Lung cancer and tobacco smoking in Crete, Greece: reflections from a population-based cancer registry from 1992 to 2013

The journey of lung cancer patients from symptoms to diagnosis in Greece. A mixed methods approach

The early diagnosis of lung cancer improves the probability of successful treatment. However, patients and physicians face several difficulties that can considerably delay the diagnostic process. A mixed-methods study that would follow the patient's journey throughout the diagnostic process could alleviate these difficulties. This study aimed to (a) track the patients' journey from the onset of symptoms until diagnosis and, (b) explore the patients' perspective of the journey until diagnosis, on the largest island of Greece. A convergent mixed-methods study was conducted with 94 patients with lung cancer. Patients completed a self-report questionnaire and were interviewed about their symptoms and journey through the healthcare system before their diagnosis. Our findings revealed several problems and delays in the diagnostic process. Both quantitative and qualitative data showed that patients did not recognize their symptoms and sought medical advice in time because they overlooked or attributed their symptoms to 'simpler'/'more common' causes. Furthermore, most patients were diagnosed 1-3 months after their first visit to a physician for their symptoms. Qualitative data analysis revealed three broad categories of problems that delayed diagnosis: (1) physician missteps, (2) administrative problems, and (3) the effect of the Covid-19 pandemic. This study found that major issues and delays prolong the diagnostic process for lung cancer. Therefore, optimization of diagnostic processes at each level of healthcare and interspecialty cooperation programs are needed. Furthermore, population-based interventions and patient education can help lung cancer patients be diagnosed early and improve their quality of life and disease outcomes.

Evidence-Based Conceptual Collection of Methods for Spatial Epidemiology and Analysis to Enhance Cancer Surveillance and Public Health

(1) Background: Although spatial statistics are often used by cancer epidemiologists, there is not yet an established collection of methods to serve their needs. We aimed to develop an evidence-based cancer-oriented conceptual collection of methods for spatial analysis; (2) Methods: A triangulation of approaches was used; literature review, consensus meetings (expert panel), and testing the selected methods on "training" databases. The literature review was conducted in three databases. This approach guided the development of a collection of methods that was subsequently commented on by the expert panel and tested on "training data" of cancer cases obtained from the Cancer Registry of Crete based on three epidemiological scenarios: (a) low prevalence cancers, (b) high prevalence cancers, (c) cancer and risk factors; (3) Results: The final spatial epidemiology conceptual collection of methods covered: data preparation/testing randomness, data protection, mapping/visualizing, geographic correlation studies, clustering/surveillance, integration of cancer data with socio-economic, clinical and environmental factors. Some of the tests/techniques included in the conceptual collection of methods were: buffer and proximity analysis, exploratory spatial analysis and others. All suggested that statistical models were found to fit well (R2 = 0.72-0.96) in "training data"; Conclusions: The proposed conceptual collection of methods provides public health professionals with a useful methodological framework along with recommendations for assessing diverse research questions of global health.

Significant Rise of Colorectal Cancer Incidence in Younger Adults and Strong Determinants: 30 Years Longitudinal Differences between under and over 50s

(1) Background: There is evidence in the recent literature that the incidence patterns of colorectal cancer (CRC) have changed considerably over the years, tending to rise rapidly in individuals under 50 years old compared with those over 50 years. The current study aimed to assess the incidence of CRC in Crete from 1992−2021 and compare them among younger and older adults. (2) Methods: Data on malignant neoplasms of colon, rectosigmoid junction, and rectum have been extracted from the database of the Regional Cancer Registry of Crete. (3) Results: The number of these cases for the period 1992−2021 was 3857 (n = 2895 colon and n = 962 rectum). The mean age-specific incidence rate (ASpIR/100,000/year) of colon cancer patients <50 years was 7.2 (95% CI 5.1−9.7), while for patients ≥50 years the ASpIR was 149 (95% CI 146.2−153.4). ASpIR presented a 29.6% increase from 2001 to 2011 in the age group of 20−34 years and further increase is expected from 2022−2030 (projected change, 42.8%). The main risk factors were the pack years (p = 0.01), alcohol consumption (0.02), and farmer occupation (0.04), especially during 2012−2021. (4) Conclusions: We confirmed an increased incidence of CRC in young adults <50 in a European population with low cancer incidence in the past and a worrisome prediction for the near future. The observed trends clearly indicate that starting CRC screening at an earlier age may be essential.

Spatio-Temporal Variation of Lung Cancer in Crete, 1992-2013. Economic or Health Crisis?

(1) Background: This is the first population-based study in Greece, with the aim to measure the changing trends of lung cancer (LC) and the associated risk factors before and after the economic crisis. Among the main objectives were the identification of LC hot spots and high-risk areas; (2) Methods: The study was conducted in Crete, the biggest island in Greece. Data (5057 LC cases) were collected from the Cancer Registry of Crete (CRC). The age-standardized incidence and mortality rates (ASIR, ASMR/100,000/year) were estimated, while additional indexes were used, including the adjusted Charlson's comorbidity index (CCI%), the deprivation index (HPI-2), and the exposure to outdoor air pollution (OAP). The analysis was performed for two time periods (Period A: 1992-2008; Period B: 2009-2013); (3) Results: ASIR presented a significant increase during the economic crisis, while an even higher increase was observed in ASMR (Period A: ASMR = 30.5/100,000/year; Period B: ASMR = 43.8/100,000/year; p < 0.001). After 2009, a significant increase in the observed LC hot spots was identified in several sub-regions in Crete (p = 0.04). The risk of LC mortality increased even more for smokers (RR = 5.7; 95%CI = 5.2-6.3) and those living in highly deprived geographical regions (RR = 5.4; 95%CI = 5.1-5.8) during the austerity period. The multiple effect of LC predictors resulted in adjusted RRs ranging from 0.7 to 5.7 within the island (p < 0.05); (4) Conclusions: The increased LC burden after the onset of the economic crisis, along with a changing pattern of LC predictors stressed the urgent need of geographically oriented interventions and cancer control programs focusing on the most deprived or vulnerable population groups.

Health inequality: a longitudinal study on geographic variations in lung cancer incidence and mortality in Taiwan

Background

This study is aimed toward an analysis of the variations in lung cancer incidence and mortality, adjusted by population factors (age, gender, and year), between administrative areas.

Methods

This is a retrospective study, using 2005–2014 data in each administrative area from the Taiwan Cancer Registry database organized by the Health Promotion Administration. The yearly age-standardized (overall) and crude (stratified by gender and age) incidence/mortality (and their growth rates) for each administrative area were collected and calculated. We used a mixed model to analyze the repeated measurements of yearly incidence and mortality rates and used general linear regression to analyze their growth rates.

Results

It was found that male and elderly populations had significantly higher lung cancer incidence and mortality in Taiwan. After adjusting for gender, age, and calendar year, there were no significant variations in incidence among the administrative areas, while the mortality in Yilan County was significantly higher than that in Taipei City (the capital city of Taiwan). On the other hand, the incidence in the female and younger population and mortality growth rates were higher. The incidence growth rate in Keelung City was significantly lower than that in Taipei City, while there were no significant variations in mortality growth rate among administrative areas.

Conclusions

This study found an inequality in the lung cancer burden among cities in Taiwan, which can serve as the basis for future resource allocations for lung cancer prevention and treatment in Taiwan.

Epidemiology of lung cancer in Northern Greece: An 18-year hospital-based cohort study focused on the differences between smokers and non-smokers

INTRODUCTION

Lung cancer remains a leading cause of cancer incidence, yet, in Greece, country-level registry-based data are limited. We have thus investigated the epidemiology of lung cancer and its trends in the George Papanikolaou Hospital, Northern Greece over 18 years (2000–2018).

METHODS

We analyzed all the cases reported in the Bronchoscopy Unit of the Hospital for the period 2000–2018. In total, 15131 subjects (12300 males and 2831 females) that presented with a mass in the imaging, were submitted to bronchoscopy. Characteristics of patients such as age, sex, smoking history and occupation were collected. Statistical analysis was performed with SPSS 21.0 software package.

RESULTS

Among all subjects, a total of 5628 (37.2%; mean age: 65.85 ± 9.6 years) cases of primary lung cancer were identified with a male to female ratio of 2:1 (41.1% to 20.4%) (p<0.001). Squamous cell lung cancer was the most common type of lung cancer identified in this population (44%) with a higher proportion in males compared to females (p<0.001). Furthermore, adenocarcinoma was mostly observed in female non-smokers compared to males (p<0.001). The majority of lung cancer cases were identified in patients occupied with agriculture and livestock breeding (41.1%). The mean age at lung cancer diagnosis was 66.13 ± 9.19 years for the whole study population. Lung cancer cases observed with a higher mean of 43.93 ± 10.84 years of smoking compared to cancer-free patients with 39.64 ± 13.23 years of smoking (p<0.001).

CONCLUSIONS

Apart from smoking, demographic characteristics including age, sex and occupation appear to have an impact on lung cancer development in this population. Smoking history alone could not predict the development of lung cancer in the studied northern Greek population.

Identifying Smoking Status and Smoking Cessation Using a Data Linkage Between the Kentucky Cancer Registry and Health Claims Data

PURPOSE

Linkage of cancer registry data with complementary data sources can be an informative way to expand what is known about patients and their treatment and improve delivery of care. The purpose of this study was to explore whether patient smoking status and smoking-cessation modalities data in the Kentucky Cancer Registry (KCR) could be augmented by linkage with health claims data.

METHODS

The KCR conducted a data linkage with health claims data from Medicare, Medicaid, state employee insurance, Humana, and Anthem. Smoking status was defined as documentation of personal history of tobacco use (International Classification of Diseases, Ninth Revision [ICD-9] code V15.82) or tobacco use disorder (ICD-9 305.1) before and after a cancer diagnosis. Use of smoking-cessation treatments before and after the cancer diagnosis was defined as documentation of smoking-cessation counseling (Healthcare Common Procedure Coding System codes 99406, 99407, G0375, and G0376) or pharmacotherapy (eg, nicotine replacement therapy, bupropion, varenicline).

RESULTS

From 2007 to 2011, among 23,703 patients in the KCR, we discerned a valid prediagnosis smoking status for 78%. KCR data only (72%), claims data only (6%), and a combination of both data sources (22%) were used to determine valid smoking status. Approximately 4% of patients with cancer identified as smokers (n = 11,968) and were provided smoking-cessation counseling, and 3% were prescribed pharmacotherapy for smoking cessation.

CONCLUSION

Augmenting KCR data with medical claims data increased capture of smoking status and use of smoking-cessation modalities. Cancer registries interested in exploring smoking status to influence treatment and research activities could consider a similar approach, particularly if their registry does not capture smoking status for a majority of patients.

Impact of the financial crisis on COPD burden: Greece as a case study

Poverty and low socioeconomic status have been associated with chronic obstructive pulmonary disease (COPD). The current financial crisis has forced millions back into poverty. Greece is one of the countries hit the hardest, and is in the middle of a deep ongoing collapse. There have been early reports stating the apparent effects of the Greek downturn on respiratory health. This review summarises the overall impact of the financial crisis on COPD burden throughout the period of economic downturn by analysing the case study of Greece. In all levels of the healthcare system, current economic restrictions have reduced the capacity to prevent, diagnose and treat COPD in parallel with current higher detection rates of COPD. Remarkably, expenditure on healthcare has been reduced by >25%, resulting in major healthcare equipment shortages. Lower wages (by up to 20%) and higher co-payments of up to 25% of a drug's purchase price have led to patients struggling to afford inhaled medications. Treatment nonadherence has been reported, resulting in 11.5% more exacerbations and 14.1% more hospitalisations annually, while the mean cost per severe COPD exacerbation has been approximated as €2600. Greece is a noteworthy example illustrating how COPD burden, quality of care and patients' outcome can be affected by economic crisis.

Association of HMGB1 Gene Polymorphisms with Lung Cancer Susceptibility and Clinical Aspects

Lung cancer is one of the most frequently diagnosed malignancies and is associated with a poor survival rate in the Chinese Han population. Analysis of genetic variants could lead to improvements in prognosis following lung cancer therapy. High-mobility group box 1 protein (HMGB1) is a ubiquitous nuclear protein found in eukaryotic cells that participates in several biological functions including immune response, cell survival, apoptosis and cancer development. We investigated the effects of HMGB1 gene polymorphisms on the risk of lung cancer progression in a Chinese Han population. Our sample of 751 participants included 372 patients with lung cancer and 379 healthy controls. Four single-nucleotide polymorphisms (SNPs) of the HMGB1 gene were examined by real-time polymerase chain reaction (RT-PCR). We found that the CT or CC+CT heterozygotes of the HMGB1 rs1045411 polymorphism reduced the risks for lung cancer, while the G/T/C haplotypes of three HMGB1 SNPs (rs1360485, rs1045411 and rs2249825) also reduced the risk for lung cancer by almost half (0.486-fold). The current study is the first to examine the risk factors associated with HMGB1 SNPs in lung cancer development in the Chinese Han population.