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SD, which can occur in any type RCC histology subtype, presents as a transformation into a highgrade tumour with a spindle-cell appearance and immunohistochemical evidence of epithelial and mesenchymal components.13 In the past, this type of tumour has also been called carcinosarcoma, metaplastic carcinoma or spindle-cell carcinoma. Morphologic patterns of SD include fibrosarcomalike, malignant fibrous histiocytoma-like, rhabdomyosarcomatous and undifferentiated tumours. SD was recognized formally by the joint Union Internationale Contre le Cancer and the American Joint Committee on Cancer working group in 1997. The largest series, reported in 2001 by de PeraltaVenturina and colleagues, 14 included 101 cases of RCC with SD from a retrospective review of all RCC cases from 4 centres, 2 in the United States and 2 in Switzerland. Of the US cases, 74 of 952 consecutive RCC patients had SD, for an overall incidence of 8%. By subtype, SD was associated with 8% of clear-cell carcinomas, and with 3% of papillary, 9% of chromophobe, 29% of collecting-duct and 11% of unclassified tumours. However, these numbers are highly variable because of the small number of cases. RCC with SD tended to be diagnosed at a more advanced stage. The overall survival was also worse for those RCC patients with SD than those without; 5-year and 10-year survival for patients with SD was 22% and 13%, respectively, as opposed to 79% and 76%, respectively, for those without p 0.0001 ; . Those tumours with less than 50% SD had a better outcome than those that had more than 50% p 0.0453 ; . This is also true if lymphovascular invasion was present. When a Cox proportional hazard regression model was run, the most significant variable was the stage of the cancer: those patients with stage III and IV RCC did worse than those with stage II. The median survival of 19 months for patients in this study was significantly longer than that of the 4 other case series, 1518 published between 1968 and 1987, that involved 1342 patients who had RCC with SD range 612 mo survival.
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The first ; treatment period and was most prevalent in the third stage, when the cancer was not visible in x ray pictures and the patient felt "cured." Optimism tended to vanish in the fourth stage, when the tumour recurred, but could develop again, though to a lesser extent, during further courses of chemotherapy. Gradually patients would find out the facts about their prognosis, partly because of physical deterioration and partly through contact with fellow patients who were in a more advanced stage of the illness and were dying. Concealment of prognosis In the consultation in which doctors informed patients that they had cancer, it was usually also mentioned that there was no cure. Details of the likely progress of the disease and about prognosis were rarely given. Patients were told that "it is extremely difficult to give any indication of the general prognosis because each patient is unique." In most cases this statement was followed immediately with an offer of chemotherapy. Uniqueness of individual patients was emphasised again with statements such as "We never know how an individual patient will respond to this therapy." Doctors said that they could provide more information about prognosis ; after the results of chemotherapy were available. In actual practice, however, when "clean" x ray pictures suggested that chemotherapy had been "successful, " patients did not request further information on prognosis, believing that they were "cured." Later, when the inevitable relapse occurred, doctors told the patient that each relapse made treatment more difficult and the prognosis worse. Doctors would state again that an individual prognosis would depend on the results of future treatment and tests. The doctor gave information about the expected course of the illness only when he or she had a clinical reason after diagnosis and with each tumour relapse ; and did not explicitly formulate the prognosis until the patient was no longer considered "treatable" and was referred back to the general practitioner. Emphasis on treatment As indicated above, a characteristic feature of the consultation in which patients were told that they had cancer was a rapid transition from the provision of bad news to a discussion about what can be done about it see box 2 ; . By far the most time and energy was spent on "treatment" options. It is, however, important to note not only that the doctor instigated this but also that the patient eagerly complied and was keen to discuss the treatment options. When the patient was told that the cancer had returned, he immediately interrupted: "What can you do about it, doctor?" Throughout the treatment and remission period second and third stages ; discussions during consultations were almost entirely restricted to issues such as the planning of chemotherapy sessions, side effects, and test results. Both parties colluded in focusing on the "treatment calendar"2 and, at the same time, in ignoring the long term prognosis and the likely shape of the illness trajectory ; . Although doctors and nurses openly discussed patients' invariably poor ; prognosis with each other--for example, at staff meetings--it was generally understood that this knowledge was not public and must not be conveyed to patients by nurses. In contrast, nurses could discuss arrangements for treatment and test results with patients at all times.

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Ann Schwartz, Ph.D. is a nationally recognized cancer researcher, but not the kind who spends hours in a laboratory. Instead, Dr. Schwartz is an epidemiologist, a scientist who studies the incidence, distribution, and control of disease in a population. It's important scientific work taking place primarily outside the laboratory exactly where Dr. Schwartz wants to be with people and statistics. "You're trying to understand people, ask the right questions, understand their histories and what makes them who they are, " said Dr. Schwartz. While her studies include laboratory work, you won't find Dr. Schwartz in the lab often. "My husband has his Ph.D. in pharmacology and he understands why I don't like working in the lab. It's the same reason I don't like to cook, " she says. "I can't follow a recipe or laboratory procedures." Today, Dr. Schwartz serves as associate center director for population science at the Karmanos Cancer Institute working in the same building where she once had a summer job with the Michigan Cancer Foundation. She oversees a team of 60 researchers conducting a wide range of population studies while also carrying out her own research. "We conduct studies to compare risk factors and behaviors in individuals with cancer to individuals without cancer to get some idea of what causes the disease and what's associated with survival, " she says. "We're looking at genetic risk factors underlying susceptibility to certain kinds of cancer. In addition to those environmental exposures things you eat or smoke or are otherwise exposed to we want to know about any genetic components that increase a person's risk." It's time-consuming work and dependent on the good will of cancer patients who agree to be interviewed and donate a blood sample. In addition, the community at large is needed for comparison. Interviewers call hundreds of phone numbers in the metro Detroit area at random and ask a few simple questions. Then, if someone in the household fits a particular profile, the interviewer asks if they'd like to participate in a research study. If they choose to participate and about 70 percent do they are invited to complete an interview and provide a DNA sample for study. According to Dr. Schwartz, researchers are trying to identify specific genetic markers working toward a day when genetic testing will help identify people with an increased risk of developing certain kinds of cancer. "Lung and pancreatic cancer, for example, are very difficult to detect early. There aren't screening methods for these cancers like there are for breast or prostate cancer. So understanding genetic risk factors may someday help us better detect and prevent these cancers and azathioprine.

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