Lack of Evidence of Pathogenetic Role of Epstein-Barr Virus in Thymic Lymphoid Hyperplasia and Thymomas in the Chinese Population of Hong Kong

A previous study from Hong Kong by McGuire et al. reported frequent demonstration of Epstein-Barr virus (EBV) DNA by Southern blot analysis in thymoma, thymic lymphoepithelioma-like carcinoma, and thymic lymphoid hyperplasia. This provoca tive finding, however, could not be confirmed by studies in the Western populations using the Southern blot technique and/or polymerase chain reaction to detect EBV- DNA or in situ hybridization to detect EBV encoded RNA (EBER), raising the possibility that the association with EBV may be restricted to Asians. This study was performed to clarify this issue by using a highly sensitive localization technique for EBER on a larger series from the Asian population of Hong Kong. Paraffin sections obtained from 10 cases of thymic lymphoid hyperplasia, 42 noninvasive thymomas (including one case previously reported to be EBV positive), 11 invasive thymomas, and 9 thymic carcinomas (including 5 cases of lymphoepithelioma-like carcinoma) were studied. EBER signal was not detected in the epithelial cells in any of the cases except for two cases of lymphoepithelioma-like carcinoma. In two thymomas, a few small lympho cytes (<0.1%) were EBER positive. Failure to detect EBER was not an artifact due to RNA denaturation, because preserved mRNA could be demonstrated by oligo-dT labelling in 56 of the 72 cases. Thus, the results of this study on Hong Kong Chinese are in keeping with those reported in Caucasians, and more recently in Japanese and Taiwan Chinese, in that there is no association of EBV with thymic lymphoid hyperpla sia or thymoma, and that EBV may be demonstrated in a proportion of thymic lymph oepithelioma-like carcinomas. The positive results previously reported cannot be ex plained, because the occasional EBV-carrying lymphocytes detected in rare cases of thymoma should be insufficient to give a positive EBV result by Southern blot tech nique. Int J Surg Pathol 2(1):17-22, 1994

Differences in Breast Cancer Survival between Public and Private Care in New Zealand: Which Factors Contribute?

Background

Patients who received private health care appear to have better survival from breast cancer compared to those who received public care. This study investigated if this applied to New Zealand women and identified factors that could explain such disparities.

Methods

This study involved all women who were diagnosed with primary breast cancer in two health regions in New Zealand, covering about 40% of the national population, between June 2000 and May 2013. Patients who received public care for primary treatment, mostly surgical treatment, were compared with those who received private care in terms of demographics, mode of presentation, disease factors, comorbidity index and treatment factors. Cox regression modelling was performed with stepwise adjustments, and hazards of breast cancer specific mortality associated with the type of health care received was assessed.

Results

Of the 14,468 patients, 8,916 (61.6%) received public care. Compared to patients treated in private care facilities, they were older, more likely to be Māori, Pacifika or Asian and to reside in deprived neighbourhoods and rural areas, and less likely to be diagnosed with early staged cancer and to receive timely cancer treatments. They had a higher risk of mortality from breast cancer (hazard ratio: 1.95; 95% CI: 1.75, 2.17), of which 80% (95% CI: 63%, 100%) was explained by baseline differences, particularly related to ethnicity, stage at diagnosis and type of loco-regional therapy. After controlling for these demographic, disease and treatment factors, the risk of mortality was still 14% higher in the public sector patients.

Conclusions

Ethnicity, stage at diagnosis and type of loco-regional therapy were the three key contributors to survival disparities between patients treated in public and private health care facilities in New Zealand. The findings underscore the need for more efforts to improve the quality, timeliness and equitability of public cancer care services.

Stage of breast cancer at diagnosis in New Zealand: impacts of socio-demographic factors, breast cancer screening and biology

Background

Examination of factors associated with late stage diagnosis of breast cancer is useful to identify areas which are amenable to intervention. This study analyses trends in cancer stage at diagnosis and impact of socio-demographic, cancer biological and screening characteristics on cancer stage in a population-based series of women with invasive breast cancer in New Zealand.

Methods

All women diagnosed with invasive breast cancer between 2000 and 2013 were identified from two regional breast cancer registries. Factors associated with advanced (stages III and IV) and metastatic (stage IV) cancer at diagnosis were analysed in univariate and multivariate models adjusting for covariates.

Results

Of the 12390 women included in this study 2448 (19.7 %) were advanced and 575 (4.6 %) were metastatic at diagnosis. Māori (OR = 1.86, 1.39-2.49) and Pacific (OR = 2.81, 2.03-3.87) compared with NZ European ethnicity, other urban (OR = 2.00, 1.37-2.92) compared with main urban residency and non-screen (OR = 6.03, 4.41-8.24) compared with screen detection were significantly associated with metastatic cancer at diagnosis in multivariate analysis. A steady increase in the rate of metastatic cancer was seen which has increased from 3.8 % during 2000-2003 to 5.0 % during 2010-2013 period (p = 0.042).

Conclusions

Providing equitable high quality primary care and increasing mammographic screening coverage needs to be looked at as possible avenues to reduce late-stage cancer at diagnosis and to reduce ethnic, socioeconomic and geographical disparities in stage of breast cancer at diagnosis in New Zealand.

Patterns of axillary lymph node metastases and recurrent disease in grade 1 breast cancer in a New Zealand cohort: Does ethnicity matter?

BACKGROUND

In New Zealand, Māori and Pacific women are more likely than New Zealand/European women to present at a younger age with larger tumours and metastatic disease. Survival rates are also differential by ethnicity. Many factors are believed to be responsible for this including differences in comorbidities, delays to presentation and delays in treatment. It is unclear whether these differences exist amongst women with grade 1 cancer in New Zealand. Therefore, we examined patterns of axillary nodal involvement, recurrent disease and mortality in grade 1 breast cancer in New Zealand women, and whether ethnicity was an important predictor for any of these outcomes.

METHOD

Data was retrieved from the Auckland Breast Cancer Registry (ABCR) and the Waikato Breast Cancer Registry (WBCR) which are prospective, population-based databases. All women newly diagnosed with grade 1 primary invasive breast cancer between 1 June 2000 and 31 May 2013 were identified from the two registries.

RESULTS

There were 2857 grade 1 breast cancers diagnosed over this time period. Axillary lymph nodes were involved in 19.0% of women, and 5.1% developed recurrent disease (locoregional or distant). Pacific and Māori women were more likely than NZ European women to have larger tumours and lymphovascular invasion (LVI). Predictors for axillary node involvement were tumour size greater than 10mm, LVI and non-screen detected cancers. Tumour size greater than 10mm, lobular carcinoma and BCS without radiotherapy were predictive of recurrent and or metastatic disease. Ethnicity was not observed to be an independent predictor for axillary nodal involvement, recurrent and/or metastatic disease, or breast cancer specific mortality amongst New Zealand women with grade 1 breast cancer.

CONCLUSION

Ethnicity was not a predictor of axillary node involvement, recurrent disease or mortality in grade 1 breast cancer in our population.

C1 inhibitor deficiency: 2014 United Kingdom consensus document

C1 inhibitor deficiency is a rare disorder manifesting with recurrent attacks of disabling and potentially life-threatening angioedema. Here we present an updated 2014 United Kingdom consensus document for the management of C1 inhibitor-deficient patients, representing a joint venture between the United Kingdom Primary Immunodeficiency Network and Hereditary Angioedema UK. To develop the consensus, we assembled a multi-disciplinary steering group of clinicians, nurses and a patient representative. This steering group first met in 2012, developing a total of 48 recommendations across 11 themes. The statements were distributed to relevant clinicians and a representative group of patients to be scored for agreement on a Likert scale. All 48 statements achieved a high degree of consensus, indicating strong alignment of opinion. The recommendations have evolved significantly since the 2005 document, with particularly notable developments including an improved evidence base to guide dosing and indications for acute treatment, greater emphasis on home therapy for acute attacks and a strong focus on service organization.

IgE recognition patterns in peanut allergy are age dependent: perspectives of the EuroPrevall study

BACKGROUND

We tested the hypothesis that specific molecular sensitization patterns correlate with the clinical data/manifestation in a European peanut-allergic population characterized under a common protocol.

METHODS

Sixty-eight peanut-allergic subjects and 82 tolerant controls from 11 European countries were included. Allergy to peanut and lowest symptom-eliciting dose was established by double-blind placebo-controlled food challenge in all but anaphylactic subjects. Information of early or late (before or after 14 years of age) onset of peanut allergy was obtained from standardized questionnaires. IgE to peanut allergens rAra h 1-3, 6, 8-9, profilin and CCD was determined using ImmunoCAP.

RESULTS

Seventy-eight percent of peanut allergics were sensitized to peanut extract and 90% to at least one peanut component. rAra h 2 was the sole major allergen for the peanut-allergic population. Geographical differences were observed for rAra h 8 and rAra h 9, which were major allergens for central/western and southern Europeans, respectively. Sensitization to rAra h 1 and 2 was exclusively observed in early-onset peanut allergy. Peanut-tolerant subjects were frequently sensitized to rAra h 8 or 9 but not to storage proteins. Sensitization to Ara h 2 ≥ 1.0 kUA /l conferred a 97% probability for a systemic reaction (P = 0.0002). Logistic regression revealed a significant influence of peanut extract sensitization and region on the occurrence of systemic reactions (P = 0.0185 and P = 0.0436, respectively).

CONCLUSION

Sensitization to Ara h 1, 2 and 3 is usually acquired in childhood. IgE to Ara h 2 ≥ 1.0 kUA /l is significantly associated with the development of systemic reactions to peanut.

Impact of mammographic screening on ethnic and socioeconomic inequities in breast cancer stage at diagnosis and survival in New Zealand: a cohort study

Background

Indigenous Māori women experience a 60% higher breast cancer mortality rate compared with European women in New Zealand. We explored the impact of differences in rates of screen detected breast cancer on inequities in cancer stage at diagnosis and survival between Māori and NZ European women.

Methods

All primary breast cancers diagnosed in screening age women (as defined by the New Zealand National Breast Cancer Screening Programme) during 1999–2012 in the Waikato area (n = 1846) were identified from the Waikato Breast Cancer Register and the National Screening Database. Stage at diagnosis and survival were compared for screen detected (n = 1106) and non-screen detected (n = 740) breast cancer by ethnicity and socioeconomic status.

Results

Indigenous Māori women were significantly more likely to be diagnosed with more advanced cancer compared with NZ European women (OR = 1.51), and approximately a half of this difference was explained by lower rate of screen detected cancer for Māori women. For non-screen detected cancer, Māori had significantly lower 10-year breast cancer survival compared with NZ European (46.5% vs. 73.2%) as did most deprived compared with most affluent socioeconomic quintiles (64.8% vs. 81.1%). No significant survival differences were observed for screen detected cancer by ethnicity or socioeconomic deprivation.

Conclusions

The lower rate of screen detected breast cancer appears to be a key contributor towards the higher rate of advanced cancer at diagnosis and lower breast cancer survival for Māori compared with NZ European women. Among women with screen-detected breast cancer, Māori women do just as well as NZ European women, demonstrating the success of breast screening for Māori women who are able to access screening. Increasing breast cancer screening rates has the potential to improve survival for Māori women and reduce breast cancer survival inequity between Māori and NZ European women.

Ethnic differences in timely adjuvant chemotherapy and radiation therapy for breast cancer in New Zealand: a cohort study

Background

Indigenous and/or minority ethnic women are known to experience longer delays for treatment of breast cancer, which has been shown to contribute to ethnic inequities in breast cancer mortality. We examined factors associated with delay in adjuvant chemotherapy and radiotherapy for breast cancer, and its impact on the mortality inequity between Indigenous Māori and European women in New Zealand.

Methods

All women with newly diagnosed invasive non-metastatic breast cancer diagnosed during 1999–2012, who underwent adjuvant chemotherapy (n = 922) or radiation therapy (n = 996) as first adjuvant therapy after surgery were identified from the Waikato breast cancer register. Factors associated with delay in adjuvant chemotherapy (60-day threshold) and radiation therapy (90-day threshold) were analysed in univariate and multivariate models. Association between delay in adjuvant therapy and breast cancer mortality were explored in Cox regression models.

Results

Overall, 32.4% and 32.3% women experienced delays longer than thresholds for chemotherapy and radiotherapy, respectively. Higher proportions of Māori compared with NZ European women experienced delays longer than thresholds for adjuvant radiation therapy (39.8% vs. 30.6%, p = 0.045) and chemotherapy (37.3% vs. 30.5%, p = 0.103). Rural compared with urban residency, requiring a surgical re-excision and treatment in public compared with private hospitals were associated with significantly longer delays (p < 0.05) for adjuvant therapy in the multivariate model. Breast cancer mortality was significantly higher for women with a delay in initiating first adjuvant therapy (hazard ratio [HR] =1.45, 95% confidence interval [CI] 1.05-2.01). Mortality risks were higher for women with delays in chemotherapy (HR = 1.34, 95% CI 0.89-2.01) or radiation therapy (HR = 1.28, 95% CI 0.68-2.40), although these were statistically non-significant.

Conclusions

Indigenous Māori women appeared to experience longer delays for adjuvant breast cancer treatment, which may be contributing towards higher breast cancer mortality in Māori compared with NZ European women. Measures to reduce delay in adjuvant therapy may reduce ethnic inequities and improve breast cancer outcomes for all women with breast cancer in New Zealand.

Treatment delay for Māori women with breast cancer in New Zealand

OBJECTIVES

To identify differences in delay for surgical treatment of breast cancer between ethnic groups and to evaluate the role of health system, sociodemographic and tumour factors in ethnic inequities in breast cancer treatment.

METHODS

A retrospective analysis of prospectively collected data from the Waikato Breast Cancer Register for cancers diagnosed in the Waikato region in New Zealand (NZ) from 1 January 2005 to 31 December 2010.

RESULTS

Approximately 95% (1449 out of 1514) of women with breast cancer diagnosed in the Waikato over the study period were included. Of women undergoing primary surgery (n = 1264), 59.6% and 98.2% underwent surgery within 31 and 90 days of diagnosis, respectively. Compared with NZ European women (mean 30.4 days), significantly longer delays for surgical treatment were observed among Māori (mean = 37.1 days, p = 0.005) and Pacific women (mean = 42.8 days, p = 0.005). Māori women were more likely to experience delays longer than 31 (p = 0.048) and 90 days (p = 0.286) compared with NZ European women. Factors predicting delays longer than 31 and 90 days in the multivariable model included public sector treatment (OR 5.93, 8.14), DCIS (OR 1.53, 3.17), mastectomy (OR 1.75, 6.60), higher co-morbidity score (OR 2.02, 1.02) and earlier year of diagnosis (OR 1.21, 1.03). Inequities in delay between Māori and NZ European women were greatest for women under 50 years and those older than 70 years.

CONCLUSION

This study shows that significant inequities in timely access to surgical treatment for breast cancer exist in NZ, with Māori and Pacific women having to wait longer to access treatment than NZ European women. Overall, a high proportion of women did not receive surgical treatment for breast cancer within the guideline limit of 31 days. Urgent steps are needed to reduce ethnic inequities in timely access to breast cancer treatment, and to shorten treatment delays in the public sector for all women.