The population-based oncological health care study OVIS - recruitment of the patients and analysis of the non-participants

Bias in survival estimates created by a requirement for consent to enter a clinical breast cancer registry

BACKGROUND

A requirement for consent for inclusion may bias the results from a clinical registry. This study gives a direct measure of this bias, based on a population-based clinical breast cancer registry where the requirement for consent was removed after further ethical review and data could be re-analysed.

METHODS

In Auckland, New Zealand, the population-based clinical breast cancer registry required written patient consent for inclusion from 2000-2012. A subsequent ethical review removed this requirement and allowed an analysis of consented and non-consented patients. Kaplan-Meier survival to 10 years (mean follow-up 5.1 years, maximum 13.9 years), demographic and clinical characteristics were compared. Of 9244 women with invasive cancer, 926 (10.4%) were not consented, and of 1642 women with ductal carcinoma in situ, 245 (14.9%) were not consented.

RESULTS

Survival was much higher for consenting patients; invasive cancer, 5 year survival 83.2% (95% confidence limits 82.2-84.1%) for consenting patients, 57.1% (53.0-60.9%) for non-consenting, and 80.8% in all patients. Analyses based only on consenting patients overestimate survival in all patients by around 2% at 2, 5, and 10 years. Non-consented patients were older, more often of Pacific ethnicity, had fewer screen-detected cancers, and more often had metastatic disease; they less frequently had primary surgery or systemic treatments.

CONCLUSION

Data from a registry requiring active consent gives an upward bias in survival results, as non-consenting patients have more extensive disease, less treatment, and lower survival. To give unbiased results active consent should be not required in a clinical cancer registry.

[Signs of social inequality in information seeking and evaluation of information among young women with breast cancer - results of a cohort study]

OBJECTIVE

The extent to which cancer patients are well-informed can have manifold effects. The aim of this study was to explore both the sources of information that young breast cancer patients with children use and how they evaluate the information obtained.

METHODS

Participants were recruited within a rehabilitation program for young mothers with non-metastatic breast cancer (the Groemitz project "gemeinsam gesund werden"). Data on information seeking, the level of information, socio-demographic data and clinical characteristics were collected using a questionnaire.

RESULTS

The patients (n=827) used several additional sources of information - most frequently the internet (69.5%; n=767). The majority felt well informed about their disease and found the information provided easy to understand. A social gradient was observed in relation to media use, information evaluation and obtaining a second opinion.

CONCLUSION

To young breast cancer patients, the internet is crucial for obtaining further information. The indication of a social gradient underlines the importance of addressing the information needs of patients with a lower socioeconomic status.

Early-Onset Breast Cancer: Effect of Diagnosis and Therapy on Fertility Concerns, Endocrine System, and Sexuality of Young Mothers in Germany

Background

The purpose of this study was to analyze the effect of breast cancer therapy on fertility concerns and sexuality of young mothers with breast cancer in Germany.

Methods

During a mother-child rehabilitation program, 1,191 young mothers with locoregional primary breast cancer, treated between 2006 and 2014, were recruited. Data included sociodemographic data, TNM stage, tumor biology, therapies, and patient-reported outcomes such as sexuality and fertility concerns.

Results

The mean age at diagnosis was 40 years. Approximately a quarter of the patients stated that family planning had not been completed at the time of diagnosis. Nearly half of all patients had been informed as to how treatment could affect fertility, but counseling at a specialized fertility center was offered to only 13%. Of all patients, 4% took a consultation and 2% underwent fertility preservation procedures.

Conclusion

Our study indicates that only a minority of patients is referred to fertility centers although family planning is incomplete at the time of diagnosis in about 25% of young women with breast cancer. Thus, these patients should not only be informed about the effects of treatment on fertility and sexuality, but should be referred to a fertility center.

Spiritual Therapy in Coping with Cancer as a Complementary Medical Preventive Practice

There are many of methods of treating cancer. However, the concept of curing the cancer is beyond our current knowledge. Some patients who have the cancer may seek an alternative manner of curing their disease. Alternative medicines, such as spiritual and complementary therapy, are able to cure the cancer and, at the least, are safe. Research on the importance of spirituality in cancer care has mainly been performed in geographically heterogeneous populations. The results are limited to these specific religious-cultural contexts and enlightened by contributions from ethnicity and religion. This article focused on the religiousness and spiritual support of cancer patients from diverse and heterogeneous groups around the globe. An electronic search of peer-reviewed articles was systematically performed to obtain the relevant literature with the CINAHL, PsycINFO, and PubMed databases. The keywords included religion, cancer, illness, psychotherapy, and spiritual and alternative treatment/therapies. The inclusion criteria for the reviews were that the documents were original quantitative research and published in English. Articles that were not directly relevant to the present objective were excluded. The present outcome of these review resources suggest that it may be helpful for clinicians to address spirituality, particularly with regard to prevention, healing, and survival of cancer patients. This article indicates that it may be useful for clinical oncologists to be informed of the prevalence of the use of spiritual medicine in their specialized field. In addition, patients should routinely be asked about the use of spiritual medicine as part of every cancer patient's evaluation.

The Treatment of Primary Breast Cancer in Older Women With Adjuvant Therapy: A Retrospective Analysis of Data From Over 3000 Patients From the PATH Biobank, With Two-Year Follow-up

BACKGROUND

Breast cancer is the most common cancer in women in Germany. Mortality from breast cancer has declined over the past 15 years, but less so in women aged 70 or older than in younger women. The discrepancy might be explained by age-related differences in treatment.

METHODS

Data from the Patients' Tumor Bank of Hope (PATH) database of women who underwent adjuvant treatment for the treatment of an invasive primary tumor without distant metastases (year of diagnosis, 2006-2011) were retrospectively analyzed. The clinical and tumor-biological findings and treatment data over two years of follow-up were compared across three age groups (under age 50, ages 50 to 69, and ages 70 and up). Chi-square tests were carried out to reveal significant differences, and post-hoc multiple comparisons were performed with and without Bonferroni correction. Treatment data were adjusted for staging and grading and tested for age-dependence with logistic regression.

RESULTS

Follow-up data were available for 3257 (65% ) of 4981 women, of whom 61% were in the middle age group and 22% in the oldest. Compared to women aged 50 to 69, those aged 70 and up less commonly received breast-conserving treatment (68.8% vs. 86.4% ), chemotherapy (27.5% vs. 44.1% ), radiotherapy (81.8% vs. 92.4% ), and trastuzumab (52.9% vs. 79.3% ; p<0.001 for all differences). All differences remained significant after stastistical adjustment.

CONCLUSION

The cause of these age-related differences is unclear. It cannot be determined from these data whether concomitant disease, the older patients' individual decisions, or other factors were responsible for their not receiving treatment as often as the younger patients did.

Recruitment of a Population-Based Sample of Young Black Women with Breast Cancer through a State Cancer Registry

Given that Black women remain underrepresented in clinical research studies, we sought to recruit a population-based sample of young Black women with breast cancer through a state cancer registry. Demographic and clinical information on all Black women diagnosed with invasive breast cancer at or below age 50 between 2009 and 2012 in Florida was obtained through the state cancer registry. Survivors were invited to participate in the study through state-mandated recruitment methods. Participant demographic and clinical characteristics were compared using Chi-squared tests for categorical variables and the two sample t-test for continuous variables to identify differences between: (i) consented participants versus all other eligible; and (ii) living versus deceased. Of the 1,647 young Black women with breast cancer, mean age at diagnosis was 42.5, with the majority having localized or regional disease, unmarried, privately insured, and employed. There were no significant differences in demographic and clinical variables between the 456 consented study participants versus the remaining 1,191 presumed eligible individuals. Compared to potential participants, women determined to be deceased prior to recruitment (n = 182) were significantly more likely to have distant disease and a triple-negative phenotype. They were also significantly more likely to be unemployed, and uninsured or have public insurance (i.e., Medicaid or Medicare). Our results demonstrate that recruitment of a population-based sample of breast cancer survivors through a state cancer registry is a feasible strategy in this underserved and underrepresented population. However, survival bias, which was observed due to the lag time between diagnosis and recruitment, is important to adjust for when generalizing findings to all young Black breast cancer patients.

Guideline conformity treatment in young women with early-onset breast cancer in Germany

BACKGROUND

The purpose of the study was to characterize the treatment of young mothers with breast cancer in Germany and to investigate whether it followed applicable guidelines.

METHOD

Retrospective data obtained between 2002 and 2011 for 1,053 mothers with children of < 12 years of age with adjuvantly treated loco-regional primary breast cancer were analyzed. Collected data included sociodemographic data, TNM stage, biology of tumor and therapies. Actually received therapies were compared to those suggested in guideline treatment plans.

RESULTS

The mean age of the patients was 39 years. 97% of the women with node positivity received an axillary dissection. Overall, 90% of the patients received chemotherapy with a guideline adherence range of 87-99% depending on clinical parameters. For radiation therapy, guideline adherence was high (range 82-100%). 95% of the patients with a hormone receptor-positive tumor received endocrine therapy; in 94%, tamoxifen therapy was performed in compliance with guidelines, whereas gonadotropin-releasing hormone (GnRH) agonist therapy complied with the guidelines in 52% of the cases.

CONCLUSION

Guideline adherence in young mothers with breast cancer in Germany was high (with the exception of GnRH therapy), as comorbidity or the ambiguity of the therapeutic success does not need to be considered as much in this young, otherwise usually healthy, cohort compared to an age-heterogeneous group.

Participation in questionnaire studies among couples affected by breast cancer

OBJECTIVE

Participation bias may be a problem in couple-based psychosocial studies. Therefore, it is important to investigate the characteristics associated with participation. The aim of this study was to analyze whether participation in a longitudinal psychosocial questionnaire study among couples affected by breast cancer was associated with socioeconomic, breast cancer-specific, and other health-related characteristics of the patients and partners.

METHODS

The analyzes are based on 2254 couples who were invited to participate in a nationwide survey on psychosocial adjustment among couples dealing with breast cancer. Participating couples (N = 792) were compared with non-participating couples (N = 1462) with regard to socioeconomic and health-related characteristics obtained from nationwide clinical and administrative registers.

RESULTS

Associations were seen between various socioeconomic variables and couple participation. The patient characteristics older age (OR = 0.15 [95% CI = 0.07-0.55]), low education (OR = 1.95 [95% CI = 1.46-2.68]), disability pension (OR = 0.59 [95% CI = 0.39-0.55]), or non-western ethnicity (OR = 0.36 [95% CI = 0.15-0.82]) reduced couple participation. The partner characteristics older age (OR = 0.23 [95% CI = 0.15-0.43]), low education (OR = 1.67 [95% CI = 1.25-2.22]), receiving disability pension (OR = 0.46 [95% CI = 0.25-0.82]), non-western ethnicity (OR = 0.17 [95% CI = 0.06-0.49]), or high morbidity (OR = 0.76 [95% CI = 0.60-0.96]) also reduced couple participation. Furthermore, couples with low income (OR = 1.49 [95% CI = 1.16-1.95]) had reduced participation. No associations were found between couple participation and breast cancer-related variables.

CONCLUSIONS

Socioeconomic characteristics of patients and partners, and morbidity of partners may influence participation in couple-based psychosocial breast cancer research. Breast cancer-related characteristics do not seem to influence participation.

Patients and Methods of the PATH Biobank - A Resource for Breast Cancer Research

Introduction: The foundation PATH (Patients' Tumour Bank of Hope) collects in a tumour bank samples of blood, tumour, and tumour-near normal tissue from breast cancer patients and supplements them systematically with health-care data. Material and Methods: For patients from the diagnosis years 2006-2009 quantitative data were evaluated with the help of mean values and standard deviations while for qualitative data absolute and relative incidences were assessed. Demographic and clinical features of women who used different numbers of information sources were tested for statistical significance by means of ANOVA and χ² tests. The benchmark report of the WBC and two DMP reports were used to compare oncological care. Results: For research purposes tumour tissue samples are available for 59 % of the cases, normal tissue for 62 % and blood serum samples for 92 %. From 3573 women (diagnoses 2006-2009), a total of 2697 women (75.5 %) took part in follow-up. The characteristics of the follow-up patients did not relevantly differ from those of all the patients. The responsible physician was named as the most important source of information about the disease. Young women in particular consulted several sources and also used the internet to obtain information. Discussion: Compared with data on therapy from WBC and the DMP breast cancer in Bavaria or, respectively, North Rhineland reports, the PATH patients represent an only slightly selected sample. The PATH biobank is a (still) poorly used data and sample source, which is made available upon request and positive evaluation of the study protocol. Thus, it is possible to address current questions in a short time without having to undertake extensive recruiting procedures.

Characteristics of cases with unknown stage prostate cancer in a population-based cancer registry

BACKGROUND

The New South Wales Central Cancer Registry (NSW CCR) is the only population-based cancer registry in Australia that has routinely collected summary stage at diagnosis since its inception in 1972. However, a large proportion of prostate cancer cases have "unknown" stage recorded by the registry. We investigated the characteristics of prostate cancer cases with "unknown" stage recorded by the NSW CCR, and examined survival for this group.

METHODS

Data were obtained from the NSW CCR for all first primary prostate cancer cases diagnosed in 1999-2007. Summary stage was recorded as localised, regional, distant or "unknown". Associations between disease stage and patient characteristics (age, place of residence at diagnosis, year of diagnosis and country of birth) and prostate cancer specific survival were investigated using multivariable logistic regression and Cox proportional hazards models respectively.

RESULTS

Of 39852 prostate cancer cases, 41.8% had "unknown" stage recorded by the NSW CCR. This proportion decreased significantly over time, increased with increasing age at diagnosis and was higher for those living in socio-economically disadvantaged areas. The proportion with "unknown" stage varied across area health services. Prostate cancer specific survival for cases with "unknown" stage was significantly poorer than for those with localised stage but better than for those with regional or distant stage.

CONCLUSIONS

Researchers or others using cancer registry stage data to examine prostate cancer outcomes need to consider the differences between cases with "unknown" stage at diagnosis and those with known stage recorded by the registry, and what impact this may have on their results.

Different aspects of self-reported quality of life in 450 german melanoma survivors

The present study was aimed at assessing quality of life (QoL) in a total of 450 melanoma patients who filled out the EORTC QLQ-C30 (Q1; 15 months post diagnosis) as part of the OVIS Study. Follow-up questionnaires (Q2) were administered two years after Q1. The analyses presented herein were based on the following assumptions: QoL of melanoma patients is worse than that of a German reference population. Further, both tumor location and tumor stage have an influence on self-reported QoL, with patients with tumors located on face, head, neck, and advanced tumor stage (T3/T4) reporting the worst QoL levels. Finally, patients' QoL improves over time based on the theory of disease adaptation. In contrast to the above assumptions, with the exception of global health/QoL scores, differences between OVIS and the reference population were below the minimal clinical important difference of ten points. Furthermore, no clinically meaningful differences were found between patients after stratifying our data by tumor location and tumor stage. Finally, no clinically relevant changes were seen between Q1 and Q2 across all scales of the EORTC QLQ-C30. However, when data were stratified by patients with stable disease versus those with progression, clinically relevant differences were found between Q1 and Q2 predominantly in women in the latter group regarding emotional function, insomnia, dyspnoea, and fatigue. The lack of clinically meaningful differences across strata (tumor location; tumor stage), time, and patients compared to a reference population is surprising. However, it is possible that the instrument used, a generic QoL instrument, is generally not sensitive enough to detect differences in melanoma patients. Our findings may further be explained by the fact that all patients included in our sample had been diagnosed well before Q1, i.e., main illness adaptation processes may have occurred before study entry.

Recruitment of representative samples for low incidence cancer populations: do registries deliver?

Background

Recruiting large and representative samples of adolescent and young adult (AYA) cancer survivors is important for gaining accurate data regarding the prevalence of unmet needs in this population. This study aimed to describe recruitment rates for AYAs recruited through a cancer registry with particular focus on: active clinician consent protocols, reasons for clinicians not providing consent and the representativeness of the final sample.

Methods

Adolescents and young adults aged 14 to19 years inclusive and listed on the cancer registry from January 1 2002 to December 31 2007 were identified. An active clinician consent protocol was used whereby the registry sent a letter to AYAs primary treating clinicians requesting permission to contact the survivors. The registry then sent survivors who received their clinician's consent a letter seeking permission to forward their contact details to the research team. Consenting AYAs were sent a questionnaire which assessed their unmet needs.

Results

The overall consent rate for AYAs identified as eligible by the registry was 7.8%. Of the 411 potentially eligible survivors identified, just over half (n = 232, 56%) received their clinician's consent to be contacted. Of those 232 AYAs, 65% were unable to be contacted. Only 18 AYAs (7.8%) refused permission for their contact details to be passed on to the research team. Of the 64 young people who agreed to be contacted, 50% (n = 32) completed the questionnaire.

Conclusions

Cancer registries which employ active clinician consent protocols may not be appropriate for recruiting large, representative samples of AYAs diagnosed with cancer. Given that AYA cancer survivors are highly mobile, alternative methods such as treatment centre and clinic based recruitment may need to be considered.