Axillary nodal involvement by primary tumor features in early breast cancer: an analysis of 2600 patients

BACKGROUND

Primary tumor characteristics, which are readily available to all clinicians, may aid in selecting the optimal adjuvant therapy for patients with breast cancer (BC). Herein, we investigated the relationship between tumor size, hormone receptor and HER2 status, Ki67 and age with axillary lymph node metastases (ALNM) in early-BC patients.

METHODS

We analyzed data on consecutive 2600 early-BC cases collected in the registry of Fondazione IRCC Istituto Nazionale dei Tumori, Milano, Italy. Correlation between Ki67 and primary tumor size (T-size) was calculated by Spearman's rank correlation coefficient. Association of ALNM with Ki67 and other tumor characteristics was investigated by logistic regression. Adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) were estimated in all cases, and separately analyzed according to age, T-size and BC subtype.

RESULTS

Large tumor size strongly associated to ALNM, with an adjusted odds ratio (OR) for each 5-mm increase of 1.32 (95% CI 1.24-1.41), except for triple-negative BC (TNBC) cases. In tumors =10 mm, without lymphovascular invasion, representing the strongest predictor of ALNM (OR 6.09, 95% CI 4.93-7.53), Ki67 resulted particularly informative, with a fourfold increased odds of ALNM for values > 30%.

CONCLUSIONS

These results raise the question whether axillary node status is redundant in cases with exceptionally good features, i.e., small tumors with low Ki67, or in those candidate to adjuvant systemic treatment/radiotherapy anyway including TNBC, and support the incorporation of primary BC tumor characteristics as stratification factors in ongoing trials aiming at de-escalating axillary surgical procedures.

Constraints on Sub-GeV Dark-Matter-Electron Scattering from the DarkSide-50 Experiment

We present new constraints on sub-GeV dark-matter particles scattering off electrons based on 6780.0 kg d of data collected with the DarkSide-50 dual-phase argon time projection chamber. This analysis uses electroluminescence signals due to ionized electrons extracted from the liquid argon target. The detector has a very high trigger probability for these signals, allowing for an analysis threshold of three extracted electrons, or approximately 0.05 keVee. We calculate the expected recoil spectra for dark matter-electron scattering in argon and, under the assumption of momentum-independent scattering, improve upon existing limits from XENON10 for dark-matter particles with masses between 30 and 100  MeV/c^{2}.

Low-Mass Dark Matter Search with the DarkSide-50 Experiment

We present the results of a search for dark matter weakly interacting massive particles (WIMPs) in the mass range below 20  GeV/c^{2} using a target of low-radioactivity argon with a 6786.0 kg d exposure. The data were obtained using the DarkSide-50 apparatus at Laboratori Nazionali del Gran Sasso. The analysis is based on the ionization signal, for which the DarkSide-50 time projection chamber is fully efficient at 0.1  keVee. The observed rate in the detector at 0.5  keVee is about 1.5  event/keVee/kg/d and is almost entirely accounted for by known background sources. We obtain a 90% C.L. exclusion limit above 1.8  GeV/c^{2} for the spin-independent cross section of dark matter WIMPs on nucleons, extending the exclusion region for dark matter below previous limits in the range 1.8-6  GeV/c^{2}.

Estimated Incidence and Prevalence of Female Breast Cancer in Italian Regions

Female breast cancer incidence and prevalence in Italy have been estimated by region and vast areas from population-based survival data of breast cancer patients and 1970–1987 specific mortality data using a mathematical model. Italian age-standardized incidence rates (ASR) for 1987 range from 70 to 90 per 100,000 women-year in the Northern regions, 55 to 73 in the Center, and 45 to 72 in the South. Overall, the ASR is about 80 in the North, 70 in the Center and 60 in the South. In the absence of competitive mortality, breast cancer cumulative risk in the 0–74 years life span is about 7 women out of 100 in the North, 6 in the Center and 5 in the South. The decreasing risk pattern from North to Center then South appears less evident when under 45 age-specific rates are considered. Very high levels for young age-groups are present both in the North (Liguria and Emilia Romagna) and South (Sardinia and Apulia). The incidence pattern by age differs from region to region and over the considered period, suggesting that a birth-cohort effect is crossing the whole country. Using to model, it can be estimated that the risk by cohort increases from the generations born at the beginning of the century to those born in the 40s, after which, for subsequent generations, it has been decreasing in all the considered areas and is similar in the North and South. We can infer that for the whole country the incidence will increase up to the years 2000–2010 when those birth-cohorts at higher risk will also be at higher risk for age. In 1987, about 250,000 Italian women had a present or past history of breast cancer: for the 1970–1987 period, prevalence has increased by approximately 5,500 cases per year.

Incidence, Mortality and Prevalence of Stomach Cancer in Italian Regions

The basic descriptive epidemiologic data on stomach cancer occurrence in Italian regions are presented and discussed. Incidence and prevalence were estimated from official mortality and survival data provided by four population-based Italian cancer registries. Age-adjusted mortality, incidence, and prevalence rates are presented by region for the year 1990. Time trends of incidence and their projection for the year 2000 are also presented by region and three broad age classes. Althrough the occurence of stomach cancer has been decreasing in Italy and most western countries over the last decades, a substantial slowing down of this decrease was evidenced in Italy, especially for women under 65 and for the regions of southern Italy. A marked tendency towards a reduction of geographic heterogeneity in stomach cancer occurrence was also shown. Such a phenomenon is consistent with the observed changes of dietary habits in Italian regions. The regions of Umbria and The Marches seem to emerge as new areas at relatively high risk of stomach cancer incidence and mortality. About 45,000 prevalent cases were estimated in Italy by 1990, half of which have been diagnosed before 1984.

The Effect of Cytological Screening on Cervical Neoplasia in the Italian Province of Varese

In the Varese province (409,142 female inhabitants in 1981), which has been covered by a cancer registry since 1976, cytologic screening for cervical cancer began in the early sixties in the municipality of Busto Arsizio (41,818 female inhabitants in 1981) and subsequently spread to the rest of the province. The distribution by age of cytologic smears and of detected in situ cancer reveals a more frequent attitude to be screened for women aged between 25 and 54 years. Overall, the incidence rate (world standardized) for invasive cancer in the province decreased from 10.3/100,000 women-year in the period 1976-81 to 7.5/100,000 in 1982-87. In Busto Arsizio a survey of the hospital archives has been carried out to identify the cases of cervical cancer diagnosed from 1966 to 1985: in this 20-year period, the incidence of cervical cancer decreased markedly, but only in those ages frequently screened. In the rest of the province, for the first period of cancer registration (1976-81), the incidence was significantly higher than in Busto Arsizio, especially for ages 35-64. Subsequently, between 1982-87, the cervical cancer incidence was low in both areas. For the period 1976-87, no difference for carcinoma in situ registration rates was observed between the two populations studied. Actually by 1976, when the Lombardy Cander Registry began its activity, the screening was diffuse throughout the province. These observations are consistent with the preventive effect of screening activity.

Breast Cancer Prevalence Measured by the Lombardy Cancer Registry

Aims and background

Breast cancer is the most important malignant neoplasm affecting women in Western countries. An increasing number of women undergo regular medical checkups, especially during the first years following the diagnosis. Therefore, from the health planning point of view, it is essential to have prevalence measures to furnish estimates for the demands that the health care system could possibly undergo.

Methods

By means of PREVAL, a computerized program, breast cancer prevalence has been measured in the Varese province using incidence and follow-up data from the Lombardy Cancer Registry (LCR).

Results

During the 1986–1988 period, breast cancer prevalence for patients alive within 10 years from diagnosis was about 625 per 100,000 resident women. Of these, 54% were over 60 years and 9% were under 45 years of age. Patients alive within 2 years from diagnosis were about 200 per 100,000 residents; considering the 1978–1980 period, patients alive within 2 years from diagnosis were just 140 per 100,000 residents. This dramatic increase in breast cancer prevalence is present also for long-term survivors (i.e. patients alive at 10–13 years from the diagnosis). Extrapolating breast cancer prevalence measured in the Varese province to the whole Lombardy region, the expected number of prevalent cases alive within 10 years of the diagnosis, presently living in Lombardy, would be 27,500. LCR's breast cancer prevalence figures were compatible with available data provided by the Finnish Cancer Registry.

Conclusion

Owing to aging of the population, the improvement in survival and the increasing incidence, the number of prevalent cases will increase. This phenomenon has and will have great importance for the health planning.

Incidence and Survival of Brain Tumors: A Population-Based Study

Since 1976 the Lombardy Cancer Registry (RTL) has recorded all malignant tumors and the benign tumors of the nervous system, bladder and liver occurring in the Varese province. The aims of this report are: to describe age-specific incidence rates of the different oncotypes of primary nervous system tumors (PNSTs) and to analyze the duration of survival of the patients according to the histotype of the neoplasm. From 1976 to 1981, the RTL recorded 498 PNST: 213 tumors of glial origin, 132 tumors of mesodermal tissues, 15 tumors of multipotential cell origin, 37 tumors of nerve roots, 8 of vascular origin, and 54 PNST in which the histotype was not specified. For tumors of glial origin, the 60–69 year age class showed the highest incidence rate: 16 per 100,000/year. The incidence rate of tumors of mesodermal tissues reached the maximum value of 7.9 per 100,000/year in the age group of 75 years and over. Tumors of multipotential cell origin had a maximum incidence of 2.2 in the 60–69 year age class. The probability of survival at 5 years after diagnosis was computed by the method of Kaplan and Meier (15), and the log rank procedure was used to test statistical differences among survivors. Tumors of glial origin, excluding ependymomas and papillomas of choroid plexus, had a 5-year survival probability of 14%. Age (categorized in ≤50 and > 50 years) and histologic grade (grades I+II and grades III+IV) were analyzed as prognostic factors for tumors of glial origin: a younger age was the most predictive prognostic factor in grade I+II tumors (probability of survival = 53% in the group ≤50 years vs 0 in the group > 50 years; p < 0.005). In the less differentiated tumors there were no differences between the two age groups. Patients with tumors of mesodermal tissues had a 5-year probability of survival of 83%. Subjects younger than 50 years had a probability of survival of 95%, whereas older patients had a probability of 79%. For the other oncotypes, the 5-year survival probability was: 50% for tumors of multipotential cell origin, 63% for ependymomas and papillomas of the choroid plexus, 64% for tumors of vascular derivation, and 21% for PNST with not specified histotype.

The Prevalence of Cancer: A Review of the Available Data

Aims and Background

Cancer prevalence in a population, defined as the proportion – or the number – of people who were diagnosed with a cancer during their lives and are still alive at a given date, is a crucial indicator for heath care planning and resource allocation. Long-term population-based cancer registries (CR) are the appropriate tools to produce prevalence figures, which, however, are scarcely available. This paper contains a review up to 1999 of the published data world-wide (reports and articles) on cancer prevalence: including measured and estimated figures.

Materials and Methods

Data on cancer prevalence from CRs are available for the Nordic countries, Connecticut, and Italy. In addition, electronic data are available for the European Union (EU). Data for the Nordic countries were first published in the mid-seventies, reporting the prevalence for 1970. The first data from Connecticut were available 10 years later. Estimates for all EU countries were published by the International Agency for Research on Cancer (IARC) in 1997. In Italy, observed and estimated data on the prevalence of respiratory and digestive tract cancer and breast cancer have been published during the nineties, followed by a systematic analysis for all cancers in 1999. By using information obtained from CRs, cancer prevalence data were calculated directly (observed prevalence) by means of incidence and follow-up information on individual cancer patients, or indirectly (estimated prevalence) by means of mathematical models, which generally use epidemiological information at the aggregate level.

Results

Cancer prevalence for all cancers combined (proportions per 100,000 inhabitants) showed values of less than 700 in males and less than 800 in females in 1970 (Finland) to over 2,300 in males and over 3,000 in females in 1992 (Italian registries). With few exceptions, in each country and period considered the cancer sites contributing most to cancer prevalence are lung, colon-rectum, prostate and bladder in males, colon-rectum, breast, uterus (both cervix and corpus) and ovary in females. At present, comparison of measurements from different areas is difficult because there exists no standardized mode of presentation.

Conclusions

In spite of their being potentially useful for health care planning, prevalence data have been produced inconsistently and late by cancer registries, at least in comparison with the systematic availability of incidence and survival statistics. The available data can be compared only to a limited extent due to differences in completeness, in the choice of indicators, in the standard populations, and in the frequency of publication. It would be desirable that in the future data will be produced systematically, with a higher level of standardization compared to the past, and, most importantly, on the same geographic and administrative scale as health-care decision-making.

Incident Lung Cancer Survival. Long-Term Follow-Up of a Population-Based Study in Italy

The long-term survival of an incident lung cancer population was evaluated in relation to clinical stage, treatment modalities and other prognostic factors. The survey was carried out among the residents in the Local Sanitary Unit of Saronno, a highly industrialized area of northern Italy, where all the lung cancer cases diagnosed during the years 1976-79 had been identified and clinically studied. The overall survival of the 222 cases included in the analysis was 32% at 1 year, 10% at 3 years and 5% at 5 years; median survival was 7 months. A significantly better prognosis was associated with surgical resection (32% at 5 years; median, 42 mo), clinical stage I (16% at 5 years; median, 15 mo), and squamous cell carcinoma (13% at 5 years; median, 11 mo). Other factors such as age, sex, social class or cancer symptoms did not affect survival when treatment was taken into account. Our data show that surgical resection is the major determinant of survival, and suggest that suboptimal access to curative treatment, particularly in patients aged 60 to 75 with limited disease, might have compromised the overall survival.

The Itacare Study

ITACARE is a collaborative study on the survival of Italian cancer patients diagnosed in the period 1978–1989. The study involves 11 Italian population-based cancer registries (CRs) (Firenze, Forlì-Ravenna, Genova, Latina, Modena, Parma, Ragusa, Torino, Varese, the childhood CR of Piedmont and the colorectal CR of Modena), and its principal aim is to identify and analyze possible differences between the areas covered by the CRs. This article describes the ITACARE database. Ten percent of the Italian population is covered by the participating CRs, most of which are located in the northern part of the country. All malignant cancer sites (classified by ICD-9) except skin cancers were included. For bladder cancers, papillomas and transitional cell tumours grade 1 and 2 were also included. Survival data on over 100,000 cases were collected. The principal information variables were sex, date of birth, diagnosis and end of follow-up, life status, ICD-9 code for tumour site, diagnosis modality (clinical, cytologic confirmation, histologic confirmation), ICD-0 morphology code, and tumour stage (grouped into broad categories). Follow-up is active in all registries. All cases were checked systematically for errors and inconsistencies, following which about 0.2% of cases were excluded from the analyses. The percentage of cases microscopically verified, which is an indicator of diagnostic accuracy and data reliability, was higher among patients under 65 years of age (90%), breast cancer patients (92%) and cases covered by the Varese, Torino and Forlì-Ravenna CRs (more than 82%). The percentage of cases known by death certificate only (an indicator of the completeness and quality of registration) was about 3% of total cases and was higher among older patients (4%). Province-specific mortality, used to compute relative survival from cancer (i.e., survival adjusted for competing causes of death), varied according to period of diagnosis, sex and area: the highest mortality was among women of the Ragusa CR (Sicily) and men in northern CRs. Overall mortality decreased during the period, more markedly in the north and among women.

Interpreting Survival Differences and Trends

Since 1990 a concerted action between European population-based cancer registries (the EUROCARE project) has been carried out with the aims of establishing whether there are differences in cancer patient survival in Europe, and the reasons for such differences. Survival differences actually exist for cancer sites for which the stage of disease at diagnosis is the major prognostic factor (such as breast, stomach and colon cancer). However, for most cancer sites, survival increases over time and the survival rates of different countries tend to converge towards higher values. Interpreting survival differences and trends is not an easy task. Longer survival may be achieved by postponing death through better treatment or by anticipating diagnosis. However, an earlier diagnosis may or may not make a treatment more effective in postponing death. The computation of stage-specific or stage-adjusted survival is not sufficient for interpretation of survival differences, because staging procedures change over time and may vary in different hospitals and countries. In addition to an early diagnosis and more effective treatment, a number of factors may bias survival estimates. They may be classified into factors that can be controlled in the analysis (at least partially), such as mortality from other causes, demographic factors, epoch of diagnosis, different statistical methodology, and factors depending on the validity of cancer registry data, such as definition of the illness, exhaustiveness and quality of registration, completeness of follow-up, definition of the date of diagnosis, and definition of disease stage including the diagnostic procedure used to establish stage. To help disentangle the effects of early diagnosis and better treatment, several statistical approaches are being developed: multivariate analysis on relative survival data, new modeling analysis to separately estimate the proportion of cured patients and the length of survival for those patients destined to die, and the standardized collection of information on stage at diagnosis and staging procedures.

Factors influencing acute and late toxicity in the era of adjuvant hypofractionated breast radiotherapy

PURPOSE

To evaluate toxicity in breast cancer patients treated with anthracycline and taxane based chemotherapy and whole breast hypofractionated radiotherapy, and to identify the risk factors for toxicity.

METHODS AND MATERIALS

537 early breast cancer patients receiving hypofractionated radiotherapy after conservative surgery were enrolled from April 2009 to December 2014, in an Italian cancer institute. The dose was 42.4 Gy in 16 daily fractions, 2.65 Gy per fraction. The boost to the tumor bed was administered only in grade III breast cancer patients and in patients with close or positive margins. Acute and late toxicity were prospectively assessed during and after radiotherapy according to RTOG scale. The impact of patients clinical characteristics, performed treatments and dose inhomogeneities on the occurrence of an higher level of acute skin toxicity and late fibrosis has been evaluated by univariate and multivariate analysis.

RESULTS

The mean age was 74 (range 46-91 yrs). 27% of patients received boost. 22% of cases (n = 119) received also chemotherapy. The median follow-up was 32 months. G1 and G2/G3 acute skin toxicity were 61.3% and 20.5% and G1 and G2/G3 late fibrosis 12.6% and 4.3% respectively. Chemotherapy (p = 0.04), diabetes (p = 0.04) and boost administration (p < 0.01) were found to be statistically significant on the occurrence of late fibrosis, but a multivariate analysis did not show any factors connected. The boost administration (p < 0.01), the breast volume (p = 0.05), dose inhomogeneities (p < 0.01) and boost volume (p = 0.04) were found to be statistically significant as concerns the occurrence of acute skin reaction at the univariate analysis, but only the boost administration (p = 0.02), at multivariate analysis.

CONCLUSIONS

The results of our study, according to the large randomized trials, confirmed that hypofractionated whole breast irradiation is safe, and only the boost administration seems to be an important predictor for toxicity. Chemotherapy does not impact on acute and late skin toxicity.

Survival for oesophageal, stomach and small intestine cancers in Europe 1999-2007: Results from EUROCARE-5

BACKGROUND

European regional variation in cancer survival was reported in the EUROCARE-4 study for patients diagnosed in 1995-1999. Relative survival (RS) estimates are here updated for patients diagnosed with cancer of the oesophagus, stomach and small intestine from 2000 to 2007. Trends in RS from 1999-2001 to 2005-2007 are presented to monitor and discuss improvements in patient survival in Europe.

MATERIALS AND METHODS

EUROCARE-5 data from 29 countries (87 cancer registries) were used to investigate 1- and 5-year RS. Using registry-specific life-tables stratified by age, gender and calendar year, age-standardised 'complete analysis' RS estimates by country and region were calculated for Northern, Southern, Eastern and Central Europe, and for Ireland and United Kingdom (UK). Survival trends of patients in periods 1999-2001, 2002-2004 and 2005-2007 were investigated using the 'period' RS approach. We computed the 5-year RS conditional on surviving the first year (5-year conditional survival), as the ratio of age-standardised 5-year RS to 1-year RS.

RESULTS

Oesophageal cancer 1- and 5-year RS (40% and 12%, respectively) remained poor in Europe. Patient survival was worst in Eastern (8%), Northern (11%) and Southern Europe (10%). Europe-wide, there was a 3% improvement in oesophageal cancer 5-year survival by 2005-2007, with Ireland and the UK (3%), and Central Europe (4%) showing large improvements. Europe-wide, stomach cancer 5-year RS was 25%. Ireland and UK (17%) and Eastern Europe (19%) had the poorest 5-year patient survival. Southern Europe had the best 5-year survival (30%), though only showing an improvement of 2% by 2005-2007. Small intestine cancer 5-year RS for Europe was 48%, with Central Europe having the best (54%), and Ireland and UK the poorest (37%). Five-year patient survival improvement for Europe was 8% by 2005-2007, with Central, Southern and Eastern Europe showing the greatest increases (⩾9%).

CONCLUSIONS

Survival for these cancer sites, particularly oesophageal cancer, remains poor in Europe with wide variation. Further investigation into the wide variation, including analysis by histology and anatomical sub-site, will yield insights to better monitor and explain the improvements in survival observed over time.

Survival in patients with primary liver cancer, gallbladder and extrahepatic biliary tract cancer and pancreatic cancer in Europe 1999-2007: Results of EUROCARE-5

BACKGROUND

The EUROCARE study collects and analyses survival data from population-based cancer registries (CRs) in Europe in order to provide data on between-country differences in survival and time trends in survival.

METHODS

This study analyses data on liver cancer, gallbladder and extrahepatic biliary tract cancers ("biliary tract cancers"), and pancreatic cancer diagnosed in 2000-2007 from 88 CRs in 29 countries. Relative survival (RS) was estimated overall, by region, sex, age and period of diagnosis using the complete approach. Time trends in 5-year RS over 1999-2007 were also analysed using the period approach.

RESULTS

The prognosis of the studied cancers was poor. Age-standardised 5-year RS was 12% for liver cancer, 17% for biliary tract cancers and 7% for pancreatic cancer. There were some between-country differences in survival. In general, RS was low in Eastern Europe and high in Central and Southern Europe. For all sites, 5-year RS was similar in men and women and decreased with advancing age. No substantial changes in survival were reported for pancreatic cancer over the period 1999-2007. On average, there was a crude increase in 5-year RS of 3 percentage points between the periods 1999-2001 and 2005-2007 for liver cancer and biliary tract cancers.

CONCLUSIONS

The major changes in imaging techniques over the study period for the diagnosis of the three studied cancers did not result in an improvement in the prognosis of these cancers. In the near future, new innovative treatments might be the best way to improve the prognosis in these cancers.

Operative mortality after gastric cancer resection and long-term survival differences across Europe

BACKGROUND

: Little is known at a population level about operative mortality after surgery for gastric cancer and whether differences between countries can explain differences in long-term survival. This study compared operative mortality recorded by ten cancer registries in seven European countries.

METHODS

: Non-conditional logistic regression analysis was performed to estimate the independent effect of the studied factors on mortality within 30 days of surgery. A multivariable survival model was employed with and without operative mortality.

RESULTS

: The overall operative mortality rate in 1611 patients studied was 8.9 (range 5.2-16) per cent. Country of residence was a significant prognostic factor in the multivariable analysis. The likelihood of operative mortality was lower in Italy, France and the UK than in the Netherlands, Spain, Slovenia and Poland. Age, type of gastrectomy and stage at diagnosis were also significant factors. Cancer site was not found to be significant in the multivariable analysis. The overall 5-year relative survival rate varied between 42.0 per cent (Italy) and 24 per cent (Poland); after excluding operative mortality, the 5-year survival rate was 44.3 and 28 per cent respectively.

CONCLUSION

: Within Europe, the substantial differences in operative mortality after gastrectomy only partly explain marked differences in survival after gastric cancer resection.

Thromboprophylaxis for caesarean section—how can uptake and coverage be improved?

The objective of this study was to determine the proportion of patients requiring thromboprophylaxis and evaluate adherence to local protocols on thromboprophylaxis after caesarean section. This was a retrospective audit of 200 consecutive patients undergoing caesarean section between January and March 2002. The study was carried out at two obstetric units in Hull. We evaluated the proportion of patients requiring prophylaxis, appropriate and inappropriate treatment given and those omitted from receiving prophylaxis. Adherence to a risk assessment protocol was also assessed. The majority of women (84.5%) had at least one risk factor for thromboembolism. Use of a checklist did not increase the appropriate use of thromboprophylaxis and did not reduce inappropriate use. The checklist was used appropriately in only 54% of cases. Thromboprophylaxis has not been associated with problems if given after operation, thus the inappropriate administration is probably not a serious mistake. Universal prophylaxis with low molecular weight heparin would prevent at-risk women being missed and should be considered.

Prognostic value of morphology and hormone receptor status in breast cancer - a population-based study

We analysed the 5-year relative survival among 4473 breast cancer cases diagnosed in 1990–1992 from cancer registries in Estonia, France, Italy, Spain, the Netherlands and the UK. Among eight categories based on ICD-O codes (infiltrating ductal carcinoma, lobular plus mixed carcinoma, comedocarcinoma, ‘special types’, medullary carcinoma, not otherwise specified (NOS) carcinoma, other carcinoma and cancer without microscopic confirmation), the 5-year relative survival ranged from 66% (95% CI 61–71) for NOS carcinoma to 95% (95% CI 90–100) for special types (tubular, apocrine, cribriform, papillary, mucinous and signet ring cell); 27% (95% CI 18–36) for cases without microscopic confirmation. Differences in 5-year relative survival by tumor morphology and hormone receptor status were modelled using a multiple regression approach based on generalised linear models. Morphology and hormone receptor status were confirmed as significant survival predictors in this population-based study, even after adjusting for age and stage at diagnosis.

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

EUROCARE-3 analysed the survival of 1815584 adult cancer patients diagnosed from 1990 to 1994 in 22 European countries. The results are reported in tables, one per cancer site, coded according to the International Classification of Diseases (ICD)-9 classification. The main findings of the tables are summarised and commented on in this article. For most solid cancers, wide differences in survival between different European populations were found, as also reported by EUROCARE-1 and EUROCARE-2, despite a remarkable (10%) overall increase in cancer survival from 1985 to 1994. Survival was highest in northern Europe (Sweden, Norway, Finland and Iceland), and fairly good in central-southern Europe (France, Switzerland, Austria and Spain). Survival was particularly low in eastern Europe, low in Denmark and the UK, and fairly low in Portugal and Malta. The mix of tumour stage at diagnosis explains much of the survival differences for cancers of the digestive tract, female reproductive system, breast, thyroid, and also skin melanoma. For tumours of the urinary tract and prostate, the differences were explained mainly by differences in diagnostic criteria and procedures. The case mix by anatomic subsite largely explains differences in survival for head and neck cancers. For oesophagus, pancreas, liver and brain cancer, with poor prognoses, survival differences were limited. Tumours, for which highly effective treatments are available, such as testicular cancer, Hodgkin's lymphoma and some haematological malignancies, had fairly uniform survival across Europe. Survival for all tumours combined (an indicator of the overall cancer care performance of a nation's health system) was better in young than old patients, and better in women than men. The affluence of countries influenced overall cancer survival through the availability of adequate diagnostic and treatment procedures, and screening programmes.

European health systems and cancer care

INTRODUCTION

Data on the survival of all incident cases collected by population-based cancer registries make it possible to evaluate the overall performance of diagnostic and therapeutic actions on cancer in those populations. EUROCARE-3 is the third round of the EUROCARE project, the largest cancer registry population based collaborative study on survival in European cancer patients. The EUROCARE-3 study analysed the survival of cancer patients diagnosed from 1990 to 1994 and followed-up to 1999. Sixty-seven cancer registries of 22 European countries characterised by differing health systems participated in the study. This paper includes essays providing brief overviews of the state and evolution of the health systems of the considered countries and comments on the relation between cancer survival in Europe and some European macro-economic and health system indicators, in the 1990s.

OVERVIEW OF THE EUROPEAN HEALTH SYSTEMS

The European health systems underwent a great deal of reorganisation in the last decade; a general tendency being to facilitate expanding involvement of the private sector in health care, a process which occurred mainly in the eastern countries (i.e. the Czech Republic, Estonia, Poland, Slovakia and Slovenia). In contrast, organisational changes in the northern European countries (i.e. Denmark, Iceland, Finland and Sweden) tended to confirm the established public sector systems. Other countries, including the UK and some southern European countries (i.e. England, Scotland, Wales, Malta and Italy) have reduced the public role while the systems remain basically public, at least at present. Our findings clearly suggest that cancer survival (all cancer combined) is related to macro-economic variables such as the gross domestic product (GDP), the total national (public and private) expenditure on health (TNEH) and the total public expenditure on health (TPEH). We found, however, that survival is related to wealth (GDP), but only up to a certain level, after which survival continues to be related to the level of health investment (both TNEH and TPEH). According to the Organisation for Economic Co-operation and Development (OECD), the TNEH increased during the 1990s in all EUROCARE-3 countries, while the ratio of TPEH to TNEH reduced in all countries except Portugal.

CONCLUSIONS

Cancer survival depends on the widespread application of effective diagnosis and treatment modalities, but our enquiry suggests that the availability of these depends on macro-economic determinants, including health and public health investment. Analysis of the relationship between health system organisation and cancer outcome is complicated and requires more information than is at present available. To describe cancer and cancer management in Europe, the European Cancer Health Indicator Project (EUROCHIP) has proposed a list of indicators that have to be adopted to evaluate the effects on outcome of proposed health system modifications.

Differences in stage and therapy for breast cancer across Europe

We examined variations in stage, diagnostic workup and therapy for breast cancer across Europe. Seventeen cancer registries in six European countries contributed 4,480 cases diagnosed in 1990-91. The clinical records of these cases were examined, and the distribution of stage, diagnostic examinations and therapy were analyzed. Stage was earliest in the French registries, followed by those of Italy and Eindhoven (Netherlands). The proportion of stage I cancers was highest in the French areas with screening in place. Estonia, the English registries and Granada (Spain) had the most advanced stage at diagnosis. Use of liver ultrasonography varied from 84% (Italian registries) to 18% (Granada). Bone scan use varied from 81% (Italian registries) to 15% (Mersey, UK). The highest proportions treated by breast-conserving surgery were in the French (57%) and English registries (63%); the lowest were in Estonia (6%) and Granada (11%). The highest proportions of Halsted mastectomies were in Italy (19%) and Granada (8%). In all countries except England, 90% of operations included axillary lymphadenectomy. Medical treatment only was given to 8% of (mostly advanced) cases overall. Estonia (21%) and the English registries (14%) had the highest proportions of patients given medication only. Chemotherapy was given to low proportions of node-positive cases in the Italian (76%) and English (74%) areas; breast-conserving surgery for stage I tumors varied from 24% in Granada to 84% in England. These wide differences in breast cancer care across Europe in the early 1990s indicate a need for continual monitoring of past treatments to help ensure application of the most effective protocols.

Cancer survival increases in Europe, but international differences remain wide

The EUROCARE project analysed cancer survival data from 45 population-based cancer registries in 17 European countries, revealing wide international differences in cancer survival. We calculated 5-year relative survival for 1836287 patients diagnosed with one of 13 cancers during the period 1978-1989. The data, from 20 cancer registries in 13 countries, were grouped into four regions: Finland, Sweden, Iceland (Northern Europe); Denmark, England and Scotland (UK and Denmark); France, The Netherlands, Germany, Italy and Switzerland (Western Europe); Estonia and Poland (Eastern Europe), and broken down into four periods (1978-1980, 1981-1983, 1984-1986, 1987-1989). For each cancer, mean European and regional survival was estimated as the weighted mean of 5-year relative survival in each country. Survival increased with time for all tumours, particularly for cancers of testis (12% increase, i.e. from 79.9 to 91.9%), breast, large bowel, skin melanoma (approximately 9-10%), and lymphomas (approximately 7%). For most solid tumours, survival was highest in Northern Europe and lowest in Eastern Europe, and also low in the UK and Denmark. Regional variation was less marked for the lymphomas. Survival improved more in Western than Northern Europe, and the differences between these regions fell for bowel cancer (from 8.0% for those diagnosed in 1978-1980 to 2% for those diagnosed in 1987-1989), breast cancer (from 7.4% to 3.9%), skin melanoma (from 13.4% to 11.0%) and Hodgkin's disease (from 7.2 to 0.6%). For potentially curable malignancies such as Hodgkin's disease, large bowel, breast and testicular cancers, there were substantial increases in survival, suggesting an earlier diagnosis and more effective treatment. The persisting regional differences suggest there are corresponding differences in the availability of diagnostic and therapeutic facilities, and in the effectiveness of healthcare systems.

Incidence and prevalence of all cancerous diseases in Italy

The burden of cancer in ageing populations is causing great concern, particularly in Italy with Europe's fastest growing elderly population. Studying all cancers combined in one group, although of limited medical value, is of great interest from the viewpoints of public health, epidemiology and the economy. Using mortality data and an estimate of cancer patients' survival we have estimated and projected incidence and prevalence in Italy of all cancers combined in one group. Five major phenomena are highlighted in the paper: (1) the decrease in the age-adjusted cancer mortality rates among females and the stable mortality rates among males since 1990; (2) the changing pattern of cancer incidence since 1990, it has started to decrease for females and is stabilising for males; (3) the decrease in cancer incidence among males and females born after 1940; (4) the increase in the proportion of cancer patients that are cured with calendar years of diagnosis; (5) the increase in the total and the healthy life expectancy (i.e. cancer-free) among the Italian population since 1970. The declining and flat trends in age-adjusted cancer incidence and mortality rates since 1990 is the combined effect of survival improvements and cancer risk reduction for younger cohort groups, after 1940. These favourable trends contribute to the increase in healthy life expectation, thus supporting the idea that we live longer and healthier.

Survival for retinoblastoma in Europe

The survival of 954 cases of retinoblastoma, diagnosed between 1978 and 1989 in 28 populations belonging to 17 European countries and covered by cancer registration, is analysed in this study. Data were collected in the framework of the EUROCARE study following a common protocol and data-check procedures and were analysed centrally by the Kaplan-Meier method and by the Cox regression model. Overall 5-year survival in the European pool was 93% (95% confidence interval (CI): 91--95%), for both sexes. Five-, 10- and 18-year survival for a subset of 235 patients diagnosed in 1978--1981 was 91, 89 and 86%, respectively. Children diagnosed in their first year of age had a slightly higher survival (94%) than those diagnosed subsequently (92%). Survival rates lower than the European average were found in the Eastern European countries, Italy, England and Wales, Scotland, Spain and Denmark. Higher survival was found in the other Nordic countries and in Central European countries. However, none of these differences was statistically significant. There was statistically significant effect related to the period of diagnosis, with a 50% reduction in the relative risk (RR) for children diagnosed in 1986--1989 compared with those diagnosed in 1978-1981.

Understanding variations in survival for colorectal cancer in Europe: a EUROCARE high resolution study

BACKGROUND

Marked differences in population based survival across Europe were found for colorectal cancers diagnosed in 1985-1989.

AIMS

To understand the reasons for these differences in survival in a new analysis of colorectal cancers diagnosed between 1988 and 1991.

SUBJECTS

A total of 2720 patients with adenocarcinoma of the large bowel from 11 European cancer registries (CRs).

METHODS

We obtained information on stage at diagnosis, diagnostic determinants, and surgical treatment (not routinely collected by CRs) and analysed the data in relation to three year observed survival, calculating relative risks (RRs) of death and adjusting for age, sex, site, stage, and determinants of stage.

RESULTS

Three year observed survival rates ranged from 25% (Cracow) to 59% (Modena), and were low in the Thames area (UK) (38%). Survival rates between registries for "resected" patients varied less than those for all patients. When age, sex, and site were considered, RRs ranged from 0.7 (95% confidence intervals (CI) 0.6-0.9) (Modena) to 2.3 (95% CI 1.9-2.9) (Cracow). After further adjustment by stage, between registry RR variation was between 0.8 (95% CI 0.6-0.9) and 1.8 (95% CI 1.5-2.2). Inter-registry RR differences were slightly reduced when the determinants of stage (number of nodes examined and liver imaging) were included in the model. The reduction was marked for the UK registries.

CONCLUSIONS

The wide differences across Europe in colorectal cancer survival depend to a large extent on differences in stage at diagnosis. There are wide variations in diagnostic and surgical practices. There was a twofold range in the risk of death from colorectal cancer even after adjustment for surgery and disease stage.

Toward a comparison of survival in American and European cancer patients

BACKGROUND

Only recently have extensive population-based cancer survival data become available in Europe, providing an opportunity to compare survival in Europe and the United States.

METHODS

The authors considered 12 cancers: lung, breast, stomach, colon, rectum, melanoma, cervix uteri, corpus uteri, ovary, prostate, Hodgkin disease, and non-Hodgkin lymphoma. The authors analyzed 738,076 European and 282,398 U.S. patients, whose disease was diagnosed in 1985-1989, obtained from 41 EUROCARE cancer registries in 17 countries and 9 U.S. SEER registries. Relative survival was estimated to correct for competing causes of mortality.

RESULTS

Europeans had significantly lower survival rates than U.S. patients for most cancers. Differences in 5-year relative survival rates were higher for prostate (56% vs. 81%), skin melanoma (76% vs. 86%), colon (47% vs. 60%), rectum (43% vs. 57%), breast (73% vs. 82%), and corpus uteri (73% vs. 83%). Survival declined with increasing age at diagnosis for most cancers in both the U.S. and Europe but was more marked in Europe.

CONCLUSIONS

Survival for most major cancers was worse in Europe than the U.S. especially for older patients. Differences in data collection, analysis, and quality apparently had only marginal influences on survival rate differences. Further research is required to clarify the reasons for the survival rate differences.