Increasing incidence of primary malignant brain tumors: influence of diagnostic methods

Computed tomography scan radiation and brain cancer incidence

BACKGROUND

Computed tomography (CT) scans make substantial contributions to low-dose ionizing radiation exposures, raising concerns about excess cancers caused by diagnostic radiation.

METHODS

Deidentified medicare records for all Australians aged 0-19 years between 1985-2005 were linked to national death and cancer registrations to 2012. The National Cancer Institute CT program was used to estimate radiation doses to the brain from CT exposures in 1985-2005, Poisson regression was used to model the dependence of brain cancer incidence on brain radiation dose, which lagged by 2 years to minimize reverse causation bias.

RESULTS

Of 10 524 842 young Australians, 611 544 were CT-exposed before the age of 20 years, with a mean cumulative brain dose of 44 milligrays (mGy) at an average follow-up of 13.5 years after the 2-year lag period. 4472 were diagnosed with brain cancer, of whom only 237 had been CT-exposed. Brain cancer incidence increased with radiation dose to the brain, with an excess relative risk of 0.8 (95% CI 0.57-1.06) per 100 mGy. Approximately 6391 (95% CI 5255, 8155) persons would need to be exposed to cause 1 extra brain cancer.

CONCLUSIONS

For brain tumors that follow CT exposures in childhood by more than 2 years, we estimate that 40% (95% CI 29%-50%) are attributable to CT Radiation and not due to reverse causation. However, because of relatively low rates of CT exposure in Australia, only 3.7% (95% CI 2.3%-5.4%) of all brain cancers are attributable to CT scans. The population-attributable fraction will be greater in countries with higher rates of pediatric scanning.

Trends and patterns of incidence of diffuse glioma in adults in the United States, 1973-2014

INTRODUCTION

The objective of the study was to identify trends in incidence of adult diffuse gliomas in the United States and evaluate the contribution of age, period, and cohort effects to the trends.

METHODS

Using the Surveillance, Epidemiology, and End Results 9 database, primary diffuse glioma patients (≥20 years old) diagnosed from 1973 to 2014 were identified. Incidence trends were analyzed using joinpoint regression and age-period-cohort modeling.

RESULTS

Overall, the incidence for adult glioma decreased slowly from 1985 to 2014 (annual percent change [APC] = 0.5%, 95% confidence intervals [CI], 0.3%-0.6%). In histology subtype-stratified analysis, glioblastoma and nonglioblastoma exhibited opposite trends. The incidence for glioblastoma increased from 1978 to 2014 (APC for year 1978-1992 = 2.7%, 95% CI, 1.8%-3.6%; APC for 1992-2014 = 0.3%, 95% CI, 0%-0.6%), while the incidence for nonglioblastoma decreased significantly from 1982 to 2014 (APC = 2.2%, 95% CI, 2.0%-2.5%). Age-period-cohort modeling revealed significant period and cohort effects, with the patterns for glioblastoma and nonglioblastoma distinctive from each other. Compared with adults born 1890s, those born 1920s had approximately 4-fold the risk of glioblastoma after adjustment of age and period effects, while the risk of nonglioblastoma was reduced by half in individuals in the 1939 cohort as compared with those in the 1909 cohort.

CONCLUSIONS

The results support the hypothesis of etiological heterogeneity of diffuse gliomas by histology subtypes. The established risk factors cannot fully explain the distinct patterns by histology subtypes, which necessitate further epidemiological studies.

Immunotherapeutic Strategies for Malignant Glioma

BACKGROUND

Despite advances in surgery, radiation therapy, and chemotherapy, only modest improvement has been achieved in the survival of patients with malignant gliomas.

METHODS

The authors review the immunologic aspects of gliomas, potential targets for therapy, and issues surrounding current immunotherapeutic strategies directed against malignant gliomas.

RESULTS

The blood-brain barrier and the purported immunological privilege of the brain are not necessarily insurmountable obstacles to effective immunotherapy for brain tumors. Preclinical studies suggest a number of potential therapeutic avenues. Translational studies offer the prospect of providing substantial new information about immunological trafficking in the nervous system and suggesting the most fruitful approaches to immunotherapy for malignant gliomas.

CONCLUSIONS

More effective adjuvant treatments for malignant gliomas are needed. The applicability of immunological approaches in the treatment of these tumors warrants continued study.

Evaluation of tumor-derived MRI-texture features for discrimination of molecular subtypes and prediction of 12-month survival status in glioblastoma

PURPOSE

Glioblastoma multiforme (GBM) is the most common and aggressive primary brain cancer. Four molecular subtypes of GBM have been described but can only be determined by an invasive brain biopsy. The goal of this study is to evaluate the utility of texture features extracted from magnetic resonance imaging (MRI) scans as a potential noninvasive method to characterize molecular subtypes of GBM and to predict 12-month overall survival status for GBM patients.

METHODS

The authors manually segmented the tumor regions from postcontrast T1 weighted and T2 fluid-attenuated inversion recovery (FLAIR) MRI scans of 82 patients with de novo GBM. For each patient, the authors extracted five sets of computer-extracted texture features, namely, 48 segmentation-based fractal texture analysis (SFTA) features, 576 histogram of oriented gradients (HOGs) features, 44 run-length matrix (RLM) features, 256 local binary patterns features, and 52 Haralick features, from the tumor slice corresponding to the maximum tumor area in axial, sagittal, and coronal planes, respectively. The authors used an ensemble classifier called random forest on each feature family to predict GBM molecular subtypes and 12-month survival status (a dichotomized version of overall survival at the 12-month time point indicating if the patient was alive or not at 12 months). The performance of the prediction was quantified and compared using receiver operating characteristic (ROC) curves.

RESULTS

With the appropriate combination of texture feature set, image plane (axial, coronal, or sagittal), and MRI sequence, the area under ROC curve values for predicting different molecular subtypes and 12-month survival status are 0.72 for classical (with Haralick features on T1 postcontrast axial scan), 0.70 for mesenchymal (with HOG features on T2 FLAIR axial scan), 0.75 for neural (with RLM features on T2 FLAIR axial scan), 0.82 for proneural (with SFTA features on T1 postcontrast coronal scan), and 0.69 for 12-month survival status (with SFTA features on T1 postcontrast coronal scan).

CONCLUSIONS

The authors evaluated the performance of five types of texture features in predicting GBM molecular subtypes and 12-month survival status. The authors' results show that texture features are predictive of molecular subtypes and survival status in GBM. These results indicate the feasibility of using tumor-derived imaging features to guide genomically informed interventions without the need for invasive biopsies.

Biopsy versus partial versus gross total resection in older patients with high-grade glioma: a systematic review and meta-analysis

BACKGROUND

Optimal extent of surgical resection (EOR) of high-grade gliomas (HGGs) remains uncertain in the elderly given the unclear benefits and potentially higher rates of mortality and morbidity associated with more extensive degrees of resection.

METHODS

We undertook a meta-analysis according to a predefined protocol and systematically searched literature databases for reports about HGG EOR. Elderly patients (≥60 y) undergoing biopsy, subtotal resection (STR), and gross total resection (GTR) were compared for the outcome measures of overall survival (OS), postoperative karnofsky performance status (KPS), progression-free survival (PFS), mortality, and morbidity. Treatment effects as pooled estimates, mean differences (MDs), or risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were determined using random effects modeling.

RESULTS

A total of 12 607 participants from 34 studies met eligibility criteria, including our current cohort of 211 patients. When comparing overall resection (of any extent) with biopsy, in favor of the resection group were OS (MD 3.88 mo, 95% CI: 2.14-5.62, P < .001), postoperative KPS (MD 10.4, 95% CI: 6.58-14.22, P < .001), PFS (MD 2.44 mo, 95% CI: 1.45-3.43, P < .001), mortality (RR = 0.27, 95% CI: 0.12-0.61, P = .002), and morbidity (RR = 0.82, 95% CI: 0.46-1.46, P = .514) . GTR was significantly superior to STR in terms of OS (MD 3.77 mo, 95% CI: 2.26-5.29, P < .001), postoperative KPS (MD 4.91, 95% CI: 0.91-8.92, P = .016), and PFS (MD 2.21 mo, 95% CI: 1.13-3.3, P < .001) with no difference in mortality (RR = 0.53, 95% CI: 0.05-5.71, P = .600) or morbidity (RR = 0.52, 95% CI: 0.18-1.49, P = .223).

CONCLUSIONS

Our findings suggest an upward improvement in survival time, functional recovery, and tumor recurrence rate associated with increasing extents of safe resection. These benefits did not result in higher rates of mortality or morbidity if considered in conjunction with known established safety measures when managing elderly patients harboring HGGs.

Indicators of Functional Status for Primary Malignant Brain Tumour Patients

Background:

We compared the functional status and survival time of patients with malignant gliomas.

Methods:

This retrospective review included 143 patients diagnosed with malignant gliomas. Patients were grouped according to histopathological diagnosis. To measure functional status, patients were assigned a Karnofksy performance status (KPS) score at the time of presentation and at one, three, six, nine, 12 months and yearly intervals thereafter. Data were analyzed using descriptive methods as well as Kruskal-Wallis tests, Chi-square tests, Log-Rank tests and Cox’s proportional hazards modeling.

Results:

Eighty-four patients were male. The median age of patients was 63 years. One hundred and seven patients had a histopathological diagnosis of glioblastoma multiforme, 23 of anaplastic astrocytoma and 13 of anaplastic oligodendroglioma. Twenty-nine patients received aggressive multimodal treatment, 83 received intermediate treatment and the remaining 31 patients received conservative therapy. Significant treatment complications occurred in 33% of patients including four post-operative deaths. The anaplastic oligodendroglioma group had lower mortality and maintained better KPS scores over time, as did patients receiving full treatment. The most significant prognostic factors for functional status included age, pretreatment KPS, and type of treatment received. The most significant factors associated with time until death included age, severity of comorbidities, pretreatment KPS, presence of confusion, histopathological diagnosis and type of treatment received.

Conclusion:

In patients with malignant gliomas, younger age, better functional status at presentation and aggressive multimodal treatment were associated with improved longer-term functional status and survival. Confirmation of the effect of multimodal treatment on patient functional status would require a randomised controlled clinical trial.

Incidence and relative survival of anaplastic astrocytomas

BACKGROUND

The purpose of this study was to investigate the relationship between age and the incidence and relative survival of anaplastic astrocytoma (AA).

METHODS

Data from the Surveillance, Epidemiology and End Results database were used to identify 3202 patients with AA. These data were analyzed to assess incidence rates, relative survival, and the standardized mortality ratio across age groups. Time trends were modeled using delayed-entry modeling.

RESULTS

The overall incidence of AA was an age-adjusted rate of 3.5 per million person/years. The overall age-standardized 5- and 10-year relative survival rates of populations with AA were 23.6% and 15.1%, respectively. The overall standardized mortality ratio for the entire cohort was 46 (95% confidence interval: 45, 48).

CONCLUSIONS

Patients with a diagnosis of AA are 46 times more likely to die than persons matched for age/sex/year of the general population. The effect of age on survival is present for only the first 2 years postdiagnosis. Measuring the effect of age on survival for populations with an AA is not amenable to using models with proportional hazards as an assumption because of the presence of a reverse fork-type interaction.

Effects of cerebral magnetic resonance imaging in outpatients on observed incidence of intracranial tumors and patient survival: a national observational study

OBJECT

It is assumed that the observed increase in brain tumor incidence may at least partially be explained by increased use of MRI. However, to date no direct estimate of this effect is available. The authors undertook this registry-based study to examine whether regional frequencies of cerebral MRI use correlate to regional incidence rates of intracranial tumors and survival of patients with these lesions.

METHODS

The authors used Norwegian national population registries from January 2002 through December 2007 to conduct this observational study. They obtained information on outpatient MRI scans in Norwegian counties and examined whether the annual regional rates of cerebral MRI scans correlated to regional age- and sex-adjusted brain tumor incidence rates. They also explored whether differences in cerebral MRI use were associated with survival and examined time trends in the study period.

RESULTS

Approximately 50,000 cerebral MRI scans are carried out annually in outpatient settings in Norway, and 6363 primary intracranial tumors were diagnosed in Norway during the study period. There was an overall positive correlation between the annual number of cerebral MRI scans per 100,000 capita and age- and sex-adjusted incidence rates of intracranial tumors in the various Norwegian counties (Spearman's rho = 0.35, p < 0.001). In a linear model, an increase in 1 MRI per 100,000 capita per year results in a 0.004 (95% CI 0.002-0.006) increase in diagnosed intracranial tumors per 100,000 capita per year (p < 0.001). Subgroup analysis showed a correlation between MRI use and the annual age- and sex-adjusted incidence rates of extraaxial tumors (p = 0.04, Spearman's rho = 0.28) but not intraaxial tumors (p = 0.394). Overall survival for unselected patients with intracranial tumors is longer with increasing number of cerebral MRI scans per capita in the county of residence at the time of the diagnosis (log rank, p = 0.029). However, after adjustment for year of diagnosis and catchment region of the Norwegian neurosurgical centers, the association between MRI scans per capita and overall survival was no longer statistically significant (p = 0.076).

CONCLUSIONS

Presumably due to the incidental discovery of benign extraaxial tumors, regional differences in the use of cerebral MRI in outpatients affect observed incidence rates of intracranial tumors.

Presurgical neuropsychological and behavioral evaluation of children with posterior fossa tumors

OBJECT

Brain tumors are associated with behavioral and neuropsychological effects. Most available data are focused on the posttreatment neurological and cognitive deficits of these patients. The aim of the present study was to investigate the pretreatment neuropsychological and behavioral impairment in children with posterior fossa tumors.

METHODS

The authors studied 24 children with posterior fossa tumors who were between 4 and 15 years of age, and who were surgically treated at the authors' institute. During the period prior to the tumor excision, neuropsychological and behavioral assessments were performed. A control group of age-matched children was also studied. The children's executive functions were assessed using the short form of the Wechsler Intelligence Scale for Children (WISC). For the assessment of visuospatial functions, spatial memory, and visuomotor integration skills, the Bender-Gestalt Test (BGT) was used. For assessment of the visual perception and visual memory, the authors used the Benton Visual Retention Test (BVRT). Furthermore, parents or caregivers completed the Child Behavior Checklist (CBCL).

RESULTS

The WISC revealed no significant difference between patients and the control group. The CBCL revealed significant somatic concerns compared with the measure's norms. Furthermore, the patients differed in aggressiveness, somatic concerns, anxiety symptoms, internalizing of problems, and total problems. In the BGT and the BVRT results, no significant difference was observed between patients and the control group. Furthermore, no significant correlation was found between neuropsychological scores and sex, age at diagnosis, histological diagnosis, presence of hydrocephalus, degree of hydrocephalus, tumor size, and tumor location.

CONCLUSIONS

Children with posterior fossa tumors suffer more frequently from somatic concerns, aggressiveness, anxiety, and internalizing disorders compared with controls. No difference was found with respect to intelligence scores.

Incidence of adult brain cancers is higher in countries where the protozoan parasite Toxoplasma gondii is common

We explored associations between the common protozoan parasite Toxoplasma gondii and brain cancers in human populations. We predicted that T. gondii could increase the risk of brain cancer because it is a long-lived parasite that encysts in the brain, where it provokes inflammation and inhibits apoptosis. We used a medical geography approach based on the national incidence of brain cancers and seroprevalence of T. gondii. We corrected reports of incidence for national gross domestic product because wealth probably increases the ability to detect cancer. We also included gender, cell phone use and latitude as variables in our initial models. Prevalence of T. gondii explained 19 per cent of the residual variance in brain cancer incidence after controlling for the positive effects of gross domestic product and latitude among nations. Infection with T. gondii was associated with a 1.8-fold increase in the risk of brain cancers across the range of T. gondii prevalence in our dataset (4-67%). These results, though correlational, suggest that T. gondii should be investigated further as a possible oncogenic pathogen of humans.

Incidence of childhood central nervous system tumors in the Nordic countries

BACKGROUND

The incidence rates of childhood central nervous system (CNS) tumors in the Nordic countries remain among the highest in the world. Large geographical and temporal variations in the incidence rates of CNS tumors have been reported. Increasing incidence rates would be a public health concern, as they might indicate increased exposure to environmental risk factors.

METHODS

All 3,983 children 0-14 years of age registered with a primary CNS tumor in 1985-2006 in the national cancer registries of the Denmark, Finland, Norway, and Sweden were identified. Tumors were classified according to the International Classification of Childhood Cancer version 3 (ICCC-3). Join-point analysis was used to detect changes in trends and to estimate annual changes in incidence rates.

RESULTS

The mean annual incidence rate of CNS tumors was 42 per million. No statistically significant change in time trends of incidence rates was observed during 1985-2006. Furthermore, the incidence by birth cohort was relatively stable during the study period.

CONCLUSION

The incidence rates of childhood CNS tumors in the Nordic countries remain among the highest in the world. The stable incidence rates during the last 22 years indicate that major changes in environmental risk factors are unlikely.

Cerebral malignancy presenting with post stroke depression

The following case report highlights about a Glioblastoma presenting with features of post stroke depression. The neuropsychological findings though initially was normal but on subsequent follow up showed gross abnormalities. The imaging studies revealed the tumor, involving the right parietal and temporal lobes with midline shift and high vascularity. The patient exhibited rapid downhill course and died within 4 weeks of initial presentation.

Neurosurgery in the elderly: brain tumors and subdural hematomas

Primary malignant brain tumors present a formidable challenge to surgeons, patients, and families. Although the prognosis in elderly patients approaches only 6 months, aggressive resection and adjuvant treatment may be indicated in a select group of patients who have preserved functional status. Subdural hematomas in the geriatric population usually are chronic. Patients often benefit from evacuation but their advanced age and significant comorbidities often increase perioperative morbidity and mortality. Minimally invasive evacuation, possibly under local anesthesia, often is indicated as an initial treatment.

Survival outcomes in glioblastoma multiforme, including the impact of adjuvant chemotherapy

Glioblastoma is an uncommon cancer, but one that is disproportionately represented in mortality rates. Recent developments in adjuvant chemotherapy have regenerated enthusiasm for the treatment of this tumor. Ongoing translational and clinical research has led to a greater understanding of the biologic and molecular behavior and heterogeneity of this tumor. Recent shifts in treatment standards, as well as further selective individualizing of therapies based on molecular information, promise progress for this difficult-to-treat neoplasm.

Trends in brain cancer incidence and survival in the United States: Surveillance, Epidemiology, and End Results Program, 1973 to 2001

OBJECT

An increasing incidence of brain cancer has been reported for the last three decades. In this study of brain cancer incidence and patient survival in the US, the authors attempt to update information on trends by examining data provided by the Surveillance, Epidemiology, and End Results (SEER) Program.

METHODS

Population-based data from the SEER Program were used to calculate the incidence of and survival rates for people with brain cancer. The approximate Poisson method was used to calculate relative risks for brain cancer and to determine a 95% confidence interval. Annual age-standardized incidence rates were calculated, and time-trend analysis was conducted using joinpoint regression analysis. The relative risks of brain cancer were 1.48 for men compared with women, 3.18 for elderly persons compared with young adults, 1.86 for Caucasian patients compared with African-American patients, and 1.35 for those in metropolitan counties compared with those in nonmetropolitan counties. The incidence of brain cancer increased until 1987, when the annual percentage of change reversed direction, decreasing from 1.68 to 20.44%. The elderly experienced an increase until 1985, but their rates were stable thereafter. Rising trends were noticed for glioblastoma multiforme (GBM), oligodendroglioma, anaplastic astrocytoma, medulloblastoma, and mixed glioma, and falling trends were observed for astrocytoma not otherwise specified and malignant glioma. The survival rate for patients with GBM has not shown improvement in the last two decades.

CONCLUSIONS

Increased risk of brain cancer is associated with being male, Caucasian, elderly, and residing in a metropolitan county. The incidence rate of brain cancer in the US is gradually declining, but the rising trend of GBM combined with its poor survival rate is disconcerting and needs further exploration.

Temporal trends in incidence of primary brain tumors in the United States, 1985-1999

A number of reports have indicated an increasing incidence of primary brain tumors over the past few decades. The purpose of this study was to describe incidence rate trends in a population-based series of newly diagnosed primary nonmalignant and malignant brain and other CNS tumors, contributing five additional years to previously published incidence trends. Data for the years 1985 through 1999 from six collaborating state cancer registries of the Central Brain Tumor Registry of the United States were used to determine incidence trends in the broad age groups 0-19, 20-64, and >or=65 years, overall and for selected histologies. Multiplicative Poisson regression was used to express trends as average annual percent change (AAPC). Joinpoint regression was used to identify sharp changes in incidence occurring over this period. Overall, incidence increased modestly (AAPC, 1.1; 95% CI, 0.8-1.4). When brain lymphomas were excluded, this increase remained statistically significant. A sharp change in incidence of brain lymphomas from increasing to decreasing over time was identified. Specific histologies that were increasing included anaplastic astrocytomas in individuals aged >or=65 years, microscopically confirmed gliomas in both adult age groups, and microscopically confirmed glioma, not otherwise specified (NOS), in children. Increases that were not specific to any population subgroup were seen for oligodendrogliomas, ependymomas, meningiomas, and nerve sheath tumors. Decreases were noted for astrocytoma, NOS, nonmicroscopically confirmed gliomas, and pituitary tumors. Improvements in diagnosis and classification are likely reflected in the decreasing trends in unspecified glioma subgroups and the accompanying increasing trends in more specific glioma subgroups. However, increases in meningiomas and nerve sheath tumors deserve further attention.

Descriptive epidemiology of vestibular schwannomas

Vestibular schwannomas, commonly termed acoustic neuromas, arise from the vestibular branch of the eighth cranial nerve (acoustic nerve) and are benign, slow-growing brain tumors that negatively impact patient quality of life. They are thought to account for the majority of intracranial nerve sheath tumors. To describe incidence rate patterns and trends of primary nerve sheath tumors of the brain/CNS and the subset of vestibular schwannomas in two population-based incidence registries, data were obtained from 11 Central Brain Tumor Registry of the United States (CBTRUS) collaborating state registries and the Los Angeles County Cancer Surveillance Program (LACCSP) (1975-1998). Average annual incidence rates were tabulated by age, gender, race, year, and region and were age-adjusted to the year 2000 U.S. standard population. Multiplicative Poisson regression models were used to compare trends in primary nerve sheath tumors of the brain/CNS overall and in subgroups, including vestibular schwannomas, controlling for age, gender, race, microscopic confirmation, and region. Joinpoint regression analysis was used to identify any sharp changes in incidence over time. The overall incidence of primary nerve sheath tumors of the brain/CNS was 1.1 per 100,000 person-years (CBTRUS, 1995-1999 and LACCSP, 1995-1998). The incidence of vestibular schwannomas was similar for both data sets: 0.6 per 100,000 person-years (CBTRUS, 1995-1999) and 0.8 per 100,000 person-years (LACCSP, 1995-1998). Moreover, the incidence of primary nerve sheath tumors of the brain/CNS overall (CBTRUS, 1985-1999 and LACCSP, 1975-1998) and of vestibular schwannomas (CBTRUS, 1992-1999 and LACCSP, 1992-1998) increased over time. However, the incidence of benign schwannomas in sites other than the acoustic nerve either decreased (CBTRUS, 1992-1999) or experienced no significant change (LACCSP, 1992-1998). While improvements in diagnosis and reporting may explain some of these trends, further consideration of potential etiologic factors may be warranted.

A population-based description of glioblastoma multiforme in Los Angeles County, 1974-1999

BACKGROUND

There have been reports that the incidence rates of brain tumors have increased over the past few decades, but most have considered all brain tumors together. The authors analyzed the pattern of glioblastoma multiforme (GBM) occurrence in Los Angeles County, California to shed light on the incidence and descriptive epidemiology of this type of brain tumor.

METHODS

Data were obtained from the Los Angeles County Cancer Surveillance Program. Incidence rates were analyzed by gender, race, age at diagnosis, period of diagnosis (1974-1981, 1982-1988, or 1989-1999), and socioeconomic status (SES). In addition, data were stratified according to anatomic subsite. A multivariate model describing changes in rates by each of these variables was constructed.

RESULTS

Age-specific incidence rates (ASIR) rose sharply after age 30 years. The peak ASIR was at age 70-74 years in males and at age 75-79 years in females. The age-adjusted incidence rate (AAIR) of GBM increased from 1974 to 1999 by an estimated 2.4% per year among males and 2.8% per year among females. Overall, males had a 60% increased risk of brain tumors compared with females. Males had a higher incidence of GBM compared with females at each anatomic subsite except the posterior fossa. The largest male:female ratio occurred in the occipital lobes. Non-Latino whites had the highest incidence rates (2.5 per 100,000) followed by Latino whites (1.8 per 100,000), and blacks (1.5 per 100,000). After 1989, compared with the period before magnetic resonance imaging (MRI) was available, there was an increase in GBM incidence rates among those with of higher SES that was most pronounced in females. The incidence of GBM was highest for frontal lobe tumors and for tumors that involved two or more lobes (overlapping tumors), followed by tumors in the temporal and parietal lobes. In the multivariate analysis, year of diagnosis, SES, gender, race (Latino but not black), site, and age at diagnosis all were important predictors of incidence rate.

CONCLUSIONS

GBM incidence increased in Los Angeles County over the last 30 years and especially after 1989, suggesting that the introduction of MRI may have contributed to the increase. Individuals older than age 65 years experienced the greatest increase in incidence over time. Older age, male gender, higher SES, and non-Latino white race increased the risk of GBM. Previously unreported incidence rates for GBM among Latino whites were significantly lower than among non-Latino whites but were intermediate between non-Latino whites and blacks.

Occupational risk factors for brain cancer in Canada

OBJECTIVE

We sought to examine the impact of occupational exposure on brain cancer risk.

METHODS

Mailed questionnaires were used to collect information on lifetime employment history, occupational exposure to 18 chemicals, and other risk factors for 1009 incident cases of brain cancer and 5039 control subjects in Canada in 1994 to 1997.

RESULTS

People exposed to asphalt and welding had respective odds ratio (and 95% confidence interval) of 1.29 (1.02-1.62) and 1.26 (0.98-1.45). An increased risk of brain cancer might be associated with exposure to asbestos, benzene, mineral or lubricating oil, isopropyl oil, and wood dust and with following occupations: teaching; protective service; metal processing and related jobs, and metal shaping and forming; knitting in textile processing; construction trades; and transport equipment operating.

CONCLUSIONS

Our study suggests a possible role for occupational exposure in the etiology of brain cancer.

Pathology and molecular genetics of astrocytic gliomas

Astrocytic gliomas are the most common primary brain tumours. Here we summarize the characteristic neuropathological features of the different types of astrocytic neoplasms according to the World Health Organization classification of tumours of the nervous system. In addition, we report on the present state of the art concerning the molecular genetics of these tumours. Over the past 20 years a number of recurrent chromosomal,genetic and epigenetic alterations have been found to be associated with the different histological types and malignancy grades of astrocytic tumours. However, we are still far from understanding the complex mechanisms that underly tumour initiation and progression in the individual case. Furthermore, the clinical significance of molecular parameters for the diagnostic and prognostic assessment of astrocytic gliomas is still limited. Therefore further investigation of the molecular mechanisms underlying oncogenesis and progression of these most common brain tumours is necessary to improve their diagnostic assessment and to devise novel, individually tailored treatment strategies.

Cellular antitumor immune response to a branched lysine multiple antigenic peptide containing epitopes of a common tumor-specific antigen in a rat glioma model

Human malignant gliomas contain epidermal growth factor receptor (EGFR) gene mutations that encode tumor-associated antigens (TAAs) that can be targeted using immunological techniques. One EGFR mutant gene (EGFRvIII) encodes a protein with an epitope that is not found in normal tissues. A number of studies have focused on this unique epitope as a potential target for tumor vaccines. In the present study, we examined the cellular immune effects of a peptide containing multiple copies of the unique EGFRvIII epitope linked together by way of a lysine bridge. Fischer rats were vaccinated with an EGFRvIII multiple antigenic peptide (MAP). While vaccination produced a humoral immune response, anti-MAP antibody production was not accompanied by expression of the Th2 response cytokine IL-4. In MAP/GM-CSF vaccinated animals, a cellular immune response was detected in association with the appearance of CD4+ and CD8+ T cells at the tumor site. Splenocytes and CD8+ T cells from vaccinated rats produced the Th1 cytokine IFN-gamma in vitro in response to stimulation by rat glioma cells expressing EGFRvIII, but not by those expressing wild-type EGFR. MAP vaccine also induced a specific lytic antitumor CTL immune response against F98 glioma cells expressing EGFRvIII, but not against F98 cells expressing either wild-type EGFR or no receptor. The in vivo growth of F98(EGFRvIII) cells was attenuated in vaccinated rats; whereas, growth of F98(EGFR) cells was not. The median survival of vaccinated rats was increased 72% over that of unvaccinated controls challenged with intracerebral F98(EGFRvIII) tumor implants. Therefore, MAP vaccination produced a predominantly cellular antitumor immune response directed against F98 gliomas expressing the EGFRvIII target antigen. The potent immunosuppressive effects of F98 glioma cells mimic the human disease and make this particular tumor model useful for studying immunotherapeutic approaches to malignant gliomas.

Incidence trends of adult primary intracerebral tumors in four Nordic countries

Brain tumors are some of the most lethal adult cancers and there is a concern that the incidence is increasing. It has been suggested that the reported increased incidence can be explained by improvements in diagnostic procedures, although this has not been totally resolved. The aim of our study was to describe the incidence trends of adult primary intracerebral tumors in four Nordic countries during a period with introduction of new diagnostic procedures and increasing prevalence of mobile phone users. Information about benign and malignant primary intracerebral tumor cases 20-79 years of age was obtained from the national cancer registries in Denmark, Finland, Norway and Sweden for the years 1969-98 and estimates of person-years at risk were calculated from the information obtained from national population registries. Annual age standardized incidence rates per 100,000 person-years were calculated and time trends analyses were carried out using Poisson regression. The overall incidence of all intracerebral tumors ranged from 8.4-11.8 for men and 5.8-9.3 for women, corresponding to an average annual increase of 0.6% for men (95% confidence interval [CI] = 0.4, 0.7) and 0.9% for women (95% CI = 0.7, 1.0). The increase in the incidence was confined to the late 1970s and early 1980s and coinciding with introduction of improved diagnostic methods. This increase was largely confined to the oldest age group. After 1983 and during the period with increasing prevalence of mobile phone users, the incidence has remained relatively stable for both men and women.

Relative survival rates and patterns of diagnosis analyzed by time period for individuals with primary malignant brain tumor, 1973-1997

OBJECT

The purpose of this study was to examine patterns of diagnosis and relative survival rates in individuals in whom a primary malignant brain tumor was diagnosed between 1973 and 1997; follow-up review of these patients continued through the end of 1999.

METHODS

The study population was composed of 21,493 patients with primary malignant brain tumors that were diagnosed between 1973 and 1997. Data on these patients were obtained from the population-based Surveillance, Epidemiology, and End Results Program. The study population was divided into three cohorts based on the year of diagnosis, and these groups were compared with respect to variables of interest by performing chi-square tests and relative survival analysis with the life table method. Over time, there were consistently more men, more Caucasians, more patients undergoing surgery, and more individuals 70 years and older who received the diagnosis of primary malignant brain tumor. An examination of proportions of individuals with astrocytoma, other; oligodendroglioma, other; and oligodendroglioma Grade III showed significant temporal changes with frontal and temporal lobe tumors occurring most often. The diagnosis was obtained at an earlier age in African-American than in Caucasian patients. Caucasians had higher proportions of glioblastoma multiforme (GBM), which was associated with decreased survival times, and of oligodendroglioma, other, whereas African Americans had higher proportions of astrocytoma, other; ependymoma Grade II or III; and medulloblastoma, all of which were associated with increased survival times. The relative survival case demonstrated a continuous improvement over time, although older patients, those who underwent biopsy only, and those with GBMs continue to have the poorest survival times. The relative survival rates of African Americans consistently were similar or worse than those of Caucasians when the groups were stratified by prognostic factors.

CONCLUSIONS

Over time, the relative survival rate of individuals with primary malignant brain tumor has improved and differences in survival are seen by examining the race of the patients.

[Brain tumors mortality in Brazil, 1980-1998]

Brain tumors are rare, but their incidence and mortality have increased in different countries, including Brazil, especially among the elderly. This paper presents the mortality pattern of brain tumors in Brazil, including distribution of mortality rates by gender, age, topography, and tumor staging, from 1980 to 1998. Age-adjusted (by world population) brain cancer mortality rates increased from 2.24/100,000 to 3.35/100,000 inhabitants among the overall population during this period (an increase of 50%). Observed rates were higher during childhood than adolescence and increased with age, reaching the highest levels among the elderly. Among individuals 70 years of age and older, an average annual increase of 6% was observed in the series. Brain and meningeal tumor rates are presented for the entire country and selected State capitals. Further study is needed to elucidate the role of both new diagnostic technologies and environmental exposures potentially associated with the observed changes in brain cancer mortality rates.

Temozolomide as an alternative to irradiation for elderly patients with newly diagnosed malignant gliomas

BACKGROUND

The optimal treatment for elderly patients (defined as patients 70 years of age or older) with malignant gliomas (MG) remains controversial. Some physicians advocate withholding therapy following diagnosis based on the observation that elderly patients do not tolerate adjuvant radiotherapy. The availability of temozolomide (TMZ), a new alkylating agent with antiglioma efficacy, offers another potential therapeutic option for these patients. The drug can be administered orally at home with minimal morbidity.

METHODS

The authors retrospectively reviewed a cohort of 86 consecutive elderly MG patients from three institutions, 32 of whom received monthly TMZ in lieu of radiation.

RESULTS

Initial Karnofsky performance score was the only predictor of survival in this cohort. No difference in survival was noted between these two groups. Toxicity was minimal in the chemotherapy-treated group and a higher percentage of patients receiving chemotherapy died at home.

CONCLUSIONS

The authors concluded that TMZ is as effective as irradiation as a treatment of elderly patients with MG. It is an alternative and, perhaps, a superior therapeutic option to irradiation, based on its ease of administration and low morbidity.

[Childhood cancer: a comparative analysis of incidence, mortality, and survival in Goiania (Brazil) and other countries]

Analysis of cancer incidence, mortality, and survival rates can yield geographic and temporal trends that are useful for planning and evaluating health interventions. This article reviews cancer incidence and mortality rates and respective trends around the world in children under 15 years old, as well as their 5-year survival rates in developed and developing countries. We conclude that even though increasing or stable childhood cancer incidence rates and decreasing mortality rates have been observed in developed countries, the trends remain unknown in developing countries. Data from the city of Goiania, Brazil, show stable childhood cancer incidence and mortality rates. Five-year survival rates (48%) in Goiania are similar to those seen in underdeveloped regions and lower than those reported in developed countries (64-70%).

Current epidemiological trends and surveillance issues in brain tumors

The absence of an overall increase in incidence rates for all primary brain tumors since the 1950s argues against a recently introduced environmental tumorigen impacting these tumors. Historical increases in brain cancer mortality and incidence rates appear to be leveling off following the widespread introduction of CT and MRI scans, indicating that increases in overall rates of malignant tumors are likely to be an artifact of diagnosis and reporting issues. Further studies are needed to understand those tumor types with rates that do appear to be increasing among adults; specifically lymphomas, nerve sheath tumors, pituitary tumors and ependymomas. Patterns of incidence by race, ethnicity, socioeconomic status, and seasonal and regional variation would assist in directing relevant new research questions. Filling in the gap of information on patterns for prevalent, second primaries and metastatic tumors may be useful in understanding the public perception regarding brain tumor rates and would be a valuable addition to healthcare planning tools.

Brain and other central nervous system tumors: rates, trends, and epidemiology

Reports that central nervous system (CNS) cancer rates are increasing have prompted debate on whether secular trends reflect environmental changes related to etiology or artifacts of case ascertainment. We present the most recent data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program on incidence rates and trends of CNS malignancies, including primary CNS lymphomas, and on survival probability. We discuss the new 2000 standard for adjusting rates; underreporting of CNS tumor rates resulting from the exclusion of nonmalignancies in most cancer registries; and information on CNS tumor risk factors, including concerns related to nonionizing electromagnetic fields and wireless mobile telephones.

The impact of age and sex on the incidence of glial tumors in New York state from 1976 to 1995

OBJECT

In this study the authors describe secular trends in the incidence of three glial tumors--glioblastoma multiforme (GBM), astrocytoma not otherwise specified (ANOS), and anaplastic astrocytoma (AA)--in New York state from 1976 through 1995. They also describe the effect of age and sex on the relative risk (RR) for these tumors, specifically GBM.

METHODS

Crude, age-, and sex-specific incidence rates were calculated for each tumor type from 1976 to 1995 by using data from the New York State Cancer Registry. Age-adjusted incidence rates were calculated by the direct standardization procedure, in which the 1970 United States Census Population Standard Million is used. The RR of GBM for the female population was calculated and plotted. Statistical comparisons were made using Pearson's correlation coefficient and regression analysis with the coefficient of variation.

CONCLUSIONS

The age-adjusted incidence of these three glial tumors increased during the study period. Increases in age-specific incidence of GBM were primarily limited to patients 60 years of age or older. The reasons for these increases cannot be fully explained with the data. Those in the female population had a lower risk of developing these tumors than those in the male. For GBM, the protective effect of sex was first evident at the approximate age of menarche, was greatest at the approximate age of menopause, and decreased in postmenopausal age strata. The overall protective effect of female sex and the described trend in RR for GBM in the female population suggests that sex hormones and/or genetic differences between males and females may play a role in the pathogenesis of this tumor.

Brain tumors in the older person

BACKGROUND

The incidence of brain tumors is increasing rapidly, particularly in the older population. Advances in molecular biology help to explain differences in biologic behavior and response to therapy of brain tumors in the elderly compared with younger patients. The number of elderly patients who desire and receive therapy for brain tumors and are included in clinical trials is increasing.

METHODS

This article reviews the literature on the epidemiology, clinical aspects, and therapy of brain tumors, with emphasis on the older patient population.

RESULTS

The increased incidence of brain tumors in the elderly is principally due to the increasing number of people who comprise the older population. Age and performance status are important independent prognostic indicators, together with tumor histology. Surgery, radiation therapy, and chemotherapy can benefit elderly patients with brain tumors with favorable histologies, tumor location, and good performance status. The response rates to available therapies are less favorable than in younger patients, and only a small number of elderly patients are enrolled in clinical studies addressing new treatment modalities.

CONCLUSIONS

Brain tumors in the elderly have specific characteristics that determine their biologic behavior and response to therapy. There is a need for clinical studies designed for treatment of brain tumors in older patients, and requirements for rehabilitation and support systems for the elderly need to be addressed.

Radiation therapy of the older patient

Radiotherapy has a major role in the multidisciplinary approach to cancer therapy. It is widely used for curative and palliative treatment of cancer involving various sites. Radiotherapy is of particular benefit to older and frail cancer patients as an alternative to surgery and to systemic therapy. The available data on the sensitivity of normal tissues to radiotherapy in elderly patients strongly suggest that older patients with good functional status tolerate radiotherapy as well as younger patients and have comparable tumor response and survival rates. Aggressive radiotherapy should not be withheld from older patients because of chronological age alone.

Primary brain tumor incidence in mice exposed to split-dose ionizing radiation and circularly polarized 60 Hz magnetic fields

Three sections of brain tissue from 2,657 female C57BL/6 mice were stained with hematoxylin and eosin and evaluated microscopically for proliferative lesions. Mice had been treated with either split-dose ionizing radiation (0, 3.0, 4.0 and 5.1 Gy), chronic lifetime 60 Hz circularly polarized magnetic field exposure (ambient or 14.2 G, 1.4 mT), or both, and were evaluated after natural death or euthanasia for humane reasons. Among 950 mice which were not treated with ionizing radiation, two benign spontaneous lipomatous hamartomas were observed. Seven primary brain tumors of various types not found in untreated animals were observed among the 1,707 irradiated mice. Possible promotional effects of magnetic field exposure on primary brain tumor development and incidence could not be assessed due to the low number of tumors observed.

Cancer surveillance series [corrected]: brain and other central nervous system cancers: recent trends in incidence and mortality

BACKGROUND

During the 1980s, the incidence of primary malignant brain and other central nervous system tumors (hereafter called brain cancer) was reported to be increasing among all age groups in the United States, while mortality was declining for persons younger than 65 years. We analyzed these data to provide updates on incidence and mortality trends for brain cancer in the United States and to examine these patterns in search of their causes.

METHODS

Data on incidence, overall and according to histology and anatomic site, and on relative survival were obtained from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute for 1975 through 1995. Mortality data were obtained from the National Center for Health Statistics. Medicare procedure claims from the National Cancer Institute's SEER-Medicare database were used for imaging trends. Statistically significant changes in incidence trends were identified, and annual percent changes were computed for log linear models.

RESULTS/CONCLUSIONS

Rates stabilized for all age groups during the most recent period for which SEER data were available, except for the group containing individuals 85 years of age or older. Mortality trends continued to decline for the younger age groups, and the steep increases in mortality seen in the past for the elderly slowed substantially. Patterns differed by age group according to the site and grade of tumors between younger and older patients. During the last decade, use of computed tomography scans was relatively stable for those 65-74 years old but increased among those 85 years old or older.

IMPLICATIONS

Improvements in diagnosis and changes in the diagnosis and treatment of elderly patients provide likely explanations for the observed patterns in brain cancer trends.

Psychosocial and neuropsychiatric aspects of patients with primary brain tumors

Primary brain tumors are increasing in incidence in the United States and are devastating to patients and families. Because brain tumors and their treatment primarily affect the brain, psychiatric and psychosocial impact is rather unique. As opposed to systemic effects of other tumors and treatment, brain tumors have a direct effect on brain functioning and therefore affect cognition, mood, and personality. In fact, patients undergo dramatic changes in mood and cognition, showing specific impairments in functioning. These impairments get translated into disabilities when a patient's daily functioning is impaired and may become a handicap when viewed in the context of quality of life (QOL). This article describes observed neuropsychiatric syndromes, including the apathy syndrome, and neurocognitive effects of brain tumors and their treatment. The neuropsychiatric and neurocognitive issues are discussed in the context of QOL and psychosocial and cognitive interventions available for this patient population.

Brain cancer incidence in the provinces of Zaragoza and Navarre (Spain): effect of age, period and birth cohort

Several studies have detected increases in malignant brain tumour incidence and mortality rates particularly among the elderly. We analyzed time trends in malignant brain tumors incidence in Zaragoza over the period 1973-1990 and Navarre over the period 1973-1991, two Spanish provinces that have been collecting data through their respective Cancer Registries for the last 20 years, using Poisson regression analysis of age, period of diagnosis and cohort. In general, age-adjusted rates showed a steady rise in both registries, except in the case of females in Navarre, for whom a decrease in risk was observed for the last period, 1988-1991. This increase is a reflection of the rise in incidence experienced by the elderly, since the cohorts successively register rates that are stable over time, and even downward in the case of females in Navarre. The risk run by generations born circa 1920-1930 was the highest encountered. Rates were higher in Navarre in both sexes and for all but the last period in females, when rates on the two registers stood level. Increasingly generalised use of CT scanning and magnetic resonance in the 1980s in Spain, coupled with better and more effective health care access for the elderly, are factors that may well have some bearing on these findings.

Epidemiology of adult medulloblastoma

Medulloblastoma is one of the most common primary tumors of the central nervous system seen in children; in contrast, it is somewhat uncommon in adult age. Due to the infrequent occurrence, data on incidence rates are sparse. The present study was aimed at ascertaining the epidemiological characteristics of medulloblastoma in adult age in Piedmont during the period 1976-1995. Piedmont is a region in northwest Italy, which had a total population of 4.30 millions/year for the period mentioned. From the files of clinical records of patients hospitalized in neurologic and neurosurgical departments, 45 cases (32 males, 13 females) of histologically verified medulloblastoma were recorded. The incidence rate (annual per million) in the whole period studied was 0.5 (95% confidence interval, 0.36-0.67). The incidence rate was high in the age group 15 to 19 years (2.33/million/year) and decreased up to age 40, consistent with the embryonal origin of the tumor. No time-trend of incidence rate was found. Male excess was evident in all age groups and in each time period. Median survival time was 17.6 years; the 5-year survival rate was 69.9%. Survival rate in the present group of adult medulloblastoma is slightly better than that reported in clinical series. A comparison was made with incidence data concerning pediatric medulloblastoma reported in the Registry of Childhood Cancer of Piedmont: from 1980 to 1989, adult medulloblastomas represented 34% of medulloblastomas. The figure is higher than that generally assumed, and indicates that the occurrence of this embryonal tumor in adult age is relevant. Our epidemiological data are consistent with an embryonal origin of medulloblastoma.

Brain tumors in childhood and adolescence

Brain tumors are the second most common neoplasm in childhood and adolescence. With the recent advances in technology, changes in tumor incidence have been reported. This study examines this statement. A 19-year retrospective case review of primary brain tumors in persons younger than 18 years of age at time of diagnosis, who had permanent residence in our catchment area, was performed. Data were examined for changes in presenting symptoms and signs and incidence rates for tumors on the basis of anatomic location and histologic tumor type. An incidence rate of 2.76 per 100,000 people younger than 18 years of age was found. During the period of this study a small, but significant, trend toward increasing incidence was evident. No changes in patterns of presentation or duration of symptoms before diagnosis was observed. The incidence rate based on histologic tumor diagnosis remained fairly constant during the study period.

Outcome in elderly patients undergoing definitive surgery and radiation therapy for supratentorial glioblastoma multiforme at a tertiary care institution

PURPOSE

To determine the efficacy of definitive surgery and radiation in patients aged 70 years and older with supratentorial glioblastoma multiforme.

METHODS AND MATERIALS

We selected elderly patients (> or = 70 years) who had primary treatment for glioblastoma multiforme at our tertiary care institution from 1977 through 1996. The study group (n = 102) included 58 patients treated with definitive radiation, 19 treated with palliative radiation, and 25 who received no radiation. To compare our results with published findings, we grouped our patients according to the applicable prognostic categories developed by the Radiation Therapy Oncology Group (RTOG): RTOG group IV (n = 6), V (n = 70), and VI (n = 26). Patients were retrospectively assigned to prognostic group IV, V, or VI based on age, performance status, extent of surgery, mental status, neurologic function, and radiation dose. Treatment included surgical resection and radiation (n = 49), biopsy alone (n = 25), and biopsy followed by radiation (n = 28). Patients were also stratified according to whether they were optimally treated (gross total or subtotal resection with postoperative definitive radiation) or suboptimally treated (biopsy, biopsy + radiation, surgery alone, or surgery + palliative radiation). Patients were considered to have a favorable prognosis (n = 39) if they were optimally treated and had a Karnofsky Performance Status (KPS) score of at least 70.

RESULTS

The median survival for patients according to RTOG groups IV, V, and VI was 9.2, 6.6, and 3.1 months, respectively (log-rank, p < 0.0004). The median overall survival was 5.3 months. The definitive radiation group (n = 58) had a median survival of 7.3 months compared to 4.5 months in the palliative radiation group (n = 19) and 1.2 months in the biopsy-alone group (p < 0.0001). Optimally treated patients had a median survival of 7.4 months compared to 2.4 months in those suboptimally treated (p < 0.0001). The favorable prognosis group had an 8.4-month median survival compared to 2.4 months in the unfavorable group (p < 0.0001). On multivariate analysis, the KPS, RTOG group, favorable/unfavorable prognosis, and optimal treatment/suboptimal treatment were significant predictors of survival.

CONCLUSION

Elderly patients with good performance status (> or = 70 KPS) when treated aggressively with maximal resection and definitive radiation had longer survival than those treated with palliative radiation and biopsy. Aggressive treatment in such patients should be considered.

Aging and primary central nervous system neoplasms

The number of primary brain tumors in the aging population has increased over the past few decades. Although overall survival rates for many patients with primary central nervous system neoplasms have not changed drastically, patients with particular tumor types are benefitting from new treatments. Many factors must be considered when treating primary brain tumors in the elderly, including overall medical condition, tumor biology, and social issues.

Cytostatic Agents in the Management of Malignant Gliomas

BACKGROUND: Cytotoxic therapy for malignant gliomas is limited by poor delivery and drug resistance, and local therapy is ineffective in managing migratory cells. However, recent developments in malignant glioma therapy involve trials of cytostatic rather than conventional cytotoxic agents. METHODS: The biology of the brain extracellular matrix, tumor invasion, and angiogenesis are reviewed, and the cytostatic agents that inhibit matrix metalloproteinases, angiogenesis, cell proliferation, and signal transduction are discussed, as well as studies of the angiogenic and migratory capacity of malignant brain tumors. RESULTS: Two specific and interrelated areas, anti-invasion (migration) and anti-angiogenesis, are potential areas to develop new treatment strategies. Tumor invasion and angiogenesis are important components of the spread and biologic effects of malignant gliomas. Several proteinase inhibitors are in clinical trial, as well as anti-angiogenic agents and signal transduction cascade inhibitors. CONCLUSIONS: Biologic control of brain tumor cell populations may offer a new management approach to add to currently available management options for malignant brain tumors.

Trends in cancer incidence and mortality in Scotland: description and possible explanations

Secular and cohort trends in mortality from cancer in Scotland during 1953-93, and incidence during 1960-90, were analysed using individual records from the national mortality and registration files. For certain cancer sites, the secular analyses of mortality were extended back to 1911 by use of published data. Mortality from cancer at older ages in Scotland has increased over the last 40 years. In each sex, this trend has been dominated by the effects of smoking: all-cancer rates and rates of lung cancer, now the most common fatal cancer in men and in women in Scotland, reached a peak in the cohort of men born at the turn of the century and the cohort of women born in the 1920s. For much of the period, the Scottish all-age rates of lung cancer were the highest reported in the world; they are now decreasing on a secular basis in men, but are still increasing in women. There have also been large increases at older ages in the incidence and mortality rates for cancer of the prostate in recent years. bladder cancer, nervous system cancer, non-Hodgkin's lymphoma, myeloma and leukaemia; for each there is likely to be a considerable artefactual element to the increase, with differing degrees of possibility that there may in addition be an element of real increase. Substantial decreases in mortality at all ages have occurred for stomach and colorectal cancers and substantial increases at all ages for pleural cancer and melanoma. Rates of mortality from breast cancer, the most common cancer in women in Scotland, have generally increased over the past 80 years; a temporary cessation in this upward trend occurred in the years during and after the Second World War, and recently rates have turned downward, probably at least in part because of better treatment. Mortality from ovarian cancer, the second most common reproductive-related female tumour in Scotland, has also increased at older ages. At younger ages, mortality from cancer in Scotland has decreased, especially in men, whereas incidence has not. This divergence, which has been a consequence of better treatment, has occurred especially for cancers of the testis and ovary, Hodgkin's disease and leukaemia. There have been increases at young adult ages, however, in both mortality from and incidence of oral and pharyngeal, oesophageal and laryngeal cancers in men, and melanoma and non-Hodgkin's lymphoma in each sex. Cervical cancer rates at young ages also increased, but this trend has reversed for incidence in the most recent birth cohorts. Incidence rates have also increased for testicular cancer in young adults and leukaemia in children. With the possible exceptions of non-Hodgkin's lymphoma and childhood leukaemia, the increasing rates are likely largely to reflect real rises in incidence, and they highlight the need for investigation of the causes of these cancers, and, when causes are known, for preventive action.

Survival rates in patients with primary malignant brain tumors stratified by patient age and tumor histological type: an analysis based on Surveillance, Epidemiology, and End Results (SEER) data, 1973-1991

OBJECT

The authors present population-based survival rate estimates for patients with malignant primary brain tumors based on an analysis of 18 years of data obtained from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute.

METHODS

Estimates of survival rates at 2 and 5 years after diagnosis for patients with specific histological tumor types were categorized by patient's age at diagnosis (< or = 20 years, 21-64 years, and 65 years or older) and by the time period in which the patients were diagnosed (1973-1980, 1981-1985, 1986-1991). Where appropriate, survival estimates were adjusted for changing patterns in the mean age at diagnosis.

CONCLUSIONS

The authors observed a pattern of declining survival rates in patients with increasing age of the patient at diagnosis for most histological groups and overall improvements in survival rates of patients across these time periods adjusting for age at diagnosis. There were improvements in 2- and 5-year survival rates over the three time periods for children and adults with medulloblastoma and for adults with astrocytoma and oligodendroglioma. Improvements in survival rates for pediatric patients with medulloblastoma have leveled off in the most recent time period, and gender differences in survival rates for patients with this tumor, which were present in the 1970s, have disappeared. Clinically significant improvements in survival rates were not apparent in patients aged 65 years and older. Changes in diagnostic and treatment procedures since the mid-1970s have resulted in improved survival rates for patients diagnosed as having medulloblastoma, oligodendroglioma, and astrocytoma, controlling for age at diagnosis. Glioblastoma multiforme continues to be the most intractable brain tumor.

Cognitive functioning and quality of life in malignant glioma patients: a review of the literature

The state of current research in the psychosocial and neurocognitive functioning of primary brain tumor patients, particularly those with gliomas, is reviewed. Specific instruments that have been used to evaluate psychosocial and neurocognitive functioning in this population are reviewed. Suggestions are made, based on the review, of the most appropriate psychosocial and neurocognitive instruments to implement in clinical research. Finally, research pertaining to psychosocial and neurocognitive interventions is reviewed and suggestions for further research are outlined. Few studies have adequately addressed the cognitive and psychosocial functioning of brain tumor patients and have focused primarily on relatively insensitive measures of outcome, including IQ scores, performance status, and neurologic examinations. The use of well-accepted, psychometrically sound quality of life instruments and more specific tests of cognitive functioning need to be included in clinical trials since most current treatments have a limited effect on the length of survival. Thus, the main rationale for selecting a given brain tumor therapy may ultimately be related to its profile of neurotoxic side-effects and impact on quality of life.