The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer

Promoting fecal occult blood testing in rural African American women

PURPOSE

The purpose of this experimental study was to test the effectiveness of a multiphasic culturally relevant intervention, delivered over a 1-year period to increase the rates of participation in fecal occult blood testing (FOBT) at the initial screening opportunity and at the 1-year follow-up screening opportunity among rural African American women.

DESCRIPTION OF STUDY

The study used a pretest/post-test design among African American women who attended senior citizen centers in a rural southern state. The centers were randomly assigned to the cultural and self-empowerment group, who received the five-phased intervention, the modified cultural group, who received phase I of the intervention only, or the traditional group, who served as the control group. Data were collected at the initial and 1-year follow-up screenings. Hemoccult kits were distributed, collected, and analyzed at no cost to the participants. Data were analyzed using descriptive statistics, repeated measures, and longitudinal models for binary outcomes.

RESULTS

Women in the cultural and self-empowerment group had a significantly higher rate of participation in FOBT than did those in the modified cultural group and the traditional group. The modified cultural group had a significantly higher rate of participation in FOBT than the did the traditional group. Predictors of participation in FOBT were the women's family history of colorectal cancer and the average number of visits to their healthcare provider.

CLINICAL IMPLICATIONS

Colorectal cancer screening and diagnostic testing opportunities should be offered consistently to women who visit their provider for routine, nonemergent office visits. As successful interventions to increase colorectal cancer screening are introduced into community settings, these interventions also should be tested within physicians' offices and other community agencies.

Differences between computer-aided diagnosis of breast masses and that of calcifications

PURPOSE

To compare the performance of a computer-aided diagnosis (CAD) system for diagnosis of previously detected lesions, based on radiologist-extracted findings on masses and calcifications.

MATERIALS AND METHODS

A feed-forward, back-propagation artificial neural network (BP-ANN) was trained in a round-robin (leave-one-out) manner to predict biopsy outcome from mammographic findings (according to the Breast Imaging Reporting and Data System) and patient age. The BP-ANN was trained by using a large (>1,000 cases) heterogeneous data set containing masses and microcalcifications. The performances of the BP-ANN on masses and microcalcifications were compared with use of receiver operating characteristic analysis and a z test for uncorrelated samples.

RESULTS

The BP-ANN performed significantly better on masses than microcalcifications in terms of both the area under the receiver operating characteristic curve and the partial receiver operating characteristic area index. A similar difference in performance was observed with a second model (linear discriminant analysis) and also with a second data set from a similar institution.

CONCLUSION

Masses and calcifications should be considered separately when evaluating CAD systems for breast cancer diagnosis.

Reducing the risk of colorectal cancer by intervening in the process of carcinogenesis: a status report

Risk factors for colorectal cancer have been identified, and significant advances have been made in understanding the process of colorectal carcinogenesis. The transition from normal colonic mucosa to adenomatous polyp to adenocarcinoma is a gradual process involving genetic and epigenetic instability that can take decades, offering numerous opportunities for early detection (e.g., colonoscopy screenings), lifestyle changes (e.g., reduced red meat intake, increased physical activity, and reduced alcohol/ tobacco exposure), and chemopreventive interventions. Aspirin and various other nonsteroidal anti-inflammatory drugs may have chemopreventive benefits for colorectal cancer and other human epithelial carcinomas, butthe long-term use of nonsteroidal anti-inflammatory drugs is associated with serious gastrointestinal side effects. Recently, overexpression of cyclooxygenase-2 has been documented in colorectal tumors and numerous other pre-cancers and cancers. The development of selective cyclooxygenase-2 inhibitors, such as celecoxib, provides an opportunity for preventive intervention in the carcinogenic process. Celecoxib has been approved for the management of familial adenomatous polyposis and is under investigation for the management of sporadic colorectal polyps and for its potential as a chemopreventive agent for other cancers.

Health care factors related to stage at diagnosis and survival among Medicare patients with colorectal cancer

BACKGROUND

With the growth in enrollment of Medicare patients in HMOs the effectiveness of care received by Medicare/HMO patients continues to be of concern. By considering the relationship of insurance to stage at diagnosis, this study inquires whether HMOs emphasize early diagnosis of colorectal cancer to a greater extent than FFS plans, if particular HMO types (group/nongroup models) are more successful in doing so, and how this pertains to survival.

METHODS

Data for 1329 Medicare patients with colorectal cancer, diagnosed 1987 to 1993, and residing in northern California, were acquired from a population-based cancer registry. Insurance included two types of Medicare HMOs (group and nongroup model) and three fee-for-service (FFS) categories: Medicare with private supplement, Medicare/Medicaid, and Medicare only. The relationships of insurance to AJCC stage at diagnosis and of insurance to survival following diagnosis were examined, respectively, with logistic regression models and survival analysis (controlling for age, ethnicity, tumor location, educational level, sex, and hospital type).

RESULTS

Likelihood of early stage colorectal cancer was greater for Medicare patients in nongroup model HMOs or having private FFS supplements than for those in group model HMOs, Medicare/Medicaid, or Medicare alone. All-cause and colorectal cancer mortality did not differ significantly among Medicare patients with group model HMO, nongroup model HMO and private FFS supplements. Medicare/Medicaid patients experienced significantly greater all-cause mortality than private FFS patients.

CONCLUSIONS

Differences within this study population in early stage diagnosis of colorectal cancer and breast cancer, respectively, by type of Medicare supplemental insurance may be attributable to which preventive screening measures are included in health plan report cards.

Evidence for an age-related influence of microsatellite instability on colorectal cancer survival

It is well established that microsatellite instability (MSI), the hallmark of defective DNA mismatch repair (MMR), is associated with prolonged survival in colorectal cancer compared with tumours that are microsatellite stable (MSS). MSI in sporadic colorectal tumours is primarily due to epigenetic silencing of MLH1. However, there are no prospective population-based studies of survival in patients with germline MMR gene mutations who develop cancer. Although MSI is almost universal in tumours from HNPCC family members, there is a potential confounding effect of ascertainment and other biases that could explain the apparent survival benefit in HNPCC families. Resolving whether germline MMR gene mutations impact on survival is important because it potentially undermines the rationale for surveillance of mutation carriers. Here, we report an investigation of the influence of MSI on survival in cohorts of cancer patients (aged < 30 years at diagnosis, n = 118; non-age-selected, n = 181) in the context of clinicopathologic variables. There was a substantial age-related influence of tumour MSI status on survival. In young patients with tumour MSI, 65% of patients with MSI tumours had germline MSH2 or MLH1 mutations. Clinicopathologic variables and tumour MSI of the cohort were studied with respect to survival and compared with control groups. Young patients had excess MSI tumours (p < 0.000001), mucinous tumours (p < 0.01), advanced disease (p approximately 0.001) and poorer 5-year survival compared with older cases. Cox proportional hazard analysis identified Dukes' stage, age at diagnosis and calendar year of treatment as independent predictors of survival. There was no detectable association between tumour MSI and survival in young patients, although we confirmed previous observations that MSI is associated with better prognosis in later onset cohorts. These findings underscore the rationale for surveillance and early identification of tumours in MMR gene carriers as well as refining understanding of the influence of MSI on cancer progression.

Changing incidence of non-Hodgkin lymphomas in the United States

BACKGROUND

The incidence of non-Hodgkin lymphoma (NHL) has been rising in many regions and populations during the last few decades. Data from the Surveillance, Epidemiology, and End Results (SEER) Program show that age-adjusted rates of NHL increased through the 1980s but leveled off in the 1990s.

METHODS

To determine whether the incidence of NHL stabilized in all population subgroups, particularly in age-defined groups with distinctive risks of NHL, the authors investigated trends in NHL incidence among persons aged 0-14 years, 15-24 years, 25-34 years, 35-44 years, 45-54 years, 55-64 years, 65-74 years, and > 75 years by gender and race using 1973-1998 data from the SEER Program, which covered approximately 10% of the U.S. population. Joinpoint regression was used to assess changes in trends across the period.

RESULTS

NHL incidence trends changed significantly among males aged 25-54 years, in whom rates began to decrease (6-16% per year) in the middle to late 1990s, as well as among most whites aged > or = 55 years, in whom rate increases slowed from 3-4% to 1-2% per year in the late 1980s. Incidence trends were steady in other groups, with uniform increases among whites aged 15-24 years (2-3% per year), women aged 25-54 years (1-6% per year), and blacks aged > or = 55 years (2-4% per year). Although recent age specific incidence rates were generally higher in males compared with females and in whites compared with blacks, among males aged 25-54 years, rates were significantly higher in black males compared with white males.

CONCLUSIONS

There have been changes in the demographic groups impacted by NHL. The trends for human immunodeficiency virus probably are related to recent decreases in NHL incidence among males aged 25-54 years. The rate change in the older white population is unexplained but represents both an alleviation of the burden of NHL in this population and a potential opportunity to generate hypotheses regarding risk factors for the development of NHL.

Chronic cyclophosphamide treatment alters the expression of stress response genes in rat male germ cells

Increases in the survival rate of men treated with chemotherapeutic drugs and their desire to have children precipitate concerns about the effects of these drugs on germ cells. Azoospermia, oligospermia, and infertility are common outcomes resulting from treatment with cyclophosphamide, an alkylating agent. Exposure of male rats to cyclophosphamide results in dose-dependent and time-specific adverse effects on progeny outcome. Elucidation of the effects of chronic low-dose cyclophosphamide treatment on the expression of stress response genes in male germ cells may provide insight into the mechanisms underlying such adverse effects. Male rats were gavaged with saline or cyclophosphamide (6 mg/kg) for 4-5 wk; pachytene spermatocytes, round spermatids, and elongating spermatids were isolated; RNA was extracted and probed on cDNA arrays containing 216 cDNAs. After saline treatment, 125 stress response genes were expressed in pachytene spermatocytes (57% of genes studied), 122 in round spermatids (56%), and 83 in elongating spermatids (38%). Cyclophosphamide treatment reduced the number of genes detected in all germ cell types. The predominant effect of chronic cyclophosphamide exposure was to decrease the expression level of genes in pachytene spermatocytes (34% of genes studied), round spermatids (29%), and elongating spermatids (4%). In elongating spermatids only, drug treatment increased the expression of 8% of the genes studied. The expression profiles of genes involved in DNA repair, posttranslational modification, and antioxidant defense in male germ cells were altered by chronic cyclophosphamide treatment. We hypothesize that the effects of cyclophosphamide exposure on germ cell gene expression during spermatogenesis may have adverse consequences on male fertility and progeny outcome.

Reovirus oncolysis of human breast cancer

We have previously shown that human reovirus replication is restricted to cells with an activated Ras pathway, and that reovirus could be used as an effective oncolytic agent against human glioblastoma xenografts. This study examines in more detail the feasibility of reovirus as a therapeutic for breast cancer, a subset of cancer in which direct activating mutations in the ras proto-oncogene are rare, and yet where unregulated stimulation of Ras signaling pathways is important in the pathogenesis of the disease. We demonstrate herein the efficient lysis of breast tumor-derived cell lines by the virus, whereas normal breast cells resist infection in vitro. In vivo studies of reovirus breast cancer therapy reveal that viral administration could cause tumor regression in an MDA-MB-435S mammary fat pad model in severe combined immunodeficient mice. Reovirus could also effect regression of tumors remote from the injection site in an MDA-MB-468 bilateral tumor model, raising the possibility of systemic therapy of breast cancer by the oncolytic agent. Finally, the ability of reovirus to act against primary breast tumor samples not propagated as cell lines was evaluated; we found that reovirus could indeed replicate in ex vivo surgical specimens. Overall, reovirus shows promise as a potential breast cancer therapeutic.

Modeling and optimization in early detection programs with a single exam

The choice of timing of screening examinations is an important element in determining the efficacy of strategies for the early detection of occult disease. In this article, we describe a flexible decision-making framework for the design of early detection programs, and we investigate the choice of timing when each individual in the screening program is examined only once. We focus on the theoretical relation between the optimal examination time and the distributions of sojourn times in health-related states. Specifically, we derive closed-form solutions of the optimal age using two specifications of utility functions, discuss the effects of natural history and utility specifications on the optimal solution, and present an application to early detection of colorectal cancer by once-only sigmoidoscopy or colonoscopy.

Clinicopathological features of prostate cancer in Jamaican men

OBJECTIVE

To document the clinicopathological features of prostate cancer in a cohort of Jamaican men, and to determine which of these features are of prognostic significance in this population.

PATIENTS AND METHODS

The clinical and pathological findings in 99 patients with prostate cancer (diagnosed consecutively after biopsy, in the Department of Pathology at the University of the West Indies) between 1993 and 1997 were reviewed retrospectively. Biopsy specimens included 74 needle biopsies and 25 transurethral resection (TUR) specimens.

RESULTS

The mean age at diagnosis was 72.3 years and 79 patients (80%) were symptomatic. The median (range, interquartile range) serum prostate-specific antigen (PSA) value at diagnosis was 37 (1-2100, 2-750) ng/mL; 63% of the patients had clinical stage T1 or T2 disease. Most (60%) of the cancers had a Gleason score of 8-10. Perineural invasion was present in a third of cases overall; high-grade prostatic intraepithelial neoplasia and periprostatic involvement were present in 18% and 8% of biopsies, respectively. The median percentage involvement of all biopsy samples was 37%, that for needle biopsies 47% and for TUR specimens 14%. Of the 90 patients with complete follow-up data, 37 (41%) died; the cause was progressive disease in 19 (51%). The mean (sd, range) survival was 41.3 (19.7, 1-73) months. On univariate analysis, age, PSA level, tumour stage, Gleason score, perineural involvement and periprostatic involvement were significantly associated with an increased risk of dying from prostatic cancer; in a multivariate model, PSA and tumour stage (4 vs. 1) were the only independent factors.

CONCLUSIONS

The mean PSA values at the time of diagnosis, the median percentage of biopsy involvement by cancer and the number of patients with tumours of high histological grade were comparatively high, probably reflecting the patients' relatively late clinical presentation. Established prognostic markers were predictive of the risk of death from prostate cancer.

The search for predictive patterns in ovarian cancer: proteomics meets bioinformatics

Proteomic patterns in serum that discriminate between malignant and benign ovaries may provide a powerful tool for screening in high risk women.

Gamma surgery for melanoma metastases in the brain

OBJECT

The aim of this study was to evaluate the usefulness and limitations of gamma surgery (GS) in the treatment of brain metastases from melanoma.

METHODS

Imaging and clinical outcomes in 45 patients treated for 92 brain metastases from melanoma between October 1989 and October 1999 were retrospectively analyzed. Follow-up imaging studies were available in 35 patients with 66 treated lesions. Twenty-four percent of the lesions disappeared, 35% shrank, 23% remained unchanged, and 18% increased in size. No undue radiation-induced changes were observed in the surrounding brain. Clinical data were available in all patients. No deaths or neurological morbidity related to GS was observed. The median survival time, calculated using the Kaplan-Meier method, was 10.4 months from the time of GS. In both univariate and multivariate Cox regression analyses, a single brain lesion and lack of visceral metastases were statistically predictive of a better prognosis. Six of eight patients with solitary metastasis (that is, a single brain metastasis with no primary visceral tumor) were still alive at the close of the study, none of them with disease progression, with a follow-up period ranging between 14 and 82 months. Sixteen patients in this series received adjunctive whole-brain radiation therapy, which had no impact on their survival time or local and distant control of the brain disease.

CONCLUSIONS

Gamma surgery is effective in treating melanoma metastases in the brain. It appears that the radiobiology of a single high dose overcomes the radioresistance barrier, yielding better results than fractionated radiation.

Age, sex, and racial differences in the use of standard adjuvant therapy for colorectal cancer

PURPOSE

Dissemination of efficacious adjuvant therapies for resectable colorectal cancer has not been comprehensively described. Trends, patterns, and outcomes of adjuvant therapy for colorectal cancer, focusing on age, sex, and racial/ethnic differences, are reported.

MATERIALS AND METHODS

Population-based random samples of patients diagnosed with colorectal cancer diagnosed in nine geographic areas were collected annually between 1987 and 1991 and in 1995 (n = 4,706). Data were obtained from medical record reviews. Multiple logistic regression was used to assess the use of standard adjuvant chemotherapy for colon and rectal cancers. The Cox proportional hazards model was used to assess 9-year mortality.

RESULTS

From 1987 until 1995, the use of adjuvant therapy increased in all age groups. There was an increase starting in 1989 for colon and in 1988 for rectal cancer. Use of standard therapy was 78% for those younger than 55 years and 24% for those older than 80 years. White patients received standard therapy more frequently than African-Americans (odds ratio, 1.75; 95% confidence interval [CI], 1.09 to 2.83). All-cause and cancer-specific mortality exceeding 9 years were lower in those who received standard therapy (all-cause risk ratio [RR], 0.73; 95% CI, 0.61 to 0.88; cancer-specific RR, 0.87; 95% CI, 0.70 to 1.09).

CONCLUSION

Standard adjuvant therapies for colorectal cancer disseminated into community practices during the 1990s. However, evidence exists of differential use of therapies by older patients and by African-Americans. The use of standard therapies in the general population is associated with lower mortality. Improved dissemination of standard adjuvant therapies to all segments of the population could help reduce mortality.

Outcomes among African-American/non-African-American patients with advanced non-small-cell lung carcinoma: report from the Cancer and Leukemia Group B

BACKGROUND

Among patients diagnosed with advanced non-small-cell lung carcinoma (NSCLC), African-Americans have lower survival rates than non-African-Americans. Whether this difference is due to innate characteristics of the disease in the two ethnicities or to disparities in health care is not known. We investigated whether the disparity in survival would persist when patients were treated with similar systemic therapies (i.e., in phase II and phase III Cancer and Leukemia Group B [CALGB] trials).

METHODS

We assessed 504 consecutive patients (458 non-African-American and 46 African-American) receiving systemic chemotherapy in CALGB studies for advanced NSCLC during the period from 1989 through 1998. Clinical and demographic characteristics, treatment received, and survival data were obtained from the CALGB database. Cox's proportional hazards model was used to assess the effect of race/ethnicity on survival after adjustment for other known prognostic factors. All statistical tests were two-sided.

RESULTS

The unadjusted 1-year survival rate was 22% (95% confidence interval [CI] = 13% to 38%) for African-American patients and 30% (95% CI = 26% to 35%) for non-African-American patients, a statistically significant difference (8%; 95% CI on the difference = 5% to 12%; P =.03). Multivariable adjustment for the effect of treatment arm, histology, and metastatic site at presentation did not alter the worse outcome for African-American patients. However, the effect of race/ethnicity disappeared after adjustment for performance status and weight loss. African-American patients were more likely than non-African-Americans to present with a poor performance status (83% versus 60%) and substantial weight loss (41% versus 27%) and to be unmarried (59% versus 28%), disabled (31% versus 15%), unemployed (17% versus 7%), and Medicaid recipients (30% versus 8%).

CONCLUSIONS

The relationship that we observed between poor performance, weight loss, and socioeconomic status suggests that social circumstances lead to African-Americans presenting with poorer prognostic features.

Clinical determinants of survival in patients with 5-fluorouracil-based treatment for metastatic colorectal cancer: results of a multivariate analysis of 3825 patients

BACKGROUND

Patients with metastatic colorectal cancer are usually offered systemic chemotherapy as palliative treatment. A multivariate analysis was performed in order to identify predictors and their constellation that allow a valid prediction of the outcome in patients treated with 5-fluorouracil (5-FU)-based therapy.

PATIENTS AND METHODS

A total of 3825 patients treated with 5-FU within 19 prospective randomised and three phase II trials were separated into learning (n = 2549) and validation (n = 1276) samples. Data were analysed by tree analysis using the recursive partition and amalgamation method (RECPAM). A predictor could only enter the RECPAM analysis if the number of patients with missing values was < 33.3% within a node, and the minimal node size was set to 50 patients. Twenty-three potential predictors were grouped into subsets of laboratory variables (11 parameters), tumour-related variables (seven parameters) and clinical variables (five parameters). In the first step, tree analysis was performed separately for each predictor subset. The selected prognostic parameters of the resulting partial models (the 'winners') were entered into the general model. The classification rule from the data of the learning set was applied to the independent validation set.

RESULTS

Winners of the subgroup analysis for laboratory variables were: platelets > or = 400 x 10(9)/l, alkaline phosphatase > or = 300 U/l, white blood cell (WBC) count > or = 10 x 10(9)/l and haemoglobin < 11 x 10(9)/l, and all predicted a worse outcome. Negative predictors within the subgroup of tumour parameters were: number of tumour sites more than one or more than two, presence of liver metastases or peritoneal carcinomatosis, which predicted a worse outcome. Furthermore, presence of lung metastases, a primary rectal cancer and presence of lymph node metastases all predicted a better outcome in the multivariate setting. Among the clinical parameters only performance status of ECOG 0 or 1 predicted better outcome. In the final regression tree, three risk groups could be identified: low risk group (n = 1111) with a median survival of 15 months for patients with ECOG 0/1 and only one tumour site; intermediate risk group (n = 904) with a median survival of 10.7 months for patients with ECOG 0/1 and more than one tumour site and alkaline phosphatase < 300 U/l or patients with ECOG > 1, WBC count < 10 x 10(9)/l and only one tumour site; high risk group (n = 534) with a median survival of 6.1 months for patients with ECOG 0/1 and more than one tumour site and alkaline phosphatase of > or = 300 U/l or patients with ECOG > 1 and more than one tumour site or WBC count > 10 x 10(9)/l. The median survival times for the good, intermediate and high risk groups in the validation sample were 14.7, 10.5 and 6.4 months, respectively.

CONCLUSIONS

Patients can be divided into at least three risk groups depending on the four baseline clinical parameters: performance status, WBC count, alkaline phosphatase and number of metastatic sites. Any molecular or biological marker should be validated against these clinical parameters and decisions for more or less intensive treatments may be studied separately in these three risk groups. Also, clinical trials should be stratified according to the three risk groups.

Ciprofloxacin induces apoptosis and inhibits proliferation of human colorectal carcinoma cells

Efficacy of chemotherapy in advanced stages of colorectal tumours is limited. The quinolone antibiotic ciprofloxacin was recently shown to inhibit growth and to induce apoptosis in human bladder carcinomas cells. We investigated the effect of ciprofloxacin on colon carcinoma lines in vitro. CC-531, SW-403 and HT-29 colon carcinoma and HepG2 hepatoma cells (control cells) were exposed to ciprofloxacin. Proliferation was assessed by bromodeoxyuridine-incorporation into DNA and apoptosis was measured by flow cytometry after propidium iodide or JC-1 staining. Expression of anti-apoptotic Bcl-2 and pro-apoptotic Bax was analyzed by semiquantitative Western blot analysis and activity of caspases 3, 8 and 9 by substrate-cleavage assays. Ciprofloxacin suppressed DNA synthesis of all colon carcinoma cells time- and dose-dependently, whereas the hepatoma cells remained unaffected. Apoptosis reached its maximum between 200 and 500 microg ml(-1). This was accompanied by an upregulation of Bax and of the activity of caspases 3, 8 and 9, and paralleled by a decrease of the mitochondrial membrane potential. Ciprofloxacin decreases proliferation and induces apoptosis of colon carcinoma cells, possibly in part by blocking mitochondrial DNA synthesis. Therefore, qualification of ciprofloxacin as adjunctive agent for colorectal cancer should be evaluated.

A population-based, community estimate of total colon examination: the impact on compliance with screening for colorectal cancer

OBJECTIVE

Colorectal cancer screening is underutilized. Total colon examination (TCE), such as with colonoscopy, can have a significant effect on the measured compliance with screening, as colonoscopy may be able to be performed as infrequently as once every 10 yr. In a population-based survey we determined the prevalence and validated the self-reporting of TCE and assessed its impact on compliance with screening.

METHODS

We interviewed an age- and sex-stratified random sample of 50- to 79-yr-old residents in two communities in southwestern Pennsylvania. Subjects reported ever having had and duration since last use of fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), rigid proctoscopy, barium enema, and colonoscopy. Self-reports of colorectal testing were validated via retrieval of procedure reports.

RESULTS

Out of 1223 individuals sampled, 496 completed a telephone interview (40.6% overall and 58.3% of eligible contacts). In those without personal or family histories of colorectal cancer or personal histories of polyps (n = 377), 50%, 19.6%, 39.8%, and 17.5% reported ever having had FOBT, FS, barium enema, and colonoscopy, respectively. Thirty-one percent reported having FOBT within the previous year or FS within the previous 5 yr. Including TCE within the previous 5 yr increased the measured compliance to 39.7%. Compliance was significantly greater among subjects with family histories of colorectal cancer (62.9% vs 39.7%, odds ratio = 2.6, 95% CI = 1.3-5.2). Self-reports of recent colonoscopy were verified in 29 of 35 instances (83%).

CONCLUSION

The prevalence of TCE in this population was significant, and including TCE substantially increased measured compliance with colorectal cancer screening. Self-reported use of colonoscopy was validated as accurate.

Immunotherapy for nonmelanoma skin cancer: does it have a future?

BACKGROUND

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) of the skin are the most common malignancies in the white human population, accounting for greater than 95% of nonmelanoma skin cancers (NMSCs). Current data show an increasing incidence of NMSC in recent decades. Although the mortality is low, this cancer group is associated with substantial morbidity. Multiple treatment modalities are available for NMSC, with surgery being a "cornerstone" of current therapy approaches. However, in patients with multiple lesions or in cases of tumors on critical locations, disfigurement and the disease recurrence may represent a serious problem associated with the surgical treatment. The purpose of this study was to review and analyze whether NMSC could represent a target for immune therapy, evaluating the aspects of the availability of tumor antigens and the existence of tumor specific immune response, including a summary of the major clinical studies dealing with immunotherapy for NMSC.

METHODS

The authors have reviewed the available medical literature on NMSC, with a focus on tumor immunology and associated abnormalities, as well as immunotherapy-based treatment trials.

RESULTS

The major advantage of NMSCs is that they arise from the skin, which makes them easily detectable and treatable. Furthermore, these tumors posses all the prerequisites, i.e., the presence of tumor-associated antigens as well as the tumor specific immune response, needed for immune intervention. This also was confirmed in various studies demonstrating clinical efficacy of cytokines and other immune response modifiers.

CONCLUSIONS

In addition to clinical cure, by activating and stimulating patient's immune resources this therapeutic option may be a "silver bullet," providing a long-term protective immunity against initial tumor.

The case for population-based screening for colorectal cancer

Screening for colorectal cancer is commanding increasing attention. Other cancer screening programmes have been a part of public consciousness for some time, but, until recently, colorectal cancer screening has remained in the background. Fuelled by new research, market opportunities and increased recognition of individual risk, screening for colorectal cancer is becoming a recommended procedure, but controversy about how best to implement widespread screening remains.

Outcome following surgery for colorectal cancer

There is evidence to suggest that survival following surgery for colorectal cancer is improving. Audits undertaken in a single institution between 1974-1979 and 1991-1994 provide the opportunity to evaluate the extent to which earlier diagnosis and better surgery contribute to the improvement in survival. There was little evidence that patients were presenting at an earlier stage during the latter period. In contrast, more patients had a potentially curative resection. This analysis confirmed that, over this period, there has been a substantial improvement in survival following surgery for colorectal cancer; this improvement was largely due to better surgery rather than earlier presentation.

Downregulation of E-cadherin and Desmoglein 1 by autocrine hepatocyte growth factor during melanoma development

During melanoma development, transformed cells evade keratinocyte-mediated control by downregulating cell adhesion molecules. This study investigated the regulation of cell adhesion by hepatocyte growth factor (HGF) in melanoma. Melanocytes and two melanoma lines, WM164 and WM35, expressed normal level E-cadherin and Desmoglein 1, whereas most melanomas (18 out of 20) expressed no E-cadherin and significantly reduced Desmoglein 1. Overexpression of dominant negative E-cadherin and Desmoglein in melanocytes demonstrated that both molecules contribute to adhesion between melanocytes and keratinocytes. In contrast to melanocytes, most melanomas expressed HGF. All melanocytic cells expressed the HGF receptor c-Met, and autocrine HGF caused constitutive activation of c-Met, MAPK and PI3K. When autocrine activation was induced with HGF-expressing adenovirus, E-cadherin and Desmoglein 1 were decreased in melanocytes, WM164 and WM35. MAPK inhibitor PD98059 and PI3K inhibitor wortmannin partially blocked the downregulation, suggesting that both pathways are involved in this process. c-Met was coimmunoprecipitated with E-cadherin, Desmoglein 1 and Plakoglobin, suggesting that they form a complex (es) that acts to regulate intercellular adhesion. Together, the results indicate that autocrine HGF decouples melanomas from keratinocytes by downregulating E-cadherin and Desmoglein 1, therefore frees melanoma cells from the control by keratinocytes and allows dissemination of the tumor mass.

Hormone replacement therapy and colorectal adenoma recurrence among women in the Polyp Prevention Trial

BACKGROUND

Epidemiologic studies have suggested that estrogen may protect against the development of colorectal cancers and adenomatous polyps. We conducted a prospective study to evaluate the association between hormone replacement therapy (HRT) and adenoma recurrence among perimenopausal and postmenopausal women participating in the Polyp Prevention Trial, a randomized dietary intervention study of individuals with colorectal adenomas.

METHODS

We used a questionnaire and interviews to collect detailed information, at baseline and at each of four annual study visits, from 620 women regarding hormone use, menopausal status, diet, alcohol consumption, and other risk factors. Adenoma recurrence was ascertained by complete colonoscopy at baseline and after 1 and 4 years. Logistic regression models were used to evaluate the association between hormone use and adenoma recurrence after adjusting for intervention group and for age and body mass index at baseline. All statistical tests were two-sided.

RESULTS

Adenomas recurred in 200 women. There was no overall association between adenoma recurrence and either overall hormone use (odds ratio [OR] = 1.01; 95% confidence interval [CI] = 0.70 to 1.45), combined estrogen and progestin use (OR = 0.94; 95% CI = 0.57 to 1.56), or unopposed estrogen use (OR = 1.04; 95% CI = 0.68 to 1.59). HRT use was associated with a reduction in risk for recurrence of distal adenomas (OR = 0.56; 95% CI = 0.32 to 1.00) and a statistically nonsignificant increase in risk for recurrence of proximal adenomas (OR = 1.39; 95% CI = 0.85 to 2.26). We observed a statistically significant interaction between the HRT-adenoma recurrence association and age (P =.02). HRT was associated with a 40% reduced risk of adenoma recurrence among women older than 62 years (OR = 0.58; 95% CI = 0.35 to 0.97) but with an increased risk among women younger than 62 years (OR = 1.99; 95% CI = 1.11 to 3.55).

CONCLUSIONS

HRT was not associated with a reduced risk for overall adenoma recurrence in this trial cohort, although there was a suggestion of an age interaction. The effect of age on the association needs to be confirmed in other adenoma recurrence trials.

Acquired immune deficiency syndrome and the increase in non-Hodgkin lymphoma incidence in New Jersey from 1979 to 1996

BACKGROUND

In New Jersey, the age-adjusted incidence rate of non-Hodgkin lymphoma (NHL) increased more than a third from 1979 to 1996, the largest increase among the major cancers.

METHODS

Data from a linkage of New Jersey's population-based cancer and acquired immune deficiency syndrome (AIDS) registries were used to obtain two sets of annual age specific incidence rates and estimated average annual percentage changes in the incidence rates, for each of five adult age groups within each gender, from Poisson regression models that 1) included all the NHL cases and 2) excluded the cases of AIDS-NHL.

RESULTS

During 1979-1996, of the NHL cases aged 15 years and older reported to the cancer registry, 687 (6%) of the 11,725 male cases and 139 (1%) of the 10,785 female cases were AIDS-NHL. The highest percentages of AIDS-NHL were in the younger age groups--15-29, 30-39, and 40-49 years. Among both men and women, average annual percentage increases in NHL occurred overall (3.1 and 3.0, respectively), and in each age group, ranging from 1.6 and 1.9, respectively, in the 50-59 years age group to 6.6 and 4.2, respectively, in the 30-39 years age group (P <<0.01). Excluding AIDS-NHL, the estimated average annual percentage increases in NHL were greatest in the 30-39 and the 60 years and older age groups among men, and these two age groups plus the 15-29 years age group among women, ranging between 2.4 and 2.9 (P < 0.05).

CONCLUSIONS

As elsewhere, factors in addition to AIDS are involved in the increasing incidence of NHL in New Jersey. Because diagnostic and classification changes probably do not explain the entire increase unrelated to AIDS, other risk factors are likely responsible. Public health interventions to reduce the incidence of NHL not related to AIDS are problematic until more is known about the causes of NHL.

White button mushroom phytochemicals inhibit aromatase activity and breast cancer cell proliferation

Estrogen is a major factor in the development of breast cancer. In situ estrogen production by aromatase/estrogen synthetase in breast cancer plays a dominant role in tumor proliferation. Because natural compounds such as flavones and isoflavones have been shown to be inhibitors of aromatase, it is thought that vegetables that contain these phytochemicals can inhibit aromatase activity and suppress breast cancer cell proliferation. Heat-stable extracts were prepared from vegetables and screened for their ability to inhibit aromatase activity in a human placental microsome assay. The white button mushroom (species Agaricus bisporus) suppressed aromatase activity dose dependently. Enzyme kinetics demonstrated mixed inhibition, suggesting the presence of multiple inhibitors or more than one inhibitory mechanism. "In cell" aromatase activity and cell proliferation were measured using MCF-7aro, an aromatase-transfected breast cancer cell line. Phytochemicals in the mushroom aqueous extract inhibited aromatase activity and proliferation of MCF-7aro cells. These results suggest that diets high in mushrooms may modulate the aromatase activity and function in chemoprevention in postmenopausal women by reducing the in situ production of estrogen.

Subsite-specific incidence rate and stage of disease in colorectal cancer by race, gender, and age group in the United States, 1992-1997

BACKGROUND

Subsite specific incidence rates of colorectal cancer vary considerably by age, gender, and race. This variation may be related not only to distinctions in exposure to genetic and environment factors but also to current strategies of early detection screening. Patterns of stage of disease in anatomic subsite may reflect the effect of screening. This study used the largest aggregation of cancer incidence data in the U.S. to examine subsite specific incidence rates of colorectal cancer and the relation of stage of disease to anatomic subsites by race, gender, and age group.

METHODS

Data on the incidence of invasive colorectal cancer were obtained from 28 population-based central cancer registries. Age-specific and age-adjusted rates and stage distributions were analyzed by subsite, race, and gender.

RESULTS

The impact of screening can be observed in the percentage of localized disease, which increased from 31.9% among cancers in the proximal colon to 37.0% in the descending colon to 41.5% in the distal colorectum. Within the same subsite, blacks were less likely than whites to receive a diagnosis of localized disease and more likely to receive a diagnosis of distant disease whereas stage distributions were approximately the same for males and females. Blacks were more likely than whites to receive a diagnosis of proximal colon cancer than distal colorectal cancer. The male-to-female rate ratios progressively increased from the proximal colon to the distal colorectum. The ratios of proximal-to-distal colorectal cancer gradually increased with advancing age.

CONCLUSIONS

Differentials in stage of disease by subsites indicate a need for a targeted effort at early detection of cancer in the proximal colon. Risk factors and higher risk populations for colorectal cancers in each subsite need to be studied further to guide actions for improving the efficacy of screening.

The changing face of cancer survivorship

OBJECTIVES

To provide a review of who is surviving cancer diagnosed within the last 20 years and key areas for research development related to cancer survivorship.

DATA SOURCES

Articles, studies, and Surveillance, Epidemiology and End Results statistics.

CONCLUSIONS

The information we have on today's survivors must be periodically revisited and revised to equip cancer patients with the knowledge and tools they need to master the new realities of their survivorship.

IMPLICATIONS FOR NURSING PRACTICE

With the increasing numbers of individuals being cured of or living long periods of time following a diagnosis of cancer, oncology nurses who work with cancer survivors must maintain their knowledge of the issues and practices critical to the well-being of the patient.

Recent decline in cancer mortality in Catalonia (Spain). A joinpoint regression analysis

The aim of this paper was to analyse recent changes in cancer mortality in Catalonia (Spain) between 1975 and 1998 using joinpoint regression models. Mortality data were obtained from the Mortality Registry of Catalonia. For each sex, age-standardised (standard world population) mortality rates were computed by the direct method, and joinpoint analysis was used to identify the best fitting points where a statistically significant change in the rates had occurred. In men, the overall cancer mortality (except skin non-melanoma) was highest in 1991 and decreased thereafter. Lung cancer was the main cause of cancer mortality, with an increase until 1989, and a subsequent levelling off (-0.8% annual between 1989 and 1998). Colorectal cancer was the second cause of cancer death, both in men and women, with a levelling-off of the rates since 1991 and 1989, respectively. In women, the mortality rate decreased for total cancer (except skin non-melanoma) since 1991 (-0.9% annually). Breast cancer increased until 1975, levelled-off and begun to decline since 1992 (-3.8% annual). Lung cancer increased since 1988 (+2.1%) and became the third cancer cause of death among women in 1998. These changes are mainly due to the decline of smoking prevalence in males, but not in females, and to the introduction of new diagnostic techniques and improved therapies for female breast cancer.

Second malignancies after ewing tumor treatment in 690 patients from a cooperative German/Austrian/Dutch study

BACKGROUND

Ewing tumor treatment involves high cumulative doses of alkylating agents and topoisomerase inhibitors, drugs capable of inducing second cancers. We analyzed the second cancer risk in a large cohort of consistently treated patients.

PATIENTS AND METHODS

Six hundred ninety Ewing tumor patients were treated between 1992 and 1999 with local therapy and vincristine. doxorubicin, ifosfamide and/or cyclophosphamide, and antinomycin D, with or without etoposide as a randomized question. Second cancer incidences were estimated by competing risk analyses; standardized incidence ratios (SIR) in comparison to registry data were compiled.

RESULTS

After a median observation time of 56 months (32 months for survivors), 6 of 690 patients had developed second cancers: MDS/AML, two, ALL/NHL, two, squamous cell carcinoma, one, liposarcoma, one. SIR were increased 20-30 fold in comparison to the general population. The cumulative second cancer risk five years after diagnosis of the Ewing tumor was 0.0093 for the total group, zero for patients without etoposide, and 0.0118 with etoposide. Additional phase II high-dose therapy increased the risk to 0.0398 after five years.

CONCLUSIONS

The second cancder risk observed was in the range to be expected in cancer survivors. High-dose therapy, and less markedly, etoposide, may contribute to the overall second cancer risk.

Changed trends of cancer mortality in the elderly

BACKGROUND

Trends in cancer mortality for the elderly have long been unfavourable.

MATERIALS AND METHODS

Mortality from 12 major cancer sites, plus total cancer mortality at age 65-84 in 23 European countries, the US and Japan was analyzed.

RESULTS

Between the late 1980s and the late 1990s total cancer mortality at age 65 to 84 has been declining in the European Union (UE) (-5.5% in males, -4.5% in females), in United States (US) males (-2.3%), but not females (+4.4%), and in Japanese females (-5.6%), but not males (+6.3%). Cancer mortality in the elderly rose for both sexes in eastern Europe. Gastric cancer mortality declined in all the areas. Lung cancer rates declined over the last decade by 8.5% in males in the EU. and by 0.9% in the US. Rates were still increasing in eastern Europe, in Japanese males and in females in all areas. Pancreatic mortality rates were increasing in both sexes in the EU and Japan up to the late 1980s, and in eastern Europe up to the 1990s, whereas rates for US males have been declining over recent years. Breast cancer mortality has declined over the last decade by 8% in the US and by 3% in the EU, while it has risen in eastern Europe and in Japan. Mortality from breast and prostate as well as ovarian cancer remained however low in elderly Japanese. Prostate cancer mortality declined in the EU and in the US, whereas it rose in eastern Europe and in Japan. Mortality from lymphomas and multiple myeloma rose in both sexes and various geographic areas, but improved diagnosis and certification may have played a role in these trends. Mortality from leukemia in the elderly increased in eastern Europe and Japan. but was stable in the US and the EU.

CONCLUSIONS

Cancer mortality in the elderly has stopped systematically rising, and is on the decline in males since the late 1980s.

Colorectal cancer screening compliance by medicine residents: perceived and actual

OBJECTIVE

Implementation of colorectal cancer (CRC) screening with widely available techniques can result in a significant reduction in CRC-related mortality. Clinical practice paradigms are often ingrained in physicians during residency. We, therefore, investigated both compliance and perceived obstacles to CRC screening in the practices of physicians-in-training.

METHODS

We conducted a retrospective analysis of medical records of patients who were receiving their primary care in the internal medicine resident clinics at the University of Nebraska Medical Center and were at average risk for CRC. In addition to demographics, data on the use of screening mammography, Pap smear, cholesterol, fecal occult blood testing (FOBT), and flexible sigmoidoscopy (FS) were collected. A questionnaire was also distributed to all internal medicine residents to assess their CRC screening knowledge and perceived screening compliance.

RESULTS

One hundred eight patient charts were reviewed. The percentage of patients appropriately screened for each test was as follows: mammography 66%, Pap smear 65%, cholesterol 53%, FOBT 13%, and FS 16%. Residents dramatically overestimated their perceived FS and FOBT screening rates, 78% and 88%, respectively. Most residents identified barriers to FS screening. Although rudimentary CRC screening knowledge appeared adequate, a number of knowledge-based deficiencies were identified.

CONCLUSIONS

Internal medicine residents at our institution demonstrate poor CRC screening compliance especially when compared with other health care maintenance interventions. This cannot be entirely accounted for by inadequate knowledge; discrepancy between the perceived and actual implementation of CRC screening may be important. Efforts to improve screening compliance should include a focus on physicians-in-training.

Gene therapy for colorectal cancer: therapeutic potential

Colorectal cancer is a leading cause of cancer mortality in Western countries. Gene therapy has been proposed as a potential novel treatment modality for colorectal cancer, but it is still in an early stage of development. The preclinical data have been promising and numerous clinical trials are underway. This brief review aims to summarise the current status of clinical trials of different gene therapy strategies, including immune stimulation, mutant gene correction, prodrug activation and oncolytic virus therapy, for patients with colorectal cancer. Data from phase I trials have proven the safety of the reagents but have not yet demonstrated significant therapeutic benefit. In order to achieve this and extend the scope of the treatment, continuing efforts should be made to improve the antitumour potency, efficiency of gene delivery and accuracy of gene targeting.

Expression of multiple cancer-testis antigen genes in gastrointestinal and breast carcinomas

Cancer-testis antigens (CTAs) such as MAGE are selectively expressed in various types of human neoplasms but not in normal tissues other than testis. This characteristic feature of CTAs makes them promising antigens for cancer-specific immunotherapy. A critical requirement for this therapy is identification of promising antigens. In this study, we investigated the expression of 6 genes recently identified by serological analysis of antigens by recombinant expression (SEREX) libraries: NY-ESO-1, LAGE-1, SCP-1, SSX-1, SSX-2, and SSX-4, in many surgical samples of gastrointestinal and breast carcinomas using reverse transcription-polymerase chain reaction. We found relatively high expression of SCP-1 (23.5%) and SSX-4 (20.6%) in gastric carcinoma, LAGE-1 (39.1%) and NY-ESO-1 (23.9%) in oesophageal carcinoma, and SCP-1 (34.1%) in breast carcinoma. We also found frequent synchronous expression with MAGE, including LAGE-1 (46.2%) in oesophageal carcinoma, SSX-4 (46.7%) in gastric carcinoma, and SCP-1 (38.3%) in breast carcinoma. Immunohistochemical analysis of the tumour samples expressing both MAGE-4 and NY-ESO-1 genes demonstrated differences in distribution between MAGE-4 and NY-ESO-1 in serial sections. We concluded that NY-ESO-1, LAGE-1, SCP-1 and SSX-4 genes may be promising candidates for cancer-specific immunotherapy in addition to MAGE, and that polyvalent cancer vaccines may be useful in cases of heterogeneous expressions of CTA genes in gastrointestinal and breast carcinomas.

Sun exposure and sun-protection behaviors and attitudes among U.S. youth, 11 to 18 years of age

BACKGROUND

Adolescence is a high-risk period for the development of melanoma and nonmelanocytic skin cancers later in life. This study examines the prevalence and correlates of sun-protection practices among U.S. youth.

METHODS

During July-October, 1998, a national, population-based telephone survey was conducted (N = 1,192 paired interviews of youth and their parents). Weighted prevalence and adjusted prevalence odds ratios and 95% confidence intervals were estimated. Multiple logistic regression analyses examined associations between sociodemographics, attitudes, and other modifiable correlates to specific behaviors.

RESULTS

Routinely practiced sun-protection behaviors among youth on sunny days were wearing sunglasses (32%) or long pants (21%), staying in the shade (22%), and applying sunscreen (31%). Fifty-eight percent used a sunscreen with SPF > or =15 when at the beach or pool. Age, sex, and sun sensitivity were associated with substantial variation in some sun-protection behaviors. Factors associated with specific sun-protection behaviors included a lower appeal to tanning, a higher perceived benefit of sun protection, and information from family and friends about sun protection.

CONCLUSION

Effective sun protection is practiced by less than one-third of U.S. youth. This baseline survey will help to monitor progress in skin cancer prevention in this critical age group in the future.

Antimutagenesis and anticarcinogenesis, from the past to the future

Observations on cancer causation are some 150 years old, but actual detailed research on elements bearing on cancer started at the beginning of the twentieth century. Rapid progress, however, is only some 40 years old. Studies in humans documented certain lifestyle related factors to lead to cancer, and research in animal models strengthened this information. With the realization that there are carcinogens that in a metabolically activated attack DNA, in contrast to other agents that act by promoting, enhancing processes through totally distinct mechanisms, it became possible to develop and apply tests for DNA reactivity, in a prokaryotic organism, the widely used Salmonella typhimurium test by Ames and in a eukaryotic system, namely freshly explanted liver cells displaying evidence of DNA repair by Williams. A battery of these two tests are over 90% accurate in defining genotoxicity. Virtually all documented human carcinogens are genotoxic. With advances in molecular biology, mutational events are traced to changes in tumor suppressor genes or in oncogenes, that can serve as markers of risk. In addition, reactive oxygen systems (ROS) are involved in both the early steps in cancer and in the developmental aspects. Thus, foods containing antioxidants such as vegetables, fruits, soy products, cocoa and tea that counteract ROS are protective in cancer causation and development. Worldwide application of current knowledge and mechanisms to cancer prevention, the definitive means of cancer control, is likely to lower not only cancer but also heart disease risk in the current century.

Recurrence and malignancy rates in a benign colorectal neoplasm patient cohort: results of a 5-year analysis in a managed care environment

OBJECTIVE

To estimate the apparent recurrence rates of benign neoplasms and the development of malignant colorectal neoplasms over a 5-yr period in a high risk managed care population.

METHODS

Using the CPT and ICD-9 CM codes, a cohort of subjects with benign neoplasms were identified with a colonoscopy in 1992 from a longitudinal claims database (MarketScan). Three groups of subjects (benign neoplasms with polypectomy, benign neoplasms without polypectomy, and no neoplasms) were evaluated. Five-year recurrence rates of benign or new malignant colorectal neoplasms were determined for the baseline benign neoplasms with polypectomy and no neoplasm groups. For the benign neoplasm without polypectomy, only rates for malignancy were evaluated.

RESULTS

Of 16,293 subjects at baseline, 39.50% were diagnosed with benign and 5.50% with malignant neoplasms. The 5-yr cumulative incidence of benign neoplasms in subjects without an index neoplasm (n = 8,967) was 7.92% compared to the recurrence of 40.93% in subjects with a benign neoplasm and polypectomy (n = 4,046) at baseline (p < 0.001). The 5-yr cumulative incidence rates of malignant colorectal neoplasms in the no neoplasm (n = 8,967) and benign neoplasm groups (n = 6,438) were 1.81% and 2.55%, respectively (p < 0.005). A lower 5-yr malignancy rate was observed in benign neoplasm group with polypectomy (2.17%) compared to the benign neoplasm group without polypectomy (3.18%) (p < 0.05).

CONCLUSION

The high recurrence rate of benign colorectal neoplasms and a higher incidence of colorectal cancer in subjects at high risk (history of benign colorectal neoplasm) highlight a healthcare opportunity for surveillance and/or interventions to reduce the morbidity associated with colorectal neoplasms.

Local excision of T2 and T3 rectal cancers after downstaging chemoradiation

OBJECTIVE

To evaluate the safety and efficacy of local excision in patients with T2 and T3 distal rectal cancers that have been downstaged by preoperative chemoradiation.

SUMMARY BACKGROUND DATA

T2 and T3 cancers treated by local excision alone are associated with unacceptably high recurrence rates. The authors hypothesized that preoperative chemoradiation might downstage both T2 and T3 lesions and significantly expand the indications for local excision.

METHODS

Local excision was performed after preoperative chemoradiation on patients with a complete clinical response or on patients who were either ineligible for or refused to undergo abdominoperineal resection. Local excision was approached transanally by removing full-thickness rectal wall and the underlying mesorectum.

RESULTS

From 1994 to 2000, 95 patients with rectal cancers underwent preoperative chemoradiation and surgical resection for curative intent. Of these, 26 patients (28%), 19 men and 7 women, with a mean age of 63 years (range 44-90), underwent local excision. Pretreatment endoscopic ultrasound classifications included 5 T2N0, 13 T3N0, 7 T3N1, and 1 not done. Pathologic partial and complete responses were achieved in 9 of 26 (35%) and 17 of 26 (65%) patients, respectively. Two of nine partial responders underwent immediate abdominoperineal resection. The mean follow-up was 24 months (median 19, range 6-77). The only recurrence was in a patient who refused to undergo abdominoperineal resection after a partial response. There was one postoperative death from a stroke. This treatment was associated with a low rate of complications.

CONCLUSION

Local excision appears to be an effective alternative treatment to radical surgical resection for a highly select subset of patients with T2 and T3 adenocarcinomas of the distal rectum who show a complete pathologic response to preoperative chemoradiation.

Community-based cancer screening for underserved women: design and baseline findings from the Breast and Cervical Cancer Intervention Study

BACKGROUND

Underutilization of breast and cervical cancer screening has been observed in many ethnic groups and underserved populations. Effective community-based interventions are needed to eliminate disparities in screening rates and thus to improve prospects for survival.

METHODS

The Breast and Cervical Cancer Intervention Study was a controlled trial of three interventions in the San Francisco Bay Area from 1993 to 1996: (1) community-based lay health worker outreach; (2) clinic-based provider training and reminder system; and (3) patient navigator for follow-up of abnormal screening results. Study design and a description of the interventions are reported along with baseline results of a household survey conducted in four languages among 1599 women, aged 40-75.

RESULTS

Seventy-six percent of women ages 40 and over had had at least one mammogram, and most had had a clinical breast examination (88%) and Pap smear (89%). Rates were significantly lower for non-English-speaking Latinas and Chinese women (56 and 32%, respectively, for mammography), and maintenance screening (three mammograms in the past 5 years) varied from 7% (non-English-speaking Chinese) to 53% (Blacks). Pap smear screening in the past 3 years was low among non-English-speaking Latinas (72%) and markedly lower among non-English-speaking Chinese women (24%). The strongest predictors of screening behavior were having private health insurance and frequent use of medical services. Having a regular clinic and speaking English were also important. Race/ethnicity, education, household income, and employment status were, overall, not significant predictors of screening behavior.

CONCLUSIONS

These baseline results support the importance of cancer screening interventions targeted to persons of foreign origin, particularly those less acculturated.

Treatment of stage I and II non-small-cell lung cancer

BACKGROUND

The appropriate staging and treatment of patients with stage I and II non-small-cell lung cancer (NSCLC) are important in that the potential for a lost curative opportunity in this population is greater than for those presenting with advanced NSCLC.

METHODS

Treatment options -- surgery, radiation therapy, and chemotherapy -- for stage I and II NSCLC are reviewed, and the impact of newer staging modalities on patient survival is discussed, including altering both the lead-time and clinicopathologic stage biases that exist in the diagnosis and treatment of NSCLC. Some predictions are also made regarding how that standard may change for clinicians in the near future, and methods for further improvements in posttreatment survival in this group are discussed.

RESULTS

Whenever possible, patients with early-stage NSCLC should be treated with surgical resection. Patients for whom resection is not an option may benefit from radiation as definitive therapy. Positive results with neoadjuvant chemotherapy have led to an ongoing randomized trial (Intergroup S9900) to compare surgery alone to neoadjuvant chemotherapy plus surgery.

CONCLUSIONS

Staging bias may affect the overall low survival of early-stage NSCLC. However, true stage-specific survival may improve with newer imaging modalities. Future advances, including closed transthoracic radiation, thermal ablative therapy techniques, and gene therapy, may supplant the need to surgically resect these tumors to achieve local control.

Barriers to tobacco cessation in clinical practice: report from a National Survey of Oncology Nurses

This study describes the survey results of a national random sample of members of the Oncology Nursing Society who reported the greatest number of barriers to delivering a tobacco cessation intervention with their patients. Nurses who perceived the greatest number of barriers were more likely to be current smokers and to be young and were less likely to have an advanced degree, to be a nurse practitioner, or to have administrative responsibilities. Those with greater barriers were less likely to deliver tobacco cessation interventions.

Annual report to the nation on the status of cancer (1973 through 1998), featuring cancers with recent increasing trends

BACKGROUND

The American Cancer Society, the National Cancer Institute (NCI), the North American Association of Central Cancer Registries, and the Centers for Disease Control and Prevention, including the National Center for Health Statistics (NCHS), collaborate to provide an annual update on cancer occurrence and trends in the United States. This year's report contains a special feature that focuses on cancers with recent increasing trends.

METHODS

From 1992 through 1998, age-adjusted rates and annual percent changes are calculated for cancer incidence and underlying cause of death with the use of NCI incidence and NCHS mortality data. Joinpoint analysis, a model of joined line segments, is used to examine long-term trends for the four most common cancers and for those cancers with recent increasing trends in incidence or mortality. Statistically significant findings are based on a P value of.05 by use of a two-sided test. State-specific incidence and death rates for 1994 through 1998 are reported for major cancers.

RESULTS

From 1992 through 1998, total cancer death rates declined in males and females, while cancer incidence rates declined only in males. Incidence rates in females increased slightly, largely because of breast cancer increases that occurred in some older age groups, possibly as a result of increased early detection. Female lung cancer mortality, a major cause of death in women, continued to increase but more slowly than in earlier years. In addition, the incidence or mortality rate increased in 10 other sites, accounting for about 13% of total cancer incidence and mortality in the United States.

CONCLUSIONS

Overall cancer incidence and death rates continued to decline in the United States. Future progress will require sustained improvements in cancer prevention, screening, and treatment.

A mathematical algorithm that computes breast cancer sizes and doubling times detected by screening

This paper presents a mathematical algorithm that computes the sizes and growth rates of breast cancer detected in a hypothetical population that is screened for the disease. The algorithm works by simulating the outcomes of the hypothetical population twice, first without screening and then with screening. The simulation without screening relies on an underlying model of the natural history of the disease. The simulation with screening uses this natural history model to track the growth of breast tumors backwards in the time starting from the time they would have been detected without screening. The method of tracking tumor growth backward in time is different from methods that track tumor growth forward in time by starting from an estimated time of tumor onset. The screening algorithm combines the natural history model, the method tracking of tumor growth backward in time, the age group, the interval between screening exams, and the detection threshold of the screening exam to compute the joint distribution of tumor size and growth rate among screen-detected and interval patients. The algorithm also computes the sensitivity and leadtime distribution. It allows for arbitrary age groups, detection thresholds and screening intervals and may contribute to the design of future screening trials.