Analysis of potential response predictors to capecitabine/temozolomide in metastatic pancreatic neuroendocrine tumors

The capecitabine and temozolomide (CAPTEM) regimen is active in the treatment of metastatic pancreatic neuroendocrine tumors (pNETs), with response rates ranging from 30 to 70%. Small retrospective studies suggest that O(6)-methylguanine DNA methyltransferase (MGMT) deficiency predicts response to temozolomide. High tumor proliferative activity is also commonly perceived as a significant predictor of response to cytotoxic chemotherapy. It is unclear whether chromosomal instability (CIN), which correlates with alternative lengthening of telomeres (ALT), is a predictive factor. In this study, we evaluated 143 patients with advanced pNET who underwent treatment with CAPTEM for radiographic and biochemical response. MGMT expression (n=52), grade (n=128) and ALT activation (n=46) were investigated as potential predictive biomarkers. Treatment with CAPTEM was associated with an overall response rate (ORR) of 54% by RECIST 1.1. Response to CAPTEM was not influenced by MGMT expression, proliferative activity or ALT pathway activation. Based on these results, no biomarker-driven selection criteria for use of the CAPTEM regimen can be recommended at this time.

Planned Repeat Cesarean Section at Term and Adverse Childhood Health Outcomes: A Record-Linkage Study

BACKGROUND

Global cesarean section (CS) rates range from 1% to 52%, with a previous CS being the commonest indication. Labour following a previous CS carries risk of scar rupture, with potential for offspring hypoxic brain injury, leading to high rates of repeat elective CS. However, the effect of delivery by CS on long-term outcomes in children is unclear. Increasing evidence suggests that in avoiding exposure to maternal bowel flora during labour or vaginal birth, offspring delivered by CS may be adversely affected in terms of energy uptake from the gut and immune development, increasing obesity and asthma risks, respectively. This study aimed to address the evidence gap on long-term childhood outcomes following repeat CS by comparing adverse childhood health outcomes after (1) planned repeat CS and (2) unscheduled repeat CS with those that follow vaginal birth after CS (VBAC).

METHODS AND FINDINGS

A data-linkage cohort study was performed. All second-born, term, singleton offspring delivered between 1 January 1993 and 31 December 2007 in Scotland, UK, to women with a history of CS (n = 40,145) were followed up until 31 January 2015. Outcomes assessed included obesity at age 5 y, hospitalisation with asthma, learning disability, cerebral palsy, and death. Cox regression and binary logistic regression were used as appropriate to compare outcomes following planned repeat CS (n = 17,919) and unscheduled repeat CS (n = 8,847) with those following VBAC (n = 13,379). Risk of hospitalisation with asthma was greater following both unscheduled repeat CS (3.7% versus 3.3%, adjusted hazard ratio [HR] 1.18, 95% CI 1.05-1.33) and planned repeat CS (3.6% versus 3.3%, adjusted HR 1.24, 95% CI 1.09-1.42) compared with VBAC. Learning disability and death were more common following unscheduled repeat CS compared with VBAC (3.7% versus 2.3%, adjusted odds ratio 1.64, 95% CI 1.17-2.29, and 0.5% versus 0.4%, adjusted HR 1.50, 95% CI 1.00-2.25, respectively). Risk of obesity at age 5 y and risk of cerebral palsy were similar between planned repeat CS or unscheduled repeat CS and VBAC. Study limitations include the risk that women undergoing an unscheduled CS had intended to have a planned CS, and lack of data on indication for CS, which may confound the findings.

CONCLUSIONS

Birth by repeat CS, whether planned or unscheduled, was associated with an increased risk of hospitalisation with asthma but no difference in risk of obesity at age 5 y. Greater risk of death and learning disability following unscheduled repeat CS compared to VBAC may reflect complications during labour. Further research, including meta-analyses of studies of rarer outcomes (e.g., cerebral palsy), are needed to confirm whether such risks are similar between delivery groups.

Vaginal birth after caesarean section: why is uptake so low? Insights from a meta-ethnographic synthesis of women's accounts of their birth choices

OBJECTIVE

To identify what women report influences their preferred mode of birth after caesarean section.

DESIGN

Systematic review of qualitative literature using meta-ethnography.

DATA SOURCES

Medline, EMBASE, ASSIA, CINAHL and PsycINFO (1996 until April 2013; updated September 2015). Hand-searched journals, reference lists and abstract authors.

STUDY SELECTION

Primary qualitative studies reporting women's accounts of what influenced their preferred mode of birth after caesarean section.

DATA EXTRACTION AND SYNTHESIS

Primary data (quotations from study participants) and authors' interpretations of these were extracted, compared and contrasted between studies, and grouped into themes to support the development of a 'line of argument' synthesis.

RESULTS

20 papers reporting the views of 507 women from four countries were included. Distinctive clusters of influences were identified for each of three groups of women. Women who confidently sought vaginal birth after a caesarean section were typically driven by a long-standing anticipation of vaginal birth. Women who sought a repeat caesarean section were strongly influenced by distressing previous birth experiences, and at times, by encouragement from social contacts. Women who were more open to information and professional guidance had fewer strong preconceptions and concerns, and viewed a range of considerations as potentially important.

CONCLUSIONS

Women's attitudes towards birth after caesarean section appear to be shaped by distinct clusters of influences, suggesting that opportunities exist for clinicians to stratify and personalise decision support by addressing relevant ideas, concerns and experiences from the first caesarean section birth onwards.

Planned Cesarean Delivery at Term and Adverse Outcomes in Childhood Health

IMPORTANCE

Planned cesarean delivery comprises a significant proportion of births globally, with combined rates of planned and unscheduled cesarean delivery in a number of regions approaching 50%. Observational studies have shown that offspring born by cesarean delivery are at increased risk of ill health in childhood, but these studies have been unable to adjust for some key confounding variables. Additionally, risk of death beyond the neonatal period has not yet been reported for offspring born by planned cesarean delivery.

OBJECTIVE

To investigate the relationship between planned cesarean delivery and offspring health problems or death in childhood.

DESIGN, SETTING, AND PARTICIPANTS

Population-based data-linkage study of 321,287 term singleton first-born offspring born in Scotland, United Kingdom, between 1993 and 2007, with follow-up until February 2015.

EXPOSURES

Offspring born by planned cesarean delivery in a first pregnancy were compared with offspring born by unscheduled cesarean delivery and with offspring delivered vaginally.

MAIN OUTCOMES AND MEASURES

The primary outcome was asthma requiring hospital admission; secondary outcomes were salbutamol inhaler prescription at age 5 years, obesity at age 5 years, inflammatory bowel disease, type 1 diabetes, cancer, and death.

RESULTS

Compared with offspring born by unscheduled cesarean delivery (n = 56,015 [17.4%]), those born by planned cesarean delivery (12,355 [3.8%]) were at no significantly different risk of asthma requiring hospital admission, salbutamol inhaler prescription at age 5 years, obesity at age 5 years, inflammatory bowel disease, cancer, or death but were at increased risk of type 1 diabetes (0.66% vs 0.44%; difference, 0.22% [95% CI, 0.13%-0.31%]; adjusted hazard ratio [HR], 1.35 [95% CI, 1.05-1.75]). In comparison with children born vaginally (n = 252,917 [78.7%]), offspring born by planned cesarean delivery were at increased risk of asthma requiring hospital admission (3.73% vs 3.41%; difference, 0.32% [95% CI, 0.21%-0.42%]; adjusted HR, 1.22 [95% CI, 1.11-1.34]), salbutamol inhaler prescription at age 5 years (10.34% vs 9.62%; difference, 0.72% [95% CI, 0.36%-1.07%]; adjusted HR, 1.13 [95% CI, 1.01-1.26]), and death (0.40% vs 0.32%; difference, 0.08% [95% CI, 0.02%-1.00%]; adjusted HR, 1.41 [95% CI, 1.05-1.90]), whereas there were no significant differences in risk of obesity at age 5 years, inflammatory bowel disease, type 1 diabetes, or cancer.

CONCLUSIONS AND RELEVANCE

Among offspring of women with first births in Scotland between 1993 and 2007, planned cesarean delivery compared with vaginal delivery (but not compared with unscheduled cesarean delivery) was associated with a small absolute increased risk of asthma requiring hospital admission, salbutamol inhaler prescription at age 5 years, and all-cause death by age 21 years. Further investigation is needed to understand whether the observed associations are causal.

Qualitative website analysis of information on birth after caesarean section

BACKGROUND

The United Kingdom (UK) caesarean section (CS) rate is largely determined by reluctance to augment trial of labour and vaginal birth. Choice between repeat CS and attempting vaginal birth after CS (VBAC) in the next pregnancy is challenging, with neither offering clear safety advantages. Women may access online information during the decision-making process. Such information is known to vary in its support for either mode of birth when assessed quantitatively. Therefore, we sought to explore qualitatively, the content and presentation of web-based health care information on birth after caesarean section (CS) in order to identify the dominant messages being conveyed.

METHODS

The search engine Google™ was used to conduct an internet search using terms relating to birth after CS. The ten most frequently returned websites meeting relevant purposive sampling criteria were analysed. Sampling criteria were based upon funding source, authorship and intended audience. Images and written textual content together with presence of links to additional media or external web content were analysed using descriptive and thematic analyses respectively.

RESULTS

Ten websites were analysed: five funded by Government bodies or professional membership; one via charitable donations, and four funded commercially. All sites compared the advantages and disadvantages of both repeat CS and VBAC. Commercially funded websites favoured a question and answer format alongside images, 'pop-ups', social media forum links and hyperlinks to third-party sites. The relationship between the parent sites and those being linked to may not be readily apparent to users, risking perception of endorsement of either VBAC or repeat CS whether intended or otherwise. Websites affiliated with Government or health services presented referenced clinical information in a factual manner with podcasts of real life experiences. Many imply greater support for VBAC than repeat CS although this was predominantly conveyed through subtle use of words rather than overt messages, with the exception of the latter being apparent in one site.

CONCLUSIONS

Websites providing information on birth after CS appear to vary in nature of content according to their funding source. The most user-friendly, balanced and informative websites appear to be those funded by government agencies.

Evaluation of the risks of chemotherapy in dogs with thrombocytopenia

Thrombocytopenia is commonly encountered in veterinary oncology. Currently, there are no standard guidelines regarding the administration of chemotherapy to the patients with thrombocytopenia. This observational epidemiological cohort study aimed to determine whether thrombocytopenic dogs were at increased risk of gastrointestinal adverse effects (vomiting, diarrhoea, inappetence) or haemorrhage following administration of standard doses of chemotherapy. The adverse effects following 77 prospectively identified episodes of thrombocytopenia (platelet count, <200 000 µL^-1 ) were compared with the adverse effects experienced in a retrospective cohort (platelet count >200 000 µL^-1 ), and evaluated by statistical analysis. Overall, there was no statistically significant difference in the incidence of gastrointestinal adverse effects or haemorrhage between thrombocytopenic and control dogs. The control group of dogs with lymphoma were statistically more likely to experience vomiting as an adverse effect of chemotherapy (P = 0.028). The results presented here showed no evidence for an increased risk of gastrointestinal adverse effects or haemorrhage in thrombocytopenic dogs after receiving standard doses of chemotherapy.

Internet information on birth options after caesarean compared to the RCOG patient information leaflet; a web survey

Background

Repeat caesarean sections make a substantial contribution to the overall caesarean section rate. It is important to understand what influences women to choose this option when the alternative of attempting vaginal birth after caesarean section is available. As many such women use the internet while seeking information on their options, the aim of this study was to assess content of websites on birth after previous caesarean and identify website characteristics which predict content.

Methods

An internet survey of the forty eight most frequently encountered websites retrieved from a search using various terms relating to birth after caesarean section via a popular search engine was performed. Websites were assessed for their content supportive of either vaginal birth after caesarean (VBAC) or elective repeat caesarean section (ERCS), using the RCOG patient information document, ‘Birth after previous caesarean; Information for You’ as a ‘gold standard’. A simple scoring method which categorised information into either supportive of VBAC (14 facts available) or ERCS (10 facts available) was employed and mean scores compared. Poisson regression analysis was used to assess the extent to which the score was predicted by website funding source, country of origin, author status and intended audience.

Results

A mean of 42.4% (SD 23.8) of facts supportive of VBAC and 44.8% (SD 25.0) of facts supportive of ERCS were featured across the 48 websites, with corresponding scores in the five most frequently encountered websites being 40.0% (SD 13.9) and 66.0% (SD 20.7). Extent of featured information supportive of ERCS was related to country of origin with the UK having higher scores on average than the US.

Conclusions

Women searching for internet information on birth after previous caesarean are exposed to incomplete information. Origin of website has a significant effect on website content.

Defining the genomic landscape of head and neck cancers through next-generation sequencing

Next-generation sequencing (NGS) has revolutionized the field of genomics and improved our understanding of cancer biology. Advances have been achieved by sequencing tumor DNA and using matched normal DNA to filter out germ line variants to identify cancer-specific changes. The identification of high incidences of activating mutations in head and neck squamous cell carcinoma (HNSCC) amenable to drug targeting has been made, with clear distinctions between the mutational profile of HPV-positive and HPV-negative tumors. This wealth of new understanding undoubtedly ameliorates our understanding of HNSCC cancer biology and elucidates clear targets for drug targeting which will guide future personalized medicine.

MRSA bacteraemia complicating amphotericin B treatment of cryptococcal meningitis

Intravenous amphotericin B is a key component of the antifungal therapy for cryptococcal meningitis recommended in South African and international guidelines. Unfortunately, its use is associated with significant toxicity including deterioration in renal function, electrolyte disturbance, anaemia and infusion reactions. Chemical phlebitis is common following administration via peripheral cannulae. This can be complicated by bacterial infection, resulting in localised cellulitis or bacterial sepsis. Here we describe two patients with cryptococcal meningitis who developed methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia during, or shortly after treatment with amphotericin B. These cases illustrate the dangers of line-related sepsis in hospitalised individuals and some of the difficulties encountered during treatment of this condition.

Maternal and neonatal outcomes following additional doses of vaginal prostaglandin E2 for induction of labour: a retrospective cohort study

OBJECTIVE

To assess maternal and neonatal outcomes following the use of additional doses of vaginal prostaglandins (PGE2) above the recommended dose for induction of labour in post-dates pregnancies.

STUDY DESIGN

Retrospective cohort study set in Aberdeen Maternity Hospital, Aberdeen, UK. A total of 3514 nulliparous women with labour induced with vaginal PGE2 (3mg tablet or 2mg gel) for a post-dates singleton pregnancy from January 1994 to December 2009 were included. Women receiving≤2 doses of PGE2 were compared with those receiving>2 doses (maximum 5 doses). Binary logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Primary outcomes included mode of delivery, terbutaline use, indication for CS, postpartum haemorrhage, neonatal unit admission, and Apgar score<7. A further analysis was conducted which stratified for number of doses of PGE2 given.

RESULTS

Of the 3514 women who met inclusion criteria, 605 (17%) received PGE2 that exceeded the licensed dose. They were more likely to deliver by caesarean section (53.4% vs. 31.8%, OR 2.2, 95% CI 1.8-2.6), have a caesarean section for 'failed' induction of labour (11.4% vs. 1.9%, OR 4.1, 95% CI 1.3-13.2) or lack of progress in labour (37% vs. 17%, OR 2.8, 95% CI 2.3-3.4), but not for fetal concerns (8.2% vs. 8.8% OR 0.9, 95% CI 0.7-1.3). Terbutaline use and postpartum haemorrhage was no more likely (0.7% vs. 0.9% OR 0.6 95% CI 0.3-1.5 and 19.8% vs. 18.9% OR1.01, 95% CI 0.97-1.06 respectively). Apgar score<7 (1.1% vs. 1.3% OR 0.9 95% CI 0.8-1.1) and neonatal unit admission (13.7% vs. 10.7% OR 1.2 95% CI 0.8-1.6) were similar in both groups.

CONCLUSION

The use of additional doses of vaginal PGE2 above the recommended dose for induction of labour was not associated with increased maternal or neonatal morbidity and almost half of these women achieved a vaginal delivery.

Age-related reference intervals for bone turnover markers from an Australian reference population

BACKGROUND

This study was performed to establish age-related serum reference intervals for procollagen type I N-propeptide (P1NP) and type I collagen C-telopeptide (CTx) in the Australian population.

METHODS

Fasting sera from 1143 males (mean age 60 years; range 20-97 years) and 1246 females (mean age 53 years; range 20-93 years) who participated in the Geelong Osteoporosis Study were analysed for CTx and P1NP using the automated Roche Modular Analytics E170 analyser.

RESULTS

Optimal age-related reference intervals were based on the central 90% of the distribution. The male CTx reference interval was divided into three age groups. For men aged 25 to 40 years, the interval was 170-600 ng/L; 40 to 60 years, the interval was 130-600 ng/L; and for men aged greater 60 years the interval was 100-600 ng/L. For P1NP the male reference interval was 15-80 μg/L for men aged between 25 to 70 years. In men greater than 70 years of age values were higher possibly due to increased bone turnover. High values are frequently seen for both CTx and P1NP in males aged younger than 25 years. This is probably due to bone growth that is not completely finalised. The female CTx reference interval was divided into four age groups. For women aged less than 30 years, the interval was 150-800 ng/L; 30-39 years, the interval was 100-700 ng/L; 40-49 years, the interval was 100-600 ng/L; and for women aged 50 years or more the interval was 100-700 ng/L. The female P1NP reference interval was divided into four age groups. For women aged less than 30 years, the interval was 25-90 μg/L; 30-39 years, the interval was 15-80 μg/L; 40-49 years, the interval was 15-60 μg/L; and for women aged 50-69 years the interval was 15-75 μg/L. In women greater than 70 years of age values were higher possibly due to increased bone turnover.

CONCLUSION

Values obtained from this large study provide sound age-related reference intervals for serum P1NP and CTx values in the Australian population.

Outcomes of pregnancy in women using illegal drugs and in women who smoke cigarettes

OBJECTIVE

To compare obstetric outcomes in women using illegal drugs with women who smoke cigarettes.

DESIGN

Retrospective cohort study.

SETTING

Aberdeen, UK.

POPULATION

All deliveries in Aberdeen in women using illegal drugs and women who smoked cigarettes during 1997-2007.

MATERIAL AND METHODS

The women who used illegal drugs were identified from a database of affected pregnant women in Aberdeen. The Aberdeen Maternity and Neonatal Databank was used to identify women who smoke cigarettes and to obtain pregnancy outcome information. Sociodemographic characteristics, maternal and perinatal outcomes were compared using chi-squared test, independent sample t-test and logistic regression analysis.

MAIN OUTCOME MEASURES

Preterm delivery, low birthweight (standardized birthweight score <-2) and admission to the neonatal unit.

RESULTS

Of the 561 illegal drug users, 96% were also cigarette smokers. Compared with women who smoke cigarettes with no reported illegal drug use, they were significantly more likely to have a preterm delivery [adjusted odds ratio (aOR) 1.6 (95% confidence interval (CI) 1.3-2.1)], low birthweight baby [aOR 1.9 (95%CI 1.4-2.6)], baby admitted to the neonatal unit [aOR 13.3 (95%CI 10.9-16.3)], deep vein thrombosis [aOR (95%CI 8.8-50.8)] and antepartum hemorrhage [aOR (95%CI 1.2-2.1)]. They were less likely to be at the extremes of age, or to develop pregnancy-induced hypertension [aOR 0.3 (95%CI 0.2-0.4)].

CONCLUSION

Illegal drug use in pregnancy appears to increase the risk of adverse outcomes, over and above that related to cigarette smoking, but appears to be associated with lower prevalence of gestational hypertension.

Linking GABA(A) receptor subunits to alcohol-induced conditioned taste aversion and recovery from acute alcohol intoxication

GABA type A receptors (GABA(A)-R) are important for ethanol actions and it is of interest to link individual subunits with specific ethanol behaviors. We studied null mutant mice for six different GABA(A)-R subunits (α1, α2, α3, α4, α5 and δ). Only mice lacking the α2 subunit showed reduction of conditioned taste aversion (CTA) to ethanol. These results are in agreement with data from knock-in mice with mutation of the ethanol-sensitive site in the α2-subunit (Blednov et al., 2011). All together, they indicate that aversive property of ethanol is dependent on ethanol action on α2-containing GABA(A)-R. Deletion of the α2-subunit led to faster recovery whereas absence of the α3-subunit slowed recovery from ethanol-induced incoordination (rotarod). Deletion of the other four subunits did not affect this behavior. Similar changes in this behavior for the α2 and α3 null mutants were found for flurazepam motor incoordination. However, no differences in recovery were found in motor-incoordinating effects of an α1-selective modulator (zolpidem) or an α4-selective agonist (gaboxadol). Therefore, recovery of rotarod incoordination is under control of two GABA(A)-R subunits: α2 and α3. For motor activity, α3 null mice demonstrated higher activation by ethanol (1 g/kg) whereas both α2 (-/-) and α3 (-/Y) knockout mice were less sensitive to ethanol-induced reduction of motor activity (1.5 g/kg). These studies demonstrate that the effects of ethanol at GABAergic synapses containing α2 subunit are important for specific behavioral effects of ethanol which may be relevant to the genetic linkage of the α2 subunit with human alcoholism.

Diabetic retinopathy at diagnosis of type 2 diabetes in Scotland

AIMS/HYPOTHESIS

The aim of this study was to examine the prevalence of and risk factors for diabetic retinopathy in people with newly diagnosed type 2 diabetes mellitus, using Scottish national data.

METHODS

We identified individuals diagnosed with type 2 diabetes mellitus in Scotland between January 2005 and May 2008 using data from the national diabetes database. We calculated the prevalence of retinopathy and ORs for risk factors associated with retinopathy at first screening.

RESULTS

Of the 51,526 people with newly diagnosed type 2 diabetes mellitus identified, 91.4% had been screened by 31 December 2010. The median time to first screening was 315 days (interquartile range [IQR] 111-607 days), but by 2008 the median was 83 days (IQR 51-135 days). The prevalence at first screening of any retinopathy was 19.3%, and for referable retinopathy it was 1.9%. For individuals screened after a year the prevalence of any retinopathy was 20.5% and referable retinopathy was 2.3%. Any retinopathy at screening was associated with male sex (OR 1.19, 95% CI 1.14, 1.25), HbA(1c) (OR 1.07, 95% CI 1.06, 1.08 per 1% [11 mmol/mol] increase), systolic BP (OR 1.06, 95% CI 1.05, 1.08 per 10 mmHg increase), time to screening (OR for screening >1 year post diagnosis = 1.12, 95% CI 1.07, 1.17) and obesity (OR 0.87, 95% CI 0.82, 0.93) in multivariate analysis.

CONCLUSIONS/INTERPRETATION

The prevalence of retinopathy at first screening is lower than in previous UK studies, consistent with earlier diagnosis of diabetes. Most newly diagnosed type 2 diabetic patients in Scotland are screened within an acceptable interval and the prevalence of referable disease is low, even in those with delayed screening.

External quality assurance for image grading in the Scottish Diabetic Retinopathy Screening Programme

AIMS

To develop and evaluate an image grading external quality assurance system for the Scottish Diabetic Retinopathy Screening Programme.

METHOD

A web-based image grading system was developed which closely matches the current Scottish national screening software. Two rounds of external quality assurance were run in autumn 2008 and spring 2010, each time using the same 100 images. Graders were compared with a consensus standard derived from the top-level graders' results. After the first round, the centre lead clinicians and top-level graders reviewed the results and drew up guidance notes for the second round.

RESULTS

Grader sensitivities ranged from 60.0 to 100% (median 92.5%) in 2008, and from 62.5 to 100% (median 92.5%) in 2010. Specificities ranged from 34.0 to 98.0% (median 86%) in 2008, and 54.0 to 100% (median 88%) in 2010. There was no difference in sensitivity between grader levels, but first-level graders had a significantly lower specificity than level-two and level-three graders. In 2008, one centre had a lower sensitivity but higher specificity than the majority of centres. Following the feedback from the first round, overall agreement improved in 2010 and there were no longer any significant differences between centres.

CONCLUSIONS

A useful educational tool has been developed for image grading external quality assurance.

A 20-year retrospective study of tonsil cancer incidence and survival trends in South East England: 1987-2006

BACKGROUND

There has been an increasing incidence of tonsil cancer worldwide. Documenting these changes is crucial to cancer prevention and control measures, resource allocation and understanding disease aetiology.

OBJECTIVE

To analyse the changing epidemiology of tonsil cancer in South East England over a 20-year period between 1987 and 2006.

DESIGN

A retrospective, quantitative study using secondary anonymised data obtained from the Thames Cancer Registry, London. Data were analysed using spss v.17 and survival analyses with Kaplan-Meier and Cox regression.

SETTING

This study was conducted in South East of England comprising London, Kent, Surrey and Sussex counties with an average population of 12 million. This population increased from 10.7 to 11.8 million (a 10% increase) between 1987 and 2006.

PARTICIPANTS

All patients with tonsil cancer in South East England registered with the Thames Cancer Registry (ICD-10 code C09) between 1987 and 2006. A total of 1794 patients' data were analysed. Ethical Considerations: Ethical approval was granted by the Kent Research Ethics Committee.

MAIN OUTCOME MEASURES

Data were analysed for demographic trends including gender, age at diagnosis, yearly incidence and survival.

RESULTS

Tonsil cancer incidence has increased significantly from 0.60 to 1.45 per 100,000 in the 20 years (P < 0.001). This increase is mainly amongst men and age groups 40-59 years with a significant reduction in age at diagnosis by 2 years from 61.6 years in the first decade to 59.6 years in the second decade (P < 0.001). Survival was worse in men, older age groups and in the presence of synchronous tumours (P < 0.001). There has been a statistically significant increase in median survival times from tonsil cancer by about 3 years from 2.7 years in the first decade to 5.7 years in the second decade of this study (P < 0.001).

CONCLUSIONS

Tonsil cancer incidence has increased in the 20 years of this study in South East England, especially amongst men and age groups 40-59 years. There has also been significant reduction in the mean age at diagnosis and an increase in median survival times for tonsil cancer. Further studies are needed to explain these trends.