The Northern region Children's malignant disease registry 1968-82: incidence and survival

[DKG certification of paediatric cancer centres - a wide field …]

Die Gesellschaft für Pädiatrische Onkologie und Hämatologie (GPOH) und die Deutsche Krebsgesellschaft (DKG) haben Kriterien für die DKG-Zertifizierung der Kinderonkologie erarbeitet, nach denen 2017 in Deutschland erstmals pädiatrisch-onkologische Abteilungen zertifiziert wurden. Das Ziel der DKG-Zertifizierung ist „die Vereinheitlichung und die transparente Darstellung der Versorgungsqualität für pädiatrische Patientinnen und Patienten mit hämato-onkologischen Erkrankungen“, wie 2018 in einer Veröffentlichung von Mensah et al. dargestellt. Die Auswahl der Zertifizierungskriterien hat innerhalb der GPOH zu einer intensiven Diskussion darüber geführt, inwieweit die Kriterien für sich genommen einer wissenschaftlichen Überprüfbarkeit standhalten und damit valide Parameter für die Bestimmung der Versorgungsqualität in der Kinderonkologie in Deutschland darstellen.

Wir haben untersucht, ob aus der Arbeit von Mensah et al. valide Folgerungen für das deutsche Gesundheitssystem ableitbar sind. Dabei zeigt sich, dass die momentan definierten DKG-Zertifizierungskriterien für die Kinderonkologie in Deutschland in kritischen Bereichen einer fundierten wissenschaftlichen Grundlage entbehren.

Diese Arbeit stellt Fallzahlen als Maß für Qualität in der Kinderonkologie infrage und regt die Entwicklung alternativer Kriterien für die Überprüfbarkeit von Qualität in der deutschen Kinderonkologie an.

Access to principal treatment centres and survival rates for children and young people with cancer in Yorkshire, UK

Background

Principal Treatment Centres (PTC) were established to provide age-appropriate care as well as clinical expertise for children and young people with cancer. However, little is known about the effects of specialist treatment centres on survival outcomes especially for teenagers and young adults. This population-based study aimed to describe access to PTC and the associated trends in survival for 0–24 year olds accounting for stage of disease at presentation and treatment.

Methods

Patients diagnosed from 1998–2009 aged 0–24 years were extracted from the Yorkshire Specialist Register of Cancer in Children and Young People, including information on all treating hospitals, followed-up until 31st December 2014. The six commonest cancer types were included: leukaemia (n = 684), lymphoma (n = 558), CNS tumours (n = 547), germ cell tumours (n = 364), soft tissue sarcomas (n = 171) and bone tumours (n = 163). Treatment was categorised into three groups: ‘all’, ‘some’ or ‘no’ treatment received at a PTC. Treatment at PTC was examined by diagnostic group and patient characteristics. Overall survival was modelled using Cox regression adjusting for case-mix including stage, treatment and other socio-demographic and clinical characteristics.

Results

Overall 72% of patients received all their treatment at PTC whilst 13% had no treatment at PTC. This differed by diagnostic group and age at diagnosis. Leukaemia patients who received no treatment at PTC had an increased risk of death which was partially explained by differences in patient case-mix (adjusted Hazard Ratio (HR) = 1.73 (95%CI 0.98–3.04)). Soft tissue sarcoma patients who had some or no treatment at PTC had better survival outcomes, which remained after adjustment for patient case-mix (adjusted HR = 0.48 (95%CI 0.23–0.99)). There were no significant differences in outcomes for other diagnostic groups (lymphoma, CNS tumours, bone tumours and germ cell tumours). For leukaemia patients survival outcomes for low risk patients receiving no treatment at PTC were similar to high risk patients who received all treatment at PTC, implying a benefit for care at the PTC.

Conclusion

This study demonstrates that for leukaemia patients receiving treatment at a PTC is associated with improved survival that may compensate for a poorer prognosis presentation. However, further information on risk factors is needed for all diagnostic groups in order to fully account for differences in patient case-mix.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3160-5) contains supplementary material, which is available to authorized users.

How common are myeloproliferative neoplasms? A systematic review and meta-analysis

Myeloproliferative neoplasms (MPNs) are a heterogeneous group of diseases including polycythemia vera (PV), essential thrombocythemia (ET), and primary(idiopathic) myelofibrosis (PMF). In this systematic review, we provide a comprehensive report on the incidence and prevalence of MPNs across the globe. Electronic databases (PubMed, EMBASE, MEDLINE, and Web of Science) were searched from their inception to August 2012 for articles reporting MPN incidence or prevalence rates. A random effects meta-analysis was undertaken to produce combined incidence rates for PV, ET, and PMF. Both heterogeneity and small study bias were assessed. Thirty-four studies were included. Reported annual incidence rates ranged from 0.01 to 2.61, 0.21 to 2.27, and 0.22 to 0.99 per 100,000 for PV, ET, and PMF, respectively. The combined annual incidence rates for PV, ET, and PMF were 0.84, 1.03, and 0.47 per 100,000. There was high heterogeneity across disease entities (I(2) 97.1-99.8%) and evidence of publication bias for ET and PMF (Egger test, P = 50.007 and P ≤ 0.001, respectively).The pooled incidence reflects the rarity of MPNs. The calculated pooled incidence rates do not reflect MPN incidence across the globe due to the high unexplained heterogeneity. Improved, widespread registration of MPNs would provide better information for global comparison of the incidence and prevalence of MPNs.

The volume effect in paediatric oncology: a systematic review

BACKGROUND

For several adult cancer types, there is evidence that treatment in high volume hospitals, high case volume providers, or in specialised hospitals leads to a better outcome. The aim of this study is to give an overview of the existing evidence regarding the volume effect in paediatric oncology related to the quality of care or survival.

MATERIALS AND METHODS

An extensive search was carried out for studies on the effect of provider case volume on the quality of care or survival in childhood cancer. Information about study characteristics, comparisons, results, and quality assessment were abstracted.

RESULTS

In total, 14 studies were included in this systematic review. Studies with a low risk of bias provide evidence that treatment of children with brain tumours, acute lymphoblastic leukaemia, osteosarcoma, Ewing's sarcoma, or children receiving treatment with allogenic bone marrow transplantation in higher volume hospitals, specialised hospitals, or by high case volume providers, is related with a better outcome.

CONCLUSIONS

This systematic review provides support for the statement that higher volume hospitals, higher case volume providers, and specialised hospitals are related to the better outcome in paediatric oncology. No studies reported a negative effect of a higher volume.

Sex-specific incidence and temporal trends in solid tumours in young people from Northern England, 1968-2005

BACKGROUND

This study examined sex-specific patterns and temporal trends in the incidence of solid tumours in the Northern Region of England from 1968 to 2005. This updates earlier analyses from the region where sex was not considered in depth. Sex-specific analyses were carried out to determine whether sex differences might provide clues to aetiology.

METHODS

Details of 3576 cases, aged 0-24 years, were obtained from a specialist population-based cancer registry. There were 1843 males (886 aged 0-14 years and 957 aged 15-24 years) and 1733 females (791 aged 0-14 years and 942 aged 15-24 years). Age-standardized incidence rates (per million population) were calculated. Linear regression was used to analyze temporal trends in incidence and annual percentage changes were estimated. Analyses were stratified by sex and by age-group.

RESULTS

There were marked differences in incidence patterns and trends between males and females and also between age-groups. For males central nervous system (CNS) tumours formed the largest proportion of under-15 cases and germ cell tumours was the largest group in the 15-24's, whilst for females CNS tumours dominated in the under-15's and carcinomas in the older group. For 0-14 year olds there were male-specific increases in the incidence of rhabdomyosarcoma (2.4% per annum; 95% CI: 0.2%-4.5%) and non-melanotic skin cancer (9.6%; 95% CI: 0.0%-19.2%) and female-specific increases for sympathetic nervous system tumours (2.2%; 95% CI: 0.4%-3.9%), gonadal germ cell tumours (8.6%; 95% CI: 4.3%-12.9%) and non-gonadal germ cell tumours (5.4%; 95% CI: 2.8%-7.9%). For 15-24 year olds, there were male-specific increases in gonadal germ cell tumours (1.9%; 95% CI: 0.3%-3.4%), non-gonadal germ cell tumours (4.4%; 95% CI: 1.1%-7.7%) and non-melanotic skin cancer (4.7%; 95% CI: 0.5%-8.9%) and female-specific increases for osteosarcoma (3.5%; 95% CI: 0.5%-6.5%), thyroid cancer (2.8%; 95% CI: 0.1%-5.6%) and melanoma (4.6%; 95% CI: 2.2%-7.1%).

CONCLUSION

This study has highlighted notable differences between the sexes in incidence patterns and trends for solid tumours. Some of these sex-specific differences could have been obscured if males and females had been analysed together. Furthermore, they suggest aetiological differences or differential susceptibility to environmental factors between males and females.

Incidence and survival for testicular germ cell tumor in young males: a report from the Northern Region Young Person's Malignant Disease Registry, United Kingdom

The incidence of testicular cancer has increased markedly in most developed countries, although the reasons for this are unclear. In this study, 253 patients with testicular cancer diagnosed younger than 25 years from 1968-1999 were identified from the Northern Region Young Persons' Malignant Disease Registry. The age-standardized incidence rate increased from 0.93 in 1968-1978 to 1.60 per 100,000 in 1990-1999. The increase in incidence was confined to those patients >15 years old, with the rate in younger children remaining very low. The 5-year survival increased significantly from 46% (95% confidence interval [CI] 33% to 58%) to 92% (95% CI 85% to 96%) during 1968-1999 and was significantly higher for seminoma than nonseminoma, 91% (95% CI 78% to 96%) and 77% (95% CI 70% to 82%), respectively. Although increased surveillance and public health campaigns designed to raise awareness of the disease and the advantages of self-examination should continue, further research is required into the etiology of this relatively common cancer among young males.

Limitations in the ability of NB84 to detect metastatic neuroblastoma cells in bone marrow

BACKGROUND

The accurate assessment of metastases is an essential component of the staging process for children with neuroblastoma.

AIMS

To study the sensitivity of the immunohistochemical marker neuroblastoma 84 (NB84) for the detection of bone marrow infiltrates in children with stage 4 neuroblastoma.

METHODS

Primary tumour specimens, bone marrow trephine biopsy specimens and lymph node metastases, taken from children with neuroblastoma that had metastasised to bone marrow, were assessed with a panel of commonly used immunohistochemical markers for neuroblastoma. A comparison was drawn between the sensitivity of the marker NB84 for primary tumours and for bone marrow metastases.

RESULTS

NB84 immunolabelled all pre-chemotherapy and post-chemotherapy (n = 24) paired primary tumour specimens, as well as each of a further 20, unpaired, pre-chemotherapy primary tumour specimens. It also labelled all (n = 4) lymph node metastases. Immunolabelling of bone marrow trephine biopsy specimens (21/33) was less sensitive. Of 16 primary tumour specimens with a paired bone marrow trephine biopsy specimen, all immunostained positive, whereas only 62.5% of bone marrow biopsy specimens immunostained positive for NB84. The number of bone marrow biopsy specimens immunostaining for NB84 was significantly lower than the number of paired primary tumour specimens (p = 0.041).

CONCLUSIONS

NB84 remains a useful marker for the diagnosis of neuroblastoma in primary tumour specimens, but not for neuroblastoma that has metastasised to bone marrow.

Thyroid cancer in children and young adults in the North of England. Is increasing incidence related to the Chernobyl accident?

Population-based data on thyroid carcinomas was obtained from the Northern Region Young Person's Malignant Disease Registry to analyse the incidence of thyroid cancers in young people (<25 years) in the North of England for the period 1968 and 1997 and to assess if changes in incidence were consistent with the spatial and temporal distribution of the fallout from the Chernobyl nuclear accident. We compared incidence rates for differentiated (papillary or follicular) thyroid carcinomas 1968-1986 with those for 1987-1997. There were 75 cases of thyroid carcinoma diagnosed over the study period, of which 63 were differentiated carcinoma and 12 were medullary carcinoma. There were 26 young adults (15-24 years) diagnosed with differentiated thyroid carcinoma in the 19-year period 1968-1986 and 30 in the subsequent 11 years 1987-1997, Age standardised rate (ASR) 3.0 versus 6.5, respectively (rate ratio 2.2, 95% confidence interval (CI): 1.3-3.6). There were three children (aged <15 years) diagnosed with differentiated carcinoma in the period 1968-1986 and four in the period 1987-1997, ASR 0.2 versus 0.6 (rate ratio 2.7, 95% CI: 0.6-12.1). Regression models showed a significant increase in the incidence of thyroid cancer after the Chernobyl accident (P=0.002). In Cumbria, the area receiving the heaviest fallout in the UK, the increase in incidence was much greater (rate ratio 12.19, 95% CI 1.5-101.2). These temporal and spatial changes in incidence are consistent with a causal association with the Chernobyl accident although a greater effect in the younger rather than the older age group would have been anticipated. However, factors including improvements in ascertainment and earlier detection of tumours may also have contributed to the increasing incidence. Further collaborative international studies are needed to investigate changes in the incidence of thyroid cancer in children and young adults.

Incidence and survival for cancer in children and young adults in the North of England, 1968-1995: a report from the Northern Region Young Persons' Malignant Disease Registry

The Northern Region Young Persons' Malignant Disease Registry records information on young people under 25 years old diagnosed with cancer in the Northern Region of England. Incidence and survival rates were calculated for children and young adults diagnosed with cancer between 1968 and 1995. There were 2099 (M:F 1.28:1) children (age 0-14 years) and 2217 (M:F 1.23:1) young adults (15-24 years) diagnosed with a first cancer between 1968 and 1995. The age-standardized rate (ASR) for childhood cancer was 121 per million 0 to 14 year-olds per year. For young adults the ASR was 175 per million 15 to 24 year-olds, per year. Incidence of childhood cancer increased over time at a rate of 12 extra cases per million children, per decade (P < 0.001). In young adults incidence rates increased by 16 extra cases per million 15 to 24 year-olds, per decade (P < 0.001). For childhood cancer 5-year survival was 42% for those diagnosed 1968-1977, 57% for 1978-1987 and 71% (95% CI 67-75) for 1988-1995. Survival for young adults over the three periods was 45%, 62% and 73% (95% CI 70-78) respectively. The cumulative risk of developing cancer before the age of 25 is 1 in 285. Over the 28-year period there were significant improvements in survival and modest increases in incidence in both children and young adults.

Childhood cancer: improved prospects for survival but is prevention possible?

With optimum treatment 65-70% of children diagnosed with cancer should be long term survivors and probably cured. Prevention is better than cure. Recent studies into the causes of childhood malignancy are reviewed. The incidence of childhood acute lymphoblastic leukaemia (ALL) is steadily increasing. The cause for this may be increasing social and economic development. Exposure to electromagnetic fields has been a cause of concern for almost 20 years. A recent large case control study has shown no increased risk of cancer or leukaemia in those who have measurably increased exposure to electromagnetic fields. Leukaemia which has the cytogenetic abnormality 11q23 or MLL gene rearrangement characteristically occurs as a second malignancy after exposure to epipodophyllotoxins which act by inhibiting topoisomerase. Infant leukaemia has the same cytogenetic profile. Mothers of babies who develop infant leukaemia have high exposure to potential dietary inhibitors of topoisomerase during pregnancy. Clusters of leukaemia can probably best be accounted for by population mixing. There may be an increased risk of ALL following vitamin K given to newborns.

Patterns of childhood solid tumor incidence in northern Israel, 1973-1990

A retrospective analysis of 515 pediatric cancer cases diagnosed over 18 years, 1973-1990, showed an annual incidence of pediatric solid tumors in northern Israel of 77.1 per million, somewhat lower than previously reported. Lymphomas predominated over central nervous system (CNS) neoplasms, suggesting an Afro-Asian rather than a Western pattern. Jewish and non-Jewish children were at approximately equal risk (1:07:1.0) for the nonleukemic cancer. However, there was a notably higher frequency in males than females (1:42:1.0) and in Ashkenasi Jews as compared to either Sephardi Jews (1.25:1.00) or non-Jews (1.23:1.0). Ethnic, age, and sex predispositions for particular types of malignancy were also noted. Non-Jews tended to have lymphomas or retinoblastomas and Sephardi Jews were predisposed to soft tissue sarcomas. Ashkenasi Jews tended to manifest CNS tumors, retinoblastoma, and osteosarcoma. Children under 5 years showed Burkitt's lymphoma and neuroblastoma, whereas the older group tended to have Hodgkin's lymphoma. Boys were more vulnerable to non-Hodgkin's lymphoma, medulloblastoma, neuroblastoma, and rhabdomyosarcoma, and girls were subject to higher incidences of bone, gonadal, germ cell, and epithelial tumors, as well as to astrocytoma. The implications for genetic or environmental contributions to several cancers are considered in conjunction with ethnic or gender predisposition to those cancers.

Leukaemia and non-Hodgkin's lymphoma in young persons resident in small areas of West Cumbria in relation to paternal preconceptional irradiation

The results of a previous study suggested that an association between childhood leukaemia and the radiation dose received occupationally by a father before the conception of his child might provide the explanation for the marked excess of childhood leukaemia and non-Hodgkin's lymphoma in the village of Seascale, West Cumbria. The present study identifies other small areas (electoral wards) in West Cumbria where excess cases of leukaemia and non-Hodgkin's lymphoma in young people have occurred and determines whether a recorded dose of radiation was received occupationally by the father before the conception of each of the affected individuals. Forty-one cases of leukaemia and non-Hodgkin's lymphoma were diagnosed during 1968-85 in young people under 25 years of age resident in the 49 electoral wards lying within the boundary of West Cumbria and the adjacent ward of Broughton. Raised incidence rate ratios (two-sided P<0.01) were found for acute lymphoblastic leukaemia among those aged 0-14 years (concentrated among those aged 0-4 years) in Seascale ward and among those aged 0-24 years (also concentrated among those aged 0-4 years) in Egremont North ward, for acute myeloid leukaemia among those aged 0-14 years in Sandwith ward, for all leukaemias among those aged 0-14 years in Broughton ward (South Lakeland) and for non-Hodgkin's lymphoma among those aged 0-14 years in Seascale ward. For West Cumbria as a whole, incidence rates were not usual. Apart from Seascale, for none of these electoral wards has a father of an affected child been linked definitely to an occupational dose of radiation recorded before the conception of the child. Particularly striking are the excesses of acute lymphoblastic leukaemia cases among young children living in the wards of Seascale and Egremont North, situated 11 km apart. The cases in Egremont North are not associated with recorded doses of radiation received occupationally by fathers before the conception of the affected children, even though the total numbers of children associated with such doses born in Seascale and Egremont North wards are similar. This finding is further evidence against a causal role for paternal preconceptional radiation exposure in the cases of childhood leukaemia in Seascale.

Variation in survival of children with cancer within a region of the United Kingdom

BACKGROUND

A population-based study of survival of 678 children, age less than 15 years, diagnosed with cancer in the Southwest region of the United Kingdom showed an improvement in 5-year survival from 53% between 1976 and 1980 to 64% between 1981 and 1985 (P = 0.008). Survival varied significantly among the five counties that make up the region (P = 0.0008); the differences were greatest for central nervous system (CNS) tumors.

METHODS

The expertise of local hospitals and entrance into national trials was examined. The region has nine hospitals acting as primary treatment hospitals for children with cancer, two neurosurgical units, and one regional oncology unit. Four of the primary hospitals saw more than six children per year and were designated "large" centers. Five saw fewer than six patients per year and were designated "small" hospitals.

RESULTS

There was a significant difference in survival of patients according to the number of patients treated per year per hospital. A hospital that treated fewer than six patients per year was designated "small" and six or more designated "large." At 5 years, patients with CNS tumors experienced a 58% survival rate in large hospitals and a 41% survival rate in small hospitals. (P = 0.03). The rate of entrance into trials for all malignancies did not differ between large (30%) and small (27%) centers. Only 5% of children with CNS tumors were placed on national trials. There was no difference in survival rates for CNS tumors in the two neurosurgical centers.

CONCLUSIONS

There were significant differences in survival by county for children with cancer, especially those with CNS tumors. In the first half of the study decade, in hospitals treating fewer than six cases of childhood cancer per year, children with CNS tumors were rarely placed on national protocols and did poorly.

Radon in Devon and Cornwall and paediatric malignancies

Exposure to radon in dwellings may cause cancer including paediatric malignancies. Devon and Cornwall have the highest exposure to radon of the counties of England. However, within these counties there is considerable variation in exposure. Exposure to radon in the 283 postcode sectors of the two counties has been published. The incidence of childhood malignancies between 1976 and 1985 was studied to compare postcode sectors of radon exposures > or = 100 Bq/m3 with sectors < 100 Bq/m3. No significant difference in the incidence rate of 106.7 per million child years in the high radon postcode sectors and 121.7 in the low (P = 0.29) was found. When the incidences of individual tumours were examined, a significantly increased rate of neuroblastoma (P = 0.02) and a non-significant increased rate of acute myeloid leukaemia were found in the high exposure postcode sectors. No association between radon exposure and overall rate of childhood malignancy was found.

Childhood cancer in Britain: the National Registry of Childhood Tumours and incidence rates 1978-1987

The National Registry of Childhood Tumours contains population-based data on childhood cancers diagnosed throughout Great Britain from 1962 onwards. This paper describes the methodology of the Registry, presents incidence rates for 1978-1987 and describes other uses of the data. Total age-standardised annual incidence was 118.3 per million. The most frequent diagnostic groups were leukaemias (age-standardised rate 39.8), brain and spinal tumours (27.0), lymphomas (11.1), sympathetic nervous system tumours (8.3), kidney tumours (7.7) and soft-tissue sarcomas (7.5). Incidence rates were similar to those reported from other Western industrialised countries. The data are also used for a wide range of epidemiological and other studies. These include analyses of geographical variations in incidence, trends in survival, health of long-term survivors and their offspring and the genetics of childhood cancer. Information is frequently provided for clinicians and research workers, and series of specific types of cancer are compiled for further study. The Registry depends for the completeness and accuracy of its data on a wide range of organisations and individuals, and it is essential that this cooperation continues if the Registry is to be maintained.

Screening for Wilms' tumour in patients with aniridia, Beckwith syndrome, or hemihypertrophy

The role of screening for early detection of Wilms' tumour (WT) in patients with aniridia (A), Beckwith-Weidemann syndrome (BWS) and hemihypertrophy (HH) has been explored. Of the 1,622 Wilms' tumour patients registered with the National Childhood Cancer Registry from 1971 to 1991, 41 were recorded as having A, BWS or HH. Twenty-eight of these had their anomaly diagnosed before the WT and 13 had screening procedures carried out, mainly abdominal ultrasound. In 8 patients the screening procedure detected the WT. There was no significant difference in stage distribution or outcome for any of the three subgroups who were not screened, screen-positive or screen-negative. We conclude that regular screening with abdominal ultrasound is not of proven value. Parents should be taught abdominal palpation and advised to seek appropriate advice for untoward symptoms.

Prognostic significance of the c-erbB-2 oncogene product in childhood medulloblastoma

The expression and prognostic significance of the c-erbB-2 oncogene product was studied in 55 cases of childhood medulloblastoma. Forty-six of the 55 tumours (83.6%) expressed the c-erbB-2 product. The percentage of tumour cells expressing the c-erbB-2 product proved to be a significant indicator of patient outcome when analysed as both a categorical and a continuous variable. As a categorical variable, patients with more than 50% positive tumour cells had a significantly worse survival, with only 10% alive at 10 years vs 48% for those with less than 50% positive tumour cells (log rank P = 0.0049). To demonstrate that this observed prognostic significance was both independent and not a result of 'data-driven' categorisation, it was also entered into the Cox model as a continuous variable. Prognostic significance was retained in P = 0.038.

Survival rates of childhood cancer patients in Osaka, Japan, 1975-1984

Survival rates for childhood cancers were analyzed with a total of 2,209 cases who were registered in a population-based cancer registry in Osaka, Japan in 1975-1984. These cases were reclassified according to Birch's classification and the survival rate of each diagnostic group was calculated by Kaplan-Meier methods. Death certificate-only cases, which amounted to 3.9% of all incidence, were excluded from the calculation. The five-year cumulative survival rate for both sexes was 46% for all cancer children. Among 12 major diagnostic groups, the most favorable survival was seen in retinoblastoma (87.5%), followed by renal tumors, epithelial neoplasms, and gonadal and germ-cell tumors. The outcome was unfavorable in leukemias, sympathetic nervous system tumors, hepatic tumors and malignant bone tumors. Comparing the survival in 1975-1979 with that in 1980-1984, the rate for all childhood cancer rose from 41% to 51%. Improvement in survival was also observed in 4 groups; acute lymphocytic leukemia, acute non-lymphocytic leukemia, non-Hodgkin's lymphoma and osteosarcoma. One attributable factor for the rise of survival was proved to be improvement of medical treatment by Cox's hazard model analysis. Comparison of survival rates in Osaka with those in England and the U.S. revealed that the prognosis for acute lymphocytic leukemia and acute non-lymphocytic leukemia was less favorable in Osaka than in England and the U.S.

Decline in incidence of medulloblastoma in children

BACKGROUND

Medulloblastoma is one of the most common intracranial tumors in children. The perception that the incidence of this tumor has declined is reinforced by a decline in enrollment to international trials for the disease.

METHODS

A retrospective population-based study of children younger than 15 years whose brain tumors were reviewed histopathologically was performed in the county of Avon, in the southwest region of England from 1976 to 1991. Then, the incidence of medulloblastoma was studied in the noncontiguous southwest and northern regions of England, with a combined childhood population base of 20.0 million child years for the period 1976-1991.

RESULTS

In Avon, 16 children with medulloblastoma presented in the period 1976-1984 and 2 in the period 1985-1991, representing a decrease in incidence from 9.6 per million per year to 1.7 per million per year. The incidence of medulloblastoma in the combined southwest and northern regions showed a significant (P = 0.006) decline from 5.5 per million per year in the period 1976-1984 to 2.8 in the period 1985-1991. Considered individually, the decline in the southwest (from 6.2 per million per year to 2.8 per million per year) was significant but that in the Northern region (from 4.7 to 2.7) was not.

CONCLUSIONS

In this report, a decline in the incidence of medulloblastoma was shown. In a recent case control study, a protective effect of maternal folate, iron, and multivitamin supplementation against primitive neuroectodermal tumors, including medulloblastoma was found. The introduction of periconceptional multivitamin supplementation in the 1980s may have caused this significant decline in the incidence of medulloblastoma.

Registration quality and descriptive epidemiology of childhood brain tumours in Scotland 1975-90

Children (0-14 years) with malignant brain and central nervous system (CNS) tumours (ICD9 191 and 192) were listed from the Scottish Cancer Registration Scheme for the years 1975-90. These cases formed the basis for validation and verification procedures aimed at providing a complete and accurate data set for epidemiological analyses. A variety of data sources were cross-checked to optimise ascertainment, and resulting from this 5.7% of validated cases were found on the cancer registry with diagnostic codes outside the ICD-9 range 191-192. A further 8.4% were newly registered cases. Analyses were conducted on the validated data set showing a significant temporal increase in incidence rates over the 16 year study period with an average annual percentage change of +2.6%. Large-scale geographical heterogeneity was also found, with a particularly high incidence in the Fife and Lothian areas and a low incidence in Grampian. Examination of associations with socioeconomic status, using the Carstairs deprivation index, revealed a rising trend in incidence strongly linked to areas with increasing levels of affluence. Our results suggest that for studies of childhood CNS tumours validation of cancer registry data is necessary and large-scale geographical variation and socioeconomic factors should be taken into account in any investigation of distribution in small geographical areas.

Neuroblastomas in Denmark 1943-80. Epidemiological and clinical studies

Two-hundred-and-fifty patients were registered in a population-based study of neuroblastomas in Denmark in the period 1943-80. The major epidemiological findings were an increased incidence with an unchanged mortality rate during the study period. The increase in incidence related solely to children 0-4 years of age and was most pronounced in infants under 1 year of age. Several reasons for the observed epidemiological rates include (i) changes in the composition of the population, (ii) improved diagnostic procedures, (iii) a shift in the diagnostic criteria, and (iv) an increase in environmental carcinogens of importance in the induction of neuroblastoma. Associated with an increased risk were lower socio-economic levels and young or advanced parental age, suggesting the importance of environmental as well as genetic factors for the induction of neuroblastoma. The epidemiological findings of an increased incidence with an unchanged mortality rate, which suggests the inclusion of borderline lesions in recent years, are of major importance in interpreting the results of mass screening for the disease. The clinical findings in 253 patients treated in Denmark from 1943 to 1980 (including 5 patients resident outside Denmark and excluding 2 patients without available hospital records) were analysed. The major finding was a zero-time shift, that is, earlier diagnosis of the disease during the study period, with increasing survival rates from decade to decade mostly due to a better age and stage distribution, a zero-time shift which was also apparent in the changes of the symptomatology. Independent prognostic variables were age, stage, and treatment with chemotherapy for children over 1 year of age with stage II disease, and for infants with stages III-IV disease. Analysis of data from a subset of the 253 children suggested that high proliferative activity detected by flow cytometry may be an important prognostic variable. The study also suggests that the pattern of metastatic spread might have changed as a consequence of prolonged survival obtained by improved treatment modalities, stressing the importance of a high frequency of autopsy among cancer patients. Hypotheses generated by the study included (i) that most neuroblastomas might be congenital, (ii) that the age influence on prognosis might be explained in terms of growth rate, cell cycle transit time, and duration of the disease, and (iii) that some neuroblastomas might be borderline lesions.

Incidence of childhood cancer in Osaka, Japan, 1971-1988: reclassification of registered cases by Birch's scheme using information on clinical diagnosis, histology and primary site

In 1971-1988, 4,021 malignant tumors occurring among children under 15 years of age were registered in the Osaka Cancer Registry, a population-based registry which covers Osaka Prefecture, Japan. These patients were reclassified into 12 diagnostic groups by Birch's scheme using information on clinical diagnosis, histology and primary site. The annual age-standardized incidence rate for childhood cancer per million children was 130.3 for males and 104.9 for females in 1971-88. Comparing the incidence rates for both sexes in 1981-88 with those in 1971-80 in Osaka, we observed a significant decrease of acute non-lymphocytic leukemia (ANLL) and a significant increase of all cancers, acute lymphocytic leukemia, non-Hodgkin lymphoma, sympathetic nervous system tumors, soft-tissue sarcomas, and gonadal and germ-cell tumors. Age-standardized incidence rates in around 1971-80 of the above-mentioned diagnostic groups were compared among 4 population-based registries; Osaka, Miyagi (Japan), SEER (U.S.), and the National Registry of Childhood Tumors (England and Wales). Rates for ANLL and gonadal and germ-cell tumors were higher and those for other diagnostic groups were lower in Osaka, especially for Hodgkin's disease. Thus, in 1980-88 in Osaka, rates for Hodgkin's disease remained low and rates for gonadal and germ-cell tumors increased, though rates for other cancers appeared to resemble the levels in caucasian populations. The incidence of childhood cancer in Japan was estimated according to the diagnostic groups in Birch's scheme.

Childhood malignancies in the south-west region of England, 1976-1985

The incidence and pattern of childhood cancer in the South-West Region of the United Kingdom was studied in the period 1976-1985 to see if there was any unevenness in distribution. This region consists of five counties with considerable variation in radon exposure and urbanisation. Cases were identified from multiple sources and the basis of the diagnosis reviewed. Internationally accepted diagnostic categories were used. Six hundred seventy-eight cases were found, giving an age standardised incidence rate of 114.2 per million childhood years. The incidence of different cancers by sex was strikingly similar to the Manchester Children's Tumour Registry, from a noncontiguous region, with three exceptions. In the South-West, there was a higher rate of soft tissue sarcoma in boys (P = 0.01) and lower rates of sympathetic nervous system and germ-cell tumours in girls (P = 0.01 and P = 0.04, respectively). There was no significant variation in cancer incidence among the five counties or with time. The incidence rate in counties of high radon exposure was not higher than with low radon exposure. The overall incidence in counties with urban districts was not significantly increased compared to those without, although there was a nonsignificant trend towards a higher incidence of leukaemia (P = 0.08). The incidence and type of childhood cancer are similar to those in a noncontiguous region. Geographical and temporal incidence are remarkably stable. Local environmental variation may not play a major role in the causality of childhood cancer.

An audit of the activities of the paediatric oncology unit in Edinburgh, 1982-1991

The activities of the paediatric oncology unit at the Royal Hospital for Sick Children, Edinburgh during 1982-1991 were audited. There were 254 new patients of whom 240 had a malignancy, seven had Langerhans cell histiocytosis and seven had non malignant tumours. Of the 254,131 (52%), 78 (31%), 14 (65), were normally resident within the Lothian, Fife and Borders regions respectively. Therefore, although the unit is a part of the Lothian Health Board, it is in practice, the referral centre for S.E. Scotland. A majority (92%) of patients were treated according to national or international protocols during the last five years and of the 240 children diagnosed to have cancer, 158 (66%) are at present in clinical remission. These figures compare favourably with national averages for protocol compliance and survival. During these ten years, an additional 69 children with cancer from S.E. Scotland were treated at other centres. Therefore, while the unit justifies its existence it has yet to realise its full potential.

Cancer in young people in the north of England, 1968-85: analysis by census wards

OBJECTIVE

To determine whether the seeming excess of childhood leukaemia and lymphoma identified in Seascale, Cumbria, UK, remains unusual when put into a wider context.

DESIGN

Analysis of cancer incidence by geographical area.

SETTING

The north of England including the Northern and North Western Regional Health Authority regions and the Southport and South Sefton districts of the Mersey Regional Health Authority.

SUBJECTS

Altogether 6686 cases of malignant disease in people under 25 years old.

MEASUREMENTS AND MAIN RESULTS

Cases of cancer diagnosed before their 25th birthday between January 1968 and December 1985 identified from three regional cancer registries were allocated to a census ward on the basis of 'usual place of residence'. Population data were derived from the 1971 and 1981 censuses, and the cancer incidence was calculated for each ward. Of the 6686 cases, there were 1035 cases of acute lymphoblastic leukaemia and 361 of non-Hodgkins lymphoma. Wards were ranked by cancer incidence and Poisson probability, using different population bases. Seascale ward is the most highly ranked ward for acute lymphoblastic leukaemia for the time periods 1968-85 or 1968-76. It is not the most highly ranked for non-Hodgkins lymphoma. However, combining acute lymphoblastic leukaemia and non-Hodgkins lymphoma incidence gives an even more extreme position for Seascale. The most extreme Poisson probability for any of the analyses was that for brain tumours in the electoral ward of Ashton St Michael, Tameside (p = 0.000009).

CONCLUSION

The incidence of acute lymphoblastic leukaemia and non-Hodgkins lymphoma in the Seascale ward remains high when put into a wider context. For other cancers there are wards with even more extreme Poisson probability values.

Cancer in Cumbria and in the vicinity of the Sellafield nuclear installation, 1963-90

OBJECTIVE

To reappraise the epidemiological findings reported by the Black Advisory Group concerning a possible excess of malignant disease, particularly of childhood acute lymphoid leukaemia and non-Hodgkin lymphomas, in the vicinity of the Sellafield nuclear installation, and to determine whether any excess of malignant disease had occurred among people aged 0-24 years in the area in the years after the Black report--that is, from 1984 to 1990.

DESIGN

Calculation of incidence of cancer using data from population based cancer registries and special surveys.

SETTING

England and Wales; county of Cumbria; county districts Allerdale and Copeland within Cumbria; Seascale ward within Copeland.

SUBJECTS

All residents under the age of 75 years in the above areas, but with particular reference to those aged 0-24 years.

MAIN OUTCOME MEASURES

Numbers of cases and incidence particularly of lymphoid leukaemia and non-Hodgkin lymphomas in those aged 0-24 years, but including other cancers and age groups.

RESULTS

Previous reports of an increased incidence of cancer, especially of leukaemia, among those aged 0-24 years in Seascale during the period up to and including 1983 are confirmed. During 1984-90 there was an excess of total cancer among those aged 0-24 years. This was based on four cases including two cases of non-Hodgkin lymphoma but none of leukaemia. There was an increased, but nonsignificant, incidence of other cancers, based on two cases (one pinealoma and one Hodgkin's disease) occurring among those aged 15-24 years during 1984-90. This was not observed in the younger age group or in previous years. For the immediately surrounding area--that is, the county districts of Allerdale and Copeland excluding Seascale and in the remainder of Cumbria--there was no evidence of an increased incidence of cancer among those aged 0-24 years in either period.

CONCLUSIONS

During 1963-83 and 1984-90 the incidence of malignant disease, particularly lymphoid leukaemia and non-Hodgkin lymphomas, in young people aged 0-24 in Seascale was higher than would be expected on the basis of either national rates or those for the surrounding areas. Although this increased risk is unlikely to be due to chance, the reasons for it are still unknown.

Childhood cancer mortality in the European Community, 1950-1989

A descriptive study on childhood cancer mortality was carried out in the European Community (EC) covering the period 1950-1989. An annual total of 3392 cancer deaths were seen among children in the EC during the period 1979-1988, yielding an age-standardised cancer mortality rate of 50 per 10(6). Leukaemia was the most prevalent cause of death among children with cancer (39%). Excess mortality was observed among boys for cancers at all sites combined and for cancers at specific sites, exclusive of malignant tumours of the kidney. This excess is presumed to be due mainly to sex differences in incidence. Markedly higher mortality rates of childhood cancer were seen in southern countries of the EC than in central and northern countries. This difference appeared to be due mainly to differences in cancer incidence among the countries and to a lesser degree to differences in treatment and survival. An overall decline in mortality from childhood cancer in the EC occurred from the early 1960s. In spite of the improvements in survival, however, childhood cancer remains a major cause of death in the EC, affecting about 15% of children between the ages of 1 and 14.

Cytogenetic abnormalities in a disseminated medulloblastoma

A 3-year-old girl developed central nervous system, bone and bone marrow metastases, and hypercalcaemia shortly after presentation with medulloblastoma. Cytogenetic studies of the involved bone marrow showed multiple abnormalities including iso(17q). This chromosome rearrangement has been reported in other cases of recurrent or disseminated medulloblastoma. More studies are required relating the karyotypes of medulloblastomas to long-term outcome to determine if the presence of iso(17q) is a prognostic factor in this malignancy.

Screening for neuroblastoma in the north of England

OBJECTIVE

To determine the feasibility of establishing a system of screening for neuroblastoma.

DESIGN

Prospective study of mass screening in four clearly defined geographical areas.

SETTING

Four health districts of the Northern region of England.

SUBJECTS

20,829 babies aged 6 months, 92% of target population.

INTERVENTIONS

Collection of urine on filter paper for analysis of content of homovanillic and vanillylmandelic acid in relation to urinary creatinine concentrations.

MAIN OUTCOME MEASURES

Derivation of reference range. Identification of babies with homovanillic or vanillylmandelic acid > 3 SD above the mean (positive cases). Investigation of positive cases for evidence of neuroblastoma.

RESULTS

The upper limit of normal (3 SD above the mean) for vanillylmandelic acid was 15 mumol/mmol creatinine and for homovanillic acid 24 mumol/mmol creatinine. Of the 20,829 babies screened, 2537 (12.2%) required a second sample to be taken because the first sample was inadequate. Of these, 527 (2.5%) provided a liquid urine specimen and 10 (0.04%) had positive results for neuroblastoma. Two of them had neuroblastoma (true positives) and eight did not (false positives). A further three children from the cohort were subsequently found to have neuroblastoma; they had raised homovanillic acid or vanillylmandelic acid values, or both, but screened negative at 6 months.

CONCLUSIONS

Screening for neuroblastoma is possible in the health care system of the United Kingdom. Evaluation of the efficacy of screening in reducing the mortality from neuroblastoma requires a controlled trial.

Sarcomas in north west England: III. Survival

Survival data on a population-based series of bone, soft tissue and visceral sarcomas diagnosed in the North West of England between 1982-84 and subjected to histopathological peer review are presented. Five-year crude survival for all cases was 34%. Survival in males and females did not differ significantly (P = 0.6, 5-year survival 32% vs 36%) but was markedly worse for patients diagnosed over the median age of 60 years, even when allowance was made for underlying mortality (P = 0.03, 34% vs 44%). Five-year survival rates for the major site groups were: bone 44%; soft tissues of head, neck and trunk 36%; soft tissues of extremities 35%; female genital tract 35%; retroperitoneum 15%; gastro-intestinal tract 13%. Analysis by the major histological types revealed the following survival rates: leiomyosarcoma--female genital tract 25%, gastro-intestinal tract 14%, non-visceral soft tissue 21%; malignant fibrous histiocytoma of soft tissue 29%; liposarcoma 52%; osteosarcoma of bone 46%; and chondrosarcoma of bone 50%.

Poor prognosis neuroblastoma: is screening the answer?

Neuroblastoma is one of the most common solid tumours of childhood and is unique amongst paediatric cancers in that it results in the urinary excretion of catecholamine metabolites which are easily measured in spot urine samples and so is a condition for which screening may be considered. The continuing poor prognosis associated with late stage disease has stimulated great interest in this proposition. The Japanese have been undertaking pioneering studies of such screening since 1974 and since 1985, all 6 months old babies have been offered screening. Preliminary data would appear to suggest that screening is effective in greatly improving the survival of children with neuroblastoma. However there are difficulties associated with the interpretation of survival data since screening undoubtedly results in the detection of cases which would otherwise have remained 'silent', and the well known problems of lead-time and length-time bias complicate matters still further. The time is not yet ready for universal implementation of screening and further investigation is required.

Childhood cancer in the West Midlands: incidence and survival, 1980-1984, in a multi-ethnic population

The purpose of this study is to describe the incidence and survival of childhood cancer in the West Midlands for the period 1980-1984. Proportional breakdown by Asian subgroup is also considered. A total of 587 patients were registered, 49 of them of Asian origin. Breakdown to Asian versus non-Asian subgroups by diagnosis revealed comparatively high rates for Hodgkin's disease, retinoblastoma and neuroblastoma in the Asian patients. However, a deficit of cases was seen for CNS tumours. Comparison of overall age-standardized rates (ASR) for all cancers revealed a substantially lower value compared to that reported for the USA white population but a similar value to the USA black and UK white populations. Diagnostic breakdown revealed that the major difference between the West Midlands Regional Children's Tumour Research Group (WMRCTRG) and the USA white ASR was in the leukaemia and lymphoma group. Overall survival for the series was 56% at 5 years. The poorest prognosis was found in acute myeloid leukaemia, with only 23% of patients surviving at 5 years, against 62% in acute lymphoblastic leukaemia. CNS tumours also had a poor outcome, with an overall survival rate of 47%, although certain individual diagnoses were more favourable. We observed a 100% survival rate in Hodgkin's disease up to 5 years from diagnosis, and both Wilms' tumour and retinoblastoma had 90% survival rates.

Sarcomas in north west England: II. Incidence

Incidence data on a population-based series of bone, soft tissue and visceral sarcomas from the North West of England are presented. The data are derived mainly from a total of 429 cases registered with the North Western Regional Cancer Registry and diagnosed during the period 1982-84, 76% of which were confirmed as sarcomas by a panel of five pathologists. Overall incidence of confirmed sarcomas per million person years was slightly higher in females (26.81) than in males (24.71) but there was no sex difference when 38 non-reviewed cases were taken into consideration (females 29.07, males (28.83). After exclusion of tumours of female genital tract, incidence of soft tissue tumours was very similar in both sexes (females 18.25, males 18.70). Bone tumours were almost twice as frequent in males (6.01) as in females (3.55).

Trends in survival for childhood cancer in Britain diagnosed 1971-85

Survival rates were analysed for a population-based series of over 15,000 childhood cancers registered in Great Britain during 1971-85. There were highly significant improvements (P less than 0.001 for trend) in survival for many major diagnostic groups. Between 1971-73 and 1983-85 the actuarial 5-year survival rates increased from 37% to 70% for acute lymphoblastic leukaemia, from 4% to 26% for acute non-lymphoblastic leukaemia, from 76% to 88% for Hodgkin's disease, from 22% to 70% for non-Hodgkin's lymphoma, from 61% to 72% for astrocytoma, from 24% to 42% for medulloblastoma, from 15% to 43% for neuroblastoma, from 58% to 79% for Wilms' tumour, from 17% to 54% for osteosarcoma, from 26% to 61% for rhabdomyosarcoma, from 59% to 94% for malignant testicular germ-cell tumours and from 43% to 77% for malignant ovarian germ-cell tumours. These increases in population-based survival rates reflect the substantial advances in treatment of a wide range of childhood cancers since 1970. The two principal diagnostic groups for which there was no evidence of any trend were retinoblastoma, which already had an excellent prognosis with a 5-year survival rate of over 85%, and Ewing's sarcoma, for which the survival rate remained below 45%.

The inter-regional epidemiological study of childhood cancer (IRESCC): case-control study of children with central nervous system tumours

Tumours of the central nervous system comprise 23% of all childhood cancers and form the most common group of solid malignancies. Little is know about their aetiology. The present report concerns the results of a case-control study of 78 incident cases of central nervous system tumours in children. No case-control differences were detected for the following: pre-natal diagnostic X-rays, general anaesthetics during pregnancy, pregnancy infections, pregnancy drugs (including sedatives, tranquillizers and anti-convulsants), alcohol consumption in pregnancy, child's birthweight, breast-feeding, childhood illnesses, previous medication in the child. A significant excess of case mothers had suffered from diseases of the nervous system (RR 2.6). There was a deficit of children who had been immunised among the case children which approached significance, and an excess of congenital abnormalities among cases which also approached significance. There was a small excess of neoplastic disease among case parents. The results of this study suggest that in our patients genetic rather than environmental factors are more important, but the small numbers included in the present study meant that no definite conclusions could be reached.

Biochemical screening for neuroblastoma in infants: a feasibility study

Neuroblastoma is the most common solid tumour of childhood with an incidence of about 1:10,000 births. Prognosis depends on age and stage at presentation and for disseminated disease presenting after the age of 1 year has scarcely altered at all in the past 20 years. In Japan a method has been pioneered of mass population screening of 6-month-old babies using a urine test for the catecholamine metabolites vanillylmandelic acid and homovanillic acid. They have been able to detect the majority of cases at 6 months and have improved the overall prognosis from 25% to 75% survival. A pilot study to assess the feasibility of such a study in the UK has been carried out in the north of England. Methodology has been established for the collection of urine by health visitors and biochemical analysis by gas chromatography with both flame ionisation and mass spectrometry detection; 4,897 samples have been collected, and reference ranges have been established.

Cytogenetic investigations of solid tumours of children

The association of non-random chromosome abnormalities with solid tumours of childhood may improve accuracy of diagnosis and prognosis and lead to a better understanding of their biology. In a pilot study in the Northern region of England fresh tumour biopsy specimens were obtained from 39 to 72 consecutive solid tumours in children who presented over a period of 21 months. Cytogenetic analysis was possible in 33 and clonal chromosomal abnormalities were detected in nine. In addition, seven of 10 tumours investigated after treatment were abnormal. Ten of these 16 abnormal karyotypes have not previously been described. This pilot study has shown that a concerted investigation of tumour cytogenetics is possible. A multicentre study is essential if our knowledge of basic tumour cytogenetics is to progress.

Myeloproliferative disease in children: a demographic study

Over eight years, eight cases of childhood myeloproliferative disease were recognised in the northern region of England (population 3.1 million). Five were classic chronic myeloid leukaemia (CML) and the three others, forms of myeloproliferative disease. No case of juvenile CML was recognised. With the exception of CML, "adult" type myeloproliferative disease of children is underrepresented in the literature and its natural history remains unknown.