EUROCARE-3: survival of cancer patients diagnosed 1990-94--results and commentary

Adjuvant platinum-based chemotherapy for early stage cervical cancer

BACKGROUND

This is an updated version of the original Cochrane review published in The Cochrane Library 2009, Issue 3. Most women with early cervical cancer (stages I to IIA) are cured with surgery or radiotherapy, or both. We performed this review originally because it was unclear whether cisplatin-based chemotherapy after surgery, radiotherapy or both, in women with early stage disease with risk factors for recurrence, was associated with additional survival benefits or risks.

OBJECTIVES

To evaluate the effectiveness and safety of platinum-based chemotherapy after radical hysterectomy, radiotherapy, or both in the treatment of early stage cervical cancer.

SEARCH METHODS

For the original 2009 review, we searched the Cochrane Gynaecological Cancer Group Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2009, Issue 1), MEDLINE, EMBASE, LILACS, BIOLOGICAL ABSTRACTS and CancerLit, the National Research Register and Clinical Trials register, with no language restriction. We handsearched abstracts of scientific meetings and other relevant publications. We extended the database searches to November 2011 for this update.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy (after radical surgery, radiotherapy or both) with no adjuvant chemotherapy, in women with early stage cervical cancer (stage IA2-IIA) with at least one risk factor for recurrence.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. Meta-analysis was performed using a random-effects model, with death and disease progression as outcomes.

MAIN RESULTS

For this updated version, we identified three additional ongoing trials but no new studies for inclusion. Three trials including 368 evaluable women with early cervical cancer were included in the meta-analyses. The median follow-up period in these trials ranged from 29 to 42 months. All women had undergone surgery first. Two trials compared chemotherapy combined with radiotherapy to radiotherapy alone; and one trial compared chemotherapy followed by radiotherapy to radiotherapy alone. It was not possible to perform subgroup analyses by stage or tumour size.Compared with adjuvant radiotherapy, chemotherapy combined with radiotherapy significantly reduced the risk of death (two trials, 297 women; hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.36 to 0.87) and disease progression (two trials, 297 women; HR = 0.47, 95% CI 0.30 to 0.74), with no heterogeneity between trials (I² = 0% for both meta-analyses). Acute grade 4 toxicity occurred significantly more frequently in the chemotherapy plus radiotherapy group than in the radiotherapy group (risk ratio (RR) 5.66, 95% CI 2.14 to 14.98). We considered this evidence to be of a moderate quality due to small numbers and limited follow-up in the included studies. In addition, it was not possible to separate data for bulky early stage disease.In the one small trial that compared adjuvant chemotherapy followed by radiotherapy with adjuvant radiotherapy alone there was no significant difference in disease recurrence between the groups (HR = 1.34; 95% CI 0.24 to 7.66) and OS was not reported. We considered this evidence to be of a low quality.No trials compared adjuvant platinum-based chemotherapy with no adjuvant chemotherapy after surgery for early cervical cancer with risk factors for recurrence.

AUTHORS' CONCLUSIONS

The addition of platinum-based chemotherapy to adjuvant radiotherapy (chemoradiation) may improve survival in women with early stage cervical cancer (IA2-IIA) and risk factors for recurrence. Adjuvant chemoradiation is associated with an increased risk of severe acute toxicity, although it is not clear whether this toxicity is significant in the long-term due to a lack of long-term data. This evidence is limited by the small numbers and poor methodological quality of included studies. We await the results of three ongoing trials, that are likely to have an important impact on our confidence in this evidence.

Survival from digestive cancer in emerging countries in Asia and Africa

The incidence of digestive cancer, including cancer of the esophagus, stomach, colon, and liver, is analyzed in developing and less developed countries in Africa, Asia, the Caribbean, and Latin America. The analysis is based on cancer registries for observed values, on a recent monograph published at International Agency for Research on Cancer and on the GLOBOCAN 2008 database for estimations. For all tumor sites analyzed, the incidence is lower in these countries than in developed countries of Europe, North America, and Japan. The 5-year relative survival from digestive cancer is also lower. In developing countries, there is room for prevention of cancer burden through lifestyle interventions and through improved early detection of cancer.

Cost-benefit analysis of esophageal cancer endoscopic screening in high-risk areas of China

AIM: To estimate the cost-benefit of endoscopic screening strategies of esophageal cancer (EC) in high-risk areas of China.

METHODS: Markov model-based analyses were conducted to compare the net present values (NPVs) and the benefit-cost ratios (BCRs) of 12 EC endoscopic screening strategies. Strategies varied according to the targeted screening age, screening frequencies, and follow-up intervals. Model parameters were collected from population-based studies in China, published literatures, and surveillance data.

RESULTS: Compared with non-screening outcomes, all strategies with hypothetical 100 000 subjects saved life years. Among five dominant strategies determined by the incremental cost-effectiveness analysis, screening once at age 50 years incurred the lowest NPV (international dollar-I$55 million) and BCR (2.52). Screening six times between 40-70 years at a 5-year interval [i.e., six times(40)f-strategy] yielded the highest NPV (I$99 million) and BCR (3.06). Compared with six times(40)f-strategy, screening thrice between 40-70 years at a 10-year interval resulted in relatively lower NPV, but the same BCR.

CONCLUSION: EC endoscopic screening is cost-beneficial in high-risk areas of China. Policy-makers should consider the cost-benefit, population acceptance, and local economic status when choosing suitable screening strategies.

[Laryngeal carcinoma: epidemiology, risk factors and survival]

Laryngeal cancer is one of the most frequent types of head and neck cancer. The incidence is decreasing for men but still increasing for women. The incidence in Germany is about 5-7/100,000 persons/year for men and 0.6-0.8/100,000 persons/year for women. Due to the increased life expectancy, the average age of patients diagnosed with laryngeal cancer is increasing. Nevertheless, adequately prepared older patients treated by standard protocols can have the same survival and complication rates as younger patients. Tobacco and alcohol are still the primary risk factors responsible for disease in at least 80% of the patients. Despite the many new diagnostic tools, still more than half of the patients are diagnosed at an advanced tumor stage. Survival rates have not improved significantly in the last 10 years in Germany, and the average 5-year overall survival rate is about 60%. However, a decrease in the survival rate, as observed in the USA, cannot be confirmed for Germany.

Radiotherapy and chemoradiation after surgery for early cervical cancer

BACKGROUND

This is an updated version of the original Cochrane review first published in Issue 4, 2009. There is an ongoing debate about the indications for, and value of, adjuvant pelvic radiotherapy after radical surgery in women with early cervical cancer. Certain combinations of pathological risk factors are thought to represent sufficient risk for recurrence, that they justify the use of postoperative pelvic radiotherapy, though this has never been shown to improve overall survival, and use of more than one type of treatment (surgery and radiotherapy) increases the risks of side effects and complications.

OBJECTIVES

To evaluate the effectiveness and safety of adjuvant therapies (radiotherapy, chemotherapy followed by radiotherapy, chemoradiation) after radical hysterectomy for early-stage cervical cancer (FIGO stages IB1, IB2 or IIA).

SEARCH METHODS

For the original review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2008. The Cochrane Gynaecological Cancer Group Trials Register, MEDLINE (January 1950 to November 2008), EMBASE (1950 to November 2008). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. For this update, we extended the database searches to September 2011 and searched the MetaRegister for ongoing trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared adjuvant therapies (radiotherapy, chemotherapy followed by radiotherapy, or chemoradiation) with no radiotherapy or chemoradiation, in women with a confirmed histological diagnosis of early cervical cancer who had undergone radical hysterectomy and dissection of the pelvic lymph nodes.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Information on grade 3 and 4 adverse events was collected from the trials. Results were pooled using random-effects meta-analyses.

MAIN RESULTS

Two RCTs, which compared adjuvant radiotherapy with no adjuvant radiotherapy, met the inclusion criteria; they randomised and assessed 397 women with stage IB cervical cancer. Meta-analysis of these two RCTs indicated no significant difference in survival at 5 years between women who received radiation and those who received no further treatment (risk ratio (RR) = 0.8; 95% confidence interval (CI) 0.3 to 2.4). However, women who received radiation had a significantly lower risk of disease progression at 5 years (RR 0.6; 95% CI 0.4 to 0.9).Although the risk of serious adverse events was consistently higher if women received radiotherapy rather than no further treatment, these increased risks were not statistically significant, probably because the rate of adverse events was low.

AUTHORS' CONCLUSIONS

We found evidence, of moderate quality, that radiation decreases the risk of disease progression compared with no further treatment, but little evidence that it might improve overall survival, in stage IB cervical cancer. The evidence on serious adverse events was equivocal.

Limited prognostic value of tissue protein expression levels of cyclin E in Danish ovarian cancer patients: from the Danish 'MALOVA' ovarian cancer study

The primary objective of this study was to assess the expression of cyclin E in tumour tissues from 661 patients with epithelial ovarian tumours. The second was to evaluate whether cyclin E tissue expression levels correlate with clinico-pathological parameters and prognosis of the disease. Using tissue arrays (TA), we analysed the cyclin E expression levels in tissues from 168 women with borderline ovarian tumours (BOT) (147 stage I, 4 stage II, 17 stage III) and 493 Ovarian cancer (OC) patients (127 stage I, 45 stage II, 276 stage III, 45 stage IV). Using a 10% cut-off level for cyclin E overexpression, 20% of the BOTs were positive with a higher proportion of serous than mucinous tumours. Sixty-two per cent of the OCs were positive for cyclin E expression with the highest percentage found in clear cell carcinomas. Results based on univariate and multivariate survival analyses with a 10% cut-off value showed that cyclin E had no independent prognostic value. In conclusion, we found cyclin E expression in tumour tissue to be of limited prognostic value to Danish OC patients.

Impact of FDG-PET and -PET/CT imaging in the clinical decision-making of ovarian carcinoma: an evidence-based approach

The most definitive role of fluorodeoxyglucose (FDG)-PET/computed tomography (CT) at present is surveillance and detecting recurrence in patients who have completed primary therapy but demonstrate a rising serum tumor marker (e.g., CA-125 levels). In this scenario, PET/CT demonstrates high sensitivity and accuracy in detecting lesions that are otherwise challenging, and appears superior (with less interobserver variability) compared with CT alone. Despite the fact that peritoneal deposits may be missed by PET/CT, the overall performance is better than CT alone. FDG-PET does not play a significant additional role in the primary diagnosis of ovarian cancers; however, the role of combined PET/CT modality has recently begun to be re-explored for initial disease staging, particularly because PET/CT can pick up small unsuspected lesions and thereby provide a better disease assessment of the whole body in a single examination. The baseline PET/CT also subserves an important role for future monitoring of therapy response. Therapy monitoring by PET could help to optimize neoadjuvant therapy protocols and to avoid ineffective therapy in nonresponders early in its course, although PET/CT has cost-effectiveness issues that need further evaluation. The prognostic value of FDG-PET/CT has been investigated in the following areas: in the preoperative setting to predict optimal cytoreduction; to assess the value of a positive FDG-PET following primary surgery; and when employed as a replacement for second-look laparotomy following completion of primary surgery and chemotherapy. The data, although promising, are still sparse in all the three domains for a definite recommendation.

Expression, prognostic and predictive impact of VEGF and bFGF in non-small cell lung cancer

Despite major advances in cancer therapeutics, the prognosis for lung cancer patients is still poor and the median survival for patients presenting with advanced non-small cell lung cancer (NSCLC) is only 8-10 months. Angiogenesis is an important biological process and a relatively early event during lung cancer pathogenesis. Anti-angiogenic agents are used in treating patients with NSCLC, and their molecular biomarkers are also being assessed to predict response. A better understanding of the biology of angiogenesis in NSCLC may reveal new targets for treating this malignancy. In this article, we review the expression and prognostic impact of the angiogenic growth factors, vascular endothelial growth factor and basic fibroblast growth factor, in NSCLC.

Survival for colon and rectal cancer in Estonia: role of staging and treatment

BACKGROUND

International comparisons have indicated low colorectal cancer (CRC) survival in Estonia, compared to other European countries. The objective of this paper is to analyse long-term survival as well as staging and treatment patterns of CRC in Estonia.

MATERIAL AND METHODS

The analysis included all incident cases of CRC diagnosed in Estonia in 1997 (n = 546), identified through the Estonian Cancer Registry and followed up for 10 years after diagnosis. Staging and treatment data were retrospectively collected from medical records. Relative survival rate (RSR) was used to estimate the outcome.

RESULTS AND CONCLUSION

The 5-year RSR was 51% for colon cancer and 38% for rectal cancer; the corresponding 10-year RSR was 50% and 39%. We observed no excess mortality for early disease. For stages II and III, the survival was markedly higher in colon cancer (5-year RSR 79% and 66%, respectively) compared to rectal cancer (66% and 30%, respectively). Around 30% of cases were diagnosed with distant disease. Among radically operated colon and rectal cancer patients, the 10-year RSR was 90% and 70%, respectively. Most patients with available pathological information had one to four lymph nodes examined. Survival has notably improved for colon cancer, but not for rectal cancer in Estonia. High proportion of cases with distant metastasis at first diagnosis along with inadequate staging and low proportion of patients treated with curatively intended surgery and appropriate chemotherapy and radiotherapy may have contributed to this outcome. Progress could be achieved by earlier diagnosis and implementing higher standards for staging and treatment. These conclusions are likely to be relevant also for other Eastern European countries.

Adjuvant (post-surgery) chemotherapy for early stage epithelial ovarian cancer

BACKGROUND

Epithelial ovarian cancer is diagnosed in 4500 women in the UK each year of whom 1700 will ultimately die of their disease.Of all cases 10% to 15% are diagnosed early when there is still a good possibility of cure. The treatment of early stage disease involves surgery to remove disease often followed by chemotherapy. The largest clinical trials of this adjuvant therapy show an overall survival (OS) advantage with adjuvant platinum-based chemotherapy but the precise role of this treatment in subgroups of women with differing prognoses needs to be defined.

OBJECTIVES

To systematically review the evidence for adjuvant chemotherapy in early stage epithelial ovarian cancer to determine firstly whether there is a survival advantage of this treatment over the policy of observation following surgery with chemotherapy reserved for treatment of disease recurrence, and secondly to determine if clinical subgroups of differing prognosis based on histological sub-type, or completeness of surgical staging, have more or less to gain from chemotherapy following initial surgery.

SEARCH METHODS

We performed an electronic search using the Cochrane Gynaecological Cancer Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL 2011, Issue 3), MEDLINE (1948 to Aug week 5, 2011) and EMBASE (1980 to week 36, 2011). We developed the search strategy using free-text and medical subject headings (MESH).

SELECTION CRITERIA

We selected randomised clinical trials that met the inclusion criteria set out based on the populations, interventions, comparisons and outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. Disagreements were resolved by discussion with a third review author. We performed random-effects meta-analyses and subgroup analyses.

MAIN RESULTS

Five randomised controlled trials (RCTs), enrolling 1277 women, with a median follow-up of 46 to 121 months, met the inclusion criteria. Four trials were included in the meta-analyses and we considered them to be at a low risk of bias. Meta-analysis of five-year data from three trials indicated that women who received adjuvant platinum-based chemotherapy had better overall survival (OS) than those who did not (1008 women; hazard ratio (HR) 0.71; 95% confidence interval (CI) 0.53 to 0.93). Likewise, meta-analysis of five-year data from four trials indicated that women who received adjuvant chemotherapy had better progression-free survival (PFS) than those who did not (1170 women; HR 0.67; 95% CI 0.53 to 0.84). The trials included in these meta-analyses gave consistent estimates of the effects of chemotherapy. In addition, these findings were robust over time (10-year PFS: two trials, 925 women; HR 0.67; 95% CI 0.54 to 0.84).Subgroup analysis suggested that women who had optimal surgical staging of their disease were unlikely to benefit from adjuvant chemotherapy (HR for OS 1.22; 95% CI 0.63 to 2.37; two trials, 234 women) whereas those who had sub-optimal staging did (HR for OS 0.63; 95% CI 0.46 to 0.85; two trials, 772 women). One trial showed a benefit from adjuvant chemotherapy among women at high risk (HR for OS 0.48; 95% CI 0.32 to 0.72) but not among those at low/medium risk (HR for OS 0.95; 95% CI 0.54 to 1.66). However, these subgroup findings could be due to chance and should be interpreted with caution.

AUTHORS' CONCLUSIONS

Adjuvant platinum-based chemotherapy is effective in prolonging the survival of the majority of patients who are assessed as having early (FIGO stage I/IIa) epithelial ovarian cancer. However, it may be withheld from women in whom there is well-differentiated encapsulated unilateral disease (stage 1a grade 1) or those with comprehensively staged Ib, well or moderately differentiated (grade 1/2) disease. Others with unstaged early disease or those with poorly differentiated tumours should be offered chemotherapy. A pragmatic approach may be necessary in clinical settings where optimal staging is not normally performed/achieved. In such settings, adjuvant chemotherapy may be withheld from those with encapsulated stage Ia grade 1 serous and endometrioid carcinoma and offered to all others with early stage disease.

Second primary lung cancer after head and neck squamous cell cancer: population-based study of risk factors

BACKGROUND

Patients with head and neck squamous cell cancer (HNSCC) are at risk of developing second primary lung cancer (SPLC).

METHODS

Among 61,883 patients with HNSCC from the Surveillance, Epidemiology and End Results (SEER) database, 4522 developed SPLC (any histology) ≥2 months after HNSCC. We correlated risk with demographic and tumor-related parameters.

RESULTS

The risk of SPLC after HNSCC was 5.8%, 11.4%, and 16.4% at 5, 10, and 15 years, respectively. From Cox regression, significantly adverse (p < .0001) risk factors for SPLC included: regional versus localized HNSCC stage (hazard ratio [HR] = 1.16), hypopharyngeal or supraglottic laryngeal site (HR = 1.57), increased age (HR = 1.26/decade), black race (HR = 1.27), and male sex (HR = 1.26). Glottic (HR = 0.75) and tonsillar or oral cavity sites (HR = 0.80) were associated with significantly (p < .0001) lower risks of SPLC.

CONCLUSION

From population-based actuarial analyses, HNSCCs with more aggressive clinicopathologic features were more apt to develop SPLC, suggestive of similar environmental and/or host factors for these cancers.

Temporal changes in magnetic resonance imaging characteristics of Gliadel wafers and of the adjacent brain parenchyma

Carmustine is used in the treatment of glioblastomas as locally applied chemotherapy in the form of biodegradable wafers, which are lined on the walls of the resection cavity at the end of the resection, to increase local concentrations and decrease systemic toxicity. A total of 44 patients with glioblastoma with gross macroscopic tumor removal were included. MRIs were performed at various times postoperatively (within 24 hours, 1 week, 1 month, 2 months, 3 months, 6 months, 9 months, and 1 year). MR protocols included a T2-, diffusion-weighted, and T1-weighted sequences with and without intravenous administration of gadolinium. On T1, the wafers change from their initial hypointense to an isointense appearance after a period during which they appear to be hypointense, with a hyperintense rim most prominent less than 1 month postoperatively. On T2 they change from a hypointense to an isointense appearance. Restricted diffusivity reshaping the silhouette of the wafer's surface at the rim of the resection cavity can be found as early as day 1 postoperatively; however, 1 month after implantation, they all show areas of restricted diffusion, which may remain up to 1 year. Contrast enhancement at the rim of the resection cavity can already be found at day 1 postoperatively, with a peak shortly after 1 month after surgery. These changes can easily be mistaken for an abscess and hamper the early differentiation between residual tumor tissue and normal postoperative changes. However, early changes in either appearance do not predict overall survival or the progression free interval.

Comparing diagnostic delay in cancer: a cross-sectional study in three European countries with primary care-led health care systems

BACKGROUND

The principal aim of this study was to determine the feasibility of a large-scale comparative study, between the UK, the Netherlands and Sweden, to investigate whether delays in the diagnostic pathway of cancer might explain differences in cancer survival between countries.

METHODS

Following a planning meeting to agree the format of a data collection instrument, data on delays in the cancer diagnostic pathway were abstracted from primary care-held medical records. Data were collected on 50 cases each (total of 150) from practices in each of Grampian, Northeast Scotland; Maastricht, the Netherlands and Skane, Sweden. Data were entered into SPSS 18.0 for analysis.

RESULTS

Data on delays in the cancer diagnostic pathway were readily available from primary care-held case records. However, data on demographic variables, cancer stage at diagnosis and treatment were less well recorded. There was no significant difference between countries in the way in which cases were referred from primary to secondary care. There was no significant difference between countries in the time delay between a patient presenting in primary care and being referred to secondary care. Median delay between referral and first appointment in secondary care [19 (8.0-47.5) days] was significantly longer in Scotland that in Sweden [1.0 (0-31.5) days] and the Netherlands [5.5 (0-31.5) days] (P < 0.001). Secondary care delay (between first appointment in secondary care and diagnosis) in Scotland [22.5 (0-39.5) days] was also significantly longer than in Sweden [14.0 (4.5-31.5) days] and the Netherlands [3.5 (0-16.5) days] (P = 0.003). Finally, overall delay in Scotland [53.5 (30.3-96.3) days] was also significantly longer than in Sweden [32.0 (14.0-71.0) days] and the Netherlands [22.0 (7.0-60.3) days] (P = 0.003).

CONCLUSIONS

A large-scale study comparing cancer delays in European countries and based on primary care-held records is feasible but would require supplementary sources of data in order to maximize information on demographic variables, the cancer stage at diagnosis and treatment details. Such a large-scale study is timely and desirable since our findings suggest systematic differences in the way cancer is managed in the three countries.

A comparison between clinical decisions made about lung cancer patients and those inherent in the corresponding Scottish Intercollegiate Guidelines Network (SIGN) guideline

Treatment and survival for patients with lung cancer vary between and within countries. We have undertaken a multifaceted study of a clinical dataset of 635 patients, to see if clinician treatment decisions were being made consistently and in accordance with the appropriate Scottish Intercollegiate Guidelines Network (SIGN) document. Subsequently, we created a dataset of 117 patients who should have undergone surgery according to the SIGN guideline. As analyses of this dataset did not provide clear distinctions between the main treatment groups, a clinician reviewed the case notes and dataset, checking for inconsistencies. The revised dataset was processed by a decision tree algorithm which suggests clinically plausible decisions. Further, statistical analyses compared the 54 patients offered surgery with the 52 who were not. These analyses suggest that there are significant differences: the most discriminating feature is significant co-morbidity (p < 0.001). The article concludes with suggestions for how future guidelines might be enhanced.

Burden of testicular, paratesticular and extragonadal germ cell tumours in Europe

We provide updated estimates of survival, incidence, complete prevalence, and proportion cured for patients with testicular/paratesticular and extragonadal germ cell cancers in Europe, grouped according to the new list of cancer types developed by RARECARE. We collected data, archived in European cancer registries, with vital status information available to 31st December 2003. We analysed 26,000 cases of testicular, paratesticular and extragonadal germ cell cancers diagnosed 1995-2002, estimating that about 15,600 new testicular/paratesticular and 630 new extragonadal cancer cases occurred per year in EU27, with annual incidence rates of 31.5/1,000,000 and 1.27/1,000,000, respectively. Slightly more than 436,000 persons were alive at the beginning of 2008 with a diagnosis of testicular/paratesticular cancer, and about 17,000 with a diagnosis of extragonadal germ cell cancer. Five-year relative survival was 96% for testicular/paratesticular cancer and 71% for extragonadal germ cell cancer; the proportions cured were 95% and 69%, respectively. We found limited variation in survival between European regions except for non-seminomatous testicular cancer, for which five-year relative survival ranged from 86% in Eastern Europe to 96% in Northern Europe. Survival for all cancer types considered decreased with increasing age at diagnosis. Further investigation is required to establish the real reasons for the lower survival in Eastern Europe. Considering the high prevalence of these highly curable cancers, it is important to monitor patients long-term, so as to quantify treatment-related risks and develop treatments having limited impact on quality of life.

Immunohistochemical evaluation of p53, FHIT, and IGF2 gene expression in esophageal cancer

The aim of the study was to evaluate the expression of tumor suppressor genes p53, fragile histidine triad gene (FHIT), and an oncogene insulin-like growth factor 2 (IGF2) as prognostic markers in the etiology of esophageal cancer. Immunohistochemistry (IHC) was performed in 39 archival tissue samples of different esophageal pathologies for the three genes. Abnormal p53 expression was maximum in all the cases of squamous cell carcinoma, while IGF2 expression was enhanced in squamous cell carcinoma (81%), adenocarcinoma (100%), and dysplasia of squamous epithelium (75%) samples when compared with normals (50%). To our surprise, 75% of normal tissues did not show FHIT expression, which was also not seen in 40% of dysplasias of squamous epithelium, 33.3% of adenocarcinoma, and 41% of squamous cell carcinoma. To the best of our knowledge, this is the first study evaluating IGF2 by IHC, as well as, correlating it with the expression of the two tumor suppressor genes, p53 and FHIT, in esophageal tissue. p53 expression was threefold higher than normal in dysplasias of squamous epithelium and adenocarcinoma, while it was eightfold higher in squamous cell carcinoma. IGF2 expression was low in normal and dysplasia tissue but was increased 1.97-fold in both types of malignancy. FHIT and p53 expression were well correlated in squamous cell carcinoma, supporting the observation that FHIT regulates and stabilizes p53. Altered/lowered FHIT levels may be a result of exposure to various exogenous agents; however, this could not be assessed in the present study as it was carried out on archival samples. A larger prospective study is warranted to establish the role of exogenous factors in FHIT expression.

Is the Two-Week Wait Path Way Appropriate for Thyroid Cancer Referrals?

Thyroid cancer is the most common endocrine malignancy but remains relatively uncommon, representing 0.5% of all newly diagnosed cancers in the UK. Differentiated thyroid cancer is the most commonly diagnosed type in the UK and, if treated in an appropriate and timely fashion, is associated with outcomes of over 90% 10-year survival. However, evidence suggests that the outcomes in thyroid and other cancers in the UK lag behind our European and American counterparts. To address these deficiencies the Department of Health set out the NHS Plan. Within this document, there was a commitment to see all new suspected cancer referrals within a new 'two-week wait' (2WW) pathway from primary care to specialist review.

Predicting survival in women with breast cancer and brain metastasis: a nomogram outperforms current survival prediction models

BACKGROUND

Brain metastases (BMs) are a common occurrence in patients with breast cancer, and accurately predicting survival in these patients is critical to appropriate management. A survival nomogram for breast cancer patients with BM was constructed, and its performance is compared to current predictive models of survival.

METHODS

A Cox proportional hazards regression with a nomogram representation was used to model survival in a population of 261 women with breast cancer and BMs treated from 1999 to 2008. The model was validated internally by 10-fold cross-validation and bootstrapping, and concordance (c) indices were calculated. The predictive performance of the nomogram described here is compared to current prognostic models, including recursive partitioning analysis, graded prognostic assessment, and diagnosis-specific graded prognostic assessment.

RESULTS

The c-index for the model described here was 0.67. It outperformed recursive partitioning analysis, graded prognostic assessment, and diagnosis-specific graded prognostic assessment, based on c-index comparisons.

CONCLUSIONS

The nomogram described here outperformed current strategies for survival prediction in breast cancer patients with BMs. Two additional advantages of this nomogram are its ability to predict individualized, 1-, 3-, and 5-year survival for novel patients and its straightforward representations of the relative effects of each of 9 covariates on neurologic survival. This represents a potentially valuable alternative to current models of survival prediction in this patient population.

Interventions for reducing anxiety in women undergoing colposcopy

BACKGROUND

Prior to the development of cervical cancer abnormal cervical cells can be detected on a cervical smear. The usual practice following an abnormal cervical smear is to perform colposcopy. Colposcopy is the visualisation of the cervix using a binocular microscope. Women experience high levels of anxiety and negative emotional responses at all stages of cervical screening. High levels of anxiety before and during colposcopy can have adverse consequences, including pain and discomfort during the procedure and high loss to follow-up rates. This review evaluates interventions designed to reduce anxiety levels during colposcopic examination.

OBJECTIVES

To compare the efficacy of various interventions aimed at reducing anxiety during colposcopic examination in women.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 3, 2010, MEDLINE and EMBASE up to July 2010. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to reduce anxiety during colposcopic examination.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Mean differences for anxiety levels, knowledge scores, pain, patient satisfaction and psychosexual dysfunction in women who underwent colposcopy were pooled in a random effects meta-analyses.

MAIN RESULTS

We found six trials that met our inclusion criteria. These trials assessed the effectiveness of different interventions for reducing anxiety in women undergoing colposcopy for the first time.All comparisons were restricted to single trial analyses or meta analysis of just two trials. There was evidence from a reasonably large trial (n = 220) that was at low risk of bias to suggest that music during colposcopy significantly reduced anxiety levels (MD = -4.80, 95% CI: -7.86 to -1.74) and pain experienced during the procedure (MD = -1.71, 95% CI: -2.37 to -1.05) compared to not listening to music. There was no statistically significant difference between anxiety levels prior to colposcopy in women receiving information leaflets versus no leaflets and information leaflets, video and counselling versus information leaflets and video with no counselling. However, knowledge scores were significantly higher and psychosexual dysfunction scores were significantly lower in women who received leaflets compared to those who did not so there was some sort of benefit to giving patients information leaflets. There is evidence for video colposcopy from a quasi randomised trial which assessed 81 women showing significant anxiety reduction.

AUTHORS' CONCLUSIONS

Anxiety appears to be reduced by playing music during colposcopy. Although information leaflets did not reduce anxiety levels, they did increase knowledge levels and are therefore useful in obtaining clinical consent to the colposcopic procedure. Leaflets also contributed to improved patient quality of life by reducing psychosexual dysfunction.

Medical treatment choices for patients affected by advanced NSCLC in routine clinical practice: results from the Italian observational "SUN" (Survey on the lUng cancer maNagement) study

Lung cancer is the most common cancer in the world today, in terms of both incidence and mortality. Non-small cell lung cancer (NSCLC) accounts for about 85% of all lung cancers, and the majority of people diagnosed with NSCLC have locally advanced or metastatic disease. Treatment algorithms have rapidly changed in the last 10 years because of the introduction of new chemotherapeutic and targeted agents in clinical practice. SUN is a 1-year longitudinal observational multicenter study that has consecutively enrolled patients affected by stage IIIB or IV NSCLC with the aim to describe the pattern of care and evolving approaches in the treatment of advanced NSCLC. 987 consecutive NSCLC patients were enrolled between January 2007 and March 2008 at the 74 participating centers throughout Italy and a 12-month follow-up was performed. Cyto-histological diagnosis was performed mainly by broncoscopy with only 24% by CT-scan guided fine-needle aspiration biopsy. 91.4% of the patients received a first-line medical treatment and 8.6% supportive care only. Median age of patients receiving first-line treatment was 66 years. First-line chemotherapy consisted of a single agent in 20% of patients and combination chemotherapy in 80%. The most frequently used chemotherapy regimens were cisplatin plus gemcitabine and carboplatin plus gemcitabine. Median survival of patients receiving first-line chemotherapy was 9.1 months. 32% percent of patients received a second-line treatment that consisted of chemotherapy in 71% of cases and erlotinib in 29%. Overall third-line treatment was given to 7.3% of patients. These results showed a pattern of care for advanced NSCLC that reflects the current clinical practice in Italy at the study time with a high adherence to the International guidelines by the Italian Oncologists.

[The surgical treatment of adenocarcinoma of the gastroesophageal junction: Moroccan experience through a series of 149 cases]

Introduction

L'incidence du cancer de la Jonction oesogastrique (JOG) ne cesse d'augmenter depuis les deux dernières décades aussi bien dans les pays industrialisés que dans les pays en voie de développement notamment le Maroc. Le rapprochement sur le plan étiopathogénique des adénocarcinomes (ADK) du cardia et ceux du bas oesophage reste un sujet de controverse posant le problème du choix thérapeutique chirurgical, notamment l’étendu de la résection. Le but de ce travail est de dresser le profil épidémiologique des patients opérés pour un ADK du cardia et analyser les gestes chirurgicaux réalisés par l’équipe chirurgicale A du centre hospitalier universitaire IBN SINA à Rabat à travers une série de 149 cas.

Méthodes:

Il s'agit d'une étude rétrospective ayant intéressé les malades opérés pour un ADK de la JOG sur une période de 15 années (1990-2004) en chirurgie A du CHU IBN SINA à Rabat.

Résultats

149 cas d'ADK de la JOG ont été retenus. L'âge moyen était de 55 ans, 76% étaient de sexe masculin avec un sex-ratio de 3/1. Les signes cliniques les plus fréquemment observés sont la dysphagie (70%), les douleurs épigastriques (67%) et le reflux gastro-oesophagien (15.5%). La notion de tabagisme n’a été rapportée que chez 20% des cas et l'oesophage de barret chez 10% des patients. Le type I de Siewert a concerné 65 cas (43.5%), le type II 40 cas (27 %), et le type III 44 cas (29.5%). Dans le type I une oesophagectomie transhiatale a été proposée, alors que les type II et III ont été traité comme un cancer de l'estomac par une gastrectomie totale. Les suites opératoires étaient simples chez 80 % des patients, la mortalité globale était de 8.5%.

Conclusion

L’oesophagectomie par voie transhiatale chez les patients fragiles avec un ADK de la JOG de type I permet des résultats carcinologiques satisfaisants avec réduction de la morbidité postopératoire par rapport à la voie transthoracique. La gastrectomie totale est le traitement de choix pour les types III, alors que le débat est toujours ouvert quant à la meilleure stratégie chirurgicale pour la prise en charge des tumeurs de type II.

An indirect comparison of the efficacy of bevacizumab plus carboplatin and paclitaxel versus pemetrexed with cisplatin in patients with advanced or recurrent non-squamous adenocarcinoma non-small cell lung cancer

OBJECTIVE

There are two new treatment options available for the treatment of adenocarcinoma histology non-small cell lung cancer (NSCLC) which offer improved benefit in terms of progression-free (PFS) and overall survival (OS) over chemotherapy. Both bevacizumab and pemetrexed when combined with chemotherapy significantly increase PFS and OS in patients with advanced NSCLC versus chemotherapy alone. The aim of this analysis was to compare the efficacy for patients with non-squamous adenocarcinoma NSCLC treated with bevacizumab, carboplatin and paclitaxel (BCP) to pemetrexed and cisplatin (PC) by using indirect comparison (ITC) methodology.

EXPERIMENTAL DESIGN

In the absence of head-to-head trials, ITC was performed on patients with adenocarcinoma histology non-squamous NSCLC to compare the relative benefit of first-line therapies BCP vs. PC by hazard ratios (HR). Subsequently, these HRs were used in a decision-analytic Markov model with a lifelong time horizon to extrapolate the long-term effectiveness of the two treatments.

RESULTS

ITC estimated HRs for the primary endpoints in the bevacizumab study E4599 showed that BCP treatment in non-squamous adenocarcinoma NSCLC patients resulted in a BCP HR of 0.82 versus PC. The long-term predictions from the Markov model yielded a mean survival of 1.48 years (95% CI 1.34, 1.62 years) (or 17.7 months) for BCP compared with 1.29 years (95% CI 1.16, 1.42 years) (or 15.4 months) for PC.

CONCLUSIONS

Based on our decision analysis, triplet BCP targeted therapy in patients with advanced non-squamous adenocarcinoma NSCLC compared with doublet PC chemotherapy results in improved expected values for overall long-term survival. Therefore, from the efficacy perspective, bevacizumab in combination with platinum-based chemotherapy can be considered as the targeted therapy of choice for patients with advanced non-squamous adenocarcinoma NSCLC.

Thymidylate synthase inhibitors for non-small cell lung cancer

INTRODUCTION

The folate-dependent enzyme thymidylate synthase (TS) plays a pivotal role in DNA replication/repair and cancer cell proliferation, and represents a valid target for the treatment of several tumor types, including NSCLC. NSCLC is the leading cause of cancer-related mortality, and several TS inhibitors have gone into preclinical and clinical testing, with pemetrexed emerging for its approval and widespread use as first-/second-line and maintenance therapy for this disease.

AREAS COVERED

This review summarizes the therapeutic options in NSCLC, as well as the background and rationale for targeting TS. The authors also review recent pharmacogenetic studies and data from clinical trials evaluating novel TS inhibitors, hoping that the reader will gain a comprehensive overview of the field of TS inhibition, specifically relating to drugs used or being developed for lung cancer patients.

EXPERT OPINION

TS is a validated target in NSCLC. However, benefits from conventional chemotherapy in NSCLC have plateaued, and more cost-effective results should be obtained with individualized treatment. Accordingly, the clinical success for TS inhibitors may depend on our ability to correctly administer these agents following biomarker-driven patient selection, including TS genotype and expression, and using the right combination therapy.

Women's knowledge about cervical cancer risk factors, screening, and reasons for non-participation in cervical cancer screening programme in Estonia

Background

The attendance rate in Estonian cervical cancer screening programme is too low therefore the programme is hardly effective. A cross-sectional population based survey was performed to identify awareness of cervical cancer risk factors, reasons why women do not want to participate in cervical screening programme and wishes for better organisation of the programme.

Method

An anonymous questionnaire with a covering letter and a prepaid envelope was sent together with the screening invitation to 2942 randomly selected women. Results are based on the analysis of 1054 (36%) returned questionnaires.

Results

Main reasons for non-participation in the national screening programme were a recent visit to a gynaecologist (42.3%), fear to give a Pap-smear (14.3%), long appointment queues (12.9%) and unsuitable reception hours (11.8%). Fear to give a Pap-smear was higher among women aged 30 and 35 than 50 and 55 (RR 1.46; 95% CI: 0.82-2.59) and women with one or no deliveries (RR 1.56, 95% CI: 0.94-2.58). In general, awareness of cervical cancer risk factors is poor and it does not depend on socio-demographic factors. Awareness of screening was higher among Estonians than Russians (RR 1.64, 95% CI: 1.46-1.86). Most women prefer to receive information about screening from personally mailed invitation letters (74.8%).

Conclusions

Women need more information about cervical cancer risk factors and the screening programme. They prefer personally addressed information sharing. Minority groups should be addressed in their own language. A better collaboration with service providers and discouraging smears outside the programme are also required.

Does radioiodine therapy in patients with differentiated thyroid cancer increase the frequency of another malignant neoplasm?

Objectives. To compare the frequency of another primary malignancy in patients with differentiated thyroid carcinoma (DTC) who received radioiodine therapy or not ((131)I). Material and Methods. 168 cases of DTC patients were retrospectively evaluated as to the frequency of another neoplasia by comparing patients with and without it, taking into account clinical, laboratory, and therapeutic parameters. Results. Another primary malignancy occurred in 8.9% of patients. Of these, 53.3% showed the malignancy before (131)I and 46.7% after it. By comparing both groups, the age at the moment of diagnosis of another neoplasia was 46.1 ± 20.2 years for the group before (131)I therapy and of 69.4 ± 11.4 years for the group after it (P = 0.02). Of the 148 patients treated with (131)I, 4.7% developed another malignancy. The latter were older (61 ± 17 years) than those who did not show another cancer type (44.1 ± 14.2 years) (P < 0.05). Conclusion. The frequency of another neoplasia found after (131)I was similar to that found before (131)I.

Optimal primary surgical treatment for advanced epithelial ovarian cancer

BACKGROUND

Ovarian cancer is the sixth most common cancer among women. In addition to diagnosis and staging, primary surgery is performed to achieve optimal cytoreduction (surgical efforts aimed at removing the bulk of the tumour) as the amount of residual tumour is one of the most important prognostic factors for survival of women with epithelial ovarian cancer. An optimal outcome of cytoreductive surgery remains a subject of controversy to many practising gynae-oncologists. The Gynaecologic Oncology group (GOG) currently defines 'optimal' as having residual tumour nodules each measuring 1 cm or less in maximum diameter, with complete cytoreduction (microscopic disease) being the ideal surgical outcome. Although the size of residual tumour masses after surgery has been shown to be an important prognostic factor for advanced ovarian cancer, it is unclear whether it is the surgical procedure that is directly responsible for the superior outcome that is associated with less residual disease.

OBJECTIVES

To evaluate the effectiveness and safety of optimal primary cytoreductive surgery for women with surgically staged advanced epithelial ovarian cancer (stages III and IV).To assess the impact of various residual tumour sizes, over a range between zero and 2 cm, on overall survival.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3) and the Cochrane Gynaecological Cancer Review Group Trials Register, MEDLINE and EMBASE (up to August 2010). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Retrospective data on residual disease from randomised controlled trials (RCTs) or prospective and retrospective observational studies which included a multivariate analysis of 100 or more adult women with surgically staged advanced epithelial ovarian cancer and who underwent primary cytoreductive surgery followed by adjuvant platinum-based chemotherapy. We only included studies that defined optimal cytoreduction as surgery leading to residual tumours with a maximum diameter of any threshold up to 2 cm.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis.

MAIN RESULTS

There were no RCTs or prospective non-RCTs identified that were designed to evaluate the effectiveness of surgery when performed as a primary procedure in advanced stage ovarian cancer.We found 11 retrospective studies that included a multivariate analysis that met our inclusion criteria. Analyses showed the prognostic importance of complete cytoreduction, where the residual disease was microscopic that is no visible disease, as overall (OS) and progression-free survival (PFS) were significantly prolonged in these groups of women. PFS was not reported in all of the studies but was sufficiently documented to allow firm conclusions to be drawn.When we compared suboptimal (> 1 cm) versus optimal (< 1 cm) cytoreduction the survival estimates were attenuated but remained statistically significant in favour of the lower volume disease group There was no significant difference in OS and only a borderline difference in PFS when residual disease of > 2 cm and < 2 cm were compared (hazard ratio (HR) 1.65, 95% CI 0.82 to 3.31; and HR 1.27, 95% CI 1.00 to 1.61, P = 0.05 for OS and PFS respectively).There was a high risk of bias due to the retrospective nature of these studies where, despite statistical adjustment for important prognostic factors, selection bias was still likely to be of particular concern.Adverse events, quality of life (QoL) and cost-effectiveness were not reported by treatment arm or to a satisfactory level in any of the studies.

AUTHORS' CONCLUSIONS

During primary surgery for advanced stage epithelial ovarian cancer all attempts should be made to achieve complete cytoreduction. When this is not achievable, the surgical goal should be optimal (< 1 cm) residual disease. Due to the high risk of bias in the current evidence, randomised controlled trials should be performed to determine whether it is the surgical intervention or patient-related and disease-related factors that are associated with the improved survival in these groups of women. The findings of this review that women with residual disease < 1 cm still do better than women with residual disease > 1 cm should prompt the surgical community to retain this category and consider re-defining it as 'near optimal' cytoreduction, reserving the term 'suboptimal' cytoreduction to cases where the residual disease is > 1 cm (optimal/near optimal/suboptimal instead of complete/optimal/suboptimal).

Aspects of prophylactic vaccination against cervical cancer and other human papillomavirus-related cancers in developing countries

Cervical cancer and other human papillomavirus- (HPV-) related cancers are preventable, but preventive measures implemented in developing countries and especially in low-income rural regions have not been effective. Cervical cancer burden derived from sexually transmitted HPV infections is the heaviest in developing countries, and a dramatic increase in the number of cervical cancer cases is predicted, if no intervention is implemented in the near future. HPV vaccines offer an efficient way to prevent related cancers. Recently implemented school-based HPV vaccination demonstration programmes can help tackle the challenges linked with vaccine coverage, and access to vaccination and health services, but prevention strategies need to be modified according to regional characteristics. In urban regions WHO-recommended vaccination strategies might be enough to significantly reduce HPV-related disease burden, but in the rural regions additional vaccination strategies, vaccinating both sexes rather than only females when school attendance is the highest and applying a two-dose regime, need to be considered. From the point of view of both public health and ethics identification of the most effective prevention strategies is pivotal, especially when access to health services is limited. Considering cost-effectiveness versus justice further research on optional vaccination strategies is warranted.

5-fluorouracil/leucovorin combined with irinotecan and oxaliplatin (FOLFIRINOX) as second-line chemotherapy in patients with metastatic pancreatic adenocarcinoma

BACKGROUND

To evaluate the efficacy and toxicity of irinotecan and oxaliplatin plus 5-fluorouracil (FU) and leucovorin (FOLFIRINOX) as second-line therapy in metastatic pancreatic adenocarcinoma (MPA).

PATIENTS AND METHODS

We retrospectively analyzed the medical records of 27 patients with MPA treated with FOLFIRINOX as second-line therapy between January 2003 and November 2009 in our hospital. The recommended schedule was oxaliplatin 85 mg/m(2) on day 1 + irinotecan 180 mg/m(2) on day 1 + leucovorin 400 mg/m(2) on day 1 followed by FU 400 mg/m(2) as a bolus on day 1 and 2,400 mg/m(2) as 46-hour continuous infusion biweekly.

RESULTS

The median age of the 27 patients (13 males and 14 females) was 63 years (45-83). All patients had progressive disease after first-line chemotherapy by gemcitabine. A total of 167 cycles were administered, with a median number of 6 cycles (1-29) per patient. One toxic death occurred (sepsis). Tolerance of treatment was acceptable, and the relative dose density delivered per patient was 92.8% for oxaliplatin, 89.1% for irinotecan and 96.4% for FU. Grade 3-4 neutropenia occurred in 55.6% of the patients, including 1 febrile neutropenia. The other toxicities were manageable. Regarding efficacy, 22 of the 27 patients were evaluable (WHO and RECIST criteria). Five patients had partial responses and 12 stable disease, resulting in an overall disease control rate of 63%. Median time to progression was 5.4 months (0.7-25.48), and median event-free survival was 3 months (0.5-24.9). Median overall survival was 8.5 months (0-26). A clinical benefit was reported for 55% of the patients.

CONCLUSIONS

These results confirmed the good safety profile and the efficacy of the FOLFIRINOX regimen as second-line treatment of MPA.

Public health impact of human papillomavirus vaccination on prevention of cervical cancer in France

OBJECTIVE

To evaluate the cervical cancer (CC) reduction at individual and population level following different prevention strategies (age-specific vaccination and/or screening) in France.

METHODS

A lifetime Markov model was constructed with 11 health states covering the progression from human papillomavirus (HPV) infection to the development of precancerous lesions, CC and death. A screening module took into account the effects of detection and early treatment. Cohorts of girls were entered into the model at age 11 years; the model was run for 95 years using one-year cycles.

RESULTS

Vaccination combined with screening substantially reduced the incidence of precancerous lesions and CC compared with screening alone. Vaccination was beneficial regardless of age at vaccination, but the greatest benefit was obtained with an early vaccination. The clinical results were the best for vaccination at 11-13 years when lifetime horizon was considered, and for vaccination at 15-17 years for shorter observation period.

CONCLUSION

The model results indicate that HPV vaccination offers additional protection against CC when combined with screening. The optimum starting age for vaccination varies depending on the observation period duration.

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.

Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

Ovarian cancer is the sixth most common cancer and seventh cause of cancer death in women worldwide. Traditionally, many patients who have been treated for cancer undergo long-term follow up in secondary care. Recently however it has been suggested that the use of routine review may not be effective in improving survival, quality of life (QoL), and relieving anxiety. In addition, it may not be cost effective.

OBJECTIVES

To compare the potential benefits of different strategies of follow up in women with epithelial ovarian cancer following completion of primary treatment.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, Issue 4), MEDLINE and EMBASE (to November 2010). We also searched CINAHL, PsycLIT, registers of clinical trials, abstracts of scientific meetings, reference lists of review articles, and contacted experts in the field.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) that evaluated follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias.

MAIN RESULTS

We found only one RCT (Rustin 2010) that met our inclusion criteria. This trial included 529 women and reported data on immediate treatment versus delayed treatment in women with confirmation of remission and with normal CA125 concentration and no radiological evidence of disease after surgery and first-line chemotherapy.Overall survival showed no significant difference between the immediate and delayed arms after a median follow up of 56.9 months (unadjusted hazard ratio (HR) = 0·98, 95% confidence interval (CI) 0·80 to 1·20; P = 0·85). Time from randomisation to first deterioration in global health score or death was significantly shorter in the early group compared with the delayed group (HR 0·71, 95% CI 0·58 to 0·88; P < 0·01). The trial was at low risk of bias.

AUTHORS' CONCLUSIONS

There is a lack of randomised studies on most aspects of follow-up care after treatment for epithelial ovarian cancers. Limited evidence from a single trial suggests that routine surveillance with CA125 in asymptomatic patients, with treatment at CA125 relapse, does not seem to offer survival advantage when compared to treatment at symptomatic relapse. Randomised controlled trials are needed to compare different types of follow up on the outcomes of survival, quality of Life, cost and psychological effects.

Adjuvant progestagens for endometrial cancer

BACKGROUND

Endometrial cancer is the most common genital tract carcinoma among women in developed countries, with most women presenting with stage 1 disease. Adjuvant progestagen therapy has been advocated following primary surgery to reduce the risk of recurrence of disease.

OBJECTIVES

To evaluate the effectiveness and safety of adjuvant progestagen therapy for the treatment of endometrial cancer.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Specilaised Register, Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2009. MEDLINE and EMBASE up to April 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of progestagen therapy in women who have had surgery for endometrial cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Risk ratios (RRs) comparing survival in women who did and did not receive progestagen were pooled in random effects meta-analyses. .

MAIN RESULTS

Seven trials assessing 4556 women were identified. Three trials included women with stage one disease only, whereas four included women with more advanced disease. Meta-analysis of four trials showed that there was no significant difference in the risk of death at five years between adjuvant progestagen therapy and no further treatment (RR = 1.00, 95% CI 0.85 to 1.18). This conclusion is also robust to single trial analyses at 4 and 7 years and in one trial across all points in time using a hazard ratio (HR). There was also no significant difference between progestagen therapy and control in terms of the risk of death from endometrial cancer, cardiovascular disease and intercurrent disease. Relapse of disease appeared to be reduced by progestagen therapy in one trial (HR = 0.71, 95% CI 0.52 to 0.97 and 5 year RR = 0.74, 95% CI 0.58 to 0.96), but there was no evidence of a difference in disease recurrence in another trial at 7 years (RR = 1.34, 95% CI 0.79 to 2.27).

AUTHORS' CONCLUSIONS

There is no evidence to support the use of adjuvant progestagen therapy in the primary treatment of endometrial cancer.

Weight changes and lifestyle behaviors in women after breast cancer diagnosis: a cross-sectional study

BACKGROUND

Weight gain rather than weight loss often occurs after breast cancer diagnosis despite breast cancer survivors frequently reported making healthful lifestyle changes. This study describes the prevalence and magnitude of changes in weight before and after breast cancer diagnosis and examines lifestyle behaviors of breast cancer survivors with stable weight, weight gain or weight loss.

METHODS

Respondents were 368 women with breast cancer characterized by stages I, II and III. All were recruited from hospitals or breast cancer support groups and had completed conventional treatment. Current weight and height were measured while weight at cancer diagnosis and 1 year before diagnosis were self-reported. Weight change was calculated as the difference between current weight and weight a year preceding breast cancer diagnosis. A 24-hour diet recall and Global Physical Activity Questionnaire assessed dietary intake and physical activity, respectively. Differences in lifestyle behaviors among weight change groups were examined using Analysis of Covariance (ANCOVA).

RESULTS

Mean weight change from a year preceding diagnosis to study entry was 2.73 kg (95% CI: 1.90-3.55). Most women (63.3%) experienced weight gain rather than weight loss (36.7%) with a higher percentage (47.8%) having at least 5% weight gain (47.8%) rather than weight loss (22%), respectively. Compared to other weight change groups, women in >10% weight gain group had the lowest fruit and vegetable servings (1.58 servings/day; 95% CI: 1.36-1.82) and highest servings of dairy products (0.41 servings/day; 95% CI: 0.30-0.52).

CONCLUSIONS

Weight gain was evident in this sample of women after breast cancer diagnosis. Information on magnitude of weight change after breast cancer diagnosis and lifestyle behaviors of breast cancer survivors with varying degrees of weight change could facilitate the development and targeting of effective intervention strategies to achieve healthy weight and optimal health for better survival.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis.

MAIN RESULTS

Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials.

AUTHORS' CONCLUSIONS

There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.

Induction of autophagy by drug-resistant esophageal cancer cells promotes their survival and recovery following treatment with chemotherapeutics

We investigated the cell-death mechanisms induced in esophageal cancer cells in response to the chemotherapeutic drugs, 5-fluorouracil (5-FU) and cisplatin. Chemosensitive cell lines exhibited apoptosis whereas chemoresistant populations exhibited autophagy and a morphology resembling type II programmed cell death (PCD). Cell populations that respond with autophagy are more resistant and will recover following withdrawal of the chemotherapeutic agents. Specific inhibition of early autophagy induction with siRNA targeted to Beclin 1 and ATG7 significantly enhanced the effect of 5-FU and reduced the recovery of drug-treated cells. Pharmacological inhibitors of autophagy were evaluated for their ability to improve chemotherapeutic effect. The PtdIns 3-kinase inhibitor 3-methyladenine did not enhance the cytotoxicity of 5-FU. Disruption of lysosomal activity with bafilomycin A 1 or chloroquine caused extensive vesicular accumulation but did not improve chemotherapeutic effect. These observations suggest that an autophagic response to chemotherapy is a survival mechanism that promotes chemoresistance and recovery and that selective inhibition of autophagy regulators has the potential to improve chemotherapeutic regimes. Currently available indirect inhibitors of autophagy are, however, ineffective at modulating chemosensitivity in these esophageal cancer cell lines.

Clinical trials of vascular disrupting agents in advanced non--small-cell lung cancer

Tumor vascular disrupting agents (VDAs), such as the flavonoid compound ASA404 and the tubulin-binding compound combretastatin, selectively disrupt established tumor blood vessels, inhibit tumor blood flow, and induce extensive necrosis at the core of solid tumors. A rationale for combining tumor VDAs with standard chemotherapy for treating advanced non-small-cell lung cancer (NSCLC) includes their complementary actions on different spatial regions of solid tumors and their additive or synergistic preclinical activity in animal models of lung cancer. A randomized, phase II, multicenter, open-label trial with a single-arm extension phase evaluated outcomes in a total of 104 patients (> 18 years of age) with histologically confirmed stage IIIb or stage IV, previously untreated NSCLC that in this trial was treated with ASA404 plus standard chemotherapy vs. standard chemotherapy alone. Adding ASA404 to standard chemotherapy numerically improved tumor response, time to disease progression, and overall survival in this phase II trial, without significantly increasing the incidence or severity of side effects. Other randomized phase II and phase III clinical trials of ASA404 and combretastatin combined with standard chemotherapy in advanced NSCLC are currently ongoing or will be reported shortly.

Pre-treatment surgical para-aortic lymph node assessment in locally advanced cervical cancer

BACKGROUND

Cervical cancer is the most common cause of death from gynaecological cancers worldwide. Locally advanced cervical cancer, FIGO stage equal or more than IB1 is treated with chemotherapy and external beam radiotherapy followed by brachytherapy. If there is metastatic para-aortic nodal disease radiotherapy is extended to additionally cover this area. Due to increased morbidity, ideally extended-field radiotherapy is given only when para-aortic nodal disease is proven. Therefore accurate assessment of the extent of the disease is very important for planning the most appropriate treatment.

OBJECTIVES

To evaluate the effectiveness and safety of pre- treatment surgical para-aortic lymph node assessment for woman with locally advanced cervical cancer (FIGO stage IB2 to IVA).

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE and EMBASE (up to January 2011). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared surgical para-aortic lymph node assessment and dissection with radiological staging techniques, in adult women diagnosed with locally advanced cervical cancer.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed whether potentially relevant trials met the inclusion criteria, abstracted data and assessed risk of bias. One RCT was identified so no meta-analyses were performed.

MAIN RESULTS

We found only one trial, which included 61 women, that met our inclusion criteria. This trial reported data on surgical versus clinical staging and an assessment of the two surgical staging techniques; laparoscopic (LAP) versus extraperitoneal (EXP) surgical staging. The clinical staging was either a contrast-enhanced CT scan or MRI scan of the abdomen and pelvis to determine nodal status.In this trial, clinical staging appeared to significantly prolong overall and progression-free survival compared to surgical staging. There was no statistically significant difference in the number of women who experienced severe (grade 3 or 4) toxicity.There was no statistically significant difference in the risk of death, disease recurrence or progression, blood loss, severe toxicity and the duration of the operational procedure between LAP and EXP surgical staging techniques.The strength of the evidence is weak in this review as it is based on one small trial which was at moderate risk of bias.

AUTHORS' CONCLUSIONS

From the one available RCT we found insufficient evidence that pre-treatment surgical para-aortic lymph node assessment for locally advanced cervical cancer is beneficial, and it may actually have an adverse effect on survival. However this conclusion is based on analysis of a small single trial and therefore definitive guidance or recommendations for clinical practice cannot be made.Therefore the decision to offer surgical pre-treatment assessment of para-aortic lymph nodes in locally advanced cervical cancer needs to be individualised. The uncertainty regarding any impact on survival from pre-treatment para-aortic lymph node assessment should be discussed openly with the women.