It was concluded that children with spina bifida frequently report clinically significant, yet under-recognized and untreated pain.

The effects of training a school team in the use of the Participation Assessment Framework and barrier-specific interventions (including but not limited to technology applications) on the participation of a student during literacy and math activities were evaluated using a multiple probe design across instructional formats. Participants included a multi-disciplinary school team, and a 10-year old student with cerebral palsy and no functional speech supported by this team. Training consisted of a combination of adult learning strategies including workshops, modeling, practice in simulated and real settings, feedback, and coaching during actual practice. The results of this preliminary study provide suggestive evidence that this systematic training was not only effective in increasing participation, but also is perceived as useful and effective by the training recipients. Results are discussed in terms of their implications for future research.

Despite the accessibility of the oral cavity to clinical examination, delays in diagnosis of oral and oropharyngeal carcinoma (OOPC) are observed in a large majority of patients, with negative impact on prognosis. Diagnostic aids might help detection and improve early diagnosis, but there remains little robust evidence supporting the use of any particular diagnostic technology at the moment. The aim of the present feasibility first-in-human study was to evaluate the preliminary diagnostic validity of a novel technology platform based on dielectrophoresis (DEP). DEP does not require labeling with antibodies or stains and it is an ideal tool for rapid analysis of cell properties. Cells from OOPC/dysplasia tissue and healthy oral mucosa were collected from 57 study participants via minimally-invasive brush biopsies and tested with a prototype DEP platform using median membrane midpoint frequency as main analysis parameter. Results indicate that the current DEP platform can discriminate between brush biopsy samples from cancerous and healthy oral tissue with a diagnostic sensitivity of 81.6% and a specificity of 81.0%. The present ex vivo results support the potential application of DEP testing for identification of OOPC. This result indicates that DEP has the potential to be developed into a low-cost, rapid platform as an assistive tool for the early identification of oral cancer in primary care; given the rapid, minimally-invasive and non-expensive nature of the test, dielectric characterization represents a promising platform for cost-effective early cancer detection.

BACKGROUND AND PURPOSE: The derived neutrophil-lymphocyte ratio (dNLR) is a validated prognostic biomarker for cancer survival but has not been extensively studied in locally-advanced oesophageal cancer treated with definitive chemoradiotherapy (dCRT). We aimed to identify the prognostic value of dNLR in patients recruited to the SCOPE1 trial. MATERIALS AND METHODS: 258 patients were randomised to receive dCRT±cetuximab. Kaplan-Meier's curves and both univariable and multivariable Cox regression models were calculated for overall survival (OS), progression free survival (PFS), local PFS inside the radiation volume (LPFSi), local PFS outside the radiation volume (LPFSo), and distant PFS (DPFS). RESULTS: An elevated pre-treatment dNLR≥2 was significantly associated with decreased OS in univariable (HR 1.74 [95% CI 1.29-2.35], p<0.001) and multivariable analyses (HR 1.64 [1.17-2.29], p=0.004). Median OS was 36months (95% CI 27.8-42.4) if dNLR<2 and 18.4months (95% CI 14.1-24.9) if dNLR≥2. All measures of PFS were also significantly reduced with an elevated dNLR. dNLR was prognostic for OS in cases of squamous cell carcinoma with a non-significant trend for adenocarcinoma/undifferentiated tumours. CONCLUSIONS: An elevated pre-treatment dNLR may be an independent prognostic biomarker for OS and PFS in oesophageal cancer patients treated with definitive CRT. dNLR is a simple, inexpensive and readily available tool for risk-stratification and should be considered for use in future oesophageal cancer clinical trials. The SCOPE1 trial was an International Standard Randomised Controlled Trial [number 47718479].

The provision of end-of-life care within nursing and residential care homes is of concern to policy makers and specialist palliative care providers. There is evidence of an increasing number of initiatives involving clinical nurse specialists (CNS) with the care of residents within these care settings, but the extent to which this is occurring in the UK has not been documented. A survey of 730 community CNS in palliative care was undertaken to describe the extent to which these practitioners are involved with the care of residents in nursing and residential care homes and the nature of this work. Although 92% of the CNS surveyed had worked with nursing homes and 80% of the CNS with residential care homes, the responses showed that this work was primarily reactive and undertaken infrequently. The majority of the work undertaken by CNS involved caring for patients with malignant conditions with a clinical focus addressing the management of physical symptoms.

BACKGROUND: Radiation-induced fibrosis (RIF) is a late complication of radiotherapy that results in progressive functional and cosmetic impairment. Autologous fat has emerged as an option for soft tissue reconstruction. There are also sporadic reports suggesting regression of fibrosis following regional lipotransfer. This systematic review aimed to identify cellular mechanisms driving RIF, and the potential role of lipotransfer in attenuating these processes. METHODS: PubMed, OVID and Google Scholar databases were searched to identify all original articles regarding lipotransfer for RIF. All articles describing irradiated fibroblast or myofibroblast behaviour were included. Data elucidating the mechanisms of RIF, role of lipotransfer in RIF and methods to quantify fibrosis were extracted. RESULTS: Ninety-eight studies met the inclusion criteria. A single, definitive model of RIF is yet to be established, but four cellular mechanisms were identified through in vitro studies. Twenty-one studies identified connective tissue growth factor and transforming growth factor β1 cytokines as drivers of fibrotic cascades. Hypoxia was demonstrated to propagate fibrogenesis in three studies. Oxidative stress from the release of reactive oxygen species and free radicals was also linked to RIF in 11 studies. Purified autologous fat grafts contain cellular and non-cellular properties that potentially interact with these processes. Six methods for quantifying fibrotic changes were evaluated including durometry, ultrasound shear wave elastography, thermography, dark field imaging, and laser Doppler and laser speckle flowmetry. CONCLUSION: Understanding how lipotransfer causes regression of RIF remains unclear; there are a number of new hypotheses for future research.

BACKGROUND: Securing adequate vascular access is essential for a successful apheresis procedure. In most, peripheral access is preferred but it is not always technically possible. Ultrasound-Guided Peripheral Vascular Access (USG-PIVA) is a well-documented technique in the setting of Emergency departments. However, limited data exists reporting its use in the context of automated red cell exchanges (a-RCEx). PURPOSE: To assess the effectiveness and feasibility of USG-PIVA to undertake successful a-RCEx. METHODS: Data was collected prospectively from patients with sickle cell disease and difficult venous access, undergoing a-RCEx at a single centre. The USG-PIVA technique was attempted and data relating to each attempt was collected and analysed. RESULTS: Between April 2014 and July 2015 84 USG-PIVA procedures were performed on 38 patients. 71 USG-PIVA (85%) were successful, 13 (15%) were unsuccessful. Veins successfully cannulated: in the upper arm, basilic (22), brachial (33) and cephalic (2) veins; in the antecubital fossa, basilic (3) and median cubital (7) and in the lower arm, cephalic (2) and radial (2). Cannulas used: Introcan Safety® Braun 22 g (1), 20 g (9) and 18 g (61). Inlet flow rates achieved: 30-60 ml/min (mean 45 ml/min). Depth of veins cannulated: 2-12 mm (mean 5 mm). two complications were observed-one cannula displacement and one nerve injury. No arterial punctures occurred. Central Venous Catheters avoided (49). CONCLUSION: The US-PIVA method offers an effective alternative to Central Venous Access in patients requiring a-RCEx procedures who lack visual or palpable peripheral access, with minimal complications seen in this series. J. Clin. Apheresis 31:501-506, 2016. © 2015 Wiley Periodicals, Inc.

BACKGROUND: Administration of doxorubicin via bolus injection may result in environmental contamination and a risk of nurses becoming exposed. Small spills are frequently observed by nurses when syringes are connected to, and disconnected from, infusion lines. AIMS: The effect of a closed-system drug transfer device (CSTD) on the release of doxorubicin was studied during administration via bolus injections. METHODS: 10 administrations with the currently used technique and 10 administrations using the CSTD were compared by analysis of doxorubicin contamination on gauze pads, tissues and gloves. FINDINGS: Using the current technique, contamination was found during nine administrations, which was mainly on the gauze pads and, to a lesser extent, on the tissues and gloves, indicating release of doxorubicin during administration. With use of the CSTD, contamination was found only on one pair of gloves. CONCLUSION: Use of a CSTD significantly decreased the number of spills and level of contamination compared with the currently used technique and, consequently, the use of such devices offers a safer working environment for nurses.

This study evaluated the effectiveness of pyramidal training with direct care staff in group homes. Training focused on teaching staff how to provide opportunities for communication to non-speaking children with developmental disabilities to communicate. Staff were taught through a combination of a workshop, and nondirective consultation following an adult education model. A multiple-probe design across three cohorts of direct care staff was used to evaluate the effectiveness of the training in terms of the number of opportunities provided by staff and the percentage of requests emitted by participating children. Results showed that pyramidal training resulted in more opportunities provided to the children and concurrent increases in children's requesting. Results are discussed in terms of the suitability of pyramidal training for group home settings, and implications for future research.

The metaphors of warfare which surround cancer are as strong today as they were 20 years ago when Susan 14) wrote Illness as Metaphor. Cancer, in the closing days of the 20th century remains much feared, and associated with inevitable death. Living with cancer is conceptualized as a battle or fight, people with the disease are in turn victims and heroes, as they battle for their own survival. Care for people with cancer remains piecemeal, and people with cancer continue to report delays in diagnosis, insensitive communication by doctors and other health professionals, and a lack of sufficient information and support ( 12). The UK Health Service is mobilizing its response to the problem of cancer; massive re-organization following the 2) proposals and wider health reforms following the government White Paper ( 6). The tripartite structure proposed for cancer services (specialist cancer centres, smaller cancer units treating common cancers, and primary care) has broad appeal and may serve as a template for other diseases. The health regions have set about implementing the structure. Specialist care for all is, at least in theory, now possible. As re-organization has progressed a number of challenges have become apparent. The Calman-Hine framework was early on recognized as powerful in lobbying for more cancer doctors, and a more organized medical training structure. What was not recognized was that nursing, placed centre stage in the Calman-Hine proposals all be it as something of an after-thought, was likely to be vastly deficient. Far too few specialist cancer nurses exist to meet the minimum requirements of implementation ( 8). Training provision nationally, the skill level of the nursing workforce, and the need for strong clinical leadership, remain major concerns in achieving high quality, effective cancer treatment and care in the UK. Unlike for medicine, the skill shortage in nursing is so enormous, and the mechanisms for national workforce planning for nursing so inadequate, that an effective response may be too difficult to galvanise. `Quick fit' solutions may be found, leaving cancer services much poorer than Sir Kenneth Calman's vision intended. Despite this, health care promises one of the most exciting decades yet for cancer nursing, and since cancer has historically offered nursing as a whole a visionary lead, benefits may accrue across the whole health care sector. Cancer nurses have for some time delivered cancer treatment in the form of chemotherapy. As technology progresses, drug delivery systems increasingly mean that chemotherapy can be given by continuous infusion, transferring the setting for treatment from hospital to home. Refinements in drugs, chemotherapy regimes and techniques for managing side-effects, mean that for the majority, treatment can be managed as an outpatient. Cancer treatment settings are becoming much less institutions, and much more centres of expertise, where people with cancer attend briefly and intermittently to have investigations and discuss treatment options with the cancer team. Cancer treatment is sandwiched between meetings with nurse specialists for support and information. Visits to the cancer centre also offer the chance to participate in cancer support groups, physical or complementary therapies. Cancer centres will increasingly become a resource for coping with the disease, where knowledge and expertise can be found, but the person with cancer will remain firmly in charge and possibly self- administer their treatment. Specialist nurses will act as the co-ordinator of this treatment journey. Among a number of cancers, a surge in numbers of men developing prostate cancer is anticipated (predictions suggest 1 in 4 men may be affected by 2018). Increasing numbers of people needing treatment, will challenge centres offering radiotherapy. For many, prostate cancer treatment requires daily attendance for radiotherapy treatment over 6 weeks, with careful monitoring during this time for treatment toxicity. The management of prostate cancer will have to change. Unlike with chemotherapy treatment, nurses have yet to be utilized in managing radiotherapy care. Evidence from a study by 7) suggests that advanced nurse practitioners may be effective in managing patients during radiotherapy treatment and offer cheaper care than their medical counterparts. In other situations, nurses will increasingly be responsible for diagnostic services, since this may be the only means by which established standards for waiting times will be met. Pilot schemes, such as nurse-led rapid diagnostic services, appear to show their safety and acceptability ( 9). After treatment, recovering, readjusting to normal life, and learning to live with the fear of cancer returning, can be very difficult (Wells 1994). Follow-up, where people are monitored for signs of the disease returning over months or years, has until recently been the norm. Guidelines ( 6), based on systematic reviews of research evidence, suggest that such follow-up is costly and offers no benefit since most people with recurrent cancer discover this for themselves, rather than this being detected during routine visits to hospital outpatient clinics. It has been suggested that follow-up should be transferred to general practitioners, but pressure on primary care services may make this difficult. A number of studies are under way to explore how specialist nurses could contribute in this area. Specialist nursing could transform follow-up, reorienting care to assisting people to monitor themselves, and also providing open access to support, information and investigation of symptoms which suggest the cancer may have reoccurred, should the need arise. These may prove cost-effective while also offering ongoing support and peace of mind to people who would prefer to maintain contact with the cancer centre (studies suggest that this may be at least a third) ( 10). For others, putting cancer behind them will be important. Here specialist nurses offering a liaison service with primary care and general practitioners could help bridge the gap between sectors of care. More comprehensive care by specialist nurses, from prevention and diagnosis, to palliative care, might also be facilitated by specialist nurses placed in primary care localities. The UK charity Macmillan Cancer Relief are evaluating a pilot of such a role in the Hadleigh Practice in Dorset. As new roles for nurses in cancer care are developing, so too are cancer nurses developing the evidence base for their practice. Cancer nursing is being embraced as a therapy ( 3), with a number of areas of care led by nurses who are practising according to well-developed therapeutic principles and with evidence for the effectiveness of these therapies; for example the management of symptoms such as breathlessness ( 4), fatigue ( 11, 13), and problems such as lymphoedema ( 1), as well as therapeutic communication and help with emotional distress. Two Macmillan Cancer Relief funded specialist nursing research units, in London and in Manchester, have been established and are dedicated to responsive research programmes aimed at developing the practice of Macmillan nurses in cancer and palliative care. This exemplary project will in time make a significant contribution to the research basis in UK cancer care. Cancer nursing has achieved an enormous amount, health care reforms continue to offer cancer nurses great potential for further developing their role, and to develop services which are more responsive to the needs of people with cancer. What is needed now, is a genuine commitment by health service policy makers and managers to nursing leadership in service provision, and the facilities to create a cadre of specialist nurses genuinely able to take their place as equals in the multidisciplinary cancer treatment team for the future.