The advantage of women in cancer survival: An analysis of EUROCARE-4 data

New insights in risk stratification of differentiated thyroid cancer

PURPOSE OF REVIEW

Numerous staging and scoring systems exist for differentiated thyroid cancer (DTC), but all harbor limitations. This has prompted investigation for new factors with prognostic implications for DTC.

RECENT FINDINGS

Several new factors that may be involved in DTC risk stratification have emerged, such as thyroid stimulating hormone and molecular markers. In addition, others are controversial and being challenged, such as age, sex and lymph node involvement.

SUMMARY

The purpose of this review is to present recent updates in the literature on new potential risk stratification predictors for DTC.

Smoking and body mass index and survival in pancreatic cancer patients

OBJECTIVE

The objective of this study was to provide further information on the role of personal characteristics and lifestyle factors, including obesity, diabetes, and tobacco smoking, on survival from pancreatic cancer.

METHODS

We obtained follow-up data of pancreatic cancer patients enrolled in 2 Italian case-control studies. Information on characteristics and habits up to the time of diagnosis was collected by trained interviewers. Vital status was ascertained through population registers and record linkage with health system databases. Hazard ratios (HRs) of all-cause mortality and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models.

RESULTS

Follow-up information was retrieved for 648 cancer patients. Compared with subjects with body mass index of less than 25 kg/m, the HRs were 1.14 (95% CI, 0.94-1.39) for overweight (ie, 25-29.9 kg/m) and 1.32 (95% CI, 0.98-1.79) for obese (ie, ≥30 kg/m) patients (trend P = 0.046). The HRs were 1.37 (95% CI, 1.14-1.65) for ever, 1.30 (95% CI, 1.03-1.65) for ex-smokers, and 1.42 (95% CI, 1.16-1.73) for current versus never smokers. Increasing amount and duration of smoking were associated with reduced survival after pancreatic cancer. No association emerged with diabetes, alcohol consumption, and diet.

CONCLUSIONS

Smoking and overweight before diagnosis may play a role in the prognosis of pancreatic cancer, besides its etiology.

Lung cancer in women: an overview with special focus on Spanish women

Lung cancer incidence is decreasing worldwide among men but rising among women due to recent changes in smoking patterns in both sexes. In Europe, the smoking epidemic has evolved different rates and times, and policy responses to it, vary substantially between countries. Differences in smoking prevalence are much more evident among European women reflecting the heterogeneity in cancer incidence rates. Other factors rather than smoking and linked to sex may increase women's susceptibility to lung cancer, such as genetic predisposition, exposure to sex hormones and molecular features, all of them linked to epidemiologic and clinical characteristics of lung cancer in women. However, biological bases of sex-specific differences are controversial and need further evaluation. This review focuses on the epidemiology and outcome concerning non-small cell lung cancer in women, with emphasis given to the Spanish population.

Sex differences in colorectal cancer survival: population-based analysis of 164,996 colorectal cancer patients in Germany

Risk of colorectal cancer (CRC) is considerably higher in men compared to women; however, there is inconclusive evidence of sex differences in CRC prognosis. We aimed to assess and explain sex differences in 5-year relative survival using standard and model-based period analysis among 164,996 patients diagnosed with CRC from 1997 to 2006 and reported to 11 German cancer registries covering a population of 33 million inhabitants. Age-adjusted 5-year relative survival was higher in women (64.5% vs. 61.9%, P<0.0001). A substantial survival advantage of women was confirmed in multivariate analysis after adjusting for CRC stage and subsite in subjects under 65 years of age (relative excess risk, RER 0.86, 95% CI 0.82-0.90), but not in older subjects (RER 1.01, 95% CI 0.98-1.04); this pattern was similar in the 1st and in the 2nd to 5th year after diagnosis. The survival advantage of women varied by CRC stage and age and was most pronounced for localized disease (RERs 0.59-0.88 in various age subgroups) and in patients under 45 years of age (RERs 0.59, 0.72 and 0.76 in patients with localized, regional or advanced disease, respectively). On the contrary, sex differences in survival did not vary by location of CRC. In conclusion, our large population-based study confirmed a survival advantage of female compared to male CRC patients, most notably in young and middle aged patients and patients with localized disease. The effect of sex hormones, either endogenous or through hormonal replacement therapy, might be the most plausible explanation for the observed patterns.

Sex Is an Independent Prognostic Indicator for Survival and Relapse/Progression-Free Survival in Metastasized Stage III to IV Melanoma: A Pooled Analysis of Five European Organisation for Research and Treatment of Cancer Randomized Controlled Trials

Purpose

To study sex differences in survival and progression in patients with stage III or IV metastatic melanoma and to compare our results with published literature.

Patients and Methods

Data were retrieved from three large, randomized, controlled trials of the European Organisation for Research and Treatment of Cancer in patients with stage III and two trials in patients with stage IV melanoma. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% CIs for females compared with males, adjusted for different sets of confounders for stage III and stage IV, respectively.

Results

In 2,734 stage III patients, females had a superior 5-year disease-specific survival (DSS) rate compared with males (51.5% v 43.3%), an adjusted HR for DSS of 0.85 (95% CI, 0.76 to 0.95), and an adjusted HR for relapse-free survival of 0.86 (95% CI, 0.77 to 0.95). In 1,306 stage IV patients, females also exhibited an advantage in DSS (2-year survival rate, 14.1% v 19.0%; adjusted HR, 0.81; 95% CI, 0.72 to 0.92) as well as for progression-free survival (adjusted HR, 0.79; 95% CI, 0.70 to 0.88). This female advantage was consistent across pre- and postmenopausal age categories and across different prognostic subgroups. However, the female advantage seems to become smaller in patients with higher metastatic tumor load.

Conclusion

The persistent independent female advantage, even after metastasis to lymph nodes and distant sites, contradicts theories about sex behavioral differences as an explanation for this phenomenon. A biologic sex trait seems to profoundly influence melanoma progression and survival, even in advanced disease.

Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004-2007

BACKGROUND

The authors consider whether differences in stage at diagnosis could explain the variation in lung cancer survival between six developed countries in 2004-2007.

METHODS

Routinely collected population-based data were obtained on all adults (15-99 years) diagnosed with lung cancer in 2004-2007 and registered in regional and national cancer registries in Australia, Canada, Denmark, Norway, Sweden and the UK. Stage data for 57 352 patients were consolidated from various classification systems. Flexible parametric hazard models on the log cumulative scale were used to estimate net survival at 1 year and the excess hazard up to 18 months after diagnosis.

RESULTS

Age-standardised 1-year net survival from non-small cell lung cancer ranged from 30% (UK) to 46% (Sweden). Patients in the UK and Denmark had lower survival than elsewhere, partly because of a more adverse stage distribution. However, there were also wide international differences in stage-specific survival. Net survival from TNM stage I non-small cell lung cancer was 16% lower in the UK than in Sweden, and for TNM stage IV disease survival was 10% lower. Similar patterns were found for small cell lung cancer.

CONCLUSIONS

There are comparability issues when using population-based data but, even given these constraints, this study shows that, while differences in stage at diagnosis explain some of the international variation in overall lung cancer survival, wide disparities in stage-specific survival exist, suggesting that other factors are also important such as differences in treatment. Stage should be included in international cancer survival studies and the comparability of population-based data should be improved.

Free testosterone drives cancer aggressiveness: evidence from US population studies

Cancer incidence and mortality are higher in males than in females, suggesting that some gender-related factors are behind such a difference. To analyze this phenomenon the most recent Surveillance, Epidemiology and End Results (SEER) database served to access cancer survival data for the US population. Patients with gender-specific cancer and with limited information were excluded and this fact limited the sample size to 1,194,490 patients. NHANES III provided the distribution of physiologic variables in US population (n = 29,314). Cox model and Kaplan-Meier method were used to test the impact of gender on survival across age, and to calculate the gender-specific hazard ratio of dying from cancer five years following diagnosis. The distribution of the hazard ratio across age was then compared with the distribution of 65 physiological variables assessed in NHANES III. Spearman and Kolmogorov-Smirnov test assessed the homology. Cancer survival was lower in males than in females in the age range 17 to 61 years. The risk of death from cancer in males was about 30% higher than that of females of the same age. This effect was present only in sarcomas and epithelial solid tumors with distant disease and the effect was more prominent in African-Americans than Caucasians. When compared to the variables assessed in the NHANES III study, the hazard ratio almost exactly matched the distribution of free testosterone in males; none of the other analyzed variables exhibited a similar homology. Our findings suggest that male sex hormones give rise to cancer aggressiveness in patients younger than 61 years.

Outcome of patients with esophageal cancer: a nationwide analysis

BACKGROUND

Esophageal cancer is 1 of the 10 most common cancers and is a particular devastating form of cancer worldwide. More than 90% patients with esophageal cancer in Taiwan have squamous cell carcinoma (SCC). In the present study, we assessed the factors affecting survival of patients with esophageal cancer using data from Taiwan, a high-incidence area for esophageal SCC.

METHODS

We performed a retrospective review of 12,482 patients who were newly diagnosed with esophageal cancer from 1998 to 2007. The data were obtained from the National Health Insurance Research Database in Taiwan. Study participants were followed-up until the end of 2008.

RESULTS

Of the 12,482 patients, 11,490 (92.1%) were male with a median age of 60 years, and 992 (7.9%) were female with a median age of 71 years at the time of diagnosis. The overall 1-, 2-, 5-, and 10-year survival rates after diagnosis were 40.3, 22.9, 12.8, and 7.6%, respectively. Among parametric models for esophageal cancer prognosis, male sex, no curative treatment (surgery and/or radiotherapy), old age, and low socioeconomic status were significantly associated with shorter survival. Furthermore, curative treatment with surgery improved the survival of esophageal cancer patients more significantly compared with patients who undergo definite radiotherapy.

CONCLUSIONS

Our data indicated that age, sex, and curative treatment were significant predictors of lifetime survival in patients with esophageal cancer. The overall survival rates of patients with esophageal cancer are relatively low, while survival of patients who undergo surgery is improved significantly.

Cancer of the colon and rectum: potential effects of sex-age interactions on incidence and outcome

Background

Sex differences in epidemiological, clinical and pathological characteristics of colorectal cancer have been under intensive investigation for the last three decades. Given that most of the sex-related differences reported were also age-related, this study sought to determine the potential effect of a sex-age interaction on colorectal cancer development and progression.

Material/Methods

Statistical data on sex- and age-specific colon or rectal cancer incidence, disease stage and survival for white persons were derived from the United States Surveillance, Epidemiology and End Results (SEER) Program. Age-specific incidence rates in 2002–2006 were analyzed by 5-year age groups (45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79, 80–84 years) in men and women. Sex differences were measured by calculating rate differences (RD) and rate ratios (RR). Equivalent analyses for a similar time period were performed for stage distribution and 5-year relative survival.

Results

Age-specific incidence rates were higher for men, for all life-time periods. However, the magnitude of the male predominance was age-dependent. The RR and RD did not remain constant over time: they increased gradually with age, peaked at 70–74 years, and declined thereafter. The distribution of stage at diagnosis was similar between men and women, but women seemed to have better survival, until the age of 64 years for colon cancer and 74 years for rectal cancer.

Conclusions

There seem to be significant age-related sex differences in the incidence of colorectal cancer, and maybe also in its prognosis.

The effect of gender and age on kidney cancer survival: younger age is an independent prognostic factor in women with renal cell carcinoma

OBJECTIVE

Gender-specific differences in incidence of renal cell carcinoma (RCC) and its outcome have previously been reported. We used age as a surrogate to test whether this might be hormone-related in a large international RCC cohort.

METHODS AND MATERIALS

This study included patients treated by nephrectomy at 10 international academic centers. Clinicopathologic features were assessed using chi-square and the Student t-tests. Kaplan-Meier survival estimates and Cox proportional hazards models addressed the effect of gender and age on disease-specific survival.

RESULTS

Of the 5,654 patients, 3,777 (67%) were men and 1,877 (33%) were women. Generally, women presented at lower T stages (P<0.001), had fewer metastases (P<0.001), and had lower-grade tumors (P<0.001). Women more frequently had clear-cell (87% vs. 82%) and less frequently had papillary RCC (7% vs. 12%) than men (P<0.001). Women had a 19% reduced risk of death from RCC than men (hazard ratio 0.81, 95% confidence interval 0.73-0.90, P<0.001). The survival advantage for women was present to the greatest degree in the age group<42 years (P = 0.0136) and in women aged 42 to 58 years (P<0.001), but was not apparent in patients aged 59 years and older (P = 0.248). Age was an independent predictor of disease-specific survival in women (hazard ratio 1.011, 95% confidence interval 1.004-1.019, P = 0.004), but not in men.

CONCLUSIONS

As a group, women present with less advanced tumors, leading to a 19% reduced risk of RCC-specific death compared with men. This survival difference is present only in patients aged<59 years. Because this gender-based survival difference is not related to pathologic features, the role of hormonal effects on the development and progression of RCC needs to be investigated.

Do female cancer patients display better survival rates compared with males? Analysis of the Korean National Registry data, 2005-2009

Background

Sex differences have been reported in the prognosis of certain cancers. In this study, we investigated whether Korean females display better survival rates compared with male patients for solid tumor sites.

Methods

We analyzed data from the Korean National Cancer Incidence Database from 599,288 adult patients diagnosed with solid cancers between 2005 and 2009. Patients were followed until December 2010. We applied a relative excess risk (RER) model adjusting for year of follow-up, age at diagnosis, and stage at diagnosis.

Results

For all solid cancer sites combined, women displayed an 11% lower risk of death compared to men (RER 0.89; 95% CI 0.88–0.90) after adjusting for year of follow-up, age, stage, and case mix. Women showed significantly lower RERs for the following sites: head/neck, esophagus, small intestine, liver, nasal cavities, lung, bone/cartilages, melanoma of skin, soft tissue, brain and CNS, and thyroid. In contrast, women displayed a poorer prognosis than did men for colorectal, laryngeal, kidney and bladder cancer. However, the survival gaps between men and women narrowed by increase in age; female patients over 75 years of age displayed a 3% higher RER of death compared with males in this age group.

Conclusions

Female cancer patients display an improved survival for the majority of solid tumor sites, even after adjustment for age and stage. Age at diagnosis was the major contributor to the women’s survival advantage.

Sex-dependent liver colonization of human melanoma in SCID mice--role of host defense mechanisms

The possibility that endocrine factors may influence the clinical course of malignant melanoma is suggested by the superior survival data of women. In preclinical models we observed a higher rate of colony formation by human melanoma cells in male compared to female SCID mice, but only in the case of the liver and not in other organs. The gender difference could be seen at an early phase of colony formation. On the other hand, in our human melanoma cell lines we failed to detect steroid receptor protein expression, and treatment with sex hormones did not considerably influence their in vitro behavior. Investigating the possible contribution of host cells to the observed gender difference, we performed in vivo blocking experiments applying pretreatment of the animals with Kupffer cell inhibitor gadolinium chloride and the NK cell inhibitor anti-asialo GM1 antibody. While Kupffer cell blockade enhanced melanoma liver colonization equally in the two sexes, a more prominent increase was observed in female than in male mice in the case of NK cell inhibition. Further supporting the importance of NK cells in the lower liver colonization efficiency of melanoma cells in females, gender difference in colony formation was lost in NSG mice lacking NK activity. Although in humans no organ selectivity of gender difference in melanoma progression has been observed according to data in the literature, our results possibly indicate a contribution of natural host defense mechanisms to gender difference in survival of patients with melanoma or other tumor types as well.

Prognostic role of gender in diffuse large B-cell lymphoma treated with rituximab containing regimens: a Fondazione Italiana Linfomi/Grupo de Estudos em Moléstias Onco-Hematológicas retrospective study

Male gender was recently reported as an adverse prognostic factor in patients with diffuse large B-cell lymphoma (DLBCL) treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). We conducted a retrospective study of adult patients with DLBCL initially treated with rituximab containing regimens between 2001 and 2007. Patients were identified from the clinical archives of 43 Italian and Brazilian institutions. The principal endpoint was overall survival (OS). One thousand seven hundred and ninety-three patients were fully eligible for the study. Thirty-eight percent, 27%, 22% and 12% of patients had an International Prognostic Index (IPI) score of 0-1, 2, 3 and 4-5, respectively; 53% were males. After a median follow-up of 36 months (1-106), the 5-year OS was 76% (95% confidence interval 74-78%). In univariate analysis, male gender was an adverse prognostic factor with a hazard ratio of 1.52. In multivariate analysis, when adjusted by IPI, again gender maintained its prognostic relevance, showing an independent additive effect. In conclusion, in patients with DLBCL treated with rituximab containing regimens, gender may increase the predictive power of the IPI. Based on these results, given possible differences in blood clearance of rituximab between males and females, the benefit of higher doses of rituximab in males should be explored.

Survival of stomach and esophagus cancer patients in Germany in the early 21st century

BACKGROUND

Esophagus and stomach cancers are associated with poor prognosis. But most published population-based cancer survival estimates for stomach and esophagus cancer refer to survival experience of patients diagnosed in the 1990s or earlier years. The aim of this study was to provide up-to-date survival estimates and trends for patients with stomach and esophagus cancer in Germany.

MATERIAL AND METHODS

Our analysis is based on data from 11 population-based cancer registries, covering 33 million inhabitants. Patients diagnosed with stomach and esophagus cancer in 1997-2006 were included. Period analysis was used to derive five-year relative survival estimates and trends by age, sex, cancer subsite, and stage for the time period of 2002-2006. German and US survival estimates were compared utilizing the SEER 13 database.

RESULTS

Overall age-standardized five-year relative survival was 31.8% and 18.3% for stomach and esophagus cancer, respectively, compared to 27.2% and 17.4% in the US. Survival was somewhat higher among female than among male patients for both cancer sites (33.6% vs. 30.6% and 21.5% vs. 17.5%, respectively) and much higher for non-cardia stomach cancer (40.4%) than for cardia cancer (23.4%). From 2002 to 2006, a moderate increase in five-year relative survival by 2.7 percent units was observed for non-cardia stomach cancer patients in Germany (p < 0.001).

CONCLUSION

Five-year relative cancer survival has reached levels around 40% for patients with non-cardia stomach cancer in Germany in the early 21st century, whereas it remained at lower levels around 20% for patients with esophagus and cardia cancer.

Oesophageal cancer survival in Europe: a EUROCARE-4 study

Oesophageal cancer survival is poor with variation across Europe. No pan-European studies of survival differences by oesophageal cancer subtype exist. This study investigates rates and trends in oesophageal cancer survival across Europe. Data for primary malignant oesophageal cancer diagnosed in 1995-1999 and followed up to the end of 2003 was obtained from 66 cancer registries in 24 European countries. Relative survival was calculated using the Hakulinen approach. Staging data were available from 19 registries. Survival by region, gender, age, morphology and stage was investigated. Cohort analysis and the period approach were applied to investigate survival trends from 1988 to 2002 for 31 registries in 17 countries. In total 51,499 cases of oesophageal cancer diagnosed 1995-1999 were analysed. Overall, European 1- and 5-year survival rates were 33.4% (95% CI 32.9-33.9%) and 9.8% (95% CI 9.4-10.1%), respectively. Males, older patients and patients with late stage disease had poorer 1- and 5-year relative survival. Patients with squamous cell carcinoma had poorer 1-year relative survival. Regional variation in survival was observed with Central Europe above and Eastern Europe below the European pool. Survival for distant stage disease was similar across Europe while survival rates for localised disease were below the European pool in Eastern and Southern Europe. Improvement in European 1-year relative survival was reported (p=0.016). Oesophageal cancer survival was poor across Europe. Persistent regional variations in 1-year survival point to a need for a high resolution study of diagnostic and treatment practices of oesophageal cancer.

Oropharyngeal Cancer Survival: A Population-Based Study of Patients Diagnosed between 1978 and 2002

Objective. This paper aims at studying oropharyngeal cancer survival from the Population-Based Cancer Registry of Zaragoza, Spain, for the 1978-2002 period. Methods. The survival rates were calculated by the Kaplan-Meier method, and the automated calculation method of the Catalan Institute of Oncology was utilized to obtain the relative survival. Results. The oropharyngeal cancer survival rate was 61.3% in the first year and 33.9% in the fifth year. One-year relative survival was 62.2% (CI 95%: 57.4-67.4), and five-year relative survival was 36.6% (CI 95%: 31.8-42.1). Comparison of survival rates by sex revealed statistically significant differences (P value = 0.017) with better survival in women. There were no differences when comparing the three age groups and the three studied time periods 1978-1986, 1987-1994, and 1995-2002. Conclusions. The data suggests that there were no significant changes in oropharyngeal cancer survival in the province of Zaragoza throughout the years.

Superior Outcome of Women With Stage I/II Cutaneous Melanoma: Pooled Analysis of Four European Organisation for Research and Treatment of Cancer Phase III Trials

Purpose

Several studies observed a female advantage in the prognosis of cutaneous melanoma, for which behavioral factors or an underlying biologic mechanism might be responsible. Using complete and reliable follow-up data from four phase III trials of the European Organisation for Research and Treatment of Cancer (EORTC) Melanoma Group, we explored the female advantage across multiple end points and in relation to other important prognostic indicators.

Patients and Methods

Patients diagnosed with localized melanoma were included in EORTC adjuvant treatment trials 18832, 18871, 18952, and 18961 and randomly assigned during the period of 1984 to 2005. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% CIs for women compared with men, adjusted for age, Breslow thickness, body site, ulceration, performed lymph node dissection, and treatment.

Results

A total of 2,672 patients with stage I/II melanoma were included. Women had a highly consistent and independent advantage in overall survival (adjusted HR, 0.70; 95% CI, 0.59 to 0.83), disease-specific survival (adjusted HR, 0.74; 95% CI, 0.62 to 0.88), time to lymph node metastasis (adjusted HR, 0.70; 95% CI, 0.51 to 0.96), and time to distant metastasis (adjusted HR, 0.69; 95% CI, 0.59 to 0.81). Subgroup analysis showed that the female advantage was consistent across all prognostic subgroups (with the possible exception of head and neck melanomas) and in pre- and postmenopausal age groups.

Conclusion

Women have a consistent and independent relative advantage in all aspects of the progression of localized melanoma of approximately 30%, most likely caused by an underlying biologic sex difference.

The impact of age and gender on papillary thyroid cancer survival

CONTEXT

Thyroid cancer predominately affects women, carries a worse prognosis in older age, and may have higher mortality in men. Superimposed on these observations is the fact that most women have attained menopause by age 55 yr.

OBJECTIVE

The objective of the study was to determine whether men contribute disproportionately to papillary thyroid cancer (PTC) mortality or whether menopause affects PTC prognosis.

DESIGN

Gender-specific mortality was normalized using age-matched subjects from the U.S. population. Multivariate Cox proportional hazard regression models incorporating gender, age, and National Thyroid Cancer Treatment Cooperative Study Group stage were used to model disease-specific survival (DSS).

PARTICIPANTS AND SETTING

Patients were followed in a prospective registry.

MAIN OUTCOME MEASURE

The relationships between gender, age, and PTC outcomes were analyzed.

RESULTS

The unadjusted hazard ratio (HR) for DSS for women was 0.40 [confidence interval (CI) 0.24-0.65]. This female advantage diminished when DSS was adjusted for age at diagnosis and stage with a HR encompassing unity (HR 0.72, CI 0.44-1.19). Additional multivariate models of DSS considering gender, disease stage, and various age groupings showed that the DSS for women diagnosed at under 55 yr was improved over men (HR 0.33, CI 0.13-0.81). However, the HR for DSS increased to become similar to men for women diagnosed at 55-69 yr (HR 1.01, CI 0.42-2.37) and at 70 yr or greater (HR 1.17, CI 0.48-2.85).

CONCLUSIONS

Although the overall outcome of women with PTC is similar to men, subgroup analysis showed that this composite outcome is composed of two periods with different outcomes. The first period is a period with better outcomes for women than men when the diagnosis occurs at younger than 55 yr; the second is a period with similar outcomes for both women and men diagnosed at ages greater than 55 yr. These data raise the question of whether an older age cutoff would improve current staging systems. We hypothesize that older age modifies the effect of gender on outcomes due to menopause-associated hormonal alterations.

Survival from colorectal cancer in Germany in the early 21st century

BACKGROUND

Colorectal cancer is the most common cancer in Germany and the second most common cause of cancer-related deaths in both men and women. The aim of this study is to provide detailed analysis of recent developments in survival of colorectal cancer patients using newly available data on a national basis.

METHODS

We included data from 11 German cancer registries covering a population of 33 million inhabitants. Period analysis and modelled period analysis were used to provide most up-to-date estimates of 5-year relative survival in 2002-2006.

RESULTS

The analysis was based on records of 164 996 colorectal cancer patients. Five-year relative survival was 63.0% overall, decreased with age and was significantly higher among women than among men in patients under 75 years. Overall age-adjusted 5-year relative survival increased from 60.6 to 65.0% over the period 2002-2006. Significant increase in survival was only observed in patients with localised or regional disease. Highest subsite-specific survival was observed in patients with cancer in descending (67.7%) and ascending (66.5%) colon.

CONCLUSION

Survival of patients with colorectal cancer continued to increase in the early 21st century in Germany, with 5-year relative survival reaching 65% in 2006. However, lack of progress still persisted in patients with advanced disease.

Role of age and tumour stage in the temporal pattern of 'cure' from stomach cancer: a population-based study in Osaka, Japan

OBJECTIVES

To evaluate progress in stomach cancer care in Japan since 1975.

DESIGN

Population-based study of data extracted from the Osaka Cancer Registry.

SETTING

Population-based cancer registry in the area of Osaka Prefecture.

PARTICIPANTS

All 66,032 cases diagnosed with a stomach cancer in Osaka Prefecture, Japan between 1975 and 2000 and registered in the Osaka Cancer Registry.

MAIN OUTCOME MEASURES

'Cure' fraction and median survival time for 'uncured' patients were estimated with multivariable mixture 'cure' model. The role played by age and stage at diagnosis on the changes in 'cure' parameters between 1975 and 2000 was evaluated. Missing stage was handled by multiple imputation approach.

RESULTS

More than 50% of the patients diagnosed with a stomach cancer in 1996-2000 were estimated 'cured' from their cancer, corresponding to a 20% increase since 1975-1980. Median survival time for 'uncured' patients however remained unchanged at about 8 months. 'Cure' fraction was over 85% for localised tumours and 30% for regional tumours, but stayed as low as 2.5% for distant metastatic cancers. Improvement was underestimated by about 10% because of ageing of cancer patients. Changes in stage distribution explained up to 40% of the increase in 'cure' fraction among men and up to 13% in women. Overdiagnosis was unlikely to play any role in these patterns.

CONCLUSIONS

'Cure' fraction from stomach cancer dramatically increased in Osaka, Japan since 1975, partly because of earlier stage at diagnosis, but mostly due to improvement in treatment of stomach cancer patients. This study, based on a leading country in term of stomach cancer management, provides insightful results for other countries in which 'cure' fraction is usually much lower.

Descriptive epidemiology of malignant mucosal and uveal melanomas and adnexal skin carcinomas in Europe

This work provides descriptive epidemiological data of malignant mucosal and uveal melanomas and adnexal skin carcinomas in Europe as defined as in the RARECARE project. We analysed 8669 incident cases registered in the period 1995-2002 by 76 population-based cancer registries (CRs), and followed up for vital status to 31st December 2003. Age-standardised incidence to the European standard population was obtained restricting the analysis to 8416 cancer cases collected by 64 not specialised CRs or with information available only for some anatomical sites. Period survival rates at 2000-2002 were estimated on 45 CRs data. Twenty-two CRs which covered the period 1988-2002 were analysed to obtain the 15-year prevalence (1st January 2003 as reference date). Complete prevalence was calculated by using the completeness index method which estimates surviving cases diagnosed prior to 1988 ('unobserved' prevalence). The expected number of new cases per year and of prevalent cases in Europe was then obtained multiplying the crude incidence and complete prevalence rates to the European population at 2008. We estimated 5204 new cases per year (10.5 per million) to occur in Europe, of which 48.7% were melanomas of uvea, 24.8% melanomas of mucosa and 26.5% adnexal carcinomas of the skin. Five-year relative survival was 40.6% and 68.9% for mucosal and uveal melanomas, respectively. Adnexal skin carcinomas showed a good prognosis with a survival of 87.7% 5 years after diagnosis. Northern Europe, United Kingdom (UK) and Ireland showed the highest 5-year survival rate for uveal melanomas (72.6% and 73.4%), while Southern Europe showed the lowest rate (63.7%). More than 50,000 persons with a past diagnosis of one of these rare cancers were estimated to be alive at 2008 in Europe, most of them (58.8%, n=29,676) being patients with uveal melanoma. Due to the good prognosis and high incidence of uveal melanomas, these malignancies are highly represented among the long-term survivors of the studied rare cancer types. Therefore, maximising quality of life is particularly important in treatment of uveal melanoma. As regards mucosal melanomas, the centralisation of treatment to a select number of specialist centres as well as the establishment of expert pathology panels should be promoted. The geographical differences in incidence and survival should be further investigated analysing the centre of treatment, the stage at diagnosis and the treatment.

Rare cancers of the head and neck area in Europe

The RARECARE project has proposed a different and more detailed grouping of cancers, based on localisation and histological type, in order to identify rare entities with clinical meaning. RARECARE gathered data on cancer patients diagnosed from 1978 to 2002 and archived in 76 population-based cancer registries, all of which had vital status information available up to at least 31st December 2003. This study provides incidence, prevalence and survival rates for rare head and neck epithelial (H&N) cancers. Among the rare H&N cancers, those of oral cavity had the highest annual crude incidence rate of 48 per million, followed by oropharynx and 'major salivary glands and salivary gland type tumours' (28 and 13 per million, respectively). Incidence rates of epithelial tumours of nasal cavities, nasopharynx, eye and adnexa and middle ears were all lower than 5 per million. The prevalence for all investigated entities was lower than 35 per 100,000. The 5-year relative survival rates ranged from 40% for epithelial cancer of oropharynx to 85% for epithelial cancer of eye and adnexa. Survival rates were lower for men and for patients aged ≥65 years. With few exceptions, the lowest and highest survival figures were observed for Eastern Europe and Northern Europe, respectively. According to the definition for rare tumours by RARECARE (incidence<6 per 100,000), as well as according to the definition for rare diseases by the European Commission (prevalence<50 per 100,000) the H&N cancers described in this paper should be considered rare and diagnosis and treatment of these cancers should therefore be centralised.

Sex disparities in cancer mortality and survival

BACKGROUND

Previous research has noted higher cancer mortality rates and lower survival among males than females. However, systematic comparisons of these two metrics by sex have been limited.

METHODS

We extracted U.S. vital rates and survival data from the Surveillance, Epidemiology and End Results Database for 36 cancers by sex and age for the period 1977 to 2006. We compared sex-specific mortality rates and examined male-to-female mortality rate ratios (MRR). We also extracted case data which included age and date of diagnosis, sex, primary cancer site, tumor stage and grade, survival time, vital status, and cause of death. Relative cancer-specific HRs for death in the 5-year period following diagnosis were estimated with Cox proportional hazards models, adjusted for covariates.

RESULTS

For the vast majority of cancers, age-adjusted mortality rates were higher among males than females with the highest male-to-female MRR for lip (5.51), larynx (5.37), hypopharynx (4.47), esophagus (4.08), and urinary bladder (3.36). Cancer-specific survival was, for most cancers, worse for males than females, but such disparities were drastically less than corresponding MRRs [e.g., lip (HR = 0.93), larynx (HR = 1.09), hypopharynx (HR = 0.98), esophagus (HR = 1.05), and urinary bladder (HR = 0.83)].

CONCLUSIONS

Male-to-female MRRs differed markedly while cancer survival disparities were much less pronounced. This suggests that sex-related cancer disparities are more strongly related to etiology than prognosis.

IMPACT

Future analytic studies should attempt to understand causes of observed sex disparities in cancer.

French brain tumor database: 5-year histological results on 25 756 cases

This work aimed to prospectively record all primary central nervous system tumor (PCNST) cases in France, for which histological diagnosis is available. The objectives were to (i) create a national registry and a network to perform epidemiological studies; (ii) implement clinical and basic research protocols; and (iii) harmonize the health care of patients affected by PCNST. For 5 years, 25 756 cases of newly diagnosed and histologically confirmed PCNST have been recorded. Histological diagnoses included glioma (48.9%), all other neuroepithelial tumors (5%), meningioma (28.8%), nerve sheath tumors (8.4%), lymphoma (3.2%) and others (5.7%). Cryopreservation was reported for 6018 PCNST specimens. Tumor resections (R) were performed in 78% cases, while biopsies accounted for 22%. Median age (MA), sex, percentage R and number of cryopreserved tumors were detailed for each histology; for example, out of 6053 glioblastomas (MA 63 years, male 59.4%, R 62%, 1611 were cryopreserved), and out of 37 atypical teratoid/rhabdoid tumors (MA 2 years, male 56.8%, R 94%, 17 were cryopreserved). This database or databank dedicated to PCNST cases contains detailed data on clinical, histological and other characteristics, such as the inclusion of data on cryopreserved specimens that are not available in other European registries. Therefore, this is a valuable resource that can be used for planning future epidemiological and clinical research.

The changing pattern of non-small cell lung cancer between the 90 and 2000 decades

BACKGROUND

In Europe, approximately 381,500 patients are diagnosed with non-small cell lung cancer (NSCLC) every year. The aim of this study is to analyse the changes in diagnosis, treatment and evolution during the last two decades, using data from a hospital registry.

MATERIAL AND METHODS

Patients diagnosed with NSCLC at the Corporació Sanitària Parc Taulí-Sabadell (Catalonia, Spain) during the periods 1990-1997 (n=748) and 2003-2005 (n=311) were included. The hospital tumour registry was used for prospective data collection.

RESULTS

Our series shows a significant increase in women diagnosed with NSCLC (6% vs 10.3%; p 0.01) in the latter period; the incidence of adenocarcinomas increased by 20% (31% vs 51.1%), whereas that of squamous cell carcinomas fell (51.3% vs 32.5%; p<0.001). The proportion of patients receiving active treatment also increased significantly, from 56.6% to 76.5% (p<0.001). Disease stage at diagnosis and the number of patients treated by radical surgical resection remained unchanged. Among the favourable independent prognostic factors for survival were: gender (women), age less than 70 years old, Karnofsky index ≥70%, early stage at diagnosis, treatment with chemotherapy, and being diagnosed in the latter period 2003-2005 (HR 0.67). Over this 10-year period, absolute gain in mean survival in our series was 115 days.

CONCLUSIONS

The absolute gain in mean survival in NSCLC patients in the period studied was 3.8 months, with a 6.75% increase in 5-year survival. Hospital registry data may help the correct assessment of epidemiological changes and the real effectiveness of treatments, which are sometimes overestimated in clinical trials.

Interobserver variability of clinical target volume delineation in supra-diaphragmatic Hodgkin's disease: a multi-institutional experience

BACKGROUND

To determine interobserver variability in clinical target volume (CTV) of supra-diaphragmatic Hodgkin's lymphoma.

MATERIALS AND METHODS

At the 2008 AIRO (Italian Society of Radiation Oncology) Meeting, the Radiation Oncology Department of Chieti proposed a multi-institutional contouring dummy-run of two cases of early stage supra-diaphragmatic Hodgkin's lymphoma after chemotherapy. Clinical history, diagnostics, and planning CT imaging were available on Chieti's radiotherapy website (www.radioterapia.unich.it). Participating centers were requested to delineate the CTV and submit it to the coordinating center. To quantify interobserver variability of CTV delineations, the total volume, craniocaudal, laterolateral, and anteroposterior diameters were calculated.

RESULTS

A total of 18 institutions for case A and 15 institutions for case B submitted the targets. Case A presented significant variability in total volume (range: 74.1-1,157.1 cc), craniocaudal (range: 6.5-22.5 cm; median: 16.25 cm), anteroposterior (range: 5.04-14.82 cm; median: 10.28 cm), and laterolateral diameters (range: 8.23-22.88 cm; median: 15.5 cm). Mean CTV was 464.8 cc (standard deviation: 280.5 cc). Case B presented significant variability in total volume (range: 341.8-1,662 cc), cranio-caudal (range: 8.0-28.5 cm; median: 23 cm), anteroposterior (range: 7.9-1.8 cm; median: 11.1 cm), and laterolateral diameters (range: 12.9-24.0 cm; median: 18.8 cm). Mean CTV was 926.0 cc (standard deviation: 445.7 cc).

CONCLUSION

This significant variability confirms the need to apply specific guidelines to improve contouring uniformity in Hodgkin's lymphoma.

[Melanoma: A protective role of pregnancy? A case report and review of literature]

Melanoma is actually one of the most common malignancies to be diagnosed during pregnancy. Nevertheless, the role of the pregnancy hormones on the melanoma course is not yet completely clear. We present the case of melanoma in a pregnant woman, with a particularly fulminant postpartum development. This raised the question of a possible protection by the pregnancy hormones against melanoma.

Trends in mortality and mean age at death from lung cancer in Austria (1975-2007)

OBJECTIVE

To investigate trends in mortality and mean age at death from lung cancer (MADLC) compared to mean age at death from all causes (MAD) over the period 1975 - 2007 in Austria. Results are assessed with respect to secular trends in smoking habits.

METHODS

MAD and MADLC were computed by year and gender as the expected value of a fitted Weibull distribution. Age-period-cohort effects on lung cancer death rates were estimated by hierarchical Poisson models.

RESULTS

In females MADLC was on average about 2 years higher than in males and tended to decrease since the mid 1980s, while after the mid 1990s MADLC in males increased such that the difference between men and women shrank to about half a year in 2007. Females dying from lung cancer lost about 6 years of life during the late 1970s but more than 10 years after 2000, while males lost 2 years in the 1970s and 5 years after 2000. Males demonstrated a decreasing risk with increasing year of birth, with the exception of cohorts born during or immediately after the World Wars that showed peak relative risks (RR). Females did not show pronounced birth cohort effect except for a peak RR for cohorts born during and after World War II.

CONCLUSIONS

MADLC provides additional information about secular trends in addition to incidence data. The declining trend of MADLC in females and in males up to the mid 1990s points to a change of smoking habits with an earlier onset of smoking in both genders. The subsequent increase in males during the last decade may be attributed to an increasing proportion of quitters because smoking cessation delays onset of lung cancer.

Trends in survival of patients diagnosed with cancers of the brain and nervous system, thyroid, eye, bone, and soft tissues in the Nordic countries 1964-2003 followed up until the end of 2006

BACKGROUND

Diagnoses of cancer of the brain, thyroid, eye, bone, and soft tissues are categorised by heterogeneity in disease frequency, survival, aetiology and prospects for curative therapy. In this paper, temporal trends in patient survival in the Nordic countries are considered.

MATERIAL AND METHODS

Age-standardised incidence and mortality rates, 5-year relative survival, and excess mortality rates for varying follow-up periods are presented, as are age-specific 5-year relative survival by country, sex and 5-year diagnostic period.

RESULTS

Brain cancer incidence rates have been rising but mortality has been relatively stable, with 5-year survival uniformly increasing from the early-1970s, particularly in younger patients. Five-year survival from brain cancer among men varies between 45% and 50% for men and 60% to 70% in women, with excess deaths decreasing with time in each of the Nordic populations. Age-standardised incidence rates of thyroid cancer have been mainly increasing during the 1960s and 1970s, although trends thereafter diverge, with 5-year relative survival increasing 20-30 percentage points over the last 40 years to around 80-90%. Thyroid cancer survival is consistently lower in Denmark, particularly in patients diagnosed aged over 60, while there is less geographic variation in excess deaths three months beyond initial diagnosis. Relative survival from eye cancer increased with time from approximately 60% in 1964-1968 to 80% 1999-2003, while for bone sarcoma, incidence rates remained stable, mortality rates declined, and 5-year survival increased slightly to around 55-65%. Soft tissue sarcoma incidence and survival have been slowly increasing since the 1960s, with little variation in survival (around 65%) for the most recent period.

CONCLUSIONS

There have been some notable changes in survival that can be linked to epidemiological and clinical factors in different countries over time. Time-varying proportions of the major histological subtypes might however have affected the survival estimates for a number of the cancer forms reviewed here.

Reactive oxygen species and melanoma: an explanation for gender differences in survival?

Epidemiological research consistently shows a female advantage in melanoma survival. So far, no definite candidate for the explanation of this phenomenon has emerged. We propose that gender differences in oxidative stress caused by radical oxygen species (ROS) underlie these survival differences. It is known that males express lower amounts of anti-oxidant enzymes, resulting in more oxidative stress than females. The primary melanoma environment is characterized by high ROS levels, from exogenous sources as well as ROS production within melanoma cells themselves. ROS are known to be able to promote metastasis through a wide variety of mechanisms. We hypothesize that the higher levels of ROS in men enhance selection of ROS-resistance in melanoma cells. Subsequently, ROS can stimulate the metastatic potential of melanoma cells. In addition, due to the lower anti-oxidant defenses in men, ROS produced by melanoma cells cause more damage to healthy tissues surrounding the tumor, further stimulating metastasis. Therefore, ROS may explain the observed differences between males and females in melanoma survival.

Gender-related differences in patients with stage I to III upper tract urothelial carcinoma: results from the Surveillance, Epidemiology, and End Results database

OBJECTIVES

To examine the effect of gender in upper tract urothelial carcinoma (UTUC) stage at nephroureterectomy (NU), as well as on cancer-specific mortality (CSM) after NU in patients with American Joint Committee on Cancer stages I-III UTUC.

METHODS

Our analyses relied on 2903 (59.9%) males and 1947 (40.1%) females who underwent an NU for pT(1-3)N(0/x)M(0) UTUC between 1988 and 2006, within 17 Surveillance, Epidemiology, and End Results registries. Univariable and multivariable logistic regression models examined the effect of gender on stage and grade distribution at NU. Subsequently, cumulative incidence plots explored the impact of gender on CSM rates, after accounting for other-cause mortality (OCM). Finally, competing-risks regression models tested the independent predictor status of gender in CSM analyses. Covariates consisted of pT stage, pN stage, tumor grade, primary tumor location, type and year of surgery, age, and race.

RESULTS

Relative to males, females had a higher proportion of pT(3) UTUC (43.1% vs 39%; P = .02) and a higher proportion of grade III/IV UTUC (63.8% vs 59.8%; P = .04) at NU. The female gender represented an independent predictor of pT(3) UTUC at NU (hazard ratio [HR]: 1.15; P = .03). After accounting for OCM, CSM rates in females were higher than those in males (HR: 1.18; P = .03). However, in multivariable competing-risks regression models, no statistically significant differences in survival were recorded between males and females (HR: 1.07; P = .4).

CONCLUSIONS

Females are more likely to have more advanced pathologic T stage and higher tumor grade at NU than males. After accounting for OCM, stage, grade, and noncancer characteristics, gender no longer affects CSM.

EUROCARE-4. Survival of cancer patients diagnosed in 1995-1999. Results and commentary

EUROCARE-4 analysed about three million adult cancer cases from 82 cancer registries in 23 European countries, diagnosed in 1995-1999 and followed to December 2003. For each cancer site, the mean European area-weighted observed and relative survival at 1-, 3-, and 5-years by age and sex are presented. Country-specific 1- and 5-year relative survival is also shown, together with 5-year relative survival conditional to surviving 1-year. Within-country variation in survival is analysed for selected cancers. Survival for most solid cancers, whose prognosis depends largely on stage at diagnosis (breast, colorectum, stomach, skin melanoma), was highest in Finland, Sweden, Norway and Iceland, lower in the UK and Denmark, and lowest in the Czech Republic, Poland and Slovenia. France, Switzerland and Italy generally had high survival, slightly below that in the northern countries. There were between-region differences in the survival for haematologic malignancies, possibly due to differences in the availability of effective treatments. Survival of elderly patients was low probably due to advanced stage at diagnosis, comorbidities, difficult access or lack of availability of appropriate care. For all cancers, 5-year survival conditional to surviving 1-year was higher and varied less with region, than the overall relative survival.