Assessing progress in reducing the burden of cancer mortality, 1985-2005

Targeted Strategies for Degradation of Key Transmembrane Proteins in Cancer

Targeted protein degradation is an attractive technology for cancer treatment due to its ability to overcome the unpredictability of the small molecule inhibitors that cause resistance mutations. In recent years, various targeted protein degradation strategies have been developed based on the ubiquitin-proteasome system in the cytoplasm or the autophagy-lysosomal system during endocytosis. In this review, we describe and compare technologies for the targeted inhibition and targeted degradation of the epidermal growth factor receptor (EGFR), one of the major proteins responsible for the onset and progression of many types of cancer. In addition, we develop an alternative strategy, called alloAUTO, based on the binding of new heterocyclic compounds to an allosteric site located in close proximity to the EGFR catalytic site. These compounds cause the targeted degradation of the transmembrane receptor, simultaneously activating both systems of protein degradation in cells. Damage to the EGFR signaling pathways promotes the inactivation of Bim sensor protein phosphorylation, which leads to the disintegration of the cytoskeleton, followed by the detachment of cancer cells from the extracellular matrix, and, ultimately, to cancer cell death. This hallmark of targeted cancer cell death suggests an advantage over other targeted protein degradation strategies, namely, the fewer cancer cells that survive mean fewer chemotherapy-resistant mutants appear.

Development of a nomogram for preoperative prediction of lymph node metastasis in non-small cell lung cancer: a SEER-based study

Background

Lymph node dissection is an important part of lung cancer surgery. Preoperational evaluation of lymph node metastases decides which dissection pattern should be chosen. The present study aimed to develop a nomogram to predict lymph node metastases on the basis of clinicopathological features of non-small cell lung cancer (NSCLC) patients.

Methods

A total of 35,138 patients diagnosed with NSCLC from 2010–2015 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly divided into training cohort and validation cohort. Possible risk factors were included and analyzed by logistic regression models. A nomogram was then constructed and validated.

Results

21.83% of all patients were confirmed with positive lymph node metastasis. Age at diagnosis, sex, stage, T status, tumor size, grade and laterality were identified as predicting factors for lymph node involvement. These variables were included to build the nomogram. The AUC of the model was 0.696 (95% CI, 0.617 to 0.775). The model was further validated in the validation set with AUC 0.693 (95% CI, 0.628 to 0.758). The model presented with good prediction accuracy in both training cohort and validation cohort.

Conclusions

We developed a convenient clinical prediction model for regional lymph node metastases in NSCLC patients. The nomogram will help physicians to determine which patients will receive the most benefit from lymph node dissection.

Incorporating competing risk theory into evaluations of changes in cancer survival: making the most of cause of death and routinely linked sociodemographic data

Background

Relative survival is the most common method used for measuring survival from population-based registries. However, the relative survival concept of ‘survival as far as the cancer is concerned’ can be biased due to differing non-cancer risk of death in the population with cancer (competing risks). Furthermore, while relative survival can be stratified or standardised, for example by sex or age, adjustment for a broad range of sociodemographic variables potentially influencing survival is not possible. In this paper we propose Fine and Gray competing risks multivariable regression as a method that can assess the probability of death from cancer, incorporating competing risks and adjusting for sociodemographic confounders.

Methods

We used whole of population, person-level routinely linked Western Australian cancer registry and mortality data for individuals diagnosed from 1983 to 2011 for major cancer types combined, female breast, colorectal, prostate, lung and pancreatic cancers, and grade IV glioma. The probability of death from the index cancer (cancer death) was evaluated using Fine and Gray competing risks regression, adjusting for age, sex, Indigenous status, socio-economic status, accessibility to services, time sub-period and (for all cancers combined) cancer type.

Results

When comparing diagnoses in 2008–2011 to 1983–1987, we observed substantial decreases in the rate of cancer death for major cancer types combined (N = 192,641, − 31%), female breast (− 37%), prostate (− 76%) and colorectal cancers (− 37%). In contrast, improvements in pancreatic (− 15%) and lung cancers (− 9%), and grade IV glioma (− 24%) were less and the cumulative probability of cancer death for these cancer types remained high.

Conclusion

Considering the justifiable expectation for confounder adjustment in observational epidemiological studies, standard methods for tracking population-level changes in cancer survival are simplistic. This study demonstrates how competing risks and sociodemographic covariates can be incorporated using readily available software. While cancer has been focused on here, this technique has potential utility in survival analysis for other disease states.

Age-specific cancer rates: a bird's-eye view on progress

PURPOSE

We aim to shed light on progress in cancer medicine through studying time trends in age-specific rates of cancer incidence and mortality over the last quarter century.

METHODS

We analyzed age-specific incidence and mortality rates of all cancer sites combined using the high-quality population-based databases of Denmark, Finland, Norway, Sweden, and the Netherlands for the period 1990-2016.

RESULTS

Over these 26 years, cancer incidence rates increased in all investigated countries irrespective of age by about 22%. By contrast, cancer mortality rates decreased across all ages, also by about 22%, except ages 80+ years in Denmark, Norway, and Sweden, where they remained unchanged. This pattern is consistent with earlier diagnoses and more effective treatments of cancer.

CONCLUSIONS

This bird's-eye view on cancer reveals substantive progress in cancer medicine.

Evolution of Cancer Pharmacological Treatments at the Turn of the Third Millennium

The medical history of cancer began millennia ago. Historical findings of patients with cancer date back to ancient Egyptian and Greek civilizations, where this disease was predominantly treated with radical surgery and cautery that were often ineffective, leading to the death of patients. Over the centuries, important discoveries allowed to identify the biological and pathological features of tumors, without however contributing to the development of effective therapeutic approaches until the end of the 1800s, when the discovery of X-rays and their use for the treatment of tumors provided the first modern therapeutic approach in medical oncology. However, a real breakthrough took place after the Second World War, with the discovery of cytotoxic antitumor drugs and the birth of chemotherapy for the treatment of various hematological and solid tumors. Starting from this epochal turning point, there has been an exponential growth of studies concerning the use of new drugs for cancer treatment. The second fundamental breakthrough in the field of oncology and pharmacology took place at the beginning of the '80s, thanks to molecular and cellular biology studies that allowed the development of specific drugs for some molecular targets involved in neoplastic processes, giving rise to targeted therapy. Both chemotherapy and target therapy have significantly improved the survival and quality of life of cancer patients inducing sometimes complete tumor remission. Subsequently, at the turn of the third millennium, thanks to genetic engineering studies, there was a further advancement of clinical oncology and pharmacology with the introduction of monoclonal antibodies and immune checkpoint inhibitors for the treatment of advanced or metastatic tumors, for which no effective treatment was available before. Today, cancer research is always aimed at the study and development of new therapeutic approaches for cancer treatment. Currently, several researchers are focused on the development of cell therapies, anti-tumor vaccines, and new biotechnological drugs that have already shown promising results in preclinical studies, therefore, in the near future, we will certainly assist to a new revolution in the field of medical oncology.

Emerging Regional and Racial Disparities in the Lifetime Risk of Human Immunodeficiency Virus Infection Among Men who Have Sex With Men: A Comparative Life Table Analysis in King County, WA and Mississippi

BACKGROUND

Little is known about the lifetime risk of human immunodeficiency virus (HIV) diagnosis among US men who have sex with men (MSM), trends in risk and how risk varies between populations.

METHODS

We used census and HIV surveillance data to construct life tables to estimate the cumulative risk of HIV diagnosis among cohorts of MSM born 1940 to 1994 in King County, Washington (KC) and Mississippi (MS).

RESULTS

The cumulative risk of HIV diagnosis progressed in 3 phases. In phase 1, risk increased among MSM in successive cohorts born 1940 to 1964. Among men born 1955 to 1965 (the peak risk cohort), by age 55 years, 45% of white KC MSM, 65% of black KC MSM, 22% of white MS MSM, and 51% of black MS MSM had been diagnosed with HIV. In phase 2, men born 1965 to 1984, risk of diagnosis among KC MSM declined almost 60% relative to the peak risk cohort. A similar pattern of decline occurred in white MS MSM, with a somewhat smaller decline observed in black MS MSM. In phase 3, men born 1985 to 1994, the pattern of risk diverged. Among white KC MSM, black KC MSM, and white MS MSM, HIV risk increased slightly compared with men born 1975 to 1984, with 6%, 14%, and 2% diagnosed by age 27 years, respectively. Among black MS MSM born 1985 to 1994, HIV risk rose dramatically, with 35% HIV diagnosed by age 27 years.

CONCLUSIONS

The lifetime risk of HIV diagnosis has substantially declined among MSM in KC and among white MSM in MS, but is rising dramatically among black MSM in MS.

Benchmarking life expectancy and cancer mortality: global comparison with cardiovascular disease 1981-2010

Objective To quantify the impact of cancer (all cancers combined and major sites) compared with cardiovascular disease (CVD) on longevity worldwide during 1981-2010.Design Retrospective demographic analysis using aggregated data.Setting National civil registration systems in member states of the World Health Organization.Participants 52 populations with moderate to high quality data on cause specific mortality.Main outcome measures Disease specific contributions to changes in life expectancy in ages 40-84 (LE40-84) over time in populations grouped by two levels of Human Development Index (HDI) values.Results Declining CVD mortality rates during 1981-2010 contributed to, on average, over half of the gains in LE40-84; the corresponding gains were 2.3 (men) and 1.7 (women) years, and 0.5 (men) and 0.8 (women) years in very high and medium and high HDI populations, respectively. Declines in cancer mortality rates contributed to, on average, 20% of the gains in LE40-84, or 0.8 (men) and 0.5 (women) years in very high HDI populations, and to over 10% or 0.2 years (both sexes) in medium and high HDI populations. Declining lung cancer mortality rates brought about the largest LE40-84 gain in men in very high HDI populations (up to 0.7 years in the Netherlands), whereas in medium and high HDI populations its contribution was smaller yet still positive. Among women, declines in breast cancer mortality rates were largely responsible for the improvement in longevity, particularly among very high HDI populations (up to 0.3 years in the United Kingdom). In contrast, losses in LE40-84 were observed in many medium and high HDI populations as a result of increasing breast cancer mortality rates.Conclusions The control of CVD has led to substantial gains in LE40-84 worldwide. The inequality in improvement in longevity attributed to declining cancer mortality rates reflects inequities in implementation of cancer control, particularly in less resourced populations and in women. Global actions are needed to revitalize efforts for cancer control, with a specific focus on less resourced countries.

A latent class model for competing risks

Survival data analysis becomes complex when the proportional hazards assumption is violated at population level or when crude hazard rates are no longer estimators of marginal ones. We develop a Bayesian survival analysis method to deal with these situations, on the basis of assuming that the complexities are induced by latent cohort or disease heterogeneity that is not captured by covariates and that proportional hazards hold at the level of individuals. This leads to a description from which risk-specific marginal hazard rates and survival functions are fully accessible, 'decontaminated' of the effects of informative censoring, and which includes Cox, random effects and latent class models as special cases. Simulated data confirm that our approach can map a cohort's substructure and remove heterogeneity-induced informative censoring effects. Application to data from the Uppsala Longitudinal Study of Adult Men cohort leads to plausible alternative explanations for previous counter-intuitive inferences on prostate cancer. The importance of managing cardiovascular disease as a comorbidity in women diagnosed with breast cancer is suggested on application to data from the Swedish Apolipoprotein Mortality Risk Study. Copyright © 2017 John Wiley & Sons, Ltd.

Use of the Prostate Core Mitomic Test in Repeated Biopsy Decision-Making: Real-World Assessment of Clinical Utility in a Multicenter Patient Population

BACKGROUND

Prostate cancer is the most common cancer diagnosed in men in developed countries. Using molecular testing may help to improve outcomes in this clinically challenging group. Since 2011, the Prostate Core Mitomic Test (PCMT), which quantifies a 3.4-kb mitochondrial DNA deletion strongly associated with prostate cancer, has been used by more than 50 urology practices accessing pathology services through our laboratory in New Jersey. However, the use of a molecular test can only be beneficial if it affects patient management and improves outcomes.

OBJECTIVE

To determine whether repeated biopsy decision-making was affected in a quantifiable manner through the adjunct use of molecular testing with the PCMT.

METHODS

In this observational study we conducted 2 independent, structured query language database queries of our patient records at our laboratory, QDx Pathology Services, in Cranford, NJ. Query 1 included all men who had a negative prostate biopsy and a negative PCMT between February 1, 2011, and June 30, 2013. Men with a previous diagnosis of cancer were excluded. Query 2 included all men who had a negative prostate biopsy and a repeated biopsy between February 1, 2011, and September 30, 2013. The data exported for each query included the unique specimen number for an index biopsy, the interval between biopsies where present, the unique specimen number for a follow-up biopsy where present, histopathology for all biopsies, the biopsy procedure dates, the patient's date of birth, and the PCMT result when utilized. The patient rebiopsy rates and intervals were compared between the patients who were using PCMT and those who were not to assess whether the adjunct use of the PCMT impacted the rebiopsy decision-making process.

RESULTS

Query 1 identified 644 men who had a negative biopsy and a negative PCMT result within the study period. Query 2 identified 823 men with a repeat biopsy after the initial negative index biopsy within the study period. Of these men, 132 had PCMT to inform their care. This patient population of 1467 men originated from US-based clinical urology practices. Evaluation of the impact on physician behavior demonstrated a general trend toward the earlier detection of prostate cancer on repeat biopsy by an average of 2.5 months and a coincident increase in cancer detection rates for urologists using the deletion assay in their rebiopsy decision-making process. Importantly, this trend was only observed when men with atypical small acinar proliferation (ASAP) on index biopsy were not considered. In the 644 men with a negative PCMT result, only 35 (5.4%) were subjected to a follow-up biopsy, with 5 (14.3%) of the 35 men identified as having cancer. Finally, the cohort of 132 men who had PCMT and repeat biopsy was compared with the published data supporting PCMT's ability to predict rebiopsy outcome. The key metrics of sensitivity and negative predictive value were comparable and within the 95% confidence intervals of the reported work.

CONCLUSION

Molecular tests, such as the PCMT, are useful in addressing the sampling error of prostate needle biopsy and providing additional evidence to inform the clinical uncertainty regarding initial negative prostate biopsy when ASAP is not present. Longitudinal monitoring of clinical impact indicators provides the necessary inputs to better allocation of healthcare resources in the short- and long-term.

Equity and length of lifespan are not the same

Efforts to understand the dramatic declines in mortality over the past century have focused on life expectancy. However, understanding changes in disparity in age of death is important to understanding mechanisms of mortality improvement and devising policy to promote health equity. We derive a novel decomposition of variance in age of death, a measure of inequality, and apply it to cause-specific contributions to the change in variance among the G7 countries (Canada, France, Germany, Italy, Japan, the United Kingdom, and the United States) from 1950 to 2010. We find that the causes of death that contributed most to declines in the variance are different from those that contributed most to increase in life expectancy; in particular, they affect mortality at younger ages. We also find that, for two leading causes of death [cancers and cardiovascular disease (CVD)], there are no consistent relationships between changes in life expectancy and variance either within countries over time or between countries. These results show that promoting health at younger ages is critical for health equity and that policies to control cancer and CVD may have differing implications for equity.

Lung cancer mortality and years of potential life lost among males and females over six decades in a country with high smoking prevalence: an observational study

BACKGROUND

Little is known about sex-specific trends in lung cancer mortality and years of potential life lost (YPLL) attributable to lung cancer over more than five decades. The aim of the present study was to describe mortality and YPLL due to lung cancer over 61 years of observation in a country with a high smoking prevalence.

METHODS

We obtained data on trends in lung cancer mortality, population-level vital statistics, sales of taxed tobacco products, and survey data on smoking behavior among the German population. We then undertook joinpoint regression analyses to determine sex-specific trends in lung cancer mortality and YPLL.

RESULTS

Rates of lung cancer mortality and rates of lung cancer among all causes of death increased more among females than among males. Although YPLL among females increased from 6.6 in 1952 to 11.3 in 2012, this figure was found to have decreased from 7.3 to 4.4 among males in the same period. Sales of tobacco subject to tax increased from 1,509 cigarette equivalents per resident aged 15 or older in 1952 to 2,916 in 1976 - after which there was a decline. The prevalence of current smoking among females aged 35 years or older remained stable between 17.9 and 18.9 % in the period from 1989 to 2009. Among males in the same age group, however, prevalence decreased from 36.7 % in 1989 to 27.5 % in 2009.

CONCLUSIONS

Lung cancer mortality and YPLL among females increased over the six decades studied. Women should be more considered in smoking policies.

Potential for improvement in cancer management: reducing mortality in the European Union

Overall age-standardized cancer mortality rates in the European Union (EU) have declined by approximately 20% through 2010 (17% in women, 22% in men) since the peak value reached in 1988. This corresponds to the avoidance of more than 250,000 cancer deaths in 2010 alone and approximately 2.2 million deaths over the 1989-2010 22-year period. A more than twofold difference remains between the highest cancer mortality rates (in Hungary and other central European countries) and the lowest (in selected Nordic countries and Switzerland). Part of this gap is due to tobacco, alcohol, and other lifestyle and environmental exposures, and another part is attributable to differences in cancer diagnosis, treatment, and management. There are also appreciable differences in 5-year cancer survival across the EU, with lower survival rates in central and eastern Europe. If overall cancer survival in EU countries with low rates could be raised to the median, approximately 50,000 additional cancer deaths would be avoided per year, and more than 100,000 would be avoided if overall survival in all countries were at least that of the 75% percentile--4% and 8%, respectively, of the approximately 1.3 million cancer deaths registered in the EU in 2010. There is, however, substantial uncertainty about any such estimate because differences in cancer survival are partly or largely attributable to earlier diagnosis, in variable proportion for each cancer site and probably to different degrees in different countries, even in the absence of changes in the date of death or avoidance of death. Consequently, these approximations are the best available and may be used cautiously to compare countries, health care approaches, and changes that occur over time.

The socioeconomic gradient in all-cause mortality for women with breast cancer: findings from the 1998 to 2006 National Cancer Data Base with follow-up through 2011

PURPOSE

To analyze the association between socioeconomic status (SES) and all-cause mortality among women diagnosed with breast cancer before and after controlling for insurance status, race and ethnicity, stage, treatment modalities, and other demographic and hospital characteristics.

METHODS

Data analyzed included follow-up through 2011 for 582,396 patients diagnosed between 1998 and 2006 with ductal carcinoma in situ or invasive (stage I-IV) breast cancer from the National Cancer Data Base. SES was measured by grouping patients into six income and education-level ZIP code categories. Hierarchical Cox regression models were used to analyze SES survival differences.

RESULTS

Five- and 10-year survival probabilities for the highest SES group were 87.8% and 71.5%, versus 79.5% and 61.5% for the lowest SES group. Controlling for all covariates reduced the highest-to-lowest SES hazard ratio from 1.69 (95% confidence interval: 1.64-1.74) to 1.27 (95% confidence interval: 1.24-1.31). Results were virtually identical in models that included comorbidity and invasive cancer patients only.

CONCLUSIONS

Differences in insurance status, race, and stage at diagnosis are important components of SES disparities and explain about two-thirds of the initial SES survival disparity. The residual SES effect likely mirrors underlying social determinants of health for all American women.

Years of life lost as a measure of cancer burden on a national level

Background:

The severity of cancers is often measured in number of deaths. However, number of years of life lost (YLL) may be a more appropriate indicator of impact on society. Here we have calculated the YLL of adult cancers in Norway for the year 2012, as well as for the previous 15-year period.

Methods:

Data on age composition, expected remaining years of life, total numbers of deaths and deaths due to cancer were retrieved from the National Census Agency Statistics Norway. YLL were calculated for both sexes aged 25–99 years based on each individual's age at death, and the expected remaining years of life at that age.

Results:

Cancer deaths represented 25.8% of all adult deaths in 2012, with a lower fraction of females (28.7% in men and 23.1% in women), whereas cancer represented 35.2% of all YLL, with a higher fraction of females (32.8% in men and 37.8% in women). Females loose on average more life years to cancer than men (14.9 vs 12.7 years). Average YLL varied from 23.7 (cervical cancer) to 7.9 (prostate cancer). Lung cancer caused almost as many YLL alone (22.1% of cancer-caused YLL) as colon, prostate and breast cancer combined (23.1%). From 1997 to 2012, cancer-caused YLL as a fraction of all YLL increased from 32.5% to 35.2%, but with major differences among diagnoses.

Conclusions:

Cancer is a major and increasing cause of premature deaths, and YLL may be a more accurate measure than number of deaths. Public health efforts and research funding should be explicitly directed at preventing premature deaths.