Seizing the moment: The time for harnessing electronic patient-reported outcome measures for enhanced and sustainable metastatic breast cancer care is now

The sustainability of healthcare systems is under pressure. Unlike care for many other chronic diseases, cancer care has yet to empower patients in effectively self-managing both the medical and emotional consequences of their condition, including adapting to changes in lifestyle and work, which is essential to achieve optimal health and recovery. Although proposed as a potential solution for sustainable healthcare and support for optimal health and recovery already decades ago, practical implementation of digital care lags behind. We believe electronic patient reported outcome measures (ePROMs) could play an important role in creating sustainable healthcare, both to guide complex treatment pathways and to empower survivors to self-manage consequences of diagnosis and treatment. That is, ePROMs can be used for screening and monitoring of symptoms, but also for treatment decision-making and to facilitate communication about quality of life. We therefore see opportunities for improvements in quality of care, quality of life, and survival of cancer patients, as well as research opportunities, as ePROMs collection can lead to better understanding of care needs. The '10 Actions for Change report' of the Advanced Breast Cancer Global Alliance stresses a critical need for improvement of care for metastatic breast cancer (MBC) patients. We therefore in this paper focus on MBC care and research.

Cancer worry is associated with increased use of supportive health care-results from the multinational InCHARGE study

PURPOSE

To assess use of health care following a diagnosis of endometrial, cervical, and ovarian cancer in the Netherlands, Norway, and Denmark. Furthermore, to analyze the association between cancer worry and use of supportive care.

METHODS

An international multicenter cross-sectional questionnaire study was undertaken among female cancer survivors with endometrial, cervical, or ovarian cancer 1-7 years post diagnosis. We investigated different aspects of cancer survivorship and follow-up care. Health care use included information on the use of supportive health care, general practitioner (GP), and follow-up visits to the department of gynecology. Cancer worry was assessed with the Impact of Cancer (IoCv2) questionnaire.

RESULTS

A total of 1433 women completed the questionnaire. Health care use decreased from time of diagnosis and was higher among cervical and ovarian cancer survivors than endometrial cancer survivors. Twenty-five percent of the women with ovarian cancer reported severe cancer worry, in contrast to 10 and 15% of women diagnosed with endometrial and cervical cancer, respectively. Women with severe worry had significantly higher use of supportive care activities. In a multivariable regression analysis, cancer worry remained a significant correlate for use of supportive health care services irrespective of disease severity or prognosis. The strongest association was found for use of a psychologist (OR 2.1 [1.71-2.58]).

CONCLUSION

Cancer worry is associated with increased use of supportive care.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted, timely, and accessible psychological support aimed at severe cancer worry may improve survivorship care and ensure optimal referral of patients in need of additional care.

Patient-reported outcome measures compared to clinician reported outcomes regarding incontinence and erectile dysfunction in localized prostate carcinoma after robot assisted radical prostatectomy: Impact on management

PURPOSE/ BACKGROUND

Patient-reported outcome measures (PROMs) are widely used after robot assisted radical prostatectomy (RARP) in order to evaluate the impact/burden of the treatment. The most bothersome side effects of RARP are urine incontinence (UI) and erectile dysfunction (ED). During the follow up consultations, clinicians report these side effects in interviewing patients. Our study examined the discrepancy between the PROMs and clinician report outcomes (CROs) and hypothesized that the disagreement could have an impact on the management of UI and ED.

METHODS

Up to 1 year after RARP, UI and ED recovery of 312 men with localized and locally advanced prostate cancer were assessed using the International Consultation Incontinence Questionnaire Short-Form (ICIQ-SF) and the International Index of Erectile Function (IIEF-EF) and CROs by interview. Discrepancies between PROs and CROs were studied in light of treatment offered and management.

RESULTS

The ICIQ-SF Score matched with CROs in all sum score categories except in ICIQ sum score 6 to 12; here the UI was underreported by clinicians in 58% and 59% of patients at 8 and 12 months (P < 0.001). Furthermore, at 8 and 12 months postoperatively, clinicians underreported UI in 29% and 23% of patients with ICIQ score 13-18 (P < 0.001). The clinician significantly over-reported the recovery of erectile function ("normal erection") (P < 0.001), especially in men with IIEF-EF sum score 6 to 16. Independently of ICIQ-SF/IIEF-EF scores, discrepancy between PROs and CROs did not affect rate of health care offered to patients.

CONCLUSIONS

This is to our knowledge the first study that compared the PROs with clinician reported functional outcomes and the impact of discrepancies on the management of side effects of RARP in prostate cancer. Observed discrepancies between the PROs and CROs did not affect offered management and counseling of UI and ED.

Health-state utilities in long-term advanced melanoma survivors comparable with the general population

BACKGROUND

Checkpoint inhibitors have been shown to substantially improve the survival of patients with advanced melanoma. With this growing group of survivors treated with immunotherapies, assessing their health-state utilities is essential and can be used for the calculation of quality-adjusted life years and for cost-effectiveness analyses. Therefore, we evaluated the health-state utilities in long-term advanced melanoma survivors.

METHODS

Health-state utilities were evaluated in a cohort of advanced melanoma survivors 24-36 months (N = 37) and 36-plus months (N = 47) post-ipilimumab monotherapy. In addition, the health-state utilities of the 24-36 months survivor group were assessed longitudinally, and utilities of the combined survival groups (N = 84) were compared with a matched control population (N = 168). The EQ-5D was used to generate health-state utility values, and quality-of-life questionnaires were used to establish correlations and influencing factors of utility scores.

RESULTS

Health-state utility scores were similar between the 24-36 months'- and the 36-plus months' survival group (0.81 vs 0.86; p = .22). In survivors, lower utility scores were associated with symptoms of depression (β = - .82, p = .022) and fatigue burden (β = - .29, p = .007). Utility scores did not significantly change after 24-36 months of survival, and the utilities of survivors were comparable to the matched control population (0.84 vs 0.87; p = .07).

DISCUSSION

Our results show that long-term advanced melanoma survivors treated with ipilimumab monotherapy experience relatively stable and high health-state utility scores.

"One more chance to survive": the experiences of patients with advanced melanoma and their partners with tumor-infiltrating lymphocyte therapy-a qualitative study and recommendations for future care

PURPOSE

Patients with advanced melanoma refractory to first-line treatment have a need for effective second-line treatment options. A recent phase 3 trial showed promising results for adoptive cell therapy with tumor-infiltrating lymphocytes (TILs) as second-line therapy in patients with advanced melanoma. However, it remains unknown how patients and their partners experience TIL therapy, which is key to evaluate and improve the quality of care.

METHODS

Semi-structured interviews about the experience of TIL therapy were conducted with patients with advanced melanoma and their partners 2-4 weeks post-treatment (short term) and >6 months after treatment (long term).

RESULTS

In total, 25 interviews were conducted with advanced melanoma patients treated with TIL (n=13) and their partners (n=12), with the majority being short-term interviews (n=17). Overall, patients and partners experienced TIL therapy as intense (uncertainty of successful TIL culture, multiple treatment-related toxicities, and extensive hospitalization). Patients and partners with young children or other caregiving responsibilities encountered the most challenges during TIL therapy. All patients, however, reported a recovery of all treatment-related toxicities within 2-4 weeks (except fatigue).

CONCLUSION

Clinical data justify the role of TIL therapy in the treatment of advanced melanoma. With the distinct nature of TIL therapy compared to the current standard of care, we have provided patient-centered recommendations that will further enhance the quality of TIL therapy.

IMPLICATIONS FOR CANCER SURVIVORS

As more patients with advanced melanoma are expected to receive TIL therapy in the future, our findings could be incorporated into survivorship care plans for this novel group of advanced melanoma survivors treated with TIL.

International development of a patient-centered core outcome set for assessing health-related quality of life in metastatic breast cancer patients

PURPOSE

For patients living with metastatic breast cancer (MBC), achieving best possible health-related quality of life, along with maximizing survival, is vital. Yet, we have no systemic way to determine if we achieve these goals. A Core Outcome Set (COS) that allows standardized measurement of outcomes important to patients, but also promotes discussing these outcomes during clinical encounters, is long overdue.

METHODS

An international expert group (EG) of patient advocates, researchers, medical specialists, nurse specialists, and pharmaceutical industry representatives (n = 17) reviewed a list of relevant outcomes retrieved from the literature. A broader group (n = 141: patients/patient advocates (n = 45), health care professionals/researchers (n = 64), pharmaceutical industry representatives (n = 28), and health authority representatives (n = 4)) participated in a modified Delphi procedure, scoring the relevance of outcomes in two survey rounds. The EG finalized the COS in a consensus meeting.

RESULTS

The final MBC COS includes 101 variables about: (1) health-related quality of life (HRQoL, n = 26) and adverse events (n = 24); (2) baseline patient characteristics (n = 9); and (3) clinical variables (n = 42). Many outcome that cover aspects of HRQoL relevant to MBC patients are included, e.g. daily functioning (including ability to work), psychosocial/emotional functioning, sexual functioning, and relationship with the medical team.

CONCLUSION

The COS developed in this study contains important administrative data, clinical records, and clinician-reported measures that captures the impact of cancer. The COS is important for standardization of clinical research and implementation in daily practice and has received accreditation by the International Consortium for Health Outcomes Measurement (ICHOM).

Prognostic value of patient-reported quality of life for survival in oesophagogastric cancer: analysis from the population-based POCOP study

BACKGROUND

Accumulating evidence of trials demonstrates that patient-reported health-related quality of life (HRQoL) at diagnosis is prognostic for overall survival (OS) in oesophagogastric cancer. However, real-world data are lacking. Moreover, differences in disease stages and tumour-specific symptoms are usually not taken into consideration. The aim of this population-based study was to assess the prognostic value of HRQoL, including tumour-specific scales, on OS in patients with potentially curable and advanced oesophagogastric cancer.

METHODS

Data were derived from the Netherlands Cancer Registry and the patient reported outcome registry (POCOP). Patients included in POCOP between 2016 and 2018 were stratified for potentially curable (cT1-4aNallM0) or advanced (cT4b or cM1) disease. HRQoL was measured with the EORTC QLQ-C30 and the tumour-specific OG25 module. Cox proportional hazards models assessed the impact of HRQoL, sociodemographic and clinical factors (including treatment) on OS.

RESULTS

In total, 924 patients were included. Median OS was 38.9 months in potentially curable patients (n = 795) and 10.6 months in patients with advanced disease (n = 129). Global Health Status was independently associated with OS in potentially curable patients (HR 0.89, 99%CI 0.82-0.97), together with several other HRQoL items: appetite loss, dysphagia, eating restrictions, odynophagia, and body image. In advanced disease, the Summary Score was the strongest independent prognostic factor (HR 0.75, 99%CI 0.59-0.94), followed by fatigue, pain, insomnia and role functioning.

CONCLUSION

In a real-world setting, HRQoL was prognostic for OS in patients with potentially curable and advanced oesophagogastric cancer. Several HRQoL domains, including the Summary Score and several OG25 items, could be used to develop or update prognostic models.

The eHealth self-management application 'Oncokompas' that supports cancer survivors to improve health-related quality of life and reduce symptoms: which groups benefit most?

BACKGROUND

Oncokompas is a web-based self-management application that supports cancer survivors to monitor their health-related quality of life (HRQOL) and symptoms, and to obtain personalised feedback and tailored options for supportive care. In a large randomised controlled trial among survivors of head and neck cancer, colorectal cancer, and breast cancer and (non-)Hodgkin lymphoma, Oncokompas proved to improve HRQOL, and to reduce several tumour-specific symptoms. Effect sizes were however small, and no effect was observed on the primary outcome patient activation. Therefore, this study aims to explore which subgroups of cancer survivors may especially benefit from Oncokompas.

MATERIALS AND METHODS

Cancer survivors (n = 625) were randomly assigned to the intervention group (access to Oncokompas, n = 320) or control group (6 months waiting list, n = 305). Outcome measures were HRQOL, tumour-specific symptoms, and patient activation. Potential moderators included socio-demographic (sex, age, marital status, education, employment), clinical (tumour type, stage, time since diagnosis, treatment modality, comorbidities), and personal factors (self-efficacy, personal control, health literacy, Internet use), and patient activation, mental adjustment to cancer, HRQOL, symptoms, and need for supportive care, measured at baseline. Linear mixed models were performed to investigate potential moderators.

RESULTS

The intervention effect on HRQOL was the largest among cancer survivors with low to moderate self-efficacy, and among those with high personal control and those with high health literacy scores. Cancer survivors with higher baseline symptom scores benefitted more on head and neck (pain in the mouth, social eating, swallowing, coughing, trismus), and colorectal cancer (weight) specific symptoms.

DISCUSSION

Oncokompas seems most effective in reducing symptoms in head and neck cancer and colorectal cancer survivors who report a higher burden of tumour-specific symptoms. Oncokompas seems most effective in improving HRQOL in cancer survivors with lower self-efficacy, and in cancer survivors with higher personal control, and higher health literacy.

Multicenter randomized controlled trial to evaluate the efficacy and tolerability of frozen gloves for the prevention of chemotherapy-induced peripheral neuropathy

BACKGROUND

This study investigated the efficacy and tolerability of wearing frozen gloves (FGs) during chemotherapy to prevent chemotherapy-induced peripheral neuropathy (CIPN) as reported by patients and influence on quality of life (QoL).

PATIENTS AND METHODS

Cancer patients starting treatment with oxaliplatin, docetaxel or paclitaxel between February 2013 and May 2016 at the medical oncology department were eligible. Patients were randomized into groups wearing FGs on both hands during treatment and those not wearing FGs during treatment. Self-reported CIPN and QoL were measured with the European Organisation for the Research and Treatment of Cancer Quality of Life (EORTC QLQ) CIPN20 and QLQ-C30 at four time points: baseline (t₀), after three cycles (t₁), end of chemotherapy (t₂) and after 6 months (t₃).

RESULTS

The study included 180 patients with 90 patients in both arms. They mostly underwent treatment of colorectal or breast cancer. Thirty-one patients (34%) discontinued FGs, mainly due to discomfort. Intention-to-treat analyses showed no important differences in reported EORTC QLQ CIPN20 subscales between the FG group and control group; however, the analyses showed the patients experienced reduced tingling in fingers/hands [β = -10.20, 95% confidence interval (CI) = -3.94 to -3.14, P = 0.005] and less trouble opening a jar or bottle due to loss of strength in hands (β = -6.97, 95% CI = -13.53 to -0.40, P = 0.04) in the FG group compared with the control group. Per-protocol analyses showed similar results: reduced aching or burning pain in fingers/hands (β = -4.37, 95% CI = -7.90 to -0.83, P = 0.02) and cramps in hands (β = -3.76, 95% CI = -7.38 to -0.14, P = 0.04). Differences in tingling in fingers/hands at t₁ were clinically relevant. In addition, those treated with FGs reported overall better QoL (β = 4.79, 95% CI = 0.37 to 9.22, P = 0.03) and physical functioning (β = 5.66, 95% CI = 1.59 to 9.73, P = 0.007) than the control. No difference in dose reductions was observed.

CONCLUSIONS

No difference in CIPN subscales was reported between intervention arms. Wearing FGs might reduce some neuropathy symptoms in the hands, potentially resulting in a better QoL; however, one-third of the FG group discontinued the study before the end of treatment. Future studies should focus on the method of limb hypothermia to prevent CIPN.

TRIAL REGISTRATION NUMBER

NL39650.015.12.

Health-related quality of life of long-term advanced melanoma survivors treated with anti-CTLA-4 immune checkpoint inhibition compared to matched controls

BACKGROUND

Checkpoint inhibitors have changed overall survival for patients with advanced melanoma. However, there is a lack of data on health-related quality of life (HRQoL) of long-term advanced melanoma survivors, years after treatment. Therefore, we evaluated HRQoL in long-term advanced melanoma survivors and compared the study outcomes with matched controls without cancer.

MATERIAL AND METHODS

Ipilimumab-treated advanced melanoma survivors without evidence of disease and without subsequent systemic therapy for a minimum of two years following last administration of ipilimumab were eligible for this study. The European Organization for Research and Treatment of Cancer quality of life questionnaire Core 30 (EORTC QLQ-C30), the Multidimensional Fatigue Inventory (MFI), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-Melanoma questionnaire (FACT-M) were administered. Controls were individually matched for age, gender, and educational status. Outcomes of survivors and controls were compared using generalized estimating equations, and differences were interpreted as clinically relevant according to published guidelines.

RESULTS

A total of 89 survivors and 265 controls were analyzed in this study. After a median follow-up of 39 (range, 17-121) months, survivors scored significantly lower on physical (83.7 vs. 89.8, difference (diff) = -5.80, p=.005), role (83.5 vs. 90, diff = -5.97, p=.02), cognitive (83.7 vs. 91.9, diff = -8.05, p=.001), and social functioning (86.5 vs. 95.1, diff = -8.49, p= <.001) and had a higher symptom burden of fatigue (23.0 vs. 15.5, diff = 7.48, p=.004), dyspnea (13.3 vs. 6.7, diff = 6.47 p=.02), diarrhea (7.9 vs. 4.0, diff = 3.78, p=.04), and financial impact (10.5 vs. 2.5, diff = 8.07, p=.001) than matched controls. Group differences were indicated as clinically relevant.

DISCUSSION

Compared to matched controls, long-term advanced melanoma survivors had overall worse functioning scores, more physical symptoms, and financial difficulties. These data may contribute to the development of appropriate survivorship care.

Cost-utility of an eHealth application 'Oncokompas' that supports cancer survivors in self-management: results of a randomised controlled trial

Purpose

The eHealth self-management application ‘Oncokompas’ was developed to support cancer survivors in monitoring health-related quality of life (HRQOL) and symptoms, and obtaining personalized feedback and options for supportive care. The aim of this study was to assess the cost-utility of Oncokompas compared with care as usual (CAU) among cancer survivors.

Methods

Survivors were randomly allocated to the intervention or control group. Direct (non-)medical, indirect non-medical costs, and HRQOL were measured at 3- and 6-month follow-up, using iMTA Medical Consumption and Productivity Costs and the EuroQol-5D questionnaires. Mean cumulative costs and quality-adjusted life-years (QALYs) were compared between both groups.

Results

In total, 625 survivors were randomized into intervention (n = 320) or control group (n = 305). Base case analysis showed that incremental costs from a societal perspective were − €163 (95% CI, − 665 to 326), and incremental QALYs were 0.0017 (95% CI, − 0.0121 to 0.0155) in the intervention group compared with those in the control group. The probability that, compared with CAU, Oncokompas is more effective was 60%, less costly 73%, and both more effective and less costly 47%. Sensitivity analyses showed that incremental costs vary between − €40 and €69, and incremental QALYs vary between − 0.0023 and − 0.0057.

Conclusion

Oncokompas is likely to be equally effective on utilities, and not more expensive than CAU, and will therefore contribute to sustainable cancer survivorship care in a (cost-)effective manner.

Implications for Cancer Survivors

Oncokompas seems to improve HRQOL and reduces the burden of several tumour-specific symptoms, while costs from a societal perspective are similar to CAU.

Electronic supplementary material

The online version of this article (10.1007/s11764-020-00912-9) contains supplementary material, which is available to authorized users.

Painful and non-painful chemotherapy-induced peripheral neuropathy and quality of life in colorectal cancer survivors: results from the population-based PROFILES registry

Purpose

This study aims to (1) examine the prevalence of painful versus non-painful chemotherapy-induced peripheral neuropathy (CIPN) among long-term colorectal cancer (CRC) survivors, (2) identify sociodemographic, clinical, and psychological factors associated with painful and non-painful CIPN, and (3) examine the associations of painful CIPN with health-related quality of life (HRQoL) in comparison with non-painful CIPN, i.e., numbness/tingling.

Methods

All CRC survivors diagnosed between 2000 and 2009 as registered by the population-based Netherlands Cancer Registry (Eindhoven region) were eligible for participation. Chemotherapy-treated survivors (n = 477) completed questions on CIPN (EORTC QLQ-CIPN20) and HRQoL (EORTC QLQ-C30).

Results

Painful CIPN was reported by 9% (n = 45) of survivors and non-painful CIPN was reported by 22% (n = 103). Time since diagnosis was related to painful CIPN, and time since diagnosis, a higher disease stage, osteoarthritis, and more anxiety symptoms were related to non-painful CIPN. Finally, survivors with painful CIPN reported a worse global quality of life and worse physical, role, cognitive, and social functioning compared to survivors with non-painful CIPN and those without any sensory CIPN. No differences were found between survivors with non-painful CIPN and those without sensory CIPN.

Conclusions

It seems that painful CIPN must be distinguished from non-painful CIPN, as only painful CIPN was related to a worse HRQoL. Future research is needed to examine whether painful CIPN must be distinguished from non-painful CIPN regarding predictors, mechanisms, and treatment.

Cancer survivor perspectives on sharing patient-generated health data with central cancer registries

PURPOSE

Central cancer registries collect data and provide population-level statistics that can be tracked over time; yet registries may not capture the full range of clinically relevant outcomes. Patient-generated health data (PGHD) include health/treatment history, biometrics, and patient-reported outcomes (PROs). Collection of PGHD would broaden registry outcomes to better inform research, policy, and care. However, this is dependent on the willingness of patients to share such data. This study examines cancer survivors' perspectives about sharing PGHD with central cancer registries.

METHODS

Three U.S. central registries sampled colorectal, non-Hodgkin lymphoma, and metastatic breast cancer survivors 1-4 years after diagnosis, recruiting them via mail to participate in one of seven focus groups (n = 52). Group discussions were recorded, transcribed, and thematically analyzed.

RESULTS

Most survivor-participants were unaware of the existence of registries. After having registries explained, all participants expressed their willingness to share PGHD with them if treated confidentially. Participants were willing to provide information on a variety of topics (e.g., medical history, medications, symptoms, financial difficulties, quality of life, biometrics, nutrition, exercise, and mental health), with a focus on long-term effects of cancer and its treatment. Participants' preferred mode for providing data varied. Participants were also interested in receiving information from registries.

CONCLUSIONS

Our results suggest that registry-based collection of PGHD is acceptable to most cancer survivors and could facilitate registry-based efforts to collect PGHD/PROs. Central cancer registry-based collection of PGHD/PROs, especially on long-term effects, could enhance registry support of cancer control efforts including research and population health management.

Older ovarian cancer survivors report lower long-term health-related quality of life than younger survivors: A study from the population-based profiles registry

OBJECTIVE

To assess long-term differences in health-related quality of life (HRQoL) of older ovarian cancer survivors compared to both an age-matched normative population and to younger survivors. In addition, the differential effect of chemotherapy on HRQoL between older and younger survivors was compared.

METHODS

Ovarian cancer survivors (n = 348) diagnosed between 2000 and 2010, as registered by the Dutch population-based Eindhoven Cancer Registry, were invited to complete the EORTC QLQ-C30 HRQoL questionnaire in 2012. HRQoL outcomes of survivors were compared with an age-matched normative population and older survivors (≥70 years) were compared with younger survivors.

RESULTS

The questionnaire was returned by 191 ovarian cancer survivors (55%), 31% were aged ≥70 years (n = 59). Compared to the normative population, survivors ≥70 years scored lower on global health status and all functioning subscales except emotional functioning, and they reported more symptoms. Survivors aged <70 years only reported worse physical and cognitive functioning in comparison with the normative population. Most differences were of medium to small clinical relevance. Age appeared to moderate the effect of chemotherapy on HRQoL. Older survivors who had received chemotherapy experienced better physical functioning and less pain and insomnia while the opposite was found in younger survivors.

CONCLUSION

In comparison with an age-matched normative population, older ovarian cancer survivors report lower HRQoL scores than younger survivors. As this represents a selection of long-term survivors, future research should focus on the trajectory of HRQoL from diagnosis throughout treatment and follow-up to identify which factors are related to worse HRQoL in the entire older ovarian cancer population and whether timely interventions are able to improve HRQoL.

Nationwide comprehensive gastro-intestinal cancer cohorts: the 3P initiative

BACKGROUND

The increasing sub-classification of cancer patients due to more detailed molecular classification of tumors, and limitations of current trial designs, require innovative research designs. We present the design, governance and current standing of three comprehensive nationwide cohorts including pancreatic, esophageal/gastric, and colorectal cancer patients (NCT02070146). Multidisciplinary collection of clinical data, tumor tissue, blood samples, and patient-reported outcome (PRO) measures with a nationwide coverage, provides the infrastructure for future and novel trial designs and facilitates research to improve outcomes of gastrointestinal cancer patients.

MATERIAL AND METHODS

All patients aged ≥18 years with pancreatic, esophageal/gastric or colorectal cancer are eligible. Patients provide informed consent for: (1) reuse of clinical data; (2) biobanking of primary tumor tissue; (3) collection of blood samples; (4) to be informed about relevant newly identified genomic aberrations; (5) collection of longitudinal PROs; and (6) to receive information on new interventional studies and possible participation in cohort multiple randomized controlled trials (cmRCT) in the future.

RESULTS

In 2015, clinical data of 21,758 newly diagnosed patients were collected in the Netherlands Cancer Registry. Additional clinical data on the surgical procedures were registered in surgical audits for 13,845 patients. Within the first two years, tumor tissue and blood samples were obtained from 1507 patients; during this period, 1180 patients were included in the PRO registry. Response rate for PROs was 90%. The consent rate to receive information on new interventional studies and possible participation in cmRCTs in the future was >85%. The number of hospitals participating in the cohorts is steadily increasing.

CONCLUSION

A comprehensive nationwide multidisciplinary gastrointestinal cancer cohort is feasible and surpasses the limitations of classical study designs. With this initiative, novel and innovative studies can be performed in an efficient, safe, and comprehensive setting.

Changes in glucose-lowering drug use before and after cancer diagnosis in patients with diabetes

AIM

This study explores the changes in glucose-lowering drug (GLD) use before and after cancer diagnosis among patients with diabetes.

METHODS

New GLD users (1998-2011) living in the Dutch ECR-PHARMO catchment area were selected from the PHARMO Database Network (n=52,228). Those with a primary cancer diagnosis were considered cases (n=3281) and matched with eligible controls (n=12,891) without cancer during follow-up. Conditional logistic regression analysis was used to assess changes in GLD use, such as treatment add-ons, treatments drops and initiation of insulin, for cases compared with controls associated with specific cancer types in four time windows (6-3 and 0-3months before cancer diagnosis; 0-3 and 3-6months after cancer diagnosis).

RESULTS

In the 3months before cancer diagnosis, patients with upper gastrointestinal (GI) cancers (oesophageal, stomach, pancreatic, liver cancers) had higher odds of initiating insulin (OR: 9.3; 95% CI: 3.6-24.1); to a lesser extent, this was also observed in the 3months prior to that (at 6months, OR: 3.9; 95% CI: 1.3-12.1). Diagnosis of colorectal (OR: 3.4; 95% CI: 1.4-8.4), pulmonary (OR: 2.5; 95% CI: 1.1-5.4) and upper GI (OR: 13.6; 95% CI: 5.0-36.9) cancers was associated with increased odds of initiating insulin in the 3months after cancer diagnosis. During all study time windows, the odds of treatment drops were higher for patients with upper GI cancers whereas, for most other cancers, these odds were higher only after a diagnosis of cancer.

CONCLUSION

The greater odds of initiating insulin during the 6months prior to diagnosis of upper GI cancers suggest reverse causation. After cancer diagnosis, drops in use of GLDs was commonly seen.

Are metformin, statin and aspirin use still associated with overall mortality among colorectal cancer patients with diabetes if adjusted for one another?

BACKGROUND

Metformin, statin and aspirin use seem associated with decreased mortality in cancer patients, though, without adjusting for one another. Independent associations of these drugs with overall mortality after colorectal cancer (CRC) diagnosis within glucose-lowering drugs (GLDs) users were assessed.

METHODS

Patients starting GLDs before CRC diagnosis (1998-2011) were selected from the Eindhoven Cancer Registry linked with the PHARMO Database Network. The Cox regression model, with time since CRC diagnosis, included time-dependent variables of cumulative exposure to metformin, statins and aspirin after cancer diagnosis and time-dependent ever-never terms for drug exposure.

RESULTS

A total of 1043 patients used GLDs before CRC diagnosis; 666 (64%) used metformin, 639 (61%) used statins and 490 (47%) used aspirin after CRC diagnosis. Multivariable analyses revealed that longer cumulative exposure to metformin was not associated with overall mortality (HRCumulative exposure/6 months 1.02; 95% CI 0.97-1.07), whereas the favourable effect of statins increased with cumulative exposure (HRCumulative exposure/6 months 0.93; 95% CI 0.89-0.98). No association between aspirin use and overall mortality was seen (HRCumulative exposure/6 months 0.98; 95% CI 0.93-1.03).

CONCLUSIONS

No independent association between cumulative exposure to metformin, aspirin and overall mortality was found. Cumulative exposure to statins after CRC diagnosis was associated with lower overall mortality, supporting a drug effect of statins among GLDs users.

Satisfaction with information provision is associated with baseline but not with follow-up quality of life among lymphoma patients: Results from the PROFILES registry

BACKGROUND

Appropriate information provision is an important determinant of patient satisfaction and might also affect health-related quality of life (HRQoL) of cancer patients. The aim of this study was to examine the relationship between perceived information provision at baseline and HRQoL, anxiety and depression among lymphoma patients two years later.

MATERIAL AND METHODS

This study is part of a longitudinal, population-based survey among all lymphoma patients diagnosed between 1999 and 2009 as registered in the Eindhoven Cancer Registry (southern part of The Netherlands). Patients between six months and 10 years after diagnoses received the first questionnaire including the EORTC QLQ-INFO25, EORTC QLQ-C30 and HADS at baseline (T1) and the second two years later (T2). All analyses are stratified for time since diagnosis (< 2 and ≥ 2 years since diagnosis).

RESULTS

At baseline 69% of the patients (n = 1186) responded, at T2 355 (30%) patients responded. For patients < 2 years since diagnosis, receiving more medical test information was associated with higher levels of cognitive functioning (ß = 0.46; p = 0.04) and lower levels of anxiety (ß = -0.41; p = 0.04) at baseline, no prospective relationships were found. For patients ≥ 2 years since diagnosis, receiving more medical test information (ß = 0.20; p = 0.03) was associated with better emotional functioning, while receiving more treatment information was associated with worse emotional functioning (ß = -0.21; p = 0.04). Among this group, satisfaction with the received information was associated with better functioning (ß ranging from -0.15 to -0.33; all p < 0.05) at baseline, and these relationships remained significant prospectively for physical (ß = -0.13; p = 0.02) and emotional functioning (ß = -0.13; p = 0.04) only. Stability of satisfaction with received information over time was associated with better emotional (ß = -0.13) and better cognitive functioning (ß = -0.09; p < 0.05) at T2.

CONCLUSION

The present study showed that satisfaction with received information among lymphoma patients was associated with better HRQoL at baseline (only for patients ≥ 2 years since diagnosis), but not at follow-up when corrected for baseline HRQoL.

Chronic fatigue in Hodgkin lymphoma survivors and associations with anxiety, depression and comorbidity

BACKGROUND

Fatigue is a frequent and persistent problem among Hodgkin lymphoma (HL) survivors. We investigated the prevalence of clinically relevant fatigue in HL survivors and the relation between fatigue and anxiety and depression.

METHODS

Fatigue was measured through the generic European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) and Fatigue Assessment Scale (FAS). Anxiety and depression were measured with the Hospital Anxiety and Depression Scale. Questionnaires were mailed to 267 HL survivors. Results were compared with a Dutch age-matched normative population.

RESULTS

Response rate was 68% (median age 46 years, mean time since diagnosis 4.6 years). Prevalence of fatigue was significantly higher among HL survivors than in the norm population (FAS 41% vs 23%, QLQ-C30 43% vs 28%), as were fatigue levels. There was a significant association between fatigue, anxiety and depression. Of the HL survivors with high symptom levels of depression, 97% also reported fatigue. In multivariate analysis, depression was strongly associated with high levels of fatigue and, to a lesser extent, anxiety and comorbidity.

CONCLUSIONS

Prevalence rates of fatigue are significantly higher in HL survivors than in the general population and differences are clinically relevant. Depression and anxiety were strongly associated with high levels of fatigue. Reducing fatigue levels by treatment of depression and anxiety should be further explored.

Time trends and inter-hospital variation in treatment and axillary staging of patients with ductal carcinoma in situ of the breast in the era of screening in Southern Netherlands

BACKGROUND

To examine variation in time and place in axillary staging and treatment of patients with ductal carcinoma in situ (DCIS) of the breast.

METHODS

Trends in patients with DCIS recorded in the Eindhoven Cancer Registry diagnosed in 1991-2010 (n = 2449) were examined.

RESULTS

The use of breast conserving surgery (BCS) went from 17% to 67% in 1991-2010 and administration of radiotherapy after BCS increased to 89%. Axillary lymph node dissection decreased to almost 0%, while sentinel node biopsy was performed in 65% of patients in 2010. The proportion who underwent BCS varied between hospitals from 49% to 80%; the proportion without axillary staging ranged from 21% to 60%. Patients with screen-detected DCIS were more likely to receive BCS.

CONCLUSION

There was considerable variation in the use of BCS, radiotherapy, and axillary staging of DCIS over time and between hospitals. Patients with DCIS were more likely to be treated with BCS if their disease was detected by screening.

Diminishing differences in treatment between patients with colorectal cancer with and without diabetes: a population-based study

AIMS

An increasing number of oncologists will be confronted with individuals having diabetes and cancer. We assessed changes in patient-, tumour- and treatment-related variables in patients with colorectal cancer with and without diabetes.

METHODS

All 17 170 cases of primary colorectal cancer between 1995 and 2010 in the South-Eastern Netherlands were included. The Cochrane-Armitage test and logistic regression analysis were used to analyse trends.

RESULTS

In total, 11 893 patients were diagnosed with colon cancer and 5277 with rectal cancer, of whom 1711 (14%) and 609 (12%), respectively, had diabetes at the time of cancer diagnosis. Patients with colorectal cancer with diabetes compared with those without were approximately 5 years older and more often diagnosed with proximal colon tumours (60 vs. 54%; P < 0.0001). Chemotherapy administration significantly increased in patients with stage III colon cancer with and without diabetes (from 17% in 1995-1998 to 50% in 2007-2010, 38% to 63%, respectively; P < 0.0001). However, in the most recent period, and after adjusting for the co-variables age, gender, year of diagnosis and specific co-morbidities, patients with stage III colon cancer with diabetes received adjuvant chemotherapy less frequently than those without [odds ratio 0.7 (95% CI 0.5-0.9); P = 0.002]. The proportion of patients with stage II/III rectal cancer with and without diabetes who underwent radiotherapy has been similar in recent years (91 vs. 87%).

CONCLUSIONS

Although the administration of chemotherapy and radiotherapy increased between 1995 and 2010 in patients with colorectal cancer with and without diabetes, patients with colorectal cancer with diabetes continue to receive chemotherapy less frequently than those without diabetes.

Impact of scalp cooling on chemotherapy-induced alopecia, wig use and hair growth of patients with cancer

INTRODUCTION

Cytotoxic therapy for patients with cancer frequently induces reversible, but long-lasting alopecia which might be prevented by scalp cooling. This study evaluates the effectiveness of scalp cooling with respect to the severity of chemotherapy-induced alopecia (CIA) and the purchase and use of wigs and head covers.

MATERIALS AND METHODS

In this observational study, scalp-cooled patients (n = 160) were compared with non scalp-cooled patients (n = 86) with several types of cancer. Patients were enrolled in 15, mostly general hospitals prior to taxane and/or anthracycline-based chemotherapy. Patients completed four questionnaires between the start and one year after the last chemotherapy.

RESULTS

Severity of CIA, and purchasing and actually wearing wigs and head covers were significantly lower among scalp-cooled than non scalp-cooled patients. Overall, scalp cooling reduced the use of wigs and head covers by 40%. Among 84 scalp-cooled patients who purchased a wig (53%), only 52 patients actually wore it (62%), and they just wore it intensively (86% daily) for less than six months (80%). Especially young patients camouflaged CIA with a head cover instead of a wig.

DISCUSSION

The relatively long duration of CIA, the wish of many patients to camouflage or rather prevent it and the 40% reduction for head covering by scalp cooling, makes it a worthwhile supportive intervention. However, (cost-) effectiveness can be improved. Many scalp-cooled patients purchased a wig unnecessarily.

Increased incidence and improved survival in endometrioid endometrial cancer diagnosed since 1989 in The Netherlands: a population based study

OBJECTIVES

To measure progress against endometrioid endometrial carcinoma (EEC) in the Netherlands by analyzing trends in incidence, survival and mortality simultaneously.

STUDY DESIGN

Descriptive study of incidence, survival and mortality rates of women with EEC in the Netherlands. Rates were age-standardized to the European standard population. Population-based data were extracted from the nationwide Dutch Cancer Registry (NCR) between 1989 and 2009. Mortality data since 1989 came from Statistics Netherlands. European age standardized incidence rates were calculated according to age, histology and stage. Five year relative survival estimates were calculated in four periods. Optimal progress against cancer is defined as decreasing incidence and/or improving survival accompanied by declining mortality.

RESULTS

80% of the 32,332 patients newly diagnosed with a corpus uteri malignancy had an EEC. The incidence of EEC rose significantly from 11/100,000 to 15/100,000, being most pronounced in women with FIGO stage IB and in the group with grade 1&2 tumours (P<0.05). Coinciding with the increased incidence, 5-year relative survival increased, especially for patients aged 60-74 years, in women with FIGO stage I, and in histology group grade 1&2, being 87%, 94% and 93%, respectively, during 2005-2009.

CONCLUSION

The incidence of EEC (being 80% of corpus uteri cancer) increased markedly between 1989 and 2009, especially in women of 60-74 years. Five-year survival for patients with EEC increased from 83 to 85%. Progress against EEC has been less than was assumed previously, because mortality proportionally decreased only slightly, and because of the increasing incidence although survival improved.

Disease-specific mortality among stage I-III colorectal cancer patients with diabetes: a large population-based analysis

AIMS/HYPOTHESIS

The aim of our study was to investigate overall and disease-specific mortality of colorectal cancer patients with diabetes.

METHODS

In this population-based study, we included all colorectal cancer patients, newly diagnosed with stage I-III cancer, between 1997 and 2007 in the registration area of the Eindhoven Cancer Registry. Stage of cancer, cancer treatment and comorbidities were actively collected by reviewing hospital medical records. Data on patients with and without diabetes were linked to Statistics Netherlands to assess vitality, date of death and underlying cause of death. Follow-up of all patients was completed until 1 January 2009.

RESULTS

We included 6,974 patients with colon cancer and 3,888 patients with rectal cancer, of whom 820 (12%) and 404 (10%), respectively, had diabetes at the time of cancer diagnosis. During follow-up, death occurred in 611 (50%) of 1,224 cancer patients with diabetes and 3,817 (40%) of 9,638 cancer patients without diabetes. Multivariate Cox regression analyses, adjusted for age, sex, socioeconomic status, stage, lymph nodes examined, adjuvant therapy and year of diagnosis, showed that overall mortality was significantly higher for colon (HR 1.12, 95% CI 1.01, 1.25) and rectal (HR 1.21, 95% CI 1.03, 1.41) cancer patients with diabetes than for those without. Disease-specific mortality was only significantly increased for rectal cancer patients (HR 1.30, 95% CI 1.06, 1.60).

CONCLUSIONS/INTERPRETATION

Diabetes at the time of rectal cancer diagnosis was independently associated with an increased risk of colorectal cancer mortality compared with no diabetes, suggesting a specific interaction between diabetes and rectal cancer. Future in-depth studies including detailed diabetes- and cancer-related variables should elucidate pathways.

Melanoma patients receive more follow-up care than current guideline recommendations: a study of 546 patients from the general Dutch population

BACKGROUND

Follow-up of melanoma patients has been a continuing issue for discussion in the past years partly due to ever increasing incidence of this disease, as well as the lack of agreement regarding the reasons for, and the frequency of follow-up. Patients' perspectives are often not included in this continuing discussion on follow-up of melanoma patients.

OBJECTIVE

To examine to what extent follow-up was experienced, according to the guideline of 2005, by physicians and melanoma patients in a Dutch population from the south-east area of the Netherlands. The patient's perspective and satisfaction over said follow-up shall also be taken into account.

METHODS

Follow-up among melanoma survivors was investigated and compared with the recommendations of the current Dutch national guideline. All 699 melanoma patients registered at the Eindhoven Cancer Registry (between 1998 and 2008), and treated in 3 regional hospitals, were contacted via postal mail. The survey questioned about treatment, symptoms, impact on daily life and follow-up. Patients with multiple melanomas (n = 16) were excluded.

RESULTS

Response rate was 80%, 418 patients were still under surveillance for their melanoma. The average time since diagnoses was 4 years, 71% had stage I melanoma. Almost 80% of patients with a Breslow thickness <1 mm, reported more frequent follow-up visits than the guideline recommends. Only 5% of the patients wanted to reduce their follow-up frequency. Eighty percent of patients were under supervision of a dermatologist: physical examination (25%), lymph node palpation (11%) and/or scar inspection (20%) did not regularly occur. These proportions were significantly higher among other specialism.

CONCLUSION

Follow-up frequency was higher than recommended by the current melanoma guideline in a large group of patients, mainly those with lower Breslow thickness.

Impact of concentration of oesophageal and gastric cardia cancer surgery on long-term population-based survival

BACKGROUND

The objective was to evaluate the impact of concentration of surgery for oesophageal and gastric cardia cancer on long-term survival in the population-based Eindhoven Cancer Registry area. In contrast to most previous studies, this study aimed to evaluate both surgically and non-surgically treated patients, to avoid the confounding effect of selective referral.

METHODS

This retrospective cohort study included all patients diagnosed with oesophageal or gastric cardia cancer between 1995 and 2006. Results for the period 1995-1998 were compared with those for 1999-2006, after concentration of surgery.

RESULTS

Between 1995 and 2006, 2212 patients were registered with the diagnosis, of whom 638 underwent resection. Before 1999, 73·4 per cent of surgically treated patients underwent a resection in a low-volume hospital (fewer than 4 resections per year) and 23·2 per cent were referred to an academic hospital. After concentration, 63·2 per cent of surgically treated patients underwent resection in one of two regional high-volume centres (15-20 resections per year) and 13·8 per cent were referred to an academic hospital. Three-year survival rates increased from 32·0 to 45·1 per cent for patients who had surgery (P = 0·004), and from 13·1 to 17·9 per cent for all included patients (P = 0·026). These improvements remained after adjustment for case mix or (neo)adjuvant treatments, and were similar for patients with squamous cell carcinoma or adenocarcinoma. However, adjustment for annual hospital volume attenuated this association for patients who had surgery.

CONCLUSION

Concentration of oesophageal and gastric cardia cancer surgery was associated with improvements in long-term, population-based overall survival for surgically as well as non-surgically treated patients, apparently mediated by an increase in volume.

The relation between information provision and health-related quality of life, anxiety and depression among cancer survivors: a systematic review

BACKGROUND

Providing information that is congruent with patients' needs is an important determinant for patient satisfaction and might also affect health-related quality of life (HRQoL) and anxiety and depression levels of cancer survivors.

DESIGN

The authors systematically reviewed the available literature on the relationship between information provision and HRQoL, anxiety and depression. A PubMed literature search for original articles published until February 2010 was carried out. Twenty-five articles, all conducted between 1996 and 2009, which met the predefined inclusion criteria, were subjected to a quality checklist.

RESULTS

Satisfied patients, patients with fulfilled information needs, and patients who experience less information barriers, in general have a better HRQoL and less anxiety and depression. Out of eight intervention studies that aimed to improve information provision, only one showed a positive association with better HRQoL.

CONCLUSION

Health care providers must pay more attention to patient-centred information provision. Additional research is needed to make definitive conclusions about information interventions as most results did not reach statistical significance due to methodological constraints. The quick development of the relatively young research field of patient-reported outcomes in cancer survivorship will make it possible to conduct better quality studies in the future.

Variation in management of early breast cancer in the Netherlands, 2003-2006

BACKGROUND

To describe variation in staging and primary treatment by hospital characteristics including type and volume and region in patients with early breast cancer (BC) in the Netherlands, 2003-2006 after completion of national guidelines in 2002.

METHODS

All patients newly diagnosed with invasive BC in 2003-2006 and recorded in the Netherlands Cancer Registry were included (n = 51 354). Multivariable logistic regression analyses examined the influence of patient and hospital characteristics, also by region, on type of breast surgery, axillary lymph node dissection (ALND), sentinel node procedure (SNP), and adjuvant irradiation and/or systemic treatment.

RESULTS

Patients <40 years more often underwent breast conserving surgery (BCS) in general hospitals (OR 1.4 (95%CI 1.1-1.5)) than in teaching and academic hospitals, whereas patients of 40-69 years less often received BCS in an academic hospital (OR 0.9 (95%CI 0.8-1.0)) than in teaching hospitals. Patients with pT1-2N0 cancer more often underwent primary ALND in a general hospital than in a larger teaching or academic hospital. Type of hospital did not seem to affect utilization of adjuvant systemic therapy, but patient age and tumour size and grade did. Over time, patients more often received SNP, BCS, and adjuvant systemic therapy, primary ALND being on the decline, but with substantial regional variation between geographic regions.

CONCLUSION

With detailed evidence-based national guidelines since 2002 the considerable regional and hospital variation in staging procedures and primary treatment among newly diagnosed patients with early breast cancer in the Netherlands decreased markedly, suggesting the presence of late adaptors rather than specific hospital characteristics.

Trends in incidence, treatment and survival of gastric adenocarcinoma between 1990 and 2007: a population-based study in the Netherlands

BACKGROUND

Survival of gastric cancer in the Western world remains poor. We conducted a retrospective population-based study to evaluate trends in incidence, treatment and outcome of gastric adenocarcinoma.

METHODS

All patients diagnosed with gastric adenocarcinoma during 1990-2007 in the Dutch Eindhoven Cancer Registry area were included (n=4,797). Trend analyses were conducted for incidence, mortality, tumour and patient characteristics, treatment and crude overall survival, according to tumour location (cardia versus non-cardia). Temporal changes in the odds of undergoing surgery and the risk of death were analysed by means of multivariable regression methods.

RESULTS

Age-standardised incidence decreased among males (24-12 per 100,000 inhabitants) and females (10-6); mortality rates decreased at a similar pace. The proportion of cardia tumours remained stable. Stage distribution worsened over time among patients with cardia (stages I and II: 32% in 1990-1993 and 22% in 2006-2007, p=0.005) and non-cardia (stage IV: 33% in 1990-1993 and 40% in 2006-2007, p=0.0003) cancer. Chemotherapy rates increased in all settings. Five-year survival worsened over time for patients with non-cardia tumours. Age and stage had significant influence on survival after stratification for tumour localisation. After adjustments for relevant factors (i.e. stage), the risk of death decreased since the late 90s for patients with a cardia tumour (hazard ratio 0.8, p=0.01).

CONCLUSION

The absence of improvement in survival rates indicates the need for earlier detection and prospective studies to evaluate new therapy regimens with standardised surgery and pathology.

A systematic review of health-related quality of life in cutaneous melanoma

Melanoma can be considered an emerging chronic disease that may considerably affect patients’ lives. The authors systematically reviewed the available literature on health-related quality of life (HRQOL) and melanoma. Of reviews and the selected studies, reference lists were hand-searched. The quality of the eligible studies was appraised based on 14 previously published criteria. Of the 158 abstracts, 44 articles were appraised, resulting in 13 selected studies written in English (published between 2001 and 2008). Most studies assessed patients from specialised centres with varying, but relatively advanced, disease stages. The most commonly used instruments were the SF-36 and EORTC QLQ-C30. Recently, a melanoma-specific HRQOL questionnaire [FACT-Melanoma (FACT-M)] was introduced for clinical trial purposes. It showed that approximately one-third of melanoma patients experienced considerable levels of distress, mostly at the time of diagnosis and following treatment. Systemic therapies affected HRQOL negatively in the short term, but to a lesser extent in the long term. Health status and patients’ psychological characteristics are associated with higher levels of HRQOL impairment. The authors found that the impact of melanoma on patients’ HRQOL is comparable to that of other cancers. Accurately assessing HRQOL impairment in melanoma patients is pivotal, as it may affect disease management, including therapy and additional counselling, future preventive behaviour and perhaps even prognosis.

Surgical resection of the primary tumour is associated with improved survival in patients with distant metastatic breast cancer at diagnosis

OBJECTIVE

Recent studies indicate that removal of the primary tumour may have a beneficial effect on mortality risk of patients with primary distant metastatic breast cancer (stage IV), although most of them did not rule out confounding by the presence of co-morbidity. In this retrospective study the impact of surgical resection of the primary tumour on the survival of patients with primary distant metastatic disease is investigated, taking into account the presence of co-morbidity and other potential confounders.

METHODS

Between 1993 and 2004, 15 769 patients with breast cancer were diagnosed in the south of the Netherlands. This study included the 728 patients with distant metastatic disease at initial presentation, which was 5% of all patients. Of them, 40% had surgery of the primary tumour. Follow-up was carried out until 1 July 2006.

RESULTS

Median survival of the patients who had surgery of their primary tumour was significantly longer than for the patients who did not have surgery (31 vs. 14 months). The 5-year survival rates were 24.5% and 13.1%, respectively (p < 0.0001). In a multivariable Cox regression analysis, adjusting for age, period of diagnosis, T-classification, number of metastatic sites, co-morbidity, use of loco-regional radiotherapy and use of systemic therapy, surgery appeared to be an independent prognostic factor for overall survival (HR = 0.62; 95% CI 0.51-0.76).

CONCLUSION

Removal of the primary tumour in patients with primary distant metastatic disease was associated with a reduction of the mortality risk of around 40%. The association was independent of age, presence of co-morbidity and other potential confounders, but a randomized controlled trial will be needed to rule out residual confounding.

[Breast cancer in young women: epidemiology and treatment dilemmas]

The incidence of breast cancer in the Netherlands in women under 40 years has been more or less stable for the last 2 decades, while the mortality rate has decreased in the same period. Breast cancer in young women generally has a worse prognosis than in older women. Systemic therapy reduces the risk oflocoregional relapse after breast-conserving therapy from approximately 2% to less than 1% on an annual basis. Breast-conserving therapy therefore seems to be a safe option in young women who have consented beforehand to receive adjuvant systemic therapy. According to current treatment guidelines, adjuvant systemic therapy will be offered to approximately 80% of young breast cancer patients. The risk of premature postmenopausal symptoms, osteoporosis and unwanted infertility are, however, disadvantages of adjuvant chemotherapy and hormonal therapy. This specific treatment-related toxicity in young breast cancer patients requires support by experts with endowments for these specific issues.

Explanatory factors for variation in the use of breast conserving surgery and radiotherapy in the Netherlands, 1990–2001

The use of Breast Conserving Surgery (BCS) followed by radiotherapy (BSC-RT) in pT1 (2cm) and pT2-tumours (2-5cm) was investigated in the Netherlands from 1990 to 2001. From the Netherlands Cancer Registry, patients were selected with invasive tumours <5.0cm. Trends were determined and explanatory factors were determined by multivariate logistic regression. Over the period 52,937 pT1-tumours and 36,285 pT2-tumours were diagnosed. The percentage BCS and BCS-RT in patients 80 years or older remained lowest. Multivariate logistic regression revealed that older age (70+), tumour size >2cm, positive clinical nodes and medium hospital size decreased the chance of BCS. For BCS-RT the same factors and negative pathological nodes decreased the chance of BCS-RT. Between regions large differences were seen. Cancer registry data are useful to monitor the guideline implementation strategies. Multidisciplinary treatment planning, surgeon and patient education could increase the use of BCS combined with RT in all age groups.

Survival after negative sentinel lymph node biopsy in breast cancer at least equivalent to after negative extensive axillary dissection

AIM

Sentinel lymph node biopsy (SLNB) without completion axillary lymph node dissection (ALND) is replacing ALND as the axillary staging procedure of choice in breast cancer patients with a clinically negative axilla even though it is unclear whether this influences patient survival. Our aim was to compare the survival of breast cancer patients with a negative SLNB without completion ALND to that of extensive ALND-negative patients.

METHODS

Eindhoven Cancer Registry data on breast cancer patients diagnosed between 1989 and 2002 with follow-up to 1 January 2005 was used. Survival was compared between 880 SLNB-negative women (median follow-up 3.6years) without completion ALND and 1681 ALND-negative women (median follow-up 7.7years) with at least 10 axillary nodes removed. Conclusions were made after correcting for age, tumour size, tumour location, tumour histology, tumour grade, mitotic activity index (MAI), hormone receptor status, and local and systemic treatment in uni- and multivariate analyses.

RESULTS

Crude 5-year survival rates were 85% for ALND-negative and 89% for SLNB-negative breast cancer patients (p=0.026). After correction for potential confounders in a multivariate Cox regression analyses, the hazard ratio for overall mortality of ALND-negative compared to SLNB-negative patients without completion ALND was 1.23 (95% confidence interval: 0.93-1.64).

CONCLUSION

Survival after a SLNB without completion ALND is at least equivalent to after an extensive ALND in node-negative breast cancer patients. This means that the SLNB only can safely replace ALND as the procedure of choice for axillary staging in breast cancer patients with a clinically negative axilla.

Impact of a programme of mass mammography screening for breast cancer on socio-economic variation in survival: a population-based study

Background

After a systematic mass mammography breast cancer screening programme was implemented between 1991 and 1996 (attendance 80%), we evaluated its impact on survival according to socioeconomic status (SES).

Methods

We studied survival rates up to 1-1-2005 for all consecutive breast cancer patients aged 50–69 and diagnosed in the period 1983–2002 in the area of the Eindhoven Cancer Registry (n = 4939). Multivariate analyses were performed using Cox regression analysis.

Results

The proportion of breast cancer patients with a low SES decreased from 22% in 1983–1990 to 14% in 1997–2002 when attendance was 85%. The proportion of newly diagnosed patients with stage III or IV disease in 1997–2002 was only 10% compared to 14% in 1991–1996 and 26% in 1983–1989 (P < 0.0001). Stage distribution improved for all socio-economic groups (P = 0.01). Survival was similar for all socio-economic groups in 1983–1990, but after the introduction of the screening programme women with low SES had lower age- and stage-adjusted survival rates (HR 2.0, 95%CI: 1.3–3.0). Survival was better for patients diagnosed in 1997–2002 compared to 1983–1990 for all socioeconomic strata; it was substantially better for the high SES group (HR 0.36, 0.2–0.5) compared to the lowest SES (HR 0.77, 0.6–1.1).

Conclusion

Although survival improved for women from each of the socio-economic strata, related to the high participation rate of the screening programme, women from lower socio-economic strata clearly benefited less from the breast cancer screening programme. That is also related to the higher prevalence of comorbidity and possibly suboptimal treatment.

Long-term quality of life among Dutch prostate cancer survivors: results of a population-based study

BACKGROUND

In this report, the authors describe the health-related quality of life (HRQL) of long-term prostate cancer survivors 5 to 10 years after diagnosis and compare it with the HRQL of an age-matched, normative sample of the general Dutch population.

METHODS

The population-based Eindhoven Cancer Registry was used to select all men who were diagnosed with prostate cancer from 1994 to 1998. Nine hundred sixty-four patients received questionnaires (the 36-item Short Form Health Survey [SF-36] and the Quality of Life-Cancer Survivors questionnaire), and 780 of 964 patients responded (81%).

RESULTS

Unselected, long-term prostate cancer survivors reported comparable HRQL scores but worse General Health Perceptions and better Mental Health scores than an age-matched, normative population. Patients who underwent radical prostatectomy had the highest physical HRQL, followed by patients who received 'watchful waiting,' and patients who received radiotherapy. Patients who received hormone treatment, in general, had the lowest physical HRQL.

CONCLUSIONS

The results of this study suggested that the long-term HRQL of prostate cancer survivors may vary significantly as a function of the type of primary treatment. Because baseline differences between treatment groups cannot be excluded as part of the explanation for these differences, the current findings need to be verified in longitudinal studies.

A comparison of quality of life, disease impact and risk perception in women with invasive breast cancer and ductal carcinoma in situ

We compared the health-related quality of life, impact of the disease, risk perception of recurrence and dying of breast cancer, and understanding of diagnosis of patients with ductal carcinoma in situ (DCIS) and invasive breast cancer 2-3 years after treatment. We included all women (N=211) diagnosed with DCIS or invasive breast cancer TNM stage I (T1, N0, and M0) in three community hospitals in the southern part of The Netherlands in the period 2002-2003. After verifying the medical files, 180 disease free patients proved eligible for study entry, 47 of whom had DCIS and 133 stage I invasive breast cancer. One-hundred and thirty-five patients returned a completed questionnaire (75% response). No significant differences were found between women with DCIS and invasive breast cancer on the physical and mental component scale of the RAND SF-36, nor on the WHO-5, which assesses well-being. In contrast, women with DCIS reportedly had a better physical health, better sex life and better relationships with friends/acquaintances than women with invasive breast cancer. Despite their better prognosis, the DCIS-group had comparable perceptions of the risk of recurrence and dying of breast cancer as women with invasive breast cancer. However, this did not appear to affect their well-being significantly.

Margin status and the risk of local recurrence after breast-conserving treatment of lobular breast cancer

BACKGROUND

Invasive lobular breast carcinoma is known for its multicentricity and is associated with a higher incidence of incomplete excision after breast-conserving therapy. The aim of the study was to examine the influence of positive surgical margins on the local recurrence rate in patients diagnosed with invasive lobular cancer and treated with breast-conserving therapy.

METHODS

All 416 women diagnosed with invasive lobular breast cancer and undergoing breast-conserving treatment between 1995 and 2002 were selected from the population-based Eindhoven Cancer Registry. Their medical charts were reviewed and detailed information was collected.

RESULTS

The risk of margin involvement was 29% after the first operation and 17% when taking into account the final margin status of the patients undergoing re-excision. During follow-up, 18 patients developed a local recurrence. The 5 year actuarial risk of developing a local recurrence was 3.5% (95% confidence interval 2.5-4.5) and the 8 year risk was 6.4% (95% confidence interval 4.7-8.0). There was no influence of positive surgical margins on the risk of local recurrence, neither in the univariate analysis nor after adjustment for age, tumour size, nodal status and adjuvant systemic treatment.

CONCLUSION

Patients with invasive lobular cancer, treated with breast-conservation, have a low risk of local recurrence, despite their high risk of having a microscopically incomplete excision of the tumour.

Elderly patients with rectal cancer have a higher risk of treatment-related complications and a poorer prognosis than younger patients: a population-based study

It is likely that the shift from post- to pre-operative radiotherapy and the introduction of total mesorectal excision (TME) surgery have contributed to the observed improved survival of rectal cancer in the south of the Netherlands. However, no improvement was seen for patients aged 70 or older. To investigate possible causes of this lack of improvement, we examined the risk of treatment-related complications and overall survival. Therefore, a random sample of 455 patients with rectal cancer aged 60 years or older, diagnosed between 1995 and 2001 was extracted from in the Eindhoven Cancer Registry database. Fifty-one percent of patients aged 60-69 years-old had any complication within one year of diagnosis compared to 65% of patients aged 70 or older (p=0.007). Older patients were at higher risk of developing treatment-related complications (odds ratio (OR) 1.8; p=0.01), as were patients with comorbidity (OR 1.7; p=0.07), and those who received pre-operative radiotherapy (OR 1.8; p=0.02). In a multivariable analysis, age older than 70 (hazard ratio (HR) 2.2; p<0.0001), comorbidity (HR 1.7; p=0.03), and having two or more complications (HR=2.2; p=0.0002) had a negative effect on survival. The lack of improvement in the prognosis of elderly patients with rectal cancer after a shift from post- to preoperative radiotherapy might partially be explained by a higher risk of treatment-related complications. In order to optimise the risk/benefit ratio of elderly patients, individualisation of treatment by means of a comprehensive geriatric assessment will be of critical importance.

Outcome of surgical treatment of pancreatic, peri-ampullary and ampullary cancer diagnosed in the south of The Netherlands: A cancer registry based study

AIMS

To gain insight into the quality of pancreatic cancer surgery in 10 low-volume (median sized) hospitals, each serving 150,000-250,000 people, in the Comprehensive Cancer Centre South (CCCS) area and of referred patients to academic centres to determine the need for further regionalization.

METHOD

The population-based Eindhoven Cancer Registry was used to select all patients in the CCCS area with pancreatic, peri-ampullary and ampullary cancer diagnosed between January 1, 1995 and April 30, 2000 (N = 1130). Of those, 124 patients (11%) underwent surgical resection (of which 40 were treated in university hospitals outside the region).

RESULTS

For all pancreatic carcinoma resections, the 3-month survival rate was 82%, varying from 95% for referred patients to 76% for patients treated within the region (p = 0.014). One- and two-year survival rates showed no difference between both groups (p = 0.36 and p = 0.55, respectively). Surgically treated patients who were referred to university hospitals outside the CCCS area were younger, more often male, more often diagnosed with pTNM stage III, exhibited less comorbidity and had a higher socio-economic status than patients surgically treated within the region.

CONCLUSION

Although the results are based on small numbers and patient selection probably influenced these outcomes, these data seem to support further hospital specialisation, to which the surgeons of the CCCS area have committed themselves.

[Compliance with the breast cancer guidelines in the region of the Comprehensive Cancer Centre South, 20031/'04]

OBJECTIVE

To examine the level of compliance with the NABON-guidelines (i.e. breast cancer consensus recommendations) issued in 1999 with particular regard to the diagnostics and treatment of breast cancer in hospitals in the region covered by the Comprehensive Cancer Centre South (covering the Noord-Brabant and Noord-Limburg areas in the Netherlands).

DESIGN

Retrospective, descriptive.

METHOD

Using the Cancer Registry, the average number ofbreast cancer patients in 16 general hospital locations in the region covered by the Comprehensive Cancer Centre South was determined. Then, from I July 2003 to 30 June 2004, at each hospital location, all successive patients in whom carcinoma of the breast (invasive or in situ) had been diagnosed were included until one-third of the annual total was reached. Data from the medical-case notes of these patients were collected in order to examine to what extent the hospital locations had complied with the NABON-norms.

RESULTS

A total of 581 breast cancer patients were included. In general the diagnostics and treatment complied with the consensus recommendations in the NABON-policy document. Improvements were mainly indicated in the area of logistics. One hospital met the guideline's recommendation that in 90% of cases, the pathology department should ensure that the results ofa histological needle-biopsy are available within 2 days of the biopsy being carried out. In 62% of patients, surgery was performed within 3 weeks of the necessity of an operation being confirmed, although the target norm was 90%. The interval between the last operation and the start of radiotherapy treatment was 44 instead of the proposed 28 days. Inter-hospital differences in diagnostics were seen mainly in the application of sentinel-node biopsy (34-95%). Furthermore, broad diversity was observed in the percentage of patients treated in the proposed space oftime between pathology result and initial surgery (3-87%) and between the last operation and start ofradiotherapy (0-46%) or chemotherapy (0-100%).

The significance of one positive axillary node

AIMS

The aim of this study was to identify a subgroup of patients with breast cancer that can safely avoid axillary dissection.

METHODS

Using data collected by the Eindhoven Cancer Registry, we compared the clinico-pathological features of 489 patients with only one positive lymph node to those of 817 patients with more than one positive lymph node in the axilla. All patients underwent complete axillary dissection, not preceded by a sentinel node biopsy.

RESULTS

Tumour size greater than 1cm, harvesting more than 15 axillary lymph nodes at histopathological examination, metastasis size larger than 2mm, extranodal extension, and nodal involvement of the axillary apex are independently associated with the occurrence of more than one metastatic axillary lymph node.

CONCLUSION

No subgroup could be identified in which axillary dissection can always be omitted. However, tumour size<1cm, finding a micrometastasis rather than a macrometastasis, and especially not finding extranodal extension were independently associated with finding only one positive axillary lymph node.

Higher long-term cancer survival rates in southeastern Netherlands using up-to-date period analysis

BACKGROUND

The aim was to compare long-term survival rates for different types of cancer estimated by means of up to date period analysis with those from more traditional cohort analysis.

PATIENTS AND METHODS

Data from the Eindhoven Cancer Registry were used. In total 140,137 newly diagnosed patients diagnosed between 1980 and 2002 and followed until 1 January 2005 were included. Five-, 10- and 20-year relative survival rates were calculated.

RESULTS

For total cancer in men and women, childhood cancer, rectal cancer, melanoma in women, breast cancer, prostate cancer and all leukaemias, much higher 10-year survival rates were found with period analyses (differences with cohort analyses were 5.1%, 3.6%, 7.4%, 5.6%, 6.5%, 4.0%, 5.1% and 10.5%, respectively). For laryngeal and bladder cancer the 10-year survival rates estimated with period analyses were about 7.5% lower compared with those estimated by means of cohort analyses.

CONCLUSIONS

Period analysis, based on the most recent period of diagnosis, enabled us to show higher survival rates for total cancer, childhood cancer, rectal cancer, melanoma, breast cancer, prostate cancer and acute leukaemia, but also lower rates for laryngeal and bladder cancer. Period analysis should be the preferred tool for showing up-to-date survival rates to cancer patients and their physicians.