The Influence of Sex and/or Gender on the Occurrence of Colorectal Cancer in the General Population in Developed Countries: A Scoping Review

Objective: Gender as the "sociocultural role of sex" is underrepresented in colorectal cancer incidence studies, potentially resulting in underestimated risk factors' consequences and inequalities men/women. We aim to explore how literature focusing on differences between men and women in the incidence of colorectal cancer interprets these differences: through sex- or gender-related mechanisms, or both? Methods: We conducted a scoping review using PubMed and Google Scholar. We categorized studies based on their definitions of sex and/or gender variables. Results: We reviewed 99 studies, with 7 articles included in the analysis. All observed differences between men and women. Six articles examined colorectal cancer incidence by gender, but only 2 used the term "gender" to define exposure. One article defined its "sex" exposure variable as gender-related mechanisms, and two articles used "sex" and "gender" interchangeably to explain these inequalities. Gender mechanisms frequently manifest through health behaviors. Conclusion: Our results underscore the need for an explicit conceptual framework to disentangle sex and/or gender mechanisms in colorectal cancer incidence. Such understanding would contribute to the reduction and prevention of social health inequalities.

Increasing access to fertility preservation for women with breast cancer: protocol for a stepped-wedge cluster randomized trial in France

BACKGROUND

With the increase in the number of long-term survivors, interest is shifting from cancer survival to life and quality of life after cancer. These include consequences of long-term side effects of treatment, such as gonadotoxicity. Fertility preservation is becoming increasingly important in cancer management. International recommendations agree on the need to inform patients prior to treatments about the risk of fertility impairment and refer them to specialized centers to discuss fertility preservation. However, the literature reveals suboptimal access to fertility preservation on an international scale, and particularly in France, making information for patients and oncologists a potential lever for action. Our overall goal is to improve access to fertility preservation consultations for women with breast cancer through the development and evaluation of a combined intervention targeting the access and diffusion of information for these patients and brief training for oncologists.

METHODS

Firstly, we will improve existing information tools and create brief training content for oncologists using a qualitative, iterative, user-centred and participatory approach (objective 1). We will then use these tools in a combined intervention to conduct a stepped-wedge cluster randomized trial (objective 2) including 750 women aged 18 to 40 newly treated with chemotherapy for breast cancer at one of the 6 participating centers. As the primary outcome of the trial will be the access to fertility preservation counselling before and after using the combined intervention (brochures and brief training for oncologists), we will compare the rate of fertility preservation consultations between the usual care and intervention phases using linear regression models. Finally, we will analyse our approach using a context-sensitive implementation analysis and provide key elements for transferability to other contexts in France (objective 3).

DISCUSSION

We expect to observe an increase in access to fertility preservation consultations as a result of the combined intervention. Particular attention will be paid to the effect of this intervention on socially disadvantaged women, who are known to be at greater risk of inappropriate treatment. The user-centred design principles and participatory approaches used to optimize the acceptability, usability and feasibility of the combined intervention will likely enhance its impact, diffusion and sustainability.

TRIAL REGISTRATION

Registry: ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT05989776. Date of registration: 7th September 2023. URL: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05989776 .

PROTOCOL VERSION

Manuscript based on study protocol version 2.0, 21st may 2023.

Net survival in colon and rectal cancer by stage according to neoadjuvant treatment. A French population-based study

AIM

Real-life estimations of survival by stage in colorectal cancer are scanty. We estimated population-based net survival by pathological stage and location, and for rectal cancer by patterns of evolution according to clinical and pathological stage with regard to neoadjuvant therapy.

METHOD

Age-standardized net survival was estimated on 19,630 colorectal cancers diagnosed between 2009 and 2015.

RESULTS

Five-year net survival was 64 % for colon and 62 % for rectal cancer. The highest absolute difference between colon and rectum was 12 % for stage II women aged 75 (91% vs. 79 %). Among patients with clinical stage III rectal cancer, 67 % no longer had pathological node involvement after neoadjuvant treatment. Survival was similar in clinical stage I, II or III and pathological stage III after neoadjuvant treatment and in pathological stage III without neoadjuvant treatment (between 67 % and 72 %). It ranged between 80 and 82 % in pathological stage II, without neoadjuvant treatment or with clinical stage I, II or III before neoadjuvant treatment. Survival ranged between 93 % and 95 % in pathological stage I, treated with surgery only or with clinical stage II or III before neoadjuvant treatment.

CONCLUSION

Prognosis is associated with stage determined on surgical specimens rather than stage at the initial workup.

Agent based modeling in health care economics: examples in the field of thyroid cancer

Although they remain little used in the field of Health Care Economics, Agent Based Models (ABM) are potentially powerful decision-making tools that open up great prospects. The reasons for this lack of popularity are essentially to be found in a methodology that should be further clarified. This article hence aims to illustrate the methodology by means of two applications to medical examples. The first example of ABM illustrates the construction of a Baseline Data Cohort by means of a Virtual Baseline Generator. The aim is to describe the prevalence of thyroid cancer in the French population over the long term according to different scenarios of evolution of this population. The second study considers a setting where the Baseline Data Cohort is an established cohort of (real) patients: the EVATHYR cohort. The aim of the ABM is to describe the long-term costs associated with different scenarios of thyroid cancer management. The results are evaluated using several simulation runs in order to observe the variability of simulations and to derive prediction intervals. The ABM approach is very flexible since several sources of data can be involved and a large variety of simulation models can be calibrated to generate observations according to different evolution scenarios.

Link between the referring physician and breast and cervical cancers screening: a cross-sectional study in France

BACKGROUND

The aims of the "médecin traitant" or referring physician (RP) reform, introduced in France in 2004, were to improve the organisation and quality of care and to allow for greater equity, particularly in terms of prevention. The objective of our study was to evaluate the effect of having a declared RP on the uptake of screening for breast and cervical cancers, and to explore the mechanisms involved.

METHODS

We used an existing dataset of 1,072,289 women, which combines data from the Health Insurance information systems, with census data. We built multivariable logistic regression models to study the effect of having a RP on the uptake of mammography and pap smear, adjusted for age, socio-economic level, health status and healthcare provision. We secondarily added to this model the variable "having consulted a General Practitioner (GP) within the year". Finally, we evaluated the interaction between the effect of having a referring physician and the area of residence (metropolitan/urban/rural).

RESULTS

Patients who had a declared RP had a significantly higher uptake of mammography and pap smear than those who did not. The strength of the association was particularly important in very urban areas. The effect of having visited a GP seemed to explain a part of the correlation between having a RP and uptake of screening.

CONCLUSIONS

Lower rates of gynaecological screening among women without an RP compared to those with an RP may partly reflect a specific behaviour pattern in women less adherent to the health care system. However, this result also shows the importance of the RP, who assumes the key role of relaying public health information in a more personalised and adapted way.

Study protocol of the CREDO randomised controlled trial: evaluation of a structured return home consultation for patients suffering from metastaticcancer

INTRODUCTION

Patients suffering from cancer are often managed by multiple health professionals. General practitioners with specific skills in oncology could facilitate care coordination between hospital and general practice in the management of these patients. To explore this hypothesis, we run a randomised clinical trial, called 'Concertation de REtour à DOmicile, CREDO'. The main objective is to explore the effectiveness of a 'return home' consultation compared with standard care. The number of unscheduled visits to care centres is used to evaluate the effectiveness of the treatment.

METHODS AND ANALYSIS

CREDO is a multicentre, randomised, open-label, prospective trial. It takes place in two specialised cancer care centres in southern France (Occitania region). Patient inclusion criteria are: be over 18 years old; be treated with a first cycle of metastatic chemotherapy in a specialised cancer care centre; have a metastatic solid cancer and be returning home after treatment. Patients are randomised in two arms: standard-arm (conventional management) or intervention-arm (CREDO management). In the intervention arm, a 'return home' consultation is carried out in three steps. First, the investigating GP (GP with specific skills in oncology) from the specialised care centre collects information about the patient and patient's management choices. Then, the investigating GP conducts an interview with the patient's referring GP to quickly communicate and discuss information about the patient. Finally, the investigating GP summarises these exchanges and transmits this information to the care centres chosen by the patient.All the patients are followed for 1 year.Statistical and medicoeconomic analysis are planned.

ETHICS AND DISSEMINATION

This clinical trial is registered under ClinicalTrials.gov identifier and was approved by the ethics committee of South-Western French Committee for the Protection of Persons (number: 2016-A01587-44) and from the French National Drug Safety Agency (ANSM, number: 2016111500034).An international publication of the final results and conference presentations will be planned.

TRIAL REGISTRATION NUMBER

NCT02857400.

Evolution of the Incidence of Oral Cavity Cancers in the Elderly from 1990 to 2018

OBJECTIVES

To describe the evolution of the incidence of oral cavity cancers (OCC) among elderly patients in France between 1990 and 2018 and to compare it to the incidence of other cancers sharing the same main risk factors.

MATERIAL AND METHODS

The incidence of cancers in mainland France from 1990 to 2018 was estimated from incidence data observed in every cancer registry of the Francim network. Incidence was modeled by a 2-dimensional penalized spline of age and year of diagnosis, associated with a random effect corresponding to the registry. The elderly population was divided into two groups: 70-79 years old and ≥80 years old.

RESULTS

There was a 72% increase in the number of OCC cases in women over 70 years of age between the periods 1990-1999 and 2010-2018. As for men, there was a stabilization in the number of cases (+2%). Over the same period, for laryngeal and hypopharyngeal cancers, there was a decrease in incidence in elderly men and an increase in elderly women, although less marked than for OCC.

CONCLUSIONS

Since the 1990s, the incidence of OCC has been increasing in elderly subjects in France, particularly in women. Population aging and growth or alcohol and tobacco consumption alone do not seem to explain this increase, which is not observed in the same proportions for other upper aerodigestive tract cancer subsites sharing the same main risk factors.

The stake of informing patients of the risk of hypofertility after chemotherapy for breast cancer

Introduction

Too few women with invasive breast cancer are informed of the risk of hypofertility after chemotherapy. However, this risk can be prevented by offering gamete preservation by a specialized team. We believe that if more women were informed about gamete preservation, more of them would accept it.

Objectives

The primary objective is to describe each step of the oncofertility care pathway from provision of information to gamete preservation. The secondary objective is to estimate the impact of not receiving information by determining the proportion of women who would have undergone gamete preservation if they had been informed.

Method

575 women aged 18-40 years treated with chemotherapy for breast cancer between 2012 and 2017 in the Ouest-Occitanie region (~3 million inhabitants) were included. We first constructed a multivariate predictive model to determine the parameters influencing the uptake of the offer of gamete preservation among women who were informed and then applied it to the population of uninformed women.

Results

Only 39% of women were informed of the risks of hypofertility related to chemotherapy and 11% ultimately received gamete preservation. If all had been informed of the risk, our model predicted an increase in gamete preservation of 15.35% in the youngest women (<30 years), 22.88% in women aged between 30 and 35 years and zero in those aged ≥36 years. We did not find any association with the European Deprivation Index (EDI).

Conclusion

Oncologists should be aware of the need to inform patients aged ≤ 35 years about gamete preservation. If all received such information, the impact in terms of gamete preservation would likely be major.

Outcomes of comprehensive geriatric assessment and surgical management in head and neck cancers of the elderly: an observational study

AIM

The aims of this study were to assess the survival benefit of optimal vs suboptimal management in elderly patients presenting with upper aerodigestive tract (UADT) cancer for which surgery was the standard of care, and determine if comprehensive geriatric assessment (CGA) was a prognostic factor for survival.

MATERIALS AND METHODS

This single-center retrospective cohort study was conducted from January 2014 to December 2018. Included patients were aged 70 or older at the time of diagnosis, and presented with UADT cancer with a theoretical indication for curative-intent surgery according to international guidelines.

RESULTS

A total of 188 patients were included, with a median age of 78 years. Treatment included surgery in 67.6% of cases and was considered optimal in 60.6% of patients. The overall 3-year survival was 55.2%, and was significantly better in case of optimal vs suboptimal treatment (74.5% vs 25.8%, p < 0.001). In univariate analysis, factors associated with a significantly improved 3-year survival included surgery (p < 0.001), age < 80 years, performance status < 2 and G8 score > 14. In multivariate analysis, CGA was associated with a better survival.

CONCLUSIONS

In patients aged over 70 presenting with UADT cancer for which the standard of care is surgery, an optimal management is associated with better overall survival. Receiving a CGA seems to provide a survival benefit in patients with a G8 score ≤ 14, through an optimization of the care pathway before and after the cancer treatment.

Experimental system of care coordination for the home return of patients with metastatic cancer: a survey of general practitioners

BACKGROUND

To promote improved coordination between general practice and hospital, the French clinical trial CREDO ("Concertation de REtour à DOmicile") is testing an innovative experimental consultation for patients with metastatic cancer who are returning home. This consultation involves the patient, the patient's referring GP (GP_ref) and a GP with specific skills in oncology (GP_onc) in a specialized care center. The objective of our study is to explore the satisfaction of GPs_ref about this consultation, in the phase of interaction between GP_onc and GP_ref.

METHODS

This observational, cross-sectional, multicenter study explored the satisfaction of GPs_ref who had participated in this type of consultation, via a telephone survey.

RESULTS

One Hundred GPs_ref responded to the questionnaire between April and September 2019 (overall response rate: 55%). 84.5% were satisfied with the consultation, and the majority were satisfied with its methods. Half of the GPs_ref learned new information during the consultation, three-quarters noted an impact on their practice, and 94.4% thought that this type of coordination between the GP_ref and the oncology specialist could improve general practice - hospital coordination.

CONCLUSIONS

For GPs, the CREDO consultation seems to be practical and effective in improving the coordination between general medicine and hospital. GPs would benefit from such coordination for all patients with cancer, several times during follow-up and at each occurrence of a medically significant event.

Treatment time interval in breast cancer: A population-based study on the impact of type and number of cancer centres attended

OBJECTIVES

We studied both the independent and combined effects of the places of biopsy and treatment on the treatment time interval based on a population-based study.

METHODS

We analysed the proportion of patients having a treatment time interval higher than the EUSOMA recommendation of 6 weeks, as a function of the number and the type of care centres the patients attended, from a French population-based regional cohort of women treated in 2015 for an incident invasive non-metastatic cancer (n = 505).

RESULTS

About 33% [95% CI: 27; 38] of patients had a treatment time interval higher than 6 weeks. About 48% of the patients underwent their biopsy and their initial treatment in the different centres. Results from multivariable analyses supported the impact of the type and number of centres attended on the proportion of time intervals over 6 weeks. This proportion was higher among patients with biopsy and treatment in different centres and among patients treated in a university hospital.

CONCLUSION

We pointed out the independent impact of the type and the number of care centres the patients attended, from biopsy to first treatment, on the treatment time interval, which is a well-known prognosis factor.

Health status of prevalent cancer cases as measured by mortality dynamics (cancer vs. noncancer): Application to five major cancers sites

BACKGROUND

Cancer prevalence is heterogeneous because it includes individuals who are undergoing initial treatment and those who are in remission, experiencing relapse, or cured. The proposed statistical approach describes the health status of this group by estimating the probabilities of death among prevalent cases. The application concerns colorectal, lung, breast, and prostate cancers and melanoma in France in 2017.

METHODS

Excess mortality was used to estimate the probabilities of death from cancer and other causes.

RESULTS

For the studied cancers, most deaths from cancer occurred during the first 5 years after diagnosis. The probability of death from cancer decreased with increasing time since diagnosis except for breast cancer, for which it remained relatively stable. The time beyond which the probability of death from cancer became lower than that from other causes depended on age and cancer site: for colorectal cancer, it was 6 years after diagnosis for women (7 years for men) aged 75-84 and 20 years for women (18 years for men) aged 45-54 years, whereas cancer was the major cause of death for women younger than 75 years whatever the time since diagnosis for breast and for all patients younger than 75 years for lung cancer. In contrast, deaths from other causes were more frequent in all the patients older than 75 years. Apart from breast cancer in women younger than 55 years and lung cancer in women older than 55 years and men older than 65 years, the probability of death from cancer among prevalent cases fell below 1%, with varying times since diagnosis.

CONCLUSIONS

The authors' approach can be used to better describe the burden of cancer by estimating outcomes in prevalent cases.

Social and territorial inequalities in breast and cervical cancers screening uptake: a cross-sectional study in France

OBJECTIVE

The objective of this cross-sectional study was to investigate the impact of socio-territorial characteristics on mammography and pap smear uptake according to the place of residence in the recommended age groups, and second outside the recommended age groups.

SETTING AND PARTICIPANTS

We used an existing dataset of 1 027 039 women which combines data from the Health Insurance information systems, with census data from Midi-Pyrénées, France.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our outcome was, for each woman, the uptake of the pap smear and the uptake of the mammography during the year.

RESULTS

A social gradient of screening uptake was found in the recommended age groups. This gradient was stronger in large urban areas:(1) For mammography: decile 10 (the most deprived) vs 1 (the least deprived), adjusted OR 0.777, 95% CI (0.748 to 0.808) in large urban area; adjusted OR= 0.808 for decile 1 to 0.726 for decile 10 in other areas vs decile 1 in urban areas;(2) For pap smear: decile 10 vs 1 adjusted OR 0.66, 95%CI (0.642 to 0.679) in large urban areas; adjusted OR= 0.747 for decile 1 to 0.562 for decile 10 in other areas vs decile 1 in urban areas).Screening rates were globally higher in large urban areas.For mammography, the social and territorial disparities were higher outside the recommended age group.

CONCLUSIONS

Offering a universal approach to every woman, as it is often the case in nationally organised screening programmes, is likely to be insufficient to ensure real equity in access. Developing global dataset combining health data and diverse socioeconomic data, at individual and contextual levels, could enable a better understanding of the mechanisms involved in this social gradient, and therefore, the development of targeted territorial actions to improve equity of access to healthcare.

[Non-genetic indications for risk reducing mastectomies: Guidelines of the National College of French Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To determine the value of performing a risk-reducting mastectomy (RRM) in the absence of a deleterious variant of a breast cancer susceptibility gene, in 4 clinical situations at risk of breast cancer.

DESIGN

The CNGOF Commission of Senology, composed of 26 experts, developed these recommendations. A policy of declaration and monitoring of links of interest was applied throughout the process of making the recommendations. Similarly, the development of these recommendations did not benefit from any funding from a company marketing a health product. The Commission of Senology adhered to the AGREE II (Advancing guideline development, reporting and evaluation in healthcare) criteria and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making recommendations in the presence of poor quality or insufficient evidence were highlighted.

METHODS

The Commission of Senology considered 8 questions on 4 topics, focusing on histological, familial (no identified genetic abnormality), radiological (of unrecognized cancer), and radiation (history of Hodgkin's disease) risk. For each situation, it was determined whether performing RRM compared with surveillance would decrease the risk of developing breast cancer and/or increase survival.

RESULTS

The Commission of Senology synthesis and application of the GRADE method resulted in 11 recommendations, 6 with a high level of evidence (GRADE 1±) and 5 with a low level of evidence (GRADE 2±).

CONCLUSION

There was significant agreement among the Commission of Senology members on recommendations to improve practice for performing or not performing RRM in the clinical setting.

Impact of a health literacy intervention combining general practitioner training and a consumer facing intervention to improve colorectal cancer screening in underserved areas: protocol for a multicentric cluster randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer burden worldwide. In France, it is the second most common cause of cancer death after lung cancer. Systematic uptake of CRC screening can improve survival rates. However, people with limited health literacy (HL) and lower socioeconomic position rarely participate. Our aim is to assess the impact of an intervention combining HL and CRC screening training for general practitioners (GPs) with a pictorial brochure and video targeting eligible patients, to increase CRC screening and other secondary outcomes, after 1 year, in several underserved geographic areas in France.

METHODS

We will use a two-arm multicentric randomized controlled cluster trial with 32 GPs primarily serving underserved populations across four regions in France with 1024 patients recruited. GPs practicing in underserved areas (identified using the European Deprivation Index) will be block-randomized to: 1) a combined intervention (HL and CRC training + brochure and video for eligible patients), or 2) usual care. Patients will be included if they are between 50 and 74 years old, eligible for CRC screening, and present to recruited GPs. The primary outcome is CRC screening uptake after 1 year. Secondary outcomes include increasing knowledge and patient activation. After trial recruitment, we will conduct semi-structured interviews with up to 24 GPs (up to 8 in each region) and up to 48 patients (6 to 12 per region) based on data saturation. We will explore strategies that promote the intervention's sustained use and rapid implementation using Normalization Process Theory. We will follow a community-based participatory research approach throughout the trial. For the analyses, we will adopt a regression framework for all quantitative data. We will also use exploratory mediation analyses. We will analyze all qualitative data using a framework analysis guided by Normalization Process Theory.

DISCUSSION

Limited HL and its impact on the general population is a growing public health and policy challenge worldwide. It has received limited attention in France. A combined HL intervention could reduce disparities in CRC screening, increase screening rates among the most vulnerable populations, and increase knowledge and activation (beneficial in the context of repeated screening).

TRIAL REGISTRATION

Registry: ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

2020-A01687-32 . Date of registration: 17th November 2020.

How to produce sound predictions of incidence at a district level using either health care or mortality data in the absence of a national registry: the example of cancer in France

BACKGROUND

In many countries, epidemiological surveillance of chronic diseases is monitored by local registries (LR) which do not necessarily cover the whole national territory. This gap has fostered interest in using non-registry databases (e.g., health care or mortality databases) available for the whole territory as proxies for incidence at the local level. However, direct counts from these databases do not provide reliable incidence measures. Accordingly, specific methods are needed to correct proxies and assess their epidemiological usefulness.

METHODS

This study's objective was to implement a three-stage turnkey methodology using national non-registry data to predict incidence in geographical areas without an LR as follows: constructing a calibration model to make predictions including accurate prediction intervals; accuracy assessment of predictions and rationale for the criteria to assess which predictions were epidemiologically useful; mapping after spatial smoothing of the latter predictions. The methodology was applied to a real-world setting, whereby we aimed to predict cancer incidence, by gender, at the district level in France over the 2007-15 period for 24 different cancer sites, using several health care indicators and mortality. In the present paper, the spatial smoothing performed on predicted incidence of epidemiological interest is illustrated for two examples.

RESULTS

Predicted incidence of epidemiological interest was possible for 27/34 solid site-gender combinations and for only 2/8 haematological malignancies-gender combinations. Mapping of smoothed predicted incidence provided a clear picture of the main contrasts in incidence between districts.

CONCLUSIONS

The methodology implemented provides a comprehensive framework to produce valuable predictions of incidence at a district level, using proxy measures and existing LR.

Multidimensional penalized splines for incidence and mortality-trend analyses and validation of national cancer-incidence estimates

BACKGROUND

Cancer-incidence and mortality-trend analyses require appropriate statistical modelling. In countries without a nationwide cancer registry, an additional issue is estimating national incidence from local-registry data. The objectives of this study were to (i) promote the use of multidimensional penalized splines (MPS) for trend analyses; (ii) estimate the national cancer-incidence trends, using MPS, from only local-registry data; and (iii) propose a validation process of these estimates.

METHODS

We used an MPS model of age and year for trend analyses in France over 1990-2015 with a projection up to 2018. Validation was performed for 22 cancer sites and relied essentially on comparison with reference estimates that used the incidence/health-care ratio over the period 2011-2015. Alternative estimates that used the incidence/mortality ratio were also used to validate the trends.

RESULTS

In the validation assessment, the relative differences of the incidence estimates (2011-2015) with the reference estimates were <5% except for testis cancer in men and < 7% except for larynx cancer in women. Trends could be correctly derived since 1990 despite incomplete histories in some registries. The proposed method was applied to estimate the incidence and mortality trends of female lung cancer and prostate cancer in France.

CONCLUSIONS

The validation process confirmed the validity of the national French estimates; it may be applied in other countries to help in choosing the most appropriate national estimation method according to country-specific contexts. MPS form a powerful statistical tool for trend analyses; they allow trends to vary smoothly with age and are suitable for modelling simple as well as complex trends thanks to penalization. Detailed trend analyses of lung and prostate cancers illustrated the suitability of MPS and the epidemiological interest of such analyses.

Management of colon cancer patients: A comprehensive analysis of the absence of multidisciplinary team meetings in two French departments

BACKGROUND

The care management of colorectal cancers has evolved, particularly since the implementation of multidisciplinary team meetings (MDTm). The aim of this study was to identify factors associated with the non-presentation of colon cancer patients in MDTm (no-MDTm) and to assess the association between no-MDTm and the diagnostic and therapeutic care management, in two areas in France, in 2010.

METHODS

Patients over 18 years diagnosed for invasive colon cancer in Gironde and Tarn during 2010 were included from the cancer registries of these two departments. We used five indicators to evaluate the care management of colon cancer patients (about diagnosis, treatment and selection of patients for chemotherapy).

RESULTS

No-MDTm patients were more likely to die early after diagnosis (OR=2.94, 95% CI=[1.52-5.66]). Elderly patients and those living in more disadvantaged areas were less often presented in MDTm (OR_≥85years=2.10, 95% CI=[1.06-4.18]; OR_EDIQ4-Q5=1.96, 95% CI=[1.23-3.14]). After adjusting for patient-related variables (age, comorbidities, deprivation) and tumor (stage at diagnosis), we found that thoracic CT scan was less often performed among no-MDTm patients (OR=0.40, 95% CI=[0.24-0.65]). There was no association between the absence of MDTm and the therapeutic care management indicators.

CONCLUSION

In conclusion, therapeutic care management was not associated with the absence of MDTm but with patient and tumor characteristics, including age, comorbidities and level of deprivation, that influence the non-presentation in MDTm.

What is the most appropriate period to define synchronous cancers?

BACKGROUND

Studies about second primary cancers (SPC) incidence exclude a period following the first cancer diagnosis given the high probability of diagnosing another primary cancer during this phase (synchronous cancers). However, definition of synchronicity period varies widely, from one to six months, without clear epidemiological justification. The objective of this study was to determine the most appropriate synchronicity period.

METHODS

Data from 13 French population-based cancer registries were used to establish a cohort of all patients diagnosed with a first cancer between 1989 and 2010. The incidence rate of subsequent cancer was computed by day within 1 year of follow-up after the first diagnosis. Incidence was modelized by joinpoint regression models with an initial quadratic trend and a second constant part (plateau). The joinpoint was the point from which the plateau began and defining the synchronicity period.

RESULTS

Our cohort included 696,775 patients with a first cancer, of which 12,623 presented a SPC. The median joinpoint for all sites combined was estimated at 120.5 days [112.0-129.0]. Analysis by gender reported a higher difference in 32 days for males (127.8 vs 96.1 days). Noteworthy differences were found depending on patient age and the site of first cancer, with joinpoint ranging from 84.7 (oesophagus cancer) to 250.1 days (bladder cancer).

CONCLUSION

Although some heterogeneity was observed based on the characteristic of the patients, the appropriate synchronicity period appears to be 4 months after the diagnosis of first cancer.

How does comorbidity affect colon cancer patients' care trajectory? Results from the French EvaCCoR cohort study

OBJECTIVE

Due to their advanced age in average, colon cancer patients are likely to be exposed to comorbidity. However, the influence of comorbidity on patients' care trajectory and survival is largely under-explored. Hence, we investigate the effect of comorbidity on patients care trajectory and survival based on an observational study in "real-life" setting.

METHODS

This prospective observational study in two French regions includes patients aged over 18 and firstly treated for a colon cancer, stage II and III, diagnosed between 1st January and 31st December 2010. We assessed the influence of comorbidity (severe vs moderate or none), using the Charlson Comorbidity Index, on overall survival and patients' management steps.

RESULTS

We analyzed 762 patients. We found comorbidity to be associated with adjuvant treatment delivery with a longer delay between surgery and chemotherapy initiation among patients with severe comorbidity. Severe comorbidity had an independent detrimental effect on overall survival that is slightly downsized after adjustment for adjuvant treatment delivery.

CONCLUSION

Using observational "real-life" data, we showed that comorbidity impacts the colon cancer patients' care trajectory directly but also through indirect pathways involving adjuvant chemotherapy delivery. However, further studies are needed to better understand this mechanism.

Evaluation of long-term living conditions in patients treated for localised prostate cancer

PURPOSE

To evaluate the evolution of living conditions (LC) in long-term survivors of localised prostate cancer 10 years after treatment compared with those of a same-age control group from the general population.

METHODS

Two hundred and eighty-seven patients diagnosed with prostate cancer in 2001 were selected in 11 French cancer registries. They were matched with controls randomly selected for age and residency. Both patients and controls completed a self-administered LC questionnaire concerning their familial, social and professional life, and general and specific quality of life (QoL) and anxiety and depression questionnaires.

RESULTS

Compared with controls, patients reported more sexual modifications (p < .0001), but without any difference in marital status. Patients' circle of friends was more stable than that of the controls (91% vs. 63%; p < .0001) and patients reported fewer friendship modifications than controls (p < .0006). Their professional and physical activities were also preserved. They reported more anxiolytic intake (p = .002) but did not consult their general practitioner more often. Type of specialist consulted differed in the two groups.

CONCLUSION

Patients treated for localised prostate cancer had the same living conditions as men of the same age. Their social life was satisfying on the whole, albeit they reported more sexual difficulties than their counterparts.

Inventory of tools for care coordination between general practice and hospital system for patients suffering from cancer in active phase of treatment: A scoping review

INTRODUCTION

During the active phase of treatment, major difficulties appear in the transmission and quality of the information communicated to the General Practitioner (GP). Our objective was to carry out an inventory of the coordination tools used to improve exchanges between the hospital and the GP in the management of the patient suffering from cancer during this phase.

MATERIAL AND METHOD

A scoping review was conducted using MEDLINE databases via PubMed, The Cochrane Library, Web of Science. Articles published between 1998 and 2018, in English and French, were analysed.

RESULTS

Over 4,863 articles were extracted, and 11 studies were included. They highlight an increase in the quality of patient care after the introduction of information sheets or training by video vignettes with GPs. They demonstrate the importance of using standardised letters between health professionals. The role of a "leader physician" is discussed, and its first evaluations are positive. An increase in information transmitted to GPs leads to a better satisfaction of patients and GPs.

CONCLUSION

Communication tools are essential for the transmission of information, but direct and oral communication between all health professionals seems to be a point to be further developed.

Improving communication between the general practitioner and the oncologist: a key role in coordinating care for patients suffering from cancer

Background

Patients suffering from cancers are increasingly numerous in general practice consultations. The General Practitioner (GP) should be at the heart of the management of patients. Several studies have examined the perceptions of GPs confronted with the patient suffering from cancer and the relationships of GPs with oncologists, but few studies have focused on the patients’ perspective. We studied the three-way relationship between the oncologist, the GP, and the patient, from the patient’s point of view.

Methods

A questionnaire validated by a group consisting of GPs, oncologists, nurses, an epidemiologist and quality analyst, was administered over a three-week period to patients suffering from cancer receiving chemotherapy in a day hospital.

Results

The analysis was based on 403 questionnaires. Patients had confidence in the GP’s knowledge of oncology in 88% of cases; 49% consulted their GP for pain, 15% for cancer-related advice, and 44% in emergencies. Perceived good GP/oncologist communication led patients to turn increasingly to their GP for cancer-related consultations (RR = 1.14; p = 0.01) and gave patients confidence in the GP’s ability to manage cancer-related problems (RR = 1.30; p < 0.01). Mention by the oncologist of the GP’s role increased the consultations for complications (RR = 1.82; p < 0.01) as well as recourse to the GP in an emergency (RR = 1.35; p < 0.01).

Conclusion

Patients suffering from cancer considered that the GP was competent, but did not often consult their GP for cancer-related problems. There is a discrepancy between patients’ beliefs and their behaviour. When the oncologist spoke to patients of the GP’s role, patients had recourse to their GP more often. Systematically integrating a GP consultation to conclude cancer diagnosis disclosure, could improve management and care coordination.

The impact of patients’ and physicians’ characteristics on surgery decision for head and neck cancer: Results of a national survey

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Background: The choice between surgical or medical treatments in head and neck cancer is a function of many patient-related and disease-related factors. We investigated how physicians' behavioral characteristics and patients’ socioeconomic status could affect medical decision-making. Methods: A nationwide cross-sectional online survey of surgeons and (radiation) oncologists specialized in head and neck oncology collected data on medical decision-making for 7 clinical vignettes involving head and neck squamous cell carcinoma patients that were representative of routine practice. Questionnaires elicited physicians' demographic and occupational characteristics along with their individual behavioral characteristics according to the decision theory framework. Patients’ gender and socioeconomic position were distributed across vignettes using a Latin square design. Results: We obtained 206 assessable answers. A multivariate analysis shows that surgeons suggested surgery more often than other professionals, which is mostly related to vignettes corresponding to clinical cases for which there is no consensus, so oncologists are 68% less likely than surgeons to choose surgery. For clinical vignette with an absence of consensus, physicians with lower risk aversion recommend more often surgery compared to those with higher risk aversion (OR = 1.88, p = 0.052). When the vignette corresponds to a clinical case for which there is a surgical consensus decision the isolated male blue-collar worker has a 75% lower chance of being offered surgery compared to the married male small business owner (OR = 0.25, p = 0.024). We did not observe any differences based on the patient's gender. Conclusions: Patients’ socioeconomic status did affect our clinical management decisions in head and neck oncology. The significant association between medical decision and individual behavioral characteristics of the physician documented still understudied mechanisms that involved nonbiological factor to explain clinical practices variations.

[COVID-19 impact on the cancer care structuration: Example of the multidisciplinary team meeting dedicated to oncology in Occitanie]

Ce travail étudie l’impact de l’épidémie de SARS-CoV2 et des recommandations qui ont été diffusées depuis le 16 mars sur l’activité des réunions de concertations pluridisciplinaires (RCP). L’activité des RCP d’Occitanie a été mesurée à partir des fiches RCP extraites du dossier communicant de cancérologie qui regroupe toutes les RCP. L’activité précédant le confinement a été comparée à celles des périodes de confinement (jusqu’au 24 avril) et des périodes équivalentes en 2019. Les critères de jugement étaient le nombre de réunions tenues, le nombre moyen de dossiers examinés par réunion, dont les premières présentations, et le nombre moyen de médecins présents. Les 191 RCP ont organisé 3943 réunions et étudié 72 070 dossiers (dont 30 127 premières soumissions). Nous avons observé une baisse de 8 % du nombre de réunions après le confinement. Le nombre de dossiers examinés a diminué de 23 % dans le mois suivant et jusqu’à 33 % dans la troisième quinzaine. Le nombre de médecins participant aux réunions a diminué initialement de 25 %. L’impact a été plus important dans la partie méditerranéenne de la région. Cette première étude à l’échelle d’une région montre que si l’impact de l’épidémie sur le nombre de RCP qui se sont réunies a été modeste, et que les RCP ont suivi les recommandations d’optimisation du quorum, la diminution du nombre de premières présentations laisse présager un retard au diagnostic et à la prise en charge des patients. Elle devra être complétée par des travaux qualitatifs et quantitatifs afin d’estimer l’impact réel de l’épidémie sur la prise en charge globale oncologique.

Contamination in control group led to no effect of PSA-based screening on prostate cancer mortality at 9 years follow-up: Results of the French section of European Randomized Study of Screening for Prostate Cancer (ERSPC)

INTRODUCTION

European Randomized Study of Screening for Prostate Cancer (ERSPC) mortality results were reported for 7 European countries (excluding France) and showed a significant reduction in Prostate cancer (PCa) mortality. As those results have not been part of the global ERSPC results, it is of interest to report PCa mortality at a median follow-up of 9 years for French section of ERSPC.

MATERIAL AND METHODS

Two administrative departments were involved in the study. Only men after randomization in the screening group were invited by mail to be screened by PSA testing with two rounds at 4-6 year intervals. Biopsy was recommended if PSA>=3.0 ng/mL. No information other that the French Association of Urology recommandations on the use of PSA was offered to the control group (own decision of physicians and patients). Follow up was based on cancer registry database. Contamination defined as the receipt of PSA testing in control arm was measured. Poisson regression models were used to estimate the Rate Ratio (RR) of PCa mortality and incidence in the screening vs. control arm.

RESULTS

Starting from 2003, 80,696 men aged 55-69 years were included. The percentage of men in the screening arm with at least one PSA test (compliance) was 31%. Compared to the control arm, PCa incidence increased by 10% in the screening arm (RR=1.10; 95% CI=[1.04-1.16], P=0.001), but PCa mortality did not differ (0.222 and 0.215 deaths/1000 person-years; RR=1.03[0.75-1.42], P=0.9).

DISCUSSION

Limitations include low participation rate. PSA testing in the control arm was observed in 32% of men (contamination).

CONCLUSIONS

Contamination in control group led to no effect of PSA-based screening on prostate cancer mortality at 9 years follow-up.

LEVEL OF EVIDENCE

3.

The AAPRISS Platform: Learning and Taking Action to Reduce Social Inequalities in Health to help PHIR

Key messages

Mixed structures housing spaces for both research and action, which create a dynamic of Population Health Intervention Research, are showing themselves to be effective and seem to meet a need. But the financial stability of this mixed structures is insufficient to sustain their activities and promote sustainable reduction of social inequalities in health.

[Regional state-of-the-art of the access to oncofertility consultation for young women with breast cancer]

OBJECTIVES

According to the 2004 Bioethics Act, oncofertility counselling must be systematically offered to all women of childbearing age before they are exposed to potentially gonadotoxic treatment. The main objective of this study was to evaluate the proportion of women under 40 years of age treated with chemotherapy for breast cancer in Midi-Pyrénées who have received an oncofertility consultation. A secondary objective was to assess practitioners' knowledge on the subject.

METHODS

A cross-reference was made between the databases of the oncology network in Midi-Pyrénées and the two approved centres for the preservation of fertility in the region. A computerized practitioner questionnaire was sent to all surgeons and oncologists who could manage these patients.

RESULTS

From 2012 and 2017, 667 women aged≤40 years received (neo)adjuvant chemotherapy treatment: only 156 (23.4%) had access to an oncofertility consultation and 58 (8.7%) received preservation. This rate (23.4%) varied according to the age of the patients, ranging from 56.9% for those aged 25-29 to 13.4% for those aged 35-39 and the managing institution. Of the 85 practitioners surveyed, 45 (55%) responded to the questionnaire, and of these 20 (44%) knew that ovarian stimulation treatment could be used even in hormone-dependent breast cancer situations and 13 (29%) of practitioners believed that the time required to preserve fertility was more than 1 month.

CONCLUSION

Our study revealed a significant disparity in access to oncofertility consultation. It is essential to set up information and awareness-raising actions on the subject.

Using ecological socioeconomic position (SEP) measures to deal with sample bias introduced by incomplete individual-level measures: inequalities in breast cancer stage at diagnosis as an example

BACKGROUND

When studying the influence of socioeconomic position (SEP) on health from data where individual-level SEP measures may be missing, ecological measures of SEP may prove helpful. In this paper, we illustrate the best use of ecological-level measures of SEP to deal with incomplete individual level data. To do this we have taken the example of a study examining the relationship between SEP and breast cancer (BC) stage at diagnosis.

METHODS

Using population based-registry data, all women over 18 years newly diagnosed with a primary BC in 2007 were included. We compared the association between advanced stage at diagnosis and individual SEP containing missing data with an ecological level SEP measure without missing data. We used three modelling strategies, 1/ based on patients with complete data for individual-SEP (n = 1218), or 2/ on all patients (n = 1644) using an ecological-level SEP as proxy for individual SEP and 3/ individual-SEP after imputation of missing data using an ecological-level SEP.

RESULTS

The results obtained from these models demonstrate that selection bias was introduced in the sample where only patients with complete individual SEP were included. This bias is redressed by using ecological-level SEP to impute missing data for individual SEP on all patients. Such a strategy helps to avoid an ecological bias due to the use of aggregated data to infer to individual level.

CONCLUSION

When individual data are incomplete, we demonstrate the usefulness of an ecological index to assess and redress potential selection bias by using it to impute missing individual SEP.

Multidisciplinary team meeting and EUSOMA quality indicators in breast cancer care: A French regional multicenter study

INTRODUCTION

We evaluate breast cancer (BC) pathway at a regional level including public, private and university institutions. We assessed the quality of multidisciplinary team meetings (MTM) and compliance with a panel of European high-quality indicators (EUSOMA QIs).

METHODS

We conducted a retrospective multicenter (n = 20) study in the largest health care region in France. Between January and April 2015, we included all patients discussed at an MTM after a diagnosis of BC (n = 619). We analyzed quality of MTM by assessing the quorum, the reliability of data transcription and the exhaustivity of pre-therapeutic MTM. We then analyzed the compliance with a selected panel of 16 EUSOMA QIs.

RESULTS

During MTM discussion, data were more than 95% consistent with medical records for 9/11 items. Pre-operative tumor histology (90.6%) and post-operative resection margins (84.3%) were the least concordant between medical records and MTM. Minimum standards as defined by EUSOMA were reached for 11/16 QIs, but not reached for pathology reports in non-invasive BC (78.2%), proportion of exclusive sentinel lymph node biopsies in patients with clinically negative axilla (85.2%), performing adjuvant chemotherapy (76.6%), and proportion of patients discussed in pre-therapeutic and post-operative MTM (63.5%).

CONCLUSIONS

In this multicentric study evaluating the quality of BC care with a representative sample of institutions, compliance with EUSOMA indicators was satisfactory for all type of institutions. However, too few patients were discussed in pre-therapeutic MTM (especially in non-university hospitals 43.7% [39.4-48.1]) versus 88.7% for others [82.2-95.1]) and data transcription was likely responsible for up to 15% of discordance.

Are there variations in adherence to colorectal cancer clinical guidelines depending on treatment place and recommendation novelty? The French EvaCCoR observational study

BACKGROUND

Studies have shown clinical practices variation between centers in colorectal cancer (CRC) management. After the implementation of national cancer plans, we tested for differences in center and patients' socioeconomic position (SEP)-related variation in CRC guidelines.

METHODS

All patients aged 18 years and over, cared for a first CRC in 2010 in Southwest of France. We used mixed effect model to test for center-related heterogeneity (CRH) in recommendation, from the oldest to the more recent: (1) at least 12 lymph nodes analysed for stage II, (2) the prescription of adjuvant chemotherapy stage III and (3) the assessment of CRC molecular phenotype regarding KRAS status for stage IV. Patients' SEP was approached by an ecological social deprivation index.

RESULTS

We found: higher adherence for the oldest than for the most recent recommendations; no CRH in recommendation No. 2 but lower adherence in academic centers; a CRH for recommendations No. 1 and 3; no SEP-related differences in clinical practices.

CONCLUSION

Results showed that older recommendations have higher adherence but did not support increasing influence of centers characteristics and CRH as recommendations are more recent.

Are comorbidities associated with long-term survival of lung cancer? A population-based cohort study from French cancer registries

Background

Survival rates of lung cancer remains poor and the impact of comorbidities on the prognosis is discussed. The objective of this study was to assess if the Charlson Comorbidity Index (CCI) was associated with 8-year survival rates by histological type.

Methods

A cohort study was conducted using randomly selected cases from 10 French cancer registries. Net survival rates were computed using the Pohar-Perme estimator of the net cumulative rate. Three Cox models were independently built for adenocarcinomas, squamous cell and small cell cancers to estimate prognostic factors including CCI grade.

Results

A total of 646 adenocarcinomas, 524 squamous cell and 233 small cell cancers were included in the analysis. The net 8-year survival rate ranged from 12.6% (95% CI: 9.8–15.4%) for adenocarcinomas and 13.4% (95% CI: 10.1–16.7%) for squamous cell carcinomas, to 3.7% (95% CI: 1.1–6.3%) for small cell cancers. Observed and net survival rates decreased for CCI grades ≥3 for all histological group considered.

After adjustment for sex, age group, stage and diagnostic mode, CCI grades 1 (HR = 1.6 [95% CI: 1.1–2.3]), 2 (HR = 1.7 [95% CI: 1.1–2.7]) and ≥ 3 (HR = 2.7 [95% CI: 1.7–4.4]) were associated with lower survival rates only for small cell cancers.

Conclusion

After adjustment for age, sex, stage and diagnostic mode, the presence of comorbidity based on CCI grades 1–2 and ≥ 3 was associated with lower survival rates for small cell cancers whereas no differences were observed for adenocarcinomas and squamous cell cancers.

A novel approach for medical research on lymphomas: A study validation of claims-based algorithms to identify incident cases

The use of claims database to study lymphomas in real-life conditions is a crucial issue in the future. In this way, it is essential to develop validated algorithms for the identification of lymphomas in these databases. The aim of this study was to assess the validity of diagnosis codes in the French health insurance database to identify incident cases of lymphomas according to results of a regional cancer registry, as the gold standard.Between 2010 and 2013, incident lymphomas were identified in hospital data through 2 algorithms of selection. The results of the identification process and characteristics of incident lymphomas cases were compared with data from the Tarn Cancer Registry. Each algorithm's performance was assessed by estimating sensitivity, predictive positive value, specificity (SPE), and negative predictive value.During the period, the registry recorded 476 incident cases of lymphomas, of which 52 were Hodgkin lymphomas and 424 non-Hodgkin lymphomas. For corresponding area and period, algorithm 1 provides a number of incident cases close to the Registry, whereas algorithm 2 overestimated the number of incident cases by approximately 30%. Both algorithms were highly specific (SPE = 99.9%) but moderately sensitive. The comparative analysis illustrates that similar distribution and characteristics are observed in both sources.Given these findings, the use of claims database can be consider as a pertinent and powerful tool to conduct medico-economic or pharmacoepidemiological studies in lymphomas.

Disentangling the influence of living place and socioeconomic position on health services use among diabetes patients: A population-based study

This research investigates the influence of place of residence and diabetic patient’s socioeconomic position on their use of health services in a universal health care system. This retrospective cross-sectional population-based study is based on the joint use of the Health Insurance information systems, an ecological indicator of social deprivation and an indicator of potential spatial accessibility of healthcare provision in the Midi-Pyrénées region. Using French healthcare insurance population-based data on reimbursement of out-of-hospital care during the year 2012, we study the use of health services among patients aged 50 and over (n = 90,136).We built logistic regression models linking health services use to socioeconomic position by geographic area, adjusted for age, gender, healthcare provision, information regarding patients precariousness, and long-term condition, used as proxy for the state of health. After adjustment for healthcare provision, the lower population density in the geographical area of concern, the lower the access to specialised care, independent of the patients’ SEP. General practitioner attendance was higher among the patients with the lowest SEP without being clearly influenced by their living place. We found no clear influence of either patients’ SEP or their living place on their access to biological follow-up. This study is an attempt to account for the geographical context and to go further in studying the social determinants of health among diabetes patients.