Integrated care in Europe: description and comparison of integrated care in six EU countries

Twenty-two children and adolescents who had received cisplatinum for the treatment of solid tumours underwent audiometry to ascertain the extent of hearing damage. Five patients complained of hearing difficulties, causing difficulty at school in one child. Hearing loss greater than 20 decibels occurred in four Median hearing loss was greater at higher frequencies (P< 0.0001), and with increasing cumulative dose of cisplatinum. However, a 'plateau' phenomenon was observed, with no apparent further deterioration in hearing loss at doses greater than 600 mg m-2. Two children who had received prior aural radiotherapy had severe hearing loss. Severe, mostly asymptomatic, ototoxicity is common in children given cisplatinum. However, there is considerable inter-patient variability in the hearing loss suffered. Cisplatinum is a cytotoxic agent which is being increasingly used in the management of paediatric solid tumours. It has contributed to improved response rates in osteosarcoma (Ettinger et al., 1981) and germ cell tumours (Pinkerton et al., 1986). Recent studies have highlighted its efficacy in certain resistant malignancies such as neuroblastoma, and its apparently greater efficacy when used in higher dose regimens (Ozols et al., 1983; Dini et al., 1987). However, its recognised side-effects include nephrotoxicity, ototoxicity, myelosuppres-sion, nausea and vomiting. Renal damage is the major dose-limiting toxicity, but this has been reduced by improved methods of drug administration. Ototoxicity has therefore assumed greater importance, especially in younger children, since it is generally thought to be irreversible, and therefore a potentially serious long term handicap. Several studies on cisplatinum ototoxicity, predominantly in adults, have yielded different results in relation to its incidence, severity and the occurrence of reversibility This may be due to variations in the populations studied, different methods of assessing hearing loss, and interactions with other ototoxic treatment. Cisplatinum-induced damage appears to be mainly confined to auditory function, with few reports of vestibular toxicity, though the latter has seldom been specifically sought. Symptoms of cisplatinum ototoxicity include deafness, tinnitus, and otalgia (Moroso & Blair, 1983). Although it can develop after several courses of treatment, ototoxicity often appears early in treatment (Melamed et al., 1985), and seems to be permanent in most patients (Aguilar-Hearing loss tends to be bilateral, cumulative with further treatment and more severe at higher frequencies, although extension into the speech range can occur (Aguilar-Markulis et al. Previous or concurrent use of other ototoxic agents may increase toxicity by more than simple algebraic summation (Aguilar-Markulis et al., 1981). Hearing loss …