Saturday, May 23, 2020

Essay The Role of Database Administrator - 1418 Words

Importance Few companies today can exist without an IT department. The IT department contains many of the company’s technology experts. Almost all companies rely on computers to some degree whether it is an international conglomerate or a small startup company. Some companies are very dependent on computer systems while others use them only for accounting for payrolls and everyday computer tasks. Most organization, even the smallest company have people whose job is to make sure that the computer system is up and running or an emergency contact to call when the computer systems goes down. In the future, I want to take the head of a database administrator of an IT department whether the size of the company is small or enormous. In larger†¦show more content†¦My career might start off as a database designer. Database designers determine what are best types of databases to solve certain problems and work with database tools in order to develop those databases. After a database designer, I could be promoted to a manager role. Knowledge managers have a much higher-level knowledge to business problems than database designers. Knowledge managers usually focus on an area like accounting and working with database designers to develop databases that meet the needs of the users. In contrast to database designers, knowledge managers handle different tasks. Knowledge managers interfere with users and database designers in order to ensure that the databases meet the needs of the users and most importantly, the company. They usually have a specialty in a field in organizing, refining or gathering. Responsibility of database jobs The responsibility of a database administrator is to serve as the link between the database designers, knowledge managers and users. The database designers are often brought in for completing specific projects and then moving onto other projects at other companies or different departments at the same company. Their job are usually finished when they finish designing the database. While they may be used in the future to perform someShow MoreRelatedTechnology Changes Role of Database Administrator1195 Words   |  5 PagesTechnology Changes Role of Database Administrator The database administrator (DBA) is responsible for managing and coordinating all database activities. The DBAs job description includes database design, user coordination, backup, recovery, overall performance, and database security. The database administrator plays a crucial role in managing data for the employer. In the past the DBA job has required sharp technical skills along with management ability. (Shelly, Cashman, Waggoner 1992)Read MoreProgramming Solution Proposal Essay937 Words   |  4 Pagesprospect customers can post in the forums and ask questions and the administrators can answer the questions. If other customers or users know the answer to the question, they can also answer. That will help the customers questions get answered faster. Upon reviewing the company website, I noticed there was no support forum. There is a small FAQ (frequently asked questions) but no forum. The personnel involved in the project have a certain role they must play, the steps of the program development cycle mustRead MoreElements of a Fulfilling and Successful Database Adminstrator775 Words   |  3 Pagessenior-level Database Administrator position for a leading provider of technology services in support of the US government. After gaining ample experience, I plan to capitalize on my technical expertise and work as a freelance consultant. Economically speak ing, technological advancement has been a major cause of job displacement, however, automated ‘machines’ require technical knowledge to design, develop, implement and maintain. Consequently, IT-related positions are still in high demand. The Database AdministratorRead MoreThe Web Application Requires Security997 Words   |  4 Pagesin order to prohibit unauthorised access and it prevents service interruptions, so Training4U can always provide a good service. Securing the application ensures that only administrators can access the admin pages, and instructors and customers can access their pages through the internet. In order to do this for the administrators a login form would be created for the admin page so that they are the only people who can access them. Also the customer’s data needs to be protected both while it is beingRead MoreDatabase Administrators1638 Words   |  7 Pages1 Introduction Database is any collection of data or information, that is specially organized for rapid search and retrieval by a computer. Databases are structured to facilitate the storage, retrieval, modification, and deletion of data in conjunction with various data-processing operations. A database consists of a file or a set of files. The information in these files may be broken down into records, each of which consists of one or more fields. Fields are the basic units of data storageRead MoreResponsibilities Of Key Leaders : The Bold Pharma Organization Essay939 Words   |  4 Pagesplay a key role in assuring the information about the organization. To start with the Director, Production department head (PDH), Safety department head (SDH), Quality Assurance Head (QAH), Quality Control Head (QCH) all of those are vital in assuring the information. The first department, which assures the information in an organization is the Quality Assurance. The Quality assurance head is the one who makes sure all the information about the organization is secured. (Margolis, 2012) Roles and ResponsibilitiesRead MoreAnnotated Bibliography On Requirements Specification1107 Words   |  5 PagesSpecification Purpose This Project will create a database to hold information about Sure Start’s extensive educational, welfare and social/recreational resources (books, CDs and videos) on their premises that Staff, Volunteers and Parents can borrow. It will contain information regarding lending dates and how long resources have been borrowed for. Scope The criteria that should be fulfilled to cover the full scope of this project is as follows: †¢ The database should be original and customised †¢ The dataRead MoreComputerized Automated Secure System Used For Run Programming Contests On The Internet Essay1476 Words   |  6 PagesCompijudge will ideally be an automated, secure system used to run programming contests on the Internet. The system will consist of four types of users: an administrator, judges, teams, and the public. The administrator will have privileges to create a programming contest, and initially register individuals for a team and later for contests. Judges will have permissions to communication with teams during a contest, and ensure to the completion of the automatic grading process for every contestRead MoreDesign And Implementation : Fixing The Bugs From The Previous Iteration982 Words   |  4 Pageswhen linking to the database. †¢ I placed my IF statement to confirm role types into the wrong file and as such the code tried to confirm the role type before the user actually logged in. Once these aspects were worked upon the application correctly found the role type of the user and redirected them to their correct home page. Creating Tutorial Upload and View Pages For my second iteration I decided to work on the core feature of my application which was to allow administrators to upload tutorialsRead MoreWhat Are The Key Roles Involved In Running The Administrative Side Of The Community?712 Words   |  3 Pagesinsight into how it operated. One member of the group noted two key roles involved in running the administrative side of the community. These two roles may sound similar, but they have striking differences that make their variation requisite to the success of the community. The higher of the two being the â€Å"Administrative,† position or the admin for short. The second role is the â€Å"Moderator,† or mod. During normal operation, these roles share many of the same responsibilities of each other. That is

Monday, May 18, 2020

A Comparative Analysis on Two Leaders - Free Essay Example

Sample details Pages: 5 Words: 1517 Downloads: 7 Date added: 2017/06/26 Category Ethics Essay Type Compare and contrast essay Did you like this example? Two leaders Quality Mother Theresa Pope John Paul II Personal Values Charity Humility Selflessness Faith Voluntarism Faith Compassion Peace Unity Liberty Personal Beliefs She believed that it is our duty to care for others. She believed that Godà ¢Ã¢â€š ¬Ã¢â€ž ¢s presence could be seen in every human suffering. She believed that we get easily caught up in our own problems wherein we forget how many people around us were less fortunate. She believed that doing good things does not have to be big, as even little things with great love could be sufficient. She believed that serving other before oneself will stop the selfishness and shallowness. He believed that freedom is doing what is righteous, not by doing what we prefer. He believed that every human life is part of Godà ¢Ã¢â€š ¬Ã¢â€ž ¢s loving plan. He believed that democracy without values can become an open or thinly disguised totalitarianism. He believed on having no fear of moving into the unknown. He believed that the world is created for manà ¢Ã¢â€š ¬Ã¢â€ž ¢s service and Godà ¢Ã¢â€š ¬Ã¢â€ž ¢s glory. Personal Attitudes Selfless Loving Cheerful Humble Religious Non-bias Religious Philanthropic Determined Caring Personal Metaprograms Motivation filter Orientation filter Success indication filter Decision-making filter Convincer filter Leadership filter Energy Direction filter Performance filter Work Satisfaction filter Preferred Interest filter Abstract/Specific filter Comparison filter Challenge Response filter Time Awareness filter Focus filter Toward Motivated Both, Possibility and necessity Internal Do Automatic Self and others Both, Active and Reflective Team Player People People Abstract to specific Sameness Choice In time Others Toward motivated Both possibility and necessity Internal Do Automatic Self and others Both Active and Reflective Team player People People Abstract to specific Sameness with differences equally Choice Through time Others Quotes associated to them à ¢Ã¢â€š ¬Ã…“There is hunger, maybe not the hunger for a piece of bread but there is a terrible hunger for love.à ¢Ã¢â€š ¬Ã‚  à ¢Ã¢â€š ¬Ã…“We think sometimes that poverty is only being hungry, naked and homeless. The poverty of being unwanted, unloved and uncared for is the greatest poverty. We must start in our own homes to remedy this kind of poverty.à ¢Ã¢â€š ¬Ã‚  à ¢Ã¢â€š ¬Ã…“The most terrible poverty is loneliness and the feeling of being unloved.à ¢Ã¢â€š ¬Ã‚  à ¢Ã¢â€š ¬Ã…“When freedom does not have a purpose, when it does not wish to know anything about the rule of law engraved in the hearts of men and women, when it does not listen to the voice of conscience, it turns against humanity and society.à ¢Ã¢â€š ¬Ã‚  à ¢Ã¢â€š ¬Ã…“Have no fear of moving into the unknown. Simply step out fearlessly knowing that I am with you, therefore no harm can befall you; all is very, very well. Do this in complete faith and confidence.à ¢Ã¢â€š ¬Ã‚  à ¢Ã¢â€š ¬Ã…“Social justice cannot be attained by violence. Violence kills what it intends to create.à ¢Ã¢â€š ¬Ã‚  Main Decision Points in their Life At the age of 18, Mother Theresa left Skopje and went to Loreta Sisters. She was unable to see her mother and sister again. After 15 years working in the Loreto School as a teacher, she realized that she had a call to take care of the sick and the dying, the hungry, the naked, the homeless. To be Godà ¢Ã¢â€š ¬Ã¢â€ž ¢s love in action to the poorest of the poor. That was the beginning of the Missionaries of Charity. She asked permission to leave Loreta Congregation and establish the new order of sisters in the streets for the poor. After his fatherà ¢Ã¢â€š ¬Ã¢â€ž ¢s death, he decided to step into priesthood wherein he illegally attended seminary classes in the secret underground seminary headed by Archbishop of Krakow. In the beginning of Pope John Paul II papacy, he firmly reaffirmed the canon law prohibiting priests to actively participate in party politics. His purpose was not to reduce Catholicismà ¢Ã¢â€š ¬Ã¢â€ž ¢s political influence but to unite the church and to reinforce moral authority. Memories and References Mother Theresaà ¢Ã¢â€š ¬Ã¢â€ž ¢s mother Dranafile had a strong personality. Her mother taught her to be good and to be helpful. Her father died at the age of 42 wherein their family was very poor. Mother Theresaà ¢Ã¢â€š ¬Ã¢â€ž ¢s mother and sister died alone because the Albanian military did not send them out the country. When he was 8yrs. old, his mother died and after four years later, his physician brother died. He lived in a disciplined way of living with routine religious observation under his fatherà ¢Ã¢â€š ¬Ã¢â€ž ¢s supervision. He was hit by a German truck which he suffered from severe concussion and shoulder injury as he was left in the road for several days. He was discovered by a passerby. Based from his experienced, he believed that God has other plans for him as a confirmation of his vocation. On the 13th of May 1981, he was gunshot and was seriously wounded by an assassin. After his recovery, he offered forgiveness from the gunmanà ¢Ã¢â€š ¬Ã¢â€ž ¢s actions. Personal Traits Compassionate Humane Determined Forgiving Determined Commited in his beliefs Personal Skills and Skills Sets Good interpersonal skills Good communication skills Had the capability to motivate and inspire other people. Multi-lingual speaker Effective peacemaker Collaborator Personal Strategies Believed in divine providence Discouraged fund raising and allows peopleà ¢Ã¢â€š ¬Ã¢â€ž ¢s time, energy, monies and skills. To understand the poor, they must know what is poverty. They did not accept government grant, no church maintenance, salary, fees, and no income of such. Used his overseas visits to resolve numerous human conflicts that may impede the harmony between countries. He personally communicates with various parties. Maintains nonviolent and calm transactions with other religions Schedule to work on the focus areas Involvement in groupwork Short term: 19/01/2015-02/02/2015 Tasks Mon Tues Wed Thurs Fri Sat Sun Discussion with classmates 10:00AM-11: 30AM 1:30PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 2:30PM 10:00AM-11: 30AM 1:30PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 2:30PM 10:00AM-11: 30AM 1:30PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 2:30PM 10:00AM-11: 30AM 1:30PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 2:30PM WORK (5:00PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Library research 3:20PM-4:20PM 3:20PM-4:20PM WORK (5:00PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 9:00PM) WORK (5:00PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Internet research 3:20PM-5:00PM WORK (5:00PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 9:00PM) WORK (5:00PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Discussion with colleagues while at work 5:00PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 9:00PM WORK (5:00PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 9:00PM) WORK (5:00PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Long term: 09/02/2015-01/11/2015 Tasks Mon Tues Wed Thurs Fri Sat Sun Contribute at least 3 ideas in group activity 10:30AM- 11:30AM 1:30PM- 2:20PM 10:30AM- 11:30AM 1:30PM- 2:20PM WORK CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Speak in front of the class as the group representative 10:30AM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 11:30AM 1:30PM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 2:30PM 10:30AM à ¢Ã¢â€š ¬Ã¢â‚¬Å" 11:30AM WORK CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Do handover about clientà ¢Ã¢â€š ¬Ã¢â€ž ¢s status and make suggestions to improve cares 5:00PM- 9:00PM 5:00PM- 9:00PM 5:00PM- 9:00PM CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Improve self-confidence Short term: 19/01/2015- 15/02/2015 Tasks Mon Tues Wed Thurs Fri Sat Sun Read inspirational quotes such as our daily bread 8:30AM-8:45AM 8:30AM-8:45AM 8:30AM-8:45AM 8:30AM-8:45AM 8:30AM-8:45AM 8:30AM-8:45AM WORK (5:00PM- 9:00PM) 8:30AM-8:45AM CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Have a encouraging conversation with tutor / classmate 12:00NN- 1:00PM SDL 12:00NN- 1:00PM 12:00NN- 1:00PM 12:00NN- 1:00PM WORK (5:00PM- 9:00PM) WORK (5:00PM- 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Working with workmates with various style / strategies in work WORK (5:00PM- 9:00PM) SDL WORK (5:00PM- 9:00PM) WORK (5:00PM- 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Long-term: 16/02/2015- 16/08/2014 Tasks Mon Tues Wed Thurs Fri Sat Sun Go to church to pray and attend mass for spiritual support 3:00PM- 3:30Pm 3:30PM- 4:00PM 3:30PM- 4:00PM WORK (5:00PM- 9:00PM) 11:00AM- 12:15PM Communicate with family overseas to ask for advices and encouragement through viber or facebook messenger WORK (5:00PM- 9:00PM) 2:00PM- 3:00PM 6:00PM-7:00PM 6:00PM-7:00PM 10:00PM- 11:00PM 12:00NN- 2:00PM WORK (5:00PM- 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Permanent job as nurse for residency Short term: 09/12/2014- 09/01/2015 Tasks Mon Tues Wed Thurs Fri Sat Sun Look for CAP providers in NZ aside from prospect school (EIT) 10:00AM- 11:00AM 4:00PM- 5:00PM 4:00PM- 5:00PM WORK (5:00PM- 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Make an inquiry about CAP program in one of CAP providers through emails / phone calls SCHOOL (9:00AM-3:00PM) WORK (5:00PM-9:00PM) 1:00PM- 3:00PM 4:00PM- 5:00PM 4:00PM- 5:00PM SCHOOL (9:00AM-3:00PM) WORK (5:00PM-9:00PM) 10:00AM- 11:00AM WORK (5:00PM- 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Completion of documents required for CAP school such as JP of documents and medical SCHOOL (9:00AM-3:00PM) WORK (5:00PM-9:00PM) 12:30PM-1:00PM 12:00NN-1:00PM 10:00AM-10:30AM WORK (5:00PM-9:00PM) WORK (5:00PM- 9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Submission of requirements to school SCHOOL (9:00AM-3:00PM) WORK (5:00PM-9:00PM) 10:00AM- 12:00AM 4:00PM- 5:00PM 4:00PM- 5:00PM SCHOOL (9:00AM-3:00PM) WORK (5:00PM-9:00PM) WORK (5:00PM-9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Long term: 09/01/2015- 27/07/2015 Tasks Mon Tues Wed Thurs Fri Sat Sun Attend school in AGI to complete Level 6 and submission of portfolios and course works SCHOOL (9:00AM-3:00PM) SDL SCHOOL (9:00AM-3:00PM) SCHOOL (9:00AM-3:00PM) SCHOOL (9:00AM-3:00PM) WORK (5:00PM-9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Inquire to fellow colleagues at work about possible school for CAP WORK (5:00PM-9:00PM) WORK (5:00PM-9:00PM) WORK (5:00PM-9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Advance searching in the internet for places with job vacancies for nurses 12:00NN- 1:00PM 4:00PM- 5:00PM 4:00PM- 5:00PM 4:00PM- 5:00PM SCHOOL (9:00AM-3:00PM) WORK (5:00PM-9:00PM) 1:00PM- 2:00PM WORK (5:00PM-9:00PM) CHURCH (11:00AM- 12:15PM) WORK (2:45PM- 11:15PM) Don’t waste time! Our writers will create an original "A Comparative Analysis on Two Leaders" essay for you Create order

Tuesday, May 12, 2020

Multiculturalism of the American Society In The Chinese in All of Us by Richard Rodriguez Free Essay Example, 1750 words

In The Chinese in All of Us , Richard Rodriguez explores Multiculturalism. Rodriguez talks about the effects that multiculturalism of the American society had on his life. Being the son of Spanish speaking Mexican immigrant parents, he narrates the constant encounters he experienced while growing up in America. In defense of all the labeling and accusations he faced as a reaction to his book, which highlighted issues such as bilingual education and affirmative action, he wrote his understanding of the issue of Multiculturalism while maintaining one s own ethnic identity. He further elaborates, that though America is a blend of various cultures and it takes pride in it, it still has its own identity. America has its own individuality, its own culture. Multiculturalism in America and its impact on the American identity is constantly debated, where one side calls it the essence of American society whereas the other side considers it a threat to the American identity. (Rodriguez n. p)A merica is a multicultural society, where different cultures coexist alongside each other. Multiculturalism started as a movement at the end of the 19th century in the United States and Europe. We will write a custom essay sample on Multiculturalism of the American Society In The Chinese in All of Us by Richard Rodriguez or any topic specifically for you Only $17.96 $11.86/pageorder now The mass immigration of southern and eastern Europeans and Latin Americans were the driving forces behind it. The genesis of multiculturalism was the concept of cultural pluralism. The different features of different cultures often combine and incorporate. In this way, a cultural blend is formed which creates an environment of tolerance and respect for each other. In a multicultural society, individuals have the freedom to practice their own religion, follow their own dressing code, to eat what they want and participate in cultural practices despite its variance from the mainstream cultural norms. Since the first half of the 19th century, the United States has witnessed a constant mass immigration. These immigrants have played a pivotal role in shaping the cultural landscape of America. The immigrants having their own values, beliefs and attitudes, created their own perception of the adopted home.

Wednesday, May 6, 2020

The Manipulation of Gender Roles in Shakespeare’s Othello...

The Manipulation of Gender Roles in Shakespeare’s Othello Of Shakespeare’s great tragedies, the story of the rise and fall of the Moor of Venice arguably elicits the most intensely personal and emotional responses from its English-speaking audiences over the centuries. Treating the subject of personal human relationships, the tragedy which should have been a love story speaks to both reading and viewing audiences by exploring the archetypal dramatic values of love and betrayal. The final source of the tragic action in Shakespeare’s The Tragedy of Othello, the Moor of Venice has been attributed to various psychological, mythical, racial, social sources: Othello’s status as racial outsider in Venetian society, his pagan roots in†¦show more content†¦The most illusive character in all of Shakespeare’s drama, Iago is perhaps the most difficult to explore psychologically for the simple reason that he lacks a personal self. He dons and sheds gender like a closet of clothes, adorning each article as it suits hi m. Ultimately evolved from the Vice figure of the medieval English morality plays, as Bernard Spivack has convincingly argued, Iago is the Shakespeare’s dramatic and humanistic manifestation of the abstracted evil which governed the dramatic movement of the previous generations of English plays. The self he presents to the world is bound only by circumstance and not by constitution. One key to Iago’s power is his â€Å"improvisational ability† (Gutierrez 12). Like the mythical Satan as Prince of Lies, he makes up his fabulous stories as he goes along, playing off of others’ actions and reactions to his ever-spinning web of lies. Iago switches between the facades of emotion easily and fluidly. He admits and affirms his hatred of Othello in the opening lines of the play (I.i.1-9) [All citations are from the Bantam edition.] and reveals his intentions of betraying Othello at his earliest convenience (I.i.44). In the very next scene, not more than 150 lines l ater, we find Iago in his role as sycophant openly fawning before theShow MoreRelatedEssay about The Impact of Gender on Shakespeares Othello 1376 Words   |  6 PagesThe Impact of Gender on Shakespeare’s Othello In the book â€Å"Gender Trouble† (1990), feminist theorist Judith Butler explains â€Å"gender is not only a social construct, but also a kind of performance such as a show we put on, a costume or disguise we wear† (Butler). In other words, gender is a performance, an act, and costumes, not the main aspect of essential identity. By understanding this theory of gender as an act, performance, we can see how gender has greatly impacted the outcome of the play inRead MoreAnalysis Of Othello By William Shakespeare Essay1606 Words   |  7 PagesThe theme of power is explored in various ways throughout ‘Othello’, Shakespeare uses the vulnerability of characters’ flaws to allow power shifts to occur through manipulation. The Elizabethan value consensus highlights the difference in gender roles, with societal expectations being defined by the divine order. The limitations of social mobility provide a strong platform for the theme of power to be embedded upon, with characters such as Desdemona and Emilia representing the struggle that womenRead MoreGender Stereotypes in Othello Essay2033 Words   |  9 Pagesregards to gender stereotypes. Shakespeare’s great play Othello uses its main characters to embody the characteristics of the stereotypical females and males according to society’s liking. The stereotypical woman is loyal and faithful to her husband, while the male stereotype possesses strength, control, and dominance. This use of stereotypes enables many misperceptions to develop and build until ultimately everyone experiences downfall and destruction. Shakespeare includes the effects of gender rolesRead MoreAnalysis Of Shakespeare s Othello 1567 Words   |  7 PagesWOMEN’S ROLE IN SOCIETY: DISECTING THE MISOGONY IN SHAKESPEARE’S OTHELLO Judging Othello from a self-proclaimed feminist Audre Lorde’s perspective allows the reader to see the double standards women faced in the Elizabethan society. Today our society assigns gender roles to children from birth. From the baby dolls needing care and EZ Bake Oven toys, little girls are encouraged at an early onset to lead domesticated lives. Boys on the other hand, are given cars and action figures that can take rough-housingRead MoreThe Tragedy Of Othello By William Shakespeare Essay1418 Words   |  6 Pagestragedy of â€Å"Othello†, believed to have been written in approximately 1603. The work revolves around four central characters; Othello, a Moorish general in the Venetian army; his new wife, Desdemona; his lieutenant, Cassio; and his trusted ensign, Iago. Throughout the play of â€Å"Othello†, William Shakespeare diagnoses and portrays two ills within his own society, which are undeniably still present in society today. Shakespeare portrays the i ssues of prejudice against race and prejudice against gender. In thisRead MoreJessica Foy. Othello Essay. English Iii. 14 February 2017.907 Words   |  4 PagesJessica Foy Othello Essay English III 14 February 2017 Emilia Essay Character development is seen in almost every character in the play Othello. Most of the characters are seen tumbling in a downwards spiral of their former self; while other characters are seen becoming more powerful due to the loss of power from the people above them. One of the characters that developed from her superior’s weaknesses is Iago’s wife, Emilia. Emilia spends most of her time with Othello’s wifeRead MoreFeminism In Othello Essay957 Words   |  4 PagesEmilia is often named â€Å"the feminist of Othello† by scholars and critics because of her, seemingly, fiery independence among a sea of submissive women ( â€Å"Act Four: The Feminist of Othello† 17). The characterization of a woman who speaks out for herself suggests that Shakespeare thought progressively; because during that time, the Elizabethan era, women were mere objects rather than human beings. The plot of Othello revolves around the misgivings of poor communication and lack o f trust among the charactersRead More Goodnight Desdemona: a Feminist Introspection of Shakespeare2482 Words   |  10 PagesAnn-Marie MacDonald’s Goodnight Desdemona (Good morningJuliet) uses intertextuality to unveil the complete Shakespearean characters of Juliet and Desdemona to reveal the feminist narrative lurking between lines of Shakespeare’s plays. Only through the intertextual re-examination of the Shakespearean text itself via the interjection of genre and the reassigning of dialogue, within the metatheatre, is the true feminist representation of the female Shakespearian characters unveiled from behind the patriarchalRead More Essay on the Love Story of Antony and Cleopatra1645 Words   |  7 Pagesand Cleopatra is formally defined as a tragedy, it stands out from Shakespeare’s earlier tragic works. The structure of paradox within the play produces a different effect to usual tragic intensity. The characters display moods and impulse rather than pro gressing through a process of edification as in King Lear. The result from this spontaneity of character produces a lack of tragic motivation such as Macbeth’s ambition, or of Othello-like tragic responsibility. However, like the preceding tragediesRead MoreEssay on Othello and Hedda Gabler: Breaking from Tradition1825 Words   |  8 Pagesvarious ways, each one representing each gender differently. The representation of women has been a common and controversial subject. The female gender roles depicted in each time period have always been present in literature throughout history. These traditional female roles that society has placed on women have not always been evident. Even with different time periods, there has always been a break in the traditional female roles. Traditional female roles have always represented women as having

Screening Lung Cancer Literature Review Free Essays

Introduction Lung Cancer is the most common form of cancer diagnosed worldwide with respect to incidence and mortality. In 2008 in the UK, lung cancer accounted for 6% of all deaths and 22% of all deaths from cancer (Cancer Research UK, 2011). It is the leading cause of cancer related death in both men (24%) and women (21%) (Cancer Research UK, 2011). We will write a custom essay sample on Screening Lung Cancer: Literature Review or any similar topic only for you Order Now The 5-year survival rate is less than 10% in UK has not significantly improved in the past 20 years despite the advances in imaging and non-imaging diagnostic tests, surgical techniques and postoperative management, radiotherapy delivery and new chemotherapeutic agents (Ghosal et al., 2009). People who are at high-risk of having lung cancer in their life-time include smokers, ex-smokers, who have COPD and who have been exposed to industrial carcinogens such as asbestos and silica (Black et al.,2006). Due to its high prevalence and mortality rates, easily identifiable at-risk population, lung cancer appears to be an ideal candidate for mass screening (Reich et a.,2007), and hence active research has been carried on since the 1950’s to detect lung cancer in an asymptomatic population at an early stage when it is localized and potentially curable (Bach et al.,2007). The efficacy of a screening programme is judged by its capability to reduce disease-specific mortality and improve survival. On reviewing the literature it is evident that lung cancer screening has been an active field of research appealing many, however also a controversial topic. It is debated mainly in terms of cost effectiveness of the services, ideal diagnostic tests, benefits, harms, influence on mortality and survival, study design, inherent biases such as lead-time bias, length time bias, overdiagnosis bias (Patz et a.,2000). Currently there is no mass screening programme in the UK. â€Å"The National Institute for Health and Clinical Excellence (NICE) considers evidence of both clinical and cost effectiveness when deciding on whether or not to sanction the introduction of new NHS treatments or services† (Whynes ,2008). The aim of this review is to give an overview about the principles underlining screening, to synthesize and evaluate information from recent evidence provided by clinical studies and RCT’s for lung cancer screening and the issues pertaining to it, review the range of diagnostic test best suitable for screening and overall assess the feasibility of a screening programme and test if evidence support the hypothesis that early detection leads to reduction in mortality. Methods Identification of Studies Literature search was conducted using electronic databases such as AMED, EMBASE, Ovid MEDLINE(R), [email protected], Science Direct, Google Scholar using search terms: lung carcinoma, lung cancer screening limiting the search from 1995-2011,clinical trials for screening lung cancer was searched without any time limits and past and on-going clinical trials were identified from National Cancer Institute USA and Cancer Research UK using the clinical trials and research search tool. Lung Cancer was searched using the same search terms to identify studies. Reference list of systemic reviews and other studies was scanned. Quality of the studies was judged on their source of publication and the number of times the particular article was cited by others. Selection of papers Initial literature search on LCS resulted in a large number of papers with potential titles which were then filtered by selecting papers based on the relevance of the title to the topic and by reading the abstracts. Full papers of the relevant studies were then retrieved and reviewed. Inclusion Papers on screening for lung cancer were considered as the theme as opposed to diagnosing and staging of LC. Primary search for studies included: systemic reviews, RCT’s,non-randomized cohort / case-control studies, economical analysis, smoking cessation and lifestyle changes. Studies including other interventions such as CXR, sputum cytology, autofluroescence bronchoscopy, LDCT,PET, biomarkers was considered, however LDCT emerged as the modality of choice due to its technical and clinical abilities. Exclusion Papers not published in English were excluded. Data extraction and synthesis Substantive data was extracted from the papers. Methodological information regarding the information on participants regarding the entry criteria used such as age, smoking history(PY) and status i.e. current or former, sub-group of high–risk patients with COPD and occupational based risk factors was collected. Data from the results of the studies in terms of prevalence, detection, survival and mortality rates was noted along with disease stage and follow-up period. Outcome Measures The primary outcome was to assess the influence of LCS on mortality. Secondary outcomes were the effectiveness of screening clinically and economically, and the impact of screening on lifestyle changes and smoking behavior. Screening â€Å"Screening means testing people for early stages of a disease before they have any symptoms† (Cancer Research UK, 2011). Screening for LC is highly debated due to lack of evidence provided by past RCT’s showing reduction in mortality and due to the high costs for screening LC . WHO Screening Guidelines 1.) â€Å"The condition should be an important health problem 2.) The disease should have significant mortality 3.) There should be a latent phase of the disease 4.) Intervention earlier in the disease process should improve outcomes 5.) The screening test itself should have certain characteristics 6.)The cost of finding a case using the screening technique should be considered in relation to medical expenditure as a whole† Table 1: WHO Screening Guidelines. (Reproduced from Ghosal et al, 2009). Results Studies Included Using the electronic databases 42 studies was included and were categorized based on the nature of the study and relating to the endpoint of this review. They were categorized as: Randomized controlled trials (RCT), non randomized cohort/control studies, cost-effectiveness studies and studies that evaluated the impact of screening on smoking behavior and lifestyle. RCT’s On reviewing the literature 8 RCT’s were identified that were conducted in the past, which are current and which are on-going. Two large RCTs namely NLST (National Lung Screening Trial) (NLST Team, 2010) conducted in the USA compared LDCT and CXR’s among screened patients and NELSON (Dutch Belgian randomised lung cancer screening trial) (Netherlands Trial Register, 2011) is currently underway in the Netherlands comparing LDCT with no LDCT. Small RCT’s namely LSS (Lung Screening Study) (Gohagan et al., 2004), DEPISCAN (French pilot RCT) (Blanchon et al.,2007), DANTE (Infante et al.,2008), ITALUNG ( Pegna et al.,2009) randomized their study population into two arms in which LDCT was considered as the active arm. In the UK an randomized trial funded by the NIHR HTA called the UKLS (UK Lung Cancer Screening Trial) (Baldwin et al.,2011) is underway and is based on the initial results of the NLST. It is working closely with the NELSON trial to maximize the data available(NIHR Health Technology Assessment programme,2011).Features of these RCT’s with their aim and outcome have been outlined in Table 2. PLCO is a large RCT studying the impact on mortality reduction by screening patients with CXR(National cancer institute,2011). Table 2: Noteworthy RCT’s using LDCT for lung cancer screening. Study Ref Country Study Design Study start Year Aim of the Study Age Range No. of Subjects No. of subjects in the LDCT arm No. of subjects in the Control Arm Smoking History Study Outcome UKLS[Ongoing]( Baldwin et al.,2011)UK LDCT vs. Obs2008 The objective of the UKLS trial is to assess whether LDCTscreening and treatment of early lesions will reduce LC mortality in comparison to a control group without screening and to investigate if LC screening programme could be implemented in UK while ensuring any benefit exceeds harms in a cost-effective manner. 4000 (28000 if progression criteria met )– – NANA NELSON[Ongoing](Netherlands Trial register, 2011).NL-B-DK LSCT vs. Obs2003 1. To prove that in a RCT, screening with LDCT in high risk subjects will lead to a 25% decrease in lung cancer mortality. 2. To estimate the impact of lung cancer screening on health related quality of life and smoking cessation; 3. To estimate cost-effectiveness and help policy making.50-75156007915790715 cigs/day 25 years OR10 cigs/day 30 yearsNA NLST[Recent](NLST Team,2010)USA LDCT vs. CXR2003 To compare LC mortality of subjects screened with LDCT and with subjects screened with CXR.55-74530002672326733? 30 PYInitial results, shows 20 % fewer lung cancer deaths among trial participants screened LDCT compared to CXR. ITALUNG-CT (Pegna et al.,2009)Italy LDCT vs. Obs2004 ITALUNG is a population-based recruitment RCT perspective of pooling data with other RCTs in Europe andUS [14,22] contributing to the cooperative effort for the evaluation of the efficacy of low-dose CT lung cancer screening.55-6932061613159320 PYPopulation-based enrolment of high-risk subjects for aRCT of lung cancer screening with low-dose CT is feasible. The number of drop-outs in the group of subjects randomized to the active arm is low. LSS ( Gohagan et al.,2004)USA LDCT vs. CXR2002 To assessthe feasibility of conducting a large scale RCT of LDCT versus CXR for LC screening.55-74331816601658?30 PARCT comparing annual spiral CT to CXR is feasible.. DANTE( Infante et al.,2007)Italy LDCT vs. CXR + Sputum cytology2001 To determine the efficacy of lung cancer screening with low-dose CT on LC mortality.LC prevalence, incidence, stage distribution, and resectability are secondary endpoints60-74247212761196?20 PYLC Stage I detection rate in the spiral CT arm was 4 times higher than CXR’s.Advance stage tumors were also detected by CT. High resection rate suggests possible increase in cure rate. Longer follow up suggested. Depiscan-France[Pilot RCT results ]( Blanchon et a.,2007).France LDCT vs. CXR2002 â€Å"To determine the feasibility of enrollment byGPs, investigations and diagnostic procedures by university hospital radiologists and multidisciplinary teams, data management by centralized clinical research assistants, and anticipate the future management of a large national trial†(Blanchon et a.,2007)50-75621385380? 15 cigs/day for 20 YearsThis pilot trial allows estimating that non-calcified nodules are 10 timesmore often detected by LDCT than from CXR. It concludes that enrollment by GP’s was difficult and expresses the need for a large co-ordinate clinical research team in a trial. Clinical Effectiveness: Studies 34 studies were included and broken down to different sub-groups: With comparators, without comparators and other methods.RCT by Garg et al.(2002) compared LDCT versus no screening among patients with COPD and smoking history. Non-randomized studies by Henschke et al.(1999,2001,2004,2006)compared LDCT with CXR Swenson et al.(2002,2003,2005) compared CT with sputum cytology, Sobue et al.,2002 compared CT with CXR and sputum cytology. Studies by Pastorino et al.(2003) and Bastarrika et al.(2005) used LDCT along with PET without any comparator group. Futher prospective, non-randomized cohort studies by Sone et al(.2001);Nawa et al.(2002); Diederich et al.(2002,2004); MacRedmond et al.(2004,2006);Novello et al.(2005);Chong et al.(2004); Menezes et al.(2009) were single arm studies using LDCT. Several of these studies have been summarized with their results elsewhere (Yau et al., 2007). A study by Chien et al. (2008)estimated the mean-sojurm time and effect of mortality reduction by LDCT .I-ECAP study (Henschke et al., 2006) reported survival rates of screen diagnosed stage I cancers.The chosen trials sample populations were predominantly male and over the age of 40(Yau et al., 2007). The participants consisted of non-smokers as well as former or current smokers and who have COPD and who have been exposed to asbestos. Other tests for LCS: In a bimodality lung cancer surveillance trial in high–risk patients Lowen et al.,(2006) combined autofluorescent bronchoscopy (AFB)and LDCT, findings from AFB were compared to sputum cytology results .186 patients were enrolled who fulfilled the high-risk criteria and 169 completed baseline tests,7% were diagnosed with lung cancer . Bimodality surveillance could detect lung cancer and pre-malignancy in patients with multiple lung cancer risk factors despite sputum cytology findings and AFB proves to be an effective test in high-risk patients (Lowen et al., 2006). A RCT in UK called the Lung-SEARCH study is looking at detecting early LC using LDCT and fluorescence bronchoscopy in people with COPD (UKCRN,2011). In a cross-sectional study by Carozzi et al.(2009), potential use of molecular genetic markers for screening and diagnostic purposes were evaluated which could be combined with LDCT . Biomarkers detected in biological fluid help us understand the connection between genetic alternations and/or molecular pathways changes which will help us detect lung cancer earlier and reduce mortality (Carozzi et al., 2009). â€Å"Multi-screening approach integrating imaging technique and biomolecular marker could be used to improve screening for lung cancer and is worth of further investigation† (Carozzi. et al.,2009) The MEDLUNG study in UK is currently underway, looking at detecting early LC amongst high-risk patients using biomarkers (UKCRN,2011) Cost Effectiveness A systemic review by Black et al., in 2006 assessed the clinical and cost-effectiveness of CT for LC screening, six studies that described full economic evaluation was identified by scanning the reference list. Further two studies evaluating the cost effectiveness in an UK and Australian setup were looked upon. Economic and mathematical models were used to calculate cost-effectiveness ratios based on study assumptions. Characteristics of the economic studies are described in Table 3. Ref. Type of evaluation synthesis Interventions Study Population Country Period of study Okamoto, 2000 CEA; Total cost for one life saved; total cost for mean life expectancy saved. Mass screening(indirect CXR for all screened sputum cytology for high-risk individuals) in 1983 1993 and CT option Age- 40-84 years Japan 5 years Marshall et al.,2000 Incremental CEA; incremental cost per LYG LDCT vs. No screening Hypothetical cohort of 100,000 high risk-individuals (60-74 years) USA 5 years Marshall et al.,2001 Incremental CEA CUA; incremental cost per LY saved and cost per QALY saved. Annual scan with LDCT vs. no screening Hypothetical cohort of 100,000 high risk-individuals (60-74 years) USA 5 years Chirikos et al.,2002 Incremental CEA; incremental cost per LYG; cost per cancer case detected. 5 annual screening with LDCT vs. no screening. Hypothetical cohort of screened and unscreened patients from general population (Age ? 45-74 years) USA 15 years Mahadevia et al.,2003 Incremental CUA; incremental cost per QALY gained. Annual screen with LDCT vs. No screening. Hypothetical cohort of 100,000 current, quitting former smokers, Age ?60; 55 % male. USA 40 years Wisnivesky et al.,2003 Incremental CEA; incremental cost per LY saved. Single scan with LDCT vs. No screening. High-risk individuals, Age ?60 USA Cost restricted to 1 year. Manser et al.,2004 Incremental CEA; incremental cost per LY saved and QALY saved. 5 annual screening with LDCT vs. no screening Hypothetical cohort of 10000 male; age ? 60 Australia 5 years Whynes, 2008 Incremental CEA; incremental cost per QALY gained Single scan with LDCT vs. no screening, if positive further diagnostic tests to be undergone. Hypothetical cohort; high-risk male population using values of test parameters from previous clinical studies. UK – Table 3~: Characteristics of economic evaluation studies (Reproduced from Black et al., 2006) and data from other studies. Impact on Lifestyle Smoking Cessation Lifestyle is a major modifiable cause of cancer and cancer-related mortality (Aalst et al.,2010). A review based on recent evidence published by studies, Aalst et al. (2010) indicated that screening may have a positive outcome hereby promoting healthy lifestyle but also cautions us that it can also encourage people to continue or start an unhealthy lifestyle. Lung cancer screening can prove to be a teachable moment for smoking cessation and may influence people to quit smoking (Taylor et al., 2006). Discussion Mortality rates gives us the true outcome of a test as it is unconfounded by bias (Black et al.,2006). An effective screening programme should be able to identify high-risk groups depending on age, gender, lifestyle and occupation and have high sensitivity and specificity eventually resulting in reduction of mortality. Studies by Henschke et al.(2000),Nawa et a.(2002), Gohagan et al.(2004),Menezes et al.(2009) reported high sensitivity and specificity above 80%,Sone et al.(2001) and Pastorino et al.,(2003) reported low sensitivities and Swensen et al.(2002) ,Diederich et al.(2002,2004) reported low specificities. Discrepancy resided amongst studies due to the variation in the entry criteria such as age, gender, PY, high-risk sample and threshold values set (?5 – ? 20mm) for detecting suspicious lesions which made it difficult to compare results and determine the ideal criteria for diagnosis of a screening programme. Prevalence screening with LDCT revealed that majority of cancers reported were Stage I non-small cell lung cancer (53-100 %)(Yau et a.,2007)though advance stage cancers were also reported with other histological types of cancers. ELCAP,DANTE, LSS studies along with Swensen et al.(2002) found that CT was more effective at identifying cancerous NCN’s than CXR’s.It should be noted that CT detects more peripherally located tumors than centrally located ones which are difficult to diagnose(Postmus et al.,2004). I-ELCAP study (Henschke et al.,2006) reported a 10-year survival rate of 88% for the whole series and 92% for resected stage I patients. By estimating shorter MST in conjunction with other parameters Chien et al.(2008) predicted that 15% mortality reduction can be seen for an annual LDCT screening. Initial results from NLST showed 20 % reduction in mortality in the LDCT arm, however final results are yet to be published(NLST Team,2010). This trial hereby the only RCT to date that has proved clinical effectiveness against mortality reduction. However it should be noted that operating characteristics can be influenced by high false positive and false negative rates. High FP rates due to detection of benign lesions and lack of standardized threshold for positive screen have been reported thus resulting in low PPV(Yau et al.,2007).This is one of the hurdles in implementing LDCT for LCS.True estimation of TN rates cannot be established due to incomplete follow-up of negative baseline scans and shorter follow-up duration thus leading to high NPV(Yau et al.2007). Accuracy also depends on the ability of the reporting radiologist(Sone et al.,2001). The assumption that a â€Å"stage-shift† would result in decrease in mortality needs to be more carefully evaluated as it would lead to decrease in inoperable cases and an increase in operable cases which means that LC incidence will occur as a result of overdiagnosis bias(Beplor et al.,2003). Both clinical effectiveness along with cost-effectiveness hurdle needs to be overcome (which presently poses a greater challenge) to fulfill the criteria of a screening programme(Gleeson ,2006) Inherent biases present in studies i.e. lead-time bias, length bias and over-diagnosis bias and should be accounted for in CEA and analytical methods as they can affect cost-effectiveness ratios (demonstrated by the cost-evaluation studies included) and survival and mortality benefit may be overestimated(Black et al,2006) .If evidence from LCS studies provide health gains in terms of quality and quantity of life with modest additional cost per patient, cost-effectiveness can be justified (Black et al.,2006).More complete and transparent CEA are required (Patz et al.,2000). According to the HTA report published in 2006 by Black et al., LDCT for screening LC does not meet the accepted NSC criteria due to unsatisfactory clinical and cost –effectiveness evidence. According to NICE the screening programme needs to pass the cost per QALY threshold of ?20,000–30,000 per QALY (NIHCE,2005). However due to the rise in public expectations which adds additional burden on the services provided by NHS, the imbalance between demand versus supply and the rise in cost of health care services, it seems that even if NSC criteria are satisfied implementation of LDCT as a screening programme would be economically and logistically challenging with respect to the capital cost involved in setting up a multi centre nationalized screening programme Conclusion Based on this literature review, it has emerged that LDCT is the choice of screening tool for LCS, however integrated imaging with AFB and PET and advances in genomic and proteomic approaches promises to compliment the ability of CT to detect LC(Carozzi et al.2010).Economic decision-making framework should include harms of screening along with the mortality and morbidity associated with it, radiation exposure risks as a result of repeated follow-ups(Black et al.,2006) .Included studies did not account for this. Past and on-going LDCT studies need to be carefully evaluated and screening progrmme should be designed based on the country’s merits and population distribution. NRCT’s have failed to establish reduction in mortality and hence evidence from large RCT’s proving the hypothesis and screening efficacy is of paramount importance for introducing a population screening progrmme. Results are awaited from these RCT’s. References: Andrea Lopes Pegna, Giulia Picozzi, Mario Mascalchi, Francesca Maria Carrozzi, Laura Carozzi,Camilla Comin, Cheti Spinelli , Fabio Falaschi, Michela Grazzini, Florio Innocenti, Cristina Ronchi, Eugenio Paci, 2009, Design, recruitment and baseline results of the ITALUNG trial for lung cancer screening with low-dose CT, Lung Cancer ;64 34–40. 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Ferretti , Etienne Lemari?e, Bernard Milleron, Dominique Chagu?e, Franc?ois Laurent, Yves Martinet,Catherine Beigelman-Aubry, Franc?ois Blanchon, Marie-Pierre Revel,Sylvie Friard, Martine R?emy-Jardin, Manuela Vasile , Nicola Santelmo,Alain Lecalier, Patricia Lef?ebure, Denis Moro-Sibilot, Jean-Luc Breton, Marie-France Carette, Christian Brambilla, Franc?ois Fournel, Alexia Kieffer , Guy Frija, Antoine Flahault, 2007, Baseline results of the Depiscan study: A French randomized pilot trial of lung cancer screening comparing low dose CT scan (LDCT) and chest X-ray (CXR), Lung Cancer ;58, 50—58. Tomotaka Sobue, Noriyuki Moriyama, Masahiro Kaneko, Masahiko Kusumoto, Toshiaki Kobayashi, Ryosuke Tsuchiya, Ryutaro Kakinuma, Hironobu Ohmatsu, Kanji Nagai, Hiroyuki Nishiyama, Eisuke Matsui, and Kenji Eguchi, 2002, Screening for Lung Cancer With Low-Dose Helical Computed Tomography: Anti-Lung Cancer Association Project, J Clin Oncol 20:911-920. Takeshi Nawa, Tohru Nakagawa, Suzushi Kusano, Yoshimichi Kawasaki, Youichi Sugawara, Hajime Nakata,2002, Lung Cancer Screening Using LowDose Spiral CT* Results of Baseline and 1-Year Follow-up Studies, Chest 2002;122;15-20. Thomas N. Chirikos, Todd Hazelton, Melvin Tockman, Robert Clark, 2002, Screening for Lung Cancer With CT*- A Preliminary Cost-effectiveness Analysis, Chest;121;1507-1514. Ugo Pastorino,Massimo Bellomi,Claudio Landoni, Elvio De Fiari, Patrizia Arnaldi, Maria Picchio, Giuseppe Pelosi, Peter Boyle,Ferruccio Fazio, 2003, Early Lung-Cancer detection with spiral CT and Positron emission tomographyin heavy smokers : 2year results, Lancet :362:593-97. UK Clinical Research Network : Portfolio Database (UKCRN), 2011, Lung-SEARCH study , accessed on 20/4/11 from S. Diederich , M Thomas , M Semik , H Lenzen ,N Roos , A Weber , W Heindel ,D Wormanns ,2004, Screening for early lung cancer with low-dose spiral computed tomography: results of annual follow-up examinations in asymptomatic smokers [abstract], Eur Radiology;.(4):691-702. http://pfsearch.ukcrn.org.uk/StudyDetail.aspx?TopicID=1StudyID=2225. UK Clinical Research Network: Portfolio Database (UKCRN), 2011,The MEDLUNG study, accessed on 20/4/11 from http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=4682 How to cite Screening Lung Cancer: Literature Review, Essay examples

Screening Lung Cancer Literature Review Free Essays

Introduction Lung Cancer is the most common form of cancer diagnosed worldwide with respect to incidence and mortality. In 2008 in the UK, lung cancer accounted for 6% of all deaths and 22% of all deaths from cancer (Cancer Research UK, 2011). It is the leading cause of cancer related death in both men (24%) and women (21%) (Cancer Research UK, 2011). We will write a custom essay sample on Screening Lung Cancer: Literature Review or any similar topic only for you Order Now The 5-year survival rate is less than 10% in UK has not significantly improved in the past 20 years despite the advances in imaging and non-imaging diagnostic tests, surgical techniques and postoperative management, radiotherapy delivery and new chemotherapeutic agents (Ghosal et al., 2009). People who are at high-risk of having lung cancer in their life-time include smokers, ex-smokers, who have COPD and who have been exposed to industrial carcinogens such as asbestos and silica (Black et al.,2006). Due to its high prevalence and mortality rates, easily identifiable at-risk population, lung cancer appears to be an ideal candidate for mass screening (Reich et a.,2007), and hence active research has been carried on since the 1950’s to detect lung cancer in an asymptomatic population at an early stage when it is localized and potentially curable (Bach et al.,2007). The efficacy of a screening programme is judged by its capability to reduce disease-specific mortality and improve survival. On reviewing the literature it is evident that lung cancer screening has been an active field of research appealing many, however also a controversial topic. It is debated mainly in terms of cost effectiveness of the services, ideal diagnostic tests, benefits, harms, influence on mortality and survival, study design, inherent biases such as lead-time bias, length time bias, overdiagnosis bias (Patz et a.,2000). Currently there is no mass screening programme in the UK. â€Å"The National Institute for Health and Clinical Excellence (NICE) considers evidence of both clinical and cost effectiveness when deciding on whether or not to sanction the introduction of new NHS treatments or services† (Whynes ,2008). The aim of this review is to give an overview about the principles underlining screening, to synthesize and evaluate information from recent evidence provided by clinical studies and RCT’s for lung cancer screening and the issues pertaining to it, review the range of diagnostic test best suitable for screening and overall assess the feasibility of a screening programme and test if evidence support the hypothesis that early detection leads to reduction in mortality. Methods Identification of Studies Literature search was conducted using electronic databases such as AMED, EMBASE, Ovid MEDLINE(R), [email protected], Science Direct, Google Scholar using search terms: lung carcinoma, lung cancer screening limiting the search from 1995-2011,clinical trials for screening lung cancer was searched without any time limits and past and on-going clinical trials were identified from National Cancer Institute USA and Cancer Research UK using the clinical trials and research search tool. Lung Cancer was searched using the same search terms to identify studies. Reference list of systemic reviews and other studies was scanned. Quality of the studies was judged on their source of publication and the number of times the particular article was cited by others. Selection of papers Initial literature search on LCS resulted in a large number of papers with potential titles which were then filtered by selecting papers based on the relevance of the title to the topic and by reading the abstracts. Full papers of the relevant studies were then retrieved and reviewed. Inclusion Papers on screening for lung cancer were considered as the theme as opposed to diagnosing and staging of LC. Primary search for studies included: systemic reviews, RCT’s,non-randomized cohort / case-control studies, economical analysis, smoking cessation and lifestyle changes. Studies including other interventions such as CXR, sputum cytology, autofluroescence bronchoscopy, LDCT,PET, biomarkers was considered, however LDCT emerged as the modality of choice due to its technical and clinical abilities. Exclusion Papers not published in English were excluded. Data extraction and synthesis Substantive data was extracted from the papers. Methodological information regarding the information on participants regarding the entry criteria used such as age, smoking history(PY) and status i.e. current or former, sub-group of high–risk patients with COPD and occupational based risk factors was collected. Data from the results of the studies in terms of prevalence, detection, survival and mortality rates was noted along with disease stage and follow-up period. Outcome Measures The primary outcome was to assess the influence of LCS on mortality. Secondary outcomes were the effectiveness of screening clinically and economically, and the impact of screening on lifestyle changes and smoking behavior. Screening â€Å"Screening means testing people for early stages of a disease before they have any symptoms† (Cancer Research UK, 2011). Screening for LC is highly debated due to lack of evidence provided by past RCT’s showing reduction in mortality and due to the high costs for screening LC . WHO Screening Guidelines 1.) â€Å"The condition should be an important health problem 2.) The disease should have significant mortality 3.) There should be a latent phase of the disease 4.) Intervention earlier in the disease process should improve outcomes 5.) The screening test itself should have certain characteristics 6.)The cost of finding a case using the screening technique should be considered in relation to medical expenditure as a whole† Table 1: WHO Screening Guidelines. (Reproduced from Ghosal et al, 2009). Results Studies Included Using the electronic databases 42 studies was included and were categorized based on the nature of the study and relating to the endpoint of this review. They were categorized as: Randomized controlled trials (RCT), non randomized cohort/control studies, cost-effectiveness studies and studies that evaluated the impact of screening on smoking behavior and lifestyle. RCT’s On reviewing the literature 8 RCT’s were identified that were conducted in the past, which are current and which are on-going. Two large RCTs namely NLST (National Lung Screening Trial) (NLST Team, 2010) conducted in the USA compared LDCT and CXR’s among screened patients and NELSON (Dutch Belgian randomised lung cancer screening trial) (Netherlands Trial Register, 2011) is currently underway in the Netherlands comparing LDCT with no LDCT. Small RCT’s namely LSS (Lung Screening Study) (Gohagan et al., 2004), DEPISCAN (French pilot RCT) (Blanchon et al.,2007), DANTE (Infante et al.,2008), ITALUNG ( Pegna et al.,2009) randomized their study population into two arms in which LDCT was considered as the active arm. In the UK an randomized trial funded by the NIHR HTA called the UKLS (UK Lung Cancer Screening Trial) (Baldwin et al.,2011) is underway and is based on the initial results of the NLST. It is working closely with the NELSON trial to maximize the data available(NIHR Health Technology Assessment programme,2011).Features of these RCT’s with their aim and outcome have been outlined in Table 2. PLCO is a large RCT studying the impact on mortality reduction by screening patients with CXR(National cancer institute,2011). Table 2: Noteworthy RCT’s using LDCT for lung cancer screening. Study Ref Country Study Design Study start Year Aim of the Study Age Range No. of Subjects No. of subjects in the LDCT arm No. of subjects in the Control Arm Smoking History Study Outcome UKLS[Ongoing]( Baldwin et al.,2011)UK LDCT vs. Obs2008 The objective of the UKLS trial is to assess whether LDCTscreening and treatment of early lesions will reduce LC mortality in comparison to a control group without screening and to investigate if LC screening programme could be implemented in UK while ensuring any benefit exceeds harms in a cost-effective manner. 4000 (28000 if progression criteria met )– – NANA NELSON[Ongoing](Netherlands Trial register, 2011).NL-B-DK LSCT vs. Obs2003 1. To prove that in a RCT, screening with LDCT in high risk subjects will lead to a 25% decrease in lung cancer mortality. 2. To estimate the impact of lung cancer screening on health related quality of life and smoking cessation; 3. To estimate cost-effectiveness and help policy making.50-75156007915790715 cigs/day 25 years OR10 cigs/day 30 yearsNA NLST[Recent](NLST Team,2010)USA LDCT vs. CXR2003 To compare LC mortality of subjects screened with LDCT and with subjects screened with CXR.55-74530002672326733? 30 PYInitial results, shows 20 % fewer lung cancer deaths among trial participants screened LDCT compared to CXR. ITALUNG-CT (Pegna et al.,2009)Italy LDCT vs. Obs2004 ITALUNG is a population-based recruitment RCT perspective of pooling data with other RCTs in Europe andUS [14,22] contributing to the cooperative effort for the evaluation of the efficacy of low-dose CT lung cancer screening.55-6932061613159320 PYPopulation-based enrolment of high-risk subjects for aRCT of lung cancer screening with low-dose CT is feasible. The number of drop-outs in the group of subjects randomized to the active arm is low. LSS ( Gohagan et al.,2004)USA LDCT vs. CXR2002 To assessthe feasibility of conducting a large scale RCT of LDCT versus CXR for LC screening.55-74331816601658?30 PARCT comparing annual spiral CT to CXR is feasible.. DANTE( Infante et al.,2007)Italy LDCT vs. CXR + Sputum cytology2001 To determine the efficacy of lung cancer screening with low-dose CT on LC mortality.LC prevalence, incidence, stage distribution, and resectability are secondary endpoints60-74247212761196?20 PYLC Stage I detection rate in the spiral CT arm was 4 times higher than CXR’s.Advance stage tumors were also detected by CT. High resection rate suggests possible increase in cure rate. Longer follow up suggested. Depiscan-France[Pilot RCT results ]( Blanchon et a.,2007).France LDCT vs. CXR2002 â€Å"To determine the feasibility of enrollment byGPs, investigations and diagnostic procedures by university hospital radiologists and multidisciplinary teams, data management by centralized clinical research assistants, and anticipate the future management of a large national trial†(Blanchon et a.,2007)50-75621385380? 15 cigs/day for 20 YearsThis pilot trial allows estimating that non-calcified nodules are 10 timesmore often detected by LDCT than from CXR. It concludes that enrollment by GP’s was difficult and expresses the need for a large co-ordinate clinical research team in a trial. Clinical Effectiveness: Studies 34 studies were included and broken down to different sub-groups: With comparators, without comparators and other methods.RCT by Garg et al.(2002) compared LDCT versus no screening among patients with COPD and smoking history. Non-randomized studies by Henschke et al.(1999,2001,2004,2006)compared LDCT with CXR Swenson et al.(2002,2003,2005) compared CT with sputum cytology, Sobue et al.,2002 compared CT with CXR and sputum cytology. Studies by Pastorino et al.(2003) and Bastarrika et al.(2005) used LDCT along with PET without any comparator group. Futher prospective, non-randomized cohort studies by Sone et al(.2001);Nawa et al.(2002); Diederich et al.(2002,2004); MacRedmond et al.(2004,2006);Novello et al.(2005);Chong et al.(2004); Menezes et al.(2009) were single arm studies using LDCT. Several of these studies have been summarized with their results elsewhere (Yau et al., 2007). A study by Chien et al. (2008)estimated the mean-sojurm time and effect of mortality reduction by LDCT .I-ECAP study (Henschke et al., 2006) reported survival rates of screen diagnosed stage I cancers.The chosen trials sample populations were predominantly male and over the age of 40(Yau et al., 2007). The participants consisted of non-smokers as well as former or current smokers and who have COPD and who have been exposed to asbestos. Other tests for LCS: In a bimodality lung cancer surveillance trial in high–risk patients Lowen et al.,(2006) combined autofluorescent bronchoscopy (AFB)and LDCT, findings from AFB were compared to sputum cytology results .186 patients were enrolled who fulfilled the high-risk criteria and 169 completed baseline tests,7% were diagnosed with lung cancer . Bimodality surveillance could detect lung cancer and pre-malignancy in patients with multiple lung cancer risk factors despite sputum cytology findings and AFB proves to be an effective test in high-risk patients (Lowen et al., 2006). A RCT in UK called the Lung-SEARCH study is looking at detecting early LC using LDCT and fluorescence bronchoscopy in people with COPD (UKCRN,2011). In a cross-sectional study by Carozzi et al.(2009), potential use of molecular genetic markers for screening and diagnostic purposes were evaluated which could be combined with LDCT . Biomarkers detected in biological fluid help us understand the connection between genetic alternations and/or molecular pathways changes which will help us detect lung cancer earlier and reduce mortality (Carozzi et al., 2009). â€Å"Multi-screening approach integrating imaging technique and biomolecular marker could be used to improve screening for lung cancer and is worth of further investigation† (Carozzi. et al.,2009) The MEDLUNG study in UK is currently underway, looking at detecting early LC amongst high-risk patients using biomarkers (UKCRN,2011) Cost Effectiveness A systemic review by Black et al., in 2006 assessed the clinical and cost-effectiveness of CT for LC screening, six studies that described full economic evaluation was identified by scanning the reference list. Further two studies evaluating the cost effectiveness in an UK and Australian setup were looked upon. Economic and mathematical models were used to calculate cost-effectiveness ratios based on study assumptions. Characteristics of the economic studies are described in Table 3. Ref. Type of evaluation synthesis Interventions Study Population Country Period of study Okamoto, 2000 CEA; Total cost for one life saved; total cost for mean life expectancy saved. Mass screening(indirect CXR for all screened sputum cytology for high-risk individuals) in 1983 1993 and CT option Age- 40-84 years Japan 5 years Marshall et al.,2000 Incremental CEA; incremental cost per LYG LDCT vs. No screening Hypothetical cohort of 100,000 high risk-individuals (60-74 years) USA 5 years Marshall et al.,2001 Incremental CEA CUA; incremental cost per LY saved and cost per QALY saved. Annual scan with LDCT vs. no screening Hypothetical cohort of 100,000 high risk-individuals (60-74 years) USA 5 years Chirikos et al.,2002 Incremental CEA; incremental cost per LYG; cost per cancer case detected. 5 annual screening with LDCT vs. no screening. Hypothetical cohort of screened and unscreened patients from general population (Age ? 45-74 years) USA 15 years Mahadevia et al.,2003 Incremental CUA; incremental cost per QALY gained. Annual screen with LDCT vs. No screening. Hypothetical cohort of 100,000 current, quitting former smokers, Age ?60; 55 % male. USA 40 years Wisnivesky et al.,2003 Incremental CEA; incremental cost per LY saved. Single scan with LDCT vs. No screening. High-risk individuals, Age ?60 USA Cost restricted to 1 year. Manser et al.,2004 Incremental CEA; incremental cost per LY saved and QALY saved. 5 annual screening with LDCT vs. no screening Hypothetical cohort of 10000 male; age ? 60 Australia 5 years Whynes, 2008 Incremental CEA; incremental cost per QALY gained Single scan with LDCT vs. no screening, if positive further diagnostic tests to be undergone. Hypothetical cohort; high-risk male population using values of test parameters from previous clinical studies. UK – Table 3~: Characteristics of economic evaluation studies (Reproduced from Black et al., 2006) and data from other studies. Impact on Lifestyle Smoking Cessation Lifestyle is a major modifiable cause of cancer and cancer-related mortality (Aalst et al.,2010). A review based on recent evidence published by studies, Aalst et al. (2010) indicated that screening may have a positive outcome hereby promoting healthy lifestyle but also cautions us that it can also encourage people to continue or start an unhealthy lifestyle. Lung cancer screening can prove to be a teachable moment for smoking cessation and may influence people to quit smoking (Taylor et al., 2006). Discussion Mortality rates gives us the true outcome of a test as it is unconfounded by bias (Black et al.,2006). An effective screening programme should be able to identify high-risk groups depending on age, gender, lifestyle and occupation and have high sensitivity and specificity eventually resulting in reduction of mortality. Studies by Henschke et al.(2000),Nawa et a.(2002), Gohagan et al.(2004),Menezes et al.(2009) reported high sensitivity and specificity above 80%,Sone et al.(2001) and Pastorino et al.,(2003) reported low sensitivities and Swensen et al.(2002) ,Diederich et al.(2002,2004) reported low specificities. Discrepancy resided amongst studies due to the variation in the entry criteria such as age, gender, PY, high-risk sample and threshold values set (?5 – ? 20mm) for detecting suspicious lesions which made it difficult to compare results and determine the ideal criteria for diagnosis of a screening programme. Prevalence screening with LDCT revealed that majority of cancers reported were Stage I non-small cell lung cancer (53-100 %)(Yau et a.,2007)though advance stage cancers were also reported with other histological types of cancers. ELCAP,DANTE, LSS studies along with Swensen et al.(2002) found that CT was more effective at identifying cancerous NCN’s than CXR’s.It should be noted that CT detects more peripherally located tumors than centrally located ones which are difficult to diagnose(Postmus et al.,2004). I-ELCAP study (Henschke et al.,2006) reported a 10-year survival rate of 88% for the whole series and 92% for resected stage I patients. By estimating shorter MST in conjunction with other parameters Chien et al.(2008) predicted that 15% mortality reduction can be seen for an annual LDCT screening. Initial results from NLST showed 20 % reduction in mortality in the LDCT arm, however final results are yet to be published(NLST Team,2010). This trial hereby the only RCT to date that has proved clinical effectiveness against mortality reduction. However it should be noted that operating characteristics can be influenced by high false positive and false negative rates. High FP rates due to detection of benign lesions and lack of standardized threshold for positive screen have been reported thus resulting in low PPV(Yau et al.,2007).This is one of the hurdles in implementing LDCT for LCS.True estimation of TN rates cannot be established due to incomplete follow-up of negative baseline scans and shorter follow-up duration thus leading to high NPV(Yau et al.2007). Accuracy also depends on the ability of the reporting radiologist(Sone et al.,2001). The assumption that a â€Å"stage-shift† would result in decrease in mortality needs to be more carefully evaluated as it would lead to decrease in inoperable cases and an increase in operable cases which means that LC incidence will occur as a result of overdiagnosis bias(Beplor et al.,2003). Both clinical effectiveness along with cost-effectiveness hurdle needs to be overcome (which presently poses a greater challenge) to fulfill the criteria of a screening programme(Gleeson ,2006) Inherent biases present in studies i.e. lead-time bias, length bias and over-diagnosis bias and should be accounted for in CEA and analytical methods as they can affect cost-effectiveness ratios (demonstrated by the cost-evaluation studies included) and survival and mortality benefit may be overestimated(Black et al,2006) .If evidence from LCS studies provide health gains in terms of quality and quantity of life with modest additional cost per patient, cost-effectiveness can be justified (Black et al.,2006).More complete and transparent CEA are required (Patz et al.,2000). According to the HTA report published in 2006 by Black et al., LDCT for screening LC does not meet the accepted NSC criteria due to unsatisfactory clinical and cost –effectiveness evidence. According to NICE the screening programme needs to pass the cost per QALY threshold of ?20,000–30,000 per QALY (NIHCE,2005). However due to the rise in public expectations which adds additional burden on the services provided by NHS, the imbalance between demand versus supply and the rise in cost of health care services, it seems that even if NSC criteria are satisfied implementation of LDCT as a screening programme would be economically and logistically challenging with respect to the capital cost involved in setting up a multi centre nationalized screening programme Conclusion Based on this literature review, it has emerged that LDCT is the choice of screening tool for LCS, however integrated imaging with AFB and PET and advances in genomic and proteomic approaches promises to compliment the ability of CT to detect LC(Carozzi et al.2010).Economic decision-making framework should include harms of screening along with the mortality and morbidity associated with it, radiation exposure risks as a result of repeated follow-ups(Black et al.,2006) .Included studies did not account for this. Past and on-going LDCT studies need to be carefully evaluated and screening progrmme should be designed based on the country’s merits and population distribution. NRCT’s have failed to establish reduction in mortality and hence evidence from large RCT’s proving the hypothesis and screening efficacy is of paramount importance for introducing a population screening progrmme. Results are awaited from these RCT’s. References: Andrea Lopes Pegna, Giulia Picozzi, Mario Mascalchi, Francesca Maria Carrozzi, Laura Carozzi,Camilla Comin, Cheti Spinelli , Fabio Falaschi, Michela Grazzini, Florio Innocenti, Cristina Ronchi, Eugenio Paci, 2009, Design, recruitment and baseline results of the ITALUNG trial for lung cancer screening with low-dose CT, Lung Cancer ;64 34–40. 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